Obstetric Conditions Flashcards

Question

When does hyperemesis gravidarum typically present?

Answer 1

* FHx HG * PMHx HG * Multiple gestation * Increased placental mass * Motion sickness * Molar pregnancies * Gestational trophoblastic disease (GTD = abnormal cells or tumours in the womb from cells which develop into placenta)

Answer 2

• Rapidly rising HCG (placental)

Answer 3

Symptoms: • Nausea • Vomiting • Weight loss ``` Signs: • Dizziness • Tachycardia • Hypotension • Dry mucous membranes • Ketotic breath ```

Answer 4

* FBC (normal) * Metabolic panel: variable, hyponatremia and hypochloraemia * Urea + Creatinine: variable, elevated in HG * Urine or Serum Ketones: positive * Foetal Ultrasound with Nuchal Translucency: variable, may show multiple gestation; GTD; hydrops fetalis; increased nuchal translucency * Serum analytes: variable, abnormally high or low hCG and PAPP-A

Answer 5

• IV Fluids (IV Ringer’s lactate), replacement fluid for deficit, ongoing losses and daily fluid maintenance + • Anti-emetic (metoclopramide/chlorpromazine (FGA) /prochlorperazine (FGA) /Promethazine (TCA)) + • PPI (Omeprazole)

Answer 6

Light spotting/bleeding at day 10-14 due to fertilised egg attaching to lining of uterus

Answer 7

``` Bleeding in Pregnancy: Early vs Late • Implantation bleeding • Ectopic pregnancy • Molar pregnancy • Chorionic Haematoma • Miscarriage • Cervical causes – ectropian/polyp/cancer ``` * Placental abruption * Placenta praevia * Vasa praevia * Uterine rupture * Post-partum haemorrhage

Answer 8

involuntary, spontaneous loss of pregnancy prior to 24 weeks associated with unprovoked vaginal bleeding +/- suprapubic pain

Answer 9

Threatened

Answer 10

Early foetal demise

Answer 11

Inevitable

Answer 12

Incomplete

Answer 13

* Older age * Embryological abnormalities e.g. chromosomal causes. * Immunological causes such as antiphospholipid syndrome. * Infections- rubella, CMV, toxoplasmosis, listeria. * Severe emotional upset * Iatrogenic post chorionic villus sampling (CVS) * Associated with smoking, alcohol, cocaine

Answer 14

• Bleeding from placental bed (chorion) causes hypoxia and placental dysfunction leading to embryonic demise.

Answer 15

* Bleeding/ Recent post-coital bleed: may pass products * Suprapubic pain * Cramping * LBP • Positive pregnancy test

Answer 16

* TVUS: consider miscarriage when gestational sac > 25 mm diameter with no visible yolk sac/foetal pole OR embryo measures 7mm or more with no obvious heart activity * Serum ß-hCG: Falling titres (< 50% in 24 hours) suggest failing pregnancy * Rhesus Blood Group: Identify Rh-negative blood group in mother

Answer 17

• Supportive: Emotional support/ Haemodynamic stability/ USS/ Histology/ ßhCG/ Anti-D (for future pregnancies) + Medical • Mifepristone (antiprogestogenic steroid, sensitising myometrium to PG-induced contractions) + • Misoprostol (Synthetic PGE1 loosening foetal tissue + uterine contractions + cervical dilatation) Surgical evacuation • Suction aspiration (vacuum removes uterine contents through cervix) OR • Dilation and Curettage (D+C) (physical dilatation of cervix and curette removing uterine tissue)

Answer 18

antiprogestogenic steroid, sensitising myometrium to PG-induced contractions)

Answer 19

Synthetic PGE1 loosening foetal tissue + uterine contractions + cervical dilatation

Answer 20

* Smoking cessation * Avoid alcohol * Avoid drugs * Treat/control chronic morbidities (DM, HTN, SLE etc..)

Answer 21

Implantation of fertilised ovum (blastocyst) outside uterine endometrial cavity, most commonly fallopian tube, which may lead to maternal death if undiagnosed due to rupture and intraperitoneal haemorrhage.

Answer 22

Fallopian tube

Answer 23

``` Tubal Ovarian Cervical Interstitial (peritoneum) Abdominal (liver etc) Hysterotomy scar pregnancy (previous surgical incision site) ```

Answer 24

* Smoking * PMHx Ectopic * IUD use (if pregnancy occurs with IUD in situ; lowers absolute risk of ectopic cf non-contraceptive-using population) * PMHx genital infections * Chronic salpingitis * Salpingitis isthmica nodosa (SIN) * Multiple sexual partners

Answer 25

Symptoms: • Dizziness • Abdominal pain: unilateral/localised • Shoulder tip pain (extreme cases due to diaphragmatic irritation) • Amenorrhea (4-8 weeks prior to presentation) • Vaginal bleeding/brown watery discharge • Dysuria (painful wee)/Dyschezia (painful poo) Signs: • Abdominal tenderness: voluntary guarding  Involuntary guarding; rebound; acute abdomen findings ≈ rupture signs • Adnexal tenderness/mass • Blood in vaginal vault • Pallor • Haemodynamic instability

Answer 26

* Urine/Serum pregnancy test: Positive * TVUS: No IU pregnancy detected/ectopic pregnancy visualised (doughnut sign = heterogenous adnexal mass separate from two ovaries)

Answer 27

• Medical management: Methotrexate (if stable, low ßhCG levels and ectopic small and unruptured) OR • Surgical: laparoscopic salpingectomy

Answer 28

A pooling of blood between the embryo and the endometrium.

Answer 29

* Bleeding * Cramping * Threatened Miscarriage * Symptoms follow severity, more blood= worse symptoms

Answer 30

• Supportive: Reassurance; Surveillance

Answer 31

Umbrella term for bleeding from genital tract after 22nd week of pregnancy

Answer 32

* Placental abruption * Placenta praevia * Cervicitis * Trauma * Vulvo-vaginal varicosities * Genital tumours * Infection

Answer 33

Placenta overlying cervical os which may be complete (grade 4), partial (grade 3), marginal (grade 2) or low-lying (grade 1).

Answer 34

* Scarred uterus/ Previous C-section * Advanced maternal age * Smoking * PMHx multiple pregnancies * Miscarriages * Prior PP * Infertility treatment * Illicit drug use

Answer 35

* Painless vaginal bleeding: severity in bleeding | * No pain

Answer 36

* FBC: Hb decreases <100g/dL * ßhCG * UUS + Doppler analysis: Position of placenta identified

Answer 37

• Resuscitation and stabilisation: Antifibrinolytic, monitor foetal heart, IV fluids -> Not stabilised, emergency caesarean section +/- Anti-D Ig: 300mcg IM • Urgent USS

Answer 38

``` • Supportive: Monitoring and pelvic rest + Corticosteroids (< 34 weeks) ± Anti-D immunoglobulin ```

Answer 39

``` • Await spontaneous labour OR • C-Section ± Anti-D Ig ```

Answer 40

Premature separation of placenta from uterine wall occurring before delivery of foetus which can be revealed (blood escapes through vagina) or concealed (bleeding occurs behind placenta without PV bleeding) and can be partial (part of placenta) or total (entire placenta)

Answer 41

Partial (part of placenta) Total (entire placenta)

Answer 42

* HTN * Pre-eclampsia * Smoking * Cocaine use * Trauma * Chorioamnionitis * Uterine malformations * Placental abruption * Oligohydramnios

Answer 43

* Vaginal bleeding* * Abdominal pain: occurs in 2/3 * Uterine contractions * Uterine tenderness

Answer 44

* Foetal monitoring – Cardiotocography (CTG), abnormalities in tracing e.g. late decelerations, loss of variability, variable decelerations, sinusoidal foetal heart tracing, foetal bradycardia (< 110bpm) * Hb and Hct: Normal or low * Kleihauer-Betke Test: Positive or Negative * USS: Retroplacental haematoma (hyperechoic, isoechoic, hypoechoic), pre-placental haematoma (jiggling appearance with shimmering effect of chorionic plate with foetal movement); increased placental thickness and echogenicity

Answer 45

Estimation of foetal cells in maternal circulation thus useful in foetal maternal haemorrhage

Answer 46

Stabilise patient: keep Hb > 100g/dL, urine output > 30mL/hour, reduce bleeding, Anti-D Ig ``` Consider if < 34 weeks Corticosteroid + Tocolytic + Consider delivery by 37-38 weeks ``` OR ``` • Urgent CSD + Blood coagulation products + Post-placental delivery utero-tonic agent: Oxytocin (10IU IM) OR misoprostrol (800-100 mcg PV) ```

Answer 47

• Conservative management: foetal heart rate monitoring, sonograms, biophysical profile; Keep Hb above 100g/dL, urine output ≥ 30mL/hour, reduce bleeding (anti-fibrinolytics given early prior to 3 hours), FFP if signs of DIC (replace clotting factors) + • Vaginal delivery + Oxytocin induction (0.5-1mU/minute then 1-2mU/minute increment PRN every 15-60 minutes; maximum 10mU/minute) + Blood coagulation products + Post-placental delivery utero-tonic agent: Oxytocin (10IU IM) OR misoprostrol (800-100 mcg PV) + Post-delivery haemostatic interventions: Surgical ligation (1st) OR Embolisation (2nd) OR Hysterectomy (3rd)

Answer 48

Condition whereby the chorionic villi attach to the myometrium.

