Obstetrics & Gynaecology Flashcards
PPH
2022.1 CBD Station
Assessment and Management of PPH in rural hospital
Prepare for interhospital transfer
Medical Expertise: Assessment – 30%
* Performs a structured initial assessment on a critically ill patient
* Identifies important historical details (red flags) diagnostic of an important condition
* Recognises signs on physical examination that indicate the patient is or at risk of imminent
deterioration
* Creates a focused investigation plan that confirms or excludes time critical diagnoses.
Medical Expertise: Management – 40%
* Initiates appropriate initial supportive treatment for any presenting problem
* Recognises and expedites any specific intervention essential to resuscitation
* Adapts and initiates standard therapies to that patient, e.g., drugs, fluids, gases, and
monitoring
* Creates an appropriate ongoing reassessment and management plan.
Health Advocacy – 30%
* Tailors treatment and disposition decisions for a patient to account for the presence of
vulnerability factors
* Integrates extra services to increase the likelihood of successful treatment in vulnerable
patients
* Advocates for patient care to prevent inappropriate management actions by other doctors.
Candidates were required to interact with the examiner and to:
* outline their initial assessment of the patient
* discuss their management of the patient.
Active management of the 3rd stage:
- syntocinon 10mg IM
- early cord clamping
- controlled cord traction (only when the uterus is contracted to avoid uterine inversion)
ASSESSMENT:
HISTORY:
- volume of blood loss
- group and screen sent?
Assess 4T’s
- Tone (prolonged labour, intrapartum oxytocin)
- Tissue (placenta complete?)
- Tears
- Thrombin (coagulopathy, anticoagulation)
EXAM:
Continuous cardiac monitoring
Pulse oximetry
Q2min BP
haemodynamic instability
altered mental status
rate and volume of blood loss
ASSESS for 4T’s:
Abdominal exam:
- palpate fundus for atony
- tenderness (rupture/inversion)
Genital tract exam:
- lacerations (perineum, vagina, cervix)
Retained products:
- check placenta and membranes intact/complete
Blood clotting:
- point of care blood clotting analyser (ROTEM/TEG)
- clotting on floor
INVESTIGATIONS:
VBG - metabolic acidosis, ionised calcium
FBC - Hb, platelet count
UEC & LFT - end organ perfusion
Full coagulation panel - coagulopathy/DIC
Fibrinogen
Group and screen
MANAGEMENT:
Call for help - obstetrics
Call blood bank and request 4units of un-crossmatched blood
Lie bed flat
High flow oxygen 15L NRB - target SaO2 >95%
2x large bore cannula or rapid infusion catheter
TONE:
External uterine massage - boggy uterus?
Empty bladder and place IDC
Bimanual uterine compression
Syntocin 5u slow IV push
Syntocin influsion 40u in 500ml 0.9% NS IV over 4hrs
Tranexamic acid 1g IV stat
Ergometrine 250mcg IV Q5min x4 (max 1mg) - contraindicated in hypertension
Carbaprost 250mcg myometrial injection Q15min up to 2mg (contraindicated in asthmatics)
Misoprostol 1mg PR
Bakri balloon intrauterine to tamponade uterus
EUA
TRAUMA:
Assess genital tract for trauma - lacerations (perineum, vagina, cervix) - suture any lacerations or apply pressure until taken to theatre
Tender uterus, FAST scan positive for uterine rupture
THROMBIN:
DIC - is blood clotting on the floor, oozing from IVC site
given tranexamic acid 1g IV (WOMAN trial showed that it reduced deaths)
give cryoprecipitate 10 unit - keep fibrinogen >2
TISSUE:
Inspect placenta and membranes for completeness
Uterine sweep for retained products or clots
Retained products
Theatre for EUA
transfuse with RBC not crystalloid
order urgent un-crossmatched blood 4 units
activation of MTP
transfuse 1:1:1 RBC:platelets:FFP
prevent hypothermia - limit patient exposure, warm blankets, all blood products through fluid warmer
