PassMed > October #2 > Flashcards
October #2 Flashcards
In Weber’s test if there is a sensorineural problem the sound is localised to the – side
unaffected
Samter’s triad =
asthma + aspirin sensitivity + nasal polyposis
Immunocompromised patients with poor dentition can develop airway compromise from cellulitis at the floor of the mouth known as –
Ludwig’s angina.
A perforated tympanic membrane caused by barotrauma treatment?
A perforated tympanic membrane caused by barotrauma is self-limiting
Auricular – occur after direct trauma to the ear and is due to a build up of blood between the– and perichondrium.
This can restrict blood supply and lead to necrosis of the connective tissue.
ENT must therefore assess the patient quickly to decide how to manage it.
Treatment is usually – and – +/- a draining wick depending on the size.
haematomas
cartilage
incision
drainage
Nasal polyps
Associations: a- a--sensitivity I-- c-- K--syndrome C---syndrome
Management
all patients with suspected nasal polyps should be :
topical – shrink polyp size in around 80% of patients
Associations: asthma (particularly late-onset asthma) aspirin sensitivity infective sinusitis cystic fibrosis Kartagener's syndrome Churg-Strauss syndrome
Management
all patients with suspected nasal polyps should be referred to ENT for a full examination
topical corticosteroids shrink polyp size in around 80% of patients
Topical — with or without – are first line treatment in otitis externa
antibiotics
steroid
depression Somatic symptoms can include x3
early morning waking and changes in appetite and weight
Pregnant women with a UTI: –is first-line
nitrofurantoin
– are contraindicated in patients with asthma when managing atrial fibrillation
Beta-blockers
Coeliac UK recommends that everyone with coeliac disease is vaccinated against — infection and has a booster every –years, as there is a potential for people with coeliac disease to develop overwhelming – sepsis due to hyposplenism
pneumococcal
five
pneumococcal
– sign: vesicles extending to the tip of the nose. This is strongly associated with ocular involvement in shingles
Hutchinson’s
Alpha-1 antitrypsin deficiency is a risk factor for — carcinoma
hepatocellular
Pneumatosis intestinalis is a hallmark feature of —- AXR
necrotising enterocolitison
Bone protection for patients who are going to take long-term — should start immediately
steroids
Phenytoin is a cause of – deficiency
folic acid
Hypertrophic obstructive cardiomyopathy - is classically associated with an S–
S- is most commonly caused by heart failure which is the result of a dilated, compliant ventricle. In young people S- can be incidental and bear no clinical significance.
A mid diastolic murmur is classically seen in–
A — is usually made up of one systolic and 2 diastolic sounds which can indicate pericarditis.
Hypertrophic obstructive cardiomyopathy is associated with a – murmur however it classically does not radiate to the carotids.
4
S3 is most commonly caused by heart failure which is the result of a dilated, compliant ventricle. In young people S3 can be incidental and bear no clinical significance.
A mid diastolic murmur is classically seen in mitral stenosis.
A pericardial rub is usually made up of one systolic and 2 diastolic sounds which can indicate pericarditis.
Hypertrophic obstructive cardiomyopathy is associated with a mid-systolic murmur however it classically does not radiate to the carotids.
Therefore S4 is the correct answer which is associated with hypertrophy of the ventricles and always indicates some form of pathology.
