Additional essay questions

Below are some questions that we set but have not used. We have not prepared marking schemes so answers will not be marked but happy to help with any issues.

A healthy 32 year old primigravida attends the antenatal clinic at 24 weeks gestation. (a) She wishes to have an elective caesarean section because she is concerned about the risks associated with planned vaginal birth. How would you counsel her? [12 marks]. (b) She decides to have planned vaginal birth but is unsure about giving birth at home, in a midwifery-led unit or in a consultant-led unit. How would you counsel her? [8 marks]

A 32 year old woman has been referred for pre-conception counseling. She has a history of rheumatic heart disease with a prosthetic mitral valve requiring anti-coagulation. (a) Discuss your assessment of this woman [10 marks]. (b) How would you counsel her given that her cardiac disease has been optimally managed? [10 marks]

A healthy 32 year old woman attends the assessment unit at 30 weeks gestation because of progressive abdominal pain. (a) Discuss your clinical assessment [6 marks]. (b) She is found to have severe polyhydramnios. Discuss your subsequent antenatal management [10 marks]. She presents in spontaneous labour at 35 weeks gestation with a cephalic presentation. Discuss the modifications that you will make to her intra-partum care [4 marks]

A healthy 77 year old woman has been referred to the gynaelogy clinic because of a progressive sensation of a lump in her vagina. Discuss your clinical assessment [12 marks]. She is found to have a uterine prolapse. Discuss her management options [8 marks].

A general practitioner seeks your advice about a 32 year old woman who has attended for routine cervical smear. The woman wishes to know the role of HPV testing. (a) Discuss the value of HPV testing to the cervical screening program [10 marks]. (b) The smear is reported as showing mild dyskaryosis and is positive for high risk HPV. Discuss the subsequent management [10 marks].      

HPV TESTING

High  risk  HPV  causes  75% of  cervical  carcinoma  and  present  in  99%   of  cervical  cancer.Presence  of  high  risk  HPV  indicates  increased  risk  of  CIN  and  its  absence  indicates  virtually  no  risk  of  CIN at  that  time.Hence  HPV  testing  is  clinically  useful  in  risk  assessment  of  managing  borderline,mild  dyskaryosis  cervical  smears and for  predicting  treatment  failure  of  CIN- Test  of  cure.  Its  role  as  primary  screening  tool  rather  than  cervical  cytology  is  under  review.HPV  triaging  is  done  for  mild  or  borderline  cervical  smears.If  HPV  negative  recourse  to  routine  call  and  recall  system  is  done  as  per  age.This  reduces  the  number  of  smear  follow  up,reduces  patient  anxiety  and  better  utilization  of  resources.Though  triaging  increases  early  referrals  for  colposcopy,this  is  temporary  .   HPV  testing  is  highly  sensitive than  colposcopy and  cytology. It  has  high  negative  predictive  value for  residual  disease,the  commonest  cause  of  treatment  failure.If  for  treated  cases  of CIN  after  cytology  and Test  of  cure  with  HPV  smear after 6 months  is  normal,borderline,mild  with  negative  HPV  she  is sent  for  routine  recall. This  reduces   the  number of annual  smears.HPV  testing  is  feasible,acceptable.Kits  are  also  available.ARTISTIC   trial  has  shown  that  HPV  testing  provides  same  protection  for  2  screening  rounds  as  cervical  cytology for  1  screening  round.This  suggests  that  screening  rounds  can  be  increased  and  its  role  as  primary  screening  is  under  review.

b)Presence  of  high  risk  DNA  helps  in  early  recognisation    of  CIN  2  or  more.Early  detection  and  treatement  protects  against  progression  to CIN  3  and  invasive  cancer.  She  is  referred  for  colposcopy  .Further  management  depends  on  whether CIN1,CIN2,CIN3  detected.If  CIN  1  she  is   followed  up  with  cervical  smear  at  12 months  with  colposcopy  as  local  preference.If  that  smear  shows  borderline  repeat  HPV  testing  is  done.Other  option  is  she  is  treated  with  LLETZ  .Presence  of  CIN 2 ,CIN  3   warrants  treatement  with  excision.LLETZ  is  the  commonest  procedure  done.It  is  done  as  outpatient, under local  anesthesia  and  tissue  is  available  for  pathology.After  treatement  of  CIN  she  is  followed  with  cervical  smear  and HPV  test  of  cure  after  6  months.If  smear  normal,borderline,mild  with  HPV negative  she  is  sent  for  routine  racall system  with  3  yrly  interval.If  HPV  positive she  is  referred  for  further colposcopic  assessment.If  colposcopy  is  normal  she  can   again  be  sent  for  routine  recall  system.If moderate  or  severe  dyskaryosis  on  smear  further  colposcopic  assessment  is  required  and  treated  appropriately.If  required  Multidisciplinary team  review  with  oncologist,colposcopist,cytologist is  arranged  for  planning  treatement.Information leaflets  are  provided.