prevent acidosis - optimise perfusion and ventilation
urgent O&G attendance
prepare for transfer to theatre
- Removal of retained products
- Balloon tamponade
- Suturing
- B- lynch sutures
- Uterine artery ligation
- Internal illiac artery ligation
- Hysterectomy
angiography - embolization of uterine or internal iliac artery
Disposition ICU
PREPARE FOR TRANSFER
Invasive blood pressure monitoring (arterial line)
Blood products
Analgesia
Pre-eclampsia
EM rapid bombs - ep 150, 151
2021.2 Case based discussion
Assessment and management of a pregnant patient who is seizing
Medical Expertise: Initial assessment and management – 30%
* Seeks evidence of time critical diagnoses when performing assessment
* Creates a focused investigation plan that confirms or excludes time critical diagnoses
* Initiates treatments specific to identified abnormalities in airway and/or ventilation
Medical Expertise: Further management – 30%
* Outlines an overall plan for ongoing treatment of the patient
* Initiates treatments specific to identified abnormalities in circulation
* Identifies important aspects of supportive care in this patient
* Anticipates and manages common complications during and after a procedure
Prioritisation and Decision Making – 40%
* Prioritises a differential diagnosis list to determine the most likely diagnoses in a patient
* Prioritises essential components of ongoing care a of any patient in the emergency
department
* Initiates treatments specific to identified abnormalities in airway and/or ventilation
* Provides a rationale to explain and justify decisions about ongoing treatment
Candidates were required to:
* outline their initial approach to the assessment and management of the patient to the
examiner
* answer further questions from the examiner regarding the evolving case.
DEFINITION:
>20weeks gestation
BP > 140/90 (previously normotensive)
1 or more signs of end-organ dsyfunction - proteinuria, derranged LFT’s, thrombocytopenia etc
INVESTIGATIONS:
FBC - anaemia (second to haemolysis), decreased haematocrit, thrombocytopenia
UEC - raised creatinine
LFT - transaminitis (in HELLP sydrome)
Urinalysis - raised protein/creatinine ratio
24hr urine collection >0.3g protein
LDH - raised in haemolysis (HELLP syndrome)
ASSESSMENT & MANAGEMENT:
Left lateral position
High flow 100% Oxygen 15L NRBM
Oropharyngeal airway + jaw thrust + suction as needed
Check GLUCOSE
Check BLOOD PRESSURE
STOP SEIZURE:
- Magnesium 4g IV over 20min, Magnesium infusion 1g/hr
- Midazolam 5mg IV or 10mg IM
Monitor Q1h:
- mental status
- RR
- deep tendon reflexes
therapeutic range 1.7-3.5mmol/L
BLOOD PRESSURE CONTROL:
*Labetalol 20mg iv, repeat in 10min (max 80mg) - followed by infusion 20mg/hr - fetal bradycardia
Hydralazine 5mg IV bolus every 10min (max 30mg) - may cause excessive hypotension and reflex tachycardia
GTN infusion starting at 10mcg/min increasing by 5mcg every 10-15min until desired effect
Target BP BP 130/80
Place invasive BP monitoring and titrate labetalol infusion to effect
COMPLICATIONS:
- pulmonanary oedema
- DIC
- placental abruption
- acute renal failure
-
IDC to monitor UO
SEIZURE PROPHYLAXIS:
Magnesium sulphate 4g IV over 20min
Continue magnesium sulphate infusion at 1g/hr
Monitor for:
- respiratory depression
- heart block
- loss of patellar reflexes
- symptomatic hypocalcemia
Antitode: calcium gluconate 1g IV over 5min
(10ml calcium gluconate 10%)
CTG Monitoring (fetal bradycardia with labetalol)
Consider betamethasone 11.4mg IM in <37/40 - promote fetal lung maturity
DEFINITIVE MANAGEMENT:
urgent obstetrics for delivery
DISPOSITION:
consult ICU
Nausea and Vomiting in Pregnancy
2023.2 Junior Doctor Discussion
molar pregnancy or multiple pregnancy (twins)
UTI/pyelonephritis
Cholecystitis - “Gallbladder dilatation and biliary sludge increase in pregnancy, predisposing to stone formation. Cholelithiasis and cholecystitis are more common in pregnant women”
