Week 1 and 2--lecture slides Flashcards
1
Q
what is type I diabetes
A
autoimmune disease leading to pancreatic islet cell destruction
ABSOLUTE insulin deficiency
*these patients always need insulin even if they are not eating
2
Q
what is type II diabetes
A
insulin resistance and relative insulin deficiency
may have worsening insulin deficiency over time
may be diet controlled, on oral agents, on insulin, or a combination
3
Q
who should be on insulin
A
all patient with DM1
those who DM2 who:
- are on max oral agents and the A1c is still above 7%
- have a new diagnosis and A1c is above 10%
- have metabolic decompensation (i.e weight loss, polyuria, HHS)
- renal or liver failure
- pre-pregnancy or during pregnancy
4
Q
name the rapid acting insulins
A
Lispo
Aspart
glulisine
(a couple hours)
5
Q
name the short acting insulins
A
human regular
around 6-7 hours
6
Q
name the intermediate acting insulins
A
NPH
18-20 hours
7
Q
name the long acting insulins
A
detemir
glargine
(about 24 hours)
8
Q
when do you use rapid acting insulins
A
for bolus insulin–> for glucose elevations related to meals/carb intake or to correct high BG
9
Q
when do you use short acting insulins
A
bolus insulin or insulin infusions
10
Q
when do you use intermediate insulins
A
basal insulin–> for glucose elevations related to hepatic glucose production in the fasting state
peak can cover lunch
11
Q
when do you use long acting insulins
A
basal insulin
12
Q
if you are using an insulin mix (in one pen) when do you give it
A
before breakfast and before dinner
13
Q
what kind of insulin of insulin pumps use
A
rapid acting
given as continuous infusion through a SQ catheter which acts as basal insulin
boluses are given through the same catheter for meals and corrections
14
Q
how do you decide on an insulin dose
A
can use weight based approach–> 0.5 units / kg for Total Daily Dose
15
Q
how do you split total daily dose of insulin between bolus and basal
A
50/50
for the bolus 50%, divide that by 3 to get the bolus dose for each meal
16
Q
for mixed insulin, how do you divide dosing
A
2/3 of total daily dose with breakfast, 1/3 with dinner
17
Q
if your patient is going to be counting carbs to get a personalized insulin dose, what is a good insulin:carb ratio to start with (for insulin sensitive patient)
A
1:20
1 unit of insulin for every 20 g of carbs
18
Q
how do you calculate the insulin sensitivity factor
A
100/TDD
i.e if TDD is 50, ISF = 2–> every 1 unit of insulin lowers glucose by 2 mmol/L
if BG is high, calculate current BG-ideal BG. Then divide that number by ISF
i.e
BG 12, goal is 6.
12-6=6
6/2 (ISF from above) = 3 units to give to correct
19
Q
is a sliding scale enough on its own
A
no–corrects hyperglycemia after the fact but does not prevent it
20
Q
what are BG and A1c targets for the outpatient
A
pre prandial glucose 4-7
2h after meal 5-10
A1c less than 7%
21
Q
what are the BG targets for the critically ill
A
8-10
allow higher
22
Q
how do you manage hypoglycemia acutely (patient is conscious)
A
ingest 15g CHO
retest in 15 min–> retreat is BG still below 4
23
Q
how do you treat BG acutely (patient is unconscious)
A
glucagon 1 mg IM if no IV
D50W 10-25 g IV over 1-3 minutes
24
Q
define delirium
A
disturbance in consciousness, reduced ability to focus, or to sustain or shift attention
change in cognition such as memory, disorientation, speech or the development of perceptual disturbance
disturbance develops over hours to days and FLUCTUATES in severity
result of a GENERAL MEDICAL CONDITION
25
how does delirium compare to dementia with regard to:
| onset
delirium--acute or subacute
dementia--insidious
26
how does delirium compare to dementia with regard to:
| course
delirium--fluctuating
dementia--progressive
27
how does delirium compare to dementia with regard to:
| conscious level
delirium--impaired, fluctuating
dementia--clear initially
28
how does delirium compare to dementia with regard to:
| cognitive defects
delirium--poor attention, poor short term memory
dementia--attention PRESERVED, also poor short term memory
29
