PACES specialties Flashcards

Question

Treatment of hyperemesis gravidarum

Answer 1

Conservative  IV fluids  Thiamine Medicals: anti-emetics  1st: Cyclizine or Promethiazine (a TCA)  2nd: Metoclopramide or Ondansetron  3rd: Corticosteroids

Answer 2

 Fasting ≥ 5.6 mmol/l |  2 hour OGTT ≥ 7.8 mmol/l

Answer 3

``` Conservative  Consultant-led care  Education on regular BM measurement  Diet: low glycaemic index foods  Exercise Medical:  1st: consider trial of lifestyle  2nd: consider trial of metformin  3rd: short acting insulin therapy ```

Answer 4

Maternal  Recurrent GDM / T2DM development  Pre-eclampsia ``` Fetal  Macrosomia (increases risk of shoulder dystocia)  Polyhydramnios  Pre-term delivery  Caesarean section  Neonatal hypoglycaemia ```

Answer 5

Pre-eclampsia: Gestational HTN + significant proteinuria* OR organ dysfunction** *Significant Proteinuria: After a +ve Urine dip: 1+ proteinuria.  Protein:Creatinine (PCR) ratio >30mg  Albumin:Creatinine (ACR) ratio >8mg ``` ** Other organ dysfunction:  Renal: Creatinine elevated  Neuro (Eclampsia, headaches, AMS)  Placental: (IUGR, Stillbirth)  Liver (HELLP)  Haematological (HELLP, DIC) ```

Answer 6

1 = treat Past medical factors: DM, CKD, Chronic Hypertension/PMHx, Auto-immune disease 2 = treat Pregnancy factors: >40, Primip, Multiple pregnancy, >35 BMI.

Answer 7

Conservative  Monitoring: every week BP, protein ratio measurements  Blood tests: HELLP check at time of presentation.  Safety netting: features of eclampsia = headache, visual changes, swelling Medical  1st: Labetalol PO  2nd: Nifedipine PO (if asthmatic)

Answer 8

Conservative:  Admit, Resusitate as needed  Call for Help  Monitoring: mother (neuro-obs) and fetus (CTG)  Consider delivery: Steroids Medical:  1st: Magnesium Sulphate 4g IV bolus -> infusion  If resp depression occurs due to Mg: Calcium Gluconate Note: HELLP treatment = Urgent delivery

Answer 9

Obstetric: Intrahepatic cholestasis, Acute fatty liver, HELLP, PUPPPs. Non-Obstetric: Gilbert’s, Acute hepatitis, Cholecystitis, drug related

Answer 10

 Obstetric: Bloody show, Placental Abruption, Placenta Praevia, Vasa Previa, Uterine rupture  Gynaecological: Cervical ectropion, Cervical polyp, idiopathic

Answer 11

Conservative  Call for help: alarm + Major Obstretric Haemorrhage  Resuscitation: wide bore cannulae  Admit Medical  Dexamethasone: Abruption - if <37 weeks. Praevia if <35 weeks.  Blood products  Consider Anti-D prophylaxis Surgical  For expedited delivery (could need hysterectomy)

Answer 12

```  Previous  Prolonged labour  Pre-eclampsia  Polyhydramnios  Placenta Praevia ```

Answer 13

 Tone  Trauma  Tissue  Thrombin (coagulopathy)

Answer 14

``` Conservative  Call for help: alarm + major obstetric haemorrhage  Lie flat + uterine massage/bimanual compression  Resuscitation: two wide bore cannulae + blood tests  Catheterise Medical  Oxytocin 10 units IV  Ergometrin 500mcg IM (NOT IN HTN)  Tranexamic Acide 1g  Blood products Surgical  1st: Intrauterine balloon  2nd: B-lynch suture  3rd: Ligation of uterine arteries  Last: Hysterectomy ```

Answer 15

 Age related: Climacteric period, Atrophic vaginitis  Malignant: Endometrial, Cervical, Ovarian, Vulval  Inflammatory: endometrial hyperplasia, endometrial or cervical polyps  STI: chlamydia

Answer 16

All increased levels of oestrogen exposure:  Oestrogen/anovulation: Early Menarche, Late Menopause, Nulliparous,  Metabolic: Obesity, PCOS, DM  Genetic: FHx, Lynch syndrome  Medications: tamoxifen, unopposed HRT

Answer 17

Non-invasive  Psychologist referral  Follow up with specialist cancer nurse Invasive treatment FIGO staging: 1 Confined to uterus (on microscope) Total hysterectomy + BSO 2 Extends to cervix Radical hysterectomy 3 Extends into pelvis Maximal debulking surgery + chemotherapy ``` 4 Metastases (bladder, rectal involvement) Maximal debulking surgery + rad/chemotherapy ```

Answer 18

 Treatment with atypia: Hysterectomy + BSO |  Treatment without atypia: Progesterone therapy – IUS + resample in 3 months.

Answer 19

