Answering Essay Questions

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Hope to pass as this exam blocked my life in the last few months. I found BusySpR very useful but hope not to use it again:)

You will find out if I pass.

Any hint or advise for OSCE?:)( a bit early)

Thank you

Thank you very much sir, for your valuable guidance. I think all of us were really helped with the short essay writings, especially. You really gave me much needed confidence in the essay writing.

Wish everybody all the best for the exam.

thankyou for your gudence sir. 

1. An information leaflet is to be provided at booking to women with a previous birth by caesarean section. (a) What information needs to be included regarding the management options available? (b) How can the risk of uterine rupture be minimised in women in spontaneous labour following one previous caesarean section?

(a) What information needs to be included regarding the management options available?

The information should include the two available choices which are VBAC ( Vaginal birth After Caesarean) and ERCS ( Elective repeat Caesarean Section)

The information should include details of the decision to reach either option which depends upon the previous CS ( emergency or elective), nature of the cut on the womb ,her future maternal plans , presence of indications for CS during this pregnancy. The decision would be reached after assessment by obstetrician and midwife considering the maternal wishes.

The chances of having a VBAC should be included which is about 3 out of 4 ( 75%). The likelyhood of VBAC would be even more 9 out of 10 ( 90%) if she has a previous vaginal birth. The chances would be less if she never had vaginal birth or if she is to be induced for labour. Vaginal delivery would be unlikely if her BMI is more than 30 at the time of booking.

The information should include the benefits of VBAC which are vaginal birth greater chance of uncomplicated normal birth in future pregnancies. Associated with shorter recovery period and shorter stay in hospital. The another advantage is less abdominal pain and not having surgery avoiding associated surgical and anaesthetic risks.

The disadvantages of VBAC are explained for eg. She may have to undergo emergency CS which is about 25 per 100 (25% ) which is slightly higher than when she is labouring for the first time ( 20%). The reason for emergency CS could be concerns regarding fetal well being or no progress during labour.

The risks of infection or having a blood transfusion are about 1 in 100 more compared to ERCS.

The risk of scar weakening or uterine rupture is about 2-8/1000 when compared to ERCS where it is almost nil.

The risk of her baby having brain damage or still birth is 2 in 1000 which is no higher than when she is labouring for the first time.

The advantages of ERCS should be included which are virtually no risk of uterine rupture, avoids risks of labour particularly risk of brain damage of the baby or still birth from lack of oxygen. The advantage of prior knowledge of the date of delivery to make arrangements for the baby's birth.

The disadvantages of ERCS are difficult and longer surgery due to the scar tissue, risk of bowel and bladder injury. The risk of blood clot can occur in the lung i.e pulmonary embolus which can be life threatening (death occurs in less than one in 1000 caesarean deliveries).

The recovery period would be longer compared to VBAC. With CS the baby would have short term breathing problems and the risk is about 3-4 % compared to 2-3 % with VBAC.

The other risks about ERCS are increased possibility of repeat CS in future pregnancies , placenta growing on to the scar and difficult to remove and hysterectomy.

The information should include the possibility of the woman if she gets in to labour before VBAC or ERCS, or if she breaks her baby waters, along with the instructions to be followed which include inform the hospital.

B) (b) How can the risk of uterine rupture be minimised in women in spontaneous labour following one previous caesarean section?

Care of plan for delivery should be made during the antenatal period and details to be written in the hand held maternity record.

The delivery should take place in a consultant led obstetric unit with facility for emergency CS .

Undertaking emergency CS in women with history of classical CS.

Augmentation of labour is associated with increased risk of uterine rupture. Senior colleague should be involved in making decision about augmentation.

Continuous electronic fetal monitoring is indicated as abnormal CTG suggests scar rupture.

Close monitoring during labour is required during labour. Severe abdominal pain persisting between contractions, shoulder tip pain and shortness of breath indicate scar rupture. Cessation of uterine contractions, vaginal bleeding and haematuria are also on concern which suggest uterine rupture. Monitoring by intrauterine pressure catheters for predicting uterine rupture may not always be reliable and may be associated with risk of infection.

Serial cervicometric progress should be assessed preferably by a same person to identify slow progress. 

A 35 year old nulliparous woman with IDDM has been referred for pre-conception assessment and counselling. (a) Justify the information you would obtain from the history and clinical examination. (b) Which investigations will you undertake and why?(c) What would you tell her about the potential effects of pregnancy on her IDDM?(d) What will you tell her about the potential effects of her IDDM on pregnancy?

(a) Justify the information you would obtain from the history and clinical examination.

History is taken about the duration of IDDM as long standing diabetes is associated with retinopathy, nephropathy and autonomic neuropathy which may alter her pregnancy care.

Information about the glycemic control( episodes of hypoglycemia, hyperglycemia, admission for diabetic ketoacidosis) is important as poor control of diabetes is associated with increased risk of congenital anomalies and pregnancy complications for eg: preeclampsia, macrosomia and polyhydramnios.

Information about insulin requirement or antihypoglycemic drugs used as only insulin or metformin can be used during pregnancy. Current medications history as ACE inhibitors may cause fetal growth restrictions and need to change to safer antihypertensives and if on statins advice to stop as not recommended in pregnancy.

Examination including BP BMI and urine dipstick for proteinuria as baseline to exclude underlying hypertension. BMI as associated obesity will significantly increase pregnancy risks and complicatons.

(b) Which investigations will you undertake and why?

The investigations include measurement of HbA1c.

She should aim to maintain their HbA1c below 6.1%. to reduce the risk of congenital malformations.

The fasting and 1 hour postprandial glucose levels are checked to assess the glycemic control and referal to diabetologist for review of the dosage of insulin or antihypoglycemic drugs.

She should be offered a renal assessment, including a measure of microalbuminuria, before discontinuing contraception. If serum creatinine is abnormal (120 micromol/litre or more) or the estimated glomerular filtration rate (eGFR) is less than 45 ml/minute/1.73 m2, referral to a nephrologist should be considered before discontinuing contraception

Retinal assessment is arranged to detect any evidence of retinopathy if not done before 6 months.

100. What would you tell her about the potential effects of pregnancy on her IDDM?

I would tell her that pregnacy is associated with increase in insulin requirement .

Kidney function may deteriorate during pregnancy both in renal function and particularly the degree of proteinuria.

Visual deterioration can occur as there is 2 fold increased risk of progression of diabetic retinopathy during pregnancy and the progression is often related to the rapid improvement in glycemic control.

Fall in glucose levels are more common during pregnancy and she may be the unaware about the low glucose levels and I would suggest her to take glucose containing food or drink. She may require glucagon injection by partner in case of hypoglycemia.

Although diabetic ketoacidosis is a serious emergency and the risk can be associated with excessive vomitings, the use of corticosteriods, and tocolytics.

500. What will you tell her about the potential effects of her IDDM on pregnancy?

I would tell her that poorly controlled diabetes is associated with increased risk of spontaneous miscarriage.

There is increased risk of preeclampsia if there is preexisting hypertension or renal disease.

Increased risk of infection particularly, urinary tract infection, respiratory and wound infections. Vaginal candidiasis is common in pregnant diabetics.

The risk of caesarean section is increased in pregnant diabetics which may be due to early induction.

The fetal risks are increased risk of congenital anomalies which is directly related to the glycemic control.

The perinatal mortality rate is increased 5 to 10%.

Fetuses of diabetic mothers are at risk of sudden unexplained intrauterine death which is not predictable by CTC , doppler or biophysical profiles.

Maternal hyperglycemia and particularly diabetic ketoacidosis is detrimental to the fetus and associated with increased perinatal mortality while hypoglycemia is well tolerated by the fetus.

Macrosomia ( >90^th centile or > 4.5 kg) is more common with poor diabetic control , which is associated with poly hydramnios and premature rupture of membranes, traumatic delivery particularly shoulder dystocia.