Others: appendicitis, pancreatitis, gastroenteritis, PUD
Investigation: US - molar pregnancy, twin pregnancy VBG - metabolic acidosis (ketoacidosis), metabolic alkalosis loss of HCl with vomiting BSL - hypoglycemia UEC - hypokalemia, renal impairment Urine - ketonuria TSH - hyperthyroidism
Management:
IV fluids - 5% dextrose
Doxylamine 12.5mg - 25mg TDS
Pyridoxine 12.5 - 25mg TDS
DIFFERENTIAL DIAGNOSIS:
- hyperemesis gravidarum
- molar pregnancy
- UTI
- transient hyperthyroidism
- cholecystitis/biliary colic (biliary sludge and stone formation increases in pregnancy)
- appendicitis
- pancreatitis
others:
- gastroenteritis
- bowel obstruction
INVESTIGATIONS:
- BSL (hypoglycemia)
- VBG (metabolic alkalosis, loss of HCl with vomiting)
- Urinalysis (pyelonephritis)
- UEC (renal failure & electrolyte disturbance - hypokalemia)
- TSH (transient hyperthyroidism)
- USS (molar, multiple pregnancy)
NON-PHARMACOLOGICAL THERAPY:
- eating small amounts frequently, crackers, plain biscuits, dry toast
- eating crackers or plain biscuits before getting out of bed in the morning
- snacking on high-protein foods between meals like nuts
- Avoid high fatty, spicy foods
- maintaining hydration with cold drinks, small sips frequently, or ice chips
- changing to a multivitamin without iron
- adequate sleep is important - fatigue will exacerbate symptoms
- ginger tablets may be effective
PHARMACOLOGICAL THERAPY:
1st line:
Pyridoxime 12.5mg TDS
doxylamine 25mg nocte (category A)
add metaclopramide 10mg tds (category A)
add ondansetron 4mg tds (category B1)
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed.
Category B1
Drugs which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed.
Studies in animals have not shown evidence of an increased occurrence of fetal damage.
PE Work Up in Pregnancy
2021.1 Discussion with junior doctor
Controversial
No good evidence to guide us yet
Only expert opinion
Pre-test probability is determined by clinical gestalt rather than probability scoring systems like wells and perc score.
D-dimer starts to rise in second trimester
Bedside ECHO
- insufficient to exclude subsegmental PE.
- increased R heart strain may be normal physiology of pregnancy
McConnels sign - RV hypokinesis preserved apical contractility
RV dilatation
- RV greater than LV
Interventricular Septal flattening - D shaped sep
Dilated IVC with no collapse on inspiration
Dilated pulmonary trunk
b) US lower limbs for DVT - readily available, cheaper than CT and VQ scans - no radiation or contrast exposure - unable to exclude PE
CXR
- readily available
- extremely low dose of radiation to fetus and mother
- useful in detecting differential diagnoses i.e. pneumoniae, pneumothorax
- cannot exclude PE
CTPA
- readily available in most ED’s
- is the gold standard for identifying PE
- less foetal radiation exposure compared to VQ scan
(CTPA = 0.1mGy, VQ scan = 0.5mGy)
- alternative pathologies can be identified (pneumoniae)
- risk of foetal hypothyroidism with iodine contrast
- radiation dose to maternal breast tissue from CTPA is 20-100 times that of V/Q scan (increasing the women’s lifetime risk of breast cancer)
- can use a bismuth shield to reduce radiation to breasts
VQ scan
- less radiation exposure to maternal breast tissue - this is useful in those who have strong family hx of breast cancer
- not readily available
- time consuming study
- exposes foetus to 0.5 mGy radiation (more radiation than CTPA)
- non diagnostic scans are high in those with lung disease
- need IDC to reduce radiation to bladder
amount of radiation to cause teratogen effect is 50mGy
Discuss with radiologist
- radiation reduction strategies
PV Bleeding in Early Pregnancy
Do Bhcg on all females of childbearing age.