how does delirium compare to dementia with regard to:
| hallucinations
delirium--common (usually visual)
dementia--often absent
30
how does delirium compare to dementia with regard to:
| delusions
delirium--fleeting, non systematized
dementia--often absent
31
how does delirium compare to dementia with regard to:
| psychomotor
delirium--increased or reduced
dementia--can be normal
32
what % of hospitalized and community populations over age 65 experience superimposed dementia
22-89%
33
what % of terminally ill patients experience delirium
80%
34
wha % of medically ill hospitalized patients under 65 experience delirium
10-30%
35
wha % of medically ill hospitalized patients over 65 exprience delirium
10-40%
36
list the common causes/etiologies of delirium
DIMS FU
drugs--intox or withdrawal
Infections--chest, GU, SSTI
Metabolic--endocrinipathy (NA, Ca, K, diabetes, thyroid), renal failure, liver failure
Structural--stroke, hemorrhage, seizure, neopllasm
Fecal impaction
Urinary retention
37
how do you diagnose delirium
1. confusion assessment method
2. MMSE
3. psych consult
38
what is the gold standard for diagnosing delirium
psych consult
39
how does a confusion assessment method assess delirium
two part screening instrument for both cognitive impairment and delirium
delirium screen is positive when:
- acute onset, fluctuating course..AND..
- inattention..AND..
- disorganized thinking..AND..
- altered LOC
*an acceptable screening instrument but dx should be ensured according to the formal criteria for delirium
40
what are the cutoff scores for the MMSE
27 or above is normal
less than 24 is abnormal
*does NOT clearly distinguish delirium from dementia
41
is delirium always reversible
not always
| *up to 82% of people have residual deficits 6 m post discharge
42
how do you prevent delirium
multiple components
orientation--cognitive exercises, clues
mobilize early
minimize psychoactive drugs
prevent sleep deprivation
use eyeglasses and hearing aides
intervene with volume depletion early
43
how do you manage delirium
ID and treat reversible causes
supportive care--> protect airway, maintain hydration and nutrition, prevent pressure ulcers, avoid physical restraints
44
list non pharma methods of managing delirium
create calm, comfy enviro
use orienting influences
regular reorienting communication with staff
involve family members in supportive care
limit room and staff changes
coordinate schedule to allow uninterrupted sleep at night
encourage normal sleep-wake cycles
close clinical f/u
45
list pharma approached to delirium
consider if delirium sx put patient or others at risk or interrupt essential therapy
can use haldol or loxapine
46
how do clinical ethics differ from medical ethics
clinical--case based, based on patient in front of you
medical ethics--issue based (i.e abortion, euthanasia)
47
what is one way of addressing a clinical ethical issue
ID the conflict
name the principles involved
and then FORMULATE A QUESTION that addresses the scenario (i.e is it clinically permissible to...)
decide which principle should have priority in this particular case (and recognize that different priorities) OR find an alternative that avoids the dilemma
could there be more info that would help resolve the dilemma? (i.e prognosis etc)
evaluate your decision--is this what a consensus of exemplary doctors would do?
48
what are the top 4 principles of medical ethics
1. autonomy
2. beneficence
3. non-maleficence
4. justice
49
medical ethics: define autonomy
the respect for patients wishes, and the ability of a capable individual to make an informed decision about accepting or refusing a treatment
50
medical ethics: define non-maleficence
first, do no harm (primum no nocere)
51
medical ethics: define justice
equal distribution of resources
52
medical ethics: beneficence
doing what is in the best interest of your patient
53
what to clinical practice guidelines do?
clarify areas of management uncertainty
standardized medical care
raises the quality of care
achieve maximum benefit for each dollar spent
pass your exams! great for studying!
*peer reviewed, peer developed and help counter effects of marketing
54
in what ways are BC guidelines tailored to BC practice
MSP
condition-based incentive fees
rural and remote availability of tests, treatment and consults --> reflects the reality of BC practice
55
target audience for BC guidelines
BC physicians, NPs, residents, med students
56
how may guidelines are there currently
58
57
what are the 5 criteria for the development of BC guidelines
1. address areas of care that are COMMON
2. address areas of significant health system cost, whether financial or social
3. focus on areas where there IS evidence
4. areas where there may be variation or confusion in practice
5. areas where there can be objective measurement of the effectiveness of the guideline
58
in what ways are guidelines used in clinical practice
1. flow sheets for chronic disease care
2. lab requisitions
3. patient guides
4. algorithms
59
name one area where the BC guidelines differ from the international and canadian guidelines
osteoporosis-
de-emphasized bone scans for everyone --> increased clinical assessment of risk before the ordering of scans
60
what are some of the things that the upcoming BC guidelines for opioid use disorder indicate? (designed for rural and remote physicians)
focused on suboxone as a first line therapy which can be prescribed without a methadone exemption
61
name the pairs of size/shape in dermatology
macule--patch
papule--plaque
nodule--tumour (cyst)
vesicle--bullae (pustule)
62
name the 3 mild topical steroids and what they are used for
for sensitive areas or mild disease
1. hydrocortisone 0.5-2.5%
2. desonide 0.05%
3. flucinolone acetonide 0.01%
63
name the 3 medium potency topical steroids and what they are used for
for most parts of the body and extremities
1. betamethasone valerate 0.05-0.1%
2. mometasone furoate 0.1%
3. beclomethasone diproprionate 0.025%
64
name three strong potency topical steroids
betamethasone diproprionate 0.05%
clobetasol proprionate 0.05%
halobetasol proprionate 0.05%
65
list 4 signs of a life threatening drug eruption
1. oropharyngeal erosions
2. blister formation
3. skin pain
4. facial swelling
66
name 7 types of drug eruptions/reactions
1. exanthematous ("maculopapular/measles like")
2. urticarial/angioedema
3. vasculitis
3. serum sickness/serum sickness-like
4. drug induced lupus
5. pigmentation
6. pseudolymphoma
7. photosensitivity
a bunch of others
67
what is TEN/SJS
rare, life threatening drug induced skin reaction
consists of mucocutaneous involvement with associated skin tenderness, redness and exfoliation
*MUST HAVE MUCOMEMBRANE INVOLVEMENT (check vaginal pain, urination pain)
68
what is the difference between SJS and TEN
SJS is less than 10% of the body's surface is involved whereas TEN is over 30% involvement
69
what are common culprits causing TEN/SJS
sulfonamides
anticonvulsants
allopurinol (especially in Asians)
NSAIDs
70
how do you manage TEN/SJS
1. ID offending drug
2. stop offending drug
3. specialized supportive care--with SPECIALIZED NURSING (i.e burn unit or ICU care)
4. consult derm, IM/ICU/burns
5. can consult others if needed given presentation
6. maintain fluid/electrolyte/ protein balacne
7. maintain thermoregulation
8. prevent sepsis
9. minimize tapes
10. meds are controversial--most are offered cyclosporine as first line
71
in terms of timeline, how can you ID the drug that may be causing a TEN/SJS reaction
started 7-21 days prior to reaction--> NEVER shorter than this, takes at least 7 days to appear
72
should you debride SJS affected skin?
