Adrenal Disease and Pregnancy

This blogpost is about the Adrenal Disease and Pregnancy. The points have been taken from a TOG article which was published in October 2021. The article covers this topic quite comprehensively. It is recommended to read the original article for complete understanding of this important exam topic. I hope you find this post helpful. 

To download the original article: Click Here

To access ALL TOGs List: Click Here

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Introduction

• Adrenal disease in pregnancy is rare
• Challenging to diagnose
• Associated with ↑ adverse outcomes for both mother & fetus
• Timely diagnosis & MDT involvement are essential to manage these high risk pregnancies

Major Adrenal Disorders

• Primary Adrenocortical Insufficiency (Addisons’s Disease)
• Cushing’s Syndrome
• Primary Aldosteronism (PA)
• Congenital Hyperplasia (CAH)
• Pheochromocytoma & Paraganglioma (PPGL)

Primary Adrenocortical Insufficiency (Addisons’s Disease)

Adrenal insufficiency (AI) classified → primary, secondary & tertiary

Primary Insufficiency in Pregnancy

• Uncommon 1 in 3000 to 5.5 in 100 000 pregnancies
• Results due to adrenocortical disease
• Both Glucocorticoid (GC) & Mineralocorticoid (MC) deficiency 
• 70-90% due to autoimmune atrophy of adrenal gland

Secondary Insufficiency  associated with ACTH secretion disorders mainly cortisol deficiency 

Tertiary Insufficiency  associated with CRH secretion disorders mainly cortisol deficiency 

Cortisol during pregnancy 

• ↑ Levels Both free & total cortisol
• Peaks at 26th weeks
• Diurnal rhythmic variation is maintained

Ref: TOG

Diagnosis

• Females with Primary AI → lower fertility rates
• Most diagnosed before pregnancy & are already on GC & MC
• Challenging to diagnose for the 1st time in pregnancy as overlap of physiological symptoms of pregnancy 
• Highly Suggestive Features → hyperpigmentation on mucous membranes, extensor surfaces & non exposed regions

Short Synacthen stimulation Test

• Non-pregnant → diagnosis likely if morning cortisol <140 nmol/L along with ↑ ACTH
• Pregnant → this cut-off not reliable as most women have values >555 nmol/L in 2nd /3rd tri
• Offer treatment if indeterminate SST & retest after delivery

Salivary free cortisol 

In pregnancy → consistent, generalisable & rationale measure of adrenal function

Consent Advice: Risk Figures Compilation

This post is the collection of all RCOG Consent Advice Papers. These papers are very important from an exam point of view and these numbers are to be memorized by heart. As these questions are very straightforward forward and it is easy to score. The only way to memorize these is to revise as much as possible.

• To date, RCOG has published 14 consent advice papers. To download papers: Click Here 
• All RCOG consent advice papers follow a standard for presenting information on risk, which is given below
• For most of the procedures, Consent Form 1 is used except for Amniocentesis for which Consent Form 3 is used
• Before taking consent, it is a good idea to be familiar with the basics of Consent. This blog post Medical Law & Ethics might be helpful in this regard.
• I have compiled this information in the form of tables and tried to give risks in different forms (percentages/fractions) as the same fact can be tested in different ways
• I hope you find this post helpful. Suggestions to improve future posts are welcome

Thanks

Presenting Information on risk

Term	Equivalent numerical ratio	Colloquial equivalent
Very common	1/1 to 1/10	A person in family
Common	1/10 to 1/100	A person in street
Uncommon	1/100 to 1/1000	A person in village
Rare	1/1000 to 1/10 000	A person in small town
Very rare	Less than 1/10 000	A person in large town

Consent Advice #1 Diagnostic Hysteroscopy Under GA 

Serious Risks
Overall	2:1000 or 1:500 or 0.2% (uncommon)
Damage to uterus	Uncommon
Damage to bowel, bladder or major blood vessels	Rare
Failure to gain entry	Uncommon
Infertility	Rare
Death	3-8/100 000 Very rare
Frequent Risks	Infection Bleeding

Consent Advice #2 Diagnostic Laparoscopy

Starting Point for MRCOG Part 2

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This blog post is especially for those who are at the very beginning of their preparation for MRCOG part 2. If you have already decided to go 4 MRCOG and want to start off your journey towards your goal, then this post might be useful.

You will find many great pieces of advice about exam preparation on the internet. I have tried to provide an outline for the exam and an essential reading materials list so that you will have an idea of what to collect and how to start the preparation. Please keep in mind that the information given in this post is not ultimate & comprehensive. You must add more to it whenever you come across relevant stuff.

Starting Point 

The starting point for your preparation is to spend some time on the MRCOG part 2 section on the  RCOG website. Most of the information I am about to share is taken and summarised from the RCOG website.

