Week 5 - ITS Tutorial - Female Urinary Incontinence, Newborn Exam, Uterovaginal Prolapse, Neonatal jaundice

Question 1

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Answer 1

Symptoms - Constantly wet, difficulty starting urine Signs - increased vulval swelling Risk factors - ex smoker, BMI, limited mobility 3. Urinary obstruction with overflow

Question 2

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Answer 2

Symptoms - urinary incontinence with increased-intra-abdominal pressure, no urgency or frequency Signs - only damp when urinary incontinent Risk facotors - smoker, BMI and parity = 4 1. Stress urinary incontinence

Question 3

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Answer 3

Symptoms - frequncy, urge, nocturia Signs - nil Risk factors - age and alcohol 2. Overactive bladder

Question 4

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Answer 4

The patient has a raised creatinine and urea level - this is due to the patient having blocked bilateral ureters leading to kidney outflow obstruction Paient is stage 4 idney disease (15-29ml/min eGFR) The patient has these biochemicl results due to having a uterine procidentia (basically stage 4 uterovaginal prolapse)

Question 5

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Answer 5

Patient 1 - Patient had Urinary obstruction with overflow - Cystometry C - increase in rectal pressure associated with increase in bladder pressure but no voiding - low flow rate when vodiing implying obstruction Patient 2 - Patient had stress urinary incontinence - Cystometry B - when rectal pressure increases (cough), blader presure increases and vodiing occurs Patient 3 - Patient had overactive bladder - Cystometry A - number of involuntary detrusor contractions occuring

Question 6

Question 4: What treatment would you recommend in each case? Consider lifestyle modifications, medical treatments, conservative treatments and surgical treatments. * Patient 1 - Urinary obstruction with overflow * Patient 2 - Stress urinary incontinence * Patient 3 - Overactive bladder

Answer 6

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Question 7

From the diagram shown remind yourself the physiology of closure of Patent ductus arteriosis.

Answer 7

Closure of ductus arteriosus - DA is required in utero to carry deoxygenated blood away from the lungs and to the arch of the aorta where it will continue to become oxygenated by the placenta - when the baby takes its first breath, the the blood vessels in the lung open up reducing pulmonary vascular resistance and the circulating prostoglandins (PGE2 & PGE1 mainly) level drop (these kept the DA open in utero) meaning the ductus arteriosus will close becomeing the ligamentum arteriosum

Question 8

What are the symptoms of PDA (patent ductus arteriosus)?

Answer 8

Symptoms Sweating Rapid breathing CYnosis Failure to thrive - poor weight gain Fatigue Signs - continuous machine like heart murmur

Question 9

40 year old Primigravida , IVF pregnancy, delivered vaginally a newborn baby at 34 weeks . At neonatal examination baby girl was found to have a continuous heart murmur. Her pregnancy was uncomplicated otherwise. She gives no history of any medical conditions for which she needed any long term medications. There are no genetic concerns in her side of the family. A diagnosis of Patent ductus Arteriosis (PDA) was made in her baby. What is the next step in immediate management of baby?

Answer 9

Refer to neonatologist - carry out a CXR, ECG, Cardiac echo - the definitive diagnostic test for a PDA

Question 10

What kind of postnatal advice will you give the mother at discharge? Use following headings for the same : Breastfeeding Contraception Care for the baby

Answer 10

Breastfeeding - continue breast feeding Contraception - give refular contraceptive advice Care for the baby - observe closely and seek help if concerned

Question 11

How long does the ductus arteriosus take to close? What gender is the PDA more common in?

Answer 11

Ductus arteriosus can take up to a couple of days to close More common in female gender children

Question 12

What is usually given as treatment for PDA?

Answer 12

Indometacin is the NSAID of choice - NSAIDs inhibit the prostoglandin pathway promoting closure of the ductus arteriosus (Can use ibruprofen)

Question 13

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Answer 13

Patient 1 - Pessary (an elastic or rigid device that is inserted into the vagina to support the uterus.) Immediate symptoms relief and is a high risk for surgery - therefore pessary recommended Patient 2 - Surgery - Doesn’t want something inside her ie pessary - is young and likely tolerable of pessary Patient 3 - Conservative management with pelvic floor exercises - patient is relatively asymptomatic and pelvic floor exercises may benefit at first presentation

Question 14

The different types of pessary include ring, cube, shelf and gelhorn pessary Discuss the pros of each type of pessry How long does each stay in for

Answer 14

Pros * Ring - simple to insert, stays in for 6/12, may not interfere with SI * Cube patient has more control on removal/insertion and can be changed after a year * Shelf - rigid and hence stays in better and longer and stays for 6/12 * Gelhorn - softer version of shelf and can be washed&replaced in 6/12, less ulceration chance

Question 15

Discuss the cons of each type of pessary

Answer 15

Ring - can fall out easily and patient has no control over removal insertion Cube - patinet may have difficulty removing it due to suction, can be a bit fiddly Shelf - can be hard/uncomfortable, higher chance of ulceration and intereferes with seual intercourse Gelhorn - can fall out easily and interferes with sexual intercourse

