Questions Flashcards
1
Q
Cervical ripening?
A
It is softening of the cervix
2
Q
Cervical effacement?
A
It is shortening of the cervix
3
Q
Types of uterine contractions during pregnancy
A
- Individual contraction of myometrial cells
- Braxton-Hicks’s contraction
- Contractions of labour
- Postpartum uterine contractions
4
Q
Mechanism of labour
A
It refers to a series of changes in the position of the fetus during its passage through the birth canal.
5
Q
Fetal lie:Longitudinal lie?
A
Longitudinal lie: the long axis of the fetus is in the same direction as the mother’s. Either the head or breech presenting
6
Q
Fetal lie: Transverse?
A
The long axis of the fetus is transverse or slightly diagonal to that of the maternal abdomen. The shoulder is usually the presenting part.
7
Q
Fetal lie: Transverse?
A
The long axis of the fetus is transverse or slightly diagonal to that of the maternal abdomen. The shoulder is usually the presenting part.
8
Q
Fetal lie: Oblique?
A
The longitudinal axis of the fetus reaches from one of the iliac fossae to the opposing hypochondrium.
9
Q
How would you monitor the foetus of a high-risk mother in labour?
A
° Continuous monitoring eg. CTG cardiotocograph
° Bottom probe picks up heart rate (top trace)
° Top probe picks up contractions (bottom trace)
° Every time a woman feel foetal movement, presses a button
10
Q
What are some examples of high-risk situations in which you might use CTG cartiotocography?
A
° Any pregnancy which is not low risk eg.
° Oxytocin infusion
° Meconium stained liquor
° Multiple pregnancy
° Intra-uterine growth restriction (IUGR)
° Abnormality on intermittent auscultation
11
Q
What is the baseline foetal heart rate?
A
110-160 bpm
12
Q
What is the baseline foetal heart rate?
A
110-160 bpm
13
Q
What is an acceleration - is that a good or a bad thing?
A
°×Rise of >15bpm for 15 seconds
° good - indicates movement
14
Q
What are the benefits of CTG?
A
° reduced rate of neonatal seizures
° increases intervention rat
15
Q
What should you do if you are worried about a CTG?
A
° Change maternal position (to left lateral)
° Give fluids - ?dehydrated (less perfusion to baby)
° Fetal scalp stimulation
° Foetal blood sample (if concerned and delivery is not imminent)
° Deliver
16
Q
cardiotocograph
A
It involves the placement oftwotransducersonto the abdomen of a pregnant woman. One transducer records thefetalheartrate using ultrasound and the other transducer monitors thecontractionsof theuterusby measuring thetensionof the maternalabdominalwall(providing an indirect indication ofintrauterinepressure).
17
Q
How to read a CTG? remembered using the acronym DR C BRAVADO:
A
° DR:Define risk
° C:Contractions
° BRa:Baseline rate
° V:Variability
° A:Accelerations
° D:Decelerations
° O:Overall impression
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31
What is the definition of postpartum haemorrhage with regard to normal vaginal delivery?
Bleeding from the genital tract of more than 500 mL after delivery of the infant.
32
What is the difference between primary and secondary postpartum haemorrhage?
° Primary: Bleeding more than 500 mL within 24 hours of delivery
° Secondary: Bleeding more than 500 mL that starts 24 hours after delivery and occurs within 12 weeks
33
What are the causes of primary postpartum haemorrhage?
° Uterine atony
° Genital tract trauma
° Retained placenta / placenta accreta
° Coagulation disorders
Uterine inversion
Uterine rupture
34
What are the risk factors for uterine atony and therefore postpartum haemorrhage?
° Multiple pregnancy
° Grand multiparity or nulliparity
° Fetal macrosomia
° Polyhydramnios
° Fibroid uterus
° Prolonged labour
° Previous PPH
° Antepartum haemorrhage
35
Why does multiple pregnancy increased the risk of PPH?
Placental site is larger than with a singleton. There is also over distension which increases risk of uterine atony.
36
What are the risk factors for genital tract trauma?
° Macrosomia
° Episiotomy
° Instrumental delivery, especially Keilland's forceps
37
What is the average amount of blood loss with caesarian section?
