5th year recap important stuff Flashcards
When do we manage an ectopic surgically?
- Haemodynamic instability
- Live ectopic pregnancy (cardiac activity seen)
- hCG greater than 1500 IU/L
- Adnexal mass >35mm
- Significant pain
- Presence of significant haemoperitoneum on ultrasound
- Patient choice/poor compliance with conservative treatment
When do we do a salpingotomy over a salpingectomy
o Previous ectopic pregnancy
o Contralateral tubal damage
o Previous abdominal surgery
o PID
Medical vs Expectant management of ectopic
Medical:
o No significant pain
o Unruptured ectopic pregnancy, mass < 35 mm and no visible heartbeat
o Low serum bHCG < 1500 IU/L
o No intrauterine pregnancy – MUST be confirmed
NB need to Measure bHCG levels on day 4 and 7 post dose administration. If levels decreased by > 15% between day 4 and 7, start weekly measurements until level less than 15 IU/L
Expectant:
- As above
- <30mm mass
- A decreasing bHCG <1,000 followed up until <15
Asthma non-acute diagnosis and management
Code as suspected asthma -> give treatment and good response will confirm diagnosis, poor treatment do spirometry tests.
+ EDUCATION ABOUT TECHNIQUE AND SPACER
Once first beginning symptoms give SABA inhaler prn, if using > 3 times a week we would initiate preventer therapy with a very low dose ICS or if <5 -> LTRA
If that doesn’t control, your initial add on therapy would be adding ICS/LTRA. After that increase very low dose ICS to low dose. Refer after this.
Life threatening vs Severe asthma attack
Both have sats <92%
Severe - PEF 33-50%; Thretening <33%
Severe - can’t complete sentences in one breath, HR/RR depends on age but above 5, RR>30 and HR>125
Threatening - silent chest, NORMAL CO2, exhaustion, cyanosis
How to manage PUL
• Definition: a situation where a pregnancy test is positive but there are no signs of intrauterine or extrauterine pregnancy on ultrasound scan
• This could mean that there is an ectopic pregnancy that cannot be visualised on TVUSS
• Management - should be focussed on pts symptoms
oBalance between not missing an ectopic pregnancy and not ending an early viable pregnancy
oRepeat hCG measurement 48 hourly to assess change:
Increase >63% likely that she has an intrauterine pregnancy and offer TVUSS 7-14days later.
Decrease <50% likely that pregnancy will not continue but this isn’t confirmed. Pregnancy test 14 days later and come back within 24hrs if positive.
If in between refer for clinical review within 24 hours.
When do we do ECV?
<36 weeks many will turn spontaneously
For nulliparous offer ECV at 36 weeks, at 37 for multiparous
CI if C section is required, APH in past week, ROM, multiple pregnancy
ECV successful 60% of time, if fails can go for vaginal delivery with hands off or Cs
How is the antenatal care of multiple pregnancies different?