``` Structural  Polyps  Adenomyosis  Leiomyoma  Malignancy Systemic  Coagulopathy  Ovulatory disorders  Endometrial disorders: endometriosis, abnormal uterine bleeding  Iatrogenic (contraceptives)  Not otherwise classified (hypothyroidism, PID) ```

Answer 20

Abnormal Uterine Bleeding

Answer 21

``` Conservative  Reassurance and education Medical If she wants contraception…  1st: LNG-IUS insertion  2nd: COCP  3rd: Depo-Provera (long acting progesterone) If she does not want contraception  Mefenamic acid or Tranexamic acid ```

Answer 22

 Infectious: Chlamydia, PID  Inflammatory: Cervical polyps, ectropion, trauma, Atrophic vaginitis  Malignancy: Cervical cancer

Answer 23

```  HPV infection  Precancerous smears: CIN & CGIN  Smoking  COCP  Multiparity ```

Answer 24

Non-invasive  Psychologist referral  Fertility counselling  Follow up with specialist cancer nurse Invasive Dependant on FIGO cancer stage… 1a Confined to cervix (on microscope) Cone biopsy (fertility sparing), Wertheim’s Hysterectomy 1b(ig) Confined to cervix (macroscopic lesions) Wertheim’s Hysterectomy (radical) 2 Beyond cervix, spares lower 1/3 vagina Wertheim’s Hysterectomy, Radio-chemotherapy 3 Beyond cervix, involves lower 1/3 vagina Radio-chemotherapy 4 Metastases (bladder, rectal involvement) Radial Pelvic exenteration

Answer 25

 Physiological cysts: follicular, corpus luteal  Epithelial (surface): Serous, mucinous, Brenner  Germ cell (interesting bit): Teratoma, dysgerminoma  Stromal (middle): thecoma, granulosa  Metastatic: Krukenberg

Answer 26

``` Risk of Malignancy Index  Ultrasound findings  Menopausal status  CA125 score >250 = refer to secondary care. ```

Answer 27

 CA125  LDH  AFP  hCG

Answer 28

 FHx: BRCA1/2  Ovulations: early menarche, late menopause, nulliparous, PCOS  Smoking

Answer 29

Conservative  Monitoring CA125 for 5 years.  Fertility counselling  Follow up with specialist cancer nurse Medical  Adjuvant Chemotherapy Surgical  RMI >25 = bilateral oophorectomy, if cancer found then see below  RMI >250 = staging laparotomy & debulking

Answer 30

 Young (reproductive age)  Pregnant  OHSS  Ovarian mass/cyst

Answer 31

``` Conservative  Admit  Refer to Gynae  NBM Medical  IV fluids  Analgesia  Anti-emetics Surgical  1st: Surgical reversal +/- cystectomy +/- oophropexy  2nd: salpingo-oophorectomy ```

Answer 32

 Tubal: defect (e.g. salpingotomy), PID/previous STI, Smoking  Uterine: copper IUD in situ, IVF

Answer 33

Expectant  Stable + pain free + tubal ectopic <35mm + no FHB + Serum hCG <1000 + will follow up.  Consider if <1500 hCG Treatment…  Repeat serum hCGs on Day, 2, 4, 7 (think: 24/7) after first test  Education Medical  No significant pain + tubal ectopic unruptured >35mm + no FHB + <1500 + will return to follow up  Consider if 5000 > x < 1500  Note: must have no confirmed intrauterine pregnancy Treatment…  IM Methotrexate  Repeat serum hCGs (4, 7 + weekly until negative) + FBC & LFTs on day 7.  Education (no pregnancies for next 3 months) Surgical (any)  Significant pain  >35 mm  FHB visible  >5000 serum hCG Treatment…  Laparoscopic > open  1st: Salpingectomy  2nd: Salpingotomy IF infertility risk factors  IF RHESUS NEGATIVE: 250IU (no kleihauer)  Education  Advise to take urine pregnancy test after 3 weeks.