MRCOG part 2 is a written exam that assesses basic clinical knowledge and its application at a level of UK ST5 trainee in obstetrics & gynaecology as defined in the RCOG curriculum.

You need to plan well ahead of time as you are required to fulfil some prerequisites before you can sit for the exam. There is a time limit and frame to take the exam after part 1. (Please visit the RCOG website for updated information)

Assessment of training

From August 2019, the Assessment of Training (AoT) will be a requirement for entry to the Part 3 MRCOG exam.

Candidates will no longer need to complete AoT before taking Part 2 MRCOG exam.

For the latest updates, kindly visit the following links:

AoT RCOG 

AoT FAQ

Exam Calendar

MROCG Part 2 is conducted two times per year in January & July at various locations across the globe.

Exam Format 

A computer-based written exam consisting of two papers covering different modules.

MRCPI Preparation Advice — Dr Saba Ansari

This post is about the MRCPI exam preparation. I would like to thank Dr. Saba Ansari (MRCPI, Dip MIS, FCPS) for taking out time from her very busy schedule to write this advice. She has done this exam in recent past and has very vast work experience in Pakistan as well as in UAE.

I had been getting quite a few queries for this particular exam. In my opinion, its always best to seek and follow advice from someone who has gone through the similar process. Dr Saba has very kindly agreed to provide further help if anyone needs it. You can leave your query in comments or can directly contact on her e-mail provided at the end of this post —  Thanks Rubab

MRCPI Preparation Advice

MRCPI (Obstetrics & Gynaecology)

Membership of the Royal College of Physicians of Ireland (MRCPI) is an internationally recognized qualification, well accepted by healthcare employers worldwide

In Ireland, passing MRCPI enables you to enter Higher Specialist Training

MRCPI is achieved through examination

All the up to date information is available on RCPI website. You must go through it when deciding to go for the exam. RCPI Ob/Gyn

Entry Requirements

• There is NO part one for MRCPI Ob/Gyn
• For MRCPI Part II Written, one must have one of the following qualifications:

MRCOG Part Two: 3 Ws & General Advice

This blog post is aimed to explore the 3 Ws of the MRCOG part 2 exam. It may ease your journey to get through this tedious and nerve-wracking exam. The first thing before embarking upon this journey is to know your 3 Ws.

Why do you want to take it?

What is the right way to prepare for it & What to study?

When is the right time to take it?

I hope if you keep reading this blog till the end you might clarify these Ws.

WHY DO YOU WANT TO TAKE IT?

This is the answer which has to come from YOU. You need to decide and know your WHY. Here I can help you decide by quoting just one sentence from RCOG website “MRCOG: A global exam. The Gold Standard Qualification in O&G”

WHAT IS THE RIGHT WAY TO PREPARE FOR IT & WHAT TO STUDY?

This is a long answer and I will try to explore this step by step.

Understand the exam:

The first step is to understand what is this exam all about and what is expected from you in MRCOG part 2 exam. It is to demonstrate that your knowledge is of a level of “Competent ST5 according to RCOG curriculum”. Visit the RCOG website and go through the MRCOG part 2 section in detail. It clearly mentioned the format of the exam, syllabus, modules tested and details of all topics in each module. Most of the candidates keep asking What to study? So RCOG website is the best and most authentic source to answer this. Do not forget it's a UK-based exam and you need to prepare according to that standard, regardless of your job status in practical life. For example, you might be working as a senior consultant in your workplace, but you need to think & act like ST5 for this exam. It is essential to understand how things work in the UK system being an overseas candidate is not an acceptable excuse.

Plan the exam:

Once you decide to sit for the exam, you need to plan well ahead of time with adequate preparation. It is generally recommended that if you are sitting for the first time, at least 6 months of dedicated study time are required and if it is your second attempt onwards, then 3-4 months are adequate. In my opinion, it all depends on your personal & professional circumstances. So there is no hard and fast rule. All you need to keep in mind is that MRCOG part 2 requires sheer hard work, serious commitment and an in-depth understanding of Ob/Gynae. This has to come from self-motivation and persistence to achieve your goal. You can seek guidance from others but all the hard work has to be ultimately done by you. 

The approach of the preparation:

You must decide your approach towards the exam. This is a fast-paced world of internet & technology. First, you need to decide whether you prefer to study in hard form or soft form, how well-versed you are with the latest technology and how much are you willing to invest in the latest gadgets. I suggest that for this exam it is a MUST to be updated in the required knowledge which is only possible if you are familiar with the proper and positive use of your smartphones & tablets (as almost all of us have it these days). Look at those gadgets with a new vision and as a potential source of your success. You do not need flagship devices but you must analyse what's best for you and how you can take maximum benefit from whatever device you have. This is the single most important change you will need to adapt in your approach towards the exam. Late Steve Jobs (CEO of Apple) played a very important role in my MRCOG journey :)

Gather the reading material: