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Answers to questions for volume 8, number 4

Acute colonic pseudo-obstruction after caesarean section

Regarding acute colonic pseudo-obstruction (ACPO),

1 it is correlated with the indication for caesarean section rather than the caesarean section itself. False 2 parasympathetic overactivity of the autonomic nervous system of the bowel is thought to be the possible aetiology. True 3 it is a recognised cause of maternal mortality in the UK. True 4 cardiac arrhythmia due to electrolyte imbalance is the main cause of death. False 5 the mortality rate is 35–45 per 1000 if there is perforation or necrosis of the bowel. False 6 its true incidence is not known. True Discussion In obstetrics ACPO has been reported most commonly after a caesarean section, but there does not seem to be any correlation between ACPO and the indication for caesarean section. The exact pathophysiology is not clearly understood, but it is most likely to involve an imbalance between the sympathetic and parasympathetic colonic innervation. In the last Confidential Enquiry into Maternal Deaths in the UK17 four maternal deaths were reported. There is a mortality rate of 36–50% where there is perforation or ischaemia of the bowel. The true incidence of the condition is unknown, as many mild cases resolve spontaneously.

With regard to the diagnosis of ACPO,

7 a plain abdominal radiograph shows multiple fluid levels with a classical ‘stepladder’ pattern. False 8 it is potentially dangerous to carry out an X-ray contrast enema examination. False 9 distension and tenderness in the right iliac fossa indicate impending caecal rupture. True Discussion A plain abdominal X-ray should be taken, as this will typically show large bowel dilatation, particularly in the caecum, which tails off at the splenic flexure or rectosigmoid.

Predisposing conditions for ACPO include

10 benign gynaecological conditions such as large fibroids and endometriosis. False 11 delivery by caesarean section. True 12 severe pre-existing systemic illness. True 13 acute abdominal trauma with intraperitoneal haemorrhage. True Discussion ACPO has also been described after vaginal delivery,8 forceps delivery11 and caesarean hysterectomy,12 during pregnancy with preterm labour and pre-eclampsia, and in multiple pregnancies.13–15

With regard to medical treatment of APCO,

14 sympathomimetic drugs are the first choice. False 15 if there is no response within three hours, decompression should be considered. True 16 its value has not been proven by randomised controlled trials. True 17 active bronchospasm is a contraindication. True Discussion Neostigmine, a parasympathomimetic drug, is the only pharmaceutical agent shown to have consistently positive results.23–29 A recent double-blind, placebo-controlled trial27 has shown promising results, but the study is too small to be significant for the risk of colonic perforation and mortality. Women with active bronchospasm requiring treatment are not considered suitable for medical treatment.27

With regard to surgical treatment of ACPO,

18 conservative management by colonoscopic decompression is successful in up to 50% of women. False 19 caecostomy is indicated if there is tenderness in the right lower quadrant. False 20 it may lead to recurrence in a subsequent pregnancy. False Discussion A success rate for colonic decompression of between 61–78% has been reported in a series with more than 20 cases.20 Open surgery is mandatory when perforation or ischaemia are suspected. At present there are insufficient data to comment on or predict any recurrence of the condition in future pregnancies and childbirth.

A clinical approach to the management of thrombosis in obstetrics. Part 1: screening and prophylaxis of venous thromboembolism

With regard to the use of low molecular weight heparins in pregnancy,

21 they are associated with fewer haemorrhagic complications than unfractionated heparins. True 22 the risk of osteoporosis is similar to that with unfractionated heparins. False 23 the activated partial thromboplastin time (aPTT) provides an accurate means of assessing their antithrombotic activity. False 24 the complication of heparin induced thrombocytopenia is less likely than with unfractionated heparins. True 25 their anticoagulant action is monitored using the International Normalized Ratio (INR). False 26 they can be given indefinitely as they do not cross the placenta. False Discussion Low molecular weight heparins have potential advantages over unfractionated heparin in pregnancy: they are likely to be associated with a lower risk of heparin induced osteoporosis21 and are less likely to cause heparin induced thrombocytopenia. The data regarding the need for monitoring anti-factor Xa in pregnant women receiving lower dose low molecular weight heparin for prophylaxis are conflicting. Experience indicates that, provided that the woman has normal renal function, monitoring of anti-Xa levels is not required.

During the postnatal period,

27 breastfeeding predisposes to deep vein thrombosis. False 28 puerperal infections increase the risk of thromboembolism. True Discussion Severe infection is a risk factor associated with venous thromboembolism (VTE).

