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RANZCOG oral > 2024 Oral Prep > Flashcards

2024 Oral Prep Flashcards

1
Q

Hx of SLE +/- VTE - pre-con/antenatal

A
  • HR preg/MDI - MFM/Obs Med/Haem
  • R4U = lupus flare/lupus nephritis/VTE/PET
  • R4B = FGR/PTB/SB/NL
  • med safety + contraception till MDT
  • FBE/UEC/uPCR/anti-DS DNA/C3/4 as baseline + aPL
  • recheck every trimester + aPLs
  • LDA+Ca from 12/40 till 37/40 (+/- LMWH if VTE)
  • regular ANC w BP + urine dipstick at each visit
  • anti-Ro/La antibody +/- Fetal echo weekly 16-26/40
  • 4 weekly serial G/S from 28/40

mtx/myco/cyclopho = unsafe
**hydroxy/aza/pred/cyclosporine=safe
**VTE Hx - Haem rv LMWH + LDA

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2
Q

Prednisolone use in pregnancy

A

early OGTT
tertiary morph (early exposure teratogenic risk)
intrapartum hydrocortisone

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3
Q

Anti Ro/La+’ve on screen on bkg of SLE
FHR50s on fetal echo

(encounter 2)

A

HE - FM/RTS/CTG

  • baby has NL is at risk of congenital heart block that can result HF/SB
  • refer to MFM for opinion and rv
  • in the absence of hydrops, can consider
    1. dex or IVIG until end of preg
    2. close monitoring with fetal echo/biometry scans
  • with worsening CHB (e.g. complete block) + hydrops - need emCS (can’t CEFM)
  • paeds rv +/- steroid +/- mgso4
  • alert paed cardiology

*anti-Ro/La +’ve, usually weekly foetal echo from 18-26 weeks

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4
Q

APLs on screen on bkg of SLE

A

R2U - PET/VTE
R2B - FGR/SB
Haem advice
LDA + Ca +/- LMWH
2 weekly serial G/S

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5
Q

Hx of T1DM/Renal transplant pre-con/antenatal
+/- insulin pump
+/- immunosuppressed
+/- retinopathy

A

High risk preg require MDI from MFM/Obs Med/Nephro/Transplant
R2U - hypo/DKA/worsen existing cx/graft failure/rejection/PET/emCS/injury
R2B - MC/congenital abn/FGR/LGA/PTB/SB
Medications are…need MD clinic +…contraception till MDT rv
Baseline bloods/urine check end-organ dysfunction FBE/UEC/HbA1c + MSU + uPCR
Diet/Monitor/Med compliance/LDA+Ca/4wkly MSU/UEC/HR ANC BP/urine/opthal rv
Tertiary morph +/- echo/serial 4wkly G/S/

statin/acei/cyclopho/myco/bisphosphonate = unsafe
cyclosporin/tac/aza = safe
*acute rejection rate is lower if transplant >12/12
**don’t forget extras if on pred
**CMV reactivation risk

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6
Q

N&V + Abdo pain + low UOP on bkg of renal transplant
+/- borderline BP +/- high Cr/uPCR etc…

(encounter 2-3)

A

HE - fever/chills/suprapubic pain/HA/visual/BP

  • I’m concerned about acute renal failure
  • FBE/UEC/LFT/CRP/uPCR to check renal function/exclude infection/PET
  • MSU to exclude UTI
  • Renal tract USS to exclude obstruction
  • Formal Obs USS +/- CTG to check growth & wellbeing
  • IVC + IDC - strict FB
  • Refer to MFM/Obs med/Nephrology team rv
  • Depending on results - expedite delivery or continue pregnancy

Expedite
- No reversible cause to treat/clinical deterioration
- Paeds rv +/- steroid +/- MgSo4
- Consent for emergency CS +/- classical with Tx team on standby

Continue pregnancy.
- Identify and treat reversible cause (e.g. abx-UTI, pred-rejection)
- monitor for improvement in renal function/UOP
- OP F/U to recheck renal function/resolution

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7
Q

nausea + vomitting
abdo pain on bkg of T1DM

(encounter 2)

A

Hx/Exam
- PO intake/fever/chills/diarrhea/sick contact
- compliance with insulin/monitoring
- vitals/BSL/ketones/CTG

I’m concerned about DKA which has many triggers
infection/starvation/insulin compliance/pump failure
DKA pose sig M&M for mum/baby - PTB/SB

  • FBE/UEC/CMP/LFT/CRP - ?infection/electrolyte derangement
  • MSU MCS - exclude UTI
  • CTG and Obstetric USS to check fetal wellbeing
  • Treatment in ICU - IVT + K correction then insulin infusion
  • Identify and treat reversible condition (e.g. UTI)
  • Consider expediting delivery if deteriorate paeds rv +/- steroid +/- MgSo4
  • If stable, improving, DC home, OPC F/U + serial G/S
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8
Q
  • 24/40 EFW5% NAFID on bkg of T1DM/renal transplant
  • 25/40 EFW5% AFI5 on bkg of T1DM/SLE
  • 23/40 EFW5% NAFID on bkg min antenatal care
  • 28/40 EFW5% AC3% raised UPAI, reduced MCA PSV - hx of IUGR

(encounter 2-3)

A

HE
- LMP vs dating (? wrong dates) - how reliable
- FM/APH…/PET sx/aneuploidy/morph/vitals/BP

  • EOIUGR - likely PI on bkg of medical condition (asymmetrical)
  • +/- screen for PET or use PET risk predicting markers if BP normal
  • +/-TORCH +/- amnio to exclude infection/aneuploidy (symmetrical)
  • d/w MFM/admit/steroid/paeds/wkly doppler/+CTG/2 wkly scan
  • monitor for PET (BP/urine dip)
  • aim for 37/40/MOD individualized

*if AEDF - consider 2nd daily dopplers…

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9
Q

results of rpt doppler of EOIUGR show
- AEDF or REDF
- decreased MCA PI

A
  • placental insufficiency -> hypoxia -> brain sparing
  • timing/mod individualized
  • discuss with MFM

*absent or raised DV indicates cardiovascular instability, sign of impending acidemia and death

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10
Q

HPV16/18 + LSIL on smear during pregnancy
On immunosuppression for T1DM/Renal transplant

A
  • HR HPV/LR pre-cancer change
  • Ref to Dysplasia -> colposcopy to exclude overt malignancy
  • colp safe in preg/no bx unless ?invasive disease
  • recheck 3/12 postpartum-ovestin if breast feeding

*indication for Colp in pregnancy
- HPV 16/18 irrespective of LBC -> Colp
- HPV Non16/18 pHSIL/HSIL/glandular lesion ->Colp
- Non16/18 –‘ve LBC/pLSIL/LSIL ->CST 12/12

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11
Q
  • PI on bkg of dyspareunia/dysmeno
  • PI on bkg of PCOS/high BMI
  • PI on bkg of bilateral nipple DC
    (encounter 1)
A

DDx
- ovulatory - PCOS/2ndary ameno
- transport - PID/Stenosis/Endometriosis
- implant - Fibroid/Asherman’s/Septum

HE
- HA/visual/menstrual/OGHx/PHx/Surg/SHx/vitals/BMI/breast/spec…
- rv separate - male - age/job/PHx

+/- bHCG
- D2-3 FSH/E2/mid-luteal phase P4/TFT/Prl/AMH
- pelvic USS - AFC/structural anomalies
+/- SBHG + T + FAI + DHEAS + 17OH (if clinical hyperT)
+/- OGTT/HbA1c (if PCOS suspected)
- Rub/HIV/HCV/HBV/syphilis serology
- FBE+/-Thal/G&S/MCS - MSU
- Semen analysis

Interim Mx
- await Ix result - f/u visit to discuss
+/- bring partner to review
- supplements/social teratogens

  • PCOS/Infertility, preconception health + LS mod before offering OI
    ***2ndary ameno = absence of menses for > 3 cycle intervals, or 6 consecutive months, in a previously menstruating woman
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12
Q

primary infertility investigation
all normal except high prolactin level

(encounter 2)

A

HE - nipple dc/ha/visual field

  • repeat prolactin
  • organize MRB
  • f/U to review result
    +/- refer to endocrinologist +/- neurosurg

(prl still high, MRB showed microadenoma)
- benign tumor
- r2u - expansion/compression/reduced ovulation/infertility
- r2b - no impact on baby
- preg possible post treatment, cease during preg, monitor sx in preg, nil CI to BF
- use contraception during treatment/serum prl 1mo post rx then 12/12 post+MRB
- dopamine agonist (bromocriptine)/transphenoid surgery
- may need ovulation induction if cycle remains irregular

dopamine agonist can be used in preg if concern of tumor expansion/monitor sx +/- MRB, req MFM/Obs Med input
**risk of expansion in preg higher with macroprolactinoma
**don’t repeat prolactin in pregnancy
**cease dopamine agonist if breast feeding

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13
Q

PI bkg of PCOS/high BMI
LS modified, weight lost
still not pregnant

(encounter 2)

A

? change in Hx/Exam

OI Mx options
- 1st line = Letrozole vs Clomiphene + Metformin
- 2nd line = Gonadotropin (FSH) + USS monitor vs Ovarian drilling
- 3rd line = IVF

Risks
- OHSS/Multiple pregnancy (less so for letrozole)

Plan
- D1 menses bHCG
- D3-7 Letrozole 2.5mg/Clomid 50mg
- D10-12 TV USS to check for dominant follicle
- D10-20 IC alt day
- D21 P4
- Menses (if not do bHCG)

*letrozole is 1st line but still off-label
**Clomid sx - hot flushes/abdo discomfort

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14
Q

OI with clomiphene, follicle tracking showed multiple dominant follicles, dominant being 17-27mm, what now (encounter 3)

A

Dx
- multiple dominant follicles increase risk of multiple preg if IC
- risk to you include GDM/PET/operative delivery
- risk to baby include PTB/FGR/SB

Mx
- abstain from IC or use barrier contraception
- try letrozole for OI next cycle

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15
Q

Abdopain days post egg collection
Abdopain days post embryo transfer

A

HE
- F&C/U&B/SOB/vitals/cardioresp/abdopelvic - fluid shift/girth/peritonism
- RFs - Type of trigger/#Egg retrieved/type of transfer/PCOS/previous OHSS

DDx - OHSS/post procedure PID/bowel perforation/torsion/theca lutein cyst
FBE (hct)/UEC/LFT/Coag/bHCG
TV USS (ov size/ascites) +/- CXR

NBM whilst investigating
Admit/observe/RBU team rv +/- Resp
Analgesia/antiemetic
Drink to thirst +/- crystalloid/colloid
Daily weighs/abdo girth
VTE prophylaxis/Daily bloods
Feedback to fertility specialist
F/U with fertility specialist +/- dating scan

*mx of theca lutein cyst (excess bHCG - hyperplasia of theca interna cells) is essentially analgesia/antiemetic and observe +/- aspiration/pelvic USS to check for resolution/monitor for sx of torsion

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16
Q

dyspareunia/dysmeno
PI bloods/SA = NAD

(encounter 2)

A

? any change in hx/exam

Dx
- Bloods excludes ovulatory cause of PI
- History suggestive of endometriosis
- Endometriosis can result in anatomical distortion -> infertility
- Imaging such as HSG and HyCoSY can shed some light
- Can’t always reliably detect anatomical distortion, tubal patency, and exclude uterine anomalies (e.g. septum)

For the purpose of PI Ix, I would recommend
1. Diagnostic lap +/- rx of endometriosis w aim to restore anatomy
2. Hysteroscopy +/- polypectomy - ?fibroid/septum/remove polyp
3. Dye studies to check tubal patency

It is a day procedure, GA, General Risks - infection/bleeding/VTE/injuries… Specific risk - staged procedure…quick recovery, F/U post procedure

*endometrial biopsy is not routine infertility ix anymore!!! do a curette when there’s concern about hyperplasia/AUB…

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17
Q

PI, suspect endo
diagnostic lap
stage 4 endo/ovaries stuck on bowel
large endometrioma >4cm
tubes/uterus normal
discuss finding & ongoing mx
(encounter 2)

PI, dysmeno
suspect endo
diagnostic lap
stage 2 endo - right hydrosalpinx/endometrioma/patent left tube
rx endo = RS/right cystectomy/excision endo
histo confirmed endo
discuss findings & ongoing mx
(encounter 2)

A

Hx/Exam
- pain/bleeding/post op recovery
- vitals/scar healing

Endometrioma/hydrosalpinx/adhesion/distorted anatomy
All contribute to infertility and chronic pelvic pain

To improve fertility outcome + pain
- refer to MD Endo unit for Gynae/CR rv
- MDT for pre-op planning
- laparoscopic excision of endo/division adhesion/salpingectomy
- multi-D, GA, laparoscopy, path, follow-up
- risks include general/specific - reduce ovarian reserve/recurrence
- TCC 3-6/12, if fail then refer to CREI - IVF

Other modalities to complement surgery for pain mx if no fertility desired
- hormonal suppression with progesterone PO/Depo/Implant/IUS
- refer to pain specialist/pain psychology/PF PT

AMH should be done if planning to or post endometrioma excision
**consider CREI if reduced ovarian reserve (from endometrioma excision)+/- salpingectomy
**endometripma excision improve accesss

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18
Q

6/12 post severe endo excision
still can’t conceive, what next

(encounter 3)

A

? change in hx/exam

Mx
- Most effective form of ART for endo-related infertility is IVF
- Alt = OI alone, superovulation + IUI but limited evidence
- Refer to REI specialist for consideration of IVF
- IVF involves
1. ovarian superovulation with FSH
2. follicle tracking with TV USS/trigger/egg retrieval 38/24 post
3. fertilization/embryo culture
4. embryo transfer or embryo freezing, transfer on D3 or D5 + P4 pessary given for luteal support
- risk includes OHSS, multiple pregnancy

*trigger when follicle >18mm
**OI - also estrogen lvl tracking every 1-3 day from day 2 of cycle until HCG trigger

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19
Q

19/40 Pink PV discharge
Hx of 17/40 pregnancy loss

or

Short CL on scan 17/40 Twin preg
Hx of Cone biopsy for CIN3

or

P/w PCB around 22/40
Nil previous hx

A

HE
- trauma/F&C/U&B/STI/CST/aneuploidy/morph - plac/PHs/Surg
- vitals/abdo-uterus/spec - open/liquor

(open cervix or short cervix)

R2U - emergency delivery
R2B - PPROM/PTL/PTB/SB
Ix - FBE/CRP (exclude infection)/MSU/HVS (exclude UTI/BV - rx)/wellbeing scan
Admit/bed rest until mx plan/senior obs/paeds rv
PV P till 36/40 +/- cerclage
McDonald Cerclage multi-d/regional/non-absorbable/removal at 36/40 or if in labor/SROM
Ref to PTL clinic - surveillance/test till 26/40 +/-steroid when viable/serial 4wkly G/S

FFN indication - sx PTL btw 22-36/40, intact membrane, cervix <3cm
**FFN CI - ruptured membranes/cerclage/cervix >3cm/soap/gel/lub/disinfectant
**<10mm - consider cerclage to begin with
**pre-cerclage checklist - aneuploidy/morph/no PPROM, inserted btw 12-24/40

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20
Q

Hx of T2/3 pregnancy loss

A

high risk of recurrence
Refer to PTL clinic
PV progesterone from 16-36/40
Cervical surveillance till 26/40
Steroid loading when viable

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21
Q

Demonstrate and talk through how to perform a B-Lynch

(encounter 3)

A
  • Senior obs present
  • Use delayed absorbable (e.g. 1-0 vicryl)
  • Hysterotomy (if VD)
  • Transverse LUS (if CS)
  • ## Check cavity empty
  • exteriorize
  • start 3cm below LUS/4cm from lateral
  • enter Ut cavity, exit 3cm above
  • go over fundus from front to back
  • re-enter Ut cavity from posterior
  • exit from contralat from inside ->out
  • go over fundus from back to front
  • re-enter 3cm above LUS/4cm from lat
  • exit 3cm below
  • pull tight whilst assistant compress
  • double knot
  • LUS/Hysterotomy closure
  • continuous, 2-layer
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22
Q

PPH mx - at 1500ml after precipitate birth 37+4/40 (encounter 2)

A
  • Obs Emergency
  • Call for help - Code pink
  • Required MDI
  • x2 WB IVC - FBE/G&S/Coag - x-match
  • IVT 3L max, warm, supine
  • notify OT for EUA/activate MTP
  • Tone - fundal massage/IDC/uterotonics - ergot/carborpost/txa
  • Trauma - asx + repair
  • Tissue - check plac/membrane
  • Thrombin - anticipate DIC
  • OT for EUA + Bakri insertion
  • If high output Bakri - laparotomy -> B-lynch/Uterine art ligation/internal iliac ligation/UAE/Hysterectomy
  • ICU/HDU postop
  • debrief/Document
  • repeat FBE +/- PRBC or Fe infusion
  • OP F/U
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23
Q

vaginal DC or PVB 2/52 post hysterectomy

(encounter 2-3)

A

Hx/Exam
- pain/fever/chill/continuous/color
- vitals/abdomen/spec

Sx most likely due to vaginal cuff infection
Need to exclude vaginal cuff dehiscence/haematoma

  • FBE/CRP to exclude systemic infection
  • MCS - vault
  • CTAP to exclude hematoma

Mx
- Admit for observation
- require MDI including ID
- expectant vs active (drainage)
- IVC + IV broad spec abx (ceft/met/gent)
- BC if febrile/VTE prophylaxis
- switch to PO Abx on DC
- F/U with USS + rv in OPC

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24
Q

PMB with or w/o USS findings

(encounter 1)

A

Hx/Exam
- urinary/bowel/fever/LOW
- menarche/menopause/parity/HRT/CST/MMG/FOBT
- Phx - breast ca/tamoxifen/DM/VTE/cardioresp
- abdopelvic surgery/FHx - EOC/BC/CR ca/SHx - support/SAD
- exam - vitals/appearance/BMI/cardioresp/abdopelvic

Mx
- Most likely atrophy or polyp
- Need to exclude EH/AH/EAC/Cervical ca
- Pipelle in room if able +/- CST
- W/L HDC to sample
+/- refer for anesthetic PAC if multiple co-morbidities
- Day procedure/GA/risks include…
- F/U for path +/- referral to GONC for Ix/Rx

