Passmed Flashcards
What is the most common cause of severe early onset fever in newborn infants
Group B strep
< 7 days birth
Risk factors for Group B strep
prematurity
prolonged rupture of the membranes
previous sibling GBS infection
maternal pyrexia e.g. secondary to chorioamnionitis
What should women who’ve hade GBS in prev pregnancy have in next
Risk of GBS carraige is 50%
Intrapartum antibiotic prophylaxis offered OR
testing in late pregnancy and antibiotics if still positive
When should swabs for GBS be offered
35-39 weeks
or 3-5 weeks prior to anticipated delivery date
When should IAP be offered
Women with prev baby with early or late onset GBS disease
Preterm
Pyrexia - >38 degrees - during labour
What is antibiotic of choice in GBS
Benzylpenicillin
Why is d-dimer in pregnancy useless
will always be positive
What is the management of pregnancy for intrahepatic cholestasis of pregnancy
Induce at 37-38 weeks as increases risk of stillbirth
Increased foetal surveilance before this
When is C scetion done in IH cholestasis of pregnancy
When non reassuring foetal status
Medical management of IH cholestasis of pregnancy
Antihistamines - symptomatic + reassurance
Ursodeoxycholic acid
Colestyramine
Topical emollients
Vit K supplementation
Features of IH cholestasis
pruritus - may be intense - typical worse palms, soles and abdomen
clinically detectable jaundice occurs in around 20% of patients
raised bilirubin is seen in > 90% of cases
What is medroxyprogesterone acetate
Depot injection
Clinical features of endometriosis
chronic pelvic pain
secondary dysmenorrhoea
pain often starts days before bleeding
deep dyspareunia
subfertility
non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
First line for endometriosis
NSAIDs abd/or paracetemol
COCP or progesterogens
Secondary treatments for endometriosis
GnRH analogues - pseudo menopause - low oestrogen
Surgery - laparoscopic excision or ablation + adhesiolysis + ovarian cystectomy - improves fertility
Placental abruption vs placenta praevia
Both: vaginal bleeding in pregnancy
Abruption:
Shcok outkeeping with visible loss
Pain constant
Tender, tense uterus
Normal lie and presentation
Foetal heart - absent/distressed
Coag problems
Beware pre-eclampsia, DIC, anuria
Praevia:
Shock in proportion to visible loss
No pain
Uterus not tender
Lie and presentation may abnormal
Foetal heart normally normal
Coag problems rare
Small bleeds before large
What should be avoided in croup
Throat examination may obstruct AW
What is croup characterised by
URTI in infants and toddlers, stridor + laryngeal oedema and secretions caused by parainfluenza virus
Mild croup features
Occasional barking cough
No audible stridor at rest
No or mild suprasternal and/or intercostal recession
The child is happy and is prepared to eat, drink, and play
Moderate croup features
Frequent barking cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation
The child can be placated and is interested in its surroundings
Severe croup features
Frequent barking cough
Prominent inspiratory (and occasionally, expiratory) stridor at rest
Marked sternal wall retractions
Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
When prompt admission of croup
Any child with moderate or severe croup
<6 months age
Known upper AW abnormalities (laryngomalacia, Downs syndrome)
Uncertainty about diagnosis - acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation
Emergency treatment croup
High flow oxygen
Nebulised adrenaline
Management of croup
Single dose oral dexamethasone (0.15mg/kg) to all children regardless of secerity
Prednisolone is alternative
Investgiations - what CXR show in croup
Post ant view - subglottic narrowing - steeple sign
Contrast lateral view - acute epiglottitis - thumb sign
What cont machinery murmur suggests
PDA
What intervention for PDA
Indomethacin - inhibit PGE2 which maintains PDA
What intervention for PDA
Indomethacin or ibuprofen - inhibit PGE2 which maintains PDA
When use PGE2 in heart failure infant
Complex congenital heart defects - shunt necessary to maintain life eg transposition of great arteries
Why is aspirin not given to children under 16
Risk of reyes syndrome
What can treat apnoea in neonates
Caffeine citrate
What babies is PDA more common on?
