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FRCEM Final SAQ > Obstetric and gynaecological emergencies > Flashcards

Obstetric and gynaecological emergencies Flashcards

1
Q

Can you give a differential diagnosis of vomiting in early pregnancy vs late pregnancy?

A

EARLY PREGNANCY RELATED CAUSES:

gestational trophoblastic disease
multiple pregnancy
hyperemesisgrvidarum
Gastro causes- gastroenteritis,PUD,pancreatitis, cholecystits
Genito-urinary causes - UTI, pyelonephritis

LATE PREGNANCY CAUSES

Gord
early labour
pre-eclampsia
HELLP syndrome

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2
Q

In treating hyperemesis gravidarum - what it the 1st line anti-emetics to prescribe in the ED?

A

1st line =

cyclizine 50mg po/im/iv tds
prochlorperezine 5-10mg tds po/im/iv
promethazine 12.5-25mg tds po/im/iv

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3
Q

In hyperemesis gravidarum - what are the indications for admission to hospital according to NICE CKS 2017?

A
  1. continued N&V AND inability to keep down liquids & oral anti-emetics
  2. continued N&V associated with ketonuria AND/OR weight loss ( > 5% pre-pregnancy body weight ) despite oral anti-emetics
  3. confirmed co-morbidity ( i.e. inability to keep down antibiotics for UTI )
  4. low threshold for patients with co-morbidity conditions i.e. DM
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4
Q

What are the complications of hyperemesis gravidarum?

A
  1. weight loss
  2. dehydration
  3. increased risk of venothrombo-embolism
  4. electrolyte disturbances
  5. vitamin deficiency
  6. mallory weiss tear/oesophageal rupture
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5
Q

What is the definition of pre-eclampsia?

A

Pre-eclampsia, as defined by NICE, is new-onset hypertension (above 140/90mmHg) after the 20th week of pregnancy in a previously normotensive patient who has significant proteinuria.

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6
Q

What clinical features suggest severe pre-eclampsia

A 
Severe headache
Visual disturbance, flashing lights or blurred vision
Papilloedema
3 beats or more of ankle clonus
Liver tenderness/ RUQ pain
Platelet count below 100 x 109/litre
Elevated liver enzymes – ALT or AST above 70 iu/litre
HELLP syndrome
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7
Q

In severe pre-eclampsia, what are the indications for ITU referal?

A
  1. eclampsia
  2. HELLP syndrome
  3. hyperkalaemia
  4. severe oliguria
  5. evidence of heart failure
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8
Q

You receive a pre-alert for a 30 year old female who had chest pain this morning. She is 8 weeks post-partum and had no complications during pregnancy or delivery. On route she has had a cardiorespiratory arrest. CPR is ongoing with an IGEL in situ. Prior to this she had previously been fit and well.

What is your differential diagnosis in a post-partum female who develops chest pain prior to a cardiac arrest?

A
  1. Pulmonary embolism
  2. Aortic dissection
  3. ACS
  4. Spontaneous Coronary Artery Dissection (SCAD) (21% 5. of AMI post partum)
  5. Arrhythmia including Long QTc
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9
Q

WHat treatment options would you consider in this patient with spontaneous coronary artery dissection post partum?

A
  1. conservative approach- suitable for stable/asymptomatic patients
  2. revascularization therapy with primary PCI & stent
  3. CABG when PCI fails
  4. FIbrinolytic therapy - which may have the benefit of establishing the true lumen but with the risk of aggrevating the disection
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10
Q

A 27 year old woman presents with worsening abdominal swelling & discomfort for 5 days and is now lethargic & markedly breathless. she has been undergoing infertility treatment and received a gonadotropin injection 2 weeks ago. she appears dehydrated but not pale, but in pain with tense distended abdomen. there is dullness of both lungs. her HR is 120bpm, BP 95/60, RR 30, HB 187g/L.

WHat is the diagnosis?
What complications can occur?
GIve an explanation for her HB level?

A
  1. Diagnosis
    * Ovarian hyperstimulation syndrome
  2. complications
  • Large ovarian cysts
  • Massive ascites
  • Fluid on renal vessels - AKI& oliguria
  • pleural effusions
  • Shock from intravascular distribution
  • VTE blood hyperviscosity from haemoconcentration
  1. HB explanation:
    due to haemoconcentration
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11
Q

A female presenting in preterm labour has cord prolapse on examination. what are your 5 key management steps in the ED?

A
  1. Call for help
  2. Female position: knee-elbow or left lateral with pillow under the hips
  3. Doctor to : apply pressure to the presenting part ( manually push up on the presenting part untill delivery
  4. Doctor: avoid handling of cord
  5. Doctor to: perform an urgent Caesarian section
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12
Q

A woman aged 22 is 10/52 pregnant and is exposed to shingles. Her family is concerned about her safety and any potential problems the shingles might cause
for his unborn grandchild. What specific advice do you need to give for his daughter and the unborn child?