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25
HDC + CST for PMB Cervical stenosis False passage Procedure abandon CST = endometrial cancer (encounter 2)
Hx/Exam - postop recovery/pain/bleeding/fever/chills - vitals... - EAC cancer of uterus - 5yrs >90% if stage 1 - disease confined to uterus - more Ix required to stage disease - CA125/CXR/CTAP - refer to GONC MDT/Rv - likely need TH/BSO/SLND - pre-op need anesthetic/SPAC - ref to medics to optimise - mutli-D, GA, open or key hole, 6 week recovery, path, MDT, F/U Stage 1a – surgery alone Stage 1b -II – surgery + adjuvant radio Stage III/IV – cytoreduction vs primary CCRt Chemo = neuropathy/alopecia/infection RT = cystitis/proctitis/colitis/vaginitis
26
Recurrent PMB Hx of HDC (encounter 2)
Hx/Exam - previous HDC result/urinary/bowel/LOW - vitals/appearance/BMI/cardio-resp/abdo-pelvic Mx - need to exclude EH/AH/EAC - need to reinvestigate with - TV USS +/- TMs (CA125/LDH) - W/L for HDC to sample etc...
27
68yo, smoker HPV 16 on CST FI on PMB Counsel on mx (encounter 2)
Hx/Exam - ongoing PMB/urinary/bowel/smoking cessation attempts - previous dysplasia hx Mx - HPV16 is a high-risk HPV that increase risk for dysplasia/SCC - To exclude dysplasia/cervical ca you will need Colposcopy - Colposcopy involves ... - During colposcopy a biopsy ... bx to path, - Depending on Bx result, you may need further treatment - Will require CST again in 12mo, x2 neg then 5yrly - Smoking cessation is vital to management of HPV *younger pts - consider vaccination if not vaccinated
28
68yo Cervical adenocarcinoma on CST CTAP -> 5cm mass Offered CCRT, want to know SE of Rx (encounter 3)
Hx/Exam - any change in sx Chemo - peripheral neuropathy - numbness/tingling - ototoxicity - hearing impairment - nausea & vomiting - myelosuppression - infection - alopecia RT - urinary frequency - diarrhea/dyschezia - vaginal stenosis *younger pt - consider fertility/ovarian insufficiency - VMS/GSM/osteo, dyspareunia
29
Post TAH/BSO abdominal distension/no flatus (encounter 3)
HE - pre-op RFs/cx intra-op/PF/BS/peritonism/UOP DDx - ileus/bowel injury/intra-abdominal bleeding/urinary retention - FBE/UEC- bleeding/infection/electrolyte - AXR to exclude bowel obstruction - NBM +/- NGT + IVC + IVT + FB + anti-emetic - chew gum/VTE/ambulate - surg rv + guide diet *dilated small bowel loops + air in colon + rectum w/o transition point = ileus
30
TAH c/b bladder injury Returned to ward post discharge from hospital with IDC for mx (encounter 3) or Postop review, had emCS c/b bladder injury requiring IDC Mild ID/explanation of surgery/complications/consequences (communication) or Bladder perforation with TVT or vaginal hysterectomy Bladder perforation at TAH/BSO for AH/left ovarian mass Bladder perforation at TLH
HE - recovery course - pain/bleeding/bowel - vitals - wound check/IDC urine color Intra-op (explanation to pt) - cystoscopy - assessed the dome/trigone - UO - double layer closure - intravesical methylene blue to check leak - pelvic drain + IDC Post-op - arrange cystogram to assess for leak - discuss findings with Urology - remove IDC + formal TOV - outpatient F/U in 6/52 *cx from bladder injury - decrease bladder capacity/urgency/incontinence/fistula **intra-op with vaginal surgery: senior gyn/inform ano/call urology + cystoscopy ?trigone injury vs dome +/- removal of TVT - re-insert then re:cysto - admit/IDC/observe... ***intraperitoneal injury (e.g. trocher at TLH) - usually need open repair ****don't forget hemostasis/completion of primary operation...
31
47yo nullip sx large pelvic mass 52yo multip sx large pelvic mass (on CTAP) 30yo LAP for 2/52 (encounter 1)
HE - PVB or PMB/bloating/LOW/U&B PHx/Surg/Med/FHx - CR/EAC...SHx/BMI/vitals/abdopelvic - DDx - uterine-Fibroids/LMS/EAC/ovarian/GIT - FBE/UEC/LFT (baseline) - +/-CTAP +/- Pelvic USS (need for RMI) +/- TMs (e.g. LDH vs CA125) +/- CXR - Refer GONC MDT + Rv to plan for surgery - PAC *PHx/Surg/SHx/BMI - key to perioperative planning **Uterine - CXR cuz hematogenous spread
32
30yo P2 CTCAP show irregular mass LDH or ALP elevated 52yo GCT on histology post TAH/BSO (postmenopausal) 7yo precocious puberty - found on ix to have ovarian mass - RSO = GCT
HE - postop recovery - Dysgerminoma - germ cell cancer of ovary - GCT - stromal cell cancer of ovary - Stage 1 >90% 5yrs - GONC MDT/rv +/- RBU referral - oocyte/embryo/OTC - Surg - Dx/Stage - fertility = USO + PW +Bx of contra +/- oment +/- appendix - Path - MDT +/- adjuvant chemo (e.g BEP for OGCTs, BEP or plat/taxol for GCT) - Ongoing postop surveillance with TM (e.g. CA125, LDH, inhibin) *most pts with OGCTs p/w stage 1A disease **1A/1B dysgerm/1A immature teratoma don't req adj chemo (BEP) ***1A SCSTs (e.g. GCTs) don't req adj chemo (Plt/taxol), if fert req - HDC exclude EH/AH ****gold std any ovarian ca = TAH/BSO/PW/Omentum/Appendix/Peritoneal bx/LN *****early stage OGCTs/GCT/1A EOC/BOT - fertility spare surg possible *******stage 1a =limited to one ovary (not ruptured), 1b both ovaries, 1c, breach of capsule/surface tumour/+’ve cells in PW/ascites ********EOC will req chemo
33
Elevated TMs post fertility sparing surgery + mass on USS bkg of OGCT or SCSTs
- GONC MDT/rv - rpt imaging - CTCAP - biopsy to confirm - BEP +/- RBU - oocyte/embryo cryo/OTC - +/- TAH/BSO/resection of local deposit *recurrence of BOT is generally treated with cytoreduction **residual ovarian syndrome - a ddx, p/w asx pelvic mass post oophorectomy, also present as chronic pelvic pain, lack of menopausal sx post oophorectomy - ix include FSH/E2 + Pelvic USS, surgical excision if sx (e.g. CPP)
34
Nodule in vaginal vault post TAH/BSO for EAC
HE - previous CST result/distant met sx (cough/sob)/urinary/bowel - Locoregional recurrence of EAC - Bx/PO Abx/monitor sx +/- CA125 - GONC MDT rv of path - PET-CT - Pelvic radiation +/- Surgery
35
Cough/SOB post TAH/BSO for EAC
HE - fever/chills/haemoptysis - distant mets - FBE/CRP/ca125/CXR (exclude infective cause) - GONC MDT rv - PET-CT - chemo/immune/hormone/radiation +/- surgery
36
N&V/abdo pain post pelvic clearance for EOC
HE - anorexia/bloating/U&B sx - SBO 2nd to EOC recurrence - Admit/NBM/NGT/Gen surg + MONC rv - IVC - FBE/UEC/CMP + IVT +/- CA125 +/- MSU MCS - CTAP exclude obstruction - As per Gen Surg - expectant vs surgery (stent) vs palliation - F/U post acute episode - PET CT +/- guided biopsy -> MDT rv - EOC recurrence rx = chemo +/- secondary cytoreduction
37
Pelvic mass with each of the following   ⬆️LDH ⬆️AFP ⬆️hcg ⬆️inhibin
⬆️LDH = dysgerm ⬆️AFP=yolksac ⬆️hcg=choriocarinoma ⬆️inhibin = GCT *multiple markers +'ve - consider mixed germ cell tumor, dysgerminoma mixed with yolk sac tumour = most common, mixed tumour may secrete LHD/AFP/hCG
38
Ovarian ca staging
stage 1 local ~90% stage 2 adjacent organ-pelvis ~70% stage 3 abdo ~30% stage 4=distant mets ~15%
39
LMS on histology from TAH/BSO (encounter 2-3)
HE - postop recovery - uterine muscle cancer - prognosis poor regardless of stage - 5yrs survival - mitotic figures - poor response to chemoRT - refer to GONC - rv + MDT - likely need PET-CT to exclude mets - surveillance alone if stage I/II - possible chemoRT if stage III/IV
40
24/40, PV discharge + known short CL with cerclage (encounter 1) 26/40, PV discharge + known short CL with cerclage (encounter 1) 19/40, fluid from vagina (encounter 1)
HE - fever/chills/vitals/spec - pool/RTS - presentation Most likely PPROM need to exclude vaginal infection - Amnisure to confirm or exclude - FBE/CRP to exclude infection/as baseline - MCS - HVS/LVS + MSU to exclude treatable infection->PTL - Wellbeing scan +/- CTG - R2U chorioamniotis/endometritis/sepsis - R2B PH/Contracture/PTB - cx/SB/cord/MP - Senior obs/Paeds to discuss long term outcome - Continue preg & resuscitate vs TOP (more appropriate for extreme PPROM) - admit observe/IV/PO abx - erythro/benpen/twice wkly bloods/hvs - +/- steroid loading/paeds rv/2 wkly scans/IOL 37/40 - +/- cerclage removal -> need MgSo4 *cerclage removal - reduce infection/tear risk if TPL, reduce latency -> PTL/PTB **PPROM - liquor pooling/amnisure/continue leak/low AFI/pad check ***leave stitch in PPROM whilst steroid loading then remove
41
24/40 known PPROM + PVB 23/40 known PPROM + elevated WCC + lactate on F/U 29/40 PPROM LLP/previous CS - fever/chills
HE - pain/APH/fever/chills/vitals/uterine tender/spec-cervix/RTS or CTG Ix - FBE/CRP/BC Mx - NBM/x2 WB IVC/IVT/triple abx-amox/gent/metro - steroid/mgso4/expedite delivery - inform con/ano/paeds/cord gas - MCS plac/membrane/histology/continue abx/recurrence MOD - VD if birth imminent/no malpresentation/IOL may take too long/high mort PTB - emCS +/- classical under GA esp if compromise fetus/malpresentation
42
D0 post classical emCS ~28+/40 for evolving chorio, c/b 1.2L PPH paged to rv tachy + hypotensive + febrile + tachypneic (encounter 2)
? change in Hx/Exam - wound/peritonism/FB/UOP Dx = sepsis - most likely chorio DDx - wound/cystitis/pneumo.. Immediate mx - Obs emergency - Call for help - MET call - Activate Sepsis pathway - MDI - simultan- resus/ix/stabilisation Resus - ABC - O2/x2 WB IVC - IVT - Broad spec abx - triple Ix - FBE/UEC/LFT/CRP/Coag/BC - MCS - urine - CXR Stabilization - analgesia/antipyretic - VTE prophylaxis - chase culture - discuss mx with ID - inform paeds re: mx Ongoing mx - aperients - anemia correction - daily bloods - PPROM prevention next preg - discuss risk of recurrence
43
request for labiaplasty for appearance (communication station)
Reason/indication/evidence - double check reason for request - indication - discuss "normal" (birth/menopause) - no evidence that it will improve 1. self-image 2. sexual function Risks - risks of procedure - general/specific - scar/adhesion/permanent disfigure - dyspareunia/altered sensation Information & F/U - summary of discussion - info for reading and consideration - follow-up to discuss further - sexual health counselling (if request surgery to improve sexual function)
44
post myomectomy c/b 1.2 bleed tachy+ poor UOP + pale + abdo pain (encounter 2) post TAH, minimal UOP (encounter 2) post lap endo, no UOP (encounter 2)
Hx/Exam - operative difficulties - vitals/peritonism/IDC patency DDx - hypovolemia/bleed/ureter-bladder injury Ix - FBE to exclude anemia/bleed - UEC to exclude renal dysfunction - G&S +/- Xmatch +/- Bladder scan - CTAP +/- CT IVP - collection/ureter Results ... Initial Mx - postop emergency - care requires MDI - x2 WB IVC + IVT (fluid resus) - NBM pending ix Sheath hematoma - Return to theatre - Take down sutures - Identify source - Suture/diathermy/procoagulant - Exclude intra-abdominal source - Washout/Intra-abdominal drain Ureteric injury - Urology advice/Radiology +/- nephrostomy - consent/cystoscopy + laparotomy - Drainage of urinoma or uroperitoneum - Identify injury +/- repair Postop - recovery in HDU or ICU - IV abx + VTE prophylaxis - FBE + anemia correction - debrief/document - F/U and M&M
45
Multi fully dilated, good labor progress suspected face presentation vs Multi 4cm dilated, in labour, face + cord presentation
HE - labor progress/urine/temp (?obstructed) - VE - MA vs MP - CTG (?NRCTG)/RTS Scenario 1 - aim for VD if MA (MP = always CS) - no ventouse/avoid forceps/if req only when face cause perineum to bulge - senior obs/paeds/cord gases at birth Scenario 2 - consider emCS - based on std obs indication at first!!!! see **** - NBM/x2 WB IVC - FBE/G&S + IVT + IDC + Tocolytic + CEFM - avoid elevating PP if CTG =N -> may cause cord prolapse - senior obs/paeds/cord gases/debrief/document *try VD with brow if detected early in labor w/o obstruct, brow rarely VD, instrumental usually CI, don't augment brow - due to risk of obstruction **obstructed/NRCTG -> automatic emCS ***cord presentation -> automatic emCS ****MP can rotate to MA or vertex - monitor closely then decide CS
46
21yo G1P0 40/40 APH 200ml settled CTG normal how do you manage? (encounter 2-3, snap x plan, prioritization station)
HE - placenta location/FM/contractions/SROM/vitals - esp BP/uterus/spec/VE - I'm concerned about undiagnosed previa & abruption - if no hx, need to exclude abruption (assess RFs) - APH @ term may be a sentinel event to abruption - Most likely due to rapid cervical dilation - I would recommend IOL for term APH - IOL involves bringing labor on... - Baby will need CEFM in case of fetal distress - Youl will need IVC - FBE/G&S then synt, VE to check progress ... HMO/MW Level can get IOL started
47
Pt p/w mastitis 2/52 postpartum, how do you manage? (encounter 2-3, snap mx plan, prioritization station)
HE - pain/redness/febrile/difficulty feeding + rv of delivery complications - PVB/pain/wound/mood/vitals - temp/rash/tender/fluctuant lesion - You have an infection of the breast - Without appropriate rx, you could become septic - I recommend admission for ix/rx with MDI - Start with IVC - FBE/CRP as a baseline - Breast milk MCS - Breast USS to exclude an abscess - Commence on Fluclox + antipyretic + IVT - I will refer you to Gen Surg + LC - Inform my consultant of the plan - Encourage ambulation/VTE propnhylaxis whilst I/P HMO level can manage initially
48
40yo DUB 6/52, actively bleeding with Hb68, how do you manage? (encounter 2-3, snap mx plan, prioritization station)
DDx - rupture ectopic/menorrhagia undiagnosed condition HE - pain/bleeding/LMP/contraception/CST/previous ectopic/PHx/Surg/Med/vitals/abdo/speculum exam - Gynae emergency, need MDI - Call for help - MET call - Simultaneous resus/ix/rx - x2 WB IVC for urgent bloods - bHCG to exclude pregnancy - FBE/Coag - check level - G&S & x-match x2 units - Urgent pelvic USS +/- Pipelle +/- I/P HDC - Txa + Primolut + Mefanemic acid - NBM + IVT until investigations are complete - Await results for definitive mx plan ED/HMO level can manage resus initially
49
21yo septic, suspected PID or 14yo LAP+febrile + N&V
DDx - TOA/PID/appendicitis HE - pain/sexual hx/PID/STI/PV DC/bleeding/vitals/bimanual/spec/urine - Call for help - follow sepsis protocol - If HD unstable, call for help - x2 WB IVC for - bHCG/FBE/UEC/CRP/Lactate/BC as a baseline/check severity - Endocervical PCR for chlam/gon/Mg - Urgent pelvic USS to exclude TOA - Commence fluid resus + Triple Abx - Ceftrixaon/Metro/Azithro - Inform consultant/discuss with ID - Antipyretic/analgesia/VTE prophylaxis - Observation with clinical/biochemical improvement - Chase MC +/- contact tracing, OP Rx/F/U plan *sex with minor -> involve SW -> mandatory DHS reporting **underage don't want to disclose to parents - assess Gillick's competence/support self disclosing to guardian ***even if urine bHCG is neg - should do serum
50
Primip, 38/40 SROM - MSL, not in labor suspected IUGR (encounter 2-3, snap mx plan, prioritization station)
DDx - fetal distress/breech presentation HE - time of SROM/fever/chills/FM/APH/AN course/EFW/Dopplers - GBS status/vitals/abdo/spec + pool or amnisure/VE/RTS - MSL may be related to fetal distress or breech - CTG to exclude distress, RTS to exclude breech - Birth should be expedited -> need to start labor - IUGR babies may not tolerate labor well - need CEFM - I would recommend IOL in setting of MSL/IUGR - Risk of operative delivery is high due to above - IOL involves FW then synt +/- IAP (prolonged SROM or GBS+...) - So you need an IVC then FBE/G&S, and syn started HMO to counsel re: indication MW level can get IOL started
51
30yo G3P2 GDM, planned IOL 38/40, cervix 3cm, head 4-5/5 above, CTG normal, how do you manage? (encounter 2-3, snap mx plan, prioritization station)
DDx - poor uterine tone/undiagnosed LLP HE - placenta position/confirm presentation with RTS... - concerns is high station - risk of cord prolapse with ARM - if there's a cord prolapse, you will need an emCS - need to have a controlled ARM - i will ensure OT is available and have my consultant to support - before starting RTS to confirm presentation, IVC - FBE/G&S - to reduce the risk, start synt before hand - have you in lithotomy/bladder empty/stabilize/ARM with fundal pressure Reg/Consultant level to manage, in the setting of competing emergency, can wait as labor not started
52
35yo, 7/7 post lap+HDC FI of HMB/dysmenorrhea, histo result show clear cell EAC from bx in POD/Curettage. Otherwise fit/healthy, explain the results to her, don't need to take a hx or do exam (communication station) English speaking chinese woman, relatively isolated in Australia, nulliparous, didn't have debrief postop, recalled urgently to clinic. Opening sentence from SP "they told me this was urgent, is this about the results...
Do you have a support person with you today? I'm afraid I have some bad news to share with you today. We found cancer in the samples we took from surgery *use ASSIST model to communicate Acknowledge - this is devastating and unexpected news with life altering implications Sorry - I'm so sorry Story - allow time for pt to express thoughts/feelings Inquire - allow time for pt to ask questions, let pt lead the conversation, offer additional information not covered by pt's questions with their permission. Solution - discuss future mx plan, provide some reassurance Travel - I will organize F/U for you, refer you to Psych support, we will be here to help you through, I will provide you with our contact number, please reach out if there's anything we can help with
53
21yo, G1P0, 3/52 post MTOP at 6/40, presented for F/U with USS result showing live IUP 10+2/40, bHCG97k, S:N, R:I, FHx of T2DM, no supplements, please assess and manage. (encounter 1)
***Something didn't work - always ask about how compliance*** HE - how was MS2step taken/pain/bleeding/vitals... - MTOP has failed - The options are STOP vs continuing pregnancy - I recommend STOP as misoprostol is teratogenic in T1 - STOP is performed under GA, day procedure, quick recovery, risks are ... POC sent -------------------------------------------------------- If you want to continue the pregnancy, I would recommend - counselling by MFM team re: risk of misoprostol exposure - aneuploidy testing - early morphology - early OGTT due to FHx of T2DM - tertiary morph in the setting of misoprostol exposure in T1 - repeat OGTT at 28/40 - anti-D 28 & 34/40 gestation - vaccination whooping cough/influenza
54
21yo failed MTOP, still pregnant, with N&V 21yo confirmed IUP 14/40 w severe N&V no multiple preg or GTD on early preg scan (encounter 1-2)
DDx - HG/GTD/Multiple preg/Thyroid/Infection/Addisonian crisis HE - tolerate anything oral/weight loss/impact on life --------------------------------------------------------- - Admit for Ix/Mx - IVC for FBE/UEC/CMP/LFT/TFT - exclude infection/electrolyte/thyroid - Consider ECG if electrolyte disturbance - MSU MCS - fetal USS to check wellbeing +/- any other AN care appropriate for that gestation ----------------------------------------------------- - start with IVT + IV antiemetic to control your sx - electrolyte replacement if deranged - 1st line rx = doxylamine + pyridoxine + thiamine - 2nd line rx = ondansetron + metoclopramide (limited) - 3rdl line rx = prednisolone - none-pharm alternatives - ginger/acupressure - I will refer you to Dietician and clinical psychology for review - I will also organize for you to have IVT weekly in ambulatory clinic *Addisonian crisis presenting as severe N&V - usually have known PHx, it's an emergency, requires MDI, fluid resus, identify/rx cause (infection/dehydration/trauma)
55
21yo G1P0 19/40 clear PV dc for 2 days absent FM, left shift on bloods rhesus negative, assess and manage? (encounter 2-3) or 25/40, PPROM from 20/40 steroid loaded contracting/T37.9/HR110 breech presentation (encounter 3)
HE - pain/ever/N&V/offensive dc/PVB/vitals/uterine tender/spec... ---------------------------------------------------------------------------- Aggressive mx of sepsis (ABC) - x2 WB IVC - FBE/UEC/CRP/G&S +/- - urine/genital MCS to identify pathogenic organisms - Fluid resus with IVT + IV triple antibiotics ----------------------------------------------------------------------------- Scenario 1 - chorio -> R2U, fetus not viable -> recommend TOP by IOL Scenario 2 - chorio -> R2U/B -> Cat 1 GA/classical... ------------------------------------------------------------------------------ - placenta/membrane swabbed for MCS - placenta also for histology - I recommend: 1. postmortem to identify other issues that may have caused this 2. cabergoline for lactation suppression 3. +/- anti-D administration 4. de-escalation of IV Abx to PO when organisms isolated 5. discussion of contraception prior to DC 6. SW 7. Psychological support ------------------------------------------------------------------------------ - F/U discuss recurrence/ strategies (e.g. cervical surveillance, lifestyle modification - smoking cessation...)
56
10/40, RHD + Mod AS on TTE + NYHAII 24/40, RHD + Mod MS on TTE + SOBOE Hx of rheumatic fever as a child (encounter 1)
HE - SOB/ortho/lethargy/murmurs - RHD -> heart dmg - risk to you AF/VTE/APO - risk to baby PTB/FGR - ref to MFM/Obs Med +/- TTE to check function - B-blocker/abx prophylaxis/TTE each trimester +/- LMWH if mechanical valve - Tertiary morph/4 weekly G/S from 28/40 - IOL from 39/40 - VD if NYHA I-II, CS if NYHA III-IV - CEFM/Telemetry - epi/strict FB/short 2nd - active 3rd/PPH avoid ergot - HDU care post/strict FB/monitor APO
57
Uterine inversion (encounter 2)
- Obs emergency - Call for help - MDI for simult resus/ix/rx - Follow principles of ABC For resus - Oxygen/x2 WB IVC - FBE/G&S/Coag - X-match PRBC - Fluid resus and consider activate MTP - IDC insertion/track EBL For inversion mx - discontinue any uterotonics until replacement - manual reduction by Johnson's maneuver - hand in vagina and push the fundus towards umbilicus - other hand stabilize uterus externally - if successful, give uterotonics (avoid ergot in setting of RHD) - attempt MROP in OT possibly followed by Bakri insertion ---------------------------------------------------------------------------------------- - if unsuccessful, use GTN in OT before 2nd attempt under GA - then surgical correction via laparotomy - Huntington's procedure or Haultain's procedure, if all fail then hysterectomy ---------------------------------------------------------------------------------------- - alternative is O'Sullivan's maneuver hydrostatic reduction if failed 1st line and don't have access to OT - laparotomy ---------------------------------------------------------------------------------- Post Mx - Abx prophylaxis/Bakri removal/HDU por ICU/VTE prophylaxis/debrief/document/RHD postpartum care
58
Describe the surgical mx of uterine inversion (encounter 2-3)
Huntington procedure - pulling on round ligament with assistant pushing on fundus from inside the vagina Haultain procedure - 1.5cm incision to posterior surface of uterus to release the constriction ring then manually reduce uterine inversion - then interrupted sutures
59
Describe O'Sullivan's maneuver (encounter 2-3)
- reverse Trendelenburg lithotomy position - silastic ventouse cup in vagina - manually seal labia - run warm saline 2-5L at least 1m above pt by gravity or light pressure
60
Hx of RHD -> MS -> mechanical valve On warfarin now Preconception advice (encounter 3)
- Mechanical valve = VTE risk - Warfarin most effective VTE prevention - Warfarin -> congenital abn use in T1 - LMWH not as effective but safe baby - Dose adjust based on renal function/BMI/anti-Xa level - high risk preg/MDI - MFM/Card/Hem Strategy - LMWH in T1 - Warfarin in T2 till 36/40 - LMWH from 36/40 till peripartum - LMWH to UFH for quicker reversal + LDA - warfarin recommenced PP, ok BF *If onset of labour prior to cessation of warfarin, reverse with vitamin K/ prothrombinex or similar and deliver by CS
61
Hx of RHD w MS prolonged labor 5L of NaCl sudden CP/SOB, O2 saturating 90% (encounter 2-3) Hx of RHD w MS postpartum SOB, tachyarrhythmia (encounter 2-3)
? CP/EBL/UOP/BP/RR/WOB/O2 sat - APO in setting of RHD/MS - Obs/Medical emergency - Call for Help - activate a MET call - Require MDI, simultaneous resus/ix/rx - Follow principles of ABC - ABC - O2/x2WB IVC +/- IDC (if not already in) Ix - FBE/UEC/CMP/Coag/Troponin - arterial blood gas - ECG exclude ischemia - urgent mobile CXR exclude APO Stabilization +/- Delivery - IV diuretics + strict FB - NIV - CPAP +/- B-blocker +/- ionotropic support - Expedite delivery Ongoing mx - Transfer to ICU - TTE/VTE prophylaxis - Cardiology OPC - TTE - precon counselling
62
Worried about SB, how to prevent
HE - identify RFs Advice - smoking cessation - side sleeping from 28/40 - FH at each visit - G/S where there are RFs for FGR +/- optimize any medical conditions - monitor FM - avoid prolonged gestation (e.g. IOL for PD) *maternal obesity, age >35yo, primiparity, low SES are some modifiable RFs in
63
DFM 36/40, bkg of GDM, no FHR, tell JR what to recommend (encounter 2) DFM 35/40 bkg of ICP, BA>45, no FHR (encounter 2-3) FDIU @morph 7/52 post uncomplicated laparotomy for dermoid (encounter 3)
HE - itch/pain/bleed/VTE hx/vitals/fundal height/uterine tenderness - COGU scan to confirm - 4 chamber/color doppler - FBE/UEC/LFT/Coag/G&S - Kleihauer - FMH - HbA1c/BSL/TFT/aPLs/BA/TORCH Expectant - unpredictable timing/infection/DIC/haemorrhage Active - mife then miso 24-48/24 post in hospital/mife SE = pain/N&V/diarrhea, PV miso, analgesia options, delivery +/- MROP Post delivery - Plac MCS/histology +/- fetal karyotype - PM with autopsy - Cabergoline for lactation suppression - Referral to SW/Bereavement service +/-Referral to Clinical Psych - Death cert + Funeral arrangement - Contraception + preg interval - OP F/U for Ix result + future preg care *will need to expedite delivery if unstable - e.g. coagulopathic or abruption -> haem opinion/Obs med input -> Vit K/FFP/Cryo -> hysterotomy... **risk of recurrence is ~2.5% ***autopsy - yield may be low if sig time lapsed since death - tissue degeneration - maceration, same for co-twin death - autopsy of dead twin from earlier in gestation is of little value
64
Post FDIU F/U Karyotype 47XX T21
HE - post delivery recovery T21 likely cause of FDIU 1:1000 (30yrs), risk increase with age Need karyotype of mother/father higher risk if carrier of balanced translocation - Genetic counselling If normal parental karyotype, recurrence rate is 1%
65
Explain value of PM and what's involved (encounter 2-3)
- find cause - rx - prevent - assist with grieving + alleviate guilt - full or limited PM, full = gold std - 50% time no cause found - alt = full body xray/MRI = low yield
66
Pt referred to OP Urogynae with POP/SUI, p/w confusion in OPC
DDx = UTI -> delirium Admission/delirium workup/medics Test for UTI +/- empirical UTI rx
67
What are the symptoms of voiding dysfunction and how do you treat someone with voiding dysfunction?
Sx - difficulty emptying, hesitancy, weak stream, dribbling DDx - detrusor underactivity or bladder outlet obstruction - Exclude UTI -> retention - UDS/renal tract USS - no cure, symptom management Mx options - bladder training - double voiding - pelvic floor exercise - Intermittent self-catheterization/IDC/suprapubic - muscarinic receptor agonist/alpha-antagonist
68
34yo G1P0 32+6, persistent/worsening central abdo pain, A-'ve, hx of bowel resection, sinusoidal trace, firm abdomen, what do you do? (encounter 1),
sinusoidal trace + abdo pain = abruption what's RFs for abruption? concurrent mx issues (e.g. PET - PPH) what was the previous bowel resection? lots of adhesion? Is birth imminent - cervix opened? - if VD not possible then CS -------------------------------------------------------------- - Obs emergency - Code green GA emCS - MDI essential - Inform Senior Obs - expect adhesion, may need CR team - x2 WB IVC - FBE/G&S-xmatch/Kleihauer - NBM + IVT - Cord gas/placenta for path/assess for features of abruption - Paeds at birth - Anti-D postpartum - Document/Debrief - postpartum F/U to discuss RFs and prevention ---------------------------------------------------------------- *BP/drugs/thyroid/fibroid
69
34yo, D2 post cat 1 emCS for placental abruption on bkg of previous bowel surgery, not PF, with worsening abdominal pain, uterus FC, minimal PVB, distended abdomen
DDx - ileus/ogilvie/intra-abdominal bleed Focused hx - Uterus position/PVB - F+C/min PVB - not intra-abdo bleed - N&V - see if pt needs NGT - RFs for either of above - bowel handling/hemoperitoneum... ----------------------------------------------------------- - NBM with IVT +/- NGT - Urgent bloods include FBE/UEC/CRP/LDH - infection/electrolyte/LDH elevated in Ogilvie - Urgent AXR to exclude BO/risk of bowel perforation - caecum - Inform consultant/Refer to Gen Surgery for advice - Analgesia/Antiemetic +/- ABx - Chew gum/VTE/ambulation - Serial AXR to check for resolution - Gradual upgrade of diet as per Gen Surg *Ogilvie may require neostigmine +/- decompression
70
26/40, sudden onset RIF pain - USS showing a 7cm suspicious ovarian cyst - USS showing ovarian cyst with torsion
HE - onset/N&V/fever/chills/U&B/vitals/abdo/spec - cervix/FFN - I'm concerned about either torsion/appendicitis - need to also exclude abruption/rupture/TPL - FBE/UEC/CRP to exclude acute infection - consider CTAP vs TV USS to exclude appendicitis - inform con/refer gen surg for opinion - NBM + IVC - IVT/analgesia/antiemetic +/- steroid - await investigation +/- surgery *TMs not be useful in pregnancy **suspicious mass - USO+PW+peritoneal/omental bx ***torsion - detorsion/cystectomy +/- USO if necrotic (need to consent well pre-op) ****COCP to reduce risk of cyst in future
71
26/40, 12/24 post lap detorsion/cystectomy abdominal pain/low BP/tachycardic
HE - pain/PF/UOP/pallor/BS/peritonism - I'm concerned about an intra-abdominal bleed - need to also exclude anemia/dehydration/ileus - FBE/UEC/LFT/CRP/G&S to check for Hb/inflammatory markers - CTAP to exclude intra-abdominal bleed/RTS - fetal wellbeing - NBM/x2 WB IVC + IVT + analgesia + IDC - await Ix +/- RTT
72
26yo G1P0 26+3/40, sudden onset RIF pain with USS showing a 7cm suspicious ovarian cyst on USS, LR AN course, RSO during same admission, results returned stage 1c EOC, elevated CA125, negative washings. (encounter 2)
- recovery hx - change in sx - you have ovarian cancer - it's early stage, prognosis is ~90% 5yrs - you will need further surgery + chemo to complete rx - surgery will involve TAH/LSO/omentectomy your options are: 1. continue pregnancy 2. continue pregnancy + chemo and complete surgery PP 3. terminate pregnancy and proceed with surgery/chemo risks to pregnancy is high if you continue, risks can include - chemo can be used in pregnancy but can cause FGR/PTL/PTB - chemo have a range of SE for you too (N&V/risk of infection...) - you will need MDI - MFM/GONC - rx/RBU - if fertility preservation investigations you will need include: - 4 weekly G/S to check wellbeing treatments you will need include: - anti-emetic/steroids to help with sx - hydrocortisone in labor
73
30yo G1P0 10/40, hx of RA on pred, LR AN Ix, please manage. (encounter 1)
HE - std AN/neck/hip issues/vitals... R2U - PET R2B - FGR/PTB/NLS Pred exposure - MFM/Obs med - LDA+ca+reg OPC+BP+uPCR - early OGTT/tertiary morph/hydro - anti-Ro/La +/- fetal echo - 4wkly G/S from 28/40 - ano rv if neck issue - MOD if hip issues
74
- 24/40, EFW10%,180/100 (encounter 1)
HE - HA/visual/RUQ/vitals/clonus/reflex - HTN crisis - MET call - MDI - NBM + x2 WB IVC + IDC + strict FB - FBE/UEC/LFT/uPCR/coag +/- hemolytic screen to exclude PET or HELLP - Anti-HTN PO vs IV/check response - transfer to ICU for MgSo4 if unresponsive - Steroid loading +/- delivery planning (CS consent +/- classical) - Post CS -> ICU/continue MgSo4/BP control/education/VTE prophylaxis... *maternal indications del - uncontrolled HTN, eclampsia, HELLP, persistent neuro/epigastric sx, worsening haem/biochem **fetal indications for del - FGR/NRCTG/abruption
75
D0 post emergency classical no UOP (encounter 2) Surgical cause vs Pre-renal cause
Hx/Exam - OP cx/EBL/abdo pain/fluid balance - HR/BP/IDC/abdo - fundus/peritonism   DDx - ureteric/PET related - fluid shift/AKI Ix - FBE/UEC to check Hb/renal function +/- renal tract USS ? post renal cause +/- CT IVP ? post renal cause Mx (ureteric) - MDI - Urology rv/IR - NBM pending Ix - ? nephrostomy vs RTT ... Mx (PET-hypovolemia/AKI) - MDI - Obs med opinion - judicious use of IVT + monitor for APO - repeat bloods + monitor UOP - correct any anemia - cease nephrotoxins (e.g. ACEI) +/- alter clexane dosing +/- diuretics
76
32/40 in ANC BP160/95 (encounter 2)
Hx/Exam - HA/visual/FM/APH/SROM/TPL - uterine tender/clonus/reflex/FHR/FH DDx - PIH/PET/HELLP Exclude abruption Ix - FBE/UEC/LFT/uPCR to screen for... - CTG to check for fetal wellbeing - Obs USS to check for FGR Initial mx - anti-HTN and check response - admit for observation and BP optim  - inform con/consider steroid loading Ongoing mx - DC with PO anti-HTN - weekly ambulatory monitoring - weekly OPC with bloods - timing/MOD depends on progress