During pregnancy,

29 there is an imbalance between the thrombolytic and the fibrinolytic systems. True 30 an increased level of antithrombin III is associated with an increased risk of thrombosis. False 31 thrombophilia is associated with an increased incidence of pregnancy loss. True Discussion Thrombotic processes may be involved in recurrent pregnancy loss, pre-eclampsia, intrauterine growth restriction and placental abruption by impairment of placental infusion.9

The following factors increase the risk of venous thromboembolism in women:

32 The use of gonadotrophin stimulation in assisted conception treatments. True 33 Excessive vomiting in pregnancy. True Discussion Complications of pregnancy, such as hyperemesis gravidarum, increase the risk.

The risk of DVT,

34 is highest in the immediate postpartum period. False Discussion The risk of deep vein thrombosis is highest in the antenatal period, with as many as 16–33% occurring in the first trimester.1,8

With regard to the use of low molecular weight heparins in pregnancy,

35 they should be given antenatally to women who have a history of a single VTE following surgery. False Discussion Women with a single prior VTE related to a non-recurring (temporary) risk factor, such as recent major surgery, trauma, or immobilisation, are at low risk of recurrence during pregnancy.

The risk of venous thromboembolism in pregnancy,

36 is approximately 1 in 1000 in the general population. True 37 is approximately 1 in 100 following caesarean section. True

With regard to the use of low molecular weight heparins in pregnancy,

38 a baseline reference platelet count should be taken before administering them to a woman with severe liver disease. False 39 low dose aspirin is contra-indicated as adjuvant therapy. False Discussion Severe liver disease is a contraindication to heparin treatment. At the Seventh American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic and Thrombolytic Therapy21 it was suggested that low dose aspirin (75–162 mg/day) might be added to women deemed to be at high thromboembolic risk.

During pregnancy

40 all women with a history of DVT or thrombophilia should be advised to wear thromboembolic stockings throughout. True Discussion The British Society for Haematology guidelines15 recommend that all women with a previous history of VTE or thrombophilia should be encouraged to wear compression stockings throughout pregnancy and for 6–12 weeks postpartum.

Is ultrasound safe?

With regard to types of ultrasound,

41 B-mode ultrasound is an oscillating wave of alternating pressure. True 42 Doppler produces a fixed ultrasound beam. True 43 each piece of ultrasound equipment has a fixed acoustic output. False 44 acoustic power output is at its highest in three-dimensional scanning. False Discussion The acoustic power of an ultrasound scanner depends on various operator-controlled parameters, including focus, pressure, intensity, scan depth, mode and transducer characteristics. The risk of bioeffects from three-dimensional ultrasound is similar to that from regular B-mode, which appears to be safe for all stages of pregnancy.

With regard to the thermal effects of ultrasound,

45 these are more hazardous when there is maternal sepsis. True 46 they are most detrimental in the third trimester. False 47 neural tube defects are a recognised consequence. True 48 self-heating of probes is most likely to occur with the use of endoprobes. True 49 the fetal temperature is up to 1°C lower than the maternal temperature. False 50 a temperature rise of 1.5°C is not detrimental to fetal health. True Discussion The fetal temperature is known to be about 0.5–1.0°C higher than the maternal temperature,3,13,14 therefore, caution is warranted in a febrile mother. Thermal effects are relevant in first trimester scanning, where there is a smaller cushioning effect from maternal tissues. Self-heating of the transducer in faulty equipment is more likely to occur with endoprobes. Temperature elevations of less than 1.5°C present no hazard to a human embryo or fetus, even if maintained indefinitely.3

Regarding the mechanical effects of ultrasound,

51 cavitation refers to the activity of gas bubbles in an acoustic field. True 52 haemorrhages in fetal lungs, intestines and kidneys have been confirmed in human studies. False 53 non thermal bioeffects are at their highest in neonatal lung. True Discussion Evidence collated from animal studies and human fetal erythrocytes in vitro21 shows that ultrasound can result in red cell lysis and in the presence of contrast agents this effect can be exacerbated. However, the fact that the fetus is engulfed in fluid should, theorectically, spare it from cavitation injury. Tissues containing gas pockets are vulnerable to cavitation injury.

