Obstetrics

Question 1

RFs

Current pregnancy (7)

Previous pregnancy (5)

PMHx (3)

DHx, FHx, SHx

Answer 1

RFs:
1st trimester = bleeding, N+V, pain
2nd trimester = headache/vision/fatigue (PET)
3rd trimester = bleeding, pain

Current pregnancy:

• Conception by intercourse or IVF
• Gestation (via LMP)
• Any problems thus far? Do you feel like you are well supported?
• Booking visit
• Attending scans and screening? (chromosome screen at 10 weeks and anomaly scan at 20 weeks)
• Any other children or previous pregnancies
• Foetal movements (if >18 weeks)

Previous pregnancy:

• Complications during pregnancy?
• Preterm?
• Mode of delivery?
• Complications during brith?
• Birth weight of baby

PMHx:

• Rhesus status
• Long term condition control pre pregnancy
• Smear history

Question 2

Hyperemesis Gravidarum:

Explanation
Examination (1)
Investigations (3)
Management (3)

Answer 2

Explanation:

• This sounds like something called ‘hyperemesis gravid arum’
• This this where there is high levels of ‘pregnancy hormone’ in your blood which can make you feel nauseous and vomit.

Examination:
Clinical examination for dehydration

Investigations:

• we need to do an array of blood tests because you risk being dehydrated which can affect many organs (U&Es/LFTs/clotting/FBC)
• we also need to test your urine
• We need to weigh you

Management:

• we ill give you some fluids intravenously which will rehydrate you.
• we can also give you an anti-sickness medication as well
• we must also give you vitamin B1 as this can become depleted when you vomit a lot.

Question 3

PET:

Explanation
Examination (2)
Investigations (3)
Management (4)

Answer 3

Explanation:

Examination:
- Full neuro and abdo

Investigations: 
We need to do 3 things: 
1. Take a set of bloods from you 
2. Measure your blood pressure 
3. Check your urine 

Management:
If we find that the results of these Ix suggest PET, we may have to initiate the following treatments:
1. Labetalol (or nifedipine if asthmatic) for blood pressure
2. Magnesium if it becomes slightly more severe
3. Deliver your baby by 36 weeks. If labour happens before this point we may have to give you some steroids.
4. Then after labour we will need to recheck your BP, urine and bloods 6 weeks afterwards.

Question 4

Miscarriage:

Examination (1) 
Explanation
DDx (1) 
Investigations (3) 
Management (2)

Answer 4

Examination:
1. I need to examine you to rule out other potential abdominal or pelvic causes of your symptoms

There are many causes for your symptoms, however the thing I am most concerned about is unfortunately a miscarriage. I cannot say for certain whether this is the case but it is what needs to be ruled out or got on top of quickly. I know this is really worrying and not what you wanted to hear so I am going to refer you to EPAC urgently to ideally be seen today where they will do some investigations to get a clearer picture of what is going on.

DDx:
- Ecoptic

Investigations:

1. We need to have a look at what is going on by doing a TVUS.
2. Since you’re bleeding, we also need to do some blood tests for your blood count and blood type.
3. We will also check at the time the levels of the pregnancy hormone which we will need to repeat in 48 hours.

Management:

1. This wasn’t your fault and I can provide any psychosocial or mental health support in that respect.
2. Depending on these results, they will treat it in one of 3 ways: wait, give you misoprostol, or surgery.

Question 5

Recurrent miscarriage:

Investigations (3)
Management

Answer 5

Investigations:
We can refer you to fertility clinic. There they may:
1. We need to investigate whether there are any structural abnormalities of your womb by doing some imaging (pelvic US +/- MRI)
2. We can also do parental karyotyping for chromosomal abnormalities
3. Check your blood for evidence of antiphospholipid syndrome, thyroid problems and clotting problems

Question 6

Ectopic pregnancy

Examination (1) 
Explanation 
DDx (1)
Investigations (3) 
Management (3)

Answer 6

Examination:
- Abdo

Explanation:
The thing I want to rule out is an ectopic pregnancy. This is where the egg has implanted outside the uterus, most commonly in the Fallopian tubes. We are worried about this because it has a high risk of rupture which we want to avoid.

DDx:
- Miscarriage

Investigations:

1. We need to double check that you are pregnant with a urinary pregnancy test
2. Then we will do an USS to confirm whether or not you have an ectopic pregnancy.
3. We will also need to take some blood to identify your blood type in case there is a bleed and you require a transfusion.

Management:
If the USS shows that you have an ectopic pregnancy then we have a few options to manage it:
1. If we think the ectopic is very low risk for rupture and very small we can have a discussion about whether to give you a drug called methotrexate or let your body handle it on it’s own.
2. If it has ruptured or is at high risk of rupture then you will require surgery.
3. We will also be following you up closely with repeat blood tests to ensure that you have been managed properly.