NO
but nursing should be aware of what to do if and when it sloughs off by itself
73
what med is often offered first line in SJS/TEN
cyclosporine
74
what is DHS/DRESS
another possibly life threatening drug eruption
measles-like--> due to altered drug metabolism which leads to build up of toxic metabolites
75
how do you manage DHS/DRESS
ID and stop offending drug
corticosteroids may need to be considered depending on specific organ involvement-> order end organ function tests--> LIVER, KIDNEY
check TSH after 3-4 months
76
in terms of timeline, how can you ID the drug that may be causing a DHS/DRESS reaction
usually started 2-6 weeks before reaction develops
77
what is the natural course of DHS/DRESS
may have multiple relapses before eventually settling but typically do very well overall and eventually recover
may have delayed thyroiditis (check TSH 3-4 months)
78
what is bullous pemphigoid
most common AUTOIMMUNE subepidermal BLISTERING disorder
usually affects older adults
can start as a generalized itchy eruption, may be non specific itch for months with occasional urticarial plaques and blistering
79
how do you diagnose bullous pemphigoid
high index of suspicion in pruritic elderly patients
usually tense bullae, if blisters are already present
take a skin biopsy to check for immune factors
80
how do you manage bullous pemphigoid
super potent topical corticosteroid or immunomodulator
if systemic required--> tetracycline abx with or without nicotinamide
*if need rapid control use systemic steroids
81
name steroid sparing treatments for bullous pemphigoid
azathioprine
methotrexate
mycophenolate
82
what is the natural course of bullous pemphigoid
most patients eventually go into remission--morbidity depends on when the diagnosis is made and if systemic therapy is used
mortality can relate to both coexisting medical disorders and treatment choices--can also get secondary infections
83
what is atopic dermatitis
inherited EPIDERMAL barrier defect with bacteria occasionally acting as a super-antigen
a chronic, recurrent, inflammatory disorder of the skin --> dont really have a cure, just management
84
when should you think possible atopic dermatitis
if you see a vesicular rash--> likely acute eczema
chronic-- ill defined erythema with scale
85
what is the atopic triad
atopic dermatitis
allergic rhinitis
asthma
86
what is the pathophysiology of atopic dermatitis
defective epidermal layr
FILAGGRIN defect--> missing ceramids
"leaky" skin barrier leads to increase in trans epidermal water loss
*subclinical skin inslammation--> normal appearing skin is still abnormal on histologic examination with T cell mediated changes
87
what can patients do to manage atopic dermatitis
no role for diet--> but can try a dairy log to see if foods are associated with flares if they are really bothered by it
minimize irritants like clothing
can try silver impregnated clothing
skin care with soaps, cleansers, not too hot water
88
how can the physician treat atopic dermatitis
1. topicals--> corticosteroids (1% hydrocortisone for the face)
2. topical calcineurin inhibitors
3. phototherapy
4. systemics--> azathioprine, cyclosporine, methotrexate, mycophenolate, dupilumab (anti IL4 alpha receptor antagonist)
89
what med should you avoid in atopic dermatitis
systemic corticosteroids
90
list examples of secondary skin changes
```
crust
scale
lichenification
erosion
ulceration
excoriation
```
91
when should you refer to derm
vesicular and bullous lesions get their attention
skin pain or if patient looks ill--> red flags
treatment failing
it urgent, call derm
92
what should you include in derm referrals
description--as much primary morphology as possible
what has been tried and for how long
past medical hx, other meds, allergies, bleeding risk, infectious risk
93
what type of topical works best
ointment
94
how much of a cream covers the entire body of an adult male once
20-30 g
95
what is psoriasis
chronic, inflammatory skin disorder with a strong genetic basis
1-2% of general pop, all races, bimodal age distribution
96
what are the classic psoriatic lesions
well demarcated geographic erythematous plaques with overlying scale
look for nail changes
97
what are some other disease associated with psoriasis
IBD
psoriatic arthritis
98
what is the ddx of red, well circumscribed lesions with overlying scale
tinea corporis
pytiriasis rosea
nummular ezcema
lichen planus
lupus
secondary syphillis
neoplastic (cutaneous T cell lymphoma)
99
where is psoriasis usually distributed
```
scalp
knees
hands
palms
feet
lumbosacral
```
100
non pharmacologic treatment of psoriasis
PHOTOTHERAPY
minimize triggers (stress, trauma, lack of sun, infections)
moisturizers, emollients
weight loss and diet
alcohol consumption
counselling
101
pharmacologic treatments for psoriasis
topicals--> corticosteroids, vitamin D analogues, calcineurin inhibitors, vit A analogues, coal tar, anthralin
systemic--> acitretin, methotrexate, cyclosporin, apremilast, biologicals (etanercept, infliximab)
102
what is urticaria
chronic, spontaneous urticaria is defined by spontaneous eruption of wheals, angioedema or both for greater than or equal to 6 weeks
103
how do you dx spontaneous urticaria
history--> transient (less than 24 hours), erythematous, pruritic plaques with central pallor
can have both acute lasting less than 6 weeks, and chronic, lasting more than 6 weeks.
104
major causes of acute urticaria
drugs
food
infectious (URTIs)
no good explanation
105
major causes of chronic urticaria
no good explanation or inducible (reaction to vibration, exposure to cold, aquagenic, dermatographism)
106
are labs helpful in dx of urticaria
not really
107
when should you refer patient with urticaria
individual lesions are lasting more than 24 hours or leave discolorations --> bruise-like is urticaria vasculitis, may indicate underlying lupus disorder
suspect drug or food cause
if associated arthritis or arthralgia
fevers
not responding to tx
108
treatment for urticaria
first line--> ANTIHISTAMINES
omalizumab
cyslosporine
monelukast
methotrexate
caution systemic corticosteroids in urticaria
109
what is dermatophytosis
fungi in skin
3 genera of fungi--> trichophyton, epidermophyton, microsporum
110
treatment of tinea corporis
terbinafine 1% daily for 14 days or terbinafine 250 mg po daily for 28 days
111
appearance of tinea corporis
plaques with central sparing with scale
112
how are the dermatophytoses names
by location:
```
capitis
faceie
corporis
cruris
pedis
ungium
incognito
```
113
management of dermatophytosis
1. confirm presence of dermatophyte before tx
2. keep area clean and dry
3. look for potential sources
4. topical antifungals
5. systemic antifungals (rarely needed)
114
what should you avoid in the treatment of dermatophytes
corticosteroids
lotriderm
kenacomb
triacomb
viaderm KC
115
treatment for scabies
5% permethrin cream applied from the neck down covering entire body, then again in 7 days
116
can pregnant women use permethrin to treat scabies
yes
117
why do people with scabies get itchy
delayed type (2-6 weeks later) hypersensitivity reaction
can control with corticosteroid cream after treatment
118
what should you use to treat a 15 year old with scattered comedones
0.01% tretinoin cream applied to entire affected area at bedtime
119
what should you use for 25 year old male with inflamed papules, scattered comedones but no scars
minocycline 100 mg x 6 weeks + 0.01% tretinoin cream to face at night
120
what to look for when assessing melanoma
ABCDE
```
asymmetry
border
color
diamete
evolution/enlargement
```
*look for the ugly duckling that is different from the rest of the moles
121
risk factors for melanoma
personal history of melanoma
family history of melanoma or atypical nevi or pancreatic cancer
increased number of typical or atypical nevi
blistering sunburns
tanning bed use
fair skin
blue or green eyes
red or blond hair
122
what is the most important prognostic factor for melanoma
bresslow's depth
123
which radiographic tests have NO radiation
U/S
| MRI
124
which radiographic tests have very very little radiation
CXR, rand xray
125
which radiographic tests have middle amount of radiation
pelvis xray
mammography
abdo CT
nuclear med bone scan
126
which radiographic tests have moderate to high radiation
abdo CT without and with contrast
whole body PET
127
which radiographic tests have the highest radiation
CTA chest, abdo, pelvis with contrast
transjugular intrahepatic portosystemic shunt placement
128
is xray one of the recommended imaging modalities for aortic dissection to rule out other etiologies?
yes--because you can get it quickly, as long as it wont cause delay in CT or MRI. wont necessarily dx aortic dissection but may ID other things causing the pain
129
what is the definitive test to dx aortic dissection
CT angio
130
what is the most appropriate radiographic test for PE?
