SPIKES protocol for delivering serious news to patients includes:
– Set the stage includes arranging for a private, comfortable setting space, introduce patient/family & team members, maintain eye contact & sit at the same level and schedule appropriate time interval & minimize space for interruptions.
– Perception: Use open-ended questions to assess the patient’s/family’s perception of the medical situation.
– Invitation: should ask patient/family how much information they would like to know and remain cognizant of their cultural, educational & religious issues.
– Knowledge:
Warn the patient/family that serious news is coming, Speak in simple & straightforward terms, stop & check whether they are understanding.
– Empathy: Express understanding & give support when responding to emotions
– Summary & strategy: Summarize & create follow-through plan, including end-of-life discussions if applicable.

The ultrasound findings of severe growth restriction, bilateral choroid plexus cysts, clenched fists, and a large ventricular septal defect are consistent with trisomy 18, the second most common autosomal trisomy, which results in fetal loss or neonatal death in the majority of cases.  In this case, the physician is to deliver a very serious news to the patient who is presenting for a routine visit, believing her pregnancy was normal.  When serious news is unexpected, it is especially important to prepare the patient and determine how the patient would like to receive the results.
The physician is supposed to provide a comfortable setting and must ask patient’s permission to share the results. This allows the patient to respond with her preference and avoids making assumptions about whom, if anyone, she would like to be present with.  For example, some patients may prefer to defer discussion of the results until a major support person (eg, husband, mother) is present. In addition to establish patient’s preferred setting, physician should determine how much information the patient would like to receive. Some patients will prefer a detailed medical information about diagnosis and prognosis, whereas others may prefer to have time to process the news emotionally and receive further information later.  The SPIKES protocol (Setting the stage, Perception, Invitation, Knowledge, Empathy, and Summary/strategy) is a six-step model that can guide physicians in delivering serious news to patients.

These statements do not allow the patient to choose how she receives the results and assume that she does not want her mother present.

This statement fails to prepare the patient for serious news and prematurely jumps to sharing results using technical, medical terminology that may be difficult for the patient to comprehend. This approach could also be upsetting to a patient undergoing a routine ultrasound who is not expecting anything abnormal.

This statement inappropriately determines when and with whom the patient should receive the results. Instead the patient should be asked how she prefers to receive the results.

While delivering unexpected, serious news, physicians should prepare the patient and determine how the patient prefers to receive the information.

Primary hyperparathyroidism is the most common cause of hypercalcaemia with incidence rates in the UK approximately 30 per 100,000 The majority of patients are postmenopausal women.

Rubella virus is the only member of the genus Rubivirus and is a type of Togavirus (Togaviridae). It is a single stranded RNA virus. Note for the exam if you are unsure – most RNA viruses encountered in clinical practice are single stranded. The exception is rotavirus which is dsRNA virus. RNA viruses that use DNA during their replication are classed as retroviruses (HIV is an example)

Lichen sclerosus is characterized by hypopigmented atrophic plaque in the perineal region along with features of pruritis and dyspareunia.
It is more common in post menopausal women and on histology there is epidermal atrophy, inflammatory infiltrate in the dermis and basal layer degeneration.

Vitiligo is characterised by hypopigmentation but without any other symptoms.
Extramammary Paget’s disease is characterized by erythematous plaque located mostly in the perianal region but its histology is different.
Lichen simplex chronicus is a chronic scaly pruritic condition characterized by itchy papules and plaques plus lichenification and it mostly results from chronic irritation and itching of the area.

Elevated fasting plasma glucose means gestational diabetes mellitus and is not considered to be in the spectrum of a normal pregnancy. In normal pregnancy however, maternal tissues become progressively insensitive to insulin. This is believed to be caused partly by hormones from the placenta and partly by other obesity and pregnancy related factors that are not fully understood. Gestational diabetes mellitus (GDM) occurs in about 5% of pregnancies but figures vary considerably depending upon the criteria used and demographic characteristics of the population.

The pelvic outlet is bounded anteriorly by the inferior border of the pubic arch, posteriorly by the sacrotuberous ligament and the tip of the coccyx and laterally by the ischial tuberosities.

