5th year recap important stuff Flashcards
(109 cards)
When do we manage an ectopic surgically?
- Haemodynamic instability
- Live ectopic pregnancy (cardiac activity seen)
- hCG greater than 1500 IU/L
- Adnexal mass >35mm
- Significant pain
- Presence of significant haemoperitoneum on ultrasound
- Patient choice/poor compliance with conservative treatment
When do we do a salpingotomy over a salpingectomy
o Previous ectopic pregnancy
o Contralateral tubal damage
o Previous abdominal surgery
o PID
Medical vs Expectant management of ectopic
Medical:
o No significant pain
o Unruptured ectopic pregnancy, mass < 35 mm and no visible heartbeat
o Low serum bHCG < 1500 IU/L
o No intrauterine pregnancy – MUST be confirmed
NB need to Measure bHCG levels on day 4 and 7 post dose administration. If levels decreased by > 15% between day 4 and 7, start weekly measurements until level less than 15 IU/L
Expectant:
- As above
- <30mm mass
- A decreasing bHCG <1,000 followed up until <15
Asthma non-acute diagnosis and management
Code as suspected asthma -> give treatment and good response will confirm diagnosis, poor treatment do spirometry tests.
+ EDUCATION ABOUT TECHNIQUE AND SPACER
Once first beginning symptoms give SABA inhaler prn, if using > 3 times a week we would initiate preventer therapy with a very low dose ICS or if <5 -> LTRA
If that doesn’t control, your initial add on therapy would be adding ICS/LTRA. After that increase very low dose ICS to low dose. Refer after this.
Life threatening vs Severe asthma attack
Both have sats <92%
Severe - PEF 33-50%; Thretening <33%
Severe - can’t complete sentences in one breath, HR/RR depends on age but above 5, RR>30 and HR>125
Threatening - silent chest, NORMAL CO2, exhaustion, cyanosis
How to manage PUL
• Definition: a situation where a pregnancy test is positive but there are no signs of intrauterine or extrauterine pregnancy on ultrasound scan
• This could mean that there is an ectopic pregnancy that cannot be visualised on TVUSS
• Management - should be focussed on pts symptoms
oBalance between not missing an ectopic pregnancy and not ending an early viable pregnancy
oRepeat hCG measurement 48 hourly to assess change:
Increase >63% likely that she has an intrauterine pregnancy and offer TVUSS 7-14days later.
Decrease <50% likely that pregnancy will not continue but this isn’t confirmed. Pregnancy test 14 days later and come back within 24hrs if positive.
If in between refer for clinical review within 24 hours.
When do we do ECV?
<36 weeks many will turn spontaneously
For nulliparous offer ECV at 36 weeks, at 37 for multiparous
CI if C section is required, APH in past week, ROM, multiple pregnancy
ECV successful 60% of time, if fails can go for vaginal delivery with hands off or Cs
How is the antenatal care of multiple pregnancies different?
- First trimester scan 11-13+6 wks to determine GA, chorionicity and screen for DS
- Determine chorionicity (T sign - monochorionic, Lambda - dichorionic)
- FBC at 20-24 wks to identify those who need extra iron/folic acid as there is a higher incidence of anaemia
- Fetal risks: Counsel on higher risk of DS, Monitor for TTTS in 2nd trimester, and IUGR
- Maternal risks: HTN, preterm birth (most before 37 wks)
- Monitoring:
Monochorionic - 2 weekly growth and doppler from 16 weeks
Dichorionic - 4 weekly growth scans and doppler from 20 weeks
GDM diagnosis criteria
• Fasting plasma glucose > 5.6 mmol/L
• 2-hour plasma glucose > 7.8 mmol/L
If risk Factors present (Previous GDM/ macrosomia, > BMI, First-degree relative with diabetes, Asian, black Caribbean or Middle-Eastern origin) woman should be offered a 2-hour 75 g oral glucose tolerance test (OGTT) at 24-28 weeks
USS schedule
10-14 weeks
• Mainly to determine gestational age, detect multiple pregnancy and determine nuchal translucency as part of screening for Down syndrome
18-21 weeks
• Primarily screens for structural anomalies
• Give couples reproductive choice (e.g. termination of pregnancy)
What are sensitising events that would require anti D prophylaxis
- Delivery of RhD+ infant
- Any TOP
- Miscarriage if > 12 weeks
- Ectopic pregnancy (if managed surgically)
- External cephalic version
- Antepartum haemorrhage
- Amniocentesis, CVS, foetal blood sampling
- Abdominal trauma
GDM Mx
o Newly diagnosed women should be seen at a joint diabetes and antenatal clinic within a week
o Women should be taught self-monitoring of BMs
o Advice about diets (low glycaemic index foods) and exs
o Fasting glucose < 7 mmol/L → trial of diet and exs
oIf glucose targets NOT met within 1-2 weeks → metformin
oIf glucose targets still NOT met → add insulin
o If at the time of diagnosis, fasting glucose > 7 mmol/L or if >6 + complications → insulin
o If metformin is not tolerated: glibenclamide
GDM Counselling
o Risk Factors: age, family or personal history, obesity, multiple pregnancy, Asian background
o 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)
o Estimated prevalence: 2-3%
o Explain the risks (MATERNAL: hypertensive disease, traumatic delivery, stillbirth; FOETAL: macrosomia, neonatal hypoglycaemia, congenital abnormalities)
o Treatment options (diet/exercise, metformin, insulin) and the importance of good glycaemic control
oExplain how to monitor blood glucose (using glucometer)
oNeed to be seen at a joint diabetes and antenatal clinic within 1 week (and every 2 weeks thereafter)
oNeed to have 4 weekly ultrasound growth scans from 28-36 weeks
oExplain that medication will be stopped after delivery but that they will be followed up to check if glucose problem continues
Hyperemesis Gravidarum
• Investigations: body weight, U&E, urine dipstick (check ketones), observations, assess severity using PUQE (score < 13 can be managed as an outpatient)
Criteria: > 5% weight loss, dehydration, electrolyte disturbance
• 1st line: antihistamines (promethazine or cyclizine)
• 2nd line: ondansetron or metoclopramide
• Steroids may be used in refractory cases
• Alternative treatment: ginger, P6 (wrist) acupressure
• Admission may be required if severely dehydrated
Pay careful consideration to the psychological impact of hyperemesis gravidarum
COUNSEL: Most patients find that the symptoms improve after about 12-14 weeks and hopefully the medication will lessen the symptoms until they go away by themselves
Stress the importance of adequate fluids (dioralyte) and nutrition
Miscarriage counselling
- 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
- Explain the diagnosis
- Reassure that this is common and under-reported (1 in 5 pregnancies)
- Explain that risk increases with age
- If asked about cause: explain that most of the time there is no cause
- Explain the management options (expectant, medical and surgical)
- If medical: explain what to expect (pain, bleeding, nausea)
- Antiemetics and pain relief will be given
- Advise to do a pregnancy test after 3 weeks
- Safety net: return if symptoms get worse, bleeding persists after 7-14 days
Types of miscarriage
Spontaneous miscarriage - fetus dies or delivers dead before 24 weeks. 15% of pregnancies spontaneously miscarry, rate increases with maternal age.