- First trimester scan 11-13+6 wks to determine GA, chorionicity and screen for DS
- Determine chorionicity (T sign - monochorionic, Lambda - dichorionic)
- FBC at 20-24 wks to identify those who need extra iron/folic acid as there is a higher incidence of anaemia
- Fetal risks: Counsel on higher risk of DS, Monitor for TTTS in 2nd trimester, and IUGR
- Maternal risks: HTN, preterm birth (most before 37 wks)
- Monitoring:
Monochorionic - 2 weekly growth and doppler from 16 weeks
Dichorionic - 4 weekly growth scans and doppler from 20 weeks
GDM diagnosis criteria
• Fasting plasma glucose > 5.6 mmol/L
• 2-hour plasma glucose > 7.8 mmol/L
If risk Factors present (Previous GDM/ macrosomia, > BMI, First-degree relative with diabetes, Asian, black Caribbean or Middle-Eastern origin) woman should be offered a 2-hour 75 g oral glucose tolerance test (OGTT) at 24-28 weeks
USS schedule
10-14 weeks
• Mainly to determine gestational age, detect multiple pregnancy and determine nuchal translucency as part of screening for Down syndrome
18-21 weeks
• Primarily screens for structural anomalies
• Give couples reproductive choice (e.g. termination of pregnancy)
What are sensitising events that would require anti D prophylaxis
- Delivery of RhD+ infant
- Any TOP
- Miscarriage if > 12 weeks
- Ectopic pregnancy (if managed surgically)
- External cephalic version
- Antepartum haemorrhage
- Amniocentesis, CVS, foetal blood sampling
- Abdominal trauma
GDM Mx
o Newly diagnosed women should be seen at a joint diabetes and antenatal clinic within a week
o Women should be taught self-monitoring of BMs
o Advice about diets (low glycaemic index foods) and exs
o Fasting glucose < 7 mmol/L → trial of diet and exs
oIf glucose targets NOT met within 1-2 weeks → metformin
oIf glucose targets still NOT met → add insulin
o If at the time of diagnosis, fasting glucose > 7 mmol/L or if >6 + complications → insulin
o If metformin is not tolerated: glibenclamide
GDM Counselling
o Risk Factors: age, family or personal history, obesity, multiple pregnancy, Asian background
o Explain the diagnosis (diabetes that occurs in pregnancy because the body isn’t able to produce enough insulin to meet the demands of carrying a baby)
o Estimated prevalence: 2-3%
o Explain the risks (MATERNAL: hypertensive disease, traumatic delivery, stillbirth; FOETAL: macrosomia, neonatal hypoglycaemia, congenital abnormalities)
o Treatment options (diet/exercise, metformin, insulin) and the importance of good glycaemic control
oExplain how to monitor blood glucose (using glucometer)
oNeed to be seen at a joint diabetes and antenatal clinic within 1 week (and every 2 weeks thereafter)
oNeed to have 4 weekly ultrasound growth scans from 28-36 weeks
oExplain that medication will be stopped after delivery but that they will be followed up to check if glucose problem continues
Hyperemesis Gravidarum
• Investigations: body weight, U&E, urine dipstick (check ketones), observations, assess severity using PUQE (score < 13 can be managed as an outpatient)
Criteria: > 5% weight loss, dehydration, electrolyte disturbance
• 1st line: antihistamines (promethazine or cyclizine)
• 2nd line: ondansetron or metoclopramide
• Steroids may be used in refractory cases
• Alternative treatment: ginger, P6 (wrist) acupressure
• Admission may be required if severely dehydrated
Pay careful consideration to the psychological impact of hyperemesis gravidarum
COUNSEL: Most patients find that the symptoms improve after about 12-14 weeks and hopefully the medication will lessen the symptoms until they go away by themselves
Stress the importance of adequate fluids (dioralyte) and nutrition
Miscarriage counselling
- Risk Factors: advanced maternal age, previous miscarriages, chronic conditions (e.g. uncontrolled diabetes), uterine or cervical anomalies, smoking, alcohol and illicit drug use, underweight or overweight
- BREAKING BAD NEWS
- Explain the diagnosis
- Reassure that this is common and under-reported (1 in 5 pregnancies)
- Explain that risk increases with age
- If asked about cause: explain that most of the time there is no cause
- Explain the management options (expectant, medical and surgical)
- If medical: explain what to expect (pain, bleeding, nausea)
- Antiemetics and pain relief will be given
- Advise to do a pregnancy test after 3 weeks
- Safety net: return if symptoms get worse, bleeding persists after 7-14 days
Types of miscarriage
Spontaneous miscarriage - fetus dies or delivers dead before 24 weeks. 15% of pregnancies spontaneously miscarry, rate increases with maternal age.
Open os:
Inevitable miscarriage - heavy bleeding, although fetus may still be alive, miscarriage is about to occur. Clots may be present.