Screening for gestational diabetes should be offered and performed between 24-28 weeks. It should be noted PCOS alone does not make screening essential. It is advised for PCOS patients who are overweight or if not overweight but has other risk factors (age >40, personal history of gestational diabetes or family history of type II diabetes). Screening is via a 2-hour post 75 g oral glucose tolerance test.

Uncontrolled endometrial proliferation due to excess and unregulated estrogen is the reason for intermenstrual bleeding and irregular menses along with abnormal uterine bleeding (AUB) in this patient. The condition is mostly associated with an increased risk of endometrial hyperplasia
ancer.
The absolute risk of endometrial hyperplasia
ancer is very low in women aged <45, therefore they can be started on combination medication with estrogen/progestin contraception (ie, medical management) without the evaluation of endometrium.  The estrogen component of medication regulates the menstrual cycle by build up the endometrium; whereas the progestin component helps in shedding of the endometrium.
However, patients who have continued irregular menstrual bleeding even while on combination contraceptives require further evaluation as they have failed to improve with medical management. In such patients, the endometrial lining will be too thick for the progestin to completely shed during menstruation and this unshed endometrium continues to undergo dysregulated proliferation, leading to an increased risk of endometrial hyperplasia
ancer. Therefore, patients age below 45 with AUB who have failed medical management require an endometrial biopsy.
AUB persistent above 6 months, obesity, and/or tamoxifen therapy are the other indications for endometrial biopsy in women age <45, as all of these will increase the amount of unopposed endometrial estrogen exposure. In patients with heavy menstrual bleeding and anemia, coagulation studies are performed to evaluate for bleeding disorders like von Willebrand disease. It is not necessary in this patient as she have a normal hemoglobin level. In patients with heavy, but regular (ovulatory) bleeding an endometrial ablation, which is a procedure used to remove the excess endometrium, can be considered as the treatment option. Endometrial ablation is contraindicated in undiagnosed cases of AUB as it prevents evaluation of the endometrium in patients with possible endometrial hyperplasia
ancer.

To check for abnormalities of the uterus like didelphys or of the Fallopian tube like scarring, a hysterosalpingogram is used but it is not useful to evaluate AUB. In addition, as the procedure could spread cancerous endometrial cells into the abdominal cavity, hysterosalpingogram is contraindicated in cases of undiagnosed AUB.

To evaluate secondary amenorrhea, ie. absence of menses for >6 months in a patient with previously irregular menses, a progesterone withdrawal test is used to determine whether amenorrhea is from low estrogen level, in negative cases there will be no bleeding after progesterone. This test is not indicated or relevant in this case as patient had continued bleeding while on oral contraceptives suggestive of high estrogen levels.

Evaluation for endometrial hyperplasia
ancer with an endometrial biopsy is required for those women age <45 with abnormal uterine bleeding who have failed medical management with oral contraceptives.

COCP’s act both centrally and peripherally. They inhibit ovulation. Both oestrogen and progestogen supress the release of FSH and LH hence preventing ovulation. Peripherally it acts by making the endometrium atrophic and hostile towards implantation. It also alters the cervical mucus and prevents the sperm from ascending the uterine cavity.

This woman at her 37 weeks of gestation, has developed multiple herpetic lesions over her genitals. In every case were the mother develops herpes simplex infection after 28 weeks of pregnancy, chances for intrapartum and vertical transmission of the infection to the neonate is considered to be very high.

Risk factors of intrapartum herpes simplex infection of the child includes premature labour, premature rupture of membrane, primary herpes simplex infection and multiple lesion in the genital area.

The most appropriate methods for managing this case includes:
– checking for herpes simplex infection using PCR testing of a cervical swab.
– starting prophylactic antiviral therapy for the mother from 38 weeks of gestation until delivery.
– preferring a cesarean section delivery if there are active lesions present in the cervix and/or vulva.

Cesarean delivery is advised in this case along with maternal antiviral therapy before delivery to minimise the risk of vertical transmission.