77
known PET from 32/40, now 33/40, BP180/100 in ANC - uPCR 1000 - Plt 120 - AST210 ALT170 (encounter 3)
HE - HA/visual/FM...vitals/clonus/reflex/VE - HTN crisis = DDx - PET/HELLP - Call for help - MET - MFM/Obs med/Haem - ABC - x2 WB IVC + IDC - FBE/UEC/LFT/Coag/G&S/CTG - Requst con/ano/paeds rv - Treat and monitor in HDU - Anti-HTN + Steroid loading +/- MgSo4 - NBM + CS consent +/- classical (indication = HELLP) Postpartum - HDU/rpt plt/VTE prophylaxis - strict FB/BP control/education - discharge with anti-HTN/titration w GP - 6/52 postpartum OP rv
78
- Hx of SLE - high BP in OPC - Hx of SLE - scan show EFW24 AC10 (encounter 1)
HE - FM/APH/SROM/TPL/usual flare sx - rash/joint pain/photosensitivity - vitals/BP/uterus +/-FH +/- spec (DFM, 145/95, discoid rash, urine protein 3+, FH=Date) DDx - lupus flare vs PET - FBE/UEC/uPCR, LFT/sFLT-PLGF (rising) to exclude PET - anti-DS DNA (rising)/C3&4 (falling) to exclude lupus flare - consider TORCH screen to exclude viral infections - CTG +/- formal obs USS to check fetal wellbeing - MFM/Obs Med input - lupus flare will require high dose pred or aza +/- BP rx - PET - anti-HTN +/- delivery vs OP F/U - if delivery planned - need to consider *BP can also be result of lupus flare - LN ->renal dysfunction -> BP, uPCR/BP are not helpful distinguish btw lupus flare & PET
79
How do you tell PUPPS rash from PG rash?
PUPPS - Sole/palms/peri-umbi spare, start from striae PG - Sole/palms/peri-umbi *PUPPS - reassurance is important - resolution post delivery
80
Suspected PG
HE - sole/palms/peri-umbi R2U - discomfort R2B - FGR/PTB/SB Derm review + Bx to confirm MFM/Derm input - fetal monitoring + timing of delivery Rx = steroids - topical -> oral + antihistamines/emollient Paeds review postpartum *treatment same for PUPPS except the fetal monitoring and early delivery **don't forget SLE + TORCH infections as a cause of a rash
81
UI
Hx/Ex - urge/nocturia vs cough/sneeze - coffee/tea/smoking/diuretics - PHx/Surg/Med/Screen - CST/MMG/Bowel - SHx - living situation/work/finance - urogenital atrophy/POP-Q Ix - MSU to exclude UTI Mx - BD/BT/PFE/modify RFs - cough/constipation/smoke/tea/coffee/etoh/fluid intake - incontinence nurse referral - topical E2/Review in 3 months +/- UDS Surgery - SUI - MUS/Burch/Bulkamid Medical - UUI - anticholinergic/b3 adrenoreceptor antagonist Surgery - UUI - sacral nerve stimulation/bladder graft/diversion ## Footnote SUI - fix cough/constipation UUI - fix fluid/diuretic intake
82
64yo vaginal lump
HE - cough/constipation/fullness/difficult void/defecate - can't empty/sex - UI - stress vs urge-nocturia - quality of life/PMB - VMS/CST/MMG/FOBT - PHx/Surg/SHx-sup/BMI/POP-Q FBE/UEC/LFT (baseline) Urine - MCS Pelvic USS (exclude uterine/adnexal abno) Mx - LS + PFE + Pessary - pessary is...F/U to rv in... *cough - asthma/copd/smoking **occupational - lifting ***constipation
83
Describe Pessary as a treatment option for POP
- to reduce vaginal/uterine prolapse symptoms - if want to avoid surgery, not fit for surgery, not finished family - need to change/expect discharge/can have ulcers
84
Apical prolapse (uterus, cervix, vault) surg options.
- Colpocle - close vag/minor op/quick recover/not if SA/can't test - Hyster - remove ut/major op/slow recover/ok SA/no mesh - Hyster options = VH v TAH v TLH - VH = safer/quicker recovery/short vagina *SSF if vault prolapse *Sacro hysteropexy is uterine preserving, not fertility preserving
85
UUI Med/Surg Options - failed conservative mx (encounter 2) - confirmed OAB, failed medical mx (encounter 3)
Hx/Exam - change in sx - compliance with conservative mx - cut down smoke/etoh/tea/coffee etc... - compliance with medical mx - meds... Medical - anticholinergic/b3 adrenoceptor agonists - daily tabs, effective - SE: dry mouth/constipation/palpitations - trial and F/U in 3mo Surgery 1. Botox injection - day procedure under GA - cystoscopy with botox injection - antibiotics intra-op, trial of void - quick recovery/effective/ no systemic SE - risks - need repeat/UTI/retention - ISC 2. sacral nerve stim (implant in pelvis stim bladder nerve) 3. augmentation cystoplasty (bowel graft to improve bladder func) 4. urinary diversion (ileal conduit/stoma) *CI to anticholinergic - narrow angle glaucoma **CI to mirabegron - poorly controlled HTN also think about cost assoc with medical rx options
86
Describe MUS
- tape support bladder neck - day procedure done under regional or GA, antibiotics pre-op - 3 incisions -either side of lower abdomen and vagina - tape passed through to support bladder neck - scar tissue form over time to hold tape in place - cystoscopy at the end to exclude blader injury - trial of void (if fail - ?IDC and return TOV vs RTT - too tight) and OP F/U - effective, quick recovery - risks include surgical cx + mesh cx *RFs for poor healing - smoking, would recommend against
87
Describe Burch
- lift bladder neck - done under GA - open or keyhole - side of vagina attached to ligament behind pubic bone with sutures so bladder neck lies in a hammock - cystoscopy at the end to exclude bladder injury - trial of void and OP F/U - as effective as MUS, no mesh - risks include surgical cx, longer surgery, slower recovery
88
Describe Bulkamid
- works by narrowing urethra - day surgery under regional or GA - cystoscopy to look inside urethra & bladder - bulking agent inject near internal opening of urethra to bladder - trial of void and OP F/U - quick recovery, doesn't use mesh - risk include repeat procedure, ISC
89
Describe SSF aka Sacrospinous colpopexy (encounter 2) or Return post conservative mx for vault prolapse want surgery (encounter)
HE - change in sx and POP-Q Options = SSF vs SCP (non-mesh vs mesh) + cystoscopy +/- VR SSF - suspend vaginal vault to sacrospinous ligament on one side - under GA, alone (e.g post hyster vault prolapse) or as part of a hysterectomy - vag approach, delayed absorbable sutures to SSL then to vaginal vault unilat - low recurrence/quick recovery/restore vaginal length - general risks include... - specific risks include buttock pain/dyspareunia/de novo SUI or worsen SUI SCP - mesh to vault to sacrum - under GA, lap approach - low recurrence - general risks - specific risks - mesh exposure/erosion/OM/dyspareunia/de novo SUI or worsen
90
Describe AP repair (encounter 2)
- risks include general/specific - de novo UUI - ga/IV abx/lithotomy/prep/drape - LA infiltration/sharp dissect bladder or rectum from vagina mucosa - fascial plication with PDS - double layer continuous - cystoscopy (anterior only) to check... - remove excess vagina mucosa skin vicryl - vaginal pack/catheter postop/TOV
91
Buttock pain post SSF (encounter 3)
HE - analgesia requirement/intra-op cx/vitals - perineal exam - loss of sensation vulva/LL weakness to exclude pudendal neuropathy DDx: hematoma/pudendal nerve entrap/small n traction & injury - inform consultant - consider FBE+/-CTAP to exclude hematoma - Hematoma - Observe + IV Abx +/- IR vs RTT - Nerve traction/injury - reassure, NSAIDs, gabapentin, enema, OP F/U - Pudendal nerve entrapment - NBM+IVT, RTT to release
92
Dyspareunia post VH/AP repair (encounter 3)
Hx/Exam - bleed/discharge/fever/type of fixation/time since op/vitals/spec DDx: granulation tissue/infection/dehiscence Ix - FBE/CRP to exclude active infective process - Vault MCS Mx Granulation tissue - Silver nitrate - OP F/U +/- rpt Infection/Dehiscence - Admit/observe + IV Abx +/- RTT - debride/repair No cause found - treatable but takes time - 1st lubrication + topical E2 ->dilator therapy ->systemic anxiolytic Consider EUA - division of adhesion and injection of LA/steroids
93
Abdominal pain post TVT (encounter 3)
Hx/Exam - analgesia requirement/UOP/intra-op cx/vitals DDx: retention/retropubic hematoma/tape too tight Ix - bladder scan to check PVR - FBE/coag/G&s/CTAP to exclude hematoma Mx - NBM + IVT until Ix returned - Inform consultant - Rx depends on cause... Hematoma - observe with serial Hb +/- IR - embolization - consider 1g Txa - ensure adequate analgesia - alternative is to RTT Urinary retention - IDC/MSU MCS +/- antibiotics Tape too tight - loosen within 14/7 beyond which would need removal & reinsertion vs split the tape *confined space, bleeding should tamponade, observation reasonable for hematoma
94
Watery discharge post hysterectomy (encounter 3) or Watery discharge post lap SCP (encounter 3)
HE - bleeding/fever/chills/intra-op cx/vitals/speculum - dehiscence/fistula DDx: VVF/worsening incontinence - masked SUI/infection   Ix - vag fluid/serum Cr to confirm nature of fluid - FBE/UEC/CRP to exclude biochem signs of infection - MSU MCS to exclude UTI - HVS MCS to exclude genital tract infection - CT IVP to identify VVF (VVF confirmed...) - VVF is communication btw bladder/vagina - risks include cystitis/urosepsis - d/w Urology re: ongoing mx - await expectant vs surgical - if small likely defunctioning IDC + abx then cystogram -> TOV - if big likely EUA/debride/repair either within first 48/24 or 6/52 - post repair will need IDC then cystogram pre-removal + Urology F/U *small RVF can also be healed by 2ndary intention
95
PV/PR bleeding post posterior vaginal wall repair (encounter 3)
HE - pain/fever/intra-op cx/vitals/speculum - dehiscence/offensive dc/PR DDx: dehiscence/endometritis/RVF - FBE/UEC/CRP to exclude infective process - HVS MCS to identify bacteria - Admit + IVC + IVT - Broad spectrum IV antibiotics + Observe - If worsening -> EUA + Debride + Repair - VTE prophylaxis - Transition to oral on DC with OPC F/U *if RVF - CR opinion - not repair during active infection, diet mx, bowel prep/repair 6/52/fistulectomy/reapproprixmation/transvaginal-transperineal vs transabdominal...
96
post posterior repair febrile, unwell (encounter 2-3)
HE - pain/bleed/discharge/vitals/spec... Admit + IVC + Bloods + MCS IV ABx + Observe + CR opinion No repair when acute infection ?spont resolution after rx of acute infection F/U +/- Plan for OT 6-8/52 Bowel prep - transvaginal/transperineal vs transabdominal (if high) May need stoma
97
Delirium post gynae surgery in elderly (encounter 3)
Hx/Exam - pain/bleeding/fever/UOP/flatus/bowel motion/vitals/assess wound/IDC if in-situ/Bladder scan - PVR DDx: pain/retention/constipation/infection Ix - FBE/UEC/CMP/LFT - MCS - MSU/HVS - ECG/CTB Mx - MDI involving Medical team - Adequate analgesia/aperients - Empirical broad spectrum abx if suspected infection - VTE prophylaxis
98
- Vulval pain & dyspareunia bkg of recurrent infection (e.g. thrush) (encounter 1) - vulval pain on IC, no obvious cause
Quickly ask for info not given in stem e.g. Menstrual/OGHxPHx/Surg/SHx... Briefly address any unexpected issues as you go e.g. CST overdue Dx/Prognosis - trigger -> inflammation -> more nerve endings -> lower pain threshold -> heightened sense of pain - treatable, takes time, impacts fertility Exam/Ix - Q-tip test - HVS/LVS MCS to exclude thrush +/- bx +/- PCR if suspicious lesions Interim Mx - await results & F/U - Psych support Mx - MDI - PT/Psych/Sexual health/RBU - CBT/PF exercise for pelvic floor spasm - SSRI/SNRI/TCA/Gabapentin - Dilator therapy - Lignocaine gel with IC - Botox injection to levator ani - ART - IUI/IVF *vulvodynia trigger - recurrent thrush, HPV/HSV/trauma/surgery
99
Pre-pregnancy counselling (general)
Hx/Exam - Menstrual hx - OGHx - Contraception/CST if on - stop, if overdue - do now - PHx/Surg - Med - if none - need folate/vitamins/iodine - SHx 1. if SAD - need to stop/offer support 2. if toddler - aware of CMV - prevention strategies - BMI - if high - need diet/exercise - Cardio-resp/Thyroid Ix - FBE/Ferritin/+/- Thal + G&S/HIV/HCV/HBV/Rubella/Syphilis - MSU MCS +/- Carrier screen
100
Suspected molar pregnancy on USS (encounter 1)
Quickly ask for info not given in stem e.g. Menstrual/OGHxPHx/Surg/SHx... Briefly address any unexpected issues as you go e.g. CST overdue Dx - abnormal development of embryo - pregnancy is not viable and you're at risk of hemorrhage Ix - FBE/bHCG/G&S - baseline/rhesus + x-match 2units of PRBC - +/- confirm o tertiary or COGU TV USS Mx - Admit - NMB+IVC+IVT - Inform consultant/theatre/request Anesthetic rv - D&E under USS - POC to path fresh +/- anti-D postop +/- conservative mx of theca lutein cyst - monitor sx of torsion, can be drained if large and high risk of torsion - OP F/U pending histology results +/- molar registry referral for bHCG tracking
101
Rising bHCG at F/U for histo confirmed mole (encounter 2) or persistent PVB 10/52 postpartum (encounter 3)
HE - ... Scenario 1 DDx = new preg vs GTN Scenario 2 DDx = GTD/GTN/RPOC - bHCG/FBE/UEC/LFT/TFT/G&S as a baseline as may need chemo (e.g. MTX) - Tertiary or COGU TV USS to confirm & exclude new preg/RPOC/theca lutein cyst - Consider CXR +/- CT head/CAP -> work out FIGO score (vascular tissue on USS or choriocarcinoma on USS) - likely GTN = persistent GTD, risk of malignant transformation - prognosis is good - 85% cure rate - high risk of uterine perforation if D&E again - as need chemo, no need to repeat D&E unless bleeding - uterine curettage is not required for dx, if not bleeding, no need for POC to confirm dx as risk of perforation is high - Referral to GONC MDT/OP rv - FIGO stage/WHO prognostic score determine type of chemo - single (mtx) vs multi-agent (actinomycin + etoposide+mtx) - chemo until bHCG is negative - monthly bHCG, 12mo with effective contraception (P4, not IUS) (ok for COCP/Depot/Implanon/Filshie/Salpingectomy) - future pregnancy: recurrence, no impact on future pregnancy, early preg USS, plac to histo postpartum, bHCG 6/52 postpartum *if need D&C, should go in with hysteroscopy to locate persistent focus **GTN is a clinical dx based on elevated serum bHCG/uterine enlargment w lesion/bilateral theca lutein cysts/metastatic disease ***whether to do brain - would be based on sx too ****IUS ok after complete resolution *****GTN can be benign (persistent GTD) or malignant - prognosis >90% even with mets (eg. met chorio), responds well to chemotherapy
102
MTX SE
GIT upset Mucositis Conjunctivitis Neutropenia/thrombocytopenia LFT derangement
103
RUQ pain + N&V + Hypertension in pregnancy (encounter 2-3) Also present with fever
HE - VE - ?IOL or CS DDx = AFLP/HELLP/PET Ix: - FBE/UEC/LFT/Coagulation Profile/uPCR/BSL Results: - ⬇️Hb/Plt/⬆️AST/ALT (AFLP vs HELLP) - Hypoglycemia/DIC - ⬇️fibrinogen ⬆️PT/APTT- (AFLP) Dx/Prog - AFLP sig M&M to baby/mother - untreated, can lead to liver failure/mat/fetal death Mx - Obstetric emergency - MDI - urgent paeds/anaesthetic rv/advice from Haem/Gastro - Treatment in ICU to correct abnormalities before delivery - Correct hypoglycemia w 50% glucose - Correct coagulo FFP/cryo/albumin/Vit K - Stabilize BP with anti-HTN - Expedite delivery via emCS +/- classical +/-Steroid +/- MgSo4 loading - GA>regional, PPH - txa/uterotonics, Hematoma - drain/staples - remain in ICU postpartum - FU 6/52 obs med postpartum/LFT *other rx = ventilation/dialysis/plasmapheresis/NACT or liver Tx **for a multi with an open cervix, ?IOL vs CS, depends on maternal and fetal status, either AFLP is not going to get better baby still needs to be born
104
talk to an angry patient re: mx plan (angry re: mx plan suggested by another staff)? Communication
- You look unhappy about... - Tell me about... - I'm sorry that... - How would you like me to help... - There are other options (risk mitigating strategies - pros/con)... - Would you like a second opinion... - Thanks for sharing your concern and listening...
105
- 35yo G0, referred from FCC, BRCA1 - request for pre-menopausal oophorectomy to reduce cancer risk (encounter 2)
? any change to Hx/Exam - Lifetime risk of EOC ~2% - germline mutations make it higher - EOC in relatives increases risk Initial ix/mx - Referral to FCC for rv/testing - Pending results discuss RRBSO alone or as part of another surgery for benign gynae issue Results - Mutation vs No mutation ----------------------------------------- Dx - BRCA2 risk of EOC/breast = 20/40 - BRCA1 risk of EOC/breast = 40/60 - no reliable screening for EOC - RR surg reduce risk (e.g. 90% for EOC) Initial Ix - Pelvic USS +/- CA125 Mx - Refer to Breast Onc -? mastectomy - Refer to GONC - pros & cons of RRBSO - Refer to Menopause clinic - risks & mx of early menopause - RRBSO can be offered from 35yo when family complete - RRBSO - day surg, GA, key-hole, pelvic washing, path, OP F/U, risks of surgery/early meno - sx/CHD/osteo --------------------------------------------- No mutation - Risk of early menopause (CHD/Osteo) > Bkg risk of EOC - No reliable screens, but would not recommend BSO - Alternatives = long term use of COCP vs BS -50% reduction vs hyster alone ---------------------------------------------- *inheritance of BRCA, autosomal dominant, 50%, genetic counselling, PDG+IVF or prenatal dx +/- TOP vs donor egg vs adoption **if someone needs to have a child before RRBSO - help with preconception planning ***onset of EOC after 40yrs for BRCA1, after 50yrs for BRCA2
106
Tubal ca on RRBSO sample, confined to FT (encounter 2-3)
HE - postop recovery - pain/PVB... - stage 1 FT cancer/prog (90%)/rx like stage 1 EOC - refer for GONC rv + MDT + discuss additional ix req - likely need CT CAP or PET CT + CA125 - likely need cytoreduction (TH/Omentum/LN) + stage + adj chemo - also ref to menopause/sup grp/psych - lifestyle modification where applicable in setting of iatrogenic meno *refer for genetic testing (in case of completely incidental finding)
107
care post RRBSO (encounter 2-3) care post inadvertent BSO at emergency surgery
HE - menopausal sx +/- open disclosure - risks of early meno = CHD/Osteoporosis - range of sx - VMS/GSM/myalgia/arthralgia/cognition - care require MDI - meno/GP - LS + HRT + Screens - LS - cease smoke/min etoh/wt bear ex/ca/vit/dexa - HRT - till meno age w f/u/risk of VTE/BCA/CVA/benefit - osteo/CVD reduce - Non-pharm (CBT) + Non-hormonal (SSRI/SNRI/Gaba) options   *no HRT in hormone sensitive tumors/VTE/CVA, HRT ok if just BRCA+ no ca
108
FHx of BC/EOC/early onset CRC No testing yet Genetic counsellor said 5yr colonoscopy + yrly MRI brst Want to discuss screen vs RR surg (encounter 1) FHx of BC/EOC No testing yet Want to discuss RRBSO (encounter 1)
HE - menstrual hx/CST/fertility/bowel habit/PHx/SurgHx/SHx/breast lump - FHx = strong risk of heritable mutation - BRCA - EOC/BC (20/40/40/60) - MMR - EOC/EAC/CRC (10/40/50) Mx - ref FCC- MMR/BRCA test/counsel - type of RR surg depend on mutation - RR surg pros & cons (menopause) - alternatives to RR surg - screen FRT ca - TM/Imaging/EB - screen not proven for FRT ca - screen for breast/GIT - MMG/C-scope - need referral to breast or CR
109
confirmed Lynch requesting RR surgery hx of midline laparotomy + peritonitis (encounter 2)
HE - change in sx - MMR mutation = Lynch syndrome - Risk for EOC/EAC/CR 10/40/50 - ref GONC MDT/rv +/- TV USS + CA125 pre-op - most definitive RR = TH + BSO + PW +/- Omental bx w Gen Surg support - PAC/multi-D/GA/path, MDT, post-op F/U - general risks...specific risks - alt = BSO+HDC for EOC > COCP > BS - screening not proven for EAC/EOC (e.g. USS+TMs+EBs) - postop - refer to menopause +/- HRT/sup grp/breast/CR - MMG/G&C scope - lifestyle mod - exercise/SAD/sup due to iatrogenic menopause *Hasson vs Palmer's w CR team avail avoid Veress or DOE via umbilicus
110
checklist for starting anyone on HRT
- uterus in-situ? - hx hormone sensitive tumour/VTE/CVA - not >60yo - no more than 10 years of HRT - f/u arranged?
111
40yo on HRT for POI p/w SOB/pleuritic CP
DDx - PE vs infection - VTE ix/rx - VTE confirmed -> change from HRT - non-HRT options for mx of VMS - pharm vs non-pharm - non-HRT options for mx of osteo & cardiovascular risks
112
intra-op detection and mx of suspected ureteric injury (e.g. transection) (encounter 3)
? change in Hx/Exam - ensure hemostasis - pause surgery - notify anesthetist - call urology for opinion/assistance - ask for IV methylene blue - whilst waiting for urology support ways to identify injury includes 1. visual inspection - urine/visible defect in operative field - hematuria + bubbles in IDC - extravasation of methylene blue - also check injury to bladder + contralateral side 2. ureteral evaluation - identity proximal, trace it - look for peristalsis 3. cystoscopy - assess bilateral UO jets - no jet = obstruction or transection - stent if thinking obstruction intra-op mx - kinked ureter - release suture +/- stent - transection - re-anastomosis vs re-implantation, if can't repair immediately - need nephrostomy until able to repair postop - IDC/Urology rv/plan - Open disclosure/M&M/FU
113
Borderline BP + proteinuria ...T2-T3, on bkg of T1DM/Renal Tx and FGR (encounter 3)
? change in Hx/Exam evolving PIH/PET DDx - renal failure/UTI Ix - FBE/UEC/LFT/uPCR to exclude PET - MSU to exclude UTI - CTG + Obs USS Results ....PIH/PET.... Mx - High risk/MDI - BP opti to prolong vs Expedite delivery - Deliver - Paeds+/-steroids+/-MgSo4 - BP opti - meds/monitor/scans/plan *monitor - bloods/baby/sx
114
rashless pruritis @33/40 (encounter 1)
HE - FM/APH/SROM/TPL/vitals/FH... Rashless pruritis = ICP - FBE/UEC/LFT/Peak BA (non-fasting) +/- hepatitic screen +/- coagulation profile +/- liver USS - ICP a problem in liver - R2U = pruritis/coagulopathy - R2B = PTB/MSL/SB - Obs Med opinion - 2-4 weekly BA + LFT - Urso +/- antihistamine +/- ointment +/- vitamin K - IOL depends on BA (e.g. 37-39 BA<40...) - no E2 contraception - see GP to recheck liver function in 6/52 - recurrence 80-90% *BA 40-99 36-37/40 *BA >= 100 36/40
115
Hx of FGM previous re-infibulation anterior epis, now post NVB request re-infibulation (communication station)
- ask why... - safety/coercion - safety of children from FGM - follow the women's response Relevant clinical info - cut/remove, no clinical reason = FGM - FGM = illegal - re-infibulation also illegal - taking someone overseas = illegal - risks of re-infibulation 1. painful 2. PP - infection/obstruct - urine/DC 3. gynae - UTI/CST 4. future pregnancy
116
Hx of FGM
- HE - impact on life ?UTI ?sexual dysfunction ?CST ?menstruation - FGM clinic referral - De-infibulation under LA antenatal or intrapartum - gynae health - CST/reduce UTI/sexual function - obstetric - allow FSE to monitor baby/VE to check labour progress/reduce risk of obstructed labour/CS/PPH/OASIS - expect faster micturition/vaginal discharge + surgical risk - infection/pain/bleeding
117
Young nulliparous woman requesting hysterectomy for HMB, failed medical mx. (Communication station)
- double check reason for request - impact of problem on life - explore why med mx failed (?SE ?compliance...) - check understanding of 1. process of surgery/recovery 2. general risks of surgery 3. impact on fertility 4. impact on ovarian function - knowledge of alternatives - recommend 2nd opinion - follow-up visit to discuss
118
16yo primary amenorrhea (encounter 1)
HE - anosmia (Kallman)/cyclical pain(imperf)/PHx/Surg/FHx/HEADSS/tanner Ix - bHCG/E2/FSH/LH/Prl/TFT/Free T/SBHG/DHEAS/17OHP/Pelvic USS+/-Karyo +/- rpt FSH/LH/E2/P/AMH (thinking POI) +/- anti-thyroid/ovarian/adrenal *primary ameno = no menses by 16, no menses 2yrs after breast develop **Repeat FSH >40/E2 <50, TSH/Prl =N, in 4 weeks confirms POI ***HEADSSS - home/employ/activity/drugs/sex/self harm/safety
119
primary amenorrhea normal hormonal profile USS show no uterus Karyotype 46XX (encounter 2)
- MRKH = congenital abnorm - missing uterus/cervix/part of vag - risk: infertility/sexual dysfunction - no general health risk - care req MDI - PAG/psych/sexual health/fertility - ongoing f/u/sup grp/vag dilator/vaginoplasty/adoption/surrogacy
120
primary amenorrhea normal hormonal profile USS show no uterus Karyotype 46XY (encounter 2)
- CAIS = Androgen receptor mutation - male genotype/female phenotype - no male reproductive tract - risk of gonadoblastoma/infertility - risk of CVD/Osteo post gonadectomy - care req MDI - PAG/psych/fertility - ongoing f/u/sup grp - gonadectomy post puberty to allow breast development - low dose E2 after gonadectomy - adoption/surrogacy w partner sperm - vaginal dilator therapy (1st line) -> vaginoplasty (2nd line) *gonads may not be seen on USS, can be in inguinal canal or labia
121
primary amenorrhea normal hormonal profile USS shows uterus/streak gonads Renal USS = horseshoe kidney Karyotype 45XO (encounter 2) alternatives - precon counselling Hx of Turner's - secondary amenorrhea - POI
- absent or mosaic X - risk infertility 10% chance of spont/early meno -cx - osteo/cvd/VMS... - general health risks = HTN/HypoT/cardiac/renal/IBD/Coeliac - preg risk - aortic dissect/GDM/PET/FGR - dysgerminoma risk (if 45XO/45XY) - care req MDI - PAG/endo/psych/fertility - screen for end-organ dysfunction - bloods/imaging* - screen for visual/deafness (opthal/audiology) - puberty induction with E then COCP - ongoing f/u/sup grp/annual HbA1c/lipids - donor oocyte/surrogacy/adoption pregnancy = HR/MDI-MFM/Obs Med/Genetics TTE pre-preg/early OGTT/LDA+Ca/tertiary morph/4wkly G/S *FBE/UEC/LFT/IBD/Coeliac/TTE/renal USS/DEXA **+/- ref to surg for gonadectomy if 45X0/45XY ***aortic root 55mm - need repair, high risk for dissection, pregnancy CI - if someone had this u would offer TOP, otherwise, regularly echo/card/MFM/ctrl HTN if an issue and screen for PET/MOD=CS
122
primary amenorrhea normal hormonal profile USS shows uterus Karyotype 46XY (clinical or communication)
- Swyer's = Absence or mutation in SRY gene - no AMH or T, FRT not regressed, no MRT - risk of infertile/meno/dysgerminoma - care req MDI PAG/endo/meno/paed surg/psych/SW/sup grp/fertility - puberty induction w E then COCP (HRT - osteo/CVD) + LS mod + DEXA... - gonadectomy w Paed surg - ongoing f/u/sup grp - donor oocyte/embryo/surrogacy/adoption *Girls and women typically have two X chromosomes (46,XX karyotype), while boys and men typically have one X chromosome and one Y chromosome (46,XY karyotype). In Swyer syndrome, individuals have one X chromosome and one Y chromosome in each cell, which is the pattern typically found in boys and men; however, they have female reproductive structures - a woman who is genetically male
123
Adult Dysmenorrhea +/- AUB (encounter 1)
HE - U&B/pressure/menstrual hx/dys's - IMB/PCB/CST/STI/PID/contraception - OGHx - G&Ps/fertility plans - PHx/Med/Surg/FHx - endo/SHx - mobility/nodularity/spec DDx - Endo/STI/Fibroid/adeno - STI screen - TV Pelvic USS - trial of COCP + Mefanemic acid - other agents available - cyclical P/IUS - follow up visit +/-diagnostic lap *Epilim is sodium valporate - no interaction
124
Adolescent Ix for dysmenorrhea USS result = bicorn + non-communicating horn (encounter 2) Diagnostic lap for dysmenorrhea Intra-op finding of bicorn + non-communicating horn (communication)
? change Hx/Exam Dx - congenital malformation - risk of endometriosis - MC/ectopic/PTB/FGR/rupture/malpres Ix - MRI - characterize anomaly - Renal USS - assoc renal anomalies Initial Mx - Ref PAG for consideration of surgery - Likely need hemi-hysterectomy - Procedure involves... Ongoing mx - F/U postop - High risk preg care
125
emergency mx of preterm APH (26-28/40) setting - rural vs tertiary +/- previous CS +/- previous hx of PTB
HE: pain/SROM/morph?LLP/rhesus/PET/BP/uterus/EBL/spec-cervix Ix: FBE/G&S/Kleihauer/RTS/CTG +/- USS - VP/MAP/PAD Mx: NBM/IVC/IVT/Steroid+/-MgSo4/+/-anti-D/paeds +/- Piper/tertiary care till 32/40/tert LLP rescan/decide MOD *if abruption/APH uncontrolled - deliver 1st before transfer, would be an emergency classical **previous cs/hx of PTB important to address as part of mx plan in setting of preterm APH
126
LLP or Placenta Previa on USS (encounter 1) Extra issues - BMI 35-38 - previous CS
HE - preg sx + missing RANC - Placenta near or over cervix - R2U - APH/Admission/CS/PPH - R2B - FGR/PTB/malpresent - avoid IC/vigorous exercise/travel - tertiary USS 24-26/40 to exclude VP/PAD +/- MRI - 4 weekly serial G/S from 28/40 - optimize hematinic + MDT for peri-op planning - 38/40 elCS - complex CS/MOD depends on resolution of LLP/previa *consider closer to hospital ~34/40, FFN/CL to gauge risk **previous CS make it less likely for LLP to resolve by 32/40 ***if no resolution by 32/40, 50% can still change, but if not 36/40, very unlikely
127
Known LLP USS confirmed VP Rural patient (encounter 2)
Hx/Exam - FM/PPROM/APH/TPL/FHR - vessel in the membrane - risk of admission/CS - risk of FGR/PTB/SB - confirm VP COGU TV USS - tertiary care - 2-4 weekly serial G/S to check for FGR - admission from 32/40 - risk of PTB ->SROM ->rupture vessels - steroid loading + Paeds rv + CS consent - optimization of hemantinics - daily CTG/IVC/Valid G&S/monitor sx - elCS from 36/40
128
Known MAP Sig APH 30/40 (encounter 2)
HE - painful or painless/EBL (1L)/vitals/spec/RTS or CTG - Immediate Delivery/Code Green - x2 WB IVC - FBE/UEC/Coag/G&S/Kleihauer + x-match 4U/IVT/IDC - GA/Trendelenburg/Midline/Classical with senior Obstetrician - Immediate cord clamp/gaes/paeds in OT - Placenta to histology/assess for abruption - ICU or HDU postpartum/debrief/document +/- anti-D/anemia correction *Electively, MDT pre-op planning, optimize hematinics, elective admission, steroid loading (pre-CS), elCS on complex CS list 38/40, cell saver, PRBC...
129
Known LLP mild APH 30/40
HE - FM/SROM/contractions/spec/RTS Inpatient plan - Inform con - Admit/observe - NBM/IVC+IVT - FBE/G&S/Kleihauer - Daily CTG - Steroid loading + Paeds rv - Formal Obs scan - growth/wellbeing - regular pad check On DC - live close to hospital avoid... - recurrent APH -> consider longer admission - organize serial G/S + check resolution
130
Known LLP -> PAD Sig APH 30/40 (encounter 2)
Hx/Exam - pain or not/FM/PPROM/contractions - vitals/EBL/Spec - RTS-FHR/position/presentation/CTG - Obs emergency - Call for help - Code pink -> green - MDI for simultan resus/ix/del Resus - ABC - O2 Hudson/x2 WB IVC/IVT/IDC +left lateral Ix - FBE/UEC/Coag/G&S/Kleihauer + x-match 6 units Delivery (uncontrolled bleeding) - NBM + CEFM - Notify con/anesthetic/paeds - Request GONC support - Urgent TF to OT +/- MTP - GA+Trendelenberg+Midline+Classical +/- hysterectomy - immediate clamp + cord gases - paeds at birth Postpartum - HDU 24/24 - debrief/document - anemia correction - +/- anti-D *Electively, pre-op MDT, MDI - urology/IR, optimize hematinic, consent for hysterectomy, internal iliac arterial balloon, discussion about fertility +/- RBU referral, admission, steroid loading, complex elCS 38/40, CVC/ART, cell saver, PRBC...
131
Known LLP USS confirmed VP 32/40 requesting care rurally (encounter 3)
- FFN/CL to assess risk of PTB - case discussion with rural center - check emCS and NICU capacity - admission from 30-32/40 - standard I/P VP Mx
132
Known LLP APH emergency -> CS Suspected or confirmed PAD (encounter 3)
Hx/Exam - baby delivered or not - hemodynamically stable or not - level of support available Mx (baby not delivered, no support) - senior obs input/PIPER opinion - close uterus/CEFM - transfer urgently to deliver elsewhere Mx (baby delivered, stable, no support) - senior obs input/opinion - inform anesthetic team - withhold synt/leave plac in-situ - close uterus/RTT when support available for hyster Mx (baby delivered, stable, supported) - senior obs input/opinion - inform anesthetic team - withhold synt/leave plac in-situ - close uterus/hysterectomy vs MTX - or exterorize - remove - oversew - tamponade with bakri (question is how do you know how deep the invasion is if this is unexpected - defect might be through the wall...) Mx (baby delivered, unstable, bleeding) - obs emergency - request senior obs support - inform anesthetic team +/- pt (if awake in unexpected situation) - convert to GA, central lines - attempt to remove placenta +/- tamponade with Bakri ...sequence of surg mx - activate MTP + commence PPH mx - Txa/Uterotonics... - ICU postop/debrief/document/routine PP care/anemia correction
133
Hx of multiple CS
tertiary morph to exclude LLP/previa/PAD
134
AMA
R2U GDM/PET RR4U early OGTT/LDA/Ca RR2B aneuploidy - 1:40 (40), 1:10 (45)/FGR/SB RR4U MFM-screen vs diagnostic/4 wkly G/S from 28/40 to identify FGR IOL from 39/40 to prevent SB assoc with PI
135
UPSI (encounter 1)
HE - time since/LMP/reg/cycle length/partners/STI/PID - R2U = unplanned pregnancy/STI - EC options - Cu/LNG/Ulipristal +/- long term options - HBV/HCV/Syphilis/Chlam/Gon/MG/Trich - inform con/D/W ID team re: prophylaxis +/- empirical PID rx - await Ix result to target rx & contact notification 1. Cu = 5d, spermicidal/embryotoxic, insert/string/LARC/ cramp/PVB/expulsion 2. LNG = 3d, delay ov, PO single dose/OTC, no long term contra/GIT sx/PVB 3. Ulipristal = 5d, delay ov, PO single dose/OTC, no long term contra/GIT sx - Long term contraception - start pill or discuss other options - F/U in 2-3 weeks - ?menses +/- bHCG
136
HCV carrier (encounter 1)
HE - IVDU/transfusion/less likely sexual/dx/rx/F/U - transmission/cirrhosis/liver ca - LFT + USS to check severity - Gastro Ref - antiviral rx + VL F/U
137
HIV exposure (encounter 1)
HE - partner VL/rx/F/U - refer to ID for advice on mx - likely need HIV PEP prophylaxis + HBIG - recommend barrier contraception in future - F/U +/- rx of any STI identified
138
HIV detected on antenatal serology (encounter 2)
- human immunodeficiency virus -> AIDS - R2U GDM (from cART)/PET (from immune reconstitution syndrome) - R2B FGR/PTB - need cART (protease inhibitor) - MFM/ID input - screen for GDM/PET - early OGTT +/- LDA+Ca - screen for co-infection (HCV) - regular VL/CD4/LFT - VL>400 copies/ml @36/40 -> plan for CS - avoid prolonged SROM/AN/Intrapartum invasive procedures (FSE/FBS/instrumental/epis) - cord blood/paeds/PEP/Formula feed safer than BF/HIV service *low CD4 - risk of pneumocytis pneumo/toxo reactivation **folate 5mg if on co-trimoxazole for pneumo prophylaxis ***if PPROM - d/w ID/Paeds ?VL, MTCT vs prolonged gestation ****MTCT <1% if undetected VL - can have VD
139
Unsighted pregnancy w PVB (encounter 1)
HE - hx of ectopic/smoke/IUD/tubal surgery & path/IVF/spec - ?POC - MC/ectopic pregnancy/normal preg - NBM + IVC + IVT +/- analgesia - bHCG - baseline/FBE/UEC/LFT - in case need MTX/G&S - Rh +/- STI screen - COGU TV USS to site the pregnancy - D/W consultant/Await Ix results *TA USS if unable to tolerated TV **nothing on USS -> rpt bHCG In 48/24 +/- rescan if >1500 ***if bHCG falling, track to 0 ****if severe pain/bleed - laparoscopy
140
Non-consensual IC (sexual assault)
HE - pain/bleeding/injuries - circumstances/assailant/police - comprehensive OGHX/med hx - vitals ... - refer to CASA - forensic examination/evidence/counselling - refer to SW - +/- refer to Police (if patient agree) +/- psychiatry input - Preg risk - EC/FU in 3/52 serum bHCG - STI - bloodborne/STI/d/w ID/PID abx/HIV or HBV PEP - Chase result/F/U in 1 week *if can’t examine & acute bleeding, need EUA +/- repair **empirical PID rx = ceft/doxy/metro ***initial blood borne may be normal - but need to recheck
141
- UPSI -> declined EC, bHCG2700, asx, 2cm left tubal mass - CS scar on TA USS in ED -> CS scar TV COGU USS (when asked) - UPSI -> failed EC, cervical ectopic - +'ve bHCG on urine at IUD clini (encounter 2)
HE - pain/bleed/vitals/peritonism Ix - bHCG/FBE/UEC/LFT/Rhesus/TV USS Ectopic pregnancy is not viable R2U - rupture/bleed/surgery/death Expectant - asx, bHCG <1000, not live, can f/u - bHCG track/monitor sx - early pregnancy USS next preg Medical - asx, bHCG<3500, not live, <35mm, f/u - MTX, d4-7 aiming for >15% drop +/- anti-D - if fail, 2nd inj, weekly bHCG till 0 - SE: GIT upset/agranulocytosis/liver... - contra3mo/avoid NSAID/etoh/folate - early pregnancy USS next preg Surgery - sx, b>=3500, live, >=35mm, cant f/u - day case, lap, GA, salping, histo.. - risks gen/specific...15% drop in fertility +/- anti-D - postop F/U in 6/52 - early pregnancy USS next preg *Cervical - suction/hysteroscopic resection vs intra-sac asp + systemic MTX **CS scar - lap wedge (exogenic) vs suction/hysteroscopic resection (endogenic) > intra-sac asp +systemic MTX > expectant ***Interstitial - lap wedge vs intra-sac asp + systemic MTX vs expectant ****MTX is only appropriate for someone who can attend F/U and is HDS
142
cervical ectopic post MTX - p/w PVB/Pain (encounter 3)
HE - pale/hypotensive/tachycardic/peritonism Mx - I'm concerned about a ruptured ectopic causing internal bleeding - Gynae emergency - Call for help = MET call - Require MDI for simultan resus/ix/rx - ABC - O2 hudson/x2 WB IVC + bolus IVT + IDC + Keep warm - FBE/UEC/Coag/G&S + X-match 2units - Inform consultant/anesthetic/OT - Arrange for urgent transfer to OT for laparoscopy +/- laparotomy rx of ectopic - Intra-op 1g Txa/specimen to path - HDU/ICU postop + repeat bloods & correction of anemia - Debrief/document postop/OP F/U
143
Laparoscopy for rx of ectopic Bleeding from anterior abdo wall from LIF port insertion (encounter 3)
- injury to inferior epigastric artery - stop operation/tamponade - inform anesthetist/consultant for support - request foley catheter/insert through port site and inflate to tamponade - percutaneous suture to close port site/check with IAP lowered - ports out under vision - intra-abdominal drain and monitor OP - postop open disclosure/document/MDT/anemia correction
144
50yo sudden onset RIF pain N&V (encounter 1)
Hx/Exam - fever/chills/dysuria/diarrhea/last BO/LOW/analgesia req - OGHx - parity/MOD/menopause/CST/PID/dysplasia/ca - PHx - appendix/Surg/med/FHx - BC/CR/EAC/SHx - support/SAD - V/A/B/abdopelvic - bimanual/cervix - I'm concerned about an ovarian torsion 2nd to unknown ovarian mass - also need to exclude ectopic pregnancy/appendicitis/diverticulitis/BO - NBM + IVC for FBE/UEC/LFT/CRP/G&S/bHCG+ IVT - Urgent TV USS to exclude uterine/ovarian mass/doppler signs of torsion +/- TMs - including CA125/CEA/CA19.9 - Where sx persist/worsen, consider theatre for diagnostic lap +/-... *partially workup mass/suspicious - seek GONC opinion/assistance/frozen **desire fertility = USO+PW +/- Omentectomy ***peri/postmeno = USO vs BSO vs TAH/BSO + PW +/- Omentectomy
145
50yo, sudden RIF pain USS show 6cm right adnexal mass pending TMs at time of surgery Post Laparoscopy + USO + PW Pathology = BOT(borderline) , cytology = N (encounter 2) 24yo, torsion CA125 - 52 Pathology = BOT mucinous (encounter 2-3)
Hx/Exam - pain/bleeding/fever/chills postop - wound review - TM results - BOT is not cancer but have unknown malignant potential - Chance of BOT in the other ovary, early stage = 95% 5yrs - Refer to GONC MDT/clinic for discussion of further mx +/- anesthetic PAC - Usually does not need chemo but may require completion surgery to stage - Options likely involve surveillance vs pelvic clearance - Surveillance involves 6-12 monthly CA125 + TV USS - As you're peri/postmenopausal, pelvic clearance is recommended - Involving TH/BSO+/-omen+/-LN - multiday stay, GA, open or lap, path - MDT rv of path + OP F/U - SW/Counselling *appendicectomy if mucinous BOT **pts with unilateral stage I BOT, USO + PW + omental bx + bx of any peritoneal lesion rather than full staging for ovarian cancer ***intra-op frozen sections can help with making decisions about appendicectomy or not ****BOT needs life long F/U until pelvic clearance
146
28yo, G1P0, 15/40 Hx of Maternal Marfan's (encounter 1)
Hx/Exam - preg sx/AN care/Ix/OGHx... - Marfan's dx/cx/med/sx - PHx/Med/Surg/FHx - Marfan's/SHx... - AVB/cardioresp - murmur/FHR - medications are you're on are... - risk to you includes aortic root dissection/rupture/HF - risk to baby includes congenital heart disease To reduce risk to you - TTE to check aortic root diameter + valve function (baseline + recheck) - refer to MFM/Cardiology for care - continue or commence b-blocker - MOD depends on aortic root diameter - intrapartum - epidural/short 2nd/minimize Valsalva - postpartum TTE + cardiology rv To reduce risk to baby - genetic counselling re: risk of congenital heart disease - tertiary morphology + fetal echo *Root diameter <40mm = normal, >45mm = elCS
147
28yo, G1P0 maternal Marfan - mitral regurg + aortic root38mm TTE = N, on metoprolol Precipitate birth 36/40 Emergency buzzer - PPH (encounter 2)
Hx/Exam - 3rd stage/placenta/symptoms - SOB/chest pain (plac in-situ, SOB) - vitals - HR155 BP100/70 ?RR ?temp - PPH is an Obs emergency - likely 2nd to precip birth - Call for Help - Code Pink - MDI for resus/ix/stabilisation - ABC - hudson o2/x2 WB IVC/IVT/IDC - FBE/UEC/LFT/Coag/G&S + x-match 2 units - Active 3rd stage (avoid ergot due to cardiac condition) - Attempt CCT +/- Dublin's - assess plac/membrane - Assess for tears +/- repair - Uterotonics (avoid ergot)...carbprost/Txa/40IU synt infusion/misoprostol - Ongoing PPH -> urgent OT T/F... - In the setting of mitral regurg + tachycardia - I'm concerned about sudden SOB may be 2nd to APO - need also to exclude aortic root dissection/rupture - urgent mobile CXR to exclude APO - seek opinion from CTS re: CT-aortogram - once resuscitated, strict fluid balance, judicious use of fluid, rate control - once stabilized pending other ix -> HDU for monitoring - debrief - risk of PTB/PPH/document/routine PP care - correction of anemia - TTE and F/U with Cardiology on DC
148
- ref for irregular menses - ref for irregular menses/PCOM - ref for irregular menses/obesity - PI (encounter 1)
Rotterdam criteria - PCOS Impact - fertility, general health, pregnancy Fertility - weight loss + metformin (MDT wt loss mx clinic - diet/exercise/meds/surg - TTC - F/U if unsuccessful then try - OI/IUI/IVF - Clomid/Letrozole/ovarian drilling (CREI) General health - BSL/lipid/HbA1c - Endometrium - COCP - wt based vs cyclical P/mirena - Hirsutism/acne - cosmetic - electrolysis/wax/topical rx - MH/OSA - psychology/resp physician Pregnancy - early OGTT to detect GDM *COCP - caution BMI >=30, CI for BMI>=35 **pre-menopause ET - highest 16mm in secretory, if oligo, don't know which stage of cycle, borderline ET/high BMI - consider sampling
149
28yo, known PCOS on bkg of high BMI (high 30s) Seen initially for irregular menses Return to F/U for rv (encounter 2)
Hx/Exam - weight loss/hirsutism rx - cycle regulation/compliance with meds - other issues - exam - BMI/hirsutism Info provided from Hx/Exam - BMI increased to 40s - use COCP for limited time - TCC for 9/12 no success - oligomenorrhea - want assistance with fertility - PCOS/anovulation likely the main cause of sub-fertility - Need to exclude other causes - E2/LH/FSH/P4/TFT/Prl/AMH - Pelvic USS to exclude EH/SMF + antral follicle count - HyCoSy to check tubal patency - also bring in partner for rv in F/U visit for hx/exam + SA - PCOS/high BMI increase risk for pregnancy/fetal development - weight loss is critical prior to conception - refer to MD Wt loss clinic - med - GLP1-receptor ag/Bariatric surg - need contraception whilst attempting weight loss - once BMI optimized - need preconception supp (high FA) + Ix - with BMI optimized and infertility ix completed, no cause - if unsuccessful with TCC, would recommend OI - 1st line letrozole... *important to cover other long term aspects of PCOS - BSL/Lipid/Cardiovascular health with GP
150
PCOS risk to mum/baby in preg BMI risk to mum/baby in preg
PCOS risk to mum - high GWG/GDM/PET/emCS risk to baby - MC/FGR/PTB BMI risk to mum risk to baby
151
9/40 thrombocytopenia (encounter 1)
HE - bleed/bruise/previous hx/VTE/meds/BP/rash - I'm concerned about ITP/contact Haem for advice - need to exclude other causes include GTP/SLE/APLS/PET/HELLP/DIC/Autoimmune - FBE/blood film + UEC/LFT/Coag/Hemolysis screen/uPCR/ANA/aPLs *sepsis can also be a cause **sepsis -> TTP -> manifest with flu-like/diarrheal illness -> fever + thrombocytopenia + hemolysis -> seizures +/- BP
152
Flu-like sx/HA/Fever +/- BP Thrombocytopenia Hemolysis High bilirubin/LDH Normal LFT
- TTP/PET/evolving HELLP
153
Hx of VTE in pregnancy New thrombocytopenia in pregnancy 18/40
DDx - most likely APS but need to exclude the others DDx - can be APS + concurrent ITP (PET/SLE screen -'ve, APS screen +'ve) Haem advice - complex area Mx is about = rx of thrombocytopenia vs anticoagulation for VTE for low plt Thrombo does not reduce VTE risks Still need LMWH, safe to give plt >50-60 if no active bleeding Peripartum/postpartum anticoag plan made antenatally e.g. cease 24/24 before IOL, stop when labour commences etc... Rx of thrombocytopenia 2nd to APS + concurrent ITP IVIG/dexamethasone Plt count monitoring
154
APS in preg
Baseline bloods - FBE/UEC/LFT/uPCR HR MFM + Haem care LDA + Ca from 12/40 PET risk Reg OPC - BP/urine dip to screen for PET +/- LMWH to prevent VTE Serial G/S from 28/40 FGR risk IOL from 39/40 SB risk
155
ITP confirmed (encounter 2)
ITP = autoimmune/ab against plt R2U = APH/PPH R2B = neonatal thrombocyto 5-10%, small risk of ICH antenatal/intrapartum RR4U - MFM/Haem ref - monitor plt regularly 2-4/52 - plt transfusion +/- IVIG/Pred when plt <20, symptomatic, or plan procedure - aim >80 for regional, >50 for NVD or CS or IM injection - optimize anemia + active 3rd stage +/- anticipate PPH +/- x-match - rpt plt postpartum + F/U with Haem RR4B - no VE/FBS/FSE - cord blood FBE + daily FBE to monitor for plt nadir - neonatal review +/- rx with IVIG +/- cranial USS to exclude ICH if plt <20 *anemia in setting of ITP - need to optimize anemia **home birth request in setting of ITP - don't recommend, need to birth where 24/24 blood bank -> plt availability ***if thrombocytopenia and concurrent LDA for PET prevention, consider stopping
156
Early GDM
early GDM, need to exclude pre-existing T2DM risk to mum - PIH/PET/operative delivery/DM risk to baby - MC/congenital abnom/polyp/PTB/LGA To reduce risk for you - check HbA1c to exclude T2DM - regular 2 weekly high-risk clinic with BP/urine dipstick - refer to endo/DNE for rv/education - BSL monitoring To reduce risk for baby - tertiary morph +/- fetal echo - 4 weekly serial G/S from 28/40 *gliclazide is not used in pregnancy
157
34/40 SOL Presumed ITP on pred (encounter 2)
HE - frequency/duration/SROM/spec-cervix/RTS-cephalic - inform con/paeds/haem/ano - urgent FBE/G&S + check plt availability - plt <50 = transfusion, >80 for regional - hydrocort intrapartum if on pred/active 3rd stage/daily FBE post - CEFM in labor/IV benpen/avoid VE/FBS/FSE/high forceps/cord blood FBE/paeds rv *cranial USS to exclude ICH if plt <20
158
60yo Vulval itch (encounter 1) Side issues - FHx of Osteo - Menopausal sx mx - Missing CST
Hx/Exam - SA/dyspareunia/impact on life - PMB/urinary/bowel sx/VMS - OGHx - parity/MOD/CST/MMG/FOBT - PHx - autoimmune/atopy/Surg/Med/FHx- osteoporosis - SHx - support/SAD - AVB/external/vulvoscopy w AC - plaque/loss architecture/bx/cellulitis/inguinal lymph nodes/spec - vagina - sparing/cervix ---------------------- menopausal sx - LS/Mx options briefly not done CST - will perform today FHx of osteoporosis - vit D/Ca/Dexa +/- Endo +/-bispho fissure/erythema/white papules/left labial lesion 3cm ------------------------ - I'm concerned about LS, need to exclude VIN/SCC - need to confirm on vulvoscopy + bx + MCS to exclude bacterial infection - autoimmune/incurable/risk of ca transform - need lifelong f/u - ultrap top steroid (clobetasol) vs high dose diprosone ointment - avoid soap/detergent/use emollient/loose clothing - chase histology +/- refer to Vulval Derm vs GONC - need F/U in 3mo to check effectiveness then annually *if rx (LS mod/steroids) not effective for sx improvement - consider anti-histamine, topical E2, TCA, pain modulator, vulvectomy (last line) **risk for osteo - early meno/vit d def/FHx
159
60yo vulval itch, bx performed in OPC home with high dose diprosone awaiting Ix result histology = SCC w dVIN (encounter 2)
Hx/Exam - sx improvement with ointment - healing of bx site - SCC is skin cancer + dVIN is the precancer component - Prognosis is good if confined to skin, no nodal disease 90% 5yrs vs 60% if node + - Urgent ref to GONC MDT/RV - Likely need additional Ix - CTAP/FBE/UEC... - Likely need WLE + SLND, PAC - anesthetic/SPAC - Multiday, GA, aim to remove and assess spread, path - GONC MDT/FU rv, if +'v LN, likely need adj RT - post rx, will need surveillance with GONC for many years
160
60yo vulval itch, bx performed in OPC home with high dose diprosone awaiting Ix result histology = dVIN vs uVIN (encounter 2)
Hx/Exam - sx improvement with ointment - healing of bx site - dVIN is precancer, related to LS - 50% of ca transformation, 50% recurrence - untreated dVIN -> SCC, average 2-4yrs - vulval derm referral for rv/mx plan - options include 1. surgical- WLE (recommended) as high risk for ca transformation 2. medical - imiquimod/ablation - laser when multi-focal - laser is usually under GA F/U - lifelong F/U (dVIN) - likely need F/U 6-12/12 for 5yrs (uVIN post surgery) *uVIN - same treatment options (surg > laser > imiquimod), but usually laser preferred esp if multifocal, as is HPV related, HPV vax, smoking cessation, reg CST **imiquimod SE - flu like sx, fever/lethargy, 3 weekly - 12-20 weeks of rx ***uVIN/HSIL - usually multifocal young women, 12% resolve in spont12/12, average 7 yrs to SCC if untreated, 50% also develop CIN/VAIN/AIN +/- SCC
161
26yo G2P1-1 P1 27/40 PTL emCS abruption - HIE - CP (L3 support) SOL 26/40 7cm dilated not wanting steroids/active mx/resus (communication station)
Intro Acknowledge Sorry Story Solutions Support Second opinion Relevant clinical information - role of steroid = reduce risk of RDS/ICH/NEC - role of MgSo4 = neuroprotection - recommended MOD = emCS > VBAC, can't monitor baby intrapartum & VBAC hx - survivability of PTB = 22/40 10%, 24/40 60%, 27/40 90% 34/40 = full term - disability of PTB = <24/40, very high chance, 40% will have long term health cx Second opinion - Paed rv - Obs Consultant rv
162
30yo, G1P0 31/40 Moderate speed MVA in rural hospital ED (encounter 1)
Hx/Exam - Details of MVA - FM/APH/SROM/TPL - AN care/Ix - Hb/rhesus +/- antiD/S/R/Aneuploidy/Morph/OGTT/G/S - OGHx - parity/mod/pelvic surgery - PHx/Surg/Med/SHx - support/SAD - vitals/seatbelt sign/abdo/uterine tenderness/contractions - CTG/RTS - presentation MVA - ? abdo trauma Abdo trauma can result in placental abruption/uterine rupture Risk to you = internal bleeding/emCS Risk to baby = PTL/PTB/FMH/SB - care require MDI - trauma survey by ED/trauma team +/- left lateral if supine with spinal precautions. +/- empirical anti-D 625IU if rhesus -'ve - kleihauer sent to exclude FMH + 4 hours CTG monitoring - if stable, for DC home with OP Obs USS to check fetal wellbeing + OP F/U *same rx as above for suspected pelvic # except liaise with ortho - implications - mobility/ROM of hip - elevated VTE risks in preg + may alter MOD **CTAP or CTPA - low risk for fetal anomaly, theoretical risk of childhood cancer, pros vs cons
163
30yo, G1P0 31/40 Moderate speed MVA in rural hospital ED Cleared from ED Sent to BC to complete CTG/Monitoring Developed constant abdominal pain + PVB Rhesus -'ve (encounter 2)
Hx/Exam - FM/contractions - vitals/abdo palp (woody) - CTG (fetal tachy+lates)/presentation (breech)/speculum (closed) - abruption/uterine rupture 2nd to MVA - this is an obs emergency - call for help - code pink/green - MDI for resus/ix/delivery - ABC - o2 hudson/x2 WB IVC/IVT/IDC - FBE/UEC/LFT/Coag/G&S/Kleihauer + x-match 2 units - Cat 1 emCS +/- classical under GA vs Transfer (31/40 rural hospital) (D/W with PIPER ?likely delivery then transfer, unlikely to have time for steroid loading with NRCTG and needing Cat 1 emCS) - assess for clots in uterus/rupture/plac to histo - Cord gases + blood group/Paeds at birth - HDU postpartum/Debrief/Document - Anemia correction + CS check - Anti-D according to FMH
164
24yo, G1P0 28/40 P/W fever/chills/coryzal sx/SOB (encounter 1)
Hx/Exam - N&V/fever/chills/cough/coryzla/sick contact/rash - Preg sx.. - AN ix/care... - OGHx...PHx-asthma...SHx..SAD... - vitals - RR/sat/cardioresp ?creps/FH/CTG/RTS (fever/chill/N&V etc...not vaccinated, smoker, desat/tachycardic) I'm concerned about influenza/covid on bkg of RFs risk to you includes pneumo/resp failure/ICU/emCS risk to baby includes PTL/PTB/Hypoxia/fetal distress To establish severity and find a cause - FBE/UEC/LFT/CRP +/- ABG +/- BC (if febrile) - Nasopharyngeal Viral PCR to identify pathogen - Sputum MCS if expectorating - CXR to exclude pneumonia - ECG to exclude tachyarrhythmia To reduce risk for you - Admit for observation/treatment (isolation) - MDI from Obs Med/ID/PT - chest physio - O2 + salbutamol neb + broncholytic - IVT + antiemetic + antipyretic - VTE prophylaxis (consider clexane) +/- antiviral +/- antibiotics - if HR/RR remains high despite rx -> consider CTPA to exclude PE - if deteriorating -> ICU support +/- delivery if unable to stabilize To reduce risk for baby - obs USS to check wellbeing - daily CTG - steroid loading +/- Paeds rv if decompensating and need delivery If stable DC, ongoing AN care involves... *COVID rx = steroid/mab/antiviral, clexane - beware if need urgent delivery
165
24yo, G1P0 28/40 COVID + on resp ward on O2 + monoclonal ab ATSP re: deterioration (encounter 2) alternative scenario with influenza with resp compromise
Hx/Exam - SOB/FM/APH/SROM... - vitals/WOB/cardioresp/spec -cervical dilation/CTG HR130 BP110/70 RR35 Sats 85% on 4L o2 T39 check crackles/increase WOB at rest cervix long closed, reduced variability with decels (not in labour) - I'm concerned about resp failure and imp for mum/baby - this is a medical & obs emergency - call for help - MET - req MDI for simultaneous resus/ix/stabilisation +/- delivery - ABC - increase flow on hudson mask to 10L/x2 WB IVC/IVT/IDC - rpt bloods FBE/UEC/LFT/CRP/BC/ABG/G&S, continue CTG - fetal distress likely 2nd to mat hypoxia - aim is to stabilize and improve oxygenation - without improvement on resp - will need to consider cat 1 del - inform con/request ano/paed rv - NBM + steroid loading +/- MgSo4 if need to expedite Cat 1 Del - consent for GA emCS +/- classical - cord gases/paeds at birth, ICU for resp support postpartum *postpartum COVID - refer to guideline for VTE prophylaxis
166
30yo Transgender XX - identify as male Referred by GP for mx of HMB wanting to preserve fertility Unremarkable Hx Normal Pelvic USS *no menstrual hx included* Humiliated by ward clerk in waiting area. Embarrassed from events in waiting area. Opens with concern "am i crazy for still wanting a child"
Intro Acknowledge Sorry Story - HMB, fertility desires Solution Support Second opinion Summary Second visit Relevant clinical - HMB ix/mx options - Fertility options - spont/IVF
167
29yo, G3P1 25/40 acute joint pain
Hx/Exam - which joint/fever/chills/rash/coryzal/sick contact/VTE - FM/APH/SROM/TPL/PET sx - AN Ix/care/OGHx.../PHx... - vitals/malar rash/joint swelling/lymphadenopathy/FH/RTS-FHR - I'm concerned about SLE - Need to exclude infection/RA - FBE/UEC/LFT/ANA/anti-DS DNA/C3-4/RF/anti-CPP/ESR/CRP - TORCH + Chlamydia/Syphilis - Formal Obs wellbeing scan - Obs Med opinion re: cause/additional ix/rx - Avoid NSAID, can have paracetamol - If it's SLE, and joint pain is related to flare, pred is the rx
168
29yo, G3P1 37/40 earlier dx with SLE in preg (hypothetical) flare of joint pain P1 twin emCS 32/40 for abruption P2 VBAC (Encounter 2)
HE - joint/rash/FM/APH/SROM/PET sx/vitals/BP/Fundus/CTG - PET vs Lupus flare - check severity of flare/exclude PET - FBE/UEC/LFT/anti-DS DNA/C3/4/uPCR - check fetal well-being - Obs USS - pregnancy exacerbate SLE -> more flares - refer to Obs Med re: flare treatment options - likely pred - discuss with MFM re: timing of delivery ?IOL for worsening joint pain - IOL would increase risk for VBAC cF to SOL - VBAC likely to be successful given previous CS indication & VBAC
169
Multiparous woman D10 postpartum Pt BIBA in COMA post grandmal seizure bkg of peripartum PET In ED, CTB shows cerebral vein thrombosis (CVT) (encounter 2)
Hx/Exam - collateral re: postpartum recovery/events preceding seizure - vitals - BP... - CVT blood clot in vein in brain, likely associated with PET - risk to you from CVT include more clots/seizures/infarct/bleed/raised ICP - risk to you from PET uncontrolled hypertension - CVA - require MDI from ICU/MFM/Obs Med/Neuro/Haem To reduce maternal risks Immediately - initial anticoagulation with LMWH - seizure prophylaxis with anti-epileptic vs ?MgSo4* - BP control to avoid other CVA Ongoing - Reduce VTE risks DOAC or warfarin 3-12/12/Avoid COCP as contraception - Reduce neuro risks driving restrictions/neurology F/U FI of seizure - Reduce risk of postpartum PET - Obs Med F/U - Ensure adequate support for family and newborn - Prophylactic LMWH throughout next pregnancy/postpartum *seizure likely from CVT > PET (usually during preg <48/24 post delivery)
170
26yo multi 21/40 p/w RUQ/Epigastric pain (encounter 1)
Hx/Exam - N&V/colicky in nature/fever/chills/urine/bowel - FM/APH/SROM/contractions - AN Ix/care - S/R/FBE/rhesus/aneuploidy/morph - OGHx...parity/MOD...PHx/Surg/Med/SHx... - vitals/jaundice/Murphy's/contraction/spec - cervix/liquor - I'm worried about cholecystitis - need to also exclude PET/HELLP/AFLP/Abruption/Uterine rupture - FBE/UEC/LFT/CRP/uPCR/BSL +/- hemolysis +/- LDH + hepatitic screen - Upper abdomen USS to exclude cholecystitis - RTS -FHR and formal Obs USS to check fetal welbeing - NBM/x2 WB IVC/IVT - simple analgesia +antiemetic +/- antibiotic - inform consultant and discuss with Gen Surg for rv/opinion
171
26yo multi 21/40 p/w RUQ/Epigastric pain confirmed cholecystitis failed medical mx general surgeon recommend lap chole explain risk and benefit (encounter 2)
Benefit - doesn't increase the risk of PTL/PTB cF gen pop - equally safe and more effective than expectant/supportive med mx Risk - surgical risks - injuries to surrounding organs... - anesthetic risks - reaction - postop recovery - VTE
172
26yo multi treated with cholecystitis ~21/40 contracting 33/40 (encounter 3)
Hx/Exam - FM/APH/SROM/onset of contraction - vitals/abdo - contraction/tenderness/spec or VE/CTG (CTG = sinusoidal trace) - Sinusoidal trace preterminal trace suggestive of underlying anemia - Obs emergency - requires immediate delivery - Call a Code Green - Urgent TF to OT for Cat 1 emCS under GA - NBM/x2 WB IVC/FBE/GS/Kleihauer/x-match 2units - Inform Paeds to attend birth - Intra-op 1. immediate clamp 2. Assess for rupture/abruption - volume 3. Placenta to histology 4. Cord gases - Postop debrief document identify any potential RFs organize F/U OPC
173
35yo G4P3 10/40 p/w PVB (encounter 1)
Hx/Exam - onset of PVB/pain/fever/chills/discharge/urine/bowel - type of conception/plan - AN ix/care - R/S/FBE/Rhesus/dating scan - aneuploidy booked... - OGHx - parity/mod/cx/CST/PID/STI - PHx/Surg/Med - folate/SHx - sup/SAD - AVB/cardioresp/abdopelvic - spec cervix (uterine prolapse on examination) PVB - PVB may be related to POP - need to exclude miscarriage/STI/dysplasia/UTI - MSU to exclude urinary tract infection - +/- endocervical swab STI screen +/- CST (if not done) - early pregnancy USS to check pregnancy viability POP - risk to you - discomfort/infection/PVB/urinary retention/labor dystocia - risk to baby - PTL/PTB/FGR To reduce your risk - refer to pelvic floor physio for PFE - seek opinion from Urogynae team ? pessary in pregnancy - pessary ring or space occupying to reduce POP, need F/U & change - consider elCS at term instead of VD if sig POP - consider surgery postpartum - sacrohysteropexy vs hysterectomy... To reduce risk for baby - consider steroid loading when viable - 4 weekly serial G/S from 28/40
174
35yo G4P3 13/40 known uterine prolapse abdominal pain (encounter 2)
Hx/Exam - location/onset/fever/chill/voiding difficulties/bowel - vitals/abdopelvic - fundus not palpable...spec...severe anterior displaced cervix...uterine prolapse... (not passed urine, tender supra-pubic, fundus not palpable, really anterior cervix) Urinary retention - I'm concerned about urinary retention - immediate mx is to insert IDC for relief - urinary retention likely second to incarcerated retroverted uterus - need to exclude cystitis with MSU MCS and consider empirical UTI rx - UEC + renal tract USS to exclude renal dysfunction/hydronephrosis - Discuss with Urogynae team re: timing of TOV and advice on prevention Incarcerated uterus - dx on clinical +/- TA USS findings uterus trapped in pelvis - risk to you - discomfort/urinary retention/uterine rupture - risk to baby - PTL/PTB/FGR/ To reduce risk for you - expectant/manual reduction (sx, 14-20/40)/surgical - as you're sx - manual reduction is recommended 1st line - day procedure, GA/regional, uterine relaxant, USS guided, posterior fornix - pressure fundus, RTS post to ensure fetal wellbeing, F/U and check - if persist beyond 20/40 or failed reduction, asx, closely monitor +/- ISC or IDC, elCS from 36/40 To reduce risk for baby - if can't reduce, steroid load when viable - 4 weekly serial G/S from 28/40 *surgical 1. colonoscopy reduction 2. intravaginal balloon 3. laparoscopic reduction
175
35yo G4P4 now uterine prolapse in preg returned to OPC postpartum with ongoing POP sx (encounter 3)
Hx/Exam - postpartum recovery/POP sx/incontinence - vitals/abdopelvic - POP-Q - consider RFs from Hx Mx - LS mod - cough/smoke/lift/BMI - Conservative mx - PT - PFE - as important as surgery Ut sparing 1. Lap sacrohysteropexy - mesh around cervix to sacrum, mesh cx, contra 2. Lap USL suspension - USL sutured to apex of vagina, no mesh, ureteric injury - +/- PAC, multi-day, GA, 4-6/52 recovery - general surgical risks of...specific risks of Ut removal - TH + vault suspension (e.g. SSF) - TH is performed by...VH/TLH/TAH...specific risks include... - SSF is performed by...specific risks include... - +/- PAC, multi-day, GA, 4-6/52 recovery - general surgical risks of... +/- AP repair +/- continence surgery + cystoscopy can be part of Ut sparing or Ut removing surgeries *https://www.yourpelvicfloor.org/conditions/uterine-preservation-surgery-for-prolapse/#What%20preparations%20are%20needed%20before%20the%20surgery?
176
Primip TF rural to tertiary Post SD c/b 4th degree Baby in poor condition in NICU (Communication station)
Intro Acknowledge Sorry Story Solution Support +/- Second opinion Summary Relevant clinic info - SD -> HIE - monitoring/testing/paed team provide update - 4th - antibiotic/analgesia/aperients/OP F/U/anal USS/discussion re: future MOD *expectation form this station is to provide a distressed woman with clear information regarding ongoing care
177
25yo multip acute PVB post recent suction for missed ab hx of low plt been investigated for lupus hx of Hashimoto thyroiditis (encounter 1)
Hx/Exam - fever/chills/offensive dc/urine/bowel - reason/details/circumstances around suction ?histology result - details for ix for low plt and lupus - OGHx - mod/parity...CST/STI/IC-contraception - PHx/Surg/Med/FHx/SHx - sup - vitals/EBL - abdo/spec - ?POC (suction for missed ab on nuchal 13/40) - I'm concerned about RPOC - need to exclude GTD->GTN/endometritis/new preg - bleeding worsened by low plt - FBE/UEC/CRP/bHCG/G&S to check hb/plt/infection - TV USS to exclude RPOC - Chase histo for previous POC
178
25yo multip acute PVB post suction for missed ab repeat TV USS show theca lutein cyst ERPOC = partial mole (encounter 2)
GTD - GTD is a tumor of placental tissue with malignant potential - Definitive management is evacuation of POC + bHCG tracking - Refer to molar registry for bHCG tracking until 0/contraception - no impact on future preg, recurrence risk is low - early preg USS, and placenta histo, bHCG 6/52 postpartum - if bHCG plateau/rise, concern for GTN - referral to GONC for MDT/OP - will need CXR +/- CTCAP + FBE/UEC/LFT (if thinking chemo) - single (MTX) vs multiagent chemo till bHCG = 0 Theca lutein cyst - conservative mx if no sx of torsion and small - lap drainage if large due to risk of torsion *partial tracking weekly till 3 consec 0 then no more **complete weekly till 3 consec 0 then monthly 6/12 ***GTN is hematogenous spread then CXR first
179
28yo Infertility Hx of LLETZ for CIN3 (encounter 1)
Hx/Exam - duration of TCC/IC/frequency - menstrual - length/duration/regularity - details of LLETZ/recovery - OGHx - rpt CST post CIN3/STI/PID...contraception - PHx/Surg/Med/SHx - SAD - vax - Hx about partner - PHx/trauma/infection... - AVB/thyroid/cardioresp/abdopelvic - spec - cervix ? stenosis (not had repeat CST post CIN3...) - I'm concerned about cervical stenosis - need to exclude other causes of PI... - D2-3 FSH/LH/E2/Midluteal P4...AMH/TSH/Prl... - TV USS +/- HyCoSy... - Repeat CST - bring partner to next visit + SA
180
28yo Infertility Hx of LLETZ for CIN3 PI Ix - Bloods = N - Uterine septum on USS - LSIL on CST (encounter 2)
Hx/Exam - change since last visit Uterine septum - uterine septum is a RF infertility - risk for implantation failure/recurrent MC - refer to tertiary gynae - hysteroscopic resection of septum LSIL on CST - on bkg of previous CIN3 - need repeat Colp +/- Bx... Further mx - plan for Colp + HDC +Diagnostic lap + Dye studies for Ix of PI - HDC can confirm imaging findings before planning resection - day procedure, under GA, risks include... - alternative = HyCoSy ?structural abn + tubal patency & perform Colp as OP
181
28yo G2T1 p/w amenorrhea on bkg of mirena mirena string missing on exam USS show IUP 12/40 + IUS in abdomen (communication station)
Intro Acknowledge Sorry Solution Support Summary Second opinion Second visit Relevant clinic - IUS abdomen - laparoscopic retrieval - IUP - continue vs TOP - suction - plan for diagnostic lap/IUS retrieval + STOP + mirena reinsertion vs implanon... Expectation is to communicate finding and discuss options available
