Volume 18 Issue 1 - Jan 2016 Flashcards
A 35-year-old primigravida with no significant past medical history presents at 30 weeks of gestation with a sudden onset of epigastric pain that is radiating to the back. Prior to this she had been seen repeatedly with right hypochondrial pain. Her BP at the last antenatal clinic visit was normal. She is apyrexial, but tachycardic (pulse 110 bpm) and hypotensive (BP = 80/50 mmHg).
What it the most likely diagnosis?
Abruptio placenta Hepatic rupture Perforated duodenal ulcer Rupture of aortic aneurysm Splenic rupture
Hepatic rupture
The answer is hepatic rupture. Hepatic masses can cause local compressive symptoms or complications on adjacent viscera, capsular stretch from progressive growth or may bleed into the hepatic tissue causing local haematoma. This may be mistaken for dyspepsia, biliary disease, appendicitis, constipation, muscular pain or referred pain from pneumonia. Very rarely, a hepatic lesion can rupture into the peritoneal cavity leading to a risk of exsanguination with fetal hypoxia, potentially leading to fetal and/or maternal death. The possibility of hepatic bleeding should be considered in any patient with severe epigastric pain radiating to the back with signs of hypovolaemic shock as in this patient.
A 40-year-old woman who presented with a recurring upper abdominal pain at 24 weeks of gestation was extensively investigated and after ultrasound scan was found to have a tumour in the liver.
What is the most common benign hepatic tumour in pregnancy?
Focal nodular hyperplasia Haemangioma Hepatic adenomas Hepatic aneurysm Hepatic cell carcinoma
Haemangioma
The answer is haemangioma. Hepatic haemangiomas are the commonest benign tumours of the liver and are present in 2–20% of healthy individuals. They are more common in middle-aged women although it is uncertain if estrogen has a pathophysiological role.
A 30-year-old who is on etanercept (an anti-TNF agent) for severe arthritis has just delivered by an emergency caesarean section.
What would be the advice on continuation of her arthritis medication?
Delay recommencing for two days (48 hours)
Delay recommencing for seven days (1 week)
Delay recommencing for 28 days (4 weeks)
Delay recommencing until after lactation
Recommence as soon as possible
Delay recommencing for seven days (1 week)
The answer is delay recommencing for seven days (1 week). Women on etanercept can resume their medication almost immediately after delivery. If they have a wound from a caesarean section, an episiotomy or a perineal tear, this should be delayed for a few days until the wound has healed to minimise the risk of wound infection. In most cases, this would be around 5–7 days.
A 30-year-old who suffers from systemic lupus erythematosus (SLE), and is currently on the biologic agent belimumab (a monoclonal antibody that inhibits B-cell activating factor), attends for prepregnancy counselling as she wishes to start trying for a baby. She is currently taking 5 mg folic acid daily.
What advice should she be given about her SLE medication?
Continue medication through to pregnancy and thereafter or switch to an alternative after discussion with Rheumatologist
Continue medication until 28 weeks of gestation then stop and recommence soon after delivery
Discontinue medication as soon as she is pregnant
Discontinue medication for at least 12 weeks before trying
Discontinue medication with a positive pregnancy test and recommence after the first trimester
Continue medication through to pregnancy and thereafter or switch to an alternative after discussion with Rheumatologist
The answer is continue medication through to pregnancy and thereafter or switch to an alternative after discussion with Rheumatologist. There is no evidence that biologic agents are teratogenic. Cessation in anticipation of pregnancy is therefore inadvisable due to the long lag time to conception, leading to the risk of flares just before pregnancy. Such flares tend to be harmful to both the mother and the fetus, leading to placental insufficiency complications such as miscarriages, preterm birth, fetal growth restriction and pre-eclampsia. Women on biologic agents are at a greater risk of infections. Offspring exposed to belimumab have normal growth and neurodevelopment. These are no contraindications in breastfeeding.
A 25-year-old presents with lower abdominal pain of 12 months duration. The pain is worse around her menses, which are also heavy. Sexual intercourse is painful. She has altered bowel habits especially around menstruation. You suspect that she may have either irritable bowel syndrome or endometriosis or both.
What approach will you take to differentiate between the two conditions?
Assessment of visceral hypersensitivity Bowel endoscopy Diagnostic laparoscopy Three months on the combined oral contraceptive pill Ultrasound of the pelvis (transvaginal
Three months on the combined oral contraceptive pill
The answer is three months of the combined oral contraceptive pill. Approximately 40% of women with endometriosis also have irritable bowel syndrome (IBS). Patients with IBS and endometriosis both have visceral hypersensitivity and endoscopy of the gastrointestinal tract has not been found to be useful in diagnosing IBS but beneficial in excluding bowel pathology that may be a differential. Although a diagnostic laparoscopy will identify most cases of endometriosis, a negative laparoscopy does not exclude the diagnosis. A therapeutic trial of ovarian suppression with the combined oral contraceptive pill or a GnRH agonist is therefore the most useful test to distinguish endometriosis from IBS.
A 30-year-old presents to the clinic with lower abdominal pain, altered bowel habits, dyspareunia and dysmenorrhoea. Clinical examination fails to identify any signs of pathology. You suspect irritable bowel syndrome.
What first treatment will you recommend?
