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OSCE question 1. |
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This topic comes up frequently in the exam, either as a written station or as a viva. It could easily be converted into a roleplay.
1. What
is the diagnosis?
| Recurrent miscarriage. Definition: three or more consecutive miscarriages. |
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2. What information would you accept as confirmation of the diagnosis?
| Scan evidence of pregnancy or histological confirmation of products of conception. +ve b-HCG. I would miss out a positive home test result, though the kits are fairly accurate. |
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3. List four causes of recurrent miscarriage.
| Uterine anomaly, intra-uterine adhesions (Ascherman's syndrome), parental chromosome abnormality - balanced translocation, SLE, anti-phospholipid syndrome, excessive LH secretion - poly-cystic ovary syndrome, luteal phase deficiency, smoking. TORCH infections cause "one off" miscarriages, but are not a cause of recurrent miscarriage. Nonetheless, because most hospitals include screening for such infections in their protocols for the investigation of recurrent miscarriage, the answer has been accepted. Similarly, sub-clinical hypo-thyroidism probably does not cause miscarriage, but has been deemed an acceptable answer. Poorly controlled diabetes also features, though one would hope that it would be sorted out before the problem becomes recurrent. |
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4. List four tests that you would arrange.
| Tests of uterine anomaly: hysterosalpingogram, hysteroscopy, ultrasound. Hysteroscopy for Ascherman's syndrome. Parental chromosomes. Screening for SLE & anti-phospholipid syndrome. LH:FSH ratio for PCOS. TORCH screen. Thyroid function tests. Assessment of diabetic control. |
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5. If all the investigations are normal, what is the chance of the next pregnancy being successful?
< 30%; 30 - 50 %; >50%.
| >50 %. Surprisingly, the figure is up to 70%. |
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6.
What advice would you give the patient if all of the tests are normal?
| Check rubella & chickenpox immunity. Advise about general health, weight, diet, smoking & alcohol. Specific health advice - e.g. hypertension, diabetes, epilepsy. Specific advice if there is congenital abnormality or hereditary disease in the family. Possibly refer for a genetic opinion. Advise about pregnancy complications if she has had problems with a previous pregnancy, e.g. hypertension, pre-maturity or Caesarean section. Advise about folic acid. To get on with pregnancy if all is well. Ask if she has any questions. The way the exam is marked, you will only be expected to come up with one or two of the above, not the whole litany. However, an OSCE. question could well be devoted to pre-pregnancy counselling. |
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