182
22yo p/w vaginal pain/bleeding on bkg of unplanned pregnancy (encounter 1)
Hx/Exam - abdo pain/dysuria/bowel/fever/chills/?contraception - unplanned ? desire to continue - LMP/regular/length/dysmeno/CST/STI/#partners - OGHx - G&Ps.../PHx/Surg/Med/SHx - SAD... - AVB/EBL/cardioresp/abdopelvic - bimanual/spec - cervix/POC Bleeding - likely MC but need to exclude ectopic - FBE/UEC/LFT/G&S/bHCG exclude infection/rhesus status/baseline bHCG + suitability for MTX if ectopic confirmed - TV USS to exclude ectopic pregnancy Vaginal pain - need to exclude STI - endocervical PCR for chlam/gon/MG/HVS for BV/trich - NBM + x2 WB IVC + IVT whilst await Ix - in case significant PVB requiring OT
183
TOA not resolving Need OT what to do to optimise mx
preop - IVabx/ano rv/consent intraop - entry technique/senior/txa/adhesio/drain postop postop - ICU/HDU/IV abx/ID/observe/PO switch/OP f/u
184
22yo p/w vaginal pain/bleeding on bkg of unplanned pregnancy TV USS show incomplete or inveitable MC Chlamydia infection on PCR (encounter 2)
Incomplete MC or missed ab - risk of pain/bleeding, common 20%, no impact on future preg - options - expectant/medical/surgery - expectant/medical - mife/miso, SE = pain/nausea/bleeding, risk is need for admission +/- further procedure, timing unpredictable, done at home, support, antiemetic/analgesia, access to hospital, F/U bHCG or USS - surgery - suction, day procedure, GA, quick recovery, risks include...specific - asherman/RPOC/uterine perf/POC to path to exclude GTD - +/- LARC insertion (with STI screen +/- treated - not for insertion if symptomatic with STI infection - ie PID) Chlamydia infection - chlam is an STI +/- screen other STI if not done - risk of transmission to others/PID -> CPP/infertility - treatable with antibiotics (doxy or azithro), retest in 3mo - notify partner, test, treat with GP - no IC until 1/52 after both are treated - use barrier contraception in future to prevent - TOC in 4/52 not req unless preg, test for reinfection in 3/12 req Unplanned pregnancy - long term contraception - consider menstrual hx/previous contraception/pt preference - hormonal vs non-hormonal...overall reliable, systemic vs local SE - implanon vs IUS @time of suction for MC vs OP *indication for suction curettage - heavy PVB/pain/infective signs/RMC - POC for testing/large G/S+CRL
185
22yo represented with abdo pain/fever/chills/offensive PV dc post D&C for incomplete MC, on bkg of chlam (treated previous admission) (encounter 3) 15yo chlamydia+ & TOA on pelvic USS in setting of Ix of LAP w vaginal discharge failed medical -> had laparoscopy -> intra-op goal/F/U (encounter 2-3)
Hx/Exam - ?UPSI again/?partner rx/fever/urinary/bowel - vitals/abdopelvic - peritonism/bimanual/spec - cervix - dc (cervical excitation...) - I'm concerned about PID 2nd to chlam - need to exclude new pregnancy-ectopic/cyst accident/non-gynae - FBE/UEC/CRP/bHCG/BC - HVS MCS +/- STI screen (depending on timing from last) - TV USS to check for TOA (pelvic USS confirms TOA) - TOA is...risk include adhesion-infertility/CPP - admit+ IVC + IVT + VTE prophylaxis + anti-pyretic - IV antibiotic - azithro+metro+ceftr - aiming 48/24 afeb-> PO - seek opinion from ID re: choice and duration of abx - monitor clinically/biochemically for improvement +/- drainage - need F/U with USS 2/52 prior to OPC w Gynae/ID - to decide duration of abx - subsequent F/U USS to assess resolution + TOC + barrier contraception - contact tracing - test/rx *consider drainage if >9cm TOA, postmenopausal, unresponsive to IV ABx - clinical or biochemical deterioration, decision to drain is a difficult one, benefit must overweigh the risks - high risk injury to organs/bleeding due to adhesion **surgical approach to TOA should be conservative - ie. drainage for source ctrl rather than extensive adhesiolysis, must discuss long term implications post-op ***send MCS from wash out sample
186
vaginal lump in preg (encounter 1) alternative
Hx/Exam - fullness/drag/PVB/DC/dyspareunia/difficult urine/bowel/fever/c - preg sx (gestation dependent) - AN care/ix - sup/vax/r/s/fbe/rhesus/aneuploidy/morph/ogtt/GS - OGHx - parity/MOD/cx/CST...PHx/Surg/Med/SHx - sup/SAD - AVB/cardioresp/abdopelvic/external inspection - vulva/spec - urethra/cervix/POP/cyst/+/- RTS+/-CTG (small, not overtly symptomatic, no impact on life) Lump in vagina - Lump is a vaginal wall cyst - likely Gartner's cyst - It is not a POP/Bartholin's cyst/Skene's duct cyst - This is a benign congenital growth of FRT - confirm with TV USS or MRI - exp mx, and intrapartum if obstructing - aspirate - postpartum review in OPC for mx + gestation appropriate RANC *Skenes duct cyst if large enough can cause bladder outlet obstruction/recurrent UTI - rx = expectant/medical/surgical - antibiotics for UTI, surgical = aspiration vs ID+marsupilisation vs excision
187
gartner's cyst in preg now postpartum return to talk about cyst mx (encounter 3)
Hx/Exam - peri/pain/bleeding/VTE/BF/mood/preg interval/contraception - fullness/difficult urination/sexual function - AV/fundus/spec - cyst - Gartner's cyst mx options = exp vs surgical - ID + Marsupilisation vs Excision - ID + Marsupilisation involves... - Excision involves... - Renal tract to exclude ectopic ureter if excision - Day procedure, regional/GA, quick recovery, risks include... - Routine postpartum care + advice + contraception
188
painful rash in T2 (encounter 1-2)
Hx/Exam - location/onset rash/myalgia/fever/chills/cough/sick contact - FM, APH/SROM/TPL... - AN care/ix - gestation dependent - OGHx - parity/mod/cx...PHx - hx of chicken pox...Med/Surg/SHx - AVB/cardioresp/rash dermatome/RTS/CTG - I'm concerned about shingles, VZ reactivated - risk to you neuropathic pain/febrile illness/LRTI - risk to baby to have FVS is exceedingly rare as your abs cross - risk to other people around you who hasn't had VZ - lesion swabbed for PCR to confirm - FBE/UEC/CRP to exclude systemic involvement - D/W MFM/ID re: need for amnio + USS 5/52 post exposure - return home, isolate from old/young/immunocompromised - monitor sx -resp/encourage PO fluids/acyclovir/antipyretic - consider neuropathic pain agents (pregabalin if residual pain) - gestation appropriate RANC
189
vesicular rash at 10/40 (encounter 1)
Hx/Exam - exposure-duration/immunity/fever/chills/rash onset - preg sx - FM... - AN care/ix to date... - OGHx - parity/mod/cx..PHx/Surg/Med/SHx - sup/SAD... - AVB/distribution of rash/cardioresp/abdopelvic+/-spec/RTS/CTG - VZV - viral infection - risk to you pain/fever/pneumo - risk of your baby FVS/FGR/PTB - FVS is low <2% <28/40, 0%>28/40 - urgent VZV serology (IgG/IgM) to confirm - d/w MFM/ID re: testing + rx +/- amnio for PCR +/- USS 5/52 +/- ZIG <96/24 +/- acyclovir >96/24 - isolate from young/old/immunocompromised - antipyretic/fluid/monitor for rash +/- rx - gestation appropriate RANC - postpartum ref to Paeds for rv +/- test +/- isolate
190
Pre-op planning - Hx of VTE
- Details of personal VTE + rx + cx + ix - FHx of VTE and any inherited thrombophilia testing -FVL/PT/AT/Protein C/S def - D/W Haem re: periop anticoagulation - Pre-op - anesthetic PAC - Intra-op - sequential/meticulous ctrl/avoid Txa - Post-op - prophylactic clexane +/- DOAC on DC/TEDS/ambulation - +/- referral to Haem for OP thrombophilia screen
191
Incidental anti-Kell antibodies detected Incidental anti-D antibodies detected (encounter 2)
HE - ? hx of transfusion - anti-Kell is an antibody that can cross plac and dmg baby's RBC - risk of hydrops/SB/HDNB - urgent referral to MFM for rv and mx - urgent anti-Kell ab titre + paternal genotype - paternal genotype will determine ongoing mx - if father KK/cc/DD - need weekly MCA PSV from 16/40 ?anemia/titer monitor - if father Kk/Cc/Dd - need to genotype baby +/- MCA PSV/titer monitor - If father kk/CC/dd - won't need any further mx - if anemia on MCA PSV - steroid/cordocentesis +/- IUT - notify Haem ahead of time to x-match in setting of antibodies - IOL 37-38/40, CEFM, cord blood FBE/G&S/Coombs/Bili, paeds rv * same for anti-c, and anti-D are the key issues **anti-D, >=1:16 - fortnightly titre required, <1:16 - monthly ok ***Weekly MCA PSV from 16/40 (straight away for anti-Kell, but for anti-D, when titre >=1:32…) ****genotype of fetus cfDNA vs CVS/amnio - if -'ve no risk for HDN, but risks still exist for future pregnancy assuming same dad
192
18/12 of infertility Hx of appendicitis in childhood
HE - Appendicitis -> ?rupture -> ?peritonitis -> adhesion - IC frequency/menstrual/OGHx...PHx...partner rv - PI Ix include for Male infertility factors - Precon ix + advice - LS/sup/vax (tubal infertility) - HyCoSy - day/saline/discomfort/may unblock tubes/mainly diagnostic - Diagnostic lap + dye studies - see below/day/ga/risks... - Bilateral salpingectomy - if bilat hydrosalpinges undergoing IVF *Diagnostic lap is useful in infertility ix if pt is young with Hx of PID/ectopic/pelvic surgery/CPP - if adhesion or endo is found - division may improve fertility **Diagnostic lap can be avoided in older individual with multiple infertility factors - better serviced by IVF instead of surgical approach (e.g. women with bilateral tubal occlusion/severe hydrosalpinx/extensive adhesions ***pelvic USS vs HyCoSy - pelvic USS also look at adnexae/AFC ****hostile abdomen - palmer's/MDT/L6 surgeons
193
Infertility workup must do
- infertility ix - female/male factors - preconception ix - preconception advice
194
Infertility workup SA show sperm count <15mil/ml (encounter 2)
Hx/Exam - pain/swelling/anosmia - LS - bike riding/hot tub/sauna - PHx - orchitis/Surg - undescended testes/Med/SHx - SAD - Exam to exclude varicocele/hydrocoele and palpate VD - concentration of sperm is low - need to exclude Kallman/Kleinfelters/microY deletion/CF - rpt SA + FSH/T +/- karyotype - tran-scrotal USS to exclude CBAVD - refer to CREI + Genetic counselling for further rv + mx - likely need ART - IVF with ICSI - retrieval/ICSI vs donor sperm - in small cases, there's a medically or surgically reversible cause (e.g. surgical repair for large varicoele) *semen analysis range - 1.5ml, 15million/ml, 40%, 4% **DDx of oligospermia Pre-testi – Kallman (low FSH/low T) Testi – Kleinfelters, microY deletion (high FSH/low T) Post-testi – CF
195
FHx of CF Preconception What can be done to reduce risk
- need CREI rv + Genetic counselling - preconception - carrier screening - sequential vs combined (if partner not carrier - no risk to baby) - preimplant - IVF + PGD +/- prenatal testing (con = need IVF) - prenatal - amniocentesis +/- TOP (con = TOP)
196
Apareunia post radiotherapy for cervical ca Apareunia post VH for POP - short/narrow vagina (communication station)
intro/ack/sor/stor/sol-draw/sup/sec/sum/sec Relevant clinical points - Radio -> vaginal atrophy & stenosis - previous difficulties is important to know - other RFs - SA/abuse/traumatic birth/traumatic 1st IC/surgery - referral to sexual health/physiotherapy - stenosis - dilator/pelvic floor - atrophy - dyspareunia = lubrication +/- E2 - pain - SSRI/SNRI/Tricyclics Aim from station - Appropriate sexual health history - Conversation is meant to enable pt to reveal RFs (i.e. sexual abuse in this case)
197
CTG interpretation
- verify pt name - gestational age - indication of CTG +/- uterine activity - identify baseline - variability - acceleration - deceleration - maternal HR - interpretation
198
Demonstrate pudendal block
- consent - IDC insertion - palpate ischial spine 1 finger breath in 4 & 8 o clock - 1cm anterior/medial from IS/1cm deep - withdraw needle + inject - repeat on contralateral side - perineum infiltration - wait for effect *left hand for left, inject with right...
199
Demonstrate forceps
- indication - consent - inform con/paeds - check adequate contractions - clean perineum - empty bladder/analgesia - e.g. pudendal - VE to check dilation/position/station - check blades unlock/lubricate - left blade in, right blade in, lock - check no rotation >45, sag suture mid-way - pull with push/contraction... - descent with each pull, maximum 3 pulls - RMLE on crowning/head born/disarticulate blades - birth/anticipate SD/delayed clamp/cord gas/paeds - check perineum + repair/document
200
39yo 32/40, Abdo pain Bkg of uterine fibroid or 35yo 37/40, fetus in transverse lie 9cm fibroid in anterior LUS
HE - APH/SROM/contractions/urinary/bowel/vitals/abdo - uterine/spec/cervix/FFN/CTG - Likely fibroid degeneration - need to exclude PTL/abruption/uterine rupture/cystitis - FBE/CRP - leukocytosis in fibroid degeneration - Urine dipstick +/- MCS - USS to check fetal wellbeing + confirm degeneration - probe tenderness - if unclear on USS -> consider MRI - degenerating fibroid - PTL - PTB - admit/observe/analgesia +/- steroid loading - on DC - serial 4 weekly g/s to exclude FGR/malpresentation - timing/MOD individualised/active 3rd/anticipate PPH/menstrual hx+/- OP Gynae *large cervical fibroid - complex CS list/MDT/senior obs/cell salvage/IAP/consent for CS hysterectomy
201
39yo, G1P0, 36/40, breech, fibroid uterus 34yo, G2P1, 37/40, breech (encounter 2)
HE - FM/APH/plac/morph/AFI/growth/previous MOD/vitals/FH - vaginal breech birth increase risk of perinatal M&M - risk to baby include head entrapment/cord prolapse/birth asphyxia/injury - elLUSCS is safer than vaginal breech/vaginal cephalic birth is safer than elLUSCS - consider ECV+ VD albeit fibroid is a relative CI vs elCS - ECV involves turning the baby - 50% success - OP procedure, RTS/CTG before/after, uterine relaxant, empty bladder, IV & OT access, risks include discomfort/NRCTG/abruption/cord prolapse/emCS/turn back at term/+/-FMH +/- anti-D *CI to ECV - LGA/FGR/fetal anomaly/uterine anomaly/abnormal dopplers/Oligo/LLP/previous CS/fibroids **note - head entrapment can happen during CS too - extend the incision e.g. inverted T can help, in addition to having someone exp, large skin/uterine incision
202
39yo, G1P0, 38/40 known breech failed ECV SROM, contracting (encounter 2-3)
Hx/Exam - duration/frequency/colour of liquor - vitals/palp/cervix - dilation/effacement/membrane/station//cord/MSL RTS - type of breech/CTG - vaginal breech delivery increase risk of perinatal M&M - consent for a Cat 1 emCS +/- classical due to fibroid - discuss risk of CS hysterectomy (if large fibroid) - care require MDI, inform consultant, urgent transfer to OT - NBM/x2 WB IVC - FBE/G&S/CEFM +/- tocolytic - anticipate PPH 2nd (fibroid uterus) - intra-op assess nature of fibroid and document - cord gases/paeds @birth - debrief/document/hip uss for fetus 6/52 - arrange OP F/U in Gynae clinic for ongoing mx of fibroid
203
34yo G1P0, intubated in ICU for flu 27/40, oligo/AREDF on scan footling breech -> SROM -> audible deceleration or footling breech advanced labor - foot past perineum +/- NRCTG (encounter 3)
HE - ? station of PP - fetus is acutely compromised - needs immediate delivery - footling breech - cervix not dilated - breech extraction -> head entrapment - safest for baby is cat 1 emCS likely classical - code green, MDI, IVC/bloods/urgent transfer/senior obs to support, paeds @birh - cord gas/placenta to histo/anticipate PPH - return to ICU/debrief/document/VTE prophylaxis - continue rx for resp/PP care *footling breech at anytime except if it's 2nd twin is dangerous, as foot wouldn't have dilated the cervix...
204
28yo 19/40 anomaly scan severe encephalocele unlikely to survive (commmunication station)
intro/ack/sor/sto/sol/sup/sec/sum/sec Relevant clinical - encephalocele = NTD - bone fusion problem - brain exposure toxic amniotic fluid - risk of hydrocephalus/seizures/SB - disability based on defect size - not inherited, small risk recurrence - risk reduction - folate - MFM referral - continue vs TOP - continue=monitor GS + CTG *Paed neurosurg, ?surgical correction amenable
205
19yo Have ID Now postop for EUA + removal of foreign body small RVF noted on EUA (communication station)
intro/ack/sor/stor/sol-draw/sup/sec/sum/sec Relevant clinic - refer to Colorectal - expectant vs surgery - expectant = await spontaneous resolution/imaging/F/U - surgery = bowel prep, multi-day stay, GA, debride + repair + antibiotics post +/- ileostomy
206
41yo CST - HSIL (encounter 1)
Hx/Exam - IMB/PCB/weight loss/urinary/bowel - OGHx - menstrual/parity/mod/fertility/STI/PID - PHx/Surg/Med/SHx - sup/SAD - HPV virus cause precancer changes to cervix - HSIL on smear suggest possible high grade precancer change - Need to assess the cervix and identify areas of abnormal cells - Colp - AC - TZ - Lugol +/- Bx (Colp imp: HSIL, T3 TZ, Colp Bx histo = CIN3) Hx/Exam - recovery after Colp - CIN3 is a precancer of cervix - 30% regress, 30% progress if untreated - T3 TZ requires a cone bx - cone bx removes part of the cervix - +/- PAC (if comorbidities)/day procedure/GA/risk include... - specific risks - transfusion/hyster/cervical stenosis/CI/PTB - F/U post cone for further mx plan/cervical surveillance future preg *HPV 16/18 - account for 90% of cervical cancer **CIN3 post LLETZ - CST 12/12, 2 negs then back to 5yr screen ***if CST abnormal, but Colp shows no lesion, or TZ not visualized, consider doing a endocervical curettage (ECC)
207
41yo CST - HSIL Colp - HSIL + Bx - CIN3 Cone - CIN3 + AIS (encounter 2)
Hx/Exam - recovery/pain/bleeding/fever/chills - vitals... - details of path report - ?clear margin (margin barely adequate) - AIS is a precancer of cervix - high risk of recurrence and progression to ca - refer to GONC MDT/Rv - hysterectomy (if -'ve margin, otherwise need rpt cone to exclude invasive disease) - preop req PAC, multi-day stay/GA/risks include...path -> MDT - OP F/U + lifelong annual vault CST *if fertility desired, 6mo co-test, and hysterectomy when family completed **invasive disease needs rad hysterectomy not extrafascial hysterectomy ***AIS on smear or bx - cone bx to treat to get margin to determine type of hyst
208
- Abnormal glandular cells on CST - Endocervical cells of unknown significance
- ? AIS/adenoca - Colp +/- ECC - TV USS -> HDC
209
30yo PI workup Bilateral hydrosalpinx (encounter 2)
HE - STI/PID hx - hydrosalpinx = blocked, from previous infections - tubal factor infertility, also risk of torsion/CPP - HSG/HyCoSy - saline flush/diagnostic > sometimes therapeutic - Lap + dye studies - day/GA/diagnostic/restore anatomy - reduce obstruction if blockage from outside/F/U - once tubes unblocked, TCC 3-6/12, if fail then IVF - if not interested in IVF -> surrogacy/adoption *+/- BS to improve outcome if need IVF on bkg of hydrosalpinx **hx of childhood SA in context of PI - consider STI screen ***explore hx of STI +/- recheck in cases of blocked tubes +/- rx
210
post diagnostic lap + dye studies for bilateral hydrosalpinx ask to see patient regard severe pain around umbilicus   (encounter 3)
Hx/Exam - op note/cx/RFs for wound breakdown - AVB/abdopalp... - I'm worried umbilical hernia - risk is strangulation of bowel/ischemi/necrosis/perforation - emergency that require MDI - inform consultant regarding the findings - NBM + IVC -FBE/UEC/CRP/G&S + IVT + contact Gen surg for urgent rv - organize an abdominal wall USS to confirm diagnosis - simple analgesia +/- antibiotics - if confirmed, need RTT - debride/primary repair of the sheath/abx - postop debrief/document/gynae M&M/FU in 6 week  
211
64yo sig pain/abdo distension post VH for uterine prolapse (encounter 3)
Hx/Exam - E+D/urine/flatus/intra-op cx - vitals/UOP/FB/peritonism (vitals stable, peritonitic, minimal UOP) - I'm concerned about iatrogenic ureteric/bladder injury - also need to exclude intra-abdominal bleeding/ileus - FBE/CRP to exclude infection/UEC to check renal function - CTAP to identify any intra-abdominal collection - NBM + IVT + IDC - Discuss findings with consultant - Contact Urology/Radiology - If uroperitoneum - need to RTT for repair or CT guided drain +/- nephrostomy - Debrief/Document/M&M/F/U
212
27yo 8/40 BMI 35 referred for 11cm dermoid ovarian cyst (encounter 1)
Hx/Exam - conception/plan - PVB/pain/mood - RANC - S/R/rhesus/Hb/MSU/aneuploidy/OGTT/morph/fol - OGHx - parity/mod/CST/STI - PHx/Surg/Med/SHx - SAD - AVB/Cardioresp/thyroid/fundus/FHR Dermoid - benign tumor, get bigger, tort, pain/necrosis/surg/PTL/PTB - complex cyst, TMs not useful in preg, will need MRI to confirm - refer to GONC MDT to rv to exclude/confirm dermoid - refer to Gynae MDT remove btw 14-20/40, likely need open cystectomy - multi-day, GA, surg risk...preg risk - PTB/SB, FHR pre/post/Obs USS/F/U BMI 35 - risk include GDM/PET/FGR/LGA/PTB/IOL/operative delivery/PPH - GWG 5-9kg/Diet/Exercise/early OGTT/tert morph/4 wkly serial GS from 28/40/Dietician/IOL from 39/40/RTS/FSE/x2 WB IVC/TOF in OT/Drugs wt based - LMWH/Abx +/- LC +/- Anesthetic RANC... *if dermoid small <10cm - consider just observe **if dermoid big >10cm - characterize/remove/if too late, then wait ***removal during preg, @CS, PP rv for elective gynae OT
213
27yo 13/40 BMI 35 11cm dermoid ovarian cyst on W/L for surgery p/w severe LAP prior to planned surgery in T2 (encounter 2)
Hx/Exam - onset/N&V/PVB - vitals/abdopal/FHR - I'm concerned about ovarian torsion - risk of irreversible dmg to ovarian tissue/necrosis/MC - need to consider appendicitis/gastroenteritis/uterine rupture/MC - FBE/UEC/CRP for evidence of infection/blood loss - MSU to exclude an UTI - TV Pelvic USS to assess ovaries and FHR/wellbeing - NBM + IVC + IVT + simple analgesia - Discuss case with consultant - Likely need an emergency open cystectomy +/- oophorectomy - General risks include...specific risk - inadvertent spillage/up-staging/path/FU - continue RANC
214
unexpected ovarian cyst @caesarean section unexpected suspicious ovarian mass @caesarean section
Principle = conservative mx is preferred with unexpected malignancy finding as unknown risk - inadvertent spillage/up-stage disease Mx (suspicious lesion) - pause op/ensure hemostasis - inform pt/inform anesthetist of finding - contact GONC for opinion/rv intra-op - consider GA for thorough assessment - exteriorize - assess mass + contralateral tube/ovary/peritoneum/LN - with adequate consent - clinical photography + USO + PW + biopsy of lesions/omentum - routine closure of CS and routine post-partum - debrief/document/chase result/GONC MDT/FU *if decision to perform cystectomy with consent -> exteriorize/remove/avoid spillage/perform cystectomy in specimen bag if possible **tumor markers may be falsely elevated due to pregnancy ***if simple cyst - cystectomy ****if suspicious do the above
215
confirmed CMV infection before 20/40 (scan/amnio) previous PTB + hx of LLETZ (communication station)
I/A/Sor/Stor/Sol/Sup/Sec/Sum/Sec Relevant clinical info Implications of CMV in T2 - congenital CMV/FGR/SB/Neurodevelopmental - SNHL - serial G/S AN/PN investigations - aud/opthal/cranial PTB risks - RDS/IVH/NEC/neurodevelopmental/NICU
216
PTB - RDS - baby in NICU explain to pt
PTB - RDS - lack of surfactant - lung collapse Ventilation - O2 sat/surfactant administration/avoid hyperoxemia Enteral feeding IVF to maintain BP Reduce comorbid disease – PDA/chronic lung disease/IVH/NEC/ROP
217
38yo G4P1 referred for 3 consecutive MC (encounter 1 or communication)
HE - menstrual hx/VTE/thyroid/previous POC testing - APLs + Thrombophilia screen + HbA1c + TFT/abs - HSG (?fibroid/septum) - parental karyotype - preconception bloods+advice - F/U visit in RMC OPC to discuss results +/- referral and mx if +'ve +/- LMWH *Thrombo screen = FVL/PT/ATIII/protein S/C def - should be tested outside pregnancy **RMC - 50% no cause found, 70% live preg w/o rx ***blight ovum = sac no embryo, likely chromosomal/genetic abnormalities, common, no impact on future pregnancy ****balanced translocation -> genetic counselling -> risk of RMC still exists with spont conception, IVF with PGD or IVF with donor oocytes can reduce risk of MC
218
44yo G4P0 referred for FVL/PT compound hetero
R2U - RMC/PET/Abruption R2B - FGR/SB Haem opinion LMWH + LDA Tertiary morph + serial G/S Monitor sx (VTE or HITS) Cease LMWH 24/24 pre IOL/CS, @SOL, UFH/prota Routine, no E2, Haem F/U HR thrombo = ATIII/protein S/C def, FVL or PT homo, FVL/PT compound hetero
219
Parental balanced translocation
Genetic rearrangement Phenotypically normal Incidence is 1:1000 increase risk of miscarriage Fertility options Spont, then usual care – still have increased risk of miscarriage Spont, then CVS/amnio – still have increased risk of miscarriage IVF with preimplantation genetic diagnosis IVF with donor oocytes
220
Uterine septum identified on RMC ix All other RMC ix normal
Septum implantation failure - RMC Hysteroscopic resection improve birth outcomes Day/GA/transcervical/risks...gen/spec- synechia/perf-> future preg imp HSG 2/12 post to check success of repair/TCC
221
Hx of metroplasty c/b large uterine perforation Now pregnant
Risk of rupture AN/during labor Clear documentation of hx of previous perforation To attend for review abdominal pain/PVB/early labor Elective CS is recommended > VD due to rupture risk
222
38yo G5P1 9/40 Hx of RMC pending ix Spont conception again Presented with swollen calf (encountered 2)
Hx/Exam - onset/pain/chest sx/fever/chills - RANC/ix - rhesus/S/R/Hb/MSU/dating/aneuploidy/OGTT/morph.. - AVB/cardioresp/LL/cellulitis/FHR - I'm concerned about a DVT - risk of extension -> PE -> life threatening for you/baby - Empirical therapeutic clexane 1mg/kg BD pending ix - FBE/UEC/LFT/Coag to check for CI to clexane or dosing - Urgent LL Doppler to exclude DVT - Inform consultant and d/w Obs Med/Haem re: advice - if DVT -'ve, consider repeat in 3-7 days - if DVT +'ve, likely need clexane rest of preg, total of 6/12 PP - clexane is safe in preg...SE include... - clexane education/impact on intrapartum analgesia options - TEDS/mobilization encouraged /ano rv antenatally - stop clexane once in labor, 24/24 pre-elCS or IOL - bridging options intrapartum - UFH - intra-op considerations - wound drain/interrupted sutures - avoid COCP PP for contraception - thrombophilia screen PP if not organized + Haem F/U +/- Obs USS as well to check fetal wellbeing *if chest sx + LL sx or -'ve LL but chest sx - investigate with CXR -> VQ vs CTPA **x4 doses of therapeutic then anti-xa +/- adjust
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- EL 37/40 DCDA
HE - - onset of labor/SROM/FM/APH/PET sx - G/S - ? >20% discordance - Spec - cervix, RTS - T1 presentation Mx - inform consultant/ano/OT - risk of labour dystocia/operative del/PPH - CEFM/x2 WB IVC - FBE/G&S +/- FSE T1 when MI or ARM need synt - Consider epidural - OT available 2nd stage for Twin 2 - Con/Paeds in room - can delay clamp then doubl clamp/cord gas - RTS/Synt in room after delivery of T1 if hypotonic uterus - High risk of emCS for T2/explain IPV/breech - if T2 - cephalic - stabilize and wait - if T2 - vertex/oblique but not engaged - ECV or IPV w breech extraction in OT or in room if NRCTG - active 3rd stage post-delivery/PPH kit in room * <30min of intertwin interval
224
TPL 28/40 MCDA in setting of poly (suspected TTTS) or 22/40 MCDA, poly in T1/oligo in T2 (suspected TTTS)
HE - - SOB/resp distress/onset of labor/SROM/FM/APH/PET sx/growth discordance - vitals/FH/spec - cervix - FFN/amnisure/HVS, RTS - T1 presentation, CTG - Inform con/OT/ano - request Paeds rv - Tocolytic nifedipine - Steroid loading - analgesia +/- abx - +/- MgSo4 - if don't progress - OP mx TTTS is - unbalanced blood flow btw babies R2U - SB in one or both/PTL/PPROM/PTB MFM referral - urgent counselling/rx Stage I - asx, CL >25mm expectant Stage I - sx or CL=<25mm 16-26/40 laser > amnioreduction Stage I - sx or CL=<25mm >26/40 amnioreduction > laser Stage II-IV - 16-26/40 laser ablation - prolong gest/improve survival lt outcome Stage II-IV - >26/40 amnioreduction > laser ablation F/U - weekly OPC, regular doppler/AFI Selective feticide - if TTTS c/b life threatening anomaly Laser - fetoscopic - risk of TAPS/recurrent TTTS *>26/40, consider amnioreduction, btw 16-26 laser **key factors in determining mx - stage, sx, CL, gestation
225
G1P0 37/40 DCDA T1 born T2 has a NRCTG Not engaged (vertex or oblique) Urgent vaginal delivery of T2 is required, show/explain any maneuvers required (encounter 2) alternatives - breech of twin 2 -> straight to breech extraction steps
Hx/Exam - consent/analgesia/contractions - ?where's PP /cervix/dilation/station - ?which side is fetal back Key maneuvers = IPV/Lovset/MSV - call for help - code pink - request help from senior obs/notify OT - MDI obs/paeds/anesthetic - consent for IPV - IVC/lithotomy/bladder empty - perineal hygiene + analgesia Cephalic = NBFD Breech/transverse = IPV-Breech extraction IPV - identify fetal back - the internal hand is opposite the side of fetal back - the other hand on abdomen - elevate vertex higher into cavity and reach for a foot - outside hand keep vertex elevated while internal hand pulls feet caudally - rotate fetus to complete breech Breech extraction - support fetus by grasping on either side of baby's iliac crest - thumb on sacrum, avoiding soft tissue - steady fetal back to maternal pubis then gentle traction till tips scapulae - assistant to apply suprapubic pressure to keep head flexed - once scapulae passed introitus, one arm delivered at a time using Lovset - if head not delivered then perform - MSV w fundal pressure +/- forceps on after coming head ... *MSV = support foetus with forearm with middle and index fingers on foetal maxillae, the other hand lifting the legs or applying suprapubic pressure (if no assistant) **In the event of head entrapment - need urgent transfer to OT and cervical incision to 2 & 10 o’clock +/- 6 o’clock ***After delivery - paired gases/active 3rd stage/assess and repair perineum/document/debrief/hip USS in 6/52 ****breech, abnormal CTG require active mx,
226
Breech extraction technique Frank vs Complete
Principle = hands off unless fetal distress Fetal distress = immediate delivery Frank - pinard - exert pressure inner aspect of knee - knee flexion - grab foot - downward traction to deliver anterior hip - upward traction to delivery posterior hip - gentle, continuous, downward traction on leg to deliver hip - keep fetal back anteriorly ... Complete - grab both ankle with one hand - gentle traction to bring leg to vulva - gentle, continuous, downward traction on leg to deliver hip - keep fetal back anteriorly ... *footling should be CS https://medicalguidelines.msf.org/en/viewport/ONC/english/6-3-total-breech-extraction-51417231.html#:~:text=Pull%20the%20pelvis%20downward%2C%20keeping%20the%20back%20anterior%2C,hips%20and%20pelvis%20with%20the%20other%20fingers.%20
227
G1P0 37/40 DCDA T1 born T2 delivered by IPV/breech extraction Poor response require resuscitation Show on mannequin how to resuscitate (encounter 3)
- call for help - neonatal code blue - req MDI - ventilation is the key to resuscitation - follow resuscitation protocol - dry/clear airway/keep warm - HR >100, stimulate/keep warm/monitor - if HR <100, IPPV required - PIP/PEEP 30:5, chest rise/fall 21% - if HR <60, commence CPR 3 compression to 1 breath 100% - if HR <60 venous access - IV adrenaline +/-volume expansion - debrief/document... *PPV rate 40-60 breaths per minute
228
34yo 28/40, rural clinic Amniotic band on scan (encounter 1)
Hx/Exam - FM/SROM/TPL - RANC - rhesus/S/R/Hb/aneuploidy/morph/OGTT/GBS - OGHx - parity/mod/cx - PHs/Surg/Med... - CTG/RTS - amniotic band is a band of tissue in the sac - formed during development/assoc aneuploidy - risk of limb amputation/orofacial clefts//FGR/PTB/SB - consider rpt tertiary scan to confirm - refer to MFM +/- amniocentesis - refer to Paeds - impact of amniotic band/PN surgical correction - refer to Prosthetic team - re: options - depends on results/discussion expectant mx vs TOP - 4 weekly serial G/S from now
229
34yo 30/40 (rural center) Amniotic band on scan Await tertiary center for ongoing mx P/w APH with contractions (encounter 2)
Hx/Exam - onset/volume/trauma/FM/placenta position/rhesus - ?SROM before - vitals -BP/EBL/uterine tenderness/contractions - CTG/RTS - lie/presentation/cervix (large volume painless APH) - I'm concerned a placenta abruption - Obs emergency requiring MDI - Call for help - Code Green (if birth not imminent) - Simultaneous resus/ix/delivery *contact PIPER to facilitate transfer to tertiary afterbirth - NBM/x2 WB IVC/IVT/urgent transfer to OT - FBE/UEC/Coag/G&S/Kleihauer + x-match PRBC + CEFM - avoid tocolytic - Cat 1 GA emCS +/- classical - consultant/paeds @birth/cord gases - assess for signs of abruption+volume/plac to histology - anticipate and manage PPH - HDU postop/debrief/document/anemia correction - identify RFs for abruption (fibroid/HTN/smoke/drugs/chorio) - counselling high risk for recurrence and optimization of RFs
230