SIr

Kindly  give  your  suggestions  please

                                                                  Gouthaman.,

should  we  consider  bloodgroup  for  assessing  prognosis  in GTD  since  latest  scoring  system  does  not  include  this .Kindly clarify

                                                                                                    S.Gouthaman

A healthy 24 year old attends the antenatal clinic at 24 weeks .

a) She wishes to have a elective cesarean section because she is concerned about the risks associated with vaginal delivery.How would you counsel her? 12

b) She decides to have planned vaginal birth but is unsure about giving birth at home ,midwifery unit or consultant led unit unit.How would you counsel her?

. First the reason for her request is explored and individual issues addressed.  Ask about any fear of childbirth stemming from other ‘s stories or her own beliefs. Previous abuse or sexual trauma could  lead  to fear of pelvic floor damage by vaginal delivery. History of any previous psychological illness, treatment taken is elicited. Ask her about social history , drug intake , lack of partner support at home which could be the reason. She is offered promise and support in labour . Involve partner in decision making about mode of delivery. Cesarean delivery is   associated with more risk of thromboembolism, longer hospital stay . Urinary incontinence rates are same after 2 years and no evidence that cesarean is protective .Anal incontinence rates are also same even though vaginal delivery causes more tears as per long term study like term breech trial. She is told that sexual function will usually not be adversely affected long term with vaginal delivery. If she is concerned about fear of pelvic   organ prolapse   reaasure her that it is unclear that pelvic organ damage due to vaginal delivery cause prolapse.

Cesarean delivery can adversely affect  future reproductive outcome increase risk of  abnormal placentation. Tell her about no proven fetal risks attributed to vaginal delivery. cerebral palsy rates not decreased even with increase in cesarean rates. The mode of delivery is influenced by maternal fetal factors at term like any obstetric indications , malpresentations and should attend antenatal appointments as per schedule . she can be offered support of perinatal mental health services for counseling. If inspite of conselling her fear and anxiety can cause more trauma her feelings anre respected and final decision is consultant based .

Once she opts for planned vaginal delivery place of birth is decided depending upon risk factors for mother and baby. She is told about advantage of home birth like familiar surrounding , more in control, less need for pain relief . She is told that home birth can be allowed only if she is low risk , no  medical complications .There should be no fetal indications like growth restriction which need continous fetal heart monitoring and immediate neonatal facilities . There should be good support at home  ,local transport facility, good communication with referral  centre in need of emergency transfer. Perinatal outome for nulliparous women in place of birth study show significant adverse outcome in home birth setting . Labour can be unpredictable and any complication can have adverse outcome . She is given option of midwifery units alongside and free standing where more chances of successful vaginal delivery with less interventions. Fetal monitoring can be done and urgent transfer if needed is faster . Alongside midwifery units can be a good option as consultant obstetrician and neonatologist , anaesthetists can be approached easily . Consultant led unit would be ideal but increase in interventions like cesarean section operative delivery. 

Dear Paul,

I was wondering whether there is any chance that you might be able to provide feedback/guidance of this essay question. I am not too sure I am completely on the right track and given the importance of this "topic of interest" I would be hugely grateful for any feedback if at all possible.

Many thanks

A general practitioner seeks your advice about a 32 year old woman who has attended for routine cervical smear. The woman wishes to know the role of HPV testing. (a) Discuss the value of HPV testing to the cervical screening program [10 marks]. (b) The smear is reported as showing mild dyskaryosis and is positive for high risk HPV. Discuss the subsequent management [10 marks].

a)

The aetiological relationship between the high risk oncotypes of HPV and cervical smears means that the presence of high risk HPV in the cervical smear increases the risk of CIN, whilst its absence implies virtually no risk at that time.  HPV testing can therefore be clinically useful for risk assessment (HPV triage) and in managing borderline or low grade abnormalities  and predicting the risk of treatment failure.  (HPV test of cure).