CXR is good for quick screening study
CT angiogram is definitive study
(VQ scan still appropriate and well rated, depending on the circumstances, ie those with impaired renal function or allergy to IV contrast)
131
what if a patient with suspected PE is pregnant--what radiographic tests do you do
CXR + doppler U/S of legs
**may be an initial test prior to CTA that may prevent the need for ionizing radiation in the appropriate clinical setting
*if doppler was negative, may have to consider whether to do CTA or VQ--if positive, DVT tx is the same at PE so treating anyway
132
what are the most appropriate radiographic tests in the setting of trauma with a patient who is STABLE
CT abdo and pelvis with contrast
CT chest with contrast
133
what are the most appropriate radiographic tests in the setting of trauma with a patient who is UNSTABLE
CXR
Abdo XR
US FAST scan
* because they can be done faster usually
* will depend on location--> local pattern of practice at VGH etc is to do CT for both stable and unstable patients
134
most appropriate radiographic test for head trauma, GCS 8
non con CT head
135
when should you give contrast in head CTs
to look at/for:
vascular structures
tumours
sites of infection
136
common indications for head CT
1. cranial facial trauma
2. acute stroke
3. suspected subarachnoid or intracranial hemorrhage
4. evaluation of headache with any kind of sensory or motor function loss
5. evaluation of sensory or motor function loss
6. evaluation of sinuses
137
what 3 windows are commonly used in CT head
brain
bone
subdural
138
what should you think when you see a midline shift on CT head
mass effect
139
what are signs of acute infarct on head CT (less than 3 hours)
hyperdense MCA sign
loss of grey-white differentiation (because cells start to swell without blood supply) --> FIRST CT SIGN OF ACUTE INFARCT
**CT not best modality for acute infarct but in BC we depend mostly on CT
140
what is the best imaging method of acute brain infarct
MRI
141
what are the signs of chronic infarct on CT
retractment of parenchyma from skull due to atrophy
focal area of hypodensity indicates encephalomalacia
mild midline shift TOWARDS the lesion might occur due to atrophy
142
what vessels are implicated in subdural hematoma
tearing of bridging veins
143
in what context do you see subdural and epidural hematoma
TRAUMA only
epidural--> skull fractures
144
what does subdural hematoma look like on head CT
crescent shape along brain surface
CAN extend across suture lined
145
what vessels are implicated in epidural hematoma
rupture of middle meningeal artery
146
what does epidural hematoma look like on head CT
bi-convex, lenticular shape
does NOT cross suture lines
147
in what context does a subarachnoid hematoma occur
in trauma AND spontaneously (thunderclap headache from ruptured aneurysm)
148
what does subarachnoid hematoma look like on head CT
look for evidence of convexity in the sulci, blood in the ventricles and blood in the cisterns
radiologist must comment on where the blood is to help the neurosurgeon
149
complications from subarachnoid bleed
hydrocephalus--> blood blocks drainage of CSF
infarction--> constriction of blood vessels from mass effect
herniation--> from mass effect
150
when do you start folic acid supplementation in pregnancy and how much do you give
1 g standard
high dose (4-5 g) for those women with pre existing med conditions or who are on other meds
start 1-2 months before conception
151
what potential genetic problem might you anticipate in a chinese mom/dad
hemoglobinopathy
152
are most vaccines safe to give in pregnancy
yes
**except for live vaccines like rubella and varicella, which you should do before pregnancy
153
what needs to be addressed at the first prenatal visit
1. age at EDD--> for abnormality screening
2. ethnic origin-->this of genetic screening for conditions
3. past obstetric history
4. confirm dates (early dating U/S and date all pregnancies by first U/S)
5. general med history
6. specific questions--> STIs (ask about genital herpes specifically because of congenital infection), chicken pox (if unsure, order serology)
7. history of mental illness
8. pre pregnant BMI (height and weight)
9. general physical exam including BP!!! and swabs/cervix cytology
10. referral to prenatal genetic screening (i.e down syndrome)--check guidelines because they change a lot
11. standard pre natal lab work
154
what populations are at high risk for thalassemias (beta type)
mediterranean
| african
155
what populations are at high risk for thalassemias (alpha type)
chinese
156
who are the only people NOT at risk for hemoglobinopathies
japanese
koreans
caucasians of northern european ancestry
first nations
inuit
* means that most women should be screened with a hemoglobin electrophoresis because of mixed ancestry etc
* if moms is normal then can stop there--if hers is abnormal, screen dad --> if both carriers, refer to medical genetics
157
if mom has history of herpes, what should you do in pregnancy
start prophylactic acyclovir in third trimester to protect baby
158
what is the standard pre natal lab work
CBC
group and screen
antibody titres
Urine cx
serology rubella/varicella
HIV test
syphillis
hep B
159
what is the most important investigation done at every pre natal visit
BP
160
what is important about symphyseal-fundal height measurements?
