TEALE FENNING Medical Education    FAQ   Search   Memberlist   Usergroups   Register   Profile   Log in to check your private messages   Log in  mrcog courses for doctors Decoding the question: Sickle cell disease          TEALE FENNING Forum Index -> MRCOG Part 2: Short Answer Essays View previous topic :: View next topic   Author Message Xerxes I Century Club Joined: 01 Mar 2007 Posts: 228 Location: Winchester Posted: Sat Feb 02, 2008 5:57 pm    Post subject: Decoding the question: Sickle cell disease I am struggling to understand what is expected in some Essay questions. An example is the sickle cell question in the mock exam (January 08 EWT) Jamaican lady with SCA referred for pre-pregnancy counselling. what are the maternal issues? (9) What risks are there for the fetus? How would you modify her care in any subsequent pregnancy? The second question is clear. The third question would have been clear if the first one wasn't there. I don't understand the first question. Looking at the scheme, for the first question we have: Recognise it is a high risk pregnancy (Shouldn't it go under 3?) assess severity if maternal disease. (fair enough) Explain the effect of pregnancy on disease (totally agree) Explain the effect of disease on pregnancy (should it not go under 3 too?) I basically messed this one up but mainly because of knowledge gap and also because I put lots of pregnancy management stuff under q1. but even after seeing the scheme, I don't think I will be clear what's meant to go where in the exam. Or the other one, Stillbirth... It says what investigations would you do. Ok, investigation is investigation but in the absence of any question regarding history and PhE before it, should we not talk about asking what happened, did she have a RTA? started to bleed a few days ago, offensive DC decreased FM, Hx of prev .. would it not affect the tests we do? If we know she had severe PET and severe IUGR or if we know that she had SROM for few weeks and offecsive DC since then, would a karyotype still be indicated? Back to top salihabduallah Century Club Joined: 04 Sep 2007 Posts: 120 Posted: Sun Feb 03, 2008 8:16 am    Post subject: what are the maternal issues? (9) - no IDA - risk of crisies , occlusive one,with infection and dehydration - increase risk of pregnancy loss, preterm labour - increase risk of early PIH and pre-eclamps. - Special care during labour and anaesthesia - MDT including heamatologist can oyu complete the marking system pls? Back to top pathi Joined: 22 Jan 2008 Posts: 3 Posted: Sun Feb 03, 2008 9:40 am    Post subject: SCA question I had the same problem but... retrospectively when I exclude the b & c answers then (a) is asking about assessment ! (I think) pathi Back to top salihabduallah Century Club Joined: 04 Sep 2007 Posts: 120 Posted: Mon Feb 04, 2008 8:22 pm    Post subject: Fetal : - IUGR -still birth -inheretence -SGA -prematurity Back to top Bryony Joined: 28 Jan 2008 Posts: 14 Location: london Posted: Tue Feb 05, 2008 1:02 pm    Post subject: Lots of sympathy - I found the essays tricky. I now think that maybe the difference between the sections could be that in the first and second parts it is what the actual risks to the mother and fetus are. The third part explain how would you manage those risks ie what tests, FBC/serial growth US... etc you would do and how often? I don't know if I am right! Any one else have suggestions? Back to top rpwalavalkar Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 973 Posted: Tue Feb 05, 2008 7:22 pm    Post subject: was the question phrased exactly like this? Quote: Jamaican lady with SCA referred for pre-pregnancy counselling. what are the maternal issues? (9) What risks are there for the fetus? How would you modify her care in any subsequent pregnancy? how the question is worded will change how you'll deal with each stem, also mark weightage will decide what to include where. stem 2 nad 3 are easy. with maternal issues --- state of disease. how this changes with pregnancy any additional risks etc. i.e. how pregnancy affects disease stem 2 - i would include how disease affects pregnancy and how that will affect the fetus. stem 3 -- pre preg precautions/changes, what you'll do different to a normal preg, include antenatal, intra partum, post partum, contraception, and any other points to consider. that's how i'd handle it. nick, is that how the marking scheme was? _________________ Dr Miss. Raj Walavalkar MBBS MRCOG TealeFenning Administrator SR O&G Wessex Region Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1862 Location: Nottingham Posted: Wed Feb 06, 2008 9:02 am    Post subject: Raj and Bryony are right between them ... Bryony wrote: I now think that maybe the difference between the sections could be that in the first and second parts it is what the actual risks to the mother and fetus are. The third part explain how would you manage those risks ie what tests, FBC/serial growth US... etc you would do and how often? This