34yo 30/40 (rural center) Amniotic band on scan Await tertiary center for ongoing mx P/W APH with contractions + SROM'd Decision for cat 1 emCS due to concern for abruption on scan, there's no liquor and baby is breech outline interventions to affect delivery (encounter 3)
Breech Anhydraminos Preterm - Senior Obs consultant to support - GTN to relax uterus (care due to abruption) - Classical incision - Breech extraction - Lovset/MSV +/- forceps after coming head *on table ECV w/o liquor would be impossible...
231
29/40 pw acute abdo pain (encounter 1)
Hx/Exam - onset/location/N&V... - FM/APH/SROM... - RANC to date... - OGHx...PHx-?appendicectomy - AVB/cardioresp/abdo/spec - cervix/FFN... (RIF-RUQ pain) I'm concerned about appendicitis Need to exclude pelvic mass/torsion/renal colic/uterine rupture/abruption FBE/UEC/CRP inflam/renal function MSU to exclude UTI Pelvic USS to... CTG/formal Obs USS to ensure fetal NBM + IVC + IVT + simple analgesia Inform my consultant Review from gen surg +/-RANC...
232
22/40 RIF pain 29/40 RIF pain 2ndary hospital 29/40 appendicitis proven on USS
HE - N&V/fever/chills/U&B/FM...PHx/Surg/vitals/BMI/peritonism/uterine/+/-CTG... Appendicitis inflammation of appendix risk to you if untreated can rupture/peritonitis/sepsis/life threatening Risk of baby - PTL/PTB/SB NBM + IVT + Abx (ceftriaxone/metronidazole) Urgent gen surg rv Likely lap to remove under GA Surgery can also precipitate PTL Risk is higher if left untreated Inform consultant/Paeds rv Steroid loading pre-op FHR pre/post + Obs USS OP f/u with ANC & Gen Surg Monitor sx of PTL... *2ndary hospital - consider transfer in case go into PTL postop
233
What advise to gen surg taking someone to OT for appendix in preg
- FH pre and post - avoid touching uterus - antibiotics - wedge - clexane/teds/early mobilisation
234
29/40 D1 post emergency lap appendix Contracting Steroid loaded pre-op (encounter 3)
Hx/Exam - onset/SROM/APH ? steroid loaded - vitals/abdo - contractions/spec - dilation/membrane - RTS - presentation/CTG (breech presentation) I'm concerned about PTL Risk of PTB Obs emergency Inform con/paeds +/- tocolytic +/- MgSo4 re: MOD recommend emCS CS less perinatal M&M compared to breech VD (only if birth imminent and pt chose to understanding all risks + facility able to safely support) NBM + IVC -FBE/G&S + IVT Inform ano/paeds/OT Cat 1 emCS +/- classical Consider tocolytic if delay to OT CEFM whilst pending
235
G5M3P1-1 15/40 RMC -> Lupus hx Early morph show demise of 1 twin (Encounter 2)
Hx/Exam - pain/bleeding/fever/chills/dc - vitals/abdo tenderness/spec/RTS - RANC ix to date ... - important to exclude acute causes abruption/rupture/infection - need to ix for causes of SB... - risk of cotwin death - PTB/SB albeit LR - seek MFM opinion - expectant vs TOP - close monitoring of surviving twin - serial 2 weekly G/S - aim IOL from 37/40 - MOD depends on which the presentation of leading twin** *MC preg – agonal hypotension/TRAP – need to monitor MCA ?anemia +/- IUT, also USS+/-MRB brain dmg **if T1 dies and is malpresentation, and T2 goes into PTL – likely need CS as T1 may obstruct labor
236
Twin preg c/b demise of 1 twin now 28/40, IUGR, PTL, NRCTG (encounter 3) or Twin preg c/b demise of 1 twin T2 earlier 38/40 SROM, T1 leading, otherwise uncomplicated
Hx/Exam - ? SROM/APH/fever/chills/doppler results/reason of IUGR - vitals-BP/VE - cervical dilation ? imminent birth/RTS - presentation of leading twin - Obs emergency - req MDI - simultaneous intrauterine resus/delivery plan - IVT+ left lateral+/- tocolytic +/- steroid +/- MgSo4 - NBM + IVC - FBE/G&S + CEFM - if VD not imminent - Cat 1 emCS - likely classical - if demised twin leading/malpresent another reason for CS - cord gas/paeds at birth - autopsy yield of dead twin is likely low yield *in co-twin demise, if surviving had uncomplicated AN course, IOL process is no different to routine, expect should have active 3rd and anticipate PPH, still birthing 2 fetus, uterus more stretched...
237
Counsel re: IVH bkg of PTB
- IVH = bleed inside brain - vessels fragile in PT baby - known risk for PTB - Graded from 1-4, 1-2 good outcome - short term impact - hydrocephalus - ventricle dilation - long term impact - cerebral palsy/need for permanent shunting
238
- CP+SOB 37/40 - SOB 36/50 Hx of PPCM (encounter 1)
HE - cough/F&C/U&B/vitals/HS/JVP - I'm concerned about heart failure - need to exclude ischemic/infection/dissection/PE - FBE/UEC/CMP/LFT/CRP/BNP/Trop - ECG/CXR+/- VQ vs CTPA/TTE - Formal Obs USS - Stabilize mum +/- Delivery - O2/analgesia/IVC/strict FB - refer to Obs Med/Cardiology - Diuresis/VTE proph/PPV +/- rate control (dig or b-blocker) +/- ICU for vasopressor support
239
37/40 PPCM on diuretics + PPV O2 not improving (encounter 2)
HE - O2 sat/cervix/CTG - VD only if NYHAI-II - if on diuretic+PPV NYHAIII-IV - GA CS/no ergot - HDU/Telemetry/strict FB - extended VTE prophylaxis - OP Cardio + TTE + acei + blocker - prognosis 50% spont resolution - 25% recurr even full recovery - 50% recurr if LV dysfunct w 25% mort - contrac - P only or non-hormonal - need pre-preg counselling/TTE *NYHAI-II - no limitations on physical activity to slight limitations
240
6/52 postpartum p/w lethargy/SOB/Orthopnea/palpitation
HE - vitals/cardioresp Ix - FBE/UEC/LFT/BNP/CXR/TTE DDx - anemia/PE/PPCM (reduce AE bilaterally/pleural effusion on CXR) Mx - admit/urgent card rv/ICU - FR/b-block/CPAP/diuresis/Clexane Prognosis/future pregnancy imp - recurrence/high M&m/preconception rv *residual defect, pregnancy is CI
241
Shoulder dystocia mx (encounter 3)
Hx/Exam - RFs ... - chin on peri - retraction - no descent - Obs emergency - Call for help - Instruct mum not to push - Evaluate for epis - McRobert's - Suprapubic pressure - Internal vs Posterior arm - Rubin II/Woodscrew - Reverse Woodscrew (poster/poster) - Posterior arm - hand/straightline - all 4s if mobility - Cleiodotomy/Symphsiotomy/Zavanelli - cord gas/paeds rv - PPH Mx/Check for OASIS - document -anterior should position/time/personel... - debrief/RFs/prevention - eg. IOL/MOD
242
Fetal Bradycardia mx (encounter 2-3)
HE - contractions/dilation/station/cord/CI to VE - plt/<36/40 - obs emergency - call for help - intrauterine resus - stop synt/left lateral/bolus +/-terbutaline - return to baseline vs persistent - birth imminent +/- instrumental vs not -> code green
243
Cord prolapse identified on VE
HE ? dilation/station - Obs emergency - Code Green - MDI for resus/delivery - pt on all 4s or exaggerated sims (if epi) - Return cord into vagina/avoid touching - elevated PP, if delay to OT - fill bladder with water - IVC/Bloods/Urgent transfer - GA/emCS/senior obs/paeds/cord gases - debrief/document
244
post NVD c/b - complex 2nd degree - horizontal urethral tear require IDC (communication)
I/A/So/Sto/Sol/Sup/Sec/Sum/Sec Relevant clinical - complex 2nd tear - dissolvable sutures/weeks to heal/not OASIS - risk of dyspareunia/anatomical deformity - OP F/U - gynae/psych from birth trauma - consider alt MOD - urethral tear/dissolvable sutures/dysuria/stricture/stenosis/LUTS - OP F/U Urology
245
- Postmeno p/w acute abdomen - Peri-meno ref for pelvic pain w USS suggestive of endometrioma - Peri-meno ref for thickended endometrium + USS ?endometrioma (encounter 1)
HE - N&V/F&C/U&B/LOW/Sexual hx/CST/PHx/SurgHx/SHx/BMI/temp/peritonism Ix - FBE/UEC/LFT/CRP (baseline + exclude infection) +/- BC Ix - TV USS (torsion/mass/TOA) +/- TMs (pelvic mass) Mx - NBM/IVC/IVT/analgesia/antiemetic/await USS - if mass -> urgent TMs to work out RMI -> GONC opinion *RMI score >200 – refer GONC, U=3 if 2-5 pts (bilat, ascites, solid areas, multiloc, mets), pre-meno=1, meno=3 **mass -> tort/TOA, TOA can be 2nd to malignancy - FRT/GIT vs sexual ***any TOA - if req OT - HR - viscera dmg/hemorrhage -> MDT preop/drain postop ****peri-meno - ?endo on scan w pelvic pain/if never CPP, need to think beyond endo, they're unlikely to suddenly develop pain if never had endo issues, esp around menopause *****CA125 can be elevated in endometriosis too!!!
246
Postmenopausal ovarian torsion on pelvic USS Postmenopausal ovarian cysts on pelvic USS Intractable pain TMs pending
HE - sx/analgesia req/RFs for EOC Urgent anesthetic review GONC opinion/assistance TAH/BSO/Omental/Peritoneal bx/PW+/-Cystoscopy whilst I/P Risks of procedure include - general/specific... *some may prefer Lap RSO/BSO instead of TAH/BSO
247
Lap RSO planned for ovarian torsion on USS for 55yo Unexpected wide-spread mucinous with right ovarian mass
- Inform anesthetist of finding - Contact GONC for intra-op rv/assistance - Pelvic washing/peritoneal sampling/RSO/omental bx +/- appendicectomy - Comprehensive diagnostic survey - RUQ/LUQ/Appendix/POD/UV/PSW - Specimen urgently to pathology - Postop debrief/documentation/F/U appt/GONC MDT +/- Upper GI/CR MDT - Mucinous EOC/PMP - ?GIT primary - further imaging + scopes *Mucous EOC (MOC) - can be primary or metastatic GIT **when MOC met to peritoneum -> PMP (usually from primary mucinous tumour of appendix, but can also start from large bowel or ovary) ***re-accumulation of mucin can occur pretty quickly - pt p/w unwell/N&V/bloating
248
Postop PRBC transfusion ATSP re: fever (encounter 2)
Hx/Exam - CP/SOB/fever/chills - tachy/hypo/febrile/angioedema/urti - transfusion reaction - allergic/febrile non-hemolyt (common) - anaphylactic/hemolytic/septic - stop transfusion - check ABC - rpt bloods - FBE/UEC/LFT/Hemolytic screen/Coag/G&S/BC - +/- IVT +/- anti-histamine +/- hydrocort - send PRBC back to lab for ix - contact haematologist for advice - check need to have more transfusion - find alternative to PRBC ?iron - regular observation +/- monitor in HDU environment - document/debrief/incident report
249
70yo TAH/BSO for right adnexal mass 55yo RSO for right ovarian torsion Histology = adenocarcinoma from GIT origin - appendix (encounter 3)
HE - recovery - E+D/PVB/pain/urine/bowel/wound - Krukenberg tumour=OVC -GIT primary - 5yrs <15% as met in nature - refer to CR ONC MDT/CR rv - further ix = PET CT/G/C-scope - further rx = chemo
250
52yo BSO for right endometrioma on USS Histology = endometrioid EOC
HE - recovery... - Cancer of the ovary - Prognosis varies depends on stage - Incompletely staged, need to stage/pelvic clearance - TAH/Omentum +/- LN - Ref to GONC - MDT/rv to plan further ix/mx - CTCAP/cytoreduction/adj chemo vs neoadjuvant/interval reduction - Surgery - multi-d/ga/path MDT/F/U -> chemo
251
- ATSI bkg - whole body rash syphilis serology EIA +'ve RPR 1:100 TPPA +'ve - PNG bkg - no rash, TPHA +'ve - syphilis on screening 14/40
HE - known contact/lesion/rash/fever/past rx/penicillin allergy - AVB/lymphadenopathy/cardioresp/abdopelvic/?chancre - STI screen +/- HCV/HBV/HIV serology if not done - refer to MFM/ID for rv/advice - risk of second/tert/latent/transmission - risk of congenital syphilis - FGR/PTB/developmental abn/SB - MTCT is primary infection 100% vs 40% 2ndary infection - highest risk if infect >20/40, rare for congen Sy if infection <20/40 - IM benzathine benzylpenicillin +/- de-sensitization allergic to pen - risk of Jarisch-Herxheimer reaction - partner notification + treatment + no IC till 7D post rx - monthly VDRL/RPR till del +/- re-treat - RPR titer postpartum 3/6/12 mo - rpt HIV/HBV/HCV serology + STI screen - 4wkly serial G/S from 28/40 - treated >30 days before birth - maternal/fetal paired serology postpartum - placental PCR - paed rv postpartum *results Non-trep + Trep + = syphilis -> treat Non-trep - Trep + = past treated or latent -> treat Non-trep + Trep - = repeat in 4/52 Trep + = treat Trep - = false positive non-trep **primary/secondary/early latent - x2 IM benzathin benzylpenicillin ***late/unknown duration - x2 IM benzathin benzylpenicillin weekly for 3/52 ****chancer = primary, systemic sx - fever/rash etc.. = secondary
252
VBAC counselling or VBAC as an AN issue
HE - previous CS - indication/cervical dilation/cx/surgical CI/how many children desired CIs to VBAC - No more than x1 LUSCS - No uterine perforation/rupture/classical CS - Angle extension (1:50) Benefit of VBAC include future VD/mat satisfaction/quicker recovery Risk include emCS/uterine rupture/haemorrhage/hysterectomy/OASIS (3 in 1000) Risk to baby due to rupture HIE/CP/SB Risk of rupture - IOL 1:100, Spontaneous 1:200 0.02 in 1000 mat mort 0.7 in 1000 foetal mort 1.8 in 1000 foetal mort from waiting beyond 39/40 Your likelihood of success is higher if Previous successful VD/VBAC No hx of labour dystocia SOL rather than IOL LR pregnancy, normal BMI, no LGA baby Alternative to VBAC - ERCS, risks include - general/specific - future preg imp - pad/peripartum hyster…
253
30yo, CPP, negative exam/ix seek 2nd opinion or pain/dyspareunia 5/52 post diagnostic lap CPP + Mirena insertion (communication station)
I/A/So/Sto/Sol/Sup/Sec/Sum/Sec Relevant clinical - pain come from somatic structure (bone/muscle) vs viscera (uterus/ovary... - then there's chronic pain w/o clear aetiology = centralized chronic pain syndrome - original trigger may no longer be present -> central sensitization -> nerve pain - rx = multi-modal, multi-disciplinary - PT/pain psychology/pain specialist - non-pharm: exercise/PF PT/CBT - pharm: TCA - amitriptyline, anticonvulsants, SNRI - avoid opioids
254
post mirena bleeding/pain expectations (communication)
irregular bleeding/cramping common up to 3mo ongoing require evaluation - malposition/expulsion/cervical dysplasia
255
Twin pregnancy (DCDA)
HE - mod of conception/support Ix - aneuploidy/early morph, OGTT R2U-GDM/PET/Op del/PPH R2B-FGR/PTB/SB RR4U-sup grp/dietician/reg HR ANC/Fe +/- LDA+Ca RR4B-tert morph/4wkG/S from 25/40/IOL 38/40 *MCMA32/40, MCDA37/40, DCDA 38/40 **MC serial G/S from 16/40 (TTTS) DC serial G/S from 24/40
256
Fever/rash, toddler in childcare
HE - exposure/rash/fever/lymphadeno Ix - Parvo IgG/IgM + amnio/PCR R2U - N/A R2B - anemia/hydrops/SB 50% infect 1/3 resolv 1/3 IUT 1/3 SB ID/MFM ref - expectant vs TOP Wkly scan MSA PSV - 12/52/anemia-IUT *alt presentation is hydrops on scan in setting of possible parvo exposure, have to consider other causes of hydrops - aneuploidy/morph/OGTT/iso/thal/TORCH
257
Incidental renal stone in pregnancy on bkg of UTI
HE - dysU/L-G/F&C/intractable pain Ix - FBE/UEC/CRP/MSU/renal tract USS R to U - obstruction/aki/sepsis/UTIs R to B - PTL/PTB (bkg of sepsis) Mx of non-acute (pain ctrl/no AKI/sepsis) - treat UTI w TOC - Urology opinion - 1st line = up fluid intake/monitor sx - 2nd line = laser lithotripsy Mx of acute (obstructed/AKI/sepsis) - IVC + IVT + analgesia + antiemetic + abx - Inform consultant - D/W Uro re: ureteral stent or nephrost +/- steroid loading +/- CTG +/- Obs USS
258
Pregnant w personal hx of inheritable condition, what options (encounter 2) Pregnant w 1:100 T21 on cFTS, counsel re: results/amnio (communication)
Sampling fetal genetic material CVS - From 11-14/40, plac Amnio - After 15/40, amniotic fluid LA/needle/sac - USS guide risks <1% preg loss/chorio/pain/PPROM +/- anti-D post procedure + monitor sx Testing -> OPC -> TOP vs Expectant *TOP for twins - can be selective **Amnio preferred testing for DCDA, less contamination ***cFTS vs diagnostic - screening - best guess, can be wrong, diagnostic confidently confirms
259
Hx of Bipolar (BPAD)
HE - dx/rx/cx/f/u Ix - EPDS +/- urgent rv Y to Q10 or >=13 +/- rpt again in 2/52 if score 10-12 R2U - worsening of MH/PND/PP R2B - Ebstein anomaly/FGR/PTB RR4u - med com/psych/lithium lvl/thyroid function RR4b - tert morph/echo/E-stay/M&B/avoid lithium w BF
260
2/52 postpartum scored 9 on EDPS scored 2 pts on Q10 bkg of Bipolar on lithium or 6/52 postpartum in clinic low mood affecting quality of life or 6/52 postpartum in clinic low energy/not eating well/early morning wake
HE - difficult eat/sleep/anhedonia/suicidal/infanticidal ideation - physiological recovery/bleeding/pain/IC/U&B/POP/CST - social support PND/risk of PP admit/MH rv/1:1 care mother/baby unit Lithium CI to BF Contraception *if not severe just PND - community psychology/GP/address RFs
261
high EDPS score antenatally or suicidal tendency
Admit MH/SW rv CBT +/- meds RANC + screen for substance use + screen for DV Discharge plan + reg OP F/U Peripartum plan - extended stay... *score 10-12 re-check in 2 weeks **>=13 immediate MH referral
262
Etoh in pregnancy
HE - tolerance/annoyance/cut down/eye opener (T-ACE) - quit attempts/other substance - prescription vs illicit/MH - EPDS - vitals/avb/tcr/abdoepelvis - hepatosplenomegaly Ix - FBE/UEC/LFT/Coag/liver USS - anemia/liver dmg/coagulopathy/NASH R2u - malnourish/cirrhosis R2b - FGR/FASD - neurodevelop/SB D&A+SW/benzo transit/thiamine/etoh withdrawal scale tertiary morph/serial/G/S/paeds PP
263
Opioids in pregnancy
HE - other substance/IVDU Ix - urine drug screen risk to u - dependence/analgesia req risk to b - NAS RR for u - methadone/ano rv RR for b - paeds rv PP for NAS
264
Smoking in pregnancy
HE - quit attempts/FH (if advance preg) Ix - .... risk to u - infection/resp/cancer risk to b - abruption/FGR/PTB/SB/SIDs RR for u QUIT-line/CBT/NRT/OCP CI RR for b 4wk G/S
265
Hx of IVDU in pregnancy
HE - other substance/still use Ix - screen for HIV/HBV/HCV RR - ongoing use -> D&A service
266
Homeless in pregnancy
SW - accommodation/care costs DHS - unborn alert - children safety Dietician - gwg RANC
267
Late Booker or Little to no antenatal care
HE - full hx/exam risk to u/b - undiagnosed issues - aneuploidy/congenital abn/GDM/anemia/FGR - baseline bloods/MCS/USS - reg OP/sup/vax/referral - serial G/S/IOL 40/40 *too late for OGTT - fasting BSL + HbA1c
268
HCV in pregnancy (clinical and communication)
HE - transfusion/IVDU/needlestick - dx/rx/cx/f/u R2U - cirrhosis/ca R2B - chronic carriage via MTCT ~6% - gastro ref/trimester LFT/rx PP - VL/LFT/liver USS + HIV/HBV sero - avoid CVS/amnio/FSE/FBS - have cord serology/paeds rv *undetected VL less likely to have MTCT **RFs for - level of VL and APH
269
HBV in pregnancy
HE - dx/rx/cx/f/u, co-screened for other bloodborne - LFT/Liver USS/VL/partner immunization R2U - chronic/cirrhosis/ca R2B - MTCT - chronic carriage MFM/ID review VL in T3, low VL = low risk of MTCT Tenofovir rx in T3 if >200K/ml Avoid invasive procedures AN/Intrapartum Avoid prolonged SROM Cord serology/paeds/bath before IM injection/IVIG/Vax BF – safe w teno/contra-barrier/VTE LMO + Gastro F/U
270
EDS in pregnancy (Danlos)
HE - dx-type/cx/rx/FU - several types - classic/hyper mobile/vascular - risk profile differ - wound healing - cervical insufficiency/PTB - aortic/uterine rupture - vascular type Genetics/MFM/Contra Baseline - cardiovascular ax tte carrier/PGD vs CVS/Amnio MDT care - MFM/ptl/pt/ot/CS 34/40
271
Liver transplant in pregnancy
HE - reason/rx/cx/F/U/med safety Ix - LFT/Liver USS R4U - GDM-if pred/PET/rejection R4B - FGR/PTB - contraception till MDT - LFT/Tac lvl/early OGTT if on pred - tertiary morph/4 weekly G/S from 28 *Mycophenolate = unsafe, need switch, need 6/52 prior to TTC
272
- Twin B 2nd stage/hand@introitus/LOC - Twin B transverse 1st stage/remain transverse 2nd stage
- transverse lie = risk of cord/labor dystocia - RTS - FHR ?NRCTG - if normal get to OT to try IPV/breech extraction vs CS - if abnormal attempt IPV in room immediately - Call for help - Code Pink - may need to upgrade to Code Green - senior Obs/Paeds in room - consent/lithotomy/empty bladder - IPV/Breech extraction... (+/- talk about the steps) - Cord gases/resus/debrief/document... *ECV then instrumental delivery is another option
273
Transverse/oblique @termv (not in labor)
- PP is not engaged - risk of PROM/cord prolapse/PTB/rupture - N.I.L - ECV 37-38/40, ECV involves...if success, F/U scan in 1/52 - if recurred, reattempt ECV38-39/40 - fail = CS, success = IOL - if fail at initial ECV, admit/await SOL, if MI +/- ECV -> CS if fail - if labour >=34/40 -> emCS *transverse lie in active labor + ROM = CS **CS with transverse lie back up (dorsosuperior) - extract footling breech ***CS with transverse lie back down (dorsoinferior) - intraabdominal version to convert to breech if MI, then extract footling breech, if SROM'd - may need to consider GTN, LUS vs Classical with senior support ****avoid ECV with ruptured membranes
274
- Retained placenta + 4th degree tear - SD c/b 3rd degree tear
- EBL/vitals (code or not) - inform consultant/ano/colorectal - arrange urgent transfer to OT - NBM+IVC+IVT+IDC - 40IU of synt + X 2 PRBC - Consent - EUA/MROP/+/-Bakri/OASIS repair - lighting/analgesia/abx - MROP include cervical check - OASIS repair w senior obs + CR assistance - HDU/debrief/document/anemia correction/analgesia/VTE prophylaxis/abx/aperients/PT rv/OP F/U - PFU/anomonometry/elCS next preg *if bleeding - attempt Dublin whilst await urgent OT transfer **if not bleeding - w/o OASIS that req OT - mob/position change+CCT may help ***3-0 PDS end-to-end EAS/IAS ****4th degree - identify apex, close lumen with continuous or interrupted rapidly absorbing sutures, knots in anal lumen -> then proceed to IAS/EAS…
275
Double bubble on mid-trimester scan early morph = N amnio+FISH = N (done due to AMA) (Communication) or Double bubble + Poly on mid-trimester scan (encounter 2)
Intro/acknowledge/sorry/story/solutions/support/second opinion/summary/second visit Clinical - duo atresia need PN AXR to confirm - duo atresia assoc w T21/CHD/other complex - risk of polyhydramnios in preg - MFM/TOP vs expectant - RR4B-echo/GS-AFI/PN correction/NICU
276
TOP options >10/40
HE - PHx - comorbidities/fitness for surg - SHx - sup/recovery... - CIs to mife/miso - allergy/severe asthma (for miso) Medical (>=15/40) - fetocide - USS-KCL injection + mife - 24/24 later, miso PV/oral in hospital - analgesia/birth/if fail/ARM/synt/hystero - risk of RPOC - EUA/MROP - POC/OP F/U Surgical (up to 24/40) - day/GA/USS/suction/POC testing/recov - risks infection....RPOC/cervical tear/ash - home same day/POC/OP F/U +/- cabergoline +/- death cert (>20/40)
277
- Hemorrhage during D&C or D&E or STOP - HMO concern they perforated @STOP
HE - ?POC all out ?tone ?vitals - Perforation - Inform anesthetist - Request senior OG assistance - Trendelenburg + Bolus + Txa + Xmatch - IDC + ABx + 10IU Synt + Tamponade - Request laparoscopy or laparotomy set - Laparotomy if uncontrolled/HD unstabl - Identify perf/ligate UtA above/below - repair defect/intra-abdo survey - +/- complete suction under vision - +/- cystoscopy +/- blake drain - HDU/anemia correction/IV Abx 24/24 - Open disclosure/document/future preg imp/OP F/U
278
P/W swollen leg post ERPOC
HE - post-op recovery/chest signs/HD stability/WOB/groin/calf... - concerned about postpartum DVT - FBE/UEC/LFT/Coag - infective/renal/synthetic function.. - LL Doppler +/- CXR +/- CTAP vs VQ +/- ECG - Inform con/ref to Haem for advice - Likely empirical LMWH whilst ix pending - Admit pending ix/dose titrate/education/anti-xa lvl - Options (not BF) - LMWH/warfarin/DOAC (preferred in non-BF pop) - TEDS/encourage mobilization - OP F/U with Haem +/- rescan +/- duration of mx +/- testing for inherited thrombophilia *BF anticoag - LMWH/warfarin
279
Procidentia workup/mx
HE-PMB/UI/SA/CST/PHx - comorb/cough/SurgHx/SHx - sup/recovery/smoke/BMI Ix - FBE/UEC/+/-MSU/pelvic/renal USS (baseline Hb/renal function/exclude ut/adnexal abn/hydronephrosis)/UDS - ?SI Mx - 1st line - pessary+/- E2+PFE+RF mod - pessary/SA/change/ulceration/E2 2nd line - surgery-VH+BSO+AP+SSF+Cysto+/-TVT vs Colpocleisis - close/CST/SA
280
Procidentia & POP mx options
- pelvis USS + UDS should be done - high BMI - uterine preserving not ideal - high risk for path - suspicious endometrial path - uterine preserving CI - uterine conserving vs not - obliterative or not - vaginal or laparoscopic - mesh or not uterine conserving - mesh or not - SHP vs USHP - lap approach/SSHP - vag approach HP vs CP Location = sacral or sacrospinous or uterosacral
281
Adolescent dysmenorrhea workup
HE - menarche/relation of pain to menses/other dys's/tried any meds - NSAIDS/PHx/Surg/FHx of Endo/HEADSS/BMI/abdo exam only Ix - FBE/Ferritin/TA USS - ?IDA/DIE/structural - non-comm horn Mx - COCP/MA/Txa/rv in 3mo +/- lap *consider STI screen or TV USS If sexually active
282
Adolescent endometriosis on laparoscopy postop counselling
- endometriosis is... - risks include CPP/infertility - excision can slow disease - but optimal excision 30% recurrence - ?early excision alter disease course - hormonal suppression important - CPP req MDI - pain/psych/PT *if want further surgery - gynae MDT/ref endometriosis unit - MD OPC available
283
ED presentation abdo-pain post RV endometriotic nodule resection or abdo-pain bowel not open D3 post extensive POD excision
HE - F&C/U&B/vitals/peritonism/BS DDx - bowel perf/collection/ileus/PID Ix - FBE/UEC/CRP +/- BC+MSU+ CTAP Mx - NBM+IVC+IVT/inform con/await ix/+/- ref Gen Surg +/- RTT/laparotomy..
284
Fetal aneuploidy dx on amnio (T13)
- T13 = 3 copies of chrom 13 - multiple congenital defects - poor prog most will pass in utero - due to chance, unlikely affect fut preg - Ref to MFM/Genetics/Paeds - Options = Continue w monitor or TOP
285
HPV16/18+HSIL on CST
HE - IMB/PCB/parity/fert/vax/smoking Explanation = HPV is...16/18 90% SCC...HSIL 30/30 Ix - Colp + AC + Lugol + TZ + Bx Mx - Bx - Path/F&U/LLETZ if CIN2-3 LLETZ=day surg/LA/GA/loop/path/F/U/ Risks include... *HPV16/18 alone need colp irrespective of LBC
286
Bleeding at LLETZ Bleeding post LLETZ
call for help inform anesthetist - 1g Txa diathermy - monsel - pressure suture at bleeding point - 3 & 9 oclock to tie off cervical br of uterinre arter pack/idc +/- laparotomy vs IR -> hysterectomy debrief/document/anemia correction/audit/FU *bleeding post lletz = endometritis/cervicitis or arterial bleeder - principle is essentially the same - start off with identification/more conservative measures + prepare for OT - IV Abx/Txa/silver nitrate/pack...
287
25yo LLETZ show SCC Stage 1 36yo G2P0 cone show invasive SCC 6mm deep 29yo G1P1 postpartum, Colp show 1cm cervical mass
HE = recover/urinary/parity/fertility SCC = cancer of cervix, 5yrs >90% stg 1 FBE/UEC/LFT - renal function CTAP/Renal tract USS-locoregional spread GONC ref-rv/MDT to plan Hyst + LND vs cone or Trache - ovarian conservation Rad Hyst + LND - GA/muti-d/gen risk/specific - infert/lymphoede Cone or Trache + SLND - GA/multi-d/gen risk/specific - infertility/MC/PTB/MOD=CS IVabx/IDC/VTE proph/Path-MDT-F/U -HE/LN/Vault smear... May need chemoradiation with +'ve LN - consider ovary transposition...or NACT Fertility options = surrogacy or adoption *same applies to SCC in-situ/adenoca **rad hyst +LN vs chemoRT for more advanced cervical ca ***5yrs 90/60/30/15 ****microinvasive disease 1A1/1A2 (<3mm/<5mm) *****radical trachelectomy =<1B1, 1B = clinically visible or microscopic >1A2, if radical trachelectomy - consider abdominal cerclage + PTL monitoring
288
JW peri-op care
Pre-op - care plan - what's acceptable now & when life threatened - identify and treat anemia (e.g. iron infusion) - anesthetic rv Intra-op - cell-salvage - meticulous hemostasis - anti-fibrinolytic - pro-coagulant Post-op - Minimize phlebotomy - Post-op bleed – RTT rather than monitor
289
40yo single, nullip, AUB FI 44yo have partner, nullip, AUB FI, tried MA/Txa, want fertility/high BMI 48yo hx of bleeding/vWD, AUB FI 38yo p3, AUB FI
HE - anemia sx/impact on life/pressure/U&B/fertility needs/CST/PHx/SurgHx - vitals/pallor/BMI/palpable mass Ix - FBE/Ferritin +/- TFT +/- Coag + TV USS/Pipelle Mx - W/L Cat 1 HD&C +/- Mirena - to exclude path - day/GA/sample/recovery/risks...interim rx = MA/TxA during bleeding + weaning dose of Primolut *fibroid/no cavity distortion/mirena good option/no real fibroid shrinking meds **GnRH agonist (zoladex) temporary shrinkage of fibroid - e.g. pre-fibroid ***endometrial ablation as an alternative to Mirena if fertility not desired but need sterilization ****AMA - desire fert - can organize AMH/AFC as part of ix of AUB *****Hx of vWD - hx of post-surg bleeding, easy bruising, hx of HMB, PPH, aPTT prolonged in severe case, normal in mild, if not tested, hx of bleeding and aPTT/PT/plt = normal, should test for vWD, plt function disorder, vascular and connective tissue disorders
290
Endometrial ablation efficacy
20% failure 50% amenorrhea Return of bleeding need re-investigation
291
Abdo-mass post EA
HE - UPSI/preg sx/vitals/FH must exclude preg with sHCG R2B - ectopic/MC/PAD/rupture/FGR/SB Tertiary morph exclude PAD Serial G/S to exclude FGR *Lap salpingectomy + HDC +/- EA should be recommended to ensure permanent sterilization before EA is performed, pt with partners with vasectomy is not reliable, they could change partners
292
44yo nullip post HDC + polypectomy no cause found for AUB AUB unchanged, AMH<1 Previously desired fertility but not anymore
HE - recovery/PVB... - low AMH = ovarian reserve low/function of age - probability of spont/ART conception is low - Mirena/EA/Hysterectomy - pros/cons of each Mirena - OP insertion/LARC/remove anytime/cramping/irregular/fail EA - day/recovery/sterilisation/20%failure/50%ameno Hyster-multi-day/long recovery/general/specific risks/definitive *most women will have no periods or lighter periods EA but possible periods will return heavier after a few years, note some cyclical bleed is not abnormal, persistent PVB post EA is however abnormal
293
40yo, single, nullip, AUB multi-fibroid uterus, failed medical (include mirena) don't want fertility but want uterus
still need to investigate as per usual - bloods/image/sample phx/surghx/shx 1. HDC+EA+BS - day/quick recovery/infert/failure/not if EH/AH/EAC/cavity issue 2. Hysteroscopic resection of SMF - hyponatremia/staged... 3. Myomectomy - risk of hyster/haemorrhage/transfusion/slow recovery 4. UAE - day/quick recovery/effective/not for SSF/SMF
294
40yo single, nullip, AH on HDC sample, want fertility
HE - postop sx - PVB/fever/chills/BMI AH is precursor to EAC, 40% cancer of concomitant EAC AH untreated high risk of progression to EAC 30% over 20yr Definitive rx if family completion = TH +/-BSO If family completed but want ut sparing - IUS + 3mo EB - 2 neg - 6mo check If fertility desired - consider RBU ref/infertility ix LS modification where relevant - weight loss Persist path/Persist sx/Progression ->TH +/- BSO
295
42yo, nullip, AUB c/b anemia+impact job, also JW 18/40 multi-fibroid uterus include cavity distortion with SMFx2 or 40yo P4 (x4 CS), AUB c/b anemia
HE - symptoms of anemia - fertility/OGHx - CST/PID/PHx/SurgHx/SHx/BMI - needed to plan for surgery best option = TAH due to size of fibroid/no VD with GnRH pre-op to shrink, need MDT meeting to discuss + peri-op plan in setting of JW include... medical - PO P inadequate/mirena won't sit/GnRH/Txa/MA temporary surgery - hystero/myomectomy only focal radio - UAE - SMF = CI
296
16yo, primary amenorrhea for the second time, want to have periods and request explanation of results (full Hx including HEADSS/Ix provided) high FSH/LH + low E2/P normal karyotype + antibodies Pelvic USS show small prepubertal uterus or 26yo POI dx (idiopathic) 40yo POI dx (idiopathic)
No different to friends...but POI - ovaries stop making ovum & estrogen Reason here is idiopathic Risks include osteoporosis + cardiovascular disease + infertility Refer to PAG/Endocrinologist/SW Provide support group information Likely need puberty induction with transdermal or oral estradiol Puberty induction will take sometime, no COCP till Ut grown Will require ongoing F/U with pelvic USS Chance to have biological children is low but possible <5% Contraception will still be necessary - so COCP Fertility options include donor eggs, embryos, adoption Bone - calcium/vit d/wt bear Heart - lipid/htn/bsl/no smoke HRT for ... *consider family members at risk of POI if strong FHx **secondary ameno = absence of period for 3mo or irregular for 6mo ***secondary ameno = same ix as primary
297
secondary amenorrhea workup
bHCG/TFT/Prl/e2/FSH/LH/ - rpt FSH/LH karyotype/adrenal/ovarian antibodies pelvic USS structural issues
298
26yo, 2 small period for over 14mo since giving birth.
HE - HA/visual/palpitation/hot flushes/weight gain/loss/galactorrhea/acne/hair - OGHx/menstrual...?cyclical pain w/o menstruation...PHx... - BMI/hirsutism/thyroid/cardioresp/abdopelvic/spec - cervix ?stenosis preg/pcos/poi/pituitary mass/cervical stenosis - bHCG/E2/LH/FSH/P/Prl/TFT/SBHG/Free T/FAI+/-17OH+/-DHEAS - Pelvic USS ? uterine structural cause/?haematometra/adnexal mass ------------------------------------------------------------------------------------------------------- - F/U +/- rpt testing E2/FSH/LH/P - POI ix = antibodies/fragile-x/anti-thyroid/antiadrenal/antiovarian/karyotype
299
26yo, attend F/U for POI c/b osteopenia 10yo post dx - had transdermal E2, then on COCP, self-ceased COCP, but now SA, not ready for children