A healthy 65 year old woman has been referred to the gynaecology clinic because of a 3 months history of persistent blood-stained vaginal discharge. (a) Discuss your clinical assessment (b) Evaluate the options for investigating her symptoms given that clinical examination was normal (c) She is found to have a well differentiated endometrial adenocarcinoma. Discuss your pre-operative counseling

(a) Discuss your clinical assessment

History is taken regarding the duration and nature of vaginal discharge and its effect on her quality of life. Enquiry is made if she feels any pain, lump, or ulcer on the genital area. She should be asked if the discharge is foul smelling. Information is obtained if she is sexually active and if so any evidence of dyspareunia and if the discharge is noticed after the coitus.

Menstural details are taken about age of menarche , regularity , cycle lenght LMP and menopausal symptoms in particular vaginal dryness. She should be asked if she is taking on hormone replacement therapy.

Details of last cervical smear are taking including the time since taken.

She should be asked if had recently lost weight and appetite which suggest malignancy.

History is taken about recent change in bowel habit or history of haematuria or rectal bleeding.

Inquiry about her parity , family history of cancers should be asked as well since familial conditions such as hereditary nonpolyposis colonic cancer is associated withan increased risk of CA. Endometrium.

Examination performed to identify supraclavicular lymphnodes, pallor and noted if she is cachexic which point towards malignancy. BMI , BP is recorded.

Abdominal examination is performed to identify abdomino pelvic masses. Careful inspection is done to identiy lump or ulcer on the vulva. Examination by speculum should identify vaginal ulcers,cervical polyps, any evidence of obvious invasion. Pelvic examination done to exclude uterine enlargement or adnexal mass.

(b) Evaluate the options for investigating her symptoms given that clinical examination was normal

As symptoms are suggestive of malignancy (endometrial or cervical) and therefore prompt investigation required. She should be assessed within 2 weeks of referral.

Trans-vaginal ultrasound scan (TVS) to measure endometrial thickness sensitivity for detecting endometrial malignancy is 80-100%, adnexal pathology can also be detected Out-patient hysteroscopy and directed biopsy is a superior diagnostic tool compared to blind biopsies, especially considering high risk of malignancy in this age group. Has similar efficacy to use of rigid hysteroscope under general anesthesia. May require paracervical block but avoids complications of general anesthesia. Is very cost-effective and has high degree of patient’s acceptability. In-patient hysteroscopy and curettage under anesthesia will be considered in case of failed out-patient hysteroscopy.

100. She is found to have a well differentiated endometrial adenocarcinoma. Discuss your pre-operative counseling.

Counseling should be undertaken in sensitive manner in the presence of a family member.

Multidisciplinary team is involved for counseling, including anaesthetist, surgical oncologist and specialist midwife.

She should be informed about that endometrial carcinoma is a malignant condition with a overall survival rate of 78%. She should be told that well diffentiated adenocarcinomas have early stage disease.

The surgery is carried out to remove her uterus, ovaries and additional procedures like lymphnode removal would be carried out depending upon further staging of the disease.

The mode of anaesthesia should be explained usually general.

She should be explained that the route of the surgery can be abdominal, vaginal or laparoscopic.

She should be informed that abdominal surgery is associated with morbidity as it is a open operation. Vaginal surgery although less invasive compared to abdominal surgery, laparoscopic assistance is required for removal of ovaries and lymphnodes.

She should be informed that laparoscopic hysterectomy (including laparoscopic total hysterectomy and laparoscopically assisted vaginal hysterectomy) for endometrial cancer is safe and adequate .

She should be told that survival rates and disease-free survival rates are not significantly different in women treated laparoscopically compared to those treated by laparotomy.

Intraoperative complications are not significantly different from abdominal surgery with additional advantage of shorter postoperative period and recovery.