500 mL, therefore PPH in this case is termed as anything above 1 L.
38
What are the symptoms of uterine inversion?
° Blood loss
° Abdominal pain
° Feeling of prolapse
39
What is the main risk factor for uterine rupture as a cause of PPH?
Previous caesarian section
40
What are the coagulation disorders than might cause PPH?
1.Chronic:
° Haemophilia
° Von Willebrands
2. Acute:
°DIC
41
What are the complications of primary postpartum haemorrhage?
° Haemorrhagic shock and death
° Sheehan's syndrome
42
How do we prevent primary PPH and the complications of it?
1. After vaginal delivery:
° 10u of Oxytocin IMI after delivery
° Controlled cord traction
2. At risk of PPH:
° Consider oxytocin infusion or ergometrine in addition to the above.
43
Immediate Management of PPH
```
Resuscitate:
° Rub up the uterus/ bimanual compression
° Call for assistance
° Insert 2 large IV cannula
° Infusion of Oxytocin 20u in 1L of Ringers lactate
°Maintain BP with clear fluids/blood
° Urinary catheter
° Monitor BP/pulse/urine output
```
44
Management if there is incomplete delivery of Placenta?
Incomplete:
° Evacuation of the uterus
° Digital exploration
° Ovum forceps and large curette
45
Management in PPH if there is Undelivered Placenta?
° Oxytocin 10u in 30ml of Normal Saline into umbilical vein
° Repeat cord traction
° Manual removal
46
If the placenta is delivered what do you do?
Feel for Uterus
47
What do you do if Utrus is NOT FELT:
1. Check vaginally for inverted uterus
2. Replace immediately
3 Hydrostatic reduction:
° Saline infusion into vagina
° Hold vulvae around tube or use rubber vacuum cup in vagina for seal
48
The Uterus if felt and is SOFT?
° Massage uterus to expel clots
° Continue Oxytocin infusion
° Egromentrine 0.5mg or Syntometrine 1 amp IMI [ repeat once if needed]
° Misoprostol 400-600microGram per rectum or sublingually.
° PGF2 Alfa 5mg in 10ml Saline: inject 1ml into myometrium.
° Balloon tamponade.
49
In PPH the uterus is FIRM
FIRM:
| ° Suture lacerations of perineum, vagina or cervix
50
What do you do if the is still bleeding after management of SOFT and FIRM Uterus
If ongoing bleeding:
EMERGENCY REFERRAL
Balloon catheter can be inserted into the uterus to temporise the situation prior to transfer.
51
Principles of Management in Pre-eclampsia and Eclampsia.
The cure for pre-eclampsia (and Eclampsia) is delivery of the fetus and Placenta. However a planned delivery in stable patient is safer than in a rushed delivery in an unstable patient.
Maternal complications of pre-eclampsia include:
° CVA
° Pulmonary oedema
° Renal failure
° HELLP (Hemolysis, elevated liver enzymes, low platelets) syndrome.
Fetal complications include:
° Intra-uterine growth restrictions
° Hypoxia
° Death
The aims of investigations and Mx of pre-eclampsia are to minimize the chances of these complications arising, identifying them early and treat appropriately when they do occur.
52
Recognizing severe pre-eclampsia
```
° BP >140/90mmHg
° Proteinuria 3+ or more
° Headache
° Blurred vision
° Epigastric/ Upper abdominal pain
° Hyper-reflexia, clonus
° Jittery
° Breathlessness (pulmonary oedema)
° Reduced urine output (less than 25ml/hour or less than 100ml/4 hours)
```
53
Risk factors for Pre-eclampsia
° History of preeclampsia in previous pregnancy or family history
° First pregnancy (primigravida)
° Significant health history prior to pregnancy: Diabetes, lupus, high blood pressure, kidney disease
° Obese (BMI >30)
° Having more than one baby (twin, triplets etc.)
° Age (young <18 or advanced >35)
54
What investigation woy
| would you do for a patient with Severe Pre-eclampsia?