Answer 49

Placenta increta

Answer 50

Placenta percreta

Answer 51

* Prophylactic insertion of internal iliac balloon * Caesarean hysterectomy * Blood loss >3L expected * Conservative management + methotrexate

Answer 52

A full thickness opening of the uterus (including serosa. If serosa is intact termed dehiscence).

Answer 53

* Previous C section/uterine surgery (myomectomy) * Multiparity * Use of prostaglandins/syntocin increase risk * Obstructed labour

Answer 54

* Severe abdominal pain- even with epidural may be sore * Shoulder tip pain- due to diaphragmatic irritation * Maternal collapse ``` Signs of uterine rupture: • Intrapartum loss of contractions • Acute abdomen • Peritonism • Fetal distress/IUD ```

Answer 55

* Urgent resus- major haemorrhage protocol, IV fluids, transfuse etc * Anti-D if rhesus negative.

Answer 56

Unprotected fetal vessels transverse the membranes below the presenting part over the internal os. Will rupture during labour or at amniotomy. Causes include ectropion, polyp, carcinoma.

Answer 57

* Placental anomalies e.g. bilobed * Low lying placenta * Multiple pregnancy * IVF

Answer 58

made at US- transabdominal and transvaginal.

Answer 59

* Antenatal diagnosis * Steroids from 32 weeks * Deliver by elective C section at 32-34 weeks. * If antepartum haemorrhage emergency C section

Answer 60

Intrahepatic cholestasis or pregnancy (ICP) is a condition caused by bile flow stasis resulting in deposition in the skin and placenta causing a pruritic condition as the result of hormonal, genetic and environmental factors.

Answer 61

* Pruritus (sparing the face) * Excoriation without rash * Mild jaundice

Answer 62

* LFTs: elevation of transaminases up to 300u/L * Coagulation profile: PT prolonged if vitamin K depleted * Bile acids: elevated > 11micromol/L * Fasting serum cholesterol: Elevated * Hepatitis C virology: Positive in hepatitis C infection

Answer 63

• Conservative: Foetal surveillance/ fluids/Antihistamines (diphenhydramine) + • Colestyramine (4-16g/day PO in 2-4 doses) + Vitamin K (phytomenadione 10mg PO/IM single dose) ± (adjunct) • Ursodeoxycholic acid (competes with cytotoxic bile acids and improves pruritus and liver function) ± • Corticosteroids: IM betamethasone (12mg IM every 24 hours for 2 doses = accelerate foetal lung maturity and improve neonatal outcomes) ± ≥ 37 weeks • Surgery: Caesarean section

Answer 64

- Meconium passage - Small risk of stillbirth - Premature birth (iatrogenic)

Answer 65

Umbrella term for a labour which may be premature, late, painful, fail to progress, involve foetal distress or require intervention.

Answer 66

Normal Labour: Stage 1: Latent (irregular uterine contractions, cervical effacement) -> Stage 1: Active (regular uterine contractions, regular contractions, 1-2cm per hour until 10cm dilation; full cervical effacement) -> Stage 2: full dilation = 2 hours (nulliparous), 1 hour (multiparous) ± 1 if anaesthetic -> Expulsion of placenta and membranes = 10 minutes.

Answer 67

described in terms of abdominal 5ths. How much of the babies head is above the pubic symphysis. 5/5 is the head is completely mobile above.

Answer 68

Can rupture at any point- could be preterm, prelabour, in the 1st stage, 2nd stage or could be born in caul.

Answer 69

* Uterus contracts, hardens and rises * Umbilical cord lengthens permanently * Gush of blood (variable amount)

Answer 70

≥ 1500mL

Answer 71

Clotting pathways Tonic contraction of uterine muscle with lattice arrangement of muscle fibres to strangulate leaky vessels

Answer 72

A period of recovery and repair of tissues to a non-pregnant state in 6 weeks. Patients will suffer from lochia, which is vaginal discharge containing blood, mucus and endometrial castings. Can be characterised as rubra (fresh red), serosa (brownish red, watery) or alba (yellow). This lasts for 10-14 days following birth.

Answer 73

Rubra Serosa Alba

Answer 74

the uterus essentially gets smaller. It reduces its weight from 1000gms to 50-100gms. Fundal height is within pelvis within 2 weeks. The endometrium regenerates within a week. The cervix, vagina and perineum regress but never return to pre-pregnancy state. Physiological diuresis occurs 2-3 days postnatally.

Answer 75

Initiated by placental expulsion, due to a decrease in oestrogen and progesterone. Prolactin is maintained. Colostrum (first milk) is rich in immunoglobulins.

Answer 76

Primiparous - 2 hour (3 if anaesthesia) Multiparous - 1 hour (2 if anaesthesia)

Answer 77

* Power- inadequate contraction * Passages- short stature, trauma, pelvic shape * Passenger- big baby, malposition

Answer 78

In the first stage of labour: • Nulliparous women- <2cm dilation in 4 hours • Parous women - <2cm dilation in 4 hours or failure to progress Second stage Primiparous - 2 hour (3 if anaesthesia) Multiparous - 1 hour (2 if anaesthesia)

Answer 79

Stress inflicted on the baby

Answer 80

• Doppler Auscultation of the fetal heart. Stage 1- before and after contraction. Every 15 mins Stage 2- at least every 5 minutes during and after a contraction for at least 1 minute. Check maternal pulse every 15 mins. • Cardiocotography • Colour of amniotic fluid

Answer 81

``` Risk Factors for fetal hypoxia: • Small fetus • Preterm/postdates • Antepartum haemorrhage • Hypertension/pre-eclampsia • Diabetes • Meconium • Epidural analgesia • Premature rupture of membranes >24 hours • Sepsis • Induction/augmentation of labour • Vaginal birth after c section (VBAC) ```

Answer 82

* Change the maternal position * Iv fluids * Stop syntocinon (oxytocin)- contractions may be too long or too strong affecting the fetal heart rate. * Scalp stimulation * Consider tocolysis- terbulatine 250 micrograms. These are used to suppress premature labour. * Maternal assessment * Fetal blood sampling- looks at the scalp pH. • Operative delivery

Answer 83

≥ 7.25 = normal 7.25-7.20 = borderline, check in 30 minutes ≤ 7.20 = abnormal thus deliver

Answer 84

Preterm birth occurs at 24-37 weeks gestation with 66% preterm labours being iatrogenic and 33% presenting with threatened premature labour (TPTL) progressing to actual labour and delivery.

Answer 85

* Infection and inflammation * Cervical trauma * Short cervical length * Low maternal weight * Multiple pregnancies * Polyhydramnios * PPROM (spontaneous rupture of membranes before 37 weeks of gestation in absence of regular painful uterine contractions) * Pre-eclampsia/Eclampsia * IUGR

Answer 86

* Uterine contractions * Advanced cervical dilation • PV Bleed

Answer 87

* CTG * Tocography: > 1 contraction per 10 minutes * TVUS of cervix: positive if <2cm * FBC: Decreased Hb with antenatal haemorrhage and raised WBC * CRP: Elevated if infection * Urine dipstick: Positive if infection * MSU culture + sensitivity: positive growth in presence of infection * Kleihauer-Betke test: Positive with foetal-maternal haemorrhage

Answer 88

• Maternal evaluation and assessment of foetal viability + • ABX: Erythromycin (250mg PO QDS) OR phenoxymethylpenicillin (250mg PO QDS) for 10 days + Corticosteroids: Betamethasone sodium phosphate (12g IM every 24 hours for 2 doses) ± Gestation > 34 weeks or chorioamnionitis • Consider induced labour

Answer 89

* Maternal evaluation and assessment of foetal viability (continuous CTG + review al data concerning gestational age) * Tocolytics: terbutaline OR nifedipine * Steroids (foetal lung maturation) * Magnesium sulphate (neuro protection)

Answer 90

Largest CV Stress occurs in first 12 weeks of pregnancy: • Blood volume increases • Plasma volume increases • Stroke volume increases • Heart rate increases • Cardiac output increases • Peripheral vascular resistance increases

Answer 91

* Pre-existing hypertension (diagnosed before pregnancy). This is more likely if hypertensive in early pregnancy. Risk of this include IUGR, abruption PET) * Pregnancy induced (comes on with pregnancy however no pre-eclampsia symptoms). Second half of pregnancy. Resolves within 6 weeks of delivery. No proteinuria or other features of pre-eclampsia. 15% progress to pre-eclampsia. * Pre-eclampsia- hypertension, proteinuria, oedema.

Answer 92

2nd trimester

Answer 93

Multisystem disorder of pregnancy which occurs in a triad of new-onset hypertension and proteinuria either before 34 weeks (early pre-eclampsia) or after 34 weeks (late onset pre-eclampsia).

Answer 94

Early pre-eclampsia is uncommon. It is associated with extensive villus and vascular lesions of the placenta. Higher risk for both maternal and fetal complications than late pre-eclampsia.

Answer 95

* Primiparity * PMHx pre-eclampsia/eclampsia * FMHx pre-eclampsia/eclampsia * BMI > 30 * Multiple gestation * Diabetes Mellitus * HTN * Kidney disease prior to pregnancy * SLE * Antiphospholipid syndrome (autoimmune disorder to phospholipids)

Answer 96

* Headache * Visual disturbance * Epigastric/RUQ pain (if there is liver involvement) * Nausea/vomiting * Rapidly progressing oedema * Hypertension * Proteinuria * Oedema * Abdominal tenderness * Disorientation * SGA * IUD * Hyper-reflexia/involuntary movements/clonus

Answer 97

• Cytotrophoblasts fail to infiltrate thus spiral arteries are incorrectly formed leading to abnormal placentation causing a reduction in placental perfusion and resultant placental ischaemia. The placenta releases factors which induces pre-eclampsia (anti-angiogenic state). High resistance, low flow network leads to maternal blood pressure increased to increase perfusion to placenta.

Answer 98

• Supportive: Hospital admission + monitoring: BP monitored QDS with risk-prediction PREP-S useful for decisions about admission and thresholds for intervention; Decide on delivery mode + Corticosteroid: Betamethasone (12mg IM ever 24 for 2 doses) - If severe hypertension (> 160/110mmHg) ± Labetalol (20mg IV then 40mg if BP still exceeded, then 80mg then hydralazine, then consult specialist)

Answer 99

Eclampsia is the presence of tonic clonic (grand mal) seizures occurring in the presence of hypertension and proteinuria caused by cerebral vasospasm/ischaemia.

Answer 100

Before delivery • Supportive: Hospital admission + monitoring: BP monitored QDS with risk-prediction PREP-S useful for decisions about admission and thresholds for intervention; Decide on delivery mode + Corticosteroid: Betamethasone (12mg IM ever 24 for 2 doses) - If severe hypertension (> 160/110mmHg) ± Labetalol (20mg IV then 40mg if BP still exceeded, then 80mg then hydralazine, then consult specialist) - If Seizures ± Magnesium sulfate

Answer 101