Adverse events associated with laparoscopic hysterectomy include conversion to open

surgery (0-26%) damage to abdominal or pelvic structures, respiratory difficulties, port-site herniation and port-site metastasis (1-40%)

A 33 year old primigravida is referred to the obstetric medicine clinic at 10 weeks gestation. She is known to have sickle cell disease. (a) Discuss the initial assessment in the antenatal clinic. (b) Discuss her further antenatal management. (c) Discuss her intra-partum care given that she presents in spontaneous labour at 35 weeks gestation.

(a) Discuss the initial assessment in the antenatal clinic.

Enquiry is made about the ethnic group of partner and sickle cell status if known. She should be asked about any painful crises and its frequency. History of blood transfusion and any complications. Social history regarding smoking , alcohol and drug abuse, family support . History is taken regarding pneumococcal, hepatitis B or rubella vaccinations. Information is obtained about the presence of secondary complications, like renal compromise, visual problems, leg ulcers and treatment details.

Blood pressure and urinalysis should be done to identify hypertension and nephropathy. Examination is done to detect leg ulcers. Baseline oxygen saturation is checked. Assessment is undertaken to exclude chronic complications of SCD. Retinal screening arranged to exclude proliferative retinopathy. Echocardiography to identify pulmonary hypertension. Serum ferritin level for iron overload. Screening done for red cell antibodies.

(b) Discuss her further antenatal management.

Antenatal care should be provided by a multidisciplinary team including an obstetrician and midwife with experience of high-risk antenatal care and a haematologist with an interest in SCD as multidisciplinary care is associated with an improvement in maternal and fetal outcomes.

If the woman has not been seen preconceptually, she should be offered partner testing to know if her partner is a carrier or is affected by a significant haemoglobinopathy . This allows appropriate counselling as early as possible in pregnancy to allow the option of first-trimester diagnosis and termination if that is the woman’s choice.

The influenza vaccine should be recommended if it has not been administered in the previous year.

Drug history is reviewed. If she is taking hydroxycarbamide, ACE Inhibitors, she should be advised to stop as these drugs are teratogenic.

Folic acid 5 mg daily should be prescribed during pregnancy to reduce the risk of neural tube defect and to compensate for the increased demand for folate during pregnancy. Iron supplementation is not required unless there is laboratory evidence of iron deficiency.

She should be considered for low-dose aspirin 75 mg once daily from 12 weeks of gestation in an effort to reduce the risk of developing pre-eclampsia. As there is increased risk of VTE, appropriate thromboprophylaxis give when she gets admitted for painful crises.

She should be advised to avoid precipitating factors of sickle cell crises such as exposure to extreme temperatures, dehydration and overexertion. In case of persistent vomiting can lead to dehydration and sickle cell crisis and women should be advised to seek medical advice early. At each appointment, opportunities should be offered for information and education.

Mild pain in managed with paracetamol, hydration and bed rest. NSAIDS can be used for 12- 28 weeks only because of risk of premature closure of ductus. Moderate to severe pain is treated with weaker opioids ( codiene, codymamol) or stronger opioids like morphine.

If the women need strong opiate therapy, they will need to be admitted to hospital to a level 2 antenatal bed in later pregnancy, under the joint care of obstetricians and haematologists.

Assessments of pain score, sedation score and oxygen saturation should be performed at least 2-hourly using a modified obstetric early warning chart.

Acute chest syndrome characterised by tachypnoea, shortness of breath and chest pain should be treated by intravenous antibiotics, oxygenation and blood transfusion.

As she is at risk of developing PET, Blood pressure and urinalysis should be performed at each consultation.

Midstream urine for culture performed monthly to screen for UTI.

She should be offered the routine first-trimester scan (11–14 weeks of gestation) and a detailed anomaly scan at 20 weeks of gestation. In addition, serial fetal biometry scans (growth scans) should be done every 4 weeks from 24 weeks of gestation.

