Babies Flashcards
placental abruption Ix and examinations
• Observations
• Pregnant Abdomen Examination (Rigid, tender abdomen)
• CTG
• USS (Rule out placenta praevia/accreta)
• Speculum (rule out vaginal source of bleeding)
• Bimanual (Should NOT be performed if placenta praevia is a possible differential)
• IMPORTANT: ultimately, placental abruption is a clinical diagnosis
• Kleihauer Test: can be performed to determine the extent of fetomaternal mixing of the blood so that a sufficient dose of anti-D can be given
• FBC, coagulation screen and 4 units of blood cross-matched (if MAJOR haemorrhage)
o FBC and group and save can be done in a minor haemorrhage
Management for placental abruption
Immediate:
Call seniors + admit
A-E approach
2x large bore IV access for fluid resuscitation and blood transfusions may be needed
Anti-D is given for all abruptions within 72 hrs of onset of bleeding
What will be monitored:
Fetal continuous monitoring via CTG
Definitive action:
maternal haemodynamic instability or foetal distress = emergency c section
If mum and baby stable and >37 weeks= induce
if mum and baby stable and <37 weeks= steroids, admit and monitor. If bleeding settles then can discharge home with weekly serial growth scans until term
Hyperemesis gravidarum Ix and Examinations
Bedside: Obs Urine ketones (dehydrated) and MSU to rule out UTI Urine MCS to rule out UTI Body weight Fluid status assessment PUQE score abdominal examination (large uterus could be a sign of molar pregnancy)
Bloods:
FBC (rule out infection)
CRP
TSH (may be decreased during pregnancy because bHCG rises which stimulates thyroid and causes negative feedback on tsh)
Glucose (only if diabetic to exclude DKA)
U and Es (vomiting so may be dehydrated or electrolyte disturbance)
TVUSS - rule out molar pregnancy
Hyperemesis management
ABCDE approach
Dehydrated- IV fluids with additional KCl
Vomiting - IV antiemetics (cyclizine)
Correct nutritional and electrolyte imbalances- thiamine, (KCl already mentioned)
Thromboprophylaxis - stockings, heparin
If mild could suggest acupuncture, ginger capsules
Chorioamnionitis/PPROM Ix
Bedside:
Obs
STERILE Speculum - pooling of amniotic fluid, discharge
swab for fetal fibronectin (this is more for PPROM)
Bloods:
FBC - WCC raised
CRP
Imaging:
CTG
Chorioamnionitis Rx
Admit + call senior
ABCDE (3 in 3 out if signs of sepsis)
in: fluids, abx, oxygen
out: cultures, lactate, urine output
Maternal- IV broad spectrum antibiotics (erythromycin or benzylpenicillin).
- paracetamol for pyrexia
Foetal/Labour-
Arrange prompt delivery (Emergency C section ONLY IF NECESSARY)
Preterm Prelabour Rupture of Membranes PPROM management
maternal:
Admit for CLOSE MONITORING
Offer oral erythromycin 250 mg QDS for a maximum of 10 days or until the patient is in established labour
Do NOT use tocolysis (increases risk of infection)
Fetal: continuous CTG monitoring for chorioamnionitis and signs of preterm labour
Offer IM steroids if before 34 weeks
offer magnesium sulphate
Labour:
Counsel the pt aboout how the decision to deliver depends on balance of risk of prematurity and risk of maternal/foetal infection if delivery is delayed
NB if close monitoring is possible and pt is stable then discharge and ask pt to come back routinely (weekly or twice weekly) for CTG and obs but safety net (any FRAB come back)
Pre-eclampsia Ix and Ex
Bedside:
Obs, Urine Dipstick (protein defined as 2+ or more. PCR>30 is the definition of proteinuria too)
peripheral limb exam (swelling, clonus and hyperreflexia)
fundoscopy
abdo examination (SFH very important because pre-eclampsia can cause IUGR)
Bloods:
FBC (platelets
pre-eclampsia bloods (LFTs specifically ALT increases in HELLP, clotting, U and Es, X match)
Imaging:
CTG
If present before 34 weeks = need a growth scan, doppler ie everything because of risk of SGA
Pre-eclampsia Rx
Admit + call senior
Maternal -
oral: labetalol (if doesnt work, could increase dose or add nifedipine), nifedipine second line, methyldopa 3rd line,
intravenous: IV labetaolol is first line, IV hydralazine
Continuous monitoring
Foetal- continuous CTG monitoring
labour
- aim to induce at 37wks BUT may need to deliver early if so will give steroids if before 34 weeks
- emergency c section (see card later) if pt is in eclampsia/unstable
Postnatal
- will be kept under observation due to labile BP
- for ALL women who gave birth (healthy or not), they will be seen by a health visitor/midwife in the first week. But for a mother with HTN disease during pregnancy (eg pre eclampsia), you will be seen in 48hrs
- will be followed up by GP at 6 week check
- Hypertension and proteinuria should resolve within 6 weeks and if this fails then may need further investigation
Menopause management
Conservative/Lifestyle - exercise (osteoporosis), weight loss, sleep hygiene
Medical/HRT - oral or transdermal oestrogen (transdermal has lower risks of VTE) + IUS + vagifem for vaginal dryness
non-HRT - CBT for depression, SSRIs can be used for vasomotor symptoms, vaginal moisturisers/lubricants
benefits and risks/contraindications for HRT
Benefits:
short term - treats vasomotor symptoms etc
Long term- osteoporosis risk reduction
reduces risk of colorectal cancers
Risks:
Short term/immediate side effects of the hormones:
Oestrogenic: breast tenderness, nausea, headaches
Progestogenic: fluid retention, mood swings, depression
Long term:
- Endometrial: increase endometrial cancer risk only if taking oestrogen alone in women with a uterus
- Breast: small increase in breast cancer risk with COMBINED HRT only (for every 1000 women taking combined HRT, there will be 5 more cases of breast cancer, Obesity is for every 1000, theres 20 more breast cancer).
- Ovarian: conflicting results. Even if increases, it will be a very small insignificant amount.
- VTE: small increase in VTE but no risk if taking transdermal oestrogen (patches or gels)
- cardiovascular: does not increase risk of CVD when started before the age of 60
Compare cyclical and continuous combined HRT
cyclical: for perimenopausal
daily oestrogen + progesterone given for last 13 days every month (for women with REGULAR periods but have symptoms)
daily oestrogen + progesterone given for last 13 days every 3 MONTHS (for women with IRREGULAR perods but have symptoms)
Continuous combined: for post menopause (>1 year since LMP)
oestrogen and progesterone given together daily (includes IUS)
Ectopic Pregnancy Ix
ABCDE
Bedside- urine pregnancy test, obs, abdo exam (look for guarding and rebound due to ruptured ectopic/haemoperitoneum causing acute abdomen), speculum (light bleeding), bimmanual (cervical excitation, adnexal tenderness and MASS)
Bloods - X match, group and save, FBC (anaemia, if rlly low is it due to haemoperitoneum?), serum b-HCG, rhesus status
Imaging: TVUSS (empty uterus, thickened endometrium potentially because shes pregnant but nothing is there, mass in adnexa seen - need to find out the size of this mass and whether it has Foetal heart beat as this could influence management. Also assess for free fluid in pouch of douglas)
Ectopic pregnancy Rx
Stress this is very serious and you can DIE from it.
Conservative (DONT OFFER THIS)- closely monitor with serial b-HCG measurements for 48hrs and if symptoms arise/b-HCG rises then intervene. The idea is that the higher the hCG, the bigger the ectopic. And if foetal heart beat more likely to rupture so you want to surgical.
Medical
- 1x IM methotrexate injection. Not as good as surgical.
- need to measure their body weight and U and Es.
SE: GI upset (abdo pain), light sensitive skin reactions. Pts need to know they cannot get pregnant for 3 months once this is resolved.
Surgical
- LAPAROSCOPIC salpingectomy or salpingotomy (if increased risk of infertility or the other tubal is already damaged) but salpingotomy has 1 in 5 chance of requiring further intervention. RhD-ve pts will receive need anti-D injection
- if other tube is healthy then this often does not affect fertility
- normally keep her overnight and
Risk: ( can use this for most gynae surgery counselling)
- Anaesthetic risk
- bleeding and VTE risk
- infection
- damage to surrounding structures (bladder and bowel)
- (retained tissue, less relevant here more relevant for miscarriage)
Follow up for medical and surgical should be expected over next few weeks where blood tests will be taken to monitor b-HCG until negative
Cannot have sex immediately after intervention - best to wait until we tell you that it’s okay from the results in the monitoring
Endometrial cancer/endometrial hyperplasia counselling
Endometrial hyperplasia with no Atypia: Levonorgestrel IUS (Mirena) + follow up
Endometrial cancer/ hyperplasia with atypia: surgery (total hysterectomy with bilateral salpingoo-oophrectomy)
Postmenopausal bleeding Ix
Bedside- obs abdominal examination (feel for masses), speculum, bimmanual (feel for masses)
TVUSS (normal is ≤4mm)
Hysteroscopy and Biopsy
Postmenopausal bleeding Counselling in PRIMARY care
Postmenopausal bleeding can be caused by many things, a lot of which are quite harmless like vaginal trauma and infection but our main priority is to rule out anything that could be harmful like cancer
So, we’re going to refer you to have a transvaginal ultrasound scan (explain what this is) to visualise the reproductive organs
Based on the result of this we can hopefully establish a diagnosis and start treatment accordingly
Further testing may be needed depending on the scan results
Which investigations are given for a woman qualifying for subfertility (>12 months of trying)
Ovarian reserve:
day 2-5 FSH (high = abnormal)
AMH
Ovulation:
LH
mid-luteal progesterone
Tubal patency:
STI screen
Hysterosalpingogram (x ray) or HyCoSy (USS so less radiation)
Uterine cavity:
TVUSS
Other: TFTs, prolactin
PID Ix
ABCDE
Bedside:
obs (start with TEMPERATURE since she has fever), abdo exam, speculum (offensive vaginal discharge), bimannual (tubuloovarian abscess = mass), urine pregnancy test, triple swab (NAAT for chlamydia and gonorrhoea, charcoal for candida, trichomonas, BV)
Bloods:
FBC, serum b-HCG (rule out ectopic), cultures, CRP, group and save
Imaging:
TVUSS - rule out tubo-ovarian abscess (though PID mostly a clinical diagnosis which you would give stat empirical abx if its clearly a PID)
PID Rx
Admit, A-E approach
Remove any IUD if present and discuss future contraceptive options
Antibiotics in outpatient setting: Ceftriaxone 500 mg IM (single dose) oral Doxycycline (doxycycline can only be taken ORALLY) and oral metronidazole 14 days - fluids - pain relief
Other - no sex until resolves, barrier contraception in the future to avoid STI/PID.
- contact tracing
- HIV and syphilis testing
- mention about small risk of infertility
Tubuloovarian abscess:
- USS guided aspiration (laparoscopic is last resort because theres normally too many adhesions)
follow up:
if managed in outpatient setting then follow up in 72 hrs to assess response.
Molar pregnancy investigations
Bedside:
obs, abdo exam, speculum (look for other sources of bleeding), bimanual (size of uterus may feel bigger than expected, rule out ectopics/other causes)
NB may need additional tests if pt is vomiting due to high bHCG eg fluid assessment, urinary ketones
Bloods:
FBC (anaemia if bleeding), serum bHCG, clotting
Imaging: TVUSS (snowstorm/bag of grapes appearance)