``` CNS • Eclampsia • Hypertensive encephalopathy • Intracranial haemorrhage • Cerebral oedema • Cortical blindness • Cranial nerve palsy ``` ``` Renal • Decrease in GFR • Proteinuria • Increase in uric acid • Increase in creatinine, potassium, urea • Oligouria/anuria • Acute renal failure ``` ``` Liver Disease • Epigastric/RUQ pain • Abnormal liver enzymes • Hepatic capsule rupture • HELLP syndrome- haemolysis, elevated liver enzymes, low platelets. ``` ``` Haematological Disease • Decreased plasma volume causes haemoconcentration • Thrombocytopenia • Haemolysis • Disseminated intravascular coagulation ``` Cardiac/pulmonary disease • Pulmonary oedema causes ARDS. • Pulmonary emboli Placental Disease • Fetal growth restriction • Placental abruption • IUD

Answer 102

Glucose intolerance resulting in hyperglycaemia which is precipitated in pregnancy.

Answer 103

• Placenta secretes TNF-a, hCS causing reduced insulin and insulin resistance -> overgrowth of insulin tissues and macrosomia -> foetal metabolic reprogramming results in long-term risk of obesity, IR and diabetes.

Answer 104

* Polyuria * Polydipsia * Foetal macrosomia

Answer 105

* FPG: > 7mmol/L * RPG: > 11.1mmol/L * OGTT: > 8.5mmol/L after 2 hours

Answer 106

1st trimester

Answer 107

* FPG <5.3mmol/L * 2-hour Post-prandial: <7.8mmol/L * HbA1c: 48mmol/L

Answer 108

• Supportive: Diet; Weight control; Exercise; BM monitoring; Growth scan ± Uncontrolled or marked initial hyperglycaemia (RPG > 11.1mmol/L) • Insulin: Insulin NPH + Insulin lispro

Answer 109

Insulin: Insulin NPH + Insulin lispro

Answer 110

* Pre-eclampsia * Polyhydramnios * Macrosomia * Microsomia * Shoulder dystocia * Neonatal hypoglycaemia

Answer 111

An infant with a birthweight that is less than the 10th centile for gestation when corrected for maternal height, weight, fetal sex and birth order.

Answer 112

Reduced size of foetus as a result of disease which is classified as symmetrical or asymmetrical. Symmetrical meaning the whole body is small, whereas asymmetrical meaning one part of the body is normal and the other is smaller. Poor growth could be due to maternal cause, fetal causes or placental causes.

Answer 113

``` Maternal factors: • Lifestyle- smoking, alcohol, drugs • Height and weight • Age • Maternal disease e.g. hypertension ``` Fetal Factors: • Infection e.g. rubella, CMV, toxoplasma • Congenital anomalies e.g. absent kidneys • Chromosomal abnormalities e.g. Downs syndrome Placental Factors • Infarcts • Abruption • Often secondary to hypertension

Answer 114

* Predisposing factors * Fundus height less than expected * Reduced liquor * Reduced fetal movements- a baby struggling for oxygen will lie still.

Answer 115

Large baby > 4.5kg or > 90th centile compared to gestational age and population based charts

Answer 116

``` Risks associated with fetal macrosomia: • Maternal anxiety • Labour dystocia • Shoulder dystocia • Post-partum haemorrhage ```

Answer 117

* Exclude diabetes * Reassure * Delivery methods depend on cases, could vaginal, could c section

Answer 118

Excess amniotic fluid with an AFI > 95th percentile

Answer 119

* Maternal diabetes * Fetal anomaly * Monochorionic twin pregnancy * Hydrops fetalis * Idiopathic

Answer 120

* Abdominal discomfort * Prelabour rupture of membranes * Preterm labour * Cord prolapse

Answer 121

• Ultrasound scan will confirm: Amniotic fluid index (AFI) > 25 Deepest vertical pocket (DVP) >8cm Fetal survery- lips, stomach • Serology- to look for toxoplasmosis, CMV, parvovirus • Antibody screen • Oral glucose tolerance test- look for diabetes

Answer 122

* Patient education/information on complications * Serial USS- for growth, LV, presentation * Induction of labour by 40 weeks

Answer 123

* Cord prolapse * Preterm labour * PPH

Answer 124

* Assisted conception * Race- African * FHx * Increased maternal age * Increased parity * Tall women > short women

Answer 125

When cleavage takes place. 0-3 days after fertilisation is dichorionic diamniotic. Whereas 4-7 days after fertilisation is monochorionic diamniotic (MCDA). If cleavage takes place 8-14 days after fertilisation it will be Monochorionic mono amniotic (MCMA)

Answer 126

1 placenta, 2 amnions Cleavage taking place 4-7 days

Answer 127

1 placenta, 1 amnion Cleavage taking place 8-14 days

Answer 128

2 placenta, 2 amnions Cleavage takes place within 0-3 days Or dizygotic twins

Answer 129

Exagerrated pregnancy symptoms high amniotic fluid index Large for dates uterus Multiple fetal poles

Answer 130

• DCDA are delivered between 37-38 weeks.

Answer 131

• MCDA twins are delivered at 36 weeks.