1. Thrombocytopenia (platelets <100 000/uL)
2. Renal function test: impaired (AST oraLT>40IU/L)
3. HELLP syndrome: platelets < 100 000/uL, AST>70uL, LDH>600uL
4. Serum creatinine >/= 120 micromol/L
55
Hypertensive Emergency, how would you manage Severe pre-eclampsia
1. Nifedipine, oral, 10mg
If unable to take oral or inadequate response:
2. Labetalol, IV infusion, 2 mg/minute to a total of 1–2 mg/kg.
Reconstitute solution as follows:
° Discard 40mL of sodium chloride 0.9% from a 200 mL container.
° Add 2 vials (2 x 100 mg) of labetalol (5 mg/mL) to the remaining 160 mL of sodium chloride 0.9% to create a solution of 1 mg/mL.
° Start at 40mL/hour to a maximum of 160 mL/hour.
° Titrate against BP – aim for BP of 140/100 mmHg.
56
How would you Prevention Of Pre-Eclampsia
For women at high risk of pre-eclampsia, e.g. pre-eclampsia in a previous pregnancy, chronic hypertension, diabetes, antiphospholipid syndrome or SLE.
From 6 weeks’ gestation onwards, preferably before 16 weeks gestation:
1. Aspirin, oral, 150 mg daily.
2. Calcium, oral.
For high-risk patients: Calcium carbonate, oral, 500 mg 12 hourly (equivalent to 1 g elemental calcium daily).
57
Empiric treatment of UTI in a pregnant woman ( symptoms present with nitrites positive AND leukocytes positive on dipstick):
1. Fosfomycin, oral, 3 g, as a single dose
OR
2. Nitrofurantoin, oral, 100 mg, 6 hourly for 5 days
58
A pregnant woman with features of pyelonephritis include:
temperature ≥38ºC, renal angle tenderness (often bilateral), other features of sepsis, i.e. vomiting, tachypnoea, tachycardia, confusion and hypotension
What is the appropriate management for this patient?
1. Admit to hospital.
2. Ensure adequate hydration with intravenous fluids, up to 3 L of sodium chloride 0.9% over 24 hours.
3.Empiric therapy:
° Ceftriaxone, IV, 1 g, daily for 48 hours, or until fever subsides.
OR
° Gentamicin, IV, 6 mg/kg, daily (ensure normal renal function).
59
Early Syphilis Treatment in pregnant women?
Benzathine benzylpenicillin, IM, 2.4 MU immediately as a single dose.
60
A woman with Amenorrhea, what investigations would be the most appropriate in the management of this patient?
1. Body mass index.
2. Urine pregnancy test.
3. Pelvic ultrasound.
4. Serum for TSH, FSH, LH, prolactinpp
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° FSH>15 units/L in a woman <40 years of age suggests premature ovarian failure.
° LH/FSH ratio of >2:1 suggests polycystic ovarian syndrom
61
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Fetal Distress Indicators
```
° Abnormal Heart Rates
° Decrease in Fetal Movement
° Maternal Cramping
° Vaginal Bleeding
° Meconium in the Amniotic Fluid
°
```
67
The following are heart rate abnormalities that can be associated with fetal distress:
° Fetal tachycardia is defined as a baseline heart rate greater than 160 bpm.
° Fetal bradycardia is defined as a baseline heart rate of less than 100 bpm.
° Severe prolonged bradycardia (less than 80 bpm for more than 3 minutes) indicates severe hypoxia.
° Variable decelerations happen when there is a sudden decrease in the fetal heart rate, and the decline is greater than or equal to 15 beats per minute and lasts for longer than 15 seconds — but less than 2 minutes from the onset to the return of the baseline rate.
° Late decelerations in a fetal heartbeat can happen through excessive uterine contractions or maternal hypotension, resulting in a decreased blood flow to the placenta. This is a cause for concern, and it can point to fetal acidemia. Fetal acidemia occurs when the blood becomes abnormally acidic.
68
What is the immediate Management of fetal distress
..