Dietary advice and anticholinergics Dietary advice and weight loss Progabalin Serotonin receptor antagonist (e.g. ondansetron) Tricyclic anti-depressants
Dietary advice and anticholinergics
The answer is dietary advice and anticholinergics. When irritable bowel syndrome (IBS) is a suspected diagnosis, anticholinergics such as smooth muscle relaxants are the traditional first line pharmacological approaches to controlling abdominal pain although they have little effect on bowel dysfunction; therefore in addition, laxatives and anti-diarrhoeals have to be used as appropriate. Initially advise changes in dietary habits with avoidance of specific types of food such as insoluble fibre, beans, fatty food, caffeine, chocolate, sugar substitutes and alcohol, which can all trigger pain in some patients with IBS.
A 30-year-old woman whose periods have become increasingly heavy over the last 6–9 months was examined and found to have an enlarged irregular uterus. Uterine fibroids were suspected and an ultrasound of the pelvis requested. This has confirmed the presence of multiple intramural fibroids, the largest of which measures 6 x 7 cm. She is not keen to have surgery and wishes to discuss medical treatment.
What should she be told about treatment with a GnRH agonist and the size of her fibroids six months after completion of treatment?
There will be a significant reduction in size, which will be maintained for 6–12 months following treatment
There will be a significant reduction in size but within 4–6 months of treatment, the fibroids will most likely return to pretreatment sizes
There will be a significant reduction in size that will be maintained for 6 months only, after which there will be a gradual return to pretreatment sizes by 12–18 months
There will be a significant reduction in size but within 3 months of stopping treatment, the fibroids will return to their pretreatment sizes
There will a reduction in size of more than 50% and by 4–6 months of stopping treatment, the fibroids would have returned to half their pretreatment sizes
The answer is there will be a significant reduction in size but within 4–6 months of treatment, the fibroids will most likely return to pretreatment sizes. GnRH agonist treatment of uterine fibroids induces a menopausal state with low estrogen levels. Treatment for 6 months has been shown to result in a significant reduction in the size of fibroids although this is associated with menopausal side effects especially if Addback therapy is not included in the treatment. After discontinuing treatment, the fibroids return to pretreatment levels within 4–6 months and menstruation tends to return within 4–8 weeks
You have discussed medical treatment of symptomatic uterine fibroids with a 32-year-old nulligravida who plans to start trying for a baby in 2–3 years’ time. She has opted for the selective progesterone receptor modulator (SPRM) ulipristal acetate.
What is the main mechanism of action of this SPRM?
It acts by inhibiting angiogenesis within the fibroids
It binds to progesterone receptors and inhibits the action of estrogens mainly
It induces apoptosis of uterine fibroid cells and inhibits proliferation
It is an anti-estrogen
It reduces blood flow to the fibroids and thereby reduce their size
It induces apoptosis of uterine fibroid cells and inhibits proliferation
The answer is it induces apoptosis of uterine fibroid cells and inhibits proliferation. Ulipristal acetate causes a reduction in the size of fibroids by inducing apoptosis in fibroid cells and inhibiting proliferation of cells. It has been shown to reduce menstrual loss in over 90% of patients after 13 weeks of treatment with either 5 or 10 mg daily. Following the initiation of treatment, amenorrhoea is achieved within 10 days in three-quarters of patients. The median change in fibroid volume is approximately 40–50% after 13 weeks of treatment and this reduction, unlike that following GnRH agonist treatment, is maintained for at least 6 months after discontinuation.
A 34-year-old presents with uterine prolapse. She has had one normal vaginal delivery and wishes to have more children. Following counselling she is offered ’Oxford hysteropexy’.
What advice should she be given about pregnancy after the procedure?
It encircles the cervix and will be removed prior to a vaginal delivery
It is associated with an increased risk of miscarriage
Pregnancy rates are much lower after the procedure
There is associated compromise of uterine circulation resulting in fetal growth restriction
Vaginal birth is not possible after the procedure
Vaginal birth is not possible after the procedure
The answer is vaginal birth is not possible after the procedure. The Oxford hysteropexy is a uterine preserving surgical procedure to correct uterine prolapse in women who wish to retain their fertility (as in this patient). The procedure involves inserting a mesh which encircles the cervix and vaginal birth is therefore not possible. The mesh has been described as acting as a cervical cerclage. Concerns raised about compromised uterine blood flow are theoretical as there is often collateral circulation.
A 70–year-old, frail and diabetic obese woman presents with troublesome procidentia. She is not sexually active and has been assessed as unfit to withstand prolonged surgery. A colpocleisis is therefore offered as the treatment of choice.
What is the main disadvantage of this procedure?
A high rate of recurrence
Less patient satisfaction than with corrective surgery
Loss of access to the cervix and uterus
Loss of sexual function
The need to have drainage channels for the passage of vaginal and cervical secretions
Loss of access to the cervix and uterus
The answer is loss of access to the cervix and uterus. The women who are suitable for obliterative procedures are those who are sexually inactive, elderly and in particular those with co-morbidities that may render them unsuitable for longer operating times and more invasive procedures associated with reconstructive surgery. Sexual inactivity both at present and in the future is a criterion for the procedure and cannot therefore be a disadvantage. The main disadvantage is lack of access to the cervix and uterus. Satisfaction rates that have been reported have been approximately 90–95%, which are much better than those of reconstructive surgery.