Incomplete miscarriage- some fetal parts have passed
Closed os:
Threatened miscarriage- bleeding but fetus is still alive, uterus is expected size. 25% will miscarry
Complete miscarriage - all fetal tissue has passed, bleeding has diminished and uterus is no longer enlarged.
Missed miscarriage - fetus has not developed or died in utero, but this isn’t recognised until bleeding occurs/ discovered incidentally on USS. Uterus is smaller than expected or empty.
Septic miscarriage - uterus contents ar einfected, vaginal loss is offensive, tender uterus, fever can be absent. If pelvic infection occurs there is abdo pain and peritonism.
Miscarriage mx
- If FHB present + Blood -> safety net to return if bleeding gets worse or persists for more than 14 days
- If no FHB + confirmed pregnancy + blood -> first line is expectant management (exceptions are very late first trimester, previous trauma with pregnancy, infection or clotting abnormality/can’t have blood transfusion)
o If bleeding resolves within 7-14 days take p test 3 weeks after and return if positive - Medical: Vaginal misoprostol (repeat day 3 if expulsion not complete) contact healthcare profession if bleeding hasn’t started within 24 hours + pain relief + anti-emetics + p test 3 weeks after
- Surgical: Manual vacuum aspiration under LA ±misoprostol to ripen cervix
What makes a febrile seizure complex?
Focal onset or focal features
Last >15 mins
Recurrence in 24h or same illness
Incomplete recovery within 1h
Febrile seizure counselling about anxiety
- Febrile seizures are not the same as epilepsy
- Short lasting seizures are not harmful to the child (no brain damage)
- They are relatively common – between 2 and 5 in 100 children
- The risk of developing epilepsy later is low but slightly higher than the general population: background risk is ~2%, simple seizure 2-7.5%, complex 10-20%
- Antipyrexials don’t prevent and it isn’t due to the actual temp but the rise in speed
Febrile seizure counselling about what happens if it happens again
1 in 3 will have another seizure – need to know how to manage
Protect from injury (cushion head with hands or soft material), move harmful objects
Do not restrain or put anything in mouth
When seizure stops: check airway is clear and put in recovery position
May be sleepy for 1h after seizure
Call an ambulance if lasts >5 mins and give rescue pack midazolam
How to manage febriel seizure
Rectal diazepam, repeated once after 5 mins OR one dose buccal midazolam
Call ambulance if after 10 mins since first dose:
Still seizing
Ongoing twitching
Another seizure begun before child regains consciousness
Questions to ask if failure to thrive?
Prenatal - SFD? Premature?
Functional issues: having enough time to feed her, good feeding schedule, difficult child
Reduced Appetite? (IDA, chewing on other things)
Feeding difficulties? Ability to latch on? Ability to stay on? swallowing, vomiting after
Malabsorption qs: Diarrhoea? Mucous?
Any G&D concerns?
What have you tried so far and what is it better with?
Failure to thrive definition
TLDR: below 2nd centile for age (no matter bw) or based on fall of 1, 2, 3 weight centile dependent on BW being <9, 9-91, >91
A fall across 1 or more weight centile spaces, if birthweight was below the 9th centile
A fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles
A fall across 3 or more weight centile spaces, if birthweight was above the 91st centile
When current weight is below the 2nd centile for age, whatever the birthweight
Generic FTT management
Next steps: further investigation, clinical growth and monitoring, interventions and goals
MDT: Midwife, GP, infant feeding specialist, paediatrician, paediatric dietician.
Conservative advice:
Encouraging relaxed and enjoyable feeding and mealtimes, as a family or with other children
Encouraging young children to feed themselves
Allowing young children to be ‘messy’ with their food
Medical advice:
Short term trial of dietary fortification (superdense energy foods)
2nd line - trial of an oral liquid nutritional supplement for infants or children
Only after MDT discussion, refractory to prev tx and if there are srs concerns about weight gain you can try an eating tube
Referral - if concerns of underlying idsorder
Puberty onset ranges
8-14 in girls and 9-15 in boys
Girls: Breast development is the first sign (8.5 - 12 years) after which there is pubic hair growth and rapid height acceleration almost immediately after. Menarche occurs 2.5 years after the start of puberty.