High altitude babies, premature, maternal rubella in first trimester
Features of PDA
L subclavicular thrill
Cont machinery murmur
Large volume. bounding, collapsing pulse
Wide pulse pressure
Heaving apex beat
What would poor feeding, grunting and lethargy in a neonate signal
Neonatal sepsis
Common oragnsims causing neonatal sepsis
Group B strep - early onset
E.coli
What is late onset neonatal sepsis cuased by
Transmission pathogens from environemnt post-delivery from contacts
Staph pecies - S.epidermis
Gram - = psueomonas aeruginosa, klebsiella, enterobacter
What is late onset neonatal sepsis cuased by
Transmission pathogens from environemnt post-delivery from contacts
Staph pecies - S.epidermis
Gram - = psueomonas aeruginosa, klebsiella, enterobacter
Risk factors for neonatal sepsis
Mother who has had a previous baby with GBS infection, who has current GBS colonisation from prenatal screening, current bacteruria, intrapartum temperature ≥38ºC, membrane rupture ≥18 hours, or current infection throughout pregnancy
Premature (<37 weeks): approximately 85% of neonatal sepsis cases are in premature neonates
Low birth weight (<2.5kg): approximately 80% are low birth weight
Evidence of maternal chorioamnionitis
Presentation neonatal sepsis
Respiratory distress (85%)
Grunting
Nasal flaring
Use of accessory respiratory muscles
Tachypnoea
Tachycardia: common, but non-specific
Apnoea (40%)
Apparent change in mental status/lethargy
Jaundice (35%)
Seizures (35%): if cause of sepsis is meningitis
Poor/reduced feeding (30%)
Abdominal distention (20%)
Vomiting (25%)
Temperature: not usually a reliable sign as the temperature can vary from being raised, lowered or normal
Term infants are more likely to be febrile
Pre-term infants are more likely to be hypothermic
The clinical presentation can vary from very subtle signs of illness to clear septic shock
Frequently, the symptoms will be related to the source of infection (e.g. pneumonia + respiratory symptoms, meningitis + neurological symptoms)
Investigations into neonatal sepsis
Blood culture
Full blood examination
CRP
Blood gas
Urine microscopy, culture and sensitivity
Lumbar puncture
Treatment for neonatal sepsis NICE
IV benzylpenicillin with gentamycin as first line regimen
Main complication of GI anaemia
Haemolytic uraemic syndrome
What is managemnet of hypospadias
Surgical correction using foreskin remnant after 6 months - normally around 12 months - avoid circumcision
What do and what can pulsatile sound in ear be
MRA - MRI of inner ear
acoustic neuroma inner ear cnacer
What is hypospadias characterised by
Ventral urethral meatus
Hooded prepuce
Chordee - ventral curvature of penis - more severe
Urethral meatus proximal opening if more severe
ass conditions - cryptorchidism, inguinal hernia
What is the most common side effect first 6 months IUS
Irregular bleeding
What are the features of acute fatty liver of pregnancy
jaundice, mild pyrexia, hepatitic LFTs, raised WBC, coagulopathy and steatosis on imaging
predominantly non-specific symptoms (e.g. malaise, fatigue, nausea
What can severe acute fatty liver disease cause
Pre-eclamspia
What resp rate should a child be referred to hopsital with bronchiolitis with
> 60
What bishop score indicates labour is progressing fine and no interventions are needed
> 8
What bishops score suggests interventions are needed
<5
How long should the first stage of labour last?
Up to 12 hours
What is a risk with oxytocin?
Oxytocin infusion carries the risk of uterine hyperstimulation
What is a membrane sweep and when is it offered?
Finger seperating chorionic membrane from the decidua
Offered from 40-41 weeks in nulliparous women
Indications for induction
prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start
maternal medical problems
diabetic mother > 38 weeks
pre-eclampsia
obstetric cholestasis
intrauterine fetal death
How is labour induced
PGE2 vaginal suppositry (dipinestrone)
Oral PGE1 - misoprostol
maternal oxytocin infusion
amniotomy (‘breaking of waters’)
cervical ripening balloon
NICE recommendations induction of labour
if the Bishop score is ≤ 6
vaginal prostaglandins or oral misoprostol
mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
if the Bishop score is > 6
amniotomy and an intravenous oxytocin infusion
What is uterine hyperstimulation
refers to prolonged and frequent uterine contractions - sometimes called tachysystole
Potential consequences of uterine hyperstimulation
potential consequences
intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia
uterine rupture (rare)
Manage by:
removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
consider tocolysis
What to do if a baby presents with jaundice in first 24 hours
Measure and record the serum bilirubin level urgently (within 2 hours) since this is likely to be pathological rather than physiological jaundice.