HE - any contraception/vit D/sup/CST/tanner staging Osteopenia - Osteoporosis - need E2 Recommence COCP (form of HRT) till menopause age As uterus is in-situ - need progesterone At risk of Osteo - Vit D + Ca + reg wt bear exercise + DEXA Ref to Endocrinologist - may need bisphosphonates Possibility children is <5% Still possible, so need contraception - COCP serve as contra CST as over age of 25yo
300
recent 17/40 loss post PPROM despite el cerclage 12/40 hx of x2 12/40 loss + x1 TOP (communication)
I/A/S/Sto/Solu/Sup/Sec/Sum/Sec Clinical - failed cervical cerclage -> abdominal cerclage pre-con or early T1/T2/open vs laparoscopy -> MOD=CS, if PTL -> emergency CS/suture left in place if future preg planned/risks include
301
short cervix management 28/40 bkg of Hx of PTB rural setting
APH/SROM/IC/Vitals/cervix Mx depends on contractions or whether cervix is opened FFN/HVS MCS +/- rx of BV/Ureaplasma Piper +/-Tocolytic -> Steroid/Transfer+/- PV progesterone till 36/40 +/- SW + relocate near tertiary hospital until 32/40 (only if not open cervix) Serial G/S for fetal wellbeing/cervical length *cerclage is 12-24/40 **preterm clinic till 26/40 ***progesterone till 36/40 ****open cervix = bedrest tertiary till 32/40
302
TPL with previous CS scar + LLP tertiary setting
HE - ?SROM +/- tocolytic/steroid +/- MgSo4 if TPL stops - interval scan-?LLP resolve/VBAC if no CIs if TPL - PTL - emCS +/- classical/senior obs/cord gas/paeds *locate placenta pre-op - anterior, higher risk...
303
22/40 p/w non-specific flu like sx elevated WCC + deranged LFT
HE - coryzal sx/toddler/childcare/pruritis/travel/sick contact - vitals-BP/rash/cardioresp DDx - viral hepatitis/autoimmune heptatitis/ICP/PET/HELLP MFM/Obs med for advice on ix Ix - rpt LFT/BA - CMV/EBV/HCV/HBV/HIV/ - autoimmune - eg ANA/AMA - Liver USS Admit/chase results/formal USS
304
deranged LFT on bkg of flu-like sx CMV IgG+ (low avidity) IgM+
- CMV most common congenital viral infection - risk of FGR/SB/Neurodevelopmental issues (SNHL) - most born asx w/o long term sequelae - PN require F/U - audiology/opthal - MFM/ID referral +/- confirm with amnio/PCR (6/52 post) - if confirmed - expectant with serial G/S vs TOP - USS/PCR not predictive of dmg or outcome - repeat LFT to check for resolution - continue RANC *risk of reinfection is lower next preg but still possible **hand/oral hygiene - toddler - transmission via saliva/urine ***1st half of preg - neuro, 2nd half visceral ****if IgM+, IgG-,
305
SGA on bkg of confirmed CMV infection
HE - FM/PET sx/BP Ix - +/- PET screen Mx - ref MFM/Paeds/+/-steroid/serial G/S/IOL timing/newborn serology/PCR *PET -> PI -> asymmetrical IUGR **TORCH infection -> symmetrical IUGR ***think about other potential causes of SGA
306
Post VH/AP repairs, unable to have IC postop Wasn't consent re: risk of vagina narrowing (communication)
Intro/Ack/Sor/Story/Sol/Sup/Sec/Sum/Sec relevant clinical - vaginal narrowing/shortening SE of VH/AP repair - grade vaginal dilators will solve the problem/takes time
307
Poorly controlled epilepsy preconception/antenatal (encounter 1)
HE - dx/rx/cx/F/U/meds Poor control is dangerous for mum/fetus - more seizures/hypoxia Poor control - need to change meds - req multi-agent Ideally in preg/lowest dose/monotherapy reduce teratogenic effects. Aim >12/12 of good control before conceiving + 5mg Folate starting 3/12 pre Contraception till MDT - MFM/Obs Med/Neuro/Genetics - inheritance Check if AED enzyme inducing & will interact with contraception AN advice R2U - more seizures (sleep/dehydration/stress)/SUDEP R2B - NTD/congenital malformation/FGR/PTB/SB/NAS Med safety/compliance/avoid sleep dep/stress/dehydrate Continue 5mg folate/early morph - ?NTD/tertiary morph/serial G/S Intrapartum - epidural *avoid sodium valproate (epilim, not enzyme inducer), lamotrigene = choice **5% risk of inheritance if one parent, 10% if two parent
308
32/40 BIBA post fall/semiconscious on bkg of epilepsy presumed grand mal seizure at home 37/40 arrived in LW unwell, had a seizure
HE - collateral/triggers/vitals/GCS/BP/clonus/reflex - Code + Left lateral + O2 + protect from injury + CTG - NBM + 2 WB IVC + MgSo4 load/maint +/- IV anti-HTN - labetalol/hydra - stabilize +/- deliver +/- steroid - FBE/UEC/LFT/lactate/uPCR to exclude PET/HELLP - CTB to exclude ICH - MFM/Neuro opinion - seizure prophylaxis +/- Neurosurg - ICH - delivery planning -timing/MOD (seizure ctrl/fetal compromise) - HDU or ICU - BP ctrl w anti-HTN/bloods/UOP/CMP whilst on MgSo4 24/24 - Debrief/document/VTE prophylaxis etc... *prophylactic PO clobazam intrapartum if poor seizure ctrl antenatally **intrapartum - consider epi/hydration/avoid over-exertion ***tocolytic if hypertonus if secondary to seizure
309
Hx of poorly ctrl epilepsy Uncomplicated NVD
PN tasks - neuro rv - agent/dose/compatibility w BF/contraception - +/- Paeds rv (risk of NAS) Advice - BF/express – BF is safe/avoid O/N feeding - Nurse on floor/shallow bath/company F/U - Neuro 6/52 - Pre-preg counselling next pregnancy
310
Hx of FGR preconception/antenatal
HE - reason for FGR/Hx of HTN/PIH/PET/aneuploidy/infection/medical/smoke/BMI Precon ix (if previous cause unknown) - APLS/Thrombophilia/HbA1c/TSH AN Ix - aneuploidy/morph, if detected -> TORCH+/- amnio-karyotype Mx - MFM rv/opinion/LDA+Ca/nutrition/no smoking/tertiary morph/4 wkly serial G/S/once detected -> weekly or twice weekly doppler + CTG + steroid loading + IOL *MOD - IUGR NAFID = prime-Cook's/synt/CEFM ->VD vs IUGR w AREDF = CS **have to know what the reason is for previous IUGR, need to ix if never investigated
311
AMA/IVF preg/Obese/PCOS 28/40 OGTT = 7/14/7 or BMI55/PCOS 16/40 OGTT = 9/18/9
HE - FM/APH/SROM/TPL/PET sx/Vitals/FH GDM is diabetes in preg R2U - PET/IOL/emCS/DM PP R2B - poly/TPL/PTB/FGR/LGA/SB LDA+Ca from 12/40/reg OP - BP/urine/MDI - Endo/DNE/Dietician Compliance w BSL monitor +/- rx/postprandial exercise/GWG 4wkly serial G/S/IOL btw 38-39/40 if EFW/AC >90%/Timing based on ctrl *OGTT normal range >=5.1, >=10, >=8.5 **early OGTT - urgent endo ref + HbA1c too for undiagnosed T2DM
312
Serial USS show EFW>90% bkg of obesity/GDMoD
HE - FM/APH... LGA - baby bigger cf to others R2U - labor dystocia/OASIS/operative delivery/PPH R2B - shoulder dystocia/birth asphyxia/HIE/CP/SB/fractures/BPI/hypoglycemia accuracy of scan reduces with increase EFW IOL btw 38-39/40 reduce SD + fractures/Alt = elCS vs expectant IOL involves - priming - Cook's/Prostaglandin...
313
Anti-Le antibody on routine G&S
anti-Lewis a RBC antibody IgM, don't cross placenta not clinically significant
314
PTSD on SNRI - bkg of PPH in previous preg - bkg of abruption ->emCS/transfusion
- dx/rx/meds/F/U - medications are...safe, not safe, need changing - important to continue safe meds for control - refer and link up with PNMH for AN/PN care - EPDS score each visit - PN - single room/avoid sleep depriv/ax mother-baby interaction
315
Hx of PPH
- explore reason for PPH/RFs - document - active 3rd stage/x2 WB IVC/PPH kit in room - valid G&S +/- x-match
316
BMI55/PCOS/Infertile/attempting preg through OI - preconception
- HR preg/MDI care - R2U - GDM/PET/IOL/op del/VTE/BF issues - R2B - mc/NTD/congen abn/FGR/LGA/SB/PTB - ideally BMI<30 before attempting preg/contraception - LS - diet/exercise/med/surg - MD wt loss mx clinic - Precon - CST/vax/sup - high dose folate *meds for wt loss - outside **not conceive during time of rapid wt loss
317
NT >=3.5mm on early morph on bkg of BMI55
- ? part of cFTS ?any other preg sx of concern - thickened NT marker of underlying congen anomalies - association with T21/CHB/FGR/SB - ref to MFM/Genetics discuss risk/further testing - NIPT (risk of failure/cost) vs diagnostic (amnio/CVS) +/- anti-D - expectant (tertiary morph/echo/serial G/S/paeds rv) vs TOP *thickened NT is not just related to T21 but a range of structural defects
318
BMI55 antenatal plan
HE - preg sx/PET sx/RANC/vitals risk/mx overlap with GDM the extra care include - exercise/GWG 5-9kg/MDI - ano - regional/airway/LC - BF difficulties - tertiary morph/timing of delivery/more involved intrapartum care
319
BMI55/GDMoI - poor ctrl - intrapartum plan
HE - preg sx/PET sx/vitals - tertiary facility - expertise/bariatic equipment - IOL from 39/40 to reduce SB - x2 WB IVC + CEFM + RTS (presentation) + intrapartum S/S - early epidural + trial should be in OT + active 3rd stage - BF - support w LC/contraception - not E2 based/wt loss mx referral - wt appropriate abx/LWH *IOL before by 39/40 for BMI>50 to reduce SB **IOL by 40/40 to reduce emCS
320
15yo p/w - LAP/Vaginal DC - No period for awhile
HE - location of pain/PVB/fever/chills/nature of DC - HEADSS - SA - partners/barrier contraception/hormonal contraception - anosmia/HA/visual/thyroid/menstrual/phx/surg/fhx - vitals-fever/?hyperandrogen/cardioresp/thyroid/abdo/no internal exam Ix - bHCG to exclude pregnancy/TSH/Prl/E2/P/LH/FSH to ix for 2nd ameno - endocervical/HVS to exclude STI (if sx, rather than uPCR) +/- hyperandrogen screen pelvic USS Mx - f/u OPC/await results +/- repeat again +/- additional tests for 2nd ameno - SW/DHS/Police for child protection if suspect abuse *don't forget stress/exercise as causes of 2ndary ameno **beware red flags for abusive relationship and reporting
321
53yo hx of breast ca, on tamoxifen referred for hot-flushes
HE - hormone sensitive breast ca/rx/cx/F/U - onset/VMS/urogenital - SA/dysparenia/urine - thyroid/PMB/CST/MMG/FOBT/DEXA/PHx/SHx-SAD/BMI/cardresp Ix - +/- TSH to exclude hyperthyroidism Mx - d/w MONC ?topical E for GSM - non-pharm vs non-hormon pharm for VMS - Options - LS... + CBT/hypnosis vs SSRI/SNRI/Gabapentin - F/U after trial of above to check resolution - osteoporosis prevention - wt bear ex/vit D/ca/Dexa
322
PMB/tamoxifen on bkg hx of breast ca
- d/w MONC/cease tamoxifen - TV USS - ET + Pipelle whilst W/L Cat 1 HDC - PAC to assess suitability for HDC - HDC involves day surg/GA.. (EH on HDC) - HE - postop recovery/check RFs - EH is precancer of endometrium - EH progression to EAC 5% in 20yr - usually mx = LS mod (wt) + P (IUS vs MPA) + serial EBs (e.g.x2) - d/w MONC - breast ca/progesterone issue - so unlikely medical - recommend hysterectomy - GONC ref for opinion - ?TAH/BSO - PAC/multi-d/ga/path/results +/- referral.., *EH on tamoxifen, talk to MONC to cease, mirena might not be compatible if PR+ breast ca
323
Gastroschisis on morph busy farmers with x2 kids (communication)
Intro/ack... - weakness in belly and bowel pushing through - associated with genetic conditions/FGR/SB - ? aneuploidy screen done - refer to MFM/paeds - counsel/ix - amnio - options - exp vs TOP - exp - rpt morph + 4wkly G/S + IOL + PP surg *gastroschisis - paraumbilical <10% mort **omephalocele - umbilical 25% mort
324
28yo pregnant on warfarin for unprovoked PE request information re: teratogenicity of warfarin +/- TOP advice
HE - planned/unplanned/wanted or not/contraception/PVB/PHx/Surg/Med/FHx/SHx - PE - dx - ix/rx - warfarin dosing/cx/F/U - AN investigations - Hb/Rhesus Warfarin is teratogenic overall risk 5% esp btw 6-12/40 affects bone/cartilage development->FGR/SB Expectant vs TOP Expectant - MFM rv/tertiary morph/4 wkly serial G/S (choose to have STOP) MS2STEP up to 10/40, so STOP Anesthetic + Hematology rv - anticoagulation plan STOP involves - day/GA/suction/USS/POC/risks - general/RPOC/rpt/perf Peri-op - bridging clexane before & after - return to warfarin w INR/Haem F/U *dose >=5mg daily, high risk for congenital abnormalities
325
23yo p/w genital ulcer in pregnancy (encounter 2)
HE - previous HSV/STI hx/UPSI/urine/bowel/vitals/exam ddx - herpes/syphilis/scc/becht ix - type specific HSV serology/genital ulcer PCR + other STI screen include syphilis (HSVII identified) HSV is a STI, No cure but suppress antiviral/partner notification R2U - pain/urinary sx/recurrence/transmission - ID opinion/+/-Admission+/-IDC/liganocaine/acyclovir/SITZ/barrier contraception/long term suppression/F/U in 1/52 to check sx R2B - congenital (in-utero) placental <5% -skin/eye/CNS/FGR/SB perinatal 50% primary vs 3% recurrence/postnatal - MFM/ID/consider serial 4wkly G/S - antiviral prophylaxis from 36/40 - CS if lesion intrapartum -3% risk/CS if not seroconverted by 34/40 (rx as primary) - avoid FSE/FBS/instrumental/prolonged PROM/paeds rv *HSV1 (15%) riskier than HSV2(<0.01%)
326
HSVII confirmed early in pregnancy now in advanced labor
HE - timing/duration of contractions/?SROM/duration/spec - ?lesions/CTG (recurrent lesions in vagina) - 3% risk of perinatal transmission - risk of neonatal HSV skin/CNS/disseminated disease - obs con/paeds rv and get involved in discussion - recommend emCS to reduce transmission risk albeit surg risks in advance labour - if decline, avoid FSE/FBS/instrumental/prolonged PROM - either way - Paeds rv postpartum - patient education re: hand hygiene + monitor baby sx
327
Hx of Abruption Attend ANC 16/40
HE - reason for abruption - smoke/cocaine/BP/twins/poly/chorio/fibroid/hypothyroidism R2U recurrence/emCS/R2B PTB/SB LDA+Ca/reg OPC-BP/urine/BP control/address RFs 4wkly serial G/S/ERCS or IOL from 38/40 *Address RFs = optimize any underlying med conditions
328
Slow progress with SOL in community present for hospital for epidural
HE - onset/membrane/duration/freq/dilation/G/S/vitals/VE/RTS Epidural - bloods/ano rv/risks hypotensive/NRCTG/prolonged 2nd stage, benefit adequate analgesia/relax PF/adequate analgesia if req operative delivery Slow progress - exclude signs of obstruction/augmentation - IV/syntocinon/more reg contractions/check progress/epidural provide analgesia/passive descent in 2nd stage...
329
Spont laborer Slow progress Augmented Got an epidural Sudden collapse - return of circulation - no return of circulation
HE - pulse/DES DDx - most likely LA toxicity/AMI/AFE/CVA Priority is resuscitation + expedite delivery - Code Blue - MDI for simultaneous resus/ix/rx - O2/left lateral/check response/clear airway - Unresponsive -> start compressions - x2 WB IVC - IV intralipid - bolus/infusion/PPH/OT mx - Attach AED leads +/- shock - Request perimortem CS kit by 3min CPR - PMCS by 4min of CPR - Birth by 5min of CPR - Anticipate PPH on ROSC - Single layer closure/pack abdomen/IV Abx - Transfer to OT for completion - ICU/HDU/anaemia correction etc... *LAST -> cardiac arrest
330
Precipt NVD 15min postpartum Sudden LOC
DDx - most likely AFE/massive PE/seizures/internal bleeding or massive PPH - Code Blue - MDI for simultaneous resus/ix/rx - O2/left lateral/check response/clear airway - Unresponsive -> start compressions - x2 WB IVC - Bloods-fluid resus (FBE/UEC/LFT/Coag/G&S/Lactate) - Attach AED leads +/- shock - Anticipate PPH on ROSC - ICU monitoring +/- vasopressor support + ix - Post resus investigation - CTB/CTPA - Correction of coagulopathy/anaemia/VTE prophylaxis/BF - Debrief...
331
Fundal height > Date, 28/40
DDx - LGA/Polyhydramnios/fibroid/error measure/error gestation/multiple HE - what's EDD based on/aneuploidy/morph/GDM/TORCH/Thal - SOB/discomfort/FM/APH/SROM/TPL/vitals/RTS-AFI (key - Poly ix)/girth Ix - G/S to check interval growth/exclude fibroid +/- Poly Ix Mx - depends on cause...
332
FH>D, high AFI
DDx - aneuploidy/idiopathic/GDM/structural/thal/infection/isoimm Ix - aneuploidy/morph/OGTT/TORCH/G&S/FBE/Thal R2U - pain/discomfort/IOL/operative del/PPH R2B - PPROM/Cord/malpresentation/PTB/SB MFM rv/reg OPC/weekly CTG/AFI/serial G/S admit 38/40 +/-IOL/ctrl ARM/CEFM/active 3rd/Paeds PP *Amnioreduction if severe SOB
333
FH>D, found to be LGA, no fibroid
reason - rapid GWG/GDM/Obesity/familial Ix - GDM R2U - IOL/op del/OASIS/PPH R2B - SD/Fracture/CP/HIE/BPI/SB/Hypoglycemia IOL by 39/40/active 3rd/anticipate PPH
334
28/40, FH>D, found to have 9cm fibroid
R2U - red degen/admission/op deliver/PPH  R2B - PTB/FGR/malpresentation/abruption HR preg/reg OP/admission for abdo pain tertiary morph/serial 4 weekly g/s - presenting part/fibroid timing/MOD individualized/active 3rd/anticipate PPH/OP Gynae F/U for rx *large fibroid - complex CS list/MDT/senior obs/cell salvage/IAP/consent for CS hyst **abnormally large/rapid growth - gynae MDT/thorough hx/?MRI/?GONC
335
Demonstrate fetal head dis-impaction maneuvers (encounter 3) or Booked CS/OA +1 attempt NBFD, failed Describe mx
- call for help - inform pt/OT team - anticipate PPH - ergot/txa drawn Push method - assistant to push from below or insertion of fetal pillow - left hand below presenting part - lift w/o flexion of hand to prevent cervical tear - unsuccessful -> inverted T incision with GTN Reverse breech (OP) - deliver both arms - grasp both feet to deliver both legs - pull on both legs to deliver body - turn body/shoulders simultaneously to turn head to OT and deliver Reverse breech (OA) - deliver both arms - grasp hips - deliver body by lifting hips w fundal pressure - turn body/shoulders simultaneously to turn head to OT and deliver - Paired gases/Paeds - Debrief/Document - M&M/Clinical audit - Offer psych support - Offer PP F/U – discuss future preg implications *https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-019-2253-3
336
Chronic HTN seen in early pregnancy visit ~8/40
HE - dx/rx/cx/F/U/diet calcium intake Ix - FBE/UEC/LFT/uPCR/metanephrines/urine catech/renal doppler R2U - PET/IOL/PPH/CVD/VTE R2B - FGR/PTB/abruption/SB LDA+Ca/UtA/sFLT/PLGF Obs med/reg OP - BP/urine dip+/-amb BP monitor/home monitor Annual BSL/Lipid/BP/LS modification/switch to other anti-HTN tertiary morph/4 wkly serial G/S/IOL 39/40
337
OP in labor
HE - coupling/incoordinate contractions/backache/prolonged labor - 20% in EL OP - 5% deliver vaginally - R2U - prolonged 2nd/operative delivery/OASIS/PPH - R2B - fetal injuries from difficult op del - Trial in OT - rotation VE/manual rotation/NBFD or Keillands -> CS if above spines
338
IVF pregnancy
R2U - VTE/PET R2B - LWB/PTB risks may also be in the setting of AMA/fertility rx
339
Home birth request
HE - check risks assoc with preg and impact this may have on request - high risk, not recommended esp if HR preg - generally LR signed off by hospital - community private MW - involve senior obs for discussion - accredited MW team in community work with hospital - document clear emergency plan
340
- 12/40 AN visit Hb93 - 10/40 AN visit Hb90 mcv78 strict vegan
HE - SOB/lethargy/nutrition/pallor/tachycardia/vitals ?MCV ?micro vs macro DDx - nutritional def (iron/folate/b12) vs Thal +/-Iron studies +/- B12/Folate Thal - HPLC - ?HbA2 elevated (=b-thal), if N - a-Thal genotype mum If HbA2 elevated - talk to Haem -> partner testing/rv Partner carrier - 1:4 of B-thal major 1:2 chance of carrier - MFM/Genetic counselling - CVS/amnio Fe def -> diet/PO/infusion Repeat Hb in 2nd/3rd trimester *think about dietician review with vegans who are anaemic
341
Overseas travel (tropical 3rd world) p/w flu-like illness/joint pain/night sweat/chills ~20/40
HE - FM/APH/location/exposure/PHx/Surg/Med/SHx/jaundice/vitals/FH... DDx - CMV/malaria/dengue/zika/hepatitis ID ref/likely need FBE/Blood film/UEC/LFT/HIV/HCV/HBV/TORCH screen (include EBV)/MCS - stool/MSU/BC/Resp PCR/USS Admit/Observe/Chase Ix IVC/IVT/antipyretic/antiemetic/analgesia +/- steroid loading +/- VTE prophylaxis OP F/U on discharge
342
ATSI patients
- offer AHLO - early GDM testing then rpt - tertiary morph/4 weekly serial G/S
343
Previous NND Previous FDIU Previous abruption (e.g. Hx of T9 and NND)
HE - cause*/ix/rx/f/u - prevention/optimization - HR clinic-reg visit/MDT +/- LDA/Ca/LMWH - aneuploidy/tertiary morph/4 wkly serial G/S - timing/MOD individualized (not PD)/CEFM *causes - fetal/placental/maternal fetal - structural, genetic, growth placental - abruption, chorio, cord, infarct, insufficient maternal - DM, HTN, autoimmune, ICP...
344
Advice on fetal anomaly screening in twin pregnancy
Aneuploidy - Non-invasive screening - cFTS vs NIPT - cFTS - involves serum marker + NT, early fetus specific risk, medicare rebate - NIPT - cell free DNA, higher detection, not fetus specific, out of pocket Congenital anomalies - anatomical survey btw 18-20/40 *consider fetal echo for MC twins as well as higher incidence of cardiac anomalies
345
DCDA - Mid trimester scan Twin 1 EFW80% Twin 2 EFW25% bkg of GDM (encounter 2)
DDx - aneuploidy/PI - PET/other med condition/infection PET/TORCH screen/MFM referral +/- amniocentesis Optimize GDM-DNE/Obs med input 2 wkly G/S +/- steroid +/- weekly doppler Timing/MOD individualized *>25% is usually used to define discordance
346
39yo Post CS for SB bkg of VP - baby found to be SGA/Kleihauer+'ve, LLP revealed on hx with further probing (communication)
Intro/Ack/Sor/Story/Solution/Sup/Sec/Summary/sec Clinical - VP - vessels in membrane, exposed, minimal protection - possible FGR from cord compression or AMA - Kleihauer+'ve - FMH - ?abruption (PET/trauma...) rather than VP rupture
347
Describe IIA ligation as part of PPH mx
- senior obs +/- GONC support - Divide peritoneum parallel to IP lig to enter retroperi space - Identify EIA/vein laterally on psoas and ureters medially - Retract ureter medially to expose CIA - Identify IIA as a branch CIA - Expose IIA and IIV runs underneath it/dissect IIA till posterior division visible - Ligate IIA 2.5cm distal to origin posterior division or bifurcation - Right angle clamp behind artery care to not injure external iliac V/internal iliac V - 1-0 chromic around vessels 2 points, 2cm part - Identify EIA/femoral pulse before and after ligating
348
25/40 twin preg T2 diaphragmatic hernia
- hole in diaphragm/abdo content into thorax - prognosis depends on extent - pulmonary hypoplasia/FGR/SB - association with syndromes/CHD/NTD - refer to MFM/Paeds rv +/- amnio +/- long term impact - expectant vs TOP - prenatal rx FETO (accelerate lung growth/development) + NICU - PN repair + TTE - +/-steroid load/serial G/S - growth/AFI/timing/MOD individualized *CHD association -> fetal echo
349
Unplanned preg/unstable social Multiple bloodborne virus Substance abuse - smoke/IVDU
- Expectant w comprehensive referral + mx - TOP with reliable contraception - MOD individualized - VL -> MTCT risks - consider duration of SROM/type of intrapartum monitoring/ix/operative del *opioid abuse - ano - high analgesia req
350
- Unexpected right adnexal mass at appendicectomy with Gen Surg - Unexpected unilateral malignant mass at cystectomy (peri-meno woman)
- scrub/inform gynae con to assist - check consent +/- contact NOK - lithotomy - head down - diagnostic survey - RUQ/LUQ/contralateral side etc... - cytology (PW) +/- micro - GONC opinion +/- BSO +/- omental/peritoneal bx +/- frozen section - baseline TMs - document/debrief/OP FU *pre - USO + contralateral bx **peri - depends on consent, ?BSO vs USO + contralateral bx - likely if ca you have to come back and do TAH etc anyway, so probably just do more conservative to start with
351
Rural setting can only resus from 34/40 29/40, FHR on RTS 250bpm ?fluid on fetal scalp Consultant on-call scrubbed MW wants to know if to prep for CS (encounter 1)
HE - FM/APH/SROM/TPL/vitals/uterus - AN course (28yo G4P3 asx/vitals/all AN care = LR) - Fetal tachy (i.e. SVT)-> HF -> Hydrops - Call PIPER/MFM/2nd on-call con - Prolong gestation where possible - 29/40 compromised, survival not good - Steroid load/Transfer Tertiary - Trial rate control - dig vs flec vs sotalol - Delivery only if rate control fail - Fetal echo @tertiary exclude structural - OP - monitor FM, twice weekly rv, wkly CTG, fetal cardiologist rv - maternal ECG + serum drug level, monitor for PET - 2nd to mirror or just alone *with or w/o hydrops, fetal tachy rx is to rate control first to prolong gestation... **triggers for delivery - worsen fetal or maternal condition (e.g. develop mirror syndrome)
352
31/40, mother on flec for mx of fetal SVT, p/w unwell/palpitations/irregular rhythm on ECG
HE - FM/APH/SROM/Vitals - BP - cardiac issue - ? 2nd to flec - admit/observe/ix - urgent Card/Obs Med rv - FBE/UEC/CMP/serum lvl +/- correction - MFM - consider change flec to dig - stable - DC - F/U as above
353
38/40, mother on flec for fetal SVT now on dig, p/w SOL, CTG - unrecordable
HE - contraction/membrane/vitals/cervix (P3 x3 NVD, 4:10, clear liquor 7cm, +2, DOA) - arrhythmia can be difficult to monitor - SVT is rarely life threatening in labor - multi, in good going labor 7cm, low station, clear liquor, DOA, could consider monitor closely, await for spont VD - inform consultant and discuss - consider scalp lactate vs setup/consent for instrumental vs Cat 1 emCS - cord gas/paeds at birth
354
FHx of ID in male members of mother's family
? Fragile X refer genetic counselling +/- genetic testing
355
Hx of depression/anxiety - medicated planning preg, want to know drug safety of SSRI
HE - dx/rx/cx/f/u...hx...vitals... SSRI - safe, potential risk of pHTN/NAS Benefit of SSRI > Theoretical risks Untreated MH R2U - MH deterioration/PND Untreated MH R2B - PTL/FGR/poor bonding Regular EDPS in OPC Refer MH team Continue meds Tertiary morph + 4 wkly serial G/S Extended stay/Paeds rv Postnatal support on discharge *Paroxetine - least safe of all SSRI, association with congenital heart defect -> if already in T2-3, continue, MFM ref - fetal echo
356
multi, now p3 1hr post NVD still oozing from peri
HE - previous del cx/3rd stage meds/plac/membrane/EBL/vitals/tone - tone/tissue/trauma/thrombin - assess +/- repair +/- uterotonics +/- antifibrinolytic - rpt Hb next day +/- correction - BF/VTE/contraception
357
describe sacrohysteropexy
uterine preserving procedure +/- VR + cystoscopy GA/multiday stay/bowel prep/Abx pre-op General/specific risks - mesh/recurrence/discitis/osteomyelitis tape around neck of womb to ligament on sacrum IDC in-situ -> TOV/OP F/U *not suitable for high BMI - risk of EH/AH/EAC, abnormal cervix... **uterine sparing but not compatible with pregnancy, younger pt need to have permanent sterilization or at least LARC - risk of MC/FGR/PTL/PTB...if pregant
358
14yo, HMB/BMI40/acne 14yo, HMB/dysmenorrhea (encounter 1)
HE - menstrual - impact on life/dizziness/palpitation/bruising/bleeding hx - HEADS/PHx/Surg/med/allergies - vitals/pallor/BMI/hirsuitism/cardioresp/thyroid/abdo/+/- external genital - FBE/Ferritin to check for anaemia +/- TFT +/- vWF/PFA - if clinical hyperandrogenism - SBHG/T4/FAI/LH/FSH/E2 (can say consider doing PCOS screen) - bHCG to exclude pregnancy - +/- Pelvic USS to exclude uterine structural abnormalities (septum/bicorn...) - Organize F/U to discuss results - consider Txa +/- Mefanemic acid (if hx not suggestive of coagulopathy) when bleed starts and stop when bleeding stops *only do coagulation panel +/- vWF/PFA, thyroid function if hx suggestive - will get penalised for over-investigating, similarly with PCOS screen, would add DHEAS + 17-OH-progesterone if there’s obvious evidence of clinical hyperandrogenism - hirsutism & male pattern alopecia **if vWF or platelet dysfunction, need haem opinion, avoid NSAID, can use all the usual hormone measures such as COCP/mirena/Txa, consider intranasal desmopressin acetate
359
14yo F/U visit for HMB/BMI40/acne ix = high free T/polycystic ovary/IDA (encounter 2)
HE - change in sx HMB - HMB likely 2nd to anovulation - HPO maturation - no long term impact, may take up to 4yrs to resolve - Can't dx PCOS with PCOM - High free T - relative androgenemia physiological - Other causes of high free T excluded - Options = COCP vs POP (better option if high BMI/acne, 4th gen - drospirenone) vs Mirena (if no SA, may need to be under GA with miso pre-op) - COCP/POP won't impact on HPO axis, F/U in months to check, SE include... - Hormonal suppression +/- Txa +/- MA IDA - diet/po/iv Fe - recheck Wt mx - diet-red meat/spinach/legumes/exercise/wt mx clinic - med - phent/lira/surg-sleeve * Rotterdam criteria - ⅔, oligo >45d/ameno, clinical/biochem hyperandrogenism - high FAI or free T, hirsutism, male pattern baldness, need to exclude CAH/Cushing/hyperprolactinemia/thyroid dysfunction/androgen secreting tumours, **Rotterdam criteria can overdiagnose PCOS in adolescents as adolescents have relative androgenemia, cystic ovaries and anovulatory cycle - all physiological hence why USS findings not used in adolescent for dx of PCOS *** if actually meet criteria - need PAG/Endo - OGTT etc… if don’t meet criteria, but have persistent sx/increase weight, RA 8yr post menarche as these pts are at risk. ****E2 is better for acne but risk of VTE high if BMI>=35, 1st/2nd gen P is worse for acne
360
14yo F/U - Still HMB despite COCP (encounter 3)
HE - compliance with tab/concerns (concerns about weight gain) Alternative = Mirena Mirena works by ...mucus/thin lining Mirena insertion involves...LA or GA... Risks are...ectopic/expulsion/PID/malposition/perforation String check/5 yr replacement/still need barrier *other special circumstances - developmental delay - menstrual suppression with COCP vs Mirena IUS, hysterectomy is not legal unless exhausted all other measures and application to family court
361
14yo HMB didn't take any hormonal suppression return 8/12 later with mum, requesting morning after pill (encounter 3)
HE - ? consensual/age of partner/time of IC - menstrual reg/LMP - preg sx - N&V/fever/chills/PVB - urine bHCG/MSU Establish Gillick's competence UPSI - LNG - vom/irreg bleeding/Ulipristal/Cu - would you like to know more (mech/dosing/SE) - long term contraception options COCP/Implanon/Depo/IUS - would you like to know more (mech/dosing/SE) - return to F/U + bHCG STI risk - Chlam/gon/Mg/trich - return to F/U +/- rx if result +'ve
362
14yo want to know how to take the COCP (encounter 3)
caution/pros/cons - 35-smoker/BMI/VTE/Enzyme inducing drug/uncontrolled HNT/liver disease - benefit - cheap/reliable w perfect use - cons - require compliance/mastalgia/mood same time everyday placebo - withdrawal bleed if vomit within 2hr of consumption - rpt dose and continue if diarrhea - use condoms for 7d if taking abx - use condoms for 7d missed pill. - 1 continue as usual - >=3 in 1st week, EC if UPSI and condoms for 7d - >=3 in 2nd week, condoms for 7d - >=3 in final week, condoms for 7d and continue w next packet *ensure no enzyme inducing drugs
363
14yo return to ED with HMB on bkg of HMB thought to be related to HPO maturation
HE - volume/dizziness/vitals/pallor... Emergency Call for help Admit for resus/ix/mx ABC - IVC/IVT FBE/Ferritin/G&S/bHCG +/- X-match, consider LH/FSH/E2 to check degree of hypoestrogenism TA or TV USS to check ET/clots Txa + MA + Primolut 5mg or Provera 10mg 2hr (if clinical normo-estrogenic - post menarchal, normal tanner staging, otherwise may consider E2 first prior to progesterone rx) Anaemia correction - Fe/PRBC OP DC plan re: HMB mx - COCP/Mirena (if already on COCP, consider doubling dose then wean to daily) *don't do bleeding profile in acute bleeding
364
Hx of Grave's on thyroxine
- obs med rv - hx of past mx - surgery or RT - titrate thyroxine - check for TSHR antibodies (TRabs) - discuss with paeds - neonatal graves
365
Hyperthyroidism
HE - palpitation/heat intolerance/vitals DDx – Grave’s/infective… Screen for TRAbs - Obs med referral PTU+/- Propranolol - rx/sx Monitor sx/Trimester TFTs Serial G/S 4 weekly from 28/40 Notify Paeds at birth - at risk of neonatal Grave's Postpartum Endo F/U - surgery/RT
366
Hypothyroidism
HE - lethargy/weight gain DDx – Hashi/Iatrogenic… Screen for anti-TPO Thyroxine sup - increase dose Monitor sx/Trimester TFTs Serial G/S 4 weekly from 28/40 Drop dose PP + Endo & LMO F/U 6/52 w rpt TFT
367
T21 on karyotype from amnio in setting of suspected duodenal atresia
- autosomal aneuploidy - 3 copies of chrom 21 - R2B - CHD/IUGR/SB – 30% - continue or TOP - which would you like to know - continue - fetal echo/serial G/S - MFM/Genetics/Paeds/SW/Sup grp - PN - cheek swab/blood test to confirm, TTE to check cardiac *recurrence 1% if parents not carriers of balanced translocation -> offer karyotype **twin T21 FDIU can impact surviving twin, can choose selective foeticide <5% of inadvertent loss of unaffected twin -> mx of FN serial G/S – see notes above about twins *** Soft markers assoc with T21 include Increased nuchal fold (>=3.5mm), absent nasal bone, echogenic bowel, ARSA -> foetal echo
368
Multiple sclerosis
- dx/rx/cx/current sx - relapse rare AN, mostly PN - MFM/Neuro involvement - rx - caution with biological IFN, contraindicated - steroids used for relapse (if use consider early OGTT +/- hydrocortisone +/- tert morph) - relapse - risk of urinary retention -> UTI - anesthetic rv - regional block vs relapse
369
Genital wart
- dx/rx/cx/current sx - ? obstructive - ? gardisil vax - if not have PN R2U - ongoing sx R2B - juvenile resp papillomatosis - PV trichloroacetic acid (1st line in preg) (can't have imiquimod/IFN/5FU in preg) - ablation - cryotherapy (2nd line in preg) (laser for large obstructive lesions) - excision - doesn't reduce recurrence - MOD: CS not protective of neonatal infection - CS considered if large obstructive lesions likely to bleed and avulse in labor