Open os:
Inevitable miscarriage - heavy bleeding, although fetus may still be alive, miscarriage is about to occur. Clots may be present.
Incomplete miscarriage- some fetal parts have passed
Closed os:
Threatened miscarriage- bleeding but fetus is still alive, uterus is expected size. 25% will miscarry
Complete miscarriage - all fetal tissue has passed, bleeding has diminished and uterus is no longer enlarged.
Missed miscarriage - fetus has not developed or died in utero, but this isn’t recognised until bleeding occurs/ discovered incidentally on USS. Uterus is smaller than expected or empty.
Septic miscarriage - uterus contents ar einfected, vaginal loss is offensive, tender uterus, fever can be absent. If pelvic infection occurs there is abdo pain and peritonism.
Miscarriage mx
- If FHB present + Blood -> safety net to return if bleeding gets worse or persists for more than 14 days
- If no FHB + confirmed pregnancy + blood -> first line is expectant management (exceptions are very late first trimester, previous trauma with pregnancy, infection or clotting abnormality/can’t have blood transfusion)
o If bleeding resolves within 7-14 days take p test 3 weeks after and return if positive - Medical: Vaginal misoprostol (repeat day 3 if expulsion not complete) contact healthcare profession if bleeding hasn’t started within 24 hours + pain relief + anti-emetics + p test 3 weeks after
- Surgical: Manual vacuum aspiration under LA ±misoprostol to ripen cervix
What makes a febrile seizure complex?
Focal onset or focal features
Last >15 mins
Recurrence in 24h or same illness
Incomplete recovery within 1h
Febrile seizure counselling about anxiety
- Febrile seizures are not the same as epilepsy
- Short lasting seizures are not harmful to the child (no brain damage)
- They are relatively common – between 2 and 5 in 100 children
- The risk of developing epilepsy later is low but slightly higher than the general population: background risk is ~2%, simple seizure 2-7.5%, complex 10-20%
- Antipyrexials don’t prevent and it isn’t due to the actual temp but the rise in speed
Febrile seizure counselling about what happens if it happens again
1 in 3 will have another seizure – need to know how to manage
Protect from injury (cushion head with hands or soft material), move harmful objects
Do not restrain or put anything in mouth
When seizure stops: check airway is clear and put in recovery position
May be sleepy for 1h after seizure
Call an ambulance if lasts >5 mins and give rescue pack midazolam
How to manage febriel seizure
Rectal diazepam, repeated once after 5 mins OR one dose buccal midazolam
Call ambulance if after 10 mins since first dose:
Still seizing
Ongoing twitching
Another seizure begun before child regains consciousness
Questions to ask if failure to thrive?
Prenatal - SFD? Premature?
Functional issues: having enough time to feed her, good feeding schedule, difficult child
Reduced Appetite? (IDA, chewing on other things)
Feeding difficulties? Ability to latch on? Ability to stay on? swallowing, vomiting after
Malabsorption qs: Diarrhoea? Mucous?
Any G&D concerns?
What have you tried so far and what is it better with?
Failure to thrive definition
TLDR: below 2nd centile for age (no matter bw) or based on fall of 1, 2, 3 weight centile dependent on BW being <9, 9-91, >91
A fall across 1 or more weight centile spaces, if birthweight was below the 9th centile
A fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles
A fall across 3 or more weight centile spaces, if birthweight was above the 91st centile
When current weight is below the 2nd centile for age, whatever the birthweight
Generic FTT management
Next steps: further investigation, clinical growth and monitoring, interventions and goals
MDT: Midwife, GP, infant feeding specialist, paediatrician, paediatric dietician.
Conservative advice:
Encouraging relaxed and enjoyable feeding and mealtimes, as a family or with other children
Encouraging young children to feed themselves
Allowing young children to be ‘messy’ with their food
Medical advice:
Short term trial of dietary fortification (superdense energy foods)
2nd line - trial of an oral liquid nutritional supplement for infants or children
Only after MDT discussion, refractory to prev tx and if there are srs concerns about weight gain you can try an eating tube
Referral - if concerns of underlying idsorder