the trend over time (not individual measurements) --ie if baby stops growing
161
in a pregnant woman (over 20 weeks), normal detailed U/S, presenting with pelvic pressure and a little bit of bleeding, what do you need to rule out
do speculum exam to rule out cervical insufficiency
*often these cases are misdiagnosed at UTIs based on abnormal urinalysis, but MOST pregnant women have abnormal UAs--> ALWAYS EXAMINE CERVIX
162
what should you do in the case of cervical insufficiency
rule out chorioamnionitis and progressive labour
discuss with patient the high risk of losing the pregnancy/ delivering right now
refer immediately to OBSGYN or MFM specialist for consideration of an emergency cerclage
163
what must you NOT do before doing the fetal fibronectin test
do NOT digitally examine the cervix--must have been nothing in the vagina for 24 hours prior to taking the fetal fibronectin sample
164
define pre termlabour
regular contractions with
1. cervix that is OPEN at 3 or more cm
- or-
2. progressive cervical changes
165
how useful is the fetal fibronectin test
negative fFN has a NPV above 95% for delivery within the next 7-14 days (PPV only at 30%)--so a negative fFN helps rule OUT labour (but not rule it in)
should be sent once you know the membranes arent ruptured and cervix is not dilated
166
what if a woman is in preterm labour--what do you do?
1. steroids to enhance fetal lung maturity --> this has really improved fetal survival in preterm labour
2. prophylactic antibiotic to prevent neonatal GBS infections (IV pen G)
3. tocolysis with nifedipine or indomethacin (only helps us to get the steroid benefit, that little bit of extra time... or time for transfer to higher level of care/ acceptable nursery)
167
woman at term pregnancy presents with a headache--most important thing to do?
BP--severe headache always worrisome for gestational hypertension and preeclampsia
*can present postpartum as well!!
168
definition of gestational HTN
dBP above 90 based on 2 measurements taken using the same arm more than 15 min apart
HTN that developed at 20 weeks or later
severe HTN is sBP above 160 or dBP about 110--> MEDICAL EMERGENCY patient is at risk of stroke!!
169
how to you dx. preeclampsia
NEW high BP and proteinuria or more than one other "bad thing"
-or-
if pre existing HTN existed, then it is resistant HTN, new or worsening proteinuria, or 1 or more other "bad things"
170
maternal signs/sx of preeclampsia
persistent or new/unusual headache
visual disturbance
persistent abdo or RUQ pain
severe nausea or vomiting
chest pain
dyspnea
peripheral edema
```
labs:
increased Cr (normally around 50 in pregnant women)
increased ALT, AST or LDH
low platelets
albumin under 20
```
171
fetal signs/sx of preeclampsia
oligohydramnios
IUGR
absent or reversed end-diastolic flow on umbilical artery doppler
intrauterine fetal death
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how do you manage pre-eclampsia if 37 weeks or over
deliver baby (even if only mild preeclampsia)
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how do you manage preeclampsia if gestation under 37 weeks and: MILD preeclampsia
mild = no adverse conditions
consider conservative management with very close monitoring (NST 3x/week and blood work 2x/week)
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how do you manage preeclampsia if gestation over 34 weeks and severe
DELIVER
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how do you manage preeclampsia if gestation under 34 weeks and severe
conservative management with very close monitoring in hospital can be considered in certain circumstances
MFM consult recommended
176
what is the most important/immediate issue in the management of eclampsia
it is crucial to stabilize the mother before proceeding to delivery
*in a medical emergency in a pregnant woman, the most important thing you can do is LOOK AFTER THE WOMAN*
even if maternal seizures are often accompanied by a fetal bradycardia due to maternal hypoxia, an immediate C section is inappropriate as it would be unsafe for the mother
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list good choices for anti-HTN therapy in pregnant women
labetalol
hydralazine
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what should you NOT use to manage HTN in pregnant women
ramipril (baby cant handle it)
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immediate management of eclampsie in women
ABCs
have mother lying on either side or wedged to the left side
padded bed rails to prevent taruma
supplemental oxygen
treat convulsions with IV MgSO4
treat HTN with IV labetalol (better) or IV hydralazine
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how do you treat seizures from eclampsie