370
Plan for IOL
- HE - Indication - Risk vs Benefit - Priming methods - Induction - CEFM/IVC... - Analgesia options - Special considerations *e.g. short 2nd stage, telemetry, no ergot...
371
planning preg w hx of cystic fibrosis FEV1 <50% recent admission to hospital for P.Aeruginosa BMI18 (encounter 1)
- dx/rx/cx (recur resp infect/pan insuff) - genetic counselling - impact on offspring - PGD (IVF) vs CVS/amnio +/- TOP vs AI w donor sper - MFM/Obs rv preconception - barrier contraception - Lung function - if FEV1 <50% assc w adverse outco - TTE to exclude cor pulmonale - Screen for diabetes esp if pancreatic issues - R2U = increase risk of infection/resp deterioration - R2B = FGR/PTL/PTB - preconceptions bloods/micro/vaccinations - Dietician - if pancreatic def/low BMI - Physio - chest physio - early OGTT + rpt - assoc DM 2nd to panc insuff - serial G/S, influenza vaccination *note fertility options only if partner is a carrier, this applies to other conditions like sickle cell too (autosomal recessive)/tay sachs - neurodegenerative disease, no cure, early childhood death - fertility options - PGD or donor gametes
372
pregnant with hx of CF carrier screen negative early OGTT +'ve BMI18 (encounter 2)
HE - preg sx... - no risk of baby being affected - early OGTT+'ve ->GDM vs T2DM - HbA1c/Obs Med/DNE - R2U = depends on type - R2B = LGA/polyhydramnios/PTL/PTB/SB - tertiary morph/serial G/S +/- echo (depends on HbA1c) - dietician/GWG/vaccination
373
34/40, chest sx with hx of CF tightening on bkg of CF (encounter 3)
HE - FM/APH/F&C/resp sx...vitals - WOB/O2 sat...abdo palp/spec/VE/RTS (5cm dilated) PTL - BS admission - observe/stabilize +/- delivery - Inform con/d/w ID/paed rv - CTG - mat hypoxia -> fetal hypoxia... - IVC bloods (FBE/CRP...)+ IV Benpen for PTL - Respiratory panel + sputum MCS + CXR +/- IV ABx for ?CAP
374
Water immersion Water birth advice bkg of HCV high VL
- good analgesia - equipment - underwater CEFM - staff - training - free from infectious disease (HCV/HBV/HIV) - BMI<35, no MSL, apyrexial, normal labor, no recent opioids - if have CI, can't offer alternatives *GBS is not a CI **Prolonged SROM is not CI as long as IV ABx is given ***https://www.safercare.vic.gov.au/sites/default/files/2021-05/GUIDANCE_Water%20for%20labour%20and%20birth.pdf
375
18yo pregnant
Young mum clinic continuous MW care SW referral Urine STI screen
376
Velamentous cord insertion
cord inserts into fetal membrane outside of placental margin assoc with previa/VP/bi-lobed placenta r2b - VP/IUGR/TTTS tertiary scan to exclude previa/VP +/- mx serial G/S to identify IUGR
377
Hx of vWD
HE - hx epistaxis/bleeding/bruising/HMB - dx - which type/rx/cx/f/u - E2 increase vWF - preg normalizes vWF & factor VIII - MFM/Haem - caution with CVS/amnio - must identify subtype of vWD & its response to DDAVP DDAVP responder -> can give prior to procedures/del to help prevent bleeding DDAVP non-responder -> may need FFP, vWF/Factor VIII concentrates ❌aspirin or NSAIDS *vWF required for plt function and stability of FVIII ** ⬆️risk of bleeding in T1-2 (e.g. ectopic, mc, CVS) - lvl not normalised enough ⬇️risk of bleeding in T3 (e.g. labour) - lvl normalised adequately ⬆️risk of bleeding postpartum - rapid ⬇️vWF & factor VIII *vWD usually autosomal dominant inheritance
378
elevated NT on cFTS
- assoc aneuploidy + structural - CHD/CDH etc... - 2ndary screening such as NIPT - MFM - diagnostic -> amnio involves... - expectant (surveillance +/- fetal echo) vs TOP
379
Heavy PVB 2/52 postpartum
HE - pain/bleed/fever/chills/postpartum recovery/BF/vitals/spec endometritis +/- RPOC FBE/UEC/CRP/Coag/G&S/X-match +/- bHCG (baseline) HVS to identify organism TV USS to exclude RPOC NMB + IVC + IVT + empirical iv abx +/- Txa bedside USS vs formal USS +/- urgent OT for suction D&C under USS +/- misoprostol Path off for histo to exclude GTD... *>6/52 consider hysteroscopic resection **postpartum uterus - thin esp ***wouldn't do miso if infective sx or heavy bleeding
380
sickle cell anemia preconception (encounter 1)
R2U - exacerbation/PET R2B - inheritance/FGR/PTB/abruption MDT rv - MFM/Haem/Genetics Screen partner for haemoglobinopathy Carrier testing for partner (autosomal recessive) Medication safety - cease ACEI/ARB/hydroxea Baseline testing- FBE/UEC/LFT/uPCR/G&S/TTE/Ferritin +/- cardiac MRI Barrier contraception await review Preconception testing - bloods/micro/vax/SAD *if asplenia, need HBV/Hib + prophylactic antibiotics – Penicillin **sickle cell anemia pt can also be treated with blood transfusion -> can lead to iron overloading and development of red cell antibodies
381
12/40 on bkg of sickle cell anemia - diagnosed on anemia screen (encounter 2)
Avoid dehydration/over-exertion/infections LDA + Ca +/- LMWH + 5mg FA Regular OPC – screen for PET Tertiary Morph/Serial G/S 4 weekly from 28/40
382
CP/SOB 32/40 bkg of sickle cell anemia (encounter 2-3)
HE - fever/chills/dehyration/FM/APH...vitals/RTS+/-CTG Admit - O2/analgesia/Obs Med rv FBE/UEC/LFT/CRP/Trop MSU +/- BC ECG/Formal Obs USS +/-IVT +/- antibiotics with ID input
383
36/40 preg gone well bkg of sickle cell anemia (encounter 3)
HE - FM/APH/SROM/TPL/HA/visual/vitals... MDI - Obs Med/anaesthetic IOL 38/40 reduce risk of abruption/PET/crisis Optimize Hb with Haem input (e.g. PRBC) CEFM/warm/hydration/epidural/avoid long labour active 3rd/hydration/VTE prophylaxis/BF/OP Haem
384
abnormal CTG bFHR160/deep decel/reduced variability bkg of TOLAC
HE - pain/bleeding/contractions changes/vitals/uterine tenderness/ve (sudden RIF pain/reduced contractions/rebound/fetal parts palpable) Uterine rupture - Code Green - GA CS - Senior consultant present - x2 IVC en route - FBE/G&S + xmatch x4 PRBC - fluid resus/consent/urgent transfer - IVAbx/IDC/Pfannenstiel/Rapid entry - delivery/immediate clamp/cord gas/paeds... - exteriorize/repair/PPH Mx... - anemia correction/VTE/BF/debrief/document - high risk for rupture future preg - ERCS only
385
Crohn's disease preconception (encounter 1)
R2U - preg has little effect on pt R2B - if active disease at conception - MC/FGR/PTB MDI – MFM/Obs Med/Gastro/Dietician Medication safety – aza/sulfa/pred FA 5mg + Biologicals until T3 Precon - bloods/micro/vax/no SAD AN/Peripartum considerations - Serial G/S 4 weekly from 28/40 - elCS if active perianal CD/ileo-anal pouch *sulfa - need high dose folate
386
Short long bone (encounter 2)
HE - aneuploidy screen + morph/vitals... DDx - aneuploidy/constitutional/error in measurement/infection/skeletal dys - Tertiary scan - MFM ref +/- amnio +/- TORCH +/- PET screen - 4 weekly serial G/S from 28/40 *constitutional = most common
387
S- antibody on routine screen (encounter 2)
R2U - blood transfusion compatibility R2B - HDNB (mod risk)/Hemolytic disease of fetus (low risk) MFM/Titre/Serial G/S - MCA PSV ?anaemia Notify Haem + x-match blood ahead of time
388
Hx of MVA c/b pelvic fracture AN care and advice (encounter 1)
op note ortho opinion ROM hip abduction consider pelvic xray likely CS
389
- Peri-menopause bleeding, TV USS 8mm - Peri-menopause bleeding, erratic bleeding
menstrual cycle - variable length, long interval >=60d menopausal symptoms persistent erratic bleeding -> TV USS ET <5mm - consider monitoring sx ET >=5mm - need sampling - Pipelle + HDC *pre-menopause AUB ET>12mm need sampling, <12mm can monitor https://www.canceraustralia.gov.au/sites/default/files/publications/ncgc-vaginal-bleeding-flowcharts-march-20111_504af02038614.pdf
390
Postpartum fever uncomplicated NVD 2nd degree
Hx based on source breast/lung/bladder/perineum OE - targeted examination (mastitis) - admit/IVC/IVT/abx/antipyretic - sepsis protocol - breast milk MCS - gen surg & LC rv - ultrasound +/- imaged guided drainage - VTE prophylaxis
391
Describe how to perform a classical CS bkg of cord prolapse - twins
GA/senior obs support/Paeds in room Know placenta position/fetal lie wide pfannenstiel or midline skin incisions dissection of layers and entry into peritoneal cavity bladder dissection vertical incision as low as possible (ideally within LUS) fingers (non-dominant hand) btw uterus and fetus to avoid laceration scissors extend the incision cephalad as needed for delivery extraction of fetus x2 as per usual double clamp for gases expect bleeding - ask for Txa CCT/check cavity 3-layer closure of uterus - deep/superficial/serosa - continuous 1-vicryl check adnexa/ensure hemostasis/sheath/skin/dressing document/debrief - discuss impact on future pregnancy
392
HR aneuploidy Diagnostic - normal FISH/microarray Karyotype - balanced translocation
reassure refer to genetic counselling normal phenotype unknown clinical significance male - possible oligospermia female - possible RMC
393
Low PAPP-A (<0.4)
R2B - PET/IUGR/SB Surveillance...
394
T18
most will pass in-utero only 5-10% survive first year congenital heart disease in >50% expectant = tertiary morph/serial GS/echo - high risk of SB top = feticide/mife/miso/hospital/analgesia/risk of RPOC
395
- Asherman' syndrome on USS for ix of RMC - Secondary amenorrhea - Hypomenorrhea after intrauterine procedure
- scarring adhesion endometrium 2nd to uterine procedures - cause infertility - preg risk w Hx of Ash - FGR/PTB/PAD -> need MFM ref - HDC +/- resection +/- intrauterine balloon - paediatric foley - general risks...specific risks - persistent infertility/rpt procedure hyponatremia/seizure - day procedure/miso...intrauterine balloon 7-10days - consider low dose E + progesterone for withdrawal bleeding - consider rpt hysterocopy in 2/52 to check cavity - avoid rpt intrauterine procedures/infections *prevention - esp intrauterine procedure in gravid uterus or those in hypooestrogenized states - ie during breastfeeding - think about low dose E...
396
Seizure post hysteroscopic resection of endometrial lesion
- Code Blue - ABC - o2/IVC/protect +/- benzo - Bloods/ECG/CTB (hyponatremia ->intracerebral swelling) - most likely hyponatremia from procedure - IDC/strict FB/Fluid restriction -> ICU/hypertonic saline - Neuro rv + OP F/U EEG/MRI *if inadvertent fluid deficit - admit/observe/serial UEC/obs med input - as above
397
IgM + IgG- on screen for toxo 25/40 for hx of eating raw meat
HE - FM/APH... - d/w ID/MFM - results mean possible infection - need IgG avidity - low-rising = infection (IgM+ IgG+ on rpt) - likely infection - MFM/ID involvement - amnio to confirm on PCR - R2B - blind/deaf/seizures/neuro development - Continue preg + abx rx vs TOP - Tertiary scan ?ascites/microcephaly/ventriculomegaly etc +/- serial scans *T1 - low infection risk, high dmg risk, T3 - high infection risk, low dmg risk **spiramycin (<18) vs pyrimethamine + sulfadiazine + folinic acid (>=18)
398
D1 post NBFD Peri pain/can't pass urine
HE - expanding/?HDS/discolor/tense/obstructive - concerned about vulval hematoma - NBM/IDC/IVC - FBE - check Hb - IV abx + analgesia + ice - inform consultant - non-expanding - as above - expanding - I&D vs IR to control bleeding - ensure VTE prophylaxis *hematoma may also occur in the absence of laceration/incision of the surrounding tissue
399
PNG woman pregnant Microcytic anemia Eosinophilia
HE - dizziness/pallor/N&V/bowel sx/PR Bleeding - iron/thal screen + stool MCS (no thal, iron deficient, hookworm in stools) - ID - advice on hookwork rx - antihelminthic (aka antiparasitic) - iron replace - recheck - hand hygiene/drink safe water/clean/cook food +/- test/rx other family members *hookworm cause blood loss during attachment to intestinal mucosa...daily loss of blood/iron/albumin can lead to anemia...
400
MPP surgery - placenta removed Bleeding placental bed mx
- inform ano - PPH mx - txa/ergot/carbo - request assistance from senior con - check cavity/empty/no other source of bleeding - exteriorize/tamponade whilst waiting for support - oversew placental bed with hemostatic sutures - Bakri insertion - watch output +/- MTP & next line mx - next line mx - UA - IIA - IR - Hyster - CCU/Debrief/Document/anemia correction/VTE prophylaxis
401
Postpartum rv check list
pain/bleeding/U&B - incontinence/POP/mood/breast feeding sexually active/dyspareunia/contraception/CST
402
Abnormal CTG
describe then mx plan
403
Hx of IHD
- dx/rx/med/f/u - baseline - TTE/ECG - R2U - load ->AMI - R2B - ?PI->FGR - MFM/Card/Ano - Medication safety
404
2ndary PPH
HE - pain/F&C/vitals/uterus - firm or not/spec cervix +/- RTS - documented membrane/placenta status DDx - RPOC +/- endometritis NBM + IVC + IVT + IV abx/antipyretic/analgesia/VTE prophylaxis FBE/UEC/LFT/CRP/Coag/G&S - infective markers/transfusion MCS - HVS/LVS/MSU TV USS to exclude RPOC Inform con/d/w ID re: antibiotic choice +/- uterotonics *Suction D&C - risk of perf/Asherman - consider low COCP postop to prevent Ash **Sig hemorrhage - laparotomy -> hysterectomy...
405
Puerperal sepsis
HE - breast/wound/urine/epi site/CP/SOB... - vitals/inspect head to toe... +/- MET call Sepsis protocol Inform con/ID+/- Paeds IVC+IVT+IDC FBE/UEC/LFT/VBG/lactate/Coag/G&S/CRP MCS - HVS/MSU/BC/wound TV USS to exclude RPOC vs Breast USS Broad spec antibiotic/Antipyretic/Analgesia/VTE prophylaxis Clinical/biochemical improvement Chase MCS to target rx Deterioration -> ICU Inform paeds *GAS high M&M, RFs such as PROM, no recurrence risk **complete full septic screen even if local source is identified for completeness, but may leave out CXR if irrelevant
406
In PET, HTN is accompanied by one or more of the following features:
impaired kidney or liver function hematological involvement neurological sx pulmonary oedema fetal growth restriction and/or placental abruption
407
GBS
- 20% of women carry - in GIT/Vagina - R2U - nil - R2B - EOGBS - screen if +'ve IAP to reduce risk
408
36/40 sudden onset LUQ pain
HE - FM/APH/SROM/TPL/cough/vitals/cardioresp/abdopelvic - Bedside USS to check for free fluid to exclude intra-abdominal bleeding - CTG to check fetal wellbeing DDx - splenic art aneurysm/uterine rupture/PTL/pneumonia/PE (Hemodynamically unstable - suspected splenic artery aneurysm rupture) - MET call - ABC - O2 + x2 WB IVC + Fluid resus - stabilize/urgent transfer to OT with Gen Surg assisting - GA/midline/deliver/identify bleeder... vs - FAST scan -> IR embolize before laparotomy...
409
MRCS (encounter 3 or communication station)
HE - reason for request/# of children planned CS benefit - predictable timing/less perinatal M&M -prolonged gestation/birth asphyxia/no OASIS CS risk - std spiel - esp future preg imp - PAD/peripartum hyster/rupture/TTN/BF NVD benefit - recovery/mat satisfaction/BF NVD risks - perinatal M&M - prolonged gestation/birth asphyxia/OASIS
410
Request for sterilization for a woman with ID from MPOA (mum)
Intro/Acknowledge/Sorry/Story/Solution/Support/Second opinion/Sum/Sec visit - explore reason for request and work on concerns - offer alternatives - sterilization is permanent and irreversible - sterilization for intellectually disabled requires court approval
411
ambiguous genitalia at birth (encounter 3)
HE - recovery postpartum/uterus/general baby check/prader staging genitalia - concern about CAH - virilized XX (e.g. CAH) or under-virilized XY (e.g. CAIS) - paeds review for advice on tests - UEC to exclude salt wasting - 17OHP level to exclude CAH - testosterone/LH/FSH/E2 - Karyotype - USS ? uterus or not - steroid treatment if salt-wasting crisis - referral to tertiary center - PAG - psychosocial support for family - SW/counsellors
412
Management of subgaleal
NICU Fluid resus Transfusion Serial head circumference Cranial imaging to exclude other ICH
413
peripartum hysterectomy steps
- senior support to make decision - request GONC to assist in OT - conversion to GA - ligasure for speed and minimize bleeding - don't do emergency salpingectomies - drop uteroovarian lig/divide round/anterior and posterior sheath - reflect bladder away/ligasure ut a & cardinal lig/tie USL - clamp across vaginal angle/colpotomy/vault closure/incorporate USL sutures - irrigation/cystoscopy *challenges = edematous tissue/vascular/stretched cervix/bulky uterus - access
414
RFs for subgaleal
inexperience maternal ITP wrong gestation wrong instrument poor application too many pulls too many pop-offs no descent - excessive force to reduce risk - senior support - change of instrument - abandon procedure
415
FDIU 22/40 2nd to IVH (1st preg), all other tests/autopsy = N Sister had 24/40 2nd to IVH + 23/7 NND 2nd to IVH Planning new pregnancy
NAIT = neonatal alloimmune thrombocytopenia maternal antibodies against fetal platelets ->fetal thrombo -> ICH risks MFM referral/care in tertiary center Parental testing of HPA antibodies If incompatibility detected - genotype dad - heterozygote 50% progeny at risk, homozygote 100% progeny at risk During pregnancy Fetal genotype (CVS or amnio) USS from 16/40 to monitor for ICH Rx = steroids or IVIG (commence empirically based on previous hx) Delivery by CS at 37-38/40 Neonatal FBE/cranial USS
416
How to assess TZ, and why is it important
acw will assist identifying TZ on colp dysplasia occurs in TZ if can't visualized entire TZ - can't exclude invasive disease T1 = whole TZ including upper limit visible T2 = upper limit of TZ partly or wholly visible in canal/completelyn around 360 T3 = part or entire upper limit of TZ cannot be seen in the canal, outer limit may be visible on ectocervix, canal, or not visible at all
417
What's the evidence for fibroid resection to improve fertility outcome
- SMF/IMF can reduce fertility and increase MC - Hysteroscopic resection of SMF can improve pregnancy outcome - Insufficient evidence to suggest myomectomy for IMF can do the same - Myomectomy for IMF for symptoms is a different indication altogether - Myomectomy for IMF can be considered if multiple failed cycles of ART
418
Techniques to manage intra-op blood loss for at open myomectomy
- tranexamic acid - diluted vasopressin - cell salvage - diathermy - uterine artery ligation - albeit potential impact if contemplating on future preg
419
Hx of traumatic birth
- support through continuity of care - see same clinician - refer to PNMH team - consider extended stay
420
Limited social support in pregnancy or Concern for DV in preg
Screen for DV Offer support Confidentiality SW involvement Crisis numbers Emergency evacuation plan DHS notification
421
Ate salad that got recalled for Listeria contamination.
- R2U fever/chills - flu-like sx/diarrhea - R2B MSL/FDIU - median incubation 8 days, up to 6/52 - monitor sx + ID advice - empirical abx for asx HR grp (e.g. confirmed Listeria outbreak) - amox or bactrim (outside of T1) for 7 days - food hygiene advice - hand hygiene, avoid raw food/eat freshly cooked...
422
Referral for mx of ?PMSS
HE - sx relation to luteal phase - eg. start luteal abate menstruation - hypothyroid sx - weight gain/lethargy - mood symptoms - sleep/eat/anhedonia/self harm... - ? SA/using OCP ? need contraception - hx of anxiety/depression - impact on QOL - OE - stigmata of hypothyroid - TFT to exclude hypothyroidism - 2 cycle diary - use GnRH analogue proof cause - no luteal phase - no sx - F/U to assess the above - CBT > COCP vs SSRI - depends on need for contraception > E patch + LNG-IUD > GnRH analogue > Hyster/BSO
423
Hx of DES exposure in-utero
- breast ca - uterine/cervical malformations - clear cell ca of vagina/cervix - vagina/cervical dysplasia - annual colposcopy + co-test - pregnancy risks - infertility/MC/PTB/PET
424
BMI48, peri-op prep
senior obs senior ano extra assistant hovermat weight based dosing of abx Traxi/Alexis Adipose layer closure NPWT
425
Fetal hydrops on scan 18/40 Work up
DDx - structural/genetic/infection/thal/isoimmunisation HE based on DDx Fluid accumulation Risk of PTB/SB aneuploidy morph G&S thal screen torch MFM - amnio Expectant vs TOP Expectant - fetal/maternal monitoring
426
Someone decline CST
explore reason offer alternative - eg self screen
427
Agitated/confused postpartum paranoia and auditory hallucinations
DDx - PPP/intracranial pathology - exclude suicidal/infanticidal ideation - 1 on 1 care - urgent psych review +/- antipsychotic... - med rv to exclude organic cause +/- Bloods +/- CTB - VTE/BF/Contraception - F/U/impact on future pregnancies
428
ANC visit 10/40 BP 190/100
DDx - essential HTN/phaeo/conn's/renal artery stenosis - MET call - Stat dose PO nifedipine or labetalol - IVC - Bloods - FBE/UEC/LFT/Coag/G&S/uPCR - urine cate/cortisol/plasma met + renal artery doppler - Admission for observation + commence reg anti-HTN - Obs med review - reg OPC + BP + PET screen - LDA + Ca/early PET screen - cFTS or PERT - Tertiary morph + serial G/S
429
6/52 Cough/fever/malaise Recent refugee Quantiferon +'ve
HE - hemoptysis/o2 sat/crackels DDx - TB Quantiferon = screening test - sputum/urine MCS to confirm + CXR - R2U - latent TB/reactivation later - R2B - FGR/PTB/SB - MFM/ID input - guidance on abx rx & F/U - DHS - notifiable disease - Family testing/rx - isolation whilst inpatient negative pressure room - serial G/s
430
Refugee
- SW input - support - +/- PNMH review - use interpreter - check for FGM - check for CST *coming from war torn nations - think about PTSD...
431
8yo referred for PVB
DDx: CPP vs PPP CPP – tumour/trauma/infection PPP – functional follicular cyst/ovarian tumour (e.g. GCT)/Adrenal (tumour/CAH) Other – exclude foreign body/sexual abuse/vulvovaginitis HE - HA/visual sx/growth spurt/perineal hygiene - breast/pubic hair development - PHx/Surg/Med/Allergies/FHx/SHx - Exam with chaperone - height/BMI/tanner staging/caredioresp/abdo/external exam only - virilization/?trauma/abuse/discharge Ix - FSH/LSH to distinguish btw CPP vs PPP - E/TFT/Prl/DHEAS/17OH exclude adrenal vs ovarian tumor - MCS - if PV discharge/perineal scraping for pinworm - Bone age - wrist xray - Pelvic USS to exclude pelvic tumour - MRI of brain to exclude cerebral tumour - F/U to discuss results +/- PAG/Endocrine referral *precocious puberty - onset menarche before 8yo **FSH/LH high in CPP, low in PPP ***suspected Paediatric foreign body - will need EUA ## Footnote GCT - USO... + HDC - risk of EH/AH with GCT
432
8yo referred for PVB all tests normal FSH/LH/E2 in puberty range
- Idiopathic precocious puberty - risks - shorter height/social/emotional issues - associated with being physically different from peers - referral to PAG/Endo/SW/counselling - GnRH agonist - reversible inhibition of HPO till normal puberty age - stabilize or regress pubertal changes - slow growth velocity/skeletal maturation to improve height
433
elevated catecholamines/serum metanephrines on high BP ix adrenal MRI = adrenal mass persistent high BP
- alpha-blocker e.g. hydralazine or prazocin - followed by b-locker to control tachycardia - monitor FHR/serial G/S - adrenalectomy is the only cure - surgery in pregnancy (i.e. with CS) vs postpartum - MDT decision - obs/med/surg - prolong gestation if adequately controlled with meds - risk of PTB/FGR/SB with prolonged gestation - serial GS to exclude FGR in setting of
434
AMA 6/40 by date Abdopain/SOB
HE - infective sx - Pelvic USS to exclude multiple preg (e.g. TCTA) - Higher order -> MFM -> HR preg -> PTB/SB/PET - Fetal reduction reduce PTB/PET rate/improve survival of others - usually performed 10-14/40 - USS/KCL
435
Pre-conception visit
R2U/R2B MDT Meds Baseline Meds ------------------------------- Precon bloods/urine/vax Avoid SAD
436
Anosmia Secondary amenorrhea
Kallman's Low E - pre-pubertal level Low/N FSH - instead of high expected with primary gonadal failure Genetic counselling Mx (fertility) - need OI -> CREI - FSH or pulsatile GnRH - should do full PI ix due to cost with OI include partner SA
437
Post NVD, ATSP re: peri pain
HE - pain/bleed/vitals...location/tense... Supra-levator - retroperitoneal Infra-levator - vaginal/vulvar Ischiorectal fossa Infra-levator - expectant - surgical - I&D - >5cm, >200ml, expanding/worsening pain/concurrent oasis - NBM/IVC/FBE/Coag/G&S - Inform con/observe with serial Hb if no evidence of coagulopathy - Analgesia/antibiotic/aperients/VTE prophylaxis - document/debrief/OP F/U *supra-levator usually will need OT, where as infra-levator more likely to self-contain albeit more painful initially **infected hematoma in setting of OASIS could make things worseHP
438
6yo PVB post straddle injury
HE - hx/exam - type of wound NBM +/- IV ABx Consent EUA + repair ...
439
hirsutism in postmenopausal woman T2DM or hirsuitism in 20yo with regular cycle
DDx - androgen-secreting tumour (adrenal or ovary) vs ovarian hyperthecosis HE - young woman - impact on life/depression/fertility plans/contraception - older woman - exogenous androgen/hirsuitism/palpable mass/cliteromegaly Free T4/SBHG/FAI/DHEAS/17OHP/Prl/TFT TV USS ?ovarian tumour vs ovarian hyperthecosis +/- CT or MRI adrenal if high DHEAS or T w/o ovarian path Ovarian hyperthecosis - no cancer severe hyperandrogenism + insulin resistance GONC ref/MDT opinion BSO vs GnRH agonist - like zoladex (if not good surgical candidate) BSO involves... Young woman rx - cosmetic options ... - medical options to complement cosmetic to minimize growth - non-contraceptive vs contraceptive - not requiring contraception - spironolactione/finasteride - requiring contraception - COCP with 4th gen progesterone - anti-oestrogen - drospirenone - psychological support - f/u in 6/12 to assess effects *sertoli-leydig cell tumours are most common ovarian virilizing tumours **LH/FSH should be part of PCOS screen - elevated with PCOS, if there's oligomenorrhea then Prl/TFT becomes relevant too ***whilst PCOS is the most common cause of hirsuitism in young women, if all ix are normal and doesn't meet criteria, it is just idiopathic hirsuitism
440
- unplanned preg - termination request
? want to continue STI risks +/- screen LARC at time of TOP Screen CIs and RFs for LARC
441
COCP CI
hormone sensitive cancer migraine with aura VTE Hx CVA Hx Liver disease Uncontrolled hypertension High BMI >35yo smoker
442
Post menopause general
PMB/POP/UI/VMS etc... MMG/FOBT/CST +/- Dexa
443
Domestic abuse (DV) in pregnancy (communication station)
Intro/ack/sorry/story/solution/support/second/summary/second opinion ensure confidentiality screen child abuse +/- police screen for physical/emotional/financial abuse solution - family/friends - shelter - emergency escape plan support - social work - accom/financial - psych - PNMH team rv/extended stay - obstetric - HR/diet/mood/fetal monitoring (regular F/U) ....
444
MW not adhering to clinical guideline for mx of twins around monitoring (communication station)
Intro/ack/sorry/story/solution/support/second/summary/second opinion setting ongoing monitoring explore reasons birth-plans solution - request to d/w pt directly benefit/risks - revisiting guideline with MW - documentation of discussion w MW/Pt support - fetal monitoring - ongoing labour support second opinion - MWIC - consultant
445
Anti-S antibody on screen
risk of HDNB risk of HD of fetus MFM referral paternal genotype +/- fetal genotype regular titer checks + serial G/S + MCA PSV to exclude anaemia inform lab ahead of planned procedures/x-match issues with antibodies present
446
Hx of SCI in preg
- MDT - MFM/PT/OT/SW - VTE risk - VTE prophylaxis - UTI risk - ID ? PO abx - Pressure sore risks - OT - tertiary morph + 4wky serial G/S - PTB risk 2nd to POP - intrapartum care - CEFM/air mattress/epidural/left lateral
447
Haematuria in preg
DDx - bladder ca/UTI/renal disease Macrohematuria - d/w Urology - MSU to exclude infection - Cytology x3 - CTIVP +/- cystoscopy +/- bx Microhematuria - d/w obs med/nephrology - rpt urine over time - UEC/albumin/rbc/wbc casts ?HTN/oedema - renal tract USS
448
Breast lump in pregnancy
MMG/USS/FNA Breast ONC referral FCC for genetic testing ?BRCA SW/support grp MDT care in preg Expectant vs TOP Expectant vs Expectant w Rx Ca needs surgery + chemo (not in T1) Chemo - risk of FGR - serial G/S Chemo - need steroids/anti-nausea - OGTT/monitor BSL/intrapartum hydrocort Chemo - need to cease sometime before birth - IOL from 37/40, Obs indication for MOD Radiation not compatible with preg Postpartum - VTE/BF - chemo safety ChemoRT - fertility preservation - OTC/GnRH agonist/transposition/shield *alternative would be rectal ca or EOC in pregnancy
449
Thalassemia in preg
Microcytic anaemia Screen for thal + ferritin- ?⬆️HbA2 +/- partner screen, 2 carriers 1:4 chance of major +/- FBS +/- TOP if negative Thal-B - D/W Haem +/- DNA testing for alpha thal 2 alpha thal trait -> Hb Bart's -> hydrops fetalis -> urgent Haem/Genetics rv - continue vs TOP
450
Haemophilia in preg
- X-linked recessive, low factor 8 or 9 lvl, expect abnormal APTT - M worse off than F, females 50% of normal factor lvl (factor 8 or 9 lvl) - MFM/Genetics - gender testing +/- lvl testing - NIPT - gender +/- factor lvl via CVS/amnio - knowing risk to fetus - expectant vs TOP - Haem input - risk of APH/PPH - ? guidance on factor 8/9 lvl testing +/- transfusion - Factor testing pre-labour - Avoid FSE/FBS/Ventouse/NBFD - Cord blood clotting factor assay/paeds rv +/- cranial USS
451
NRCTG Pt in labour Bkg of hemophilia
HE - DES + CTG interpretation because of the bleeding risk - depends on urgency/parental pref - low station lift out with NB>full CS - full CS > mid-cavity NB
452
Respiratory infection in pregnancy
DDx - resp infection/VTE/cardiac/asthma Admit ix/rx Stabilize - O2/analgesia/antipyretic/mucolytic/VTE prophylaxis Check fetal wellbeing - CTG Bloods/resp panel/Formal Obs USS Empirical rx (e.g. abx) -> chase MCS -> ID/Obs med input - target rx Expedite delivery (steroid/mgso4/paeds) vs prolong gestation -> F/U visit -> continue RANC Worsening mat = hypoxia -> foetal distress = delivery *asthma specific - rx reversible cause/preventer compliance usage/pred as escalation of rx - monitor BSL/home with action plan to avoid triggers - same as above, worsening = maternal hypoxia -> trigger for delivery
453
Pancreatitis Cholecystitis Renal colic in preg
contact relevant specialty re: ix/mx plan support mx (sx mx) ax fetal wellbeing OPC f/u improved and discharge trigger for delivery = deteriorating condition delivery - gestation - PTB package
454
Choroid plexus cyst
cyst in brain if in setting of other soft markers - ?T18 if isolated with LR aneuploidy reassuring MFM - referral for discussion consider serial G/S to check resolution
455
Intracardiac echogenic focus
nil association nil F/U required if unsure about cardiac - MFM referral to check
456
Renal pylectasis
Isolated finding, nil sig impact With other soft markers ->?T21 Serial Obs USS to check stability Postnatal renal USS to check resolution
457
Single umbilical artery
risk of FGR/SB serial G/S + FH to track growth iol from 39/40 to reduce risk of SB
458
Echogenic bowel on routine morph
DDx - CF/T21/Infection/Bleeding HE - infective sx or trauma/APH TORCH screen Kleihauer +/- anti-D MFM - amnio +/- CFTR mutation testing
459
Balanced translocation on karyotyping
MFM/Genetic counselling Parental karyotype Prognosis depends on functional gene involvment If one parent has the same rearrangements w/o involvement of functional genes then good prognosis Expectant vs TOP
460
- Structural cardiac issue on morph - Multiple fetal anomaly
Tertiary morph +/- fetal echo to better define problem MFM - amnio - complex genetic conditions - expectant+/- postpartum surgery vs TOP Provide info about risks during preg - mx plan MDT - paed surg/genetics/SW/support grp - prognosis/surgical correction options RANC + serial G/S to check fetal wellbeing - risk of FGR...
461
Pregnant w a personal + FHx of ID
Ax competence/MPOA MFM/Genetic referral Maternal karyotype - FMR1 testing - albeit difficult to predict phenotype Prenatal diagnostics - CVS or Amnio Tertiary morph Expectant vs TOP
462
Post SD counselling
paeds F/U if SD injury BPI - weakness up to 12mo - 90% w/o permanent injury up to 16% recurrence future - early OGTT/ctrl GDM if +'ve/tracking growth/IOL btw 38-39 if LGA vs elCS
463
LLETZ risks + alt
general specific- PTB/cervical stenosis - fertility/menstrual issues alt = laser - no risk for PTB/quick/no bleeding but limited depth/no histology...not frequently used for CIN2/3
464
Burst abdomen
key to intra-op mx except repair is to check for bowel or other injuries
465
Major intra-op intra-abdo vascular injury
Fluid resus + MTP Senior support Trendelenburg Midline lap Pressure/Pack/Txa Await vascular team
466
Breech CS preterm IUGR NRCTG
Anticipate difficulty Senior obs Wider skin incision Exaggerated curvlinear Blunt extension Aim to not break water Grab foot, if frank, pinards alternatively hips w fundal pressure from assistant Gentle traction by hips till axilla - back against skin Lovset... *head entrapment - widen skin/GTN/forceps/inverted T

RANZCOG oral (2 decks)

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