69
Investigation to do for pre-eclampsia and Eclampsia
```
° Haematocrit
° Platelets
° Creatinine
° AST
° 24 hours urinary protein
° Fetal heart (once mother is stabilized)
```
70
Fluid Management in Pre-eclampsia & Eclampsia
° Catheterise
° Monitor fluid input and output
° 300ml IV fluid bolus- 200ml normal Saline with Magnesium Sulphate then 100ml Ringers lactate run 1 hour
° Maintainance fluids-RL at 80ml/hour
° If urine output <30ml/hour give 200ml RL bolus
° If urine output continues to be <30ml/hour reduce maintenance fluids to 80ml/hour
71
Menopause definition
Menopause is the permanent physiologic cessation of menses due to loss of ovarian activity determined retrospectively after 12 consecutive months of no menstrual bleeding and low estrogen levels.
72
PHYSIOLOGY of Perimenopause:
* Transitional period from reproductive to non-reproductive stage
* Begins on average 4 years prior to last menstrual period
* Usually lasts 2–8 years
* Characterized by increasing menstrual irregularity and fluctuating hormone levels
* ↓ Oocytes → ↓ estrogens → ↓ inhibition of FSH → ↑ FSH → ↑ follicular response → ↑ estrogen (mid-cycle)
* Significant fluctuations in estrogen throughout the cycle
73
PHYSIOLOGY of Late menopause transition:
* Accelerated oocyte atresia
* Severely depleted follicle supply → more anovulatory cycles
• ↓ Oocytes → ↓ estrogens → ↓ inhibition of FSH → ↑ FSH → ↓ quality of oocytes are unable to respond → estrogen stays ↓
74
Symptoms associated with perimenopause
1.Menstrual changes:
* Late reproductive years: Menstrual cycles shorten (cycles get closer).
* Menopausal transition: shorter cycles → longer cycles → very irregular/sporadic cycles → final menstrual period
2. Vasomotor symptoms:
* Hot flushes
* Occur in 50%–90% of women
* Usually last 1–5 minutes, but may last up to 45 minutes
* Night sweats: can significantly disrupt sleep → chronic fatigue
3. Emotional symptoms:
• Mood swings and irritability
• Stress and anxiety
4. Symptoms related to sexual function :
• Genitourinary syndrome of menopause (GSM): vulvovaginal atrophy (the physical changes of vulva, vagina, and lower urinary tract due to estrogen deficiency)
* Vaginal dryness and itching
* Dyspareunia
75
Symptoms and conditions associated with post-menopause
These symptoms are a result of long-term estrogen deficiency:
1. Bone loss:
• Osteoporosis
• Fragility fractures
2. Cardiovascular disease:
• Lipid profiles worsen (↑ cholesterol).
• Weight gain
• ↑ Risk for myocardial infarction and thromboembolic events
```
3. Hair, muscle, and skin changes:
• Hair thins.
• Skin becomes drier and rougher.
• ↓ Lean mass and muscle tone
• ↑ Fat mass
```
```
4. Symptoms of GSM:
• Dryness/dyspareunia
• ↑ Risk of pelvic organ prolapse
• Incontinence issues
• ↑ Urinary tract infections (UTIs)
```
76
Symptoms post-menopause Mnemonic
HAVOCS:
* Hot flashes
* Atrophy of the Vagina
* Osteoporosis
* Coronary artery disease
* Sleep disturbances
77
Menopause Diagnosis
Primarily clinical
Pelvic exam: Assess vaginal atrophy in context of sexual complaints.
78
Menopause General measures
Counselling:
- Stop smoking.
- Maintain a balanced diet.
- Regular exercise
79
Menopause Medicine treatment :Continuous Combined Therapy
Hormone therapy (HT) with Intact uterus (no hysterectomy)
1. Continuous Combined Therapy
• Estradiol/norethisterone acetate, oral, 1 mg/0.5 mg for 28 days.
OR
• Estradiol/norethisterone acetate, oral, 2 mg/1 mg for 28 days.
OR
• Conjugated estrogens, oral, 0.3-0.625 mg for 28 days.
AND
• Medroxyprogesterone acetate, oral, 2.5-5 mg daily for 28 days
80
Menopause Medicine treatment : Sequentially opposed therapy
2. Sequentially opposed therapy
•Estradiol valerate/ cyproterone acetate, oral:
- Estradiol valerate, oral, 1-2 mg for 11 days.
- Estradiol valerate/ cyproterone acetate, 1-2 mg/1 mg for 10 days.
- Placebo, oral, for 7 days.