With regard to safety indices,

54 the thermal index (TI) is a measure of the radiation hazard from ultrasound. False 55 the mechanical index (MI) measures acoustic streaming. False 56 the MI is directly proportional to frequency. False 57 the TI is dependent on the acoustic power of the ultrasound machine. True 58 the MI should be lower than 2.5. False Discussion The thermal index is an indicator of the temperature elevation possible at a particular equipment setting. The mechanical index is an indicator of the likelihood of cavitation events and is inversely proportional to the frequency. For general use the mechanical index should be less than 1.9.31

Regarding the long-term adverse effects of ultrasound,

59 the prevalence of left-handedness is significantly higher in children who have been screened antenatally using ultrasound. False 60 an increased incidence of acute lymphatic leukaemia has been confirmed in children exposed to more than four ultrasound examinations in utero. False Discussion There is a paucity of controlled studies on adverse ultrasound effects. On follow-up, some studies have reported a significant increase of non right-handedness in boys exposed to ultrasound in utero.41–44 In a meta-analysis of epidemiological studies on ultrasound exposure, Salvesan and Eik-Nes45 concluded that there was no association between diagnostic ultrasound exposure during pregnancy and reduced birthweight, childhood malignancies or neurological development. This was later endorsed in a safety tutorial issued by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB).44

Use of the new progestogens in contraception and gynaecology

With regard to progestogens,

61 nomegestrol and nestorone are the two with the greatest progestational activity. False 62 cyproterone acetate is the most anti-androgenic. True 63 drospirenone is the only synthetic progestogen with anti-mineralocorticoid activity. False 64 generations of different progestogens are classified according to their chemical composition. False 65 drospirenone has approximately a quarter of the anti-androgenic potency of cyproterone acetate. False 66 etonogestrel is metabolised to 3-keto-desogestrel. False 67 there is robust evidence to support their use in the treatment of premenstrual syndrome. False Discussion Trimegestone and nestorone are thought to have the most progestational activity to date. Progesterone and drospirenone have anti-mineralocorticoid activity, with gestodene and trimegestone having a weak effect. It is preferable to classify progestogens according to their biochemical families. Drospirenone has about a third of the anti-androgenic potency of cyproterone acetate. Recent meta-analyses do not recommend the use of progesterone or progestogens (old or new) in the management of premenstrual syndrome.18

With regard to combined oral contraceptive pills,

68 most modern ones contain mestranol. False 69 most have been shown to reduce acne. True 70 those containing 35 µg ethinylestradiol/2mg cyproterone acetate produce a similar improvement in acne to those containing 30 µg ethinylestradiol/dienogest or drospirenone. True Discussion Ethinylestradiol has replaced mestranol as the standard estrogen component in modern combined oral contraceptive pills.

With regard to nestorone,

71 it is active when given transdermally. True 72 a vaginal ring releasing 15 µg ethinylestradiol/150 µg nestorone is equally acceptable as the NuvaRing®. False Discussion There have been no studies comparing the new vaginal ring containing 15 µg ethinylestradiol/150 µg nestorone with the NuvaRing®.

A contraceptive implant

73 containing nomegestrol acetate needs to be replaced annually. True 74 containing nestorone is to be marketed soon in the UK. False

With regard to contraceptive implants,

75 a single-rod implant containing nomegestrol acetate is well accepted by users. True

With regard to hormonal therapy,

76 reducing the pill-free interval helps relieve severe premenstrual symptoms in some women. True

With regard to the new progestogens,

77 they are more effective in regulating menstrual disorders than norethisterone. False 78 dienogest is an effective adjuvant treatment for endometriosis following conservative surgery if given weekly. False Discussion There is no evidence that the new progestogens are more effective in regulating menstrual bleeding. Some recent research has suggested that 1 mg of dienogest daily is as effective as 3.75 mg triptorelin given intramuscularly every 4 weeks over a 16-week period following surgical treatment of endometriosis.17

Preparations of hormone replacement therapy

79 containing nomegestrol acetate fail to control menopausal symptoms. False 80 containing drospirenone have a small positive effect on blood pressure. True Discussion Transdermal HRT preparations containing nomegestrol acetate effectively control vasomotor symptoms.

Young people and the Fraser guidelines: confidentiality and consent

Under the Sexual Offences Act 2003,

81 the age of consent to heterosexual activity is 16 years in England, Wales and Scotland. True 82 the age of consent to homosexual activity is 18 years in England, Wales and Scotland. False 83 if two teenagers aged 15 years of age have consensual intercourse it should be reported to the police. False 84 it is against the law for two 15-year-olds to kiss. True 85 if someone is found to have had intercourse with a 12-year-old, they can automatically be charged with rape, even if the 12-year-old agreed to it. True 86 if a 16-year-old girl has intercourse with a 15-year-old boy, it is the girl who is considered to have committed an offence. True 87 forced penetration of the mouth by a penis is classified as rape. True Discussion In England, Wales and Scotland the age of consent to any form of sexual activity is 16 years for males and females. The Crown Prosecution Service and Department of Health have indicated that there is little to be gained by prosecuting mutually agreed underage sex, even though it is strictly illegal. If an individual has intercourse with a child under 13 years of age they can automatically be charged with rape. If an individual over 16 years of age has sexual activity with someone under 16, it is the older individual who commits an offence.