Answer 132

No, bigger risk

Answer 133

Expulsion of blood with EBL ≈ > 500mL within 24 hours of delivery to 12 weeks post-partum

Answer 134

1) 1º PPH: Blood loss ≥ 24 hours of delivery | 2) 2º PPH: Significant vaginal bleed between 24 hours < X > 12 weeks following delivery

Answer 135

- Minor: 500-1000mL + X hypovolaemic shock | - Major: ≥ 1000mL + hypovolaemic shock

Answer 136

4 Ts * Tone: Atonic uterus ≈ no uterine 3rd stage contraction causes lack of intramyometrial BVs and placental site * Tissue: Retained placental tissue, inhibiting uterine contractility (atonic) * Trauma: perineal tear/episiotomy/cervical tear; uterine incision/extension/rupture * Thrombin (coagulopathy): DIC sepsis/placental abruption/PPH/AFE/IUD

Answer 137

• Assess + Resuscitate mother: Observations/EBL/IV access/Fluids/Blood + Identify cause + manage: Placenta delivered/Uterus contracted/Trauma  May be multifactorial + Atonic uterus * Mechanical compression: Bimanual/IU balloon/Brace sutures * Pharmacological: Syntocinon (Synth. OT)/Ergometrine/Carboprost/Misoprostol (PGE1)/Tranexamic acid (antifibrinolytic) * Interventions: Embolisation (occluding artery)/Uterine artery ligation (clamping blood supply to uterus)/Hysterectomy (removal of uterus) ± salpigo-oophrectomy

Answer 138

- Family Planning - Contraception - Review medication list - Refer for preconception counselling if essential - Advice to start folic acid (400mcg or 500mg)

Answer 139

NF Tuberous sclerosis Huntington's CF Achondroplasia Tay-Sachs Friedreich's Ataxia CAH G6P dehydrogenase deficiency DMD Fragile X syndrome Marfan's syndrome

Answer 140

Heterogeneous disease characterised by chronic reversible inflammation eliciting symptoms of wheeze, dyspnoea, tightness, cough which varies with time and intensity due to variable airflow limitations

Answer 141

* Serum eosinophilia * Allergic sensitization (Atopy) * FHx asthma * Environmental tobacco exposure * Triggers: U-GO-SEA * Abnormal lung function with airway hypersensitivity

Answer 142

* Wheezing * Increased work of breathing * Features of atopy: dermatitis, allergic rhinitis * History of response to treatment within appropriate time frame * Dyspnea on exertion * Expiratory wheeze * Dry night-time cough

Answer 143

* PEF: Absolute values * Spirometry: Scalloping of expiratory flow volume loop; FEV1/FEVC < 0.7 * Bronchodilator-response spirometry: Inhaled corticosteroid or ß2 agonist yields reversibility (12% improvement in FEV1 or FVC) * Bronchial provocation tests (BPT): Inhaled Mannitol (indirect) or Methacholine (PD20; Provocation Dose for 20% reduction) (direct) shows FEV1 decreased (15-20%) * Fractional Expired Nitric Oxide (FeNO) test: Elevated (> 50ppb; normal ≈ 25ppb) * CXR: Normal; Hyperinflation; Rule out other pathologies * FBC: Possible eosinophilia, IgE * Blood culture: Aspergillus * Bronchoscopy: Normal; Look for structural abnormalities such as tracheomalacia or bronchomalacia