OR
• Estradiol valerate, oral, 1-2 mg daily for 21 days.
ADD
• Medroxyprogesterone acetate, oral, 5-10 mg daily from day 12-21.
- Followed by no therapy from day 22-28.
OR
• Conjugated oestrogens, oral, 0.3-0.625 mg daily for 21 days.
ADD
• Medroxyprogesterone acetate, oral, 5-10 mg daily from day 12-21.
- Followed by no therapy from day 22-28.
81
Contraindications to Hormonal Therapy:
* Current, past or suspected breast cancer.
* Known or suspected oestrogen-dependent malignant tumours.
* Undiagnosed genital bleeding.
* Untreated endometrial hyperplasia.
* Previous idiopathic or current venous thrombo-embolism.
* Known arterial CHD.
* Active liver disease.
* Porphyria.
* Thrombophilia.
82
Medicine treatment for Menopause if Uterus absent (post hysterectomy)
HT is given as estrogen only:
• Estradiol valerate, oral, 1–2 mg daily.
OR
• Conjugated equine estrogens, oral, 0.3 mg daily or 0.625 mg on alternative days up to a maximum of 1.25 mg daily.
IF:
HT is contra-indicated, poorly tolerated or ineffective:
• Fluoxetine, oral
- Initiate at 20 mg on alternate days.
- If there is no response after 12 weeks, increase the dose to 20 mg daily.
If on tamoxifen:
• Citalopram, oral, 10 mg daily.
- If there is no response after 12 weeks, increase the dose to 20 mg daily.
83
REFERRAL
* Premature menopause, i.e. < 40 years of age.
* Severe osteoporosis.
* Post-menopausal bleeding.
• Hormone-dependent cancers, thrombo-embolism, liver disease; and unacceptable side-effects to hormone replacement therapy e.g. exacerbation of depression, enlargement of uterine fibroids, exacerbation of endometrioses
84
1. A woman, who is 22 weeks pregnant, has a routine ultrasound performed. The ultrasound shows that the placenta is located at the edge of the cervical opening. As the nurse you know that which statement is FALSE about this finding:
A. This is known as marginal placenta previa.
B. The placenta may move upward as the pregnancy progresses and needs to be re-evaluated with another ultrasound at about 32 weeks gestation.
C. The patient will need to have a c-section and cannot deliver vaginally.
D. The woman should report any bleeding immediately to the doctor.
The answer is C. All the other options are CORRECT. Option C is FALSE. This is a type of placenta previa called marginal (or low-lying). There is a chance the woman can delivery vaginally, but if the placenta was completely over the cervix or partially covering it a c-section would be required. At the 20 week ultrasound the location of the placenta is detected. The location will be re-evaluated at about 32 weeks. If a placenta is found to be low lying there is a chance the placenta will move upward (away from the cervix) as the uterus grows to accommodate the baby.
85
2. Your patient who is 34 weeks pregnant is diagnosed with total placenta previa. The patient is A positive. What nursing interventions below will you include in the patient’s care? Select all that apply:
A. Routine vaginal examinations
B. Monitoring vital signs
C. Administer RhoGAM per MD order
D. Assess internal fetal monitoring
E. Placing patient on side-lying position
F. Monitoring pad count
G. Monitoring CBC and clotting levels
The answers are: B, E, F, and G. Option A is WRONG because vaginal exams are avoided to prevent causing damage to the placenta presenting at the cervical opening. Option C is WRONG because the patient is A positive and does NOT need RhoGAM, which is for patients who are RH negative. Option D is WRONG because external monitoring should be used NOT internal, which can damage the placenta at the cervical opening.
86
3. A 28 year old female, who is 33 weeks pregnant with her second child, has uncontrolled hypertension. What risk factor below found in the patient’s health history places her at risk for abruptio placentae?
A. childhood polio
B. preeclampisa
C. c-section
D. her age
The answer is B. Preeclampisa is a risk factor for experiencing abruptio placentae. The patient is at risk for developing this condition again since she is currently experiencing uncontrolled hypertension with this pregnancy.