MgSO4 IV
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which tests help you diagnose HELLP
CBC
liver enzymes
bilirubin
peripheral blood smear
182
what is HELLP
a severe form of preeclampsia in which women present with:
Hemolysis
Elevated Liver enzymes
Low Platelets
pathogenesis unclear but may be related to abnormalities in placental development
up to 20% of patients do NOT have associated HTN or proteinuria
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what are the diagnostic criteria for HELLP
platelets 100 or lower
total bilirubin 20 or higher
AST 70 or higher
peripheral smear showing characteristics of microangiopathic hemolytic anemia (schistocytes)
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potential complications of HELLP
DIC
placental abruption
acutre renal failure
pulmonary edema
subcapsular liver hematoma
detached retinas
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what is the definitive treatment for HELLP
delivery
*NO role for expectant management in a pregnant woman with HELLP--patients require stabilization and delivery
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first test in bright red vaginal bleeding in 32 week pregnancy with NO PREVIOUS PRENATAL CARE
ultrasound --find out where the placenta is before doing digital exam
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how do you diagnose placenta previa
transvaginal U/S is gold standard
low lying placenta is less than 20 mm from internal cervical os
placenta previa is overlying the cervical os
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classic presentation of placenta previa
painless vaginal bleeding
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management of placenta previa with acute bleeding or contractions
ABCs
large bore IV access
CBC, type, G + S and cross match
coagulation profile
monitor FHR, maternal vitals
deliver via section if severe hemorrhage and/or abnormal FHR
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most common cause of third trimester bleeding
bloody show associated with labour
191
what are the most IMPORTANT causes of third trimester bleeding
placenta previa
placenta abruption
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what are some other causes of third trimester bleeding
vasa previa
cervical polyp or ectropion
cervical cancer
genital tract trauma
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signs and symptoms of placental abruption
VAGINAL BLEEDING
ABDOMINAL PAIN
uterine tenderness
abnormal FHR
preterm labour
high frequency contractions
uterine hypertonus
IUFD
maternal hypovolemic shock
abnormal bleeding, DIC
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risk factors for placental abruption
previous abruption
HTN
trauma
cocaine
smoking
multiple gestation
PPROM
chorioamnionitis
195
how do you diagnose abruption
CLINICALLY
no single diagnostic test
high index of suspicion in:
- abdo pain and/or bleeding
- trauma
- otherwise unexplained pre term labour
external bleeding not necessary for diagnosis
lab findings may support dx
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potential complications from severe abruption
preterm delivery
severe hemorrhage
maternal shock
DIC
couvelaire's uterus
need for blood transfusion
renal failure
hysterectomy
fetal or maternal death
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first stage of labour
onset until full cervical dilation
latent and active phases
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second stage of labour
full cervical dilation until delivery of infant
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third stage of labour
delivery of infant until delivery of placenta
200
fourth stage of labour
delivery of placenta until 1 hour post partum
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possible complications of oxytocin use to augment delivery
uterine hyperstimulation
water intoxication
uterine rupture
202
most important test in post menopausal bleeding
endometrial biopsy
203
risk factors for endometrial cancer
obesity
DM
hx PCOS
late menopause
history of infertility
LYNCH syndrome
tamoxifen use
HRT with unopposed estrogen use
hx endometrial hyperplasia
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treatment for trichomonas
metronidazole 2 g PO single dose
| same as BV... can also do 500 mg PO BID
205
how does trichomonas appear on wet mount
multiple mobile flagellated organisms
206
outpatient management of PID
ceftriazone 250 mg IM single dose PLUS doxycycline 100 mg PO BID for 14 days
-or-
oral cefixime 800 mg PLUS doxy
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what is the risk of infertility with PID
one episode--increased risk of infertility of about 15-20%