Question 16

What category of patient is each type of pessary used in? Ie which is for younger and which is for older women Which is for the sexually active Which is the last line pessary

Answer 16

Ring - available for any category of pessary except high grades of prolapse Cube - can be used in sexually active younger women Shelf - older women, last line where all other pessaries have failed and women should not be sexually active Gelhorn - older women, not sexually active

Question 17

Describe the pros and cons of the ring pessary and the category of women it can be used in

Answer 17

Ring - Pros - can stay in for 6 months and are simple to insert, may not interfere with the sexually active Cons - can fall out easily an the patient has no control over its insertion or removal Category of patinet - can be used in all categeories apart from those who have high grade prolapses Ring is a good pessary as initial trial

Question 18

Describe the pros and cons of the cube pessary and the category of women it can be used in

Answer 18

Cube Pros - it can be changed after a year and the patient has more control over its removal and insertion Cons - can be a bit fiddly, also can be difficult to remove due to suction Category of patient - used in younger women and can be used in the sexually active

Question 19

Describe the pros and cons of the shelf pessary and the category of women it can be used in

Answer 19

Shelf Pros - rigid and hence stays in better and longer Stays for 6/12 months Cons - higher chance of ulceration and interferes with sexual intercourse, also can be hard and uncomfortable Category of patinet - older women who are not sexually active - where all other pessaries have failed

Question 20

Describe the pros and cons of the gelhorn pessary and the category of women it can be used in

Answer 20

Gelhorn Pros - softer version of the shelf therefore less hard and uncomfortable, also can stay in for 6/12 months, less chance of ulceratin Cons - can fall out easily and interferes with sexual intercourse Category of patient - used in older women who are not sexually active

Question 21

Station 4: Neonatal Jaundice Question 1. How does the composition of Haemoglobin change after birth? When does the composition reach adult level? Do you know which chromosome is responsible for this transition ?

Answer 21

After birth a switch occurs that shuts off gamma chains of feotal haemoglobin production and instead adult haemoglobins A2B2 and A2S2 begin production (alpha 2 beta 2 subunits - 97% and alpha 2 delta 2 subunits) Adult concentration of haemoglobin is reached by approx 6 months of age Genetic information on chromosme 11 dictates this transition

Question 22

How is bilirubin metabolised in the body?

Answer 22

Red blood cells are broken down in the spleen into heme and then into biliverdin via heme oxygenase and then into bilirubin via biliverdin reductase - this unconjugated bilirubin then is carried by albumin to the liver - the liver conjugates the bilirubin by adding glucoronic acid and this bilirubin is excreted via bile salts into the intestine to be removed in the faeces

Question 23

When the liver cannot conjugate the bilirubin leading to a build up of unconjugated bilirubin, the bilirubin therefore cannot be excreted into the faces and is instead excreted via the kidneys into the urine What are sympoms of neonatal jaundice?

Answer 23

Yellowing of the skin and sclera of the eyes Yellowing of the palms or soles of feet Dark urine Pale stools Bilirubin gives the stools its dark colour

Question 24

Question 4: Why does jaundice occur? When does Jaundice occur commonly in a newborn ? Development of Jaundice, after how long after birth would raise a suspicion of an underlying problem?

Answer 24

Jaundice occurs in newborn babies because these abbies have a high level of red blood cells which are broken down and replaced frequently, the newborn babies liver is not fully developed and less effective at removing bilirubin from the blood Jaundice occurs commonly in newborn babies between 2 days and resolves by 14 days after birth Jaundice occurring within the first 24/48 hours or continuing after 14days is worrying

Question 25

Question 5: What are the main treatments for neonatal Jaundice? Most cases of jaundice in babies do not require treatment as the symptoms normally pass within 10-14 days. Treatment is usually only recommended if tests show a baby has very high levels of bilirubin in their blood because there is a small risk in these cases that the bilirubin could pass into the brain and cause brain damage.

Answer 25

Phototherapy - main treatment for jaundice (give when bilirubin levels >350micromoles per litre) Exchange transfusion - blood transfusion to exchange if bilirubin levels are dangerously high (.450micromoles per litre)

Question 26

Question6:What is Kernicterus ?

Answer 26

Kernicterus is a rare but serious complication of untreated jaundice in babies caused by excess bilirubin damaging the brain or central nervous system.In newborn babies with very high levels of bilirubin in the blood (hyperbilirubinaemia), the bilirubin can cross the blood-brain barrier. The bilirubin can damage the brain and spinal cord, which can be life-threatening.Brain damage caused by high levels of bilirubin is also called bilirubin encephalopathy

Question 27

What are the symptoms of kernicterus? What complications can occur due to Kernicterus?

Answer 27

The babies can have decreases awareness of the world around them and may become unusually floppy (hypotonia) If significant brain damage occurs before treatment - baby can develop serious permanent problems ie Cerebral palsy Hearing loss Learning difficulties Poor feeding Many others