PACES Flashcards
Counselling: PPROM
Risk Factors: smokers, STI, previous P-PROM, multiple pregnancy
• Explain need for admission
• Explain the risks of P-PROM (infection which can cause damage to the baby)
• Explain the risks of prematurity (and that you’d ideally like to keep the baby inside for as
long as possible, but this has to be balanced with the infection risk)
• Explain the importance of close monitoring (CTG, maternal observations)
• Explain the role of antenatal steroids
• Discuss the likelihood of delivery
Counselling: Breech
Risk Factors: uterine malformations, fibroids, placenta praevia, poly/oligohydramnios, foetal anomaly (CNS malformations, chromosomal disorders), prematurity
• Explain what breech means
• Offer ECV and explain the risks (50% success rate, placental abruption, foetal distress
requiring an emergency C-section)
• Explain the benefits and risks of vaginal breech and C-section
o Vaginal:ifsuccessful,hasthefewestcomplications,however,40%riskofneeding an emergency C-section
o C-section:smallreductioninperinatalmortality,implicationsonfuturepregnancy (placenta praevia, VBAC, uterine rupture)
Counselling: HIV in pregnancy
Explain the need to be seen at a joint HIV physician and obstetric clinic every 1-2 weeks
• Explain the need to monitor viral load every 2-4 weeks, at 36 weeks and at delivery
• Stress the importance of good compliance with ART
• Discuss options for delivery (depending on viral load at 36 weeks gestation)
• Advise not to breastfeed
• Explain neonatal treatment with ART for 2-4 weeks and testing to confirm / deny HIV
transmission
Counselling: Pre-Eclampsia
• Risk Factors: previous hypertensive disease in pregnancy, multiple pregnancy, diabetes mellitus, kidney disease, first pregnancy, obesity, over 35 or under 20 years, family history, PCOS, IVF
• Adapt the counselling based on severity
• Explain that admission is needed (at least until BP can be controlled)
• Explain pre-eclampsia and the risks (early delivery, reduced placental function, IUGR, risks
to mother)
o Epidemiology:2-3% of pregnancies
• Explain treatment (labetalol)
• Explain that BP will be monitored closely with regular blood tests (2/week) and foetal
surveillance (every 2 weeks)
• Explain that early delivery before 37 weeks may be necessary
• Risk of Recurrence: ~15%
• Note: risk of future CVS disease if a women has hypertension in current or previous
pregnancy (major adverse events, stroke, hypertension)
Counselling: Pre-Eclampsia
• Risk Factors: previous hypertensive disease in pregnancy, multiple pregnancy, diabetes mellitus, kidney disease, first pregnancy, obesity, over 35 or under 20 years, family history, PCOS, IVF
• Adapt the counselling based on severity
• Explain that admission is needed (at least until BP can be controlled)
• Explain pre-eclampsia and the risks (early delivery, reduced placental function, IUGR, risks
to mother)
o Epidemiology:2-3% of pregnancies
• Explain treatment (labetalol)
• Explain that BP will be monitored closely with regular blood tests (2/week) and foetal
surveillance (every 2 weeks)
• Explain that early delivery before 37 weeks may be necessary
• Risk of Recurrence: ~15%
• Note: risk of future CVS disease if a women has hypertension in current or previous
pregnancy (major adverse events, stroke, hypertension)
Counselling: Gestational Diabetes
Risk Factors: age, FH of PMH, obesity, multiple pregnancy, Asian background
• Explain the diagnosis (diabetes that occurs in pregnancy because the body isn’t able to
produce enough insulin to meet the demands of carrying a baby)
• Estimated prevalence: 2-3%
• Explain the risks (MATERNAL: hypertensive disease, traumatic delivery, stillbirth; FOETAL:
macrosomia, neonatal hypoglycaemia, congenital abnormalities)
• Treatment options (diet/exercise, metformin, insulin) and the importance of good glycaemic
control