The aim of triage is to identify those that are at high risk  i.e. HPV +ve and refer onwards to colposcopy, but also to identify those that are –ve and therefore at virtually no risk at that time, allowing return to normal recall (3yrs if < 50yrs or 5yrs if >50yrs).   The aim is also to curtail the extensive follow up for women after treatment for CIN.  If following treatment they are HPV –ve and have normal smears at 6/12, 1yr and 18/12 then they no longer require prolonged surveillance (for 5yrs).  If HPV and cytology –ve, the risk of at least CIN II is <0.5%.   By returning these women to routine recall earlier, it may decrease anxiety for the women involved and save cytological resources.  It may be however that there initially may be an increase in “high risk” cases picked up and referred onwards to colposcopy, however it should  ultimately have a positive effect in reducing cytological surveillance in women with low grade smears (who are HPV –ve) and for those who require  post treatment  f/up, thereby saving considerable resources in the long run.

b)

A smear which shows mild dyskaryosis and is HPV +ve is at risk of CIN and progression (>50% risk of CIN II-III) Therefore, this lady should be referred to colposcopy for further assessment of her cervix.  If at colposcopy there is confirmed CIN then it should be treated.  Treatment may either be via local excision or destructive techniques.  Excision has the benefit of making tissue available for histology to confirm the diagnosis and adequacy of treatment.  Destructive techniques rely heavily on exclusion of invasive disease at colposcopy and bx.  The most widely used technique to treat CIN in the UK is diathermy loop excision (LLETZ).

Following treatment (i.e. LLETZ) I would inform the lady that she may have some browny, bloodstained discharge for a couple of weeks.  I would also advise on precautions to minimise infection, including avoidance of tampons for 4/52, avoidance of SI for 4/52 and avoidance of swimming for 2/52.  I would also inform of a possible  temporary change in her menstrual pattern, which may be associated with increased bleeding and pain.  I would also discuss the small increased risk of PTL in pregnancy, but without any increase in perinatal mortality.

If colposcopy is –ve for CIN, I would repeat a smear in 6/12.  If dyskariosis and HPV status persists I would discuss treatment at that stage (i.e. LLETZ).

Please post the model answers for thes essay questions.

regards

shabana

Thanks  for  the  suggestions .  For  HPV  essay  regarding  the  second  part  kindly  give  your  suggetions  please.

                                                                    S.Gouthaman

indication of CS in HIV

i) with HAART more than 400 copies /ml (NICE 2011 guideline on CS)

ii) wit HAART/ART more than 50 copies/ml (HIV in pregnancy GTG guideline)

Consider either vaginal birth or CS for women on ART with viral loads between 50-400 copies/ml (NICE 2011 CS)

What levels we have to quote in exam as there are discrepancies in 2 guideline.

2) there is no difference in following for VB/CS:(NICE 2011 CS)

i) uterine rupture

ii) neonatal repiratory morbidity

iii) HIE

iv) injury to bladder/ureter

when such diff are given in thte old guideline, and i could not get why there are no differences.

Please make it clear

Sir  thanks  for  the  suggestions. I  have  rewritten  the  first  part .Kindly  give  your  suggestions

High  risk  HPV  is  associated  with  95%  of  cervical  cancers.Presence  of  HPV  increases  the risk  of  CIN  and  its  absence  indicates  virtually  no  risk  of  CIN  at  that  time.In  the  cervical  screening  programme  HPV  testing  is  used  for  triaging  mild  ,borderline  smears.It  is  also  used  as  test  of  cure  after  treatement  of CIN 1,2,3. IN  HPV triaging  of  mild ,borderline  smears  if  HPV  is  negative  routine  recall  once  in  3years  or  5  years  as  per  age  is  suggested. This  reduces  the  number  of  recalls  as in  routine  screening  programme  3  negative  smears  at  6 months  interval  is  needed  for  mild, borderline  smears  before  retuning  to  routine  recall.One  more  advantage  of  triaging  is  it  helps  in reducing  the  default  rate.If  HPV  positive  colposcopic  referral  is  indicated. Though  it  increases  referral  to  colposcopy,it  allows  for  earlier  detection  of  high  grade CIN  and  treatement.This  reduces  the  progression  to  invasive  lesions  .It  is  costeffective .In  test  of  cure  after  treatment  of  CIN  lesions  cytology  and  HPV  testing  is  done.If  normal,mild,borderline  smear  and HPV  negative  recall is  done  at  3 years  only.Absence of HPV  indicates  cure  because  of  its  high  negative  predictive  value.This  again  reduces  the  number  of  recalls  and  costeffective. If  HPV  positive  it  indicates  absence  of  cure  and  requires  further  colposcopic  assessment.

a.       Explore the specific reason of maternal request of caesarean section. Counsel her sensitively and inform her about the benefit of planned vaginal birth and risks associated with caesarean section. Good communication between woman and health professional should be there, enabling her to make an informed decision. Provide evidence based information leaflets tailored to the needs of woman. Explain her that if there is no absolute indication for CS then planned vaginal birth is most suitable for her. If she is concerned about pain during vaginal birth, inform her about availability of epidural analgesia in labour.

