OSCE emergencies (Obs and Gynae) 2/2 Flashcards
placenta praevia
Where the placenta is lower than the presenting part of the foetus
- low lying placenta when placenta is within 20mm
- placenta praevia when the placenta is ove rthe intenral cervical os
risks of placenta praevia
Risks
Placenta praevia is associated with increased morbidity and mortality for the mother and fetus. The risks include:
- Antepartum haemorrhage
- Emergency caesarean section
- Emergency hysterectomy
- Maternal anaemia and transfusions
- Preterm birth and low birth weight
- Stillbirth
The risk factors for placenta praevia are:
- Previous caesarean sections
- Previous placenta praevia
- Older maternal age
- Maternal smoking
- Structural uterine abnormalities (e.g. fibroids)
- Assisted reproduction (e.g. IVF)
how is placenta praevia picked up
- 20 week anomaly scan
- usually asymptomatic
- painless vaginal bleeding
The main complication of placenta praevia is …….. How is it managed?
is haemorrhage before, during and after delivery.
When this occurs, urgent management is required and may involve:
- Emergency caesarean section
- Blood transfusions
- Intrauterine balloon tamponade
- Uterine artery occlusion
- Emergency hysterectomy
prevention of haemorrhage in placenta praevia
- give corticosteroids between 34+35 + 6 weeks to mature fetal lungs
- planned delivery between 36- 37 weeks
- planned caesarean
placenta accreta
when the placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of the baby.
spectrum of placenta accreta
- Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond
- Placenta increta is where the placenta attaches deeply into the myometrium
- Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder
risk factors for placenta accreta
- Previous placenta accreta
- Previous endometrial curettage procedures (e.g. for miscarriage or abortion)
- Previous caesarean section
- Multigravida
- Increased maternal age
- Low-lying placenta or placenta praevia
diagnosis of placenta accreta
Ideally: antentally by US (planning for birth)
Can also be diagnosed at birth when it becomes difficult tod eliver the placenta -> PPH
management of placenta accreta
Delivery is planned between 35 to 36 + 6 weeks gestation to reduce the risk of spontaneous labour and delivery. Antenatal steroids are given to mature the fetal lungs before delivery.
The options during caesarean are:
- Hysterectomy with the placenta remaining in the uterus (recommended)
- Uterus preserving surgery, with resection of part of the myometrium along with the placenta
- Expectant management, leaving the placenta in place to be reabsorbed over time
Expectant management comes with significant risks, particularly
bleeding and infection.
Placental abruption
refers to when the placenta separates from the wall of the uterus during pregnancy. The site of attachment can bleed extensively after the placenta separates. Placental abruption is a significant cause of antepartum haemorrhage
risk factors for placental abruption
- Previous placental abruption
- Pre-eclampsia
- Bleeding early in pregnancy
- Trauma (consider domestic violence)
- Multiple pregnancy
- Fetal growth restriction
- Multigravida
- Increased maternal age
- Smoking
- Cocaine or amphetamine use
The typical presentation of placental abruption is with:
- Sudden onset severe abdominal pain that is continuous
- Vaginal bleeding (antepartum haemorrhage)
- Shock (hypotension and tachycardia)
- Abnormalities on the CTG indicating fetal distress
- Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage
Severity of Antepartum Haemorrhage
- Spotting: spots of blood noticed on underwear
- Minor haemorrhage: less than 50ml blood loss
- Major haemorrhage: 50 – 1000ml blood loss
- Massive haemorrhage: more than 1000 ml blood loss, or signs of shock
management of placental abruption
- Management of major hameorrhage
- US to exclude placenta praevia
- Antental steroids
- Rhesus -D negative women require anti-D prophylaxis
- Emergency C section if mother of fetus unstable
- Active management of third stage
Two key causes of sepsis in pregnancy are:
- Chorioamnionitis
- Urinary tract infections
Chorioamnionitis
is an infection of the chorioamniotic membranes and amniotic fluid. Chorioamnionitis is a leading cause of maternal sepsis and a notable cause of maternal death (along with urinary tract infections). It usually occurs in later pregnancy and during labour.