Boys: testicular enlargement >4ml is the first sign. Pubic hair growth 10-14 yo. Height growth spurt when testicular volume is 12-15ml. Voice breaks ~13yo.
Investigations to order if you’re querying precocious puberty
Height, weight and head circumference
Bone age
Mid parental height
This is calculated as the mean of the father’s and mother’s height with 7 cm added for the mid-parental target height of a boy, and 7 cm subtracted for a girl.
Growth velocity
Pelvic USS in females for endometrial thickness
BMI adjusted to age and gender is used first line to assess obesity
Exam: Tanner staging
Bloods: LH ++ > FSH + (elevated in gonadotrophin dependent PP); TFTs
CAH: 17 hydroxyprogesterone or 11 deoxycortisol which would be raised
Imaging: USS ovaries/uterus (looking for multicystic and enlarged uterus in premature onset of normal puberty)
Types of precocious puberty
PREMATURE ONSET OF NORMAL PUBERTY:
- Will follow the usual sequence of breast enlargement (thelarche) -> pubic hair (pubarche)/growth spurt (gap) -> periods
- Parents might have early puberty
- Associated with obesity
Gonadotrophin dependent PP (PP + growth spurt): This can be idiopathic, familial or less commonly due to CNS abnormalities (intracranial tumours) and hypothyroidism
Gonadotrophin independent PP is due to exogenously raised sex steroids e.g. due to CAH, COCP, ovarian tumour (granulosa) or testosterone (Leydig) tumour. These pts might have isolated PP e.g. isolated pubic hair and virilisation of female genitalia. Ask about episodes of severe sicknesss with lots of vomiting and weight loss in childhood requiring them to go to hopsital and get salt replacement.
How do you treat PP?
Treat the underlying cause
Give GnRH agonists - this arrests the pulsatile release of GnRH, decreasing LH and FSH
Check that the child is not suffering any psychological side effects of early puberty
Delayed puberty ddx
DDx:
- Constitutional Delay
- IUGR at birth and never catch up
- Endocrine e.g. hypothyroid, GH deficiency, panhypopituitarism (craniopharyngioma), iatrogenic cushings
- Psychosocial deprivation
- Syndromic: Downs, Turners (widely spaced nipples, rec otitis media)
- Chronic paeds disease
- Nutritional + EXCESSIVE EXERCISE
Features of consitutional delay + Mx
Delayed puberty
Short during childhood
FHx in parents often of the same sex
Legs may be long compared to back
Androgen and oestrogens can help kick start puberty
Self-esteem and psychological affect
Mx: Reassure puberty will happen, check to see if psychologically they are okay, if they want meds you can give oral oxandrolone in young males (will just help catch up growth) or IM low dose testosterone in older males (will accelerate growth and induce 2ndary) females can be treated with oestradiol.