Answer 144

``` Step 1 – SABA Step 2 – ICS Step 3 – LABA Step 4 - -> ICS Step 5 – LRTA Step 6 – Biologic ``` • Short-Acting Beta Agonist: Salbutamol (PRN) ± • Low-dose inhaled corticosteroid (ICS): Budesonide (0.25-0.5mg/day nebulized); Fluticasone (100-200mcg/day)  Increase ICS dose as step 4 ± • Long-Acting Beta Agonist: Salmeterol (50mcg BD) ± • Leukotriene Receptor Antagonist (LTRA): Monteleukast (4mg PO OD) ± • Immunomodulator (Biologics): Omalizumab (Anti-IgE mAb)

Answer 145

Biologic IgE mAb thus reduces mast cell degranulation and histamine release

Answer 146

1) Mild Asthma | • PEF: 50-75%

Answer 147

2) Acute Severe Features | • PEF: 33-50% predicted  

Answer 148

Acute Severe

Answer 149

Mild HR 110bpm and RR 25 are diagnostic thresholds for acute severe asthma

Answer 150

Life-threatening asthma

Answer 151

* Oxygen to maintain SpO2 @ 94-98% * Salbutamol 5mg via oxygen-driven nebuliser * Ipratropium bromide 0.5mg on oxygen-driven nebuliser * Prednisolone 40-50mg or IV hydrocortisone 100mg * No sedatives of any kind * CXR Give treatment regimen acutely - Oxygen - SABA - ICS - Prednisolone - CXR

Answer 152

Autosomal recessive disease due to ∆CFTR, fo8und in lungs, intestines, pancreatic ducts, sweat glands and reproductive organs, causing reduced apical chloride secretion ≈ reduced osmotic gain and reduced mucous clearance ≈ accumulation of viscous mucous causing damage to respiratory and digestive systems. Common clinical manifestations: pancreatic dysfunction (malabsorption), lung disease (mucus retention) and inflammation

Answer 153

• Supportive: Physiotherapy; ABX; foetal monitoring (31 weeks) + Inhaled bronchodilator: Salbutamol + Inhaled mucolytic: Mannitol + Dornase alfa (rhDNAse) + Anti-inflammatory agent: Corticosteroid/Ibuprofen/Azithromycin ± CFTR modulator: Ivacaftor

Answer 154

Potentiates CFTR by acting as an agonist thus increase Cl- apical secretion to reduce mucous build up

Answer 155

Formation of a blood clot in the deep veins which is due to interaction of Virchow’s triad: stasis, hypercoagulability and endothelial damage.

Answer 156

* Venous stasis: Reduced flow/ Immobility/ Surgery/ Age * Hypercoagulability: Increased clotting factors/ Surgery/ Oestrogen pills * Endothelial damage: Atherosclerosis/ Catheters/ ICD/ Smoking

Answer 157

Interplay between venous stasis, hypercoagulability, endothelial damage

Answer 158

* High risk: Previous VTE -> Antenatal LMWH * High risk: 3 ≥ RFs (parity > 3, smoker, varicose veins, immobility, FHx, multiple pregnancy) -> Antenatal LMWH * Intermediate risk: Previous VTE; High risk thrombophilia; Medical comorbidities -> Consider LMWH * Low risk: 3 ≤ RFs -> Mobilisation and avoidance of dehydration

Answer 159

* Swelling * Oedema * Leg pain/discomfort * Tenderness * Increased leg temp * Lower abdo pain * Elevated white cell count

Answer 160

V-Q scan > CT-PA as reduced sensitivity but reduced exposure of radiation to breast tissue which reduces breast cancer risk

Answer 161

Wells Score <4 or > 4 DAMN BC DVT Sx (3) Another Ddx Unlikely (3) Mobility reduced (1.5) kNown history of DVT (1.5) Blood in cough (1) Cancer (1)

Answer 162

• Anticoagulation: LMWH + • Thrombolysis: Alteplase/ Streptokinase ± (Failed thrombolytic therapy/CI) • Surgery: Thrombectomy

Answer 163

Warfarin is teratogenic

Answer 164

* Midface hypoplasia * Short proximal limbs * Short phalanges * Scoliosis

Answer 165

Metabolic disorder characterised destruction of pancreatic ß-cells causing insulin deficiency resulting in hyperglycaemia, loss of weight, polydipsia and polyuria and secondary complications of a microvascular and macrovascular nature

Answer 166

• Autoimmune pancreatic ß-cell destruction (GAD, TP, IA-2) in genetically-susceptible individuals (HLA ∆) -> reduced insulin secretion -> reduced uptake into cell -> secretion of glucagon, adrenaline, cortisol and GH -> promote glucose production (glycogenolysis, gluconeogenesis and ketogenesis) -> further raise blood glucose -> microvascular and macrovascular problems

Answer 167

• Basal bolus insulin: insulin glargine/insulin detemir/insulin degludec + insuin lispro/aspart + Aspirin: 75-150mg (reduce pre-eclampsia risk in 1/3)

Answer 168

Progressive metabolic disease defined by defective insulin secretion and resistance leading to abnormal glucose metabolism resulting in hyperglycaemia, weight gain and vascular pathology

Answer 169

• Supportive: Diet restriction/ Exercise/ Fluids/ Examination/ Monitoring + • Basal-bolus insulin: Insulin NPH (BDS) + Insulin lispro (pre-prandial)

Answer 170

Dysregulation of thyroid resulting in reduced production of T3 and T4 of multifactorial cause

Answer 171

• Autoimmune thyroiditis/Drugs = Thyroid dysregulation -> Lymphocyte infiltration + Antithyroid peroxidase or antithyroglobulin Ab -> reduced thyroid hormone synthesis (Amiodarone)/Secretion (Lithium) -> reduced T4 and T3 in target tissues

Answer 172

* Weakness * Lethargy* * Cold sensitivity* * Constipation * Weight gain* * Depression * Facial oedema * Glossitis * Coarse hair * Goitre * Oligomenorrhea/amenorrhoea * Infertility * Bradycardia * Diastolic hypertension ± narrow pulse pressure

Answer 173

* TSH: Elevated* * Free T4: Low* * FBC: Leukocytosis (autoimmune lymphocytes); Anaemia

Answer 174

• Levothyroxine: 1.6mcg/kg/day PO - > Normalises TSH - > Measure TSH ever 6/52 and may need to increase dose

Answer 175

Condition whereby excessive production of thyroid hormones by thyroid gland

Answer 176

- Specialist review - Anti-thyroid Rx - Foetal monitoring - Radioactive Iodine contraindicated in Pregnancy

Answer 177

* T3/T4: High* * TSH: Low* * US-Thyroid: Vascularised/Diffuse/Enlarged

Answer 178

* Heat intolerance* * Sweating* * Weight loss* * Palpitations* * Tremor * Diffuse goitre * Exophthalmos * Scalp hair loss * Tachycardia * Wide pulse pressure

Answer 179

Manage closely - therapy may not be indicated if T4 levels are close to the normal range in pregnancy. • Propylthiouracil: 500-1000mg PO loading dose + 250mg PO every 4 hours + • Labetalol: 60-80mg PO 4-6 hours

Answer 180

* Advanced age * Sex (M) * FHx * Ethnicity * Obesity * Dyslipidemia * Dietary fiber * Iatrogenic (NSAIDs/Oral steroids/Venlafaxine/Soluble drugs/Illicit Drug Use * Alcohol intake * Salt intake

Answer 181

160-179/100-109

Answer 182

140-159/90-99

Answer 183

180-209/110-119

Answer 184

≥ 210/ ≥ 120

Answer 185

A + B --> C + D A: Age < 55 or T2DM -> ACEi/ARB C: Caribbean or Black or Age 55 < = CCB Then add in A/C/D

Answer 186

New onset of heart failure between 24th week of pregnancy and 6 months post-delivery with no cause

Answer 187

* Maternal Age * Hypertension * Multiparity * Multiple pregnancy

Answer 188

* SOB * Poor exercise tolerance * Palpitations * Peripheral and pulmonary oedema * Raised JVP * Basal crackles on lung auscultation

Answer 189

Autoimmune disease caused by antibodies targeting the phospholipid cell membrane which causes arterial and venous thrombosis. This can be primary or secondary to other immune disorders.

Answer 190

anti-cardiolupin (anti-cl) lupus anticoagulant (LA)

Answer 191

* Arterial/venous thrombosis * Stroke * TIA * MI * Valvular heart disease * DVT * Budd-Chiari Syndrome (occlusion of hepatic veins -> ascites, abdo pain + hepatitis) * Recurrent miscarriages * Recurrent early pregnancy loss * Late pregnancy loss- usually preceded by FGR * Placental abruption * Severe early onset pre-eclampsia * Severe early onset fetal growth restriction

Answer 192

* ßhCG: Positive * APTT: Increased * FBC: Thrombocytopenia * Antibodies: Anti-cardiolipin; Lupus anticoagulant (LA) Lab tests must be positive on two occasions

Answer 193

• Supportive: Foetal surveillance; Mobility; TED stocking; Stop Warfarin; + • COX-1i: Aspirin 75mg ± (Thrombotic event) • Anticoagulant: LMWH

Answer 194

Chronic inflammatory condition affecting small joints of hands and feet which is characterised by joint pain, swelling and persistent morning swelling resulting in reduced mobility and reduced quality of life.

Answer 195

* Advanced age: 50-55 years * Female * Genetic: FHx RA

Answer 196

• Aberrant immune response causing inflammation which drives synovial changes via angiogenesis (VEGF/VEGT), cellular hyperplasia, inflammatory influx and interleukin expression -> Results in: erosions; tendon rupture; soft tissue damage; joint instability; pannus formation

Answer 197

• Joint pain: Painful on movement • Joint swelling: Tender + swollen -> Bouchard’s Nodes (PIP) • Stiffness: > 1 hour of joint stiffness * Swan neck deformity: DIP hyperflexion + PIP hyperextension * Boutonniere’s deformity: DIP hyperextension + PIP hyperflexion Non-Articular Manifestations * Fever * Fatigue * Weight loss * Sjogren’s Syndrome * Scleritis * Carpal tunnel syndrome * Atlanto-axial subluxation * Polyneuropathy * Lymphadenopathy * Felty’s Syndrome (RA + Splenomegaly + Neutropenia) * Anemia * Thrombocytosis * Pleural effusion * Lung fibrosis * Rheumatoid pneumoconiosis (Caplan’s Syndrome) * Pericarditis * Pericardial effusion * Raynaud’s Syndrome • Analgesic nephropathy * Leg uclers * Gangrene

Answer 198

DIP hyperextension + PIP hyperflexion

Answer 199

DIP hyperflexion + PIP hyperextension

Answer 200

* ßhCG: Positive * Rheumatoid factor (RF): Positive * Anti-cyclic citrullinated peptide (anti-CCP) Ab: Positive * XR/CT: Erosions

Answer 201

Pregnancy | • Corticosteroid: Prednisolone

Answer 202

Continuing tendency to have seizures (convulsion/transient abnormal event caused by paroxysmal discharge of cerebral neurons)

Answer 203

No, pre-pregnancy and during pregnancy rates remain similar Well controlled 1st trimester can greatly reduce seizures within pregnancy

Answer 204

AEDs may be teratogenic thus use safer ones such as lamotrigine, not sodium valproate or valproic acid which may cause foetal valproate syndrome.

Answer 205

Folic Acid 5mg

Answer 206

rigid tonic phase + jerking (clonic phase) with muscle jerking rhythmically and eyes remain open then stuporous state (post-ictal depression). Lasts seconds to minutes and associated with: tongue biting, urinary incontinence, post-ictal flaccidness, confusion or drowsiness and headache

Answer 207

Tonic then Clonic then Stuporous

Answer 208

childhood with ceasing activity (absence), staring and going pale and atonic (loss of tone). These seizures last for seconds. Despite being ‘absence’ these seizures still have excitation detected by EEG with 3Hz spikes. Children tend to develop generalized tonic-clonic seizures in adult life.

Answer 209

Grand mal seizures

Answer 210

Isolated muscle jerking (myoclonic)

Answer 211

Focal seizure: type of partial seizure which may be complex or partial. Symptoms depend on area of brain affected

Answer 212

Jacksonian seizure originates in motor cortex with jerking movement, corner of mouth or thumb and index finger spreading to contralateral side of epileptic focus. These may last for hours (= Todd’s paralysis).

Answer 213

olfactory/visual hallucinations, blank staring, feeling of unreality (jamais-vu), undue familiarity (deja-vu) with surroundings

Answer 214

* LOC * Tonic stiffening (Grand mal) * Clonic jerking (Grand mal) * Stupurous state (Grand mal) * Ceasing activity/atonic (Petit mal) * Myoclonic (MTA seizures) * Tonic (MTA/Grand mal) * Akinetic (MTA) * Fever (Febrile seizure) * Jerking movements spreading to contralateral side (Jacksonian/Motor cortex seizure) + Lasts for hours (Todd’s paralysis) * Deja-vu (Temporal lobe seizure) * Jamais vu (Temporal lobe seizure) * Tongue biting/urinary incontinence/stupurous state (Grand Mal associated) * Stares and pales (Petit mal associated) * Loss of memory * Aura * Visual disturbances

Answer 215

* Maternal abdominal trauma * Preterm premature rupture of the membranes * Hypoxia/acidosis * Major and minor congenital malformations * Adverse perinatal outcomes * Long term developmental effects * Haemorrhagic disease of the newborn * Risk of childhood epilepsy

Answer 216

• AEDs: Lamotrigine/Carbamazepine (Partial; All seizures in pregnancy) ± Seizure • IV Benzodiazepine: IV Lorazepam

Answer 217

Sodium valproate Phenytoin

Answer 218

• IV Benzodiazepine: IV Lorazepam

Answer 219

Development of Anaemia, low Hb > 2SD from mean) during pregnancy 110g/dL 1/3 and 2/3 105g/dL 2/3

Answer 220

* Fatigue * NV * Dyspnoea (SOBE) * Nail changes: koilonychia (spoon nails) * Angular cheilitis * Glossitis * Gastric difficulties: Gastritis/Achlorhydria * Hair loss * Pica * Restless legs syndrome

Answer 221

* FBC: Hb: < 130g/dL (m)/< 120g/dL (np-w)/ <110g/dL (p-w); MCV < 80fl (may not show in pregnancy); MCH (low); MCHC (low) * Smear: Microcytic, hypochromic pencil red cells * Serum Iron: Decreased * Ferritin: Low (< 12 ng/mL) * Urinalysis: Blood loss?

Answer 222

• Iron replacement: Ferrous sulfate (2-3mg/kg/day)/Ferrous gluconate(2-3mg/kg/day)/ Ferrous fumarate (2-3mg/kg/day)  Note: Pregnant women take Pregaday (Iron 322mg/ Vitamin B9 0.35mg) ± Ascorbic acid: 500mg PO BDS-QDS + • Supplements: Folic Acid 400mcg

Answer 223

Haematological disorder caused by thrombocytopenia (< 100 x 109/L) in the absence of a known cause (idiopathic) which is secondary to an autoimmune phenomenon involving antibody-mediated destruction of peripheral platelets

Answer 224

Neonatal thrombocytopenia due to IgG Abs travelling across the placenta

Answer 225

* Women of childbearing age | * Pregnancy

Answer 226

antiplatelet Abs directed against GPIIb-IIIa/ impaired platelet production (suppression of megakaryocyte development)/ T-cell mediated destruction of platelet and megakaryocyte in bone marrow.

Answer 227

* 1º ITP: Unknown cause | * 2º ITP: ITP secondary to a known disease

Answer 228

* Bleeding: Bruising/Petechiae/Haemorrhagic bullae | * Rash: Purpura – non-blanching, flat rash

Answer 229

• FBC: Platelet count <100 x 109/L Consider… • HIV serology • H. pylori breath test/stool antigen test • Hepatitis C serology • TFTs: Hypo or Hyper -> Test prior to elective splenectomy (exclude reversible causes of thrombocytopenia) • Pregnancy test

Answer 230

• Supportive: Observation, watch and wait + • Corticosteroid: Prednisolone

Answer 231