What should fundal height measure
The week of parity +/- 2cm
What is potters sequence
a rare fatal genetic disorder, characterised by severe oligohydramnios, resulting either from polycystic kidney or bilateral renal agenesis. This causes a specific appearance of the newborn, called Potter facies. The affected babies usually die within a few hours of birth or are stillbirths, and have wrinkly skin, low-set ears, flat noses and chins, and widely separated eyes with epicanthic folds.
Causes of polyhydraminos
Duodenal atresia
Foetal anaemia
Maternal diabetes
Trisomy 21
Causes of oligohydraminos
premature rupture of membranes
Potter sequence
(bilateral renal agenesis + pulmonary hypoplasia)
intrauterine growth restriction
post-term gestation
pre-eclampsia
What is oligohydraminos
500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.
What is worrying in development?
Referral points
doesn’t smile at 10 weeks
cannot sit unsupported at 12 months
cannot walk at 18 months
Fine motor skill problems
hand preference before 12 months is abnormal and may indicate cerebral palsy
Gross motor problems
most common causes of problems: variant of normal, cerebral palsy and neuromuscular disorders (e.g. Duchenne muscular dystrophy)
Speech and language problems
always check hearing
other causes include environmental deprivation and general development delay
What are half of cord prolapses caused by?
Artificial rupture of membranes
Features of foetal varicella zoster syndrome
skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
When can you give oral aciclovir to a woman ant presenting with chickenpox?
> 20 weeks
Presents within 24 hours of rash
If under 20 weeks should use with caution
Why sometimes need to use PPI with SSRIs
Risk of GI bleeding
What head circumference presents with fragile X
larger than normal
Causes of microcephaly
normal variation e.g. small child with small head
familial e.g. parents with small head
congenital infection
perinatal brain injury e.g. hypoxic ischaemic encephalopathy
fetal alcohol syndrome
syndromes: Patau
craniosynostosis
When is bone marrow biopsy required for ITP?
When abnormal features eg splenomegaly, bone pain, and diffuse lymphadenopathy,
Physiological features of anorexia nervosa
Features
reduced body mass index
bradycardia
hypotension
enlarged salivary glands
Physiological abnormalities
hypokalaemia
low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3
Drugs to avoid in breastfeeding
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone
What is acute dystonia treated with
Procyclidine (anticholingergic)
Caused by first gen anitpsychotics
SSRIs in pregnancy
BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
Use during the first trimester gives a small increased risk of congenital heart defects
Use during the third trimester can result in persistent pulmonary hypertension of the newborn
Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
How logn does it take for steroids to be effective in neonate when given to mother for lungs
1-2 dyas
When admit w bronchiolitis
Apnoea (observed or reported)
Persistent oxygen saturation of <92% in air
Inadequate oral fluid intake (<50% of normal fluid intake)
Persisting severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
Whencan do ECV for transverse lie
when sac not rupturef
What is used to reduce risk of blood loss in hystercetomy
GnRH - reduce size of uterus and fibroid - risk of bleeding is related to uterus size
What test is done in schools hearing
Pure tone audiometry
First line for endometrail cancer
Transvaginal US
How long before negative pregnancy test after abortion?
4 weeks
If positive before then reassure and repeat at 4 weeks
What is used to screen newborns hearing
Otoacoustic emission test
What to give IV to women with sev hyperemsis gravidarum
IV saline with potassium chloride
Why is IV saline and dextrose contraindicated in hypermesis gravidarum
Women with hyperemesis gravidarum are at risk of hypokalemia and wernickes encephalopathy
Therefore only give dextrose if K is normal (otherwise cause hypo as K absorbed into cells) and thiamine supplements
Triad of vasa previa
rupture of membranes followed by painless vaginal bleeding and fetal bradycardia.
What do NICE recommend for severe pre-eclampsia/eclampsia after 37 weeks gestation?