Even if tubal ligation - tubal ligation is not 100% effective and this increases risk of ectopic pregnancy
Screening for domestic violence as this increases in pregnancy
Speculum exam is an opportunity for STI screening and to check for non-obstetric causes of bleeding
Molar pregnancy:
“tumors from abnormal fertilization of an ovum, with over proliferation of trophoblastic tissue”
- uterus large for dates
- abnormally high bhcg - hyperemesis
- USS ‘snow storm’ appearance
treatment is surgical with a work up for metastatic disease
ED POCUS for ectopic pregnancy:
- empty uterus with serum bhcg > 6500
- complex adnexal mass
- FAST positive
- tubal ring or blob sign
Medical Management of Ectopic Pregnancy with Methotrexate:
- folic acid antagonist
Suitable for:
- BhCG <5000
- no fetal cardiac activity
- ectopic mass <4cm,
- hemodynamically stable (no sign of rupture)
- reliable for follow up
- normal baseline liver and renal function tests
Counselling:
- need to discontinue folic acid supplements and avoid alcohol
- need to avoid strenuous exercise and sexual intercourse due to risk of tubal rupture
- 5% failure rate, need to represent if symptoms of rupture
- follow up is crucial
Contraindications to Methotrexate: Tintinalli’s table
- embryonic cardiac activity detected by TV US
- ectopic pregnancy >4cm on TV US
- Bhcg >5000
- unreliable for follow up
- immunocompromised
- allergy to methotrexate
- liver or renal disease
- active peptic ulcer disease
- haemodynamically unstable
- breast feeding
MANAGEMENT STABLE MISCARRIAGE:
- expectant
- medical (misoprostol)
- surgical
DIFFERENTIAL DIAGNOSIS:
- ectopic pregnancy
- miscarriage (threatened vs. spontaneous)
- Anembryonic pregnancy (blighted ovum) - “gestational sac with no yolk sac, no foetal pole”
- Non obstetrical causes (infections, lacerations, cervical malignancy)
- Gestational trophoblastic disease (molar pregnancy)
HISTRORY:
How pregnant?
- urinary bhcg
- bloods bhcg
- USS
- LMP, regular cycles
IVF
Blood group if known
previous pregnancies, terminations, miscarriages, live births
how much bleeding
abdominal pain (central vs. lateral)
history of trauma (sexual intercourse)
genital infections - pv discharge, malodorous
bleeding disorders - anticoagulation
Ectopic pregnancy risk factors:
- previous ectopic pregnancy
- previous STI/PID
- previous tubal surgery, previous ruptured appendix (peritonitis)
- IVF pregnancy (risk of heterotopic pregnancy)
- conception with IUD in place
- Cigarette smoking (may alter embryo tubal transport)
RUPTURED ECTOPIC CLINICAL FEATURES:
- syncope
- right shoulder tip pain (intra-peritoneal blood irritating the diaphragmatic parietal peritoneum)
- orthostatic hypotension
- abdominal tenderness with perotonism
- Adnexal mass
DISCRIMINATORY ZONE:
>1500 - IUP visible transvaginal USS
>6500 - IUP visible trans-abdominal USS
MASSIVE BLEEDING IN MISCARRIAGE:
- speculum exam to remove contents from the os
- oxytocin 40IU in 500ml NS over 4hrs
- ergometrine 250mcg IM
- tranexamic acid 1g IV
- OT for D&C
ANTI-D FOR Rh (D) NEGATIVE
Prevent alloimmunisation - prevent development of antibodies to foetal red cells that are Rh (D) positive
needs to be given in the first 72hrs
first trimester - 250IU for singleton pregnancy, 625IU for multiple pregnancy
Second & 3rd trimester - 625IU
successive dosing should be guided by the kleihauer test and degree of fetomaternal haemorrhage
is a blood product
small risk
if they have had one dose in early pregnancy and present with multiple episodes of bleeding. the initial dose will cover them up until 20 weeks so no need to repeat the dose.