``` • Supportive: Observation, watch and wait + (Bleeding but platelets > 30 x109/L) • Corticosteroid: Prednisolone ± IVIG + (Platelets < 30 x109/L) • IVIG+Corticosteroid OR Anti-D Ig ```

Answer 232

``` • IVIG ± Corticosteroids: Prednisolone/Methylprednisolone/Dexamethasone ± Platelet transfusion ```

Answer 233

Syndrome typified by microangiopathic haemolytic anaemia and thrombocytopenia purpura Thus thrombosis and low platelets

Answer 234

Fever Anaemia Thrombocytopenia Renal insufficiency Neurological dysfunction

Answer 235

* Obesity * Female gender * Pregnancy * Cancer therapies * HIV infection * Antiplatelet agents

Answer 236

• ∆ADAMTS-13 + Environmental change (pregnancy/ infection/ autoimmune condition) -> reduced ADAMTS-13 -> increased vWF -> increased coagulation status -> microangiopathic haemolytic anaemia due to shear stress sites -> microangiopathic haemolytic anaemia + fever + thrombocytopenia + anaemia + renal insufficiency + neurological dysfunction

Answer 237

* Fever * Headache * Bruising + Bleeding (-> Thrombocytopenia) * Confusion * Anaemia (fatigue/pica/angular stomatitis/headaches) * Coma (Severe neurological) * Focal abnormalities (Severe neurological) * Seizures (Severe neurological) * NVD (HUS) * Abdominal pain (HUS)

Answer 238

* ßhCG: Positive * FBC: Thrombocytopenia (< 100 x 109/L); Low Hb (-> Anaemia) * Haptoglobin: Decreased * Peripheral smear: Microangiopathic blood film + schistocytes * Reticulocyte count: Raised * Urinalysis: Proteinuria * Urea + Creatinine: Increased * Direct Coombs’ test: Negative

Answer 239

• Plasma exchange: 24 hours of presentation; ineffective in children with suspected HUS (exclude); should respond within 3 weeks + Corticosteroids: Prednisolone/Methylprednisolone ± Aspirin: 75-300mg PO OD ( reduce platelet aggregation) ± Folic acid: 3-5mg PO OD

Answer 240

Replace the ADAMTS-13 enzyme

Answer 241

Acquired syndrome caused by activation of coagulation pathways resulting in intravascular thrombi, depletion of platelets and coagulation factors which may lead to vascular obstruction/ischaemia and multi-organ failure.

Answer 242

* Acute DIC: rapid-onset generalised bleeding + micro/microcirculatory thrombosis -> hypoperfusion, infarction and end-organ damage * Chronic DIC: subacute bleeding + diffuse thrombosis

Answer 243

• Extrinsic tissue factor (VIIa) pathway increases thrombin -> cleaves fibrinogen -> fibrin + reduced fibrinolytic pathway -> Positive feedback + depletion of procoagulants + platelets ≈ fibrin deposition widespread = multi-organ failure • Fibrinolytic system malfunction: Increased plasminogen activator inhibitor type 1 (PAI-1) = reduced plasminogen -> plasmin (conversion) = reduced plasmin -> reduced D-dimers (+ FDPs) • Inflammatory pathways potentiate coagulation: IL-6 and TNF-a + Protein C (anti-inflammatory, inhibition of cytokine production) depression + coagulation products (Xa, thrombin, fibrin -> pro-inflammatory cytokine release from endothelium) -> activate coagulation

Answer 244

Consumption of platelets due to hypercoagulability of blood secondary to (extrinsic clotting pathways + fibrinolytic system depletion + inflammatory pathways) causes imbalance in platelets throughout the vasculature (some more at the site of clots and few elsewhere)

Answer 245

• S of generalised bleeding: Petechiae/Purpura/Ecchymosis/oozing/haematuria • Delirium/coma (systemic S of micro/macrovascular thrombosis) • Oliguria (systemic S of circulatory collapse) • Tachycardia (systemic S of circulatory collapse) • Hypotension (systemic S of circulatory collapse) • Gangrene (systemic S of micro/macrovascular thrombosis) • Acral cyanosis (systemic S of micro/macrovascular thrombosis) • Purpura fulminans (systemic S of micro/macrovascular thrombosis) -> thrombotic purpura in small vessels leading to skin necrosis and DIC

Answer 246

* FBC: Thrombocytopenia/ Fibrinogen reduced * PT: Increased * aPTT: Unpredictable (prolonged sometimes) * D-dimer: Elevated

Answer 247

``` • Rx underlying disorder + • Platelet transfusion -> if count < 20 x 109/L + Coagulation inhibitors: FFP/CryoPpt ```

Answer 248

Rhesus incompatibility is a condition featuring destruction of foetal red blood cells (RBCs) from transplacental passage of maternally derived IgG Abs due to mother being RhD negative and baby being RhD positive thus IgG Abs produced against RhD antigen of baby.

Answer 249

RhD -ve (M) + RhD +ve (Fetus) -> B lymphocyte clones recognising RBC antigen promoting IgG Abs against Rhesus D antigen -> attach to fetal RBCs + macrophages sequester in fetal spleen = extravascular haemolysis -> foetal anaemia -> compensates for loss by extramedullary haematopoiesis ≈ HSM, portal hypertension, cardiac compromise, tissue hypoxia, hypoviscosity and increased brain perfusion -> hydrops fetalis and IU fetal death may occur unless corrected

Answer 250

* FMH * Invasive fetal procedures PMHx: Amniocentesis (2%) vs CVS (14%) * Placental trauma

Answer 251

* Anaemia signs * Jaundice signs * Lethargy * Low muscle tone * CTG changes (?)

Answer 252

* Maternal blood type: Rh-negative * Maternal serum Rh Ab screen: Positive screen * Klaihauer-Betke test: Variable – Positive

Answer 253

• Klaihauer-Betke test: Variable – Positive

Answer 254

• Anti-D immunoglobulin

Answer 255

Venous engorgement and mucosal oedema creates a more challenging and vulnerable airway