87
4. A 36 year old woman, who is 38 weeks pregnant, reports having dark red bleeding. The patient experienced abruptio placentae with her last pregnancy at 29 weeks. What other signs and symptoms can present with abruptio placentae? Select all that apply:
A. Decrease in fundal height
B. Hard abdomen
C. Fetal distress
D. Abnormal fetal position
E. Tender uterus
The answers are: B, C, and E. Option A is wrong because there may be an INCREASE in fundal height (not decrease) due to concealed bleeding. Option D is wrong because this tends to occur in placenta previa because the placenta attaches too low in the uterus at the cervical opening.
88
5. Select all the patients below who are at risk for developing placenta previa:
A. A 37 year old woman who is pregnant with her 7th child.
B. A 28 year old pregnant female with chronic hypertension.
C. A 25 year old female who is 36 weeks pregnant that has experienced trauma to abdomen.
D. A 20 year old pregnant female who is a cocaine user.
The answer is A and D. Risk factors for developing placenta previa include: Maternal age >35 years old, multiples (twins etc.), already had a baby, drug use: cocaine or smoking, surgery to the uterus that will leave scarring: fibroid removal, c-section etc.
89
6. You’re performing a head-to-toe assessment on a patient admitted with abruptio placentae. Which of the following assessment findings would you immediately report to the physician?
A. Oozing around the IV site
B. Tender uterus
C. Hard abdomen
D. Vaginal bleeding
The answer is A. Oozing around the IV site can indicate the patient is entering into DIC (disseminated intravascular coagulation) because clotting levels have been depleted. Therefore, the MD should be notified. Option B, C, and D are findings found in this condition, but Option A is a SEVERE complication that can develop from it.
90
7. Which statement is TRUE regarding abruptio placenta?
A. This condition occurs due to an abnormal attachment of the placenta in the uterus near or over the cervical opening.
B. A marginal abruptio placenta occurs when the placenta is located near the edge of the cervical opening.
C. Nursing interventions for this condition includes measuring the fundal height.
D. Fetal distress is not common in this condition as it is in placenta previa
The answer is C. All the other options are INCORRECT
91
8. Select all the signs and symptoms associated with placenta previa:
A. Painless bright red bleeding
B. Concealed bleeding
C. Hard, tender uterus
D. Normal fetal heart rate
E. Abnormal fetal position
F. Rigid abdomen
The answer is A, D, and E. These are all sign and symptoms of placenta previa. The other options are associated abruptio placentae.
92
9. Disseminated intravascular coagulation (DIC) can occur in __________________. This happens because when the placenta becomes damaged and detaches from the uterine wall, large amounts of _____________ are released into mom’s circulation, leading to clot formation and then clotting factor depletion.
A. Placenta previa, fibrinogen
B. Placenta previa, platelets
C. Abruptio placentae, fibrinogen
D. Abruptio placentae, thromboplastin
The answer is D
93
10. A patient who is 25 weeks pregnant has partial placenta previa. As the nurse you’re educating the patient about the condition and self-care. Which statement by the patient requires you to re-educate the patient?
A. “I will avoid sexual intercourse and douching throughout the rest of the pregnancy.”
B. “I may start to experience dark red bleeding with pain.”
C. “I will have another ultrasound at 32 weeks to re-assess the placenta’s location.”
D. “My uterus should be soft and non-tender.”
The answer is B. All the other options are CORRECT about partial placenta previa. Option B is WRONG because this condition will present with PAINLESS, bright red bleeding NOT with pain and dark red bleeding, which happens in abruptio placentae.
94
What is Gestational Diabetes Mellitus (GDM)?
It’s a form of diabetes that develops during pregnancy, usually during the 2nd or 3rd trimester (hence why we call it gestational). It tends to disappear after the birth of the baby.