• Explain how to monitor blood glucose (using glucometer)
• Need to be seen at a joint diabetes and antenatal clinic within 1 week (and every 2 weeks
thereafter)
• Need to have ultrasound growth scans every 4 weeks from 28-36 weeks
• Explain that medication will be stopped after delivery but that they will be followed up to
check if glucose problem continues
Counselling: Obstetric Cholestasis
- Risk Factors: personal or family history of OC, history of liver disease, multiple pregnancy
- Explain diagnosis and risks (stillbirth and premature birth)
- Explain need for early delivery (37 weeks)
- Explain regular monitoring with weekly LFTs
- Advise paying close attention to foetal movements
- Symptomatic treatment with ursodeoxycholic acid and emollients (and maybe vitamin K)
- High recurrence rate (up to 90%)
Counselling: Placenta Praevia
Risk Factors: previous placenta praevia, multiple pregnancy, previous C-section, smoking and drug use, advanced maternal age
• Presenting with Asymptomatic Low-Lying / Placenta Praevia
o Explain the importance of the finding (increases risk of bleeding) o Explain that 90% of placentas will move away from the os
o Rescanat32weeksandthengofromthere
o Advisetoavoidhavingsex
• Presenting with Symptomatic Placenta Praevia (with bleeding)
o Admituntilbleedinghasstoppedandforafurther48hours
o Explaintheimportanceofthefindingandthatthefoetusneedstobemonitored o Explainthatpromptdeliveryneedstobediscussed(basedongestation)
o Explaintherisksofdelivery:
Major blood loss
May require a blood transfusion May require a hysterectomy
Counselling: Miscarriage
• Risk Factors: advanced maternal age, previous miscarriages, chronic conditions (e.g. uncontrolled diabetes), uterine or cervical anomalies, smoking, alcohol and illicit drug use, underweight or overweight
• Breaking bad news
o Explainthediagnosis
o Reassurethatthisiscommonandunder-reported(1in5pregnancies) Explain that risk increases with age
If asked about cause: explain that most of the time there is no cause o Explainthemanagementoptions(expectant,medicalandsurgical)
If medical: explain what to expect (pain, bleeding, nausea)
Antiemetics and pain relief will be given o Advisetodoapregnancytestafter3weeks
• Safety net: return if symptoms get worse, bleeding persists after 7-14 days
Counselling: Ectopic
• Risk Factors: PID, smoking, IUD/IUS, assisted reproductive technology, tubal surgery
o Explainthediagnosis(implantationofapregnancyoutsidethewomb,meaningthat
it is not viable)
o Explain the risks of an ectopic (damage to surrounding structures, bleeding and
rupture)
o Explain that the treatment options available are based on ultrasound findings and
the level of a pregnancy hormone in the blood (and explain which options are
available)
• Medical Management
o Explainadministration(1xIMinjection)
o Manage expectations (tummy pain, nausea, diarrhoea – should pass within a few
days)
o Explainthattheycangohomeaftertheinjectionbutwillneedtocomebackacouple
of times over the next week for a blood test
o Avoidsexduringtreatment,don’tconceivefor6monthsandavoiddrinkingalcohol
and excessive exposure to sunlight
o Explainthatthereisariskoftreatmentfailure,requiringfurtherintervention
• Surgical Management
o Explain that salpingectomy is the best procedure (but salpingotomy can be
considered if fertility issues or problems with contralateral tube)
o Explainthatsalpingotomyhasa1in5riskofrequiringfurtherintervention
o Reassure that fertility isn’t drastically reduced by salpingectomy vs salpingotomy
(salpingotomy still leaves behind a damaged tube) o Explainfollow-up
• Discuss ongoing contraception
Counselling: Gestational Trophoblastic Disease
Risk Factors: advanced maternal age (or younger than 20), prior molar pregnancy (1-2% risk of recurrence), prior miscarriages, Asian heritage
• Breaking bad news
o Explain the diagnosis (when the foetus doesn’t form properly, and a baby doesn’t
develop, instead there is an irregular mass of pregnancy tissue)
o Explainrisks(importanttotreatbecauseitcaninvadeanddamageothertissues)
o Explainimmediatemanagement(suctioncurettage)
o Explain follow-up (referral to trophoblastic screening centre to monitor pregnancy
hormone levels)
o Molarpregnancydoesnotaffectfertility(butthereisa1in80chanceofrecurrence) o Do not try to get pregnant until after follow-up is complete
Counselling: PCOS
Risk Factors: family history, obesity
• Explain the diagnosis (a disease with no clear cause that leads to abnormalities in hormone
levels (which, in turn, result in the symptoms experienced))
• Explain that it is very common (1 in 10 in the UK (many are unaware))
• Explain the main consequences (irregular periods, subfertility, metabolic syndrome,
cardiovascular disease, acne)
• Explain the management tailored to patient’s biggest concern:
o Fertility:recommendweightloss→clomiphene+/-metformin→considerLOD
o Periods:COCPorprogestogens(aimingforatleast3-4bleedsperyear)
o Metabolic Syndrome: check for DM, high cholesterol, heart disease (manage
accordingly)
Termination of Pregnancy
Medical Management
• Mifepristone (oral) followed 24
TOP: Counselling
Explain the options available based on the gestation (medical and surgical)
o Explain that the best option is dependent on how many weeks pregnant they are
(higher gestation = more pregnancy tissue)
• Medical: explain that one pill will be taken by mouth followed by another in 24-48 hours
either buccal/sublingual/oral
o Bleedingcanlastabout2weeks
o Pregnancytestafter3weeks
o Occasionallyunsuccessfulandrequiressurgicalremoval
• Surgical: explain that it involves gently dilating the cervix and removing the pregnancy tissue using a suction tube (only takes about 10 mins)
o Mayneedtoripencervixbeforehand
o Canbedoneunderlocalorgeneralanaesthesia
Subfertility: Counselling
Risk Factors: advanced maternal age, smoking and alcohol use, obesity, irregular periods,
STI
• Explain that there is still a chance of getting pregnant naturally (15% of couples fail to
conceive after 1 year)
• Explain that you would like to start investigations (blood test looking at hormone levels,
ultrasound scan looking at structure of the uterus and follicle count and HSG if there are risk
factors)
• Encourage continuing regular unprotected sex at least every other day
• Discuss management options depending on likely cause of subfertility
Counselling: Menopause
Explain that changes that typically occur at menopause (hot flushes, sexual dysfunction, mood changes)
• Explain lifestyle factors (healthy diet, weight loss, smoking cessation)
• Explain medical options (HRT, SSRIs, topical lubricants/oestrogens)
o Tailortoneedsofthepatient
o Explainrisks/side-effects
• Explain need for contraception
o Until>1yearamenorrhoeicif>50yrs
• Until > 2 years amenorrhoeic if < 50 yrs
• Advice on bone health, keeping up to date with national screening (breast and cervical),
contraception, support groups
Thrush counselling
• Risk Factors: recent antibiotic use, oral contraceptives, diabetes mellitus, excessive
washing
• Explain the diagnosis
• Explain treatment (usually either intravaginal clotrimazole or oral fluconazole)
• Explain hygiene measures (not cleaning too often, avoiding using fabric conditioners and
soap substitutes)
PID counselling
Risk Factors: younger women (< 25 years), STI, multiple sexual partners, past PID
• Assess whether severely unwell and needing admission
• Explain diagnosis (infection that has spread up to the womb)
• Explain risks of PID: infertility, ectopic pregnancy, chronic pelvic pain
• It will be treated with antibiotics (1 injection and 2 tablets taken for 14 days)
• Do not have sex until course is complete
o RecommendfullSTIscreenandencouragecontacttracing
• Discuss contraception (consider removal of IUD if present)
• Follow Up: in 3 days’ time and in 2-4 weeks