A

There is increased morbidity associated with Varicella in adults, including pneumonia, hepatitis and encephalitis. Pregnant women who develop chicken pox should contact their GP immediately. PO acyclovir should be prescribed if the rash is present within 24 hours of it appearing. If the woman develops varicella or shows serological conversion in first 28/7 of pregnancy she has a small risk of Fetal Varicella Syndrome (FVS).

Pregnant women with unclear history of chicken pox who have been exposed should be offered a blood test to determine immunity. If not immune they should be offered Varicella Zoster Immunoglobulin (VZIG). This is effective up to 10/7 after contact. The aim of VZIG is that it may prevent chicken pox or attenuate it and reduce risk of FVS.

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13
Q

In pregnant patient with pre-eclampsia

  • when would you consider the need for magnesium?
A

Consider the need for magnesium sulfate treatment, if 1 or more of the
following features of severe pre-eclampsia is present:
*ongoing or recurring severe headaches
*visual scotomata
*nausea or vomiting
*epigastric pain
*oliguria and severe hypertension
*progressive deterioration in laboratory blood tests (such as rising creatinine or liver
transaminases, or falling platelet count). [2010, amended 2019]

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14
Q

What pertinent points in the sexual behaviour history would you ask a female that has\ had unprotected sexual activity the night before and is now worried about contracting an infection?

A

think of the 5 P’s:

P - Partners

P - Practices - oral/anal/vaginal

P- previous STI

P- protection from STI

P- prevention from pregnancy

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15
Q

Give 4 indications for emergency c/s in pregnant trauma patient?

A
  1. fetal distress with viable foetus
  2. uterine rupture
  3. placental abruption & maternal shock
  4. maternal cardiac arrest ( peri-mortem c-section )
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16
Q

What drugs would you use to treat pre-eclampsia

A
  1. labetalol 10mg iv bolus followed by infusion of 1-
    2mg/hr
  2. Hydralazine 5mg iv bolus (intravenous)
  3. Nifedipine (oral)
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17
Q

In a patient that has had an eclamptic fit and you are treating with IV magnesium infusion.

WHat are the features of magnesium toxicity?

A

Depending on the serum concentration:

Magnesium toxicity clinical features include -

  1. Loss of patellar/deep tenodn reflexes
  2. Drowsiness
  3. Slurring of speech
  4. Flushing
  5. Muscle weakness
  6. Respiratory depression
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18
Q

Name the drug used in the treatment of Magnesium toxicity only to be used if the patient is in cardia arrest?

A

10ml of 10% calcium chloride

19
Q

2 commonest causes of primary post partum haemorage ( which is > 500mL in 24 hours post delivery ) ?

A

The 4 T’s of primary PPH causes:

  1. Tone ( uterine atony )
  2. Torn /trauma( uterine, vaginal/cervical tears )
  3. Tissue ( retained products of conceptions )
  4. thrombin ( bleeding diathesis )
20
Q

management of vaginal thrush?

A

antifungal agents in the form of intravaginal- clotrimazole pessary or oral fluconazole

21
Q

how would you differentiate between the PV discharges

bacterial vaginosis vs trichomoniases vs vulvovaginal candidiasis?

A

Bacterial vaginosis:

thin white fishy smelling discharge
treat with oral metronidazole 400mg bd for 5 days
Trichomoniasis:

frothy green-grey offensive smelling dishcarge
take a high vaginal swab
treat with oral metronidazole 400mg bd for 5 days

candidiasis :

thick white cheese like non-offensive

22
Q

What are the symptoms and signs of PID?

A

Symptomps

· Abnormal vaginal bleeding (intermenstrual, postcoital)

· Abnormal vaginal or cervical discharge.

· Right upper quadrant pain. (Fitz–Hugh–Curtis syndrome)

· Pelvic or lower abdominal pain (usually bilateral).

· Deep dyspareunia.

Signs

• cervical motion tenderness on bimanual vaginal
examination

  • fever (>38°C)
  • lower abdominal tenderness - usually bilateral

• Adnexal tenderness on bimanual vaginal
examination

23
Q

What are the comlications of PID?

A
  1. RUQ pain with perihepatitis ( Fitz hugh curtis syndrome )
  5. 6.
24
Q

What are the indications to admit a patient with PID?

A
  1. pregnancy
  2. presence of tubo-ovarian abscess
  3. failure to respond to or intolerance to oral medical
    therapy
  4. Clinical severe disease
  5. surgical emergency cannot be excluded
25
Q

What is the OPD regime of antibiotic therapy in patient with mild/ moderate PID?

A

OPD regime:

Ceftriaxone 500mg IM stat
doxycyline 100mg po BD for 14 days
metronidazole 400mg po bd for 14 days

26
Q

What are the risk factors pre-eclampsia

A

HIgh risk factors:

Type 1/ 2 diabetes
auto-immune disease ( SLE )
Chronic hypertension

Moderate risk factors include:

  1. Age > 40
  2. First pregnancy
  3. Multiple pregnancy
  4. Obesity
  5. And family history of pre-eclampsia
27
Q

when would you consider the need for magnesium suplhate in a patietn presenting with pre-eclampsia?