Answer 34

Disease related  Rupture -> internal bleeding -> hypovolaemic shock -> death Treatment related  Treatment failure (95% success in methotrexate)  Future infertility

Answer 35

Expectant  Discharge with safety netting  To return if lasts >14 days  Urine pregnancy test after 3 weeks Note: 1st line but consider other if any of…  Increased risk of haemorrhage or its effects (inc. late first trimester, sickle cell)  Previous traumatic pregnancy experience  Infection Medical  PV Misoprostol 800 micrograms if missed, 600 if incomplete  Education about what to expect  Urine pregnancy test after 3 weeks ``` Surgical  Manual vacuum aspiration under local  Surgical removal under general  Misoprostol often given neo-adjuvantly to aid cervix ripening  No follow up usually needed ```

Answer 36

```  Urge incontinence  Stress incontinence  Mixed incontinence  Functional incontenence  Dietary: related (caffeine intake)  Neurological: stroke-related  Malignancy: bladder, prostate ```

Answer 37

Conservative  Pads & packs  BLADDER RETRAINING for 6 weeks at minimum (hold it for as long as you can) Medical:  Oxybutynin (leads to cant see, cant pee, cant spit, cant shit.)  mirabegron (a beta-3 agonist) can be used in elderly afraid of these side effects. Surgical:  Colposuspension (Birch’s procedure: where suture support the vaginal wall by attaching them to Cooper’s ligament)

Answer 38

``` Conservative:  Kegels – pelvic floor exercises Medical:  Duloxetine (noradrenaline and serotonin reuptake inhibitor) if surgery is not appropriate. Enhances contraction of the pelvic muscle by stimulating the pudendal nerve. Surgical:  Mid-urethral tape surgery. ```

Answer 39

 Cyclical pelvic pain  Dysmenorrhoea  Deep Dyspareunia  Subfertility

Answer 40

``` Conservative  Analgesia: NSAIDs, Paracetamol  Counselling on subfertility Medical  COCP  GnRH analogues (pseudomenopause) Surgery  Laparoscopic excision  Laser treatment ```

Answer 41

 Infectious: STI, PID, Candida, BV, TV, Bartholin’s Cyst  Non-infectious: Endometriosis, Vulvodynia  Age related: atrophic vaginitis Note: Superficial is suggestive of acquired STI, Bartholin’s & vulvodynia Deep is suggestive of PID, Endometriosis.

Answer 42

Primary  Endocrine: Turner’s syndrome, Kallmann syndrome, CAH  Obstetric: Imperforate hymen & other genital tract abnormalities Secondary  PREGNANCY  Hypothalamic: stress, exercise, anorexia  Pituitary: Hyperprolactinaemia, thyroid disease  Gonadal: PCOS, premature ovarian insufficiency, Fibroids

Answer 43

 Idiopathic  Lifestyle: obesity, smoking In women…  Ovary: PCOS, premature ovarian insufficiency  Tubal: PID, STI, post-ectopic pregnancy  Uterine: Fibroids, Endometriosis/Adenomyosis  Endocrine: hyperprolactinaemia, thyroid disease In men…  Endocrine: Kleinefelter’s, Kallmans, Hyperprolactinaemia  Gonadal: CBAVD, Cystic fibrosis  Acquired: torsion, chemotherapy

Answer 44

``` In women… Bloods  Day ~21 serum progesterone  LH & FSH  Prolactin  TFTs Imaging  Hysterosalpingogram (tubal pathology)  TVUSS (fibroids) ``` In men…  Semen analysis  Prolactin

Answer 45

``` Conservative  Family planning: increased sex frequency during ovulation  Weight loss  Smoking/alcohol cessation  Disease optimisation (e.g. DM) Medical  Clomiphene  IVF  ICSI ```

Answer 46

Rotterdam Criteria needs 2 out of 3:  USS showing ovarian cysts (12+ in one ovary)  Evidence of oligo/anovulation (>2 years)  Hyperandrogenism

Answer 47

``` Not hoping to conceive… Conservative  Patient education: cardiovascular & metabolic risk  Diet & Exercise  Family planning counselling: infertility, miscarriage  Hair removal Medical  Metformin  COCP*  Co-cypyrindiol (dianette) *note: prolonged anovulation leads to endometrial hyperplasia – withdrawal bleed can be induced using a progestogen for 14 days. Hoping to conceive… Medical  Clomiphene (Multip pregnancy risk↑ : SERM – increases GnRH pulsatility)  Metformin Surgical  Laparoscopic ovarian drilling ```

Answer 48

 Early menarche  Obese  Age  Afro-Caribbean

Answer 49

Conservative: symptom control  LNG-IUS  Analgesia: NSAIDs – mefanmenic acid  COCP Medical:  GnRH agonists (short term) Surgical  Fertility preserving: Myomectomy.  Endometrial ablation  Hysterectomy

Answer 50

 Sub/infertility  Iron deficiency anaemia  Red degeneration (during pregnancy)

Answer 51

 B: Breastfeeding < 6 weeks, Breast cancer  A: Migraine with aura  S: Smoker >15 a day, >35 y/o, Stroke/IHD/VTE history, Surgery (during), Severe DM.  H: uncontrolled hypertension.

Answer 52

``` Conservative  Weight loss: D&E  Sleep hygiene  Cognitive behaviour therapy Medical  SSRIs  HRT ```