95
Gestational Diabetes Mellitus (GDM), Risk Factors for “Momma”
M- Maternal age over 25
O- Overweight or obese…MUAC >30
M-Macrosomia (fetal) previous baby was large…example: >9 lbs
M-Multiple pregnancies
A-A history (previous gestational diabetes diagnosis or family history of diabetes mellitus)
96
Pathophysiology of Gestational Diabetes
mm
97
Signs and Symptoms of Gestational Diabetes
| Similar to those of hyperglycemia…remember the 3 P
* Polyphagia (constant hunger)
* Polydipsia (very thirsty)
* Polyuria (voiding all the time)
* Sugar in urine (why a pregnant woman’s urine is always checked at her OB visits along for protein)
• (Misc: acetone breath “fruity”, dry/hot, UTIs and vaginal yeast infections)
98
GDM Maternal complications
* Increased risk of urinary tract infections
* Development of a hypertensive disease with pre-eclampsia
* Excessive weight gain during the pregnancy
* Deterioration of existing retinopathy and diabetic nephropathy that regresses 6 weeks after delivery
* Derailment of the metabolism (hyperglycemia)
99
GDM Fetal complications
* development of anomalies
* macrosomia
* polyhydramnios)
* Pulmonary malfunctions
* hyperbilirubinemia
* hypoglycemia in a newborn child.
100
Diagnosis for GDM
° Symptoms of diabetes (polyuric, polydipsia, polyphagia, fatigue and weight loss)
° Either a fasting plasma glucose ≥ 5.6 mmol/L
° OR a plasma glucose of ≥ 7.8 mmol/L two hours after a 75 g oral glucose tolerance test.
101
Management of Gestational Diabetes
Metformin, oral, 500 mg daily.
Increase dose to 500 mg 12 hourly after 7 days.
Titrate dose to a maximum of 850 mg 8 hourly according to glucose control.
Contra-indications to metformin: liver or renal impairment.
If not tolerated change to insulin
102
What are the Indications for screening for GDM
1. Family Hx of DM
2. Previous macrosomic baby
3. Unexplained pervious stillbirth
4. Obesity
5. Polycystic ovary syndrome before the pregnancy
6. Previous Hx of GDM
7. Persistent glucosuria during pregnancy
8. Polyhydramnios in index pregnancy.
9. Glycosuria (≥1+ glucose in urine).
10. A fetus that is large for gestational age
103
What are the forms of sexual assault?
1. Rape
2. Child sexual abuse
3. Elderly sexual abuse
4. Sexual harassment
5. Groping
6. Domestic violence
104
Who are the Victims of Sexual assault?
1. Women
2. Children
3. Orphans
4. Physically impaired or disabled individuals
5. Mentally impaired individuals
6. Men(they don’t usually report)
105
Perpetrators
1. Family members
2. Neighbors
3. Strangers
4. Seniors
5. Spouse
106
What are the Effects of sexual assault?
1. Unwanted pregnancy
2. Sexual dysfunction
3. Unsafe abortion
4. Infertility
5. Sexually transmitted infections including 6. HIV /AIDS
7. Pelvic pain and Urinary tract infections
8. Post-traumatic stress disorder
9. Self-harm
10. Suicide
11. Flashbacks
12. Eating disorders
13. Depression
14. Substance abuse
107
Risk factors to sexual abuse /assault?
Women who are victimized :
1. Being young
2. consuming alcohol or drugs
3. having previously been raped or sexually abused
4. Having many sexual partners
5. Involvement in sex work
6. Poverty
108
What constitutes rape?
As per the law, a mere touch of the penis to vulva constitutes rape
A man is said to have committed rape if he has sexual intercourse with a woman
1. Without her consent
2. Against her will
3. With her consent but obtained under fear or by fraud
4. With the consent of a female of unsound mind or under the influence of alcohol or drugs
5. Consent taken by impersonation
6. With or without consent when the girl is below 16 years of age
109
Clinical features of sexual assault
1. Bruises around the thighs, genitalia, anus, perineum, buttocks, and lower abdomen.
2. Tears and abrasions to the female genitalia, particularly the hymen may be torn.
3. Anal fissures
4. Swollen margin and/or bleeding from margins.
5. Hemorrhage from the genital area
6. Evidence of semen in or around the genital area.
110
Way to prevent sexual assault?
1. Self-defense classes
2. Pepper sprays
3. Electric guns
4. Speed dials on cellular phones
5. Keep company to avoid being caught in dangerous situations.
6. Watch what you are drinking and eating
7. Avoid giving too much information to strangers or people you don’t know.
8. Avoid meeting people from the internet and various social networks, alone.
9. Avoid putting up personal information on the internet, especially on sites not secure.
10. Don’t share