Elective CS increases the maternal and neonatal morbidity. Chances of postpartum veno-thromboembolism are significantly higher with CS as compared to vaginal birth. Transient tachypnea of newborn and respiratory complications are more in babies born by CS. Admission in NICU is more in these groups of babies. Post operative respiratory discomfort is more in mother due to pain in wound of caesarean scar. Convalescence is delayed and return to normal routine activities takes time with caesarean section as compared to vaginal birth. There is requirement of blood transfusion with caesarean section,and readmission to hospital,often.Furthermore there are always risk of surgery, such as damage to bowel,ureter and bladder and risks of anaesthesia  with caesarean section, which are not so with planned vaginal birth. Discuss implication of CS on future pregnancies  that risk of repeat caesarean section in future pregnancies is very common and  risk of uterine  scar rupture is there with VBAC. There are chances of placenta previa,accreta in future pregnancies with previous caesarean section.Furthermore experience of normal labour prepares the newborn for forthcoming life. If  she has anxiety about vaginal childbirth refer her for counselling from a health professional with expertise in perinatal  mental health support with access to planned place of birth.

b.      Counsel her so that she is able to make an informed decision. For healthy uncomplicated pregnancy, homebirth can be opted, but this is usually associated with inadvertent complications like neonatal compromise,PPH. Sufficient transit time is required to transfer her to maternity unit, if such complication arises during labour. Although with home birth chances of vaginal delivery increases. For such females delivery in midwifery unit is most suitable. The delivery takes place under supervision of specialist midwife. Channels are always open for any suggestion from consultant obstetrician. In case of any inadvertent complication like PPH, fetal distress, umbilical cord prolapse, there is a provision to transfer her to consultant- led unit. Availability of electronic fetal monitoring is there, so any fetal distress would be diagnosed at earliest and necessary intervention could be taken.

Furthermore, delivery in consultant led unit for uncomplicated primigravida is not required, as it unnecessarily increases the burden over unit.

Provide information leaflet to her and contact of support groups. 

Dr.Paul

Please give your valuable suggestion for this answer.

Hi Paul . Would you kindly give us a sketch on how to  approach this question ie maternal request counselling, as it seems to be a probable.

A)    NHS Cervical screening programme is to detect pre-invasive lesions of cervix and cervical intraepithelial neoplasia/ cervical cancer.Liquid based cytology has been approved to be used in UK in NHSCSP,since 2008. It has better sensitivity and specificity as compared to conventional papanicolaou smear. It has additional advantage that HPV testing can be done in this sample by Hybrid- capture DNA testing.HPV 16 and 18 are responsible for 75-80 % of cervical cancers worldwide. Primary screening by HPV testing generally detects > 90 % of cases of CIN 2/3 and cervical cancer.HPV testing increase the sensitivity of Liquid based cytology by 25% but specificity is decreased by 6%. The smears which are diagnosed as borderline or mild dyskaryosis, on cytology;after HPV testing, if positive, can be ascertained if they need to be referred to colposcopy. Thus management has improved and detection rate of abnormal smears has improved with HPV testing.HPV testing has twin advantage of better negative predictive value so allow longer screening interval and automated platform to optimise throughput. Further specificity can be improved by addition of HPV typing i.e detection of viral P16 antigen and mRNA coding for E6, E7 viral proteins. 

B)    The smear if shows mild dyskaryosis  and positive for high risk HPV , should be referred for colposcopy. She enters in 62 day pathway of Cancer Reform Strategy. She should be examined by lead colposcopist within eight week of referral. Reasons for delay in examination should be documented. If colposcopy suggests normal or low grade findings, she is at low risk of developing cancer. No treatment is required then and patient has to follow up for repeat cytology after 6 months, till cytological regression occurs or treatment is undertaken. If repeat cytology comes negative then return her to routine call and recall system of repeat smear at duration of 3 years as per her age of 32 years. If repeat cytology suggests borderline nuclear changes, repeat cytology at 12 months. If repeat cytology suggests mild dyskaryosis or worse, with HPV positive; she has to be treated. Treatment should be carried out in well equipped and staffed clinic. Consent either verbal or written must be recorded. Colposcopic assessment is must prior to treatment.Treatment  include cold knife conisation or cryo- cautery by double freeze thaw freeze technique as lower incidence of residual disease is there, with it. Other modalities are LLETZ , laser ablation, laser conisation and cold coagulation. All treatment must be documented. After treatment of mild dyskaryosis proper follow up is required for 2 years. Follow up for repeat cytology at 6, 12 and 24 months. If these 3 consecutive smears report normal, then return her to routine recall system of 3 years duration as per her age of 32 years. If still mild, moderate or severe dyskaryosis reported, refer her for coploscopy and a biopsy is warranted, then.

Dear Paul,

Kindly provide your valuable suggestion for this answer.

Sir.

Kindly check my answer on HPV screening.

Sir.

Kindly check my answer on HPV screening.