is spot on. Let's look at the question again. Jamaican lady with SCA referred for pre-pregnancy counselling. What are the maternal issues? (9) What risks are there for the fetus? (?marks) How would you modify her care in any subsequent pregnancy? (? marks) Firstly, we need the exact question and breakdown of marks. I have this at home. The first and second stem are the same but split into mum and baby. However, the first part does require assessment (well done pathi ) of the woman hence the term 'issues'. What are the maternal issues? Effect of pregnancy on sickle cell disease - crises, longterm etc but most importantly 1% chance of death (I told you never to omit mortality when you can get it into your essasy) Effect of disease on maternal aspects of pregnancy - APH ? Increased - PET - intervention Fertility - she is not pregnant!! These are all dependent on the severity of her disease and any drug treatment which you need to establish by taking a history, examining her, and doing a few tests i.e. assessment! What risks are there for the fetus? Effect of disease on fetal aspects of pregnancy - inheritance (discuss with numbers outlining the different risks according to zygosity) - anomalies - miscarriage - PTD / PPROM - IUGR - stillbirth - fetal distress - neonatal issues How would you modify her care in any subsequent pregnancy? This is the easy part. Go step by step through pregnancy beginning with pre-pregnancy advice as follows: pre-pregnancy - fertility treatment, Rubella, folate, partner, disease stabilisation, contraception until stable, no drugs or monotherapy where possible, drug changes if necesssary TM1 - early referral 3ry centre, discuss karyotyping with details about each method and the associated risks, discuss TOP for a condition the parents have and if this is acceptable to them, TM2 - detailed scan, continue folate throughout TM3 - see every 2-4 weeks as required, more if unstable etc, serial USS every 4 weeks from 24 weeks and more if IUGR, admit and agressively treat any crises (you know how to do this), avoid infection / pain / hypoxia etc PET screening limited use Labour - ? induce, limit pain, epidural good idea therefore, CS only if indicated Post-partum - BF not CI, contraception - parenteral progesterone best Important negatives - no role for prophylactic exchange transfusion (1 mark!) General (your GAP points ) - MDT approach, patient involvement, counselling, support, 3ry centre, pt awareness of risks and sigsn and symptoms There's more but that is my basic overview in 6-8 minutes of planning / bubbling. It is easy really To be honest all of you that have attended the Essay Writing Technique Course should be able to do this. All I have done is gone through the schemes / approaches we gave you for a medical disorder in pregnancy question. You may not believe me but go through your books and see what you do not have that I have just put down. Even the breakdown of each section is covered. If you are still struggling or you missed the course come in 2 weeks for the Essay Practice Course. This is exactly what we do. We bubble 30-40 essays like these in this format but obviously more accurately and with detailed marking schemes. All of the questions are in the new RCOG style so you can get this division of questions sorted before the big day. It's great fun and is always one of best received courses. Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1862 Location: Nottingham Posted: Wed Feb 06, 2008 9:07 am    Post subject: salihabduallah wrote: what are the maternal issues? You included ... Quote: increase risk of pregnancy loss, preterm labour This is a fetal issue Quote: MDT including heamatologist This is under management i.e. section 3 although liaison with the physician will be important in your assessment of disease severity. Remember, NO MARKS if you get things in the wrong places Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1862 Location: Nottingham Posted: Wed Feb 06, 2008 9:10 am    Post subject: Re: Decoding the question Xerxes I wrote: Recognise it is a high risk pregnancy (Shouldn't it go under 3?) yes but no harm in having this statement in both parts. Have it as a statement in section 1 and in section 3 act on it i.e. 3ry referal and MDT care required. Xerxes I wrote: Explain the effect of disease on pregnancy (should it not go under 3 too?) No - section 1. You then discuss how you modify her care because of this. All they are doing is frocing you to justify your actions, which as we discussed on the Course, is essential 100% of the time in 100% of the essays and, if we are honest, for the rest of your working life!! Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1862 Location: Nottingham Posted: Wed Feb 06, 2008 9:12 am    Post subject: Oops - just realised this is one of our questions! I thought it was a RCOG one. Teach me to read the question Cannot remember that the marking was - how did I do? 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