Answer 256

Increased minute ventilation | Increased O2 consumption

Answer 257

``` Increased PVR Increased volume Increased HR Increased SV Increased CO ``` These show signs of hypovolaemia late

Answer 258

Hypoxia Hypovolaemia Hyper/Hypokalaemia Hypothermia Thromboembolism Toxins Tension pneumothorax Tamponade

Answer 259

development of a depressive illness 1 month following childbirth (including bipolar but more commonly unipolar illness)

Answer 260

* Psychosocial: isolation/sexual+physical violence/socioeconomic disparity * Psychiatric illness: PMHx + FHx (environmental) * Genetic: May be familial * Sleep deprivation * Complications of pregnancy and birth: Risk * Young maternal age: u16 ≈ risk

Answer 261

* Low mood * Anhedonia * Anergia/fatigue * Suicidal ideation * Low self-esteem * Inappropriate guilt * Poor concentration * Weight change (gain or loss) * Change in appetite * Sleep disturbance

Answer 262

• Whooley Questions (Identification Q’s): Feeling down, depressed or hopeless in last month? + Little interest and pleasure in doing things in last month?

Answer 263

• Edinburgh Postnatal Depression Scale: Score > 12

Answer 264

* Whooley Questions (Identification Q’s): Feeling down, depressed or hopeless in last month? + Little interest and pleasure in doing things in last month? * Edinburgh Postnatal Depression Scale: Score > 12

Answer 265

minor mood disturbance occurring 3-10th day PP

Answer 266

• Spontaneous resolution

Answer 267

Development of psychosis shortly postpartum (7-14 days)

Answer 268

* Tangentiality * Hallucinations * Reduced reality * Emotional control (incongruous effect) * Arousal/Anxious * Disorganised behaviour/ Delusions * Loss of volition/social settings/Low mood * Emotional flatness * Speech slowed (alogia) * Slowness in thought (cognitive deficit)

Answer 269

• 1st episode: Anti-psychotics (Aripiprazole) + Psychological interventions

Answer 270

ß-herpes virus infecting majority (50%) humans which is usually asymptomatic but immunocompromised individuals yield reactions when re-activation from latent stage occurs or primary infection occurs.

Answer 271

Immunocompromised HIV Immunosuppressants

Answer 272

person-to-person/vertical transmission/blood transfusion/transplantation (organ or haematopoietic stem cell) then CMV triggers humoral and cell-mediated adaptive immunity to control viral infection thus latency

Answer 273

Often asymptomatic * Maculopapular rash/Blueberry muffin rash * Malaise * Fever * Diarrhoea * Visual floaters + blindness * Microcephaly * Hypotonicity + Poor motor function w/ abnormal head lag * Hearing loss/deafness * Intracerebral calcification * Microcephalus * IUGR * Retinitis * HSM * Hepatitis * Petechiae/purpura

Answer 274

* FBC: Anaemia/Leukopenia/Thrombocytopenia * NAAT: No. genomic copies per volume of specimen * Serology (ELISA): CMV-IgM/CMV-IgG

Answer 275

Baseline monitoring however CMV Rx with Ganciclovir leads to bone suppression

Answer 276

• Antiviral: IV Ganciclovir/PO Valganciclovir

Answer 277

Condition caused by protozoan parasite Toxoplasma gondii whereby cats are the hosts, contaminating and water food with bradyzoites (tissue cysts) which is usually unnoticed as asymptomatic unless immunocompromised

Answer 278

Bradyzoites

Answer 279

Vertical/Food ingested

Answer 280

Signs of encephalitis in the mother • Chorioretinitis: Lesions in fundus w/ proof of Toxoplasmosis -> Consider other differentials • Blurry vision • Slurred speech (encephalitis) • Headache (encephalitis) • Confusion (encephalitis) • Focal neurological deficit (encephalitis) • Unsteady gait/imbalance (encephalitis) ``` Foetal abnormalities in the neonate. • Foetal microcephaly • Foetal intracranial calcification • Foetal hydrocephalus • Foetal IUGR • Cataracts • Retinitis • Pneumonitis • Myocarditis • Hepatitis • Jaundice • Hepatitis • Maculopapular rash • Anaemia • Bone abnormalities ```

Answer 281

* Serology: anti-Toxoplasma IgG elevated + anti-Toxoplasma IgM elevated * CT/MRI-Brain: Ring-enhancing brain lesion(s) – often multiple, in the basal ganglia

Answer 282

``` DHFR inhibitor: Pyrimethamine + DHP synthetase inhibitor: Sulfadiazine + THF: Calcium folinate ```

Answer 283

= mild, self-limiting, systemic infection caused by rubella virus which is often asymptomatic but can precipitate symptoms in immunocompromised individuals.

Answer 284

direct or droplet contact with infected body fluids (commonly nasopharyngeal secretions) -> infectious for 7-30 days post-infection/7 days pre-rash and 10 days post-rash -> replicates in local lymph nodes and spreads haematogenously

Answer 285

* Maculopapular rash: erythematous, discrete, maculopapular ± pruritic/accentuated by heat; face * Koplik spots (gray spots on buccal mucosa) * Fever: Low-grade * Malaise * Arthralgia: Fingers/Wrists/Knees * Lymphadenopathy: Post-auricular/posterior cervical/occipital * Conjunctivitis: Non-purulent conjunctivitis * Intracerebral calcification * Hydrocephalus * Growth restriction * Hydrocephalus * Microcephalus * Cataracts * Microphthalmia * Retinitis * Cardiomegaly * PDA * Maculopapular rash/Blueberry muffin rash (maculopapular rash of magenta colour due to persistent dermal erythropoiesis) * Hepatomegaly * Jaundice * Hepatitis * Virus in urine

Answer 286

• Serology (ELISA): Elevated Rubella-specific IgM positive (acute) / IgG (x4 increase

Answer 287

* Specialist referral | * IM Ig

Answer 288

Human alpha herpes virus (varicella zoster) causing an exanthematous condition (chickenpox) or shingles featuring fever, malaise, pruritic, vesicular rash with worse outcomes in immunocompromised people.

Answer 289

Contact/Vertical then spread to regional lymph nodes leading to 1º viraemic phase -> spread to liver, spleen and reticuloendothelial system cells then 2º viraemic phase: mononuclear cells transport VZV to skin and mucous membranes ≈ vesicular rash – vasculitis of small blood vessels and degeneration of epithelial cells ≈ fluid-filled vesicles

Answer 290

Dorsal root ganglion; Shingles

Answer 291

* Fever * Vesicular rash: Dew drop on a rose petal; appears central (face, scalp or truncal) then spreads distally (accral); lesions scab over as new peripheral lesions develop * Vesicles on mucous membranes: Nasopharynx/Conjunctiva/Mouth/Vulva * Pruritus * Fatigue/Malaise * Tachycardia

Answer 292

Vesicular rash: Dew drop on a rose petal; appears central (face, scalp or truncal) then spreads distally (accral); lesions scab over as new peripheral lesions develop

Answer 293

* PCR: Positive for virus DNA | * Viral culture: positive for VZV

Answer 294

• Antiviral: Aciclovir ± Supportive care: Paracetamol + Diphenhydramine

Answer 295

Slapped cheek syndrome caused by parvovirus B19

Answer 296

* Fever * Coryza * Muscle aches * Erythematous rash (slapped cheeks): Spreads from cheek to trunk and limbs

Answer 297

• Conservative: Analgesia + Fluids

Answer 298

Hand, foot and mouth disease caused by Coxsackie A virus which presents with tiredness, dry cough, fever, ulcers and red spots across the body.

Answer 299

* Fever * Ulcers and spots * Dry cough

Answer 300

• Supportive: Fluids; Analgesia; Isolation

Answer 301

2 days pre-rash

Answer 302

14-21 days

Answer 303

7 days pre-rash and 10 days post-rash

Answer 304

10 days before day of rash

Answer 305

Urogenital chlamydia infection common STI caused by Chlamydia trachomatis (gram negative bacillus) which is usually asymptomatic

Answer 306

• Unprotected sex with infected

Answer 307

* Vaginal/Anal discharge * Post-coital bleeding * Abdnominal/Pelvic Tenderness * Reiter’s Syndrome (arthritis; cervicitis; urethritis and conjunctivitis) * Proctitis * Pharyngitis

Answer 308

Arthritis Cervicitis Urethritis Conjunctivitis

Answer 309

* Conjunctivitis (5-12 days) | * Pneumonia (1-3 months)

Answer 310

* NAAT: VVS/ECS/FCU | * Direct immunofluorescence

Answer 311

Azithromycin

Answer 312

• Unprotected sex with carrier -> adherence to urogenital epithelium -> phagocytosed by macrophages and neutrophils -> neutrophil-rich (purulent) exudate -> transmission across epithelial membrane

Answer 313

* Dysuria * Mucopurulent discharge ** * Post-coital bleeding** * Septic arthritis** (single joint) * Lower abdominal pain * Rectal infection * Salpingitis * PID * Pharyngeal infection

Answer 314

* NAAT: FCU/ECS/VVS/PS | * Culture + Light microscopy: Negative gram stain diplocci

Answer 315

• Ceftriaxone: 250mg IM + • Azithromycin: 1g PO orally

Answer 316

* Genital ulcer (vesicular) * Oral ulcer * Tingling neuropathic pain * Lymphadenopathy * Febrile flu-like prodrome * Neuropathic tingling pain * Dysuria * Bilateral crops of painful blisters * Lymphadenopathy * Local oedema * Discharge

Answer 317

* Viral culture * HSV PCR * Serology: Glycoprotein G with Ab to HSV-1/HSV-2

Answer 318

• Aciclovir: 400mg PO TDS 7-10 days

Answer 319

Retrovirus which is RNA inserting into DNA of host, which is an opportunistic infection transmitted by vertical and horizontal transmission, mediated by CD4+ T-helper cells.