With regard to issues of consent to medical intervention in minors,

88 a 14-year-old girl can consent to have an abortion without informing her parents. True 89 a sister aged over 18 years can sign the consent form for an abortion for a 14-year-old. False 90 if a teenager requesting an abortion is ‘Fraser competent’ the doctor can require that one of their parents signs the consent form to ensure the teenager has social support. False 91 they do not have the right to absolute confidentiality in receiving health care. True 92 children have less of a right to confidentiality than adults. False 93 a doctor cannot prescribe the combined oral contraceptive pill to a 12-year-old without informing her parents. False 94 a 15-year-old girl requesting the combined oral contraceptive pill must demonstrate that she understands all the complications of taking it before it can be given. False 95 only a doctor can assess Fraser ruling competence. False 96 if Fraser ruling competence criteria are met, a young girl is likely to be safe from abuse in her relationship. False Discussion Children of all ages can sign their own consent forms, provided they can demonstrate Fraser ruling competence. If a minor is not deemed Fraser competent, only someone with parental responsibility or a court of law can sign on their behalf. If a girl requesting an abortion is Fraser competent and does not want her parents to be involved, the clinician must respect her wishes. Any professional working with young people, including nurses and youth workers, can assess Fraser ruling competence. However, ascertainment of such competence is no reflection of whether a minor is at risk of exploitation.

With regard to teenagers,

97 about one in 10 has had sexual intercourse by the age of 16 years. False Discussion About 25% of teenagers in the UK have had sexual intercourse by the age of 16 years.1

Regarding child sexual abuse,

98 approximately one in 10 young people has been the subject of sexual abuse. True 99 the majority of adolescents who are being sexually abused will have abnormal findings on examination. False 100 a diagnosis of sexual abuse is likely to be made on the history alone. True Discussion Most adolescents who have been sexually abused show no physical signs, especially if they have been otherwise sexually active.

Patient confidentiality in STIs: current guidance and legal issues

If a patient is receiving treatment at a genitourinary medicine clinic,

101 it is their responsibility for arranging the necessary after care, as GPs are not involved. False 102 staff are able to share information about them through a network of health advisors. True Discussion It is accepted practice that a patient's general practitioner may not be routinely informed when they attend a clinic.5 The treating clinician has the responsibility for providing and arranging the necessary after care.

The following statements about the legal position of doctors are true:

103 They cannot be held liable for onward transmission of HIV by a patient. False 104 They are bound by a legal duty to protect patient confidentiality which cannot be breached under any circumstances. False Discussion Although no case has been brought to a court in the UK, there have been a few cases in the USA, Australia and Canada where a doctor has been held liable for the onward transmission of HIV by a patient.11 The General Medical Council (GMC) guidance on serious communicable diseases3 states: ‘You may disclose information about a patient, whether living or dead, in order to protect a person from risk of death or serious harm’.

With regard to the legal position of health workers,

105 patients must be made aware that personal information about them may need to be shared within the health care team. True 106 other health care professionals may need to be informed about patients with serious communicable diseases for the protection of staff. True 107 information can be disclosed to a known sexual contact of a patient with HIV if there is reason to believe that the patient has not informed them and cannot be persuaded to do so. True Discussion It is the duty of the clinician to ensure that patients are aware that information may be shared within the health care team to provide for their care.

Regarding HIV positive women,

108 during pregnancy, joint consultation with both partners leads to lesser acceptance and a higher rate of abandonment of women. False Discussion Studies have shown that it leads to a greater acceptance and less abandonment, and that it promotes reduction of mother–child transmission.21

According to guidance from the GMC,

109 when a health care worker is diagnosed with HIV, their employing health authority must always be informed. False Discussion According to the guidance, the employing health authority need to be informed if the health care worker ‘is practising, or has practised, in a way which places patients at risk’.

After the death of a patient with an STI,

110 a doctor must consider whether this will benefit the patient's family before disclosing confidential information. True

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