Delayed puberty things to ask:
History things to ask:
- Malabsorptive screen -> stools
- Constitional screen -> parents
- Nutrition and exercise
- Psych -> anorexia, emotional neglect
- Iatrogenic -> steroids, chemotherapy
- Congenital -> turners (rec ear infections, widely spaced nipples)
- Hypothalamic /pituitary disorders (changes to vision)
- Endocrine (tiredness, weight gain)
- Systemic disease (unlikely more FTT) - CKD, CCHD
Delayed puberty investigations
Examination + Tanner staging
Bedside obs + weight and height plotting
Bloods: usuals + screen for chronic disorders + genetic screen
Chronic: TFTs, LH FSH, Oestrogen/Testosterone, IGF-1 (GH is pulsatile), Growth hormone provocation test
+ KARYOTYPING (45XO)
Imaging: Bone age, MRI if cranio
Delayed puberty investigations
Examination + Tanner staging
Bedside obs + weight and height plotting
Bloods: usuals + screen for chronic disorders + genetic screen
Chronic: TFTs, LH FSH, Oestrogen/Testosterone, IGF-1 (GH is pulsatile), Growth hormone provocation test
+ KARYOTYPING (45XO)
Imaging: Bone age, MRI if cranio
Hyperemesis Gravidarum
Criteria: > 5% weight loss, dehydration, electrolyte disturbance
Investigations: body weight, U&E, urine dipstick (check ketones), observations, assess severity using PUQE (score < 13 can be managed as an outpatient)
Mx:
• 1st line: antihistamines (promethazine or cyclizine)
• 2nd line: ondansetron or metoclopramide
• Steroids may be used in refractory cases
If admitted:
Admission may be required if severely dehydrated
o IV normal saline with KCl (monitor U&E)
o Thiamine supplementation
o Offer thromboprophylaxis
• Pay careful consideration to the psychological impact of hyperemesis gravidarum
Counsel:
Explain that it a very severe form of morning sickness
Medication should help reduce the nausea
Most patients find that the symptoms improve after about 12-14 weeks and hopefully the medication will lessen the symptoms until they go away by themselves
Stress the importance of adequate fluids (dioralyte) and nutrition
Risk Factors: previous hyperemesis, multiple pregnancy, first pregnancy, obesity
TOP (things to ask in history, next steps and options)
Things to ask in history:
Need to explore sexual history ?Long term partner ?Coercion/ rape ?happened before
Ensure this is her own (not the father’s) decision
Need to determine gestation
Ask who they’ve told so far, would they consider telling anyone else if no one, will they come to the clinic with them etc
Next steps: Urine and blood pregnancy test, blood group status, determine GA and TVUSS/TA USS
Options: Depends on women choice and GA
SURGICAL options: Aspiration (7-13) done under LA/GA (takes about 10 min then recovery room) or D&E (>13) (done under LA, GA, or spinal, takes about 30 min discharge same day, requires dilator beforehand e.g. mifepristone). Both require Abx and Rhesus cover.
MEDICAL: Antiprogesterone (mifepristone) given first + prostaglandin (misoprostol) given 24-48 hrs after up to 9 weeks, most effective <7.
9 weeks +1 - 13 weeks + 6 can do inpatient medical
mifepristone 200 mg orally, followed 24–48 hours later by misoprostol 800 micrograms given by the vaginal, buccal or sublingual route, followed by misoprostol 400 micrograms every 3 hours until abortion occurs.
FETICIDE: If > 22 weeks to prevent live birth
KCl pumped into umbilical vein or fetal heart
Selective abortion - may be performed if high order pregnancy
Urge incontinence questions
FUNDHIPS + Cancer screen
Nocturia? If nocturia isn’t present or if transient consider other causes such as constipation, atrophic vaginitis and prolapse -> ask about heaviness throughout the day + sex symptoms
Gynae screen: discharge, PV bleeds, dysapareunia
uterine prolapse symptoms, counselling and manageen
symptoms of heaviness worsen on standing, throughout the day urinary symptoms (stress and/or urge incontinence), constipation, disordered defecation sexual symptoms (dyspareunia)
Counselling:
caused by weakening of your pelvic floor this is a muscle that keeps all of your organs in your pelvis in the right place. Usually we try to avoid treating this condition unless it’s having an impact on your daily life. Your urinary symptoms may be caused by a part of your vaginal wall pressing on your bladder.
C:
Weight reduction
Avoiding heavy lifting and high impact exercise
Pelvic floor exercises - can see a physio to help you with this esp since you are experience some incontinence with this prolapse
Vaginal hormone treatment (oestrogen creams etc)
M:
Insert a ring pessary or a shelf pessary into the vagina that acts as an artificial pelvic floor
Changed every 6-9 months
Requires oestrogen replacement post menopausally to prevent vaginal ulceration - using topical or standard HRT
S: If your symptoms worsen, or the prolapse becomes more severe, there are some surgical options, and we can refer you to a specialists gynae surgeons
Hysteropexy: open/laparoscopic, uterus + cervix attached to sacrum using bifurcated mesh.