Answer 320

* MSM * Female partners of bisexual men * PWID * Partners of those with HIV * Adults from endemic areas * Children from endemic areas * Sexual partners from endemic areas

Answer 321

HIV is detected by an APC which presents to CD4+ T-helper cells via gp120, CCR5 co-receptor and CXCR4 co-receptor -> recognises MHC-2 APCs to activate B cells and CD8+ (Cytotoxic) T cells to release cytokines and antibodies -> HIV uses RTase to integrate proviral RNA into host DNA -> during infection, inserted RNA is transcribed and translated from host DNA which buds off and infects more host cells -> HIV demonstrates viral tropism (high mutation rate thus several strains of virus)

Answer 322

This is a glycoprotein found on a variety of cells such as macrophages, dendritic cells and T-helper cells

Answer 323

CCR5 CXCR4 gp120

Answer 324

Retrovirus - Reverse transcriptase Budding Viral tropism

Answer 325

Virus transmitted via sexual contact -> R5 strain binds CCR5 co-receptor infection macrophages and dendritic cells in mucosal and epithelial surfaces -> return to lymph nodes -> presents to T-helper cells -> large spike of virus in patient blood -> Flu-like symptoms: Fever, Rash, Myalgia, Pharyngitis, Headache

Answer 326

Immune system upregulated -> reduced level of virus in blood (viral load) + return of CD4+ T-cells to normal level

Answer 327

CD4+ T-cell count reduces (≤ 200 cells/mm3) -> immunocompromised + opportunistic infections: Pneumocystis PNA, TB, Cerebral toxoplasmosis, CMV, Skin infections, Neurological disease, Kaposi’s sarcoma, Cervical cancer, Non-Hodgkin’s Lymphoma

Answer 328

Acute: Virus transmitted via sexual contact -> R5 strain binds CCR5 co-receptor infection macrophages and dendritic cells in mucosal and epithelial surfaces -> return to lymph nodes -> presents to T-helper cells -> large spike of virus in patient blood -> Flu-like symptoms: Fever, Rash, Myalgia, Pharyngitis, Headache Chronic: Immune system upregulated -> reduced level of virus in blood (viral load) + return of CD4+ T-cells to normal level AIDS: CD4+ T-cell count reduces (≤ 200 cells/mm3) -> immunocompromised + opportunistic infections: Pneumocystis PNA, TB, Cerebral toxoplasmosis, CMV, Skin infections, Neurological disease, Kaposi’s sarcoma, Cervical cancer, Non-Hodgkin’s Lymphoma

Answer 329

* CD4 + cells aggregate in lymphoid tissues- reducing circulating numbers * Reduction in CD8 T cells (cytotoxic T cells), leading to a dysregulated expression of cytokines and increased susceptibility to viral infections * Reduction ß-cell efficacy: in antibody class switching- meaning there is a reduced affinity of antibodies produced. * Chronic immune activation

Answer 330

* Vertical (MTCT – intrauterine/intrapartum/postpartum) | * Horizontal: Blood-borne/Contaminated needles/Sexual intercourse

Answer 331

Antibodies - IgG/IgM (Chronic) Viral load (Acute) Antigen p24 (Acute)

Answer 332

* ELISA for Antibodies (best in chronic infection) -> IgM and IgG = 20-25 days window (exposure till detection) * Rapid Testing: Blood/saliva with results in 20-30 minutes with 4th generation being ‘combined’ * Recent Infection Testing Algorithm (RITA): Identify infection in previous 4-6 months measuring Abs and affinity of Abs.

Answer 333

* Fevers and night sweats * Weight loss/Wasting syndrome (≥ 10% loss of BW unexplained) * Skin rash(es): HZV/Dermatitis/Fungal infections (Tinea corporis etc..) * Kaposi’s sarcoma: pink/violaceous patch on skin/mouth * Oral signs: thrush, ulcers and leukoplakia * Recurrent opportunistic infections -> M. tuberculosis/Atypical mycobacterial infections/Noncardiosis/Salmonella/HSV/CMV/VZV/Pneumocystis jiroveci/Histoplasmosis/Candidiasis/Cryptococcosis/Coccidiomycosis

Answer 334

Pneumocystic Jirovecii

Answer 335

AIDS - ≤ 200 cells/mm3

Answer 336

Symptoms will include insidious onset of SOB and dry cough. Signs will include oxygen desaturation on exercise. CXR may be normal or show interstitial infiltrates and reticulonodular markings. Sometimes resembles heart failure with bat wing sign, alveolar oedema with/without cardiomegaly.

Answer 337

Diagnosis is made by broncheoalveolar lavage +/- immunofluorescence. CXR

Answer 338

high dose co-trimoxazole and steroids. Prophylactic treatment is low dose co-trimoxazole

Answer 339

AIDS - ≤ 150 cells/mm3

Answer 340

* Headache * Fever * Focal neurology * Seizures * Reduced consciousness * Raised ICP

Answer 341

* reduced visual acuity * floaters * abdominal pain * diarrhoea * PR bleeding.

Answer 342

Presents as reduced short-term memory with/without motor dysfunction.

Answer 343

Causative organism: JC virus. CD4 <100 Reactivation of latent infection. White matter changes likely. Can resemble MS. Rapidly progressing focal neurology, confusion and personality change. * Distal sensory polyneuropathy * Mononeuritis multiplex * Vacuolar myelopathy * Aseptic meningitis * Guillan Barre syndrome * Viral Meningitis * Crytococcal meningitis * Neurosyphilis

Answer 344

Multiple aetiologies including metabolic causes such as chronic immune activation, anorexia, malabsorption/diarrhoea, hypogonadism.

Answer 345

Human herpes virus 8 (HHV8). CD4 threshold- any but increased incidence with increased immunosuppression Usually presents on the skin as spongy raised nodules/papules. It is a vascular tumour. Can present cutaneously, but also mucosally and viscerally (pulmonary, GI). Treatment- HIV needs treated, local therapies can be used and possibly systemic chemotherapy

Answer 346

Kaposi's Sarcoma Cervical Cancer Non-Hodgkin's Lymphoma

Answer 347

Clinical syndrome resulting from infection and subsequent dysregulated immune response

Answer 348

birth-72 hours = EOS 72 hours - 1 month = LOS

Answer 349

* Fever: ≥ 37.5ºC * Tachypnoea * Tachycadia * Hypotension * Bradycardia (neonates and infants) * Altered mental state/behaviour: Reduced cerebral oxygen delivery * Decreased peripheral perfusion * Change in feeding pattern of neonate * Dry nappies/decreased urine output * Low oxygen saturation * Mottling of skin/ashen appearance/cyanosis * Tachypnoea * Tachycardia * Hypotension

Answer 350

``` Management: • Fluids + • Oxygen + • IV ABX: Ceftriaxone ```

Answer 351

inflammation of breast

Answer 352

• blocked duct/engorgement/breast abscess

Answer 353

* Redness (erythema) * Tender on palpation * Systemic Sx: fever, rigors, lethargy, muscle aching * Depression * Nausea * Headache

Answer 354

* Drainage of breast: feeding frequency, attachment improved, positioning chin towards blockage (tongue wall-like movement to breast), heat applied before feed (improve flow), focus on area or feeding by pump and massage * US: heat to area * ABX: Flucloxacillin 500mg PO QDS 5/7 (Clindamycin if allergic to penicillin)

Answer 355

Anatomical or process problem leading to nipple/breast damage • Supportive: Mother: body supported (reduced tension + support infant body) + cradle hold (infant head on forearm and mother supports infant back) Infant position: (body faces mother + straight + chest close to mother + nose in line with mother’s nipple + chin close to breast)

Answer 356

* Avoid breastfeeding until sores resolved * Express milk and discard to maintain milk supply * Self-resolves

Answer 357

(= Dermatitis/Eczema characterised by papules and vesicles on an erythematous base due to underlying atopy (allergic rhinitis/eczema/hay fever

Answer 358

• 1º genetic defect in filaggrin protein ≈ dryness + increased permeability + loss of barrier function -> increased permeability ≈ inflammation + scratching

Answer 359

* Pruritic * Erythematous * Dry scaly patches * Common on face and extensor in children * Common in flexor compartment in adults * Scratching * Excoriations and lichenifications

Answer 360

* Avoid exposures + triggers * Oil/soap substitute * Steroids (mometasone PO OD 10/7) * Oral therapies (H2-As)

Answer 361

• Colonisation with C. albicans (often following ABX Rx) Signs and Symptoms: • Burning pain in nipple • Pain occurs during and after feeds • Pain radiates into breasts * Infant has white lesions on buccal mucosa * Topical antifungal (fluconazole) for both

Answer 362

• Idiopathic vasospasm (Raynaud’s phenomenon) causing change of bloodflow to alter and reduce causing blanching -> Occur in women with poor circulation or FHx; may be present before; exacerbated by cold Signs and Symptoms: • Nipple colour change (purple/blue/blanching) • Radiation to breast Management • Supportive: cover after feeds, heat applied, warm clothes and environment • CCB: Nifedipine PO OD 20mg slow release

Answer 363

* Hypoplastic breasts (wide-spaced + prominent areolas) * Breast reduction surgery ≈ hyposensitive breasts * Placental remains ≈ interference with lactogenesis * Compromised thyroid function * PPH ≈ pituitary hypoperfusion * Abnormal autocrine regulation (asymmetrical production)