Routine prophylactic transfusion is not required. Top-up blood transfusion may be required if the haemoglobin is falling, and certainly if the haemoglobin is less than 6.5 g/dl

If blood transfusion is required it should be CMV Negative.

100. Discuss her intra-partum care given that she presents in spontaneous labour at 35 weeks gestation.

The relevant multidisciplinary team (senior midwife in charge, senior obstetrician, anaesthetist and haematologist) should be informed as soon as labour is confirmed.

There is an increased frequency of sickle cell crisis and ACS in the intrapartum period

During labour, she should be should be kept warm and given adequate fluid during labour. If oral hydration is not tolerated or is inadequate, intravenous fluids should be administered using a fluid balance chart to prevent fluid overload

Venous access can be difficult, especially if they have had multiple previous admissions, and as such anaesthetic review/intravenous access should be obtained early.

Arterial blood gas analysis should be performed and oxygen therapy instituted if oxygen saturation is 94% or less.

Hourly observations of vital signs should be performed if temperature is raised over 37.5oC requires investigation with low threshold to commence broad-spectrum antibiotics.

Continuous electronic fetal heart rate monitoring is recommended because of the increased rate of stillbirth, placental abruption and compromised placental reserve.

Regional anaesthesia during labour may reduce the necessity of general anaesthesia for delivery. It is also likely to reduce the need for high doses of opioids if the woman has sickle-related pain in the lower body.

Pethidine should be avoided because of the risk of seizures when administered to a woman with SCD.

Caesarean section should be considered if labour is not progressing well and or for other obstetric indications.

Thanks for you patience, Dr. Paul 

Dear Sir, I would like to bring to your notice that in your answers related to PCOS, it appears that PCO is related to ovarian cancer. But the guideline says no proven relationship of PCO with ovarian cancer. Please clarify.

                                                                                                                             Thank you

woman will have the valid  option of chosing vaginal birth after caesarean section which is also known asVBAC The other option is to chose for caesarean section .It is called elective repeat caesarean section commonly referred to as ERCS…it is scheduled before the onset of spontaneous  labour in the 39 th week  but it is decided according to the individual needs of the women taking into consideration of time of onet of  any previuos labour

.She should be supported in her decision if the women decides to opt for  VBAC..She should be informed that uterine rupture is very rare but is increased after VBAC(about 50 per 10000) as compared to 1 per 10000 in ERCS..The risk of rupture increases even more if VBAC remains unsuccessful. Also there is a risk of undergoing emergency c-section which  causes health risk to mother as compared to ERCS.

.Also the intrapartum  infant death is rare about 10 per 10000…this is the same as the risk for women in their first pregnancy but is increased as compared to elective repeat caesarean.

There is an increased risk  of transfusion as well as endometritis which is the infection of the womb and both these risks are due to failed  VBAC.

VBAC has the benefits for mother as well as for the baby..For mother ,there is short hospital stay and rapid recovery.Future pregnancies will be potentially easier.For baby ,there will be reduced risk of  temporary respiratory problems which are likely to occur in case of ERCS.

ERCS has  the risk of prolonged recovery as well as future pregnancies will require caerean delivery.More over ther will be increase risk of placenta  situated in the lower part of the womb which is  called placenta previa .it has the risk of bleeding before and during delvery leading to increased need for the blood transfusions .It can be life threatening.Also  when placent a issituated in the lower part of the womb ….it  can be adherent to the wall of the womb which is called placenta acreta… which is difficult to remove and it can cause bleeding which is difficult to stop. And  may need removal of the uterus(womb)which will be life saving.

For baby ,there is risk of temporary respiratory (breathing) problem after caesarean section( 1-3% at 39 weeks and 6% at 38 weeks)

On the other hand ERCS has the advantage for the mother  that she is prevented  from the risk of trauma to the perineum by vaginal delivery.Also  in case of failure of VBAC she is  saved from the risk of undergoing emergency c-section .There will be no

risk of scar rupture  and its later difficulties.Moreover  in  ERCS  ,DELIVERY IS PLANNED.