Preterm Labour
Pelvic pressure
* Lower abdominal cramping
* Lower back pain
* Amniotic fluid loss
* PV bleeding
* Regular uterine activity
- feels similar to previous labour
Abdominal palpation:
Palpable, painful regular contraction
Foetal lie and presentation
CTG monitoring
POCUS:
amniotic fluid
fetal presentation
cervical length
Sterile speculum
- rupture of membranes - liquour pooling
- visualise cervix/membranes - dilated cervix
- High vaginal swab test for fetal fibronectin
USS to assess cervical length <1.5cm = labour likely
Maternal pushing 10cm dilated, effaced cervix Head on view Bulging perineum Foetal descent - head below ischial spines
2)
CTG - assess uterine contractions
USS - assess cervical length <1.5cm
Fetal fibronectin vaginal swab
Ferning seen in amniotic fluid under microscopy
3)
Foetal lung maturation - 11.4mg betamethasone IM lateral thigh
Prevent respiratory distress syndrome in the newborn
Tocolysis - nifedipine 20mg po, repeat in 30min if ongoing contractions (total of 3 doses)
Intra-partum antibiotics to cover for GBS - benzylpenicillin 1.2g QID
broaden antibiotic cover if suspect chorioamnionitis
- ampicillin 2g iv
- metronidazole 500mg iv
- gentamicin 5mg/kg iv
Magnesium sulfate - foetal neuroprotection (reduce cerebral palsy) is not evidence base and I would discuss with obs and gynae
Loading dose: 4 g IV bolus over 15 minutes
o Maintenance dose: 1 g/hour for 24 hours
Arrange retrieval to obstetrics centre with NICU
Neonatal resuscitation
Start timer
Prevent hypothermia - dry with warm towels, place under radiant heat, cover head with bonnet
- <29wks don’t dry and place in plastic bag
Stimulate - rub vigorously with warm towel
Airway and breathing - no need to suction
Assess HR - auscultate at apex
POSITIVE PRESSURE VENTILATION:
- if apnoea >30sec
- RR <12
- HR <100
- Neopuff
- BVM
- Neonatal TV only 20-30mL
- Rescue breaths 3-5secs to clear alveolar amniotic fluid, followed by RR 30-40/min using room air
- Peak inspiratory pressures of 1cmH2O for every gestational week i.e. 38weeker PIP of 38cmH2O
CHEST COMPRESSIONS:
- HR < 60
- 2 hand encircling technique or 2 finger technique
- 3 compressions to 1 ventilation
- rate 100/min
INTUBATION:
- if HR <60 despite >30sec PPV
FLUIDS AND DRUGS:
- Umbilical vein or proximal tibia IO preferred
ADRENALINE:
- if HR <60 despite 90sec PPV and 30sec chest compressions
- 10-30mcg/kg IV OR 50-100mcg/kg ETT
0.9% NS 10ml/kg IV
O negative blood 10ml/kg IV
10% gluclose 5ml/kg IV
Degree of acidosis correlates with death and cerebral palsy
- pH 6.9-7.0 - 3%
- pH 6.8-6.9 - 10%
- pH < 6.8 - 40%
Ceasing resuscitation
- in no cardiac output for 10minutes
- consider early cessation (or not attempting resuscitation) if
- < 23 weeks gestation
- birth weight < 400g
- anencephaly
- confirmed trisomy 13 or 18
Shoulder Dystocia
Call for help - MET call (obstetrics and neonatal team)
Lie flat
Move buttocks to the edge of the bed
Discourage mother from pushing
McRoberts manoeuvre
- knees to chest
- hip flexion and abduction
- widens the AP diameter of the pelvis
Rubens 1 manoeuvre
Pubic Symphysis Pressure
- pressure in a rocking motion n the pubic symphysis in a downward lateral motion
- to release the anterior shoulder from under the pubic bone
Episiotomy and internal manoeuvres
Rubins II manoeuvre:
- insert dominant hand into vagina, digital pressure posterior aspect of anterior shoulder to rotate the shoulder into the oblique diameter.
Dislodging the anterior shoulder from under the pubic bone.
Attempt deliver once shoulders are in the oblique diameter.
Wood’s screw Manoeuvre
introduces their second hand to locate the anterior aspect of the posterior shoulder. rotate the shoulders with both hands.
Rotate 180 degrees so the anterior shoulder is now posterior. Attempt delivery.
Reverse wood screw
rotate 180 degrees in the opposite direction
Delivery of the Posterior Arm
grasp the posterior hand to sweep the arm across the chest and deliver the arm.
Putting mother on all fours
Cleidotomy - one or both clavicles are ractured to reduce the bi-acromial diameter
Symphysiotomy
Zavanelli manoeuvre – push head back up and deliver by c/s
Communication Station
2022.2 Station
Headache in Pregnancy
2021.2 History Station
PID
upper genital tract infection
- endometritis
- salpingitis
- tubo-ovarian abscess
- pelvic peritonitis
- fitz-hugh curtis syndrome (peri-hepatitis - liver capsule inflammation –> adhesions)
Cause:
- STI (chlamydia, gonorrhoea, trichomonas, mycobacterium genitalia)
- post instrumentation (IUD placement, endometrial biopsy - polymicrobial caused by vaginal flora)
COMPLICATIONS:
- infertility
- ectopic pregnancy
- chronic pelvic pain
- fitz hugh curtis syndrome
- tubo-ovarian abscess
HISTORY:
- pelvic pain
- fever
- dysuria
- abnormal uterine bleeding (intermenstrual bleeding)
- abnormal pv discharge
- dyspareunia
- sexual history
- previous STI’s
- recent instrumentation ( IUD insertion within 3 weeks)
EXAMINATION:
Temp, HR, BP (sepsis)
Abdominal Exam:
- focal tenderness
- mass/fullness (tubo-ovarian abscess)
- peritonism (pelvic peritonitis)
PV/Bimanual Exam:
- adnexal tenderness
- cervical motion tenderness
Speculum Exam:
- purulent discharge
- friable cervix
DIAGNOSIS:
- endocervical swab (NAAT or PCR for gonorrhoea, chlamydia, mycobacterium genitalium)
- HVS trichomonas
** gram stain and culture of gonorrhoea for susceptibility testing (increase in multi-drug resistant gonorrhoea)
first void urine
patient self collected vaginal swab
Pelvic USS:
- fallopian tube wall thickness >5mm
- pelvic free fluid
- cogwheel sign (cogwheel appearance on the cross-section tubal view)
- tubo-ovarian abscess
Bloods:
- leukocytosis
- raised CRP
- mildly derranged LFT’s in fitz hugh curtis syndrome
Screen for HIV, Syphilis, Hep A, Hep B, Hep C
Admission Criteria for PID:
- pregnancy
- sepsis (fever, tachycardia etc)
- severe pain requiring parenteral opioids
- unable to tolerate po tablets
- failed outpatient therapy
- suspect tubo-ovarian abscess
- other surgical emergencies cannot be excluded (ovarian torsion, appendicitis)
Antibiotics:
Ceftriaxone 500mg IM
Doxycycline 100mg bd - 14 days (or azithromycin 1g stat, repeat in 1week if pregnant or compliance issues)
Metronidazole 400mg bd - 14 days
Moxifloxacin 400mg daily - 14 days for mycoplasma genitalium
**Removal of IUD?
- all patients should be screened for STI’s before IUD placement
- IUD can remain in PID as long as clinical improvement within 48-72hrs of treatment
COUNSELLING:
- contact tracing
- contraception
- opportunistic testing for HIV/Syphylis/Hep ABC
- prevention (abstinence, barrier protection, monogomy)
- vaccination (Hep A, Hep B, HPV)
- follow up