Aromatase inhibitors (e.g. anastrozole) may cause –
osteoporosis
–abuse increases risk of placental abruption
Cocaine
Agents used to control rate in patients with atrial fibrillation: x3
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation x3
Agents used to control rate in patients with atrial fibrillation
beta-blockers
a common contraindication for beta-blockers is asthma
calcium channel blockers
digoxin
not considered first-line anymore as they are less effective at controlling the heart rate during exercise
however, they are the preferred choice if the patient has coexistent heart failure
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation
sotalol
amiodarone
flecainide
others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine
Factors favouring rate control x2
Factors favouring rhythm control x5
Factors favouring rate control
Older than 65 years
History of ischaemic heart disease
Factors favouring rhythm control Younger than 65 years Symptomatic First presentation Lone AF or AF secondary to a corrected precipitant (e.g. Alcohol) Congestive heart failure
Causes of folic acid deficiency:
x4
Consequences of folic acid deficiency:
x2
Prevention of neural tube defects (NTD) during pregnancy:
all women should take —mcg of folic acid until the –th week of pregnancy
women at higher risk of conceiving a child with a NTD should take -mg of folic acid from before conception until the –th week of pregnancy
women are considered higher risk if any of the following apply:
→ either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
→ the woman is taking — drugs or has — disease, d—, or – trait.
→ the woman is–
Causes of folic acid deficiency: phenytoin methotrexate pregnancy alcohol excess
Consequences of folic acid deficiency:
macrocytic, megaloblastic anaemia
neural tube defects
Prevention of neural tube defects (NTD) during pregnancy:
all women should take 400mcg of folic acid until the 12th week of pregnancy
women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
women are considered higher risk if any of the following apply:
→ either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
→ the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
→ the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
ECG changes in pericarditis
x2
all patients with suspected acute pericarditis should have –
ECG changes
the changes in pericarditis are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events
‘saddle-shaped’ ST elevation
PR depression: most specific ECG marker for pericarditis
all patients with suspected acute pericarditis should have transthoracic echocardiography
– is used to assess drug sensitivities in TB
Sputum culture
The— test is the main technique used to screen for latent tuberculosis
False negative tests may be caused by:
Mantoux
miliary TB sarcoidosis HIV lymphoma very young age (e.g. < 6 months)
Diagnosis of active tuberculosis
Chest x-ray
— is the classical finding of reactivated TB
bilateral hilar —
Sputum smear
3 specimens are needed
rapid and inexpensive test
stained for the presence of — (— stain)
all mycobacteria will stain — (i.e. nontuberculous mycobacteria)
the sensitivity is between 50-80%
this is decreased in individuals with HIV to around 20-30%
Sputum culture
the — investigation
more sensitive than a sputum smear and nucleic acid amplification tests
can assess —
can take – weeks (if using liquid media, longer if solid media)
— (NAAT)
allows rapid diagnosis (within 24-48 hours)
more sensitive than smear but less sensitive than culture
Chest x-ray
upper lobe cavitation is the classical finding of reactivated TB
bilateral hilar lymphadenopathy
Sputum smear
3 specimens are needed
rapid and inexpensive test
stained for the presence of acid-fast bacilli (Ziehl-Neelsen stain)
all mycobacteria will stain positive (i.e. nontuberculous mycobacteria)
the sensitivity is between 50-80%
this is decreased in individuals with HIV to around 20-30%
Sputum culture
the gold standard investigation
more sensitive than a sputum smear and nucleic acid amplification tests
can assess drug sensitivities
can take 1-3 weeks (if using liquid media, longer if solid media)
Nucleic acid amplification tests (NAAT)
allows rapid diagnosis (within 24-48 hours)
more sensitive than smear but less sensitive than culture
Haemangioma
Should be considered in the differential of a – in a child
Accounts for 90% of — tumours in children less than 1 year of age
—on imaging
Spontaneous regression may occur and malignant transformation is almost unheard of
Haemangioma
Should be considered in the differential of a parotid mass in a child
Accounts for 90% of parotid tumours in children less than 1 year of age
Hypervascular on imaging