Delivery within 24-48 hours, therefore give IV magnesium sulphate if within 24 hours or concerned women has eclampsia
Symptoms of ovarian hyperstimulation syndrome
shortness of breath, fever, oliguria, and peripheral oedema.
What is a side effect of ovarian induction
Ovarian hyperstimulation syndorme
What women should take high dose folic acid in pregnancy
Epilepsy (antiepileptics_)
Diabetes
Obesity
Parents have a neural tube defect
FH neural tube defects
Prev preg with neural tube degect
you take anti-retroviral medicine for HIV
SSRI discontinuation syndrome symptoms
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia
What cardiac problems can citalopram cause?
QT prolongation and torsades de pointes
Can you continue breastfeeding on flucloxacillin
YES
Why do FBC if taking clozapine and present with tonsilitis?
Risk of agranulocytosis/neutropenia with clozapine, need to check neutropenia isnt causing infection with any infection present with
What decelerations on CTG are non reassuring/abnormal
Variable decelerations occurring with over 50% of contractions may be non-reassuring or abnormal depending on their response to conservative treatment.
ABNORMAL - single prolonged deceleration over 3 minutes
4 features on CTG
foetla HR
variability
Decelerations
Accelerations
Abnormal decelerations on CTG
either non-reassuring variable decelerations still observed 30 minutes after starting conservative measures with >50% of contractions or late decelerations not improving with conservative measures, present for over 30 minutes and occurring with >50% of contractions or a bradycardia or single prolonged deceleration for more than 3 minutes.
Non reassuring accelerations on ECG
either variable decelerations of ≤60 bpm and taking ≤60 seconds to recover, present for >90 minutes and occurring with >50% of contractions or variable decelerations of ≥60 bpm or taking ≥60 seconds to recover, present for up to 30 minutes and occurring with >50% of contractions or late decelerations present for up to 30 minutes and occurring with >50% of contractions.
Reassuring foetal variability CTG
over 5 BPM
Non reassuring variability CTG
<5 or >25 for 30-90 mins
Non reassuring
<5 or >25 for >25 minutes
Non reassuring foetal HR on CTH
161-180 BPM
Abnormal HR on CTG
<100 or >180
How often monitor blood sugar in pregnancy if diabetes
fast, pre meal, 1 hr post meal and bed time
Most important risk of oestrogen only HRT
Endometrial cancer - for women with a womb!!!
What painkillers should be avoided with SSRIs?
Triptans
Earliest that ECV can be offered
36 weeks
When should insulin be started immediately in pregnancy with GDM
If fasting plasma glucose is over 7
When should insulin be started immediately in pregnancy with GDM
If fasting plasma glucose is over 7
Why is lithium not first line in mania
1-2 week onset of action - longer acting
first line is risperidone/Haloperidol/ Olanzapine/Quetiapine
Why monitor BMs closely and adjust insulin accordingly if giving steroids in pregnancy
Steroids can cause hyperglycaemia
sIGNS OF dehydration on bloods
Low serum urea
Raised haematocrit
Ketonuria
Examination findings
Electrolyte imbalances in hyperemesis gravidarum
Hypokalemia
Hyponatremia
Metabolic alkalosis
What score measures HG severity
PUQE
First line antiemetics
Cyclizine
Prochlorperazine
Prometha\inw
Chlorproma\ine
Second mline antiemttics hyperemesis
Metoclopramide
Domperidone
Ondanestron
Third line antiemetics hyperemsis
Corticosteroids
What is the most importnat treatabel cause of miscarriage
Antiphospholipid syndrome (AI disease stopping placental function)
Treatment for antiphospholipid syndrime causing miscarriage
Heparin
How does antiphospholipid syndrome cause miscarriage and pregnancy problems
Inhibitis trophoblastic function and didfferentiation
Acitvation of complement pathways at maternal foetal interface -> local inflam response, VTE
How determine viability of pregnancy
Measure crown rump length
<7 and no HB = rescan in 7 days
>7 and no HB - second opinion, scan in at least 7 days
Measure gestational sac if foetal pole not visible
<25mm - at least 7 days later rescan
>25mm = second opinion, rescan at least 7 dyas later