How to describe PEMPT
Close up your bottom, as if you’re trying to stop yourself going to the toilet
at the same time, draw in your vagina as if you’re gripping a tampon, and your urethra as if to stop the flow of urine
at first, do this exercise quickly, tightening and releasing the muscles immediately
then do it slowly, holding the contractions for as long as you can before you relax: try to count to 10
try to do 3 sets of 8 squeezes every day: to help you remember, you could do a set at each meal
If you are having trouble trying to do this, I can refer you to a specialist physio who will help identify if you are using the right technique and give you some tips to help you along the way.
Types of prolapse
Urethrocele -Prolapse of ant vaginal wall w urethra only
Cytocele - Prolapse of upper ant vaginal wall, inc bladder. Often assoc prolapse of urethra = cytourethrocoele
Apical prolapse - Prolapse of uterus, cervix + upper vagina.
Rectal prolapse - Prolapse of lower post wall of vagina, involving ant wall of rectum
Other management of TOP
Blood tests: Hb, blood group, Rhesus status
Rhesus negative should receive anti-D within 72h of TOP.
Surgical -> consider in rhesus negative regardless of GA
Medical -> consider after 10 weeks if Rhesus negative
STI screen - chlamydia, HIV, gonorrhea, syphilis
Surgical Abx
200mg doxy/ 500mg azithromycin within 2 hours of procedure
PAIN MANAGEMENT FOR BOTH MEDICAL AND SURGICAL
NSAIDS, local anaesthesia eg lidocaine for cervical dilation, paracetamol
Discussion of contraception options if not on contraception
Can be administered at time of surgical TOP
Oral pills, condoms, injections, implants can be started on day of misoprostol administration
Or after next menstrual cycle: IUD, sterilization
Discussion of contraception ‘health’ - not forgetting pill etc
Must always read the leaflet in the pill packet
Psychological input Eg if raped - victim support
What will happen on the day?
Pregnancy test
USS
Pain relief will be given before and after
Medical - Take first pill in clinic, Then either have a second appointment (24-48 hours later) or sent home with a different pill
Surgical - An appointment will be booked
LA - area numbed + some sedation so you are awake but relaxed Or may have GA (unusual)
Vacuum takes 5-10 minutes and most people go home a few hours after
D&E - dilation for several hours/ day before hand - procedure 20 minutes some go home the same day
Likely to experience stomach cramps so need to take regular pain relief such as ibuprofen
It’s also likely that you will have some bleeding, which may be quite heavy with medical so it’s recommended you bring sanitary towels (not tampons) with you on the day and also have a good stock at home.
Can have sex when you feel ready - CONTRACEPTION
If on going bleeding, severe pain, smelly discharge, temperature or ongoing signs of pregnancy the clinic will have a 24 hour helpline.
Exercising in pregnancy
- Avoid sports that involve you being on your back for long periods after 16 weeks
- Avoid contact sports, risks of fall, scuba diving or high altitude sports
- As a general rule, you should be able to hold a conversation as you exercise when pregnant.
- no more than 15 minutes of continuous exercise, 3 times a week. Increase this gradually to daily 30-minute sessions.
Abdomen Pain in kids questions
- Obstruction -> N&V (colour), flatus, distension
1b. Appendicitis/Meckels -> anorexia, pain, vomiting - Constipation -> PR blood, dietary fibre, stools
- Infection -> UTI -> Urinary changes, fevers / Gastroenteritis - contacts
- Hirschsprungs -> delayed meconium
- Malabsorptive -> weight loss, greasy stools, diarrhoea, ulcers (IBD)
- Psych -> stressed, IBS, abdominal migraine (midline pain lasting 1-72hr, well between episodes) (RAP)
Extra abdominal: - DKA -> increased frequency
- Torsion