Spontaneous regression may occur and malignant transformation is almost unheard of
Malignant salivary gland tumours
Types of malignancy
Mucoepidermoid carcinoma
30% of all –malignancies
Usually — potential for local invasiveness and metastasis (depends mainly on grade)
Adenoid cystic carcinoma
– growth pattern
Tendency for — spread
Nerve growth may display skip lesions resulting in incomplete excision
Distant metastasis — (visceral rather than nodal spread)
5 year survival 35%
Mixed tumours
Often a malignancy occurring in a previously benign – lesion
Acinic cell carcinoma --- grade malignancy May show -- invasion --- potential for distant metastasis 5 year survival --
Adenocarcinoma
Develops from – portion of gland
Risk of regional nodal and distant metastasis
5 year survival depends upon stage at presentation, may be up to – with small lesions with no nodal involvement
Lymphoma
Large rubbery lesion, may occur in association with —tumours
Diagnosis should be based on regional nodal biopsy rather than —
Treatment is with — (and radiotherapy)
Malignant salivary gland tumours
Types of malignancy
Mucoepidermoid carcinoma 30% of all parotid malignancies
Usually low potential for local invasiveness and metastasis (depends mainly on grade)
Adenoid cystic carcinoma Unpredictable growth pattern
Tendency for perineural spread
Nerve growth may display skip lesions resulting in incomplete excision
Distant metastasis more common (visceral rather than nodal spread)
5 year survival 35%
Mixed tumours Often a malignancy occurring in a previously benign parotid lesion
Acinic cell carcinoma Intermediate grade malignancy
May show perineural invasion
Low potential for distant metastasis
5 year survival 80%
Adenocarcinoma Develops from secretory portion of gland
Risk of regional nodal and distant metastasis
5 year survival depends upon stage at presentation, may be up to 75% with small lesions with no nodal involvement
Lymphoma Large rubbery lesion, may occur in association with Warthins tumours
Diagnosis should be based on regional nodal biopsy rather than parotid resection
Treatment is with chemotherapy (and radiotherapy)
Patients who have received an organ transplant are at risk of –cancer (particularly — carcinoma) due to long-term use of –
Patients who have received an organ transplant are at risk of skin cancer (particularly squamous cell carcinoma) due to long-term use of immunosuppressants
– is recommended to start early in the course of COPD, as soon as patients start feeling shortness of breath with regular activity
Pulmonary rehabilitation is recommended to start early in the course of COPD, as soon as patients start feeling shortness of breath with regular activity
COPD: stable management
General management
>–cessation advice: including offering nicotine replacement therapy, – or —
annual —vaccination
one-off — vaccination
— to all people who view themselves as functionally disabled by COPD
Bronchodilator therapy
a — or — is first-line treatment
for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has ‘asthmatic features/features suggesting steroid responsiveness’
No asthmatic features/features suggesting steroid responsiveness:
add a — + —
if already taking a SA-A, discontinue and switch to a SA-A
Asthmatic features/features suggesting steroid responsiveness
LA-A + inhaled —
if patients remain breathless or have exacerbations offer triple therapy i.e. LA-A + LA-A + –
if already taking a SA–A, discontinue and switch to a SA–A
NICE recommend the use of combined inhalers where possible
Oral theophylline
NICE only recommends theophylline after trials of — or to people who cannot used inhaled therapy
the dose should be reduced if — or – antibiotics are co-prescribed
Oral prophylactic antibiotic therapy
– prophylaxis is recommended in select patients
patients should not smoke, have optimised standard treatments and continue to have exacerbations
other prerequisites include a — thorax (to exclude bronchiectasis) and —- (to exclude atypical infections and tuberculosis)
LFTs and an ECG to exclude – prolongation should also be done as — can prolong the — interval
M—
should be ‘considered’ in patients with a chronic productive cough and continued if symptoms improve
Cor pulmonale
features include — oedema, raised —, systolic – heave, loud P-
use a — for oedema, consider long-term oxygen therapy
ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE
Factors which may improve survival in patients with stable COPD
smoking cessation - the single most important intervention in patients who are still smoking
long term oxygen therapy in patients who fit criteria
lung volume reduction surgery in selected patients
Next question
COPD: stable management
NICE updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018.
General management
>smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
annual influenza vaccination
one-off pneumococcal vaccination
pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)
Bronchodilator therapy
a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment
for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has ‘asthmatic features/features suggesting steroid responsiveness’
There are a number of criteria NICE suggest to determine whether a patient has asthmatic/steroid responsive features:
any previous, secure diagnosis of asthma or of atopy
a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)
Interestingly NICE do not recommend formal reversibility testing as one of the criteria. In the guidelines they state that ‘routine spirometric reversibility testing is not necessary as part of the diagnostic process or to plan initial therapy with bronchodilators or corticosteroids. It may be unhelpful or misleading…’. They then go on to discuss why they have reached this conclusion. Please see the guidelines for more details.
No asthmatic features/features suggesting steroid responsiveness
add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA)
if already taking a SAMA, discontinue and switch to a SABA
Asthmatic features/features suggesting steroid responsiveness
LABA + inhaled corticosteroid (ICS)
if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
if already taking a SAMA, discontinue and switch to a SABA
NICE recommend the use of combined inhalers where possible
Oral theophylline
NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy
the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed
Oral prophylactic antibiotic therapy
azithromycin prophylaxis is recommended in select patients
patients should not smoke, have optimised standard treatments and continue to have exacerbations
other prerequisites include a CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis)
LFTs and an ECG to exclude QT prolongation should also be done as azithromycin can prolong the QT interval
Mucolytics
should be ‘considered’ in patients with a chronic productive cough and continued if symptoms improve
Cor pulmonale
features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2
use a loop diuretic for oedema, consider long-term oxygen therapy
ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE
Factors which may improve survival in patients with stable COPD
smoking cessation - the single most important intervention in patients who are still smoking
long term oxygen therapy in patients who fit criteria
lung volume reduction surgery in selected patients
Peri-arrest rhythms: tachycardia
If any of the above adverse signs are present then synchronised DC shocks should be given
Treatment following this is given according to whether the QRS complex is narrow or broad and whether the rhythm is regular or irregular
Broad-complex tachycardia
Regular
assume ventricular tachycardia (unless previously confirmed SVT with bundle branch block)
loading dose of — followed by 24 hour —
Irregular
- AF with bundle branch block - treat as for —
- Polymorphic VT (e.g. Torsade de pointes) - IV —
Narrow-complex tachycardia
Regular
— manoeuvres followed by IV —
if above unsuccessful consider diagnosis of –and control – (e.g. Beta-blockers)
Irregular
probable atrial fibrillation
if onset < 48 hr consider —-
rate control (e.g. ) and —
Broad-complex tachycardia
Regular
assume ventricular tachycardia (unless previously confirmed SVT with bundle branch block)
loading dose of amiodarone followed by 24 hour infusion
Irregular
- AF with bundle branch block - treat as for narrow complex tachycardia
- Polymorphic VT (e.g. Torsade de pointes) - IV magnesium
Narrow-complex tachycardia
Regular
vagal manoeuvres followed by IV adenosine
if above unsuccessful consider diagnosis of atrial flutter and control rate (e.g. Beta-blockers)
Irregular
probable atrial fibrillation
if onset < 48 hr consider electrical or chemical cardioversion
rate control (e.g. Beta-blocker or digoxin) and anticoagulation
Klebsiella pneumonia-> commonly due to–
Klebsiella pneumonia is more common in – and patients with a history of —-. It is also frequently caused by —.
Klebsiella commonly affects the — lobes of the lungs.
Haemophilus influenzae is common in— patients with — and can present as a — pneumonia. It does not cause ‘red-currant jelly’ sputum.
Mycoplasma is an — pneumonia which classically presents with a gradual onset dry cough and occasionally other features, such as — and erythema multiforme.
Staphylococcus aureus pneumonia commonly occurs after influenza and can also be a complication of —infection.
On chest x-ray, — consolidation, c— or a p—- might be seen.
Streptococcus pneumoniae is the most common cause of pneumonia and characteristically presents with a — and — chest pain.
aspiration
Klebsiella pneumonia is more common in diabetics and patients with a history of alcohol excess. It is also frequently caused by aspiration. In this scenario, the recent stroke has caused problematic dysphagia. Klebsiella commonly affects the upper lobes of the lungs.
Haemophilus influenzae is common in older patients with chronic obstructive pulmonary disease (COPD) and can present as a hospital-acquired pneumonia. It does not cause ‘red-currant jelly’ sputum.
Mycoplasma is an atypical pneumonia which classically presents with a gradual onset dry cough and occasionally other features, such as autoimmune haemolytic anaemia and erythema multiforme.
Staphylococcus aureus pneumonia commonly occurs after influenza and can also be a complication of measles infection. On chest x-ray, multi-lobar consolidation, cavitation or a pneumothorax might be seen.
Streptococcus pneumoniae is the most common cause of pneumonia and characteristically presents with a high fever and pleuritic chest pain.
Blisters/bullae
no mucosal involvement (in exams at least*): —-
mucosal involvement: —
Blisters/bullae
no mucosal involvement (in exams at least*): bullous pemphigoid
mucosal involvement: pemphigus vulgaris
ECG features of hypokalaemia -- waves small or absent -- waves (occasionally inversion) prolong --- interval -- depression long ---
ECG features of hypokalaemia U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT
One registered user suggests the following rhyme
In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT
To convert from oral morphine to diamorphine the total daily morphine dose should be divided by – (120 / – = —mg)
To convert from oral morphine to diamorphine the total daily morphine dose should be divided by 3 (120 / 3 = 40mg)
Palliative care prescribing: pain. NICE guidelines
Starting treatment
when starting treatment, offer patients with advanced and progressive disease regular — (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
if no comorbidities use —mg of MR a day with –mg morphine for breakthrough pain.
For example, –mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required
— morphine should be used in preference to transdermal patches
— should be prescribed for all patients initiating strong opioids
patients should be advised that nausea is often transient. If it persists then an — should be offered
drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered
Starting treatment
when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required
oral modified-release morphine should be used in preference to transdermal patches
laxatives should be prescribed for all patients initiating strong opioids
patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered
drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered
SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points
the breakthrough dose of morphine is one— the daily dose of morphine
all patients who receive opioids should be prescribed a —
opioids should be used with caution in patients with chronic kidney disease
—e is preferred to morphine in palliative patients with mild-moderate renal impairment
if renal impairment is more severe, –, – and —are preferred
metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy.
The assertion that— are particularly effective for metastatic bone pain is not supported by studies.
Strong opioids have the lowest number needed to treat for relieving the pain and can provide quick relief, in contrast to radiotherapy and bisphosphonates*.
All patients, however, should be considered for referral to a clinical oncologist for consideration of further treatments such as radiotherapy
SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points
the breakthrough dose of morphine is one-sixth the daily dose of morphine
all patients who receive opioids should be prescribed a laxative
opioids should be used with caution in patients with chronic kidney disease
oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment
if renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred
metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy. The assertion that NSAIDs are particularly effective for metastatic bone pain is not supported by studies. Strong opioids have the lowest number needed to treat for relieving the pain and can provide quick relief, in contrast to radiotherapy and bisphosphonates*. All patients, however, should be considered for referral to a clinical oncologist for consideration of further treatments such as radiotherapy
Conversion between opioids
From To Conversion factor
Oral codeine Oral morphine Divide by –
Oral tramadol Oral morphine Divide by —
Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more constipation.
From To Conversion factor
Oral morphine Oral oxycodone Divide by —
transdermal perparations
a transdermal fentanyl 12 microgram patch equates to approximately – mg oral morphine daily
a transdermal buprenorphine 10 microgram patch equates to approximately – mg oral morphine daily.
From To Conversion factor
Oral morphine–Subcutaneous morphineDivide by
Oral morphine–Subcutaneous diamorphineDivide by
Oral oxycodone–Subcutaneous diamorphineDivide by –
Conversion between opioids
From To Conversion factor
Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 10**
Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more constipation.
From To Conversion factor
Oral morphine Oral oxycodone Divide by 1.5-2***
The current BNF gives the following conversion factors for transdermal perparations
a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily
a transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine daily.
From To Conversion factor
Oral morphine Subcutaneous morphine Divide by 2
Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5
Small bowel bacterial overgrowth syndrome (SBBOS)
Risk factors for SBBOS
— with congenital gastrointestinal abnormalities
s—
d—
–aspiration and culture:
clinicians may sometimes give a course of – as a diagnostic trial
Management
correction of underlying disorder
antibiotic therapy: — is now the treatment of choice due to relatively low resistance. —or — are also effective in the majority of patients.
Risk factors for SBBOS
neonates with congenital gastrointestinal abnormalities
scleroderma
diabetes mellitus
It should be noted that many of the features overlap with irritable bowel syndrome:
chronic diarrhoea
bloating, flatulence
abdominal pain
Diagnosis
hydrogen breath test
small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce
clinicians may sometimes give a course of antibiotics as a diagnostic trial
Management
correction of underlying disorder
antibiotic therapy: rifaximin is now the treatment of choice due to relatively low resistance. Co-amoxiclav or metronidazole are also effective in the majority of patients.
Peptic ulcer disease (uncomplicated)
Risk factors
drugs:x4
– syndrome: rare cause characterised by excessive levels of –, usually from a — secreting tumour
the role of alcohol and smoking is not clear
Peptic ulcer disease (uncomplicated)
Risk factors
Helicobacter pylori is associated with the majority of peptic ulcers:
95% of duodenal ulcers
75% of gastric ulcers
drugs:
NSAIDs
SSRIs
corticosteroids
bisphosphonates
Zollinger-Ellison syndrome: rare cause characterised by excessive levels of gastrin, usually from a gastrin secreting tumour
the role of alcohol and smoking is not clear
Non-invasive ventilation - key indications
COPD with —
type – respiratory failure secondary to –
cardiogenic pulmonary oedema unresponsive to —
weaning from tracheal intubation
Non-invasive ventilation - key indications
COPD with respiratory acidosis pH 7.25-7.35*
type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
cardiogenic pulmonary oedema unresponsive to CPAP
weaning from tracheal intubation
Gestation Purpose of visit
8 - 12 weeks (ideally < 10 weeks) x5
10 - 13+6 weeks
11 - 13+6 weeks
16 weeks x2
18 - 20+6 weeks
25 weeks (only if primip) x3
28 weeks x2
31 weeks (only if primip) Routine care as above 34 weeks Routine care as above Second dose of ---
Information on labour and birth plan
36 weeks Routine care as above
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, ‘baby-blues’
38 weeks Routine care as above
40 weeks (only if primip) Routine care as above
Discussion about options for prolonged pregnancy
41 weeks Routine care as above
Discuss labour plans and possibility of induction
Gestation Purpose of visit
8 - 12 weeks (ideally < 10 weeks) Booking visit
general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
BP, urine dipstick, check BMI
Booking bloods/urine
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
hepatitis B, syphilis
HIV test is offered to all women
urine culture to detect asymptomatic bacteriuria
10 - 13+6 weeks Early scan to confirm dates, exclude multiple pregnancy
11 - 13+6 weeks Down’s syndrome screening including nuchal scan
16 weeks Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick
18 - 20+6 weeks Anomaly scan
25 weeks (only if primip) Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
28 weeks Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
31 weeks (only if primip) Routine care as above
34 weeks Routine care as above
Second dose of anti-D prophylaxis to rhesus negative women*
Information on labour and birth plan
36 weeks Routine care as above
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, ‘baby-blues’
38 weeks Routine care as above
40 weeks (only if primip) Routine care as above
Discussion about options for prolonged pregnancy
41 weeks Routine care as above
Discuss labour plans and possibility of induction