In case she does nt undergo spontaneous labour  then she has to decide to undergo induction of labour or ERCS.Induction of labour leads to doubling of the in risk of scar problems and it is possible that magnitude of increase is higher if prostaglandins are used for induction..prostaglandins are in the form of tablets or pessaries to be used to place in vagina.

(b)A quickand careful review of the obstetric history  ,operation notes  if available and the antenatal record is essential to find out the risk factors that influence the likelihood of success of VBAC.A previous vaginal birth increases the chances of success of VBAC.an interdelivery  interval of less than 18 months decreases its chances to be successful.maternal age 40 or more,gestational age >41 weeks,nonwhite ethinicity ,male infant and short maternal stature all are associated with lower rates of vaginal delivery.

Indication of failed  progress in labour for previou csection , , in the present pregnanacy  fetal macrosomia .cervical dilatation <4 cm  at admission also associatedwith lower success.

Careful counseling in the antenatal period taking into account the woman s particular circumstances  influencing her choice of opting VBAC( TYPE OF SCAR; upper segment extensions  will increase the risk of rupture) and planning  in advance with full documentation of the plan  will reduce the maternal risks.Possibility of placenta acreta to be ruled out if placenta is anteriordiscussed with the woman  with its potential problems and management options.Also arrangement of necessary blood products in consultation with haematologist.

General steps to reduce risks to moter; sting intra venous access(can be capped and flushed),

Group and save blood to prepare for the need for transfusion in case of failed VBAC.

Discuss active management of labour to  reduce the risk of pph            

Continuous monitoring of fetal heart  rate during labour.Using partogram  and prompt  recognition of delayed progress(static progress  over 2 hrs) in labour avoiding unnecssay delay  in decisionhence mortality

Optimizing labour progress , to reduce the need for oxytocin  use for augmentation  as it increase the risk of rupture by 2- 3 times.If at all it is needed decision will be made at consultant level.

There is no alternative to vigilant monitoring  during labour  preventing rupture of the scar by recognizing                                                                                                                                ealier the imminent signs of impending rupture  to allow  early recourse to                emergency c-section.cardinal signs of imminent rupture ;CTG changes (esp.variable decelerations or late decelerations ) hematuria,secondary arrest,small amount of vaginal bleeding ,pain over scar which persists  in between contractions.

Sign of rupture as fetal bradycardia,upward displacement of the presenting part ,sudden loss of contractions,maternal hypotension,profuse vaginal bleeding.shoulder tip pain or abdominal pain should be recognized to allow rapid  recourse to laparotomy to  stop  the haemorrhge  Timely resuscitation of the mother with fluids ,blood transfusions and appropriate blood products .

,prompt delivery of fetus in 10 min.,effective repair of the uterus if possible Early senior involvement  in decision for need for hysterectomy as a life saving procedure. Adequate education of  all staff ensuring awareness of signs and symptoms of uterine rupture is the cornerstone reducing maternal mortality.

Q1.women should be given evidence based information according to her needs .that should be in the form of verbal ,audio visual ,and  information leaflet.women with special needs like who cannot  read or speak english or with learning disabilitydealt with accordigly.women should be given information regading ERCS and VBAC .regarding advantage; vaginal birth is succesful in 75% of cases if no persistent cause found.It will be increase to even 90% if she has previous NVD.VBAC is associated with reduce maternal morbidity ,reduce duration of hospital stay and cost.Disadvantage will be increase maternal anxiety regarding outcome,slight increas risk of uterine rupture 2-9%;and 25%risk of emergency c\s.regarding ERCS advantages will be more control ;no risk of uterine rupture.Disadvantages will be slightly increase risk of maternal and neonatal morbidity and hospital stay ;anaesthesia and surgical risk and long term implication like .low lying and adherent placenta.Risk of uterine rupture can be minimized by proper selection of patients,avidance of repeated factors.intra partum maternal and foetal monitoring.involvement of senior staff early ,and proper comunication.