Candidate’s instructions
Ms Cropper, aged 40 years, and her partner have come to the antenatal clinic to discuss their Down’s syndrome screening and CVS results. They had expected to see the consultant but he has been called away and you are left to counsel this couple who have been waiting at least 1 hour. At this station you are asked to counsel the couple and discuss the further management of this pregnancy.
The results of the quadruple test and the subsequent scan and chorionic villous sampling are as follows:
Neural tube defect and Down’s syndrome screening (Ms CROPPER,
**SCREEN POSITIVE** at 16 weeks’ gestation
aged 40)
Increased risk of Down’s syndrome of 1 in 50 (background risk 1 in 100) Anomaly scan at 17 weeks
No obvious fetal anomalies
CVS result
Abnormal – trisomy 21
YOU WILL BE AWARDED MARKS FOR:
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Explaining the diagnosis and implications
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Further management and appropriate counselling
129
CIRCUIT B
Role-player’s instructions
You are a professional unmarried couple and this is your first pregnancy. Ms Cropper is a 40-year-old teacher. You had expected to see the consultant to discuss the Down’s syndrome screening and are disgruntled at the length of wait and the apparently casual attitude of the staff you have come across to date. You eventually get to see the registrar (the candidate) who should introduce himself/herself. If not, ask the candidate exactly who they are and what is their level of experience.
You are not convinced of the result as the couple who had the chorionic villous sampling before you looked ‘far more likely to have a Down’s syndrome baby than us’ (your words) – could the results have been mixed up?
The candidate should explore the results with you and the reason for having the screening in the first place, i.e. your age risk. All the results point to the diagnosis being correct. The options that you want to discuss are termination and what it involves, and the possibility of continuing the pregnancy. The candidate should offer to arrange a paediatric consultation for you but you should not lead the candidate in this particular area.
You are naturally upset and concerned about the possibility of future pregnancies and how, if you have a termination, you are going to cope with it mentally and how much time will you need off work.
130
DOWN’S SYNDROME
Mark sheet
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Explains diagnosis
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Apologizes for delay
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Explains the results, avoiding jargon
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Answers questions sensitively and without interrupting 0
1
2
3
4
5
6
Further management
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Explains the reason for the test in the first place was age-related
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Offers options of termination or continuing pregnancy
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If continuing pregnancy, offers paediatric consultation
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Explains termination
– cervagem
– mifepristone
– extra-amniotic
– risk of ERPC
– postmortem may be useful
0
1
2
3
4
5
Appropriate counselling
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Gives them option to come back after a time to think it over
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Counselling after TOP before and after
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Follow-up and trying for another pregnancy
0
1
2
3
4
5
Global score
0
1
2
3
4
Totaclass="underline"
/20
131
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Circuit B, Station 9
Ectopic pregnancy – explain laparoscopy
Candidate’s instructions
The casualty officer initially referred the patient you are about to see. You have already seen Angela Benham (who is a Jehovah’s Witness) in the accident and emergency department with vaginal spotting and severe left iliac fossa pain, which had been present for 6 hours. She is otherwise fit and well. She has had unprotected intercourse and her last menstrual period was 7 weeks ago. You suspected an ectopic pregnancy. The pregnancy test is positive and the ultrasound scan now shows an empty uterus.
You feel she needs a laparoscopy in the first instance. Explain the suspected diagnosis and the proposed management to Ms Benham.
MARKS WILL BE AWARDED FOR:
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Explaining the diagnosis
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Discussing treatment options
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Identifying and answering patient’s concerns
You have 14 minutes.
133
CIRCUIT B
Role-player’s instructions
You are Angela Benham, a 28-year-old woman who works as a personal assistant.
You have been trying to get pregnant over the past 6–12 months. You have presented with some vaginal bleeding and quite severe pain in the left lower quadrant of your abdomen. You have already done a home pregnancy test, which was positive. You have had a vaginal scan, which was uncomfortable, and are waiting for the registrar to talk to you about the results.
He/she is going to tell you that the pregnancy is in the tube and that you will need a laparoscopy (telescope) into the abdomen and may need some other form of surgery. You have no idea about your reproductive anatomy and must get him to explain in layman’s terms. As he continues you realize that you have lost the pregnancy whatever happens and you get very emotional about it. You are also worried about future fertility and contraception.
You are a Jehovah’s Witness and are adamant about no blood products.
Questions you may ask
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‘Why is it not in the uterus?’
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‘Can’t it be moved into the uterus?’
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‘Can I go and see my GP to discuss it’
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‘I need to talk to my husband’
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Are there any drugs that can be used to salvage the pregnancy?’
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Ask about future fertility, as you have been trying for 6–12 months to get pregnant
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‘What are the risks of it happening again?’
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‘I don’t want a hysterectomy’
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‘Are you going to kill my baby and what is going to happen to it?’
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‘Are you telling me I am going to have an abortion?’
134
ECTOPIC PREGNANCY – EXPLAIN LAPAROSCOPY
Mark sheet
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Explains the diagnosis of tubal pregnancy correctly, i.e. 7 weeks amenorrhoea, positive pregnancy test and empty uterus on scan
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Acknowledges pregnancy loss/bereavement aspect
0
1
2
3
4
Management
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Explains urgency of the situation
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Explains proposed management laparoscopy (possible laparotomy)
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Explains salpingostomy/salpingectomy (RCOG guidelines)
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Explains the procedures of the above
0
1
2
3
4
Discusses future fertility
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Ovarian function
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Risk of a further ectopic
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Discusses future types of contraception
0
1
2
3
4
Deals with JW aspect
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Talks about the possibility of large blood loss
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Needs to test for blood group and risk of isoimmunization
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Possible autotransfusion
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Discusses patient signing a separate consent form 0
1
2
3
4
Global score
0
1
2
3