A

according to NICE guidelines on pre eclampsia -

consider the need for magnesium sulphate in patient with severe pre-eclampsia ( BP must be > 160/110mmhg) and any 1 of the following:

  1. ongoing or recurring severe headaches
  2. visual scotomata
  3. nausea / vomiting
  4. epigastric pain/ tenderness
  5. oliguria & severe hypertension
  6. progressive decline in blood lab tests ( HELLP Syndrome )
28
Q

What is the definition of pre-eclampsia according to NICE?

A

Pre-eclampsia according to NICE

is new diagnosis of hypertension in pregnancy bp > 140/90 after 20 weeks GA and proteinuria > 2+

29
Q

what is fitz -hugh -curtis syndrome

A

is it the Fibrosis of the Hepatic Capsule ( FHC )

caused by gonoCCocus and Chlamydia in Females

30
Q

WHat diagnostic test would you perform to diagnose PID?

A

· Pregnancy test

· Endocervical swabs for gonorrhoea and Chlamydia.

· High vaginal swab.

31
Q

on examination of a female patient you find ano-genital herpetic lesions. how would you manage this?

A

Management-

  1. Swabs for viral cultures and Tzank smear ( intranuclear inclusions)
  2. check pregnancy status

Treatment-

  1. Analgesia- oral Paracetamol, ibuprofen.
  2. Lignocaine gel
  3. Sitz bath

3, Antivirals- 3 main group

7- 10 day course of your trust recommended antiviral (eg Acyclovir 400mg tds, Vancyclovir 1g po bd, Famciclovir)

32
Q

what is the definition of secondary post partum haemorge?

A

abnormal uterine bleeding after 24 hours of delivery up to 12 weeks post partum

33
Q

what are the ultrasound features of a molar pregnancy?

A

snow storm

absent fetus

34
Q
  1. what non-medical therapy could you use to treat primary post partum haemorage?
  2. what medical therpay would you prescribe?
A
  1. bimanual compression of the uterus to stimulate contraction
  2. oxytocinon 10iu iv slow over 10 minutes
    or
    ergometrine 0.5mg im
35
Q

a female prostitute with a pinful genital ulcer and tender swollen inguinal lymph nodes.

  1. What is the most likely diagnosis and the causative organism?
  2. what is the treatment of choice?
  3. name a complication associated with this condition.
A
  1. ChancroiD - Damn Painful Haemophilus Ducreyi!
  2. 1g Azithromycin po STAT
  3. *Large inguinal abscess ( buboes )
    • extensive adenitits
    • phimosis
36
Q

What are the indications to admit a female with PID?

A

4 P’s to admit PID:

  1. pregnancy
  2. pyrexia > 38
  3. pelvic peritonitis
  4. PUS - clinical signs of tubo-ovarian abscess
37
Q

What are the clinical features of uterine rupture?

A
  1. maternal shock
  2. abdominal guarding and rigidity
  3. abnormal fetal lie
  4. palpable fetal parts ( and unable to palpate the uterine fundus )
  5. fetal bradycardia
  6. on CTG: late decelerations and reduced variability
38
Q

a female sex worker presents with painless genital ulcer and painless inguinal lymph nodes.

what is the diagnosis and which organism causes it?

A
  1. primary syphilis- treponema pallidum

treat with benzathine penicillin 2.4iu IM stat

39
Q

WHat are the indications to admit a pregnant patient with hyperemesis gravidarum?

A
  1. > 2+ ketonuria
  2. significant weight loss. (> 5% loss of pre-pregnancy body weight)
  3. severe dehydration
40
Q

In treating hyperemisis gravidarum what is 1st and second line agents?

A

1stline - cyclizine and promethazine ( cycle to the PROM

2nd line - prochlorperazine , oral metronidazole, ondansetron

41
Q

a 35 year old presents with multiple skin pimply lesions on her vulva - what is the diagnosis and what 2 organism are responsible?

A

condylomata acuminata ( genital warts )

organisms responsible: HPV 6 and 11

42
Q

a female comes to you after an UPSI and requests emergency contraception.

  1. what are your options if it has been less than 48 hours since the UPSI?
  2. it has been more than 72 hours - what option can you give her?
  3. she is worried that she will fall pregnant - which method is superior and what will you tell her?
A
  1. levonelle 1.5 mg

OR

ulipristal acetate ( licenced for up to 120 hours )

  1. copper IUCD
  2. copper IUCD has a failure rate of 1 in 1000, making it 10-20 times more effeective than oral contraceptive options. also oral levonelle and urlipristal acetate are less effective in woman with higher BMI’s
43
Q

A female with a fishy vaginal discharge.

WHat is amsell’s criteria ?

A

any 3 of:

  1. thin, white/yellow homogenous discharge
  2. positive “whiff “ test - fishy odour release on addition of 10% potassium hydroxide )
  3. vaginal PH > 4.5
  4. clue cells on microscopy

makes the diagnosis of bacterial vaginosis caused by Gardnerella vaginalis.

treat with metronidazole

FRCEM Final SAQ (16 decks)

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