Chorioamnionitis can be caused by a large variety of bacteria, including gram-positive bacteria, gram-negative bacteria and anaerobes.
presentation of sepsis
The non-specific signs of sepsis include:
- Fever
- Tachycardia
- Raised respiratory rate (often an early sign)
- Reduced oxygen saturations
- Low blood pressure
- Altered consciousness
- Reduced urine output
- Raised white blood cells on a full blood count
- Evidence of fetal compromise on a CTG
Additional signs and symptoms related to chorioamnionitis include:
- Abdominal pain
- Uterine tenderness
- Vaginal discharge
Additional signs and symptoms related to a urinary tract infection include:
- Dysuria
- Urinary frequency
- Suprapubic pain or discomfort
- Renal angle pain (with pyelonephritis)
- Vomiting (with pyelonephritis)
Investigations for maternal sepsis
Arrange blood tests for patients with suspected sepsis:
- Full blood count to assess cell count including white cells and neutrophils
- U&Es to assess kidney function and for acute kidney injury
- LFTs to assess liver function and as a possible source of infection (e.g. acute cholecystitis)
- CRP to assess inflammation
- Clotting to assess for disseminated intravascular coagulopathy (DIC)
- Blood cultures to assess for bacteraemia
- Blood gas to assess lactate, pH and glucose
Additional investigations can be helpful based on the suspected source of infection:
- Urine dipstick and culture
- High vaginal swab
- Throat swab
- Sputum culture
- Wound swab after procedures
- Lumbar puncture for meningitis or encephalitis
management of maternal sepsis
Senior management early.
Sepsis 6
- Blood culture
- Urine output
- Fluids
- Antibiotics - pipercillin and tazobactam (tazocin) + gentamicin
- Lactate
- Oxygen (aim for 94-98%)
If antenatal
- Emergency caesarena section if fetal distress
- General anaesthesia usually required, spinal anaesthesia avoided -> think it can decrease BP further
investigation of choice for miscarriage
transvaginal US
Features sonographer look for in early pregnancy (each appear sequentially and as each appeats the previous feature becomes less relevant)
- Mean gestational sac diameter
- Fetal pole and crown-rump length
- Fetal heartbeat (considered viable- appears once CR length is >7mm)
miscarriage (<6 weeks gestation)
Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be managed expectantly provided they have no pain and no other complications or risk factors (e.g. previous ectopic). Expectant management before 6 weeks gestation involves awaiting the miscarriage without investigations or treatment. An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen.
A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed. When bleeding continues, or pain occurs, referral and further investigation is indicated.
miscarriage (>6 weeks gestation)
referral to early pregnancy assessment unit
- US
- Essential to exclude ectopic pregnancy
- Expectant, medical or surgical management
expectant management of miscarriage
Expectant management is offered first-line for women without risk factors for heavy bleeding or infection. 1 – 2 weeks are given to allow the miscarriage to occur spontaneously. A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete.
Persistent or worsening bleeding requires further assessment and repeat ultrasound, as this may indicate an incomplete miscarriage and require additional management.
Medical Management of miscarriage
Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.
Medical management of miscarriage involves using a dose of misoprostol to expedite the process of miscarriage. This can be as a vaginal suppository or an oral dose.
The key side effects of misoprostol are:
- Heavier bleeding
- Pain
- Vomiting
- Diarrhoea
surgical management of miscarriage
Surgical management can be performed under local or general anaesthetic.
There are two options for surgical management of a miscarriage:
- Manual vacuum aspiration under local anaesthetic as an outpatient
- Electric vacuum aspiration under general anaesthetic
Prostaglandins (misoprostol) are given before surgical management to soften the cervix.
Incomplete Miscarriage
An incomplete miscarriage occurs when retained products of conception (fetal or placental tissue) remain in the uterus after the miscarriage. Retained products create a risk of infection.
There are two options for treating an incomplete miscarriage:
- Medical management (misoprostol)
- Surgical management (evacuation of retained products of conception)
ectopic pregnancy
Ectopic pregnancy is when a pregnancy is implanted outside the uterus. The most common site is a fallopian tube. An ectopic pregnancy can also implant in the entrance to the fallopian tube (cornual region), ovary, cervix or abdomen.
Certain factors can increase the risk of ectopic pregnancy:
- Previous ectopic pregnancy
- Previous pelvic inflammatory disease
- Previous surgery to the fallopian tubes
- Intrauterine devices (coils)
- Older age
- Smoking
when does ectopic pregnancy typically present
6 to 8 weeks
The classic features of an ectopic pregnancy include:
- Missed period
- Constant lower abdominal pain in the right or left iliac fossa
- Vaginal bleeding
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
It is also worth asking about:
- Dizziness or syncope (blood loss)
- Shoulder tip pain (peritonitis)
investigations for ectopic pregnancy
- transvaginal US
- hCG repeated after 48 hours
US findings for ectopic pregnancy
bagel sign in fallopian tube
- empty uterus
In an intrauterine pregnancy, the hCG will roughly ………………. every 48 hours.
Double
- This will not be the case in a miscarriage or ectopic pregnancy.
A rise of more than 63% after 48 hours is likely to indicate an
intrauterine pregnancy
A rise of less than 63% after 48 hours may indicate an
ectopic pregnancy
A rise of less than 63% after 48 hours may indicate an
ectopic pregnancy
A fall of more than 50% is likely to indicate a
A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete.
management of ectopic pregnancy
- Expectant management (awaiting natural termination)
- Medical management (methotrexate)
- Surgical management (salpingectomy or salpingotomy)
Criteria for expectant management:
Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l
Amniotic fluid embolisation
severe condition where the amniotic fluid passes into the mother’s blood
- usually occurs around labour and delivery
amniotic fluid embolism pathophysiology
- The amniotic fluid contains fetal tissue, causing an immune reaction from the mother
- This immune reaction to cells from the foetus leads to a systemic illness. It has more similarities to anaphylaxis than venous thromboembolism
The main risk factors for amniotic fluid embolus are:
- Increasing maternal age
- Induction of labour
- Caesarean section
- Multiple pregnancy
Amniotic fluid embolisation presentation
- Shortness of breath
- Hypoxia
- Hypotension
- Coagulopathy
- Haemorrhage
- Tachycardia
- Confusion
- Seizures
- Cardiac arrest
management of fluid embolism
A – Airway: Secure the airway
B – Breathing: Provide oxygen for hypoxia
C – Circulation: IV fluids to treat hypotension and blood transfusion in haemorrhage
D – Disability: Treat seizures and consider other neurological deficits
E – Exposure
Cardiopulmonary resuscitation and immediate caesarean section are required if cardiac arrest occurs
presentation and investigations for premature ovarian insufficiency
<40 yo
- - irregular menstrual periods
- low oestrogen
- raised FSH (must be persistently raised for 2 consecutative samples more than 4 weeks apart)
management of premature ovarian insufficiency
hormone replacement therapy (HRT) until at least the age at which women typically go through menopause. HRT reduces the cardiovascular, osteoporosis, cognitive and psychological risks associated with premature menopause. It is worth noting there is still a small risk of pregnancy in women with premature ovarian failure, and contraception is still required.
investigations for heavy menstrual bleeding
Bedside
- pelvic exmaiantion with speculum and bimanual (fibroids, ascites)
Laboratory
Bloods
- FBC - iron def anaemia
- coagulation screen e.g. Von Willebrand disease0
- Ferritin
- TFT (hypothyroidism)
Imaging
- pelvic and transvagial US
Special tests
- outpaitent hysteroscopy
management of heavy menstrual bleedign
Non- contraceptive
- tranexamic acid
- mefanamic acid - if associated pain
COntracpetion
- Mirena first lie
- COCP second line
Surgical
- endometiral ablation
- Hysterectomy
PCOS rotterdam criteria
- Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
- Hyperandrogenism, characterised by hirsutism and acne
- Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
presentation of PCOS
- Oligomenorrhoea or amenorrhoea
- Infertility
- Obesity (in about 70% of patients with PCOS)
- Hirsutism
- Acne
- Hair loss in a male pattern
investigations for PCOS
- Testosterone
- Sex hormone-binding globulin
- Luteinizing hormone
- Follicle-stimulating hormone
- Prolactin (may be mildly elevated in PCOS)
- Thyroid-stimulating hormone
Hormonal blood tests typically show:
- Raised luteinising hormone
- Raised LH to FSH ratio (high LH compared with FSH)
- Raised testosterone
- Raised insulin
- Normal or raised oestrogen levels
pelvic US for PCOS
transvaginal US
* 12 or more developing follicles in one ovary
* Ovarian volume of more than 10cm3
general management of PCOS
SCREEN FOR T2DM - OGTT
It is crucial to reduce the risks associated with obesity, type 2 diabetes, hypercholesterolaemia and cardiovascular disease. These risks can be reduced by:
- Weight loss
- Low glycaemic index, calorie-controlled diet
- Exercise
- Smoking cessation
- Antihypertensive medications where required
- Statins where indicated (QRISK >10%)
Patients should be assessed and managed for the associated features and complications, such as:
- Endometrial hyperplasia and cancer
- Infertility
- Hirsutism
- Acne
- Obstructive sleep apnoea
- Depression and anxiety
manaagement of PCOS
Conservative
- weight loss
Medical
- COCP - hirsutism and acne
Infertility
- clomifene
- ovarian drilling
- IVF
TDM
- metrformin and letrozole
ovarian torsion
Ovarian torsion is a condition where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).
Ovarian torsion is usually due to an ovarian mass larger than 5cm, such as a cyst or a tumour. It is more likely to occur with benign tumours. It is also more likely to occur during pregnancy.
presentation of ovarian torsion
- sudden onset unilateral pain
- nausea and vomiting
- ## palpable mass in pelvis
diagnosis of ovarian torsion
transvaginal US
- whirlpoor sing - free fluid in pelvis and oedema of ovary
- doppler may show lack of blood flow
management of ovarian torsion
Depending on the duration and severity of the illness they require laparoscopic surgery to either:
- Un-twist the ovary and fix it in place (detorsion)
- Remove the affected ovary (oophorectomy)
management of ovarian torsion
Depending on the duration and severity of the illness they require laparoscopic surgery to either:
- Un-twist the ovary and fix it in place (detorsion)
- Remove the affected ovary (oophorectomy)
Where a necrotic ovary is not removed, it may become
infected, develop an abscess and lead to sepsis. Additionally it may rupture, resulting in peritonitis and adhesions.
hypermesis gravidarum
Hyperemesis gravidarum is the severe form of nausea and vomiting in pregnancy. The RCOG guideline (2016) criteria for diagnosing hyperemesis gravidarum are “protracted” NVP plus:
- More than 5 % weight loss compared with before pregnancy
- Dehydration
- Electrolyte imbalance
managment of mild hyperemesis gravidarum
Antiemetics e.g. prochlorperazine or cyclizine
Anti-acids e.g. omeprazole
admission for HG should be considered when
- Unable to tolerate oral antiemetics or keep down any fluids
- More than 5 % weight loss compared with pre-pregnancy
- Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
- Other medical conditions need treating that required admission
Moderate-severe cases may require ambulatory care (e.g. early pregnancy assessment unit) or admission for:
- IV or IM antiemetics
- IV fluids (normal saline with added potassium chloride)
- Daily monitoring of U&Es while having IV therapy
- Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
- Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission
most common causes of PID
- Neisseria gonorrhoeae tends to produce more severe PID
- Chlamydia trachomatis
- Mycoplasma genitalium
Non-STI
- Gardnerella vaginalis
- Haemophilus influenzae
- E.coli
RF for PID
- Not using barrier contraception
- Multiple sexual partners
- Younger age
- Existing sexually transmitted infections
- Previous pelvic inflammatory disease
- Intrauterine device (e.g. copper coil)
presentation of PID
- Pelvic or lower abdominal pain
- Abnormal vaginal discharge
- Abnormal bleeding (intermenstrual or postcoital)
- Pain during sex (dyspareunia)
- Fever
- Dysuria
Examination findings for PID
- Pelvic tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
may have signs of sepsis
investigations for PID
- NAAT swabs for gonorrhoea, chlamydia and mycoplasma genitalium if available
- Charcoal swab (high vaginal) for bacterial vaginosis, candidiasis and trichomoniasis
- HIV test
- Syphilis test
Look for pus cells under microscopy
Always
- do pregnancy test
management of PID
- A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
- Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
- Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
PID and signs of sepsis
SEPSIS 6
- IV antibitoics
- pelvic abscess may need drainage
complications of PID
- Sepsis
- Abscess
- Infertility
- Chronic pelvic pain
- Ectopic pregnancy
- Fitz-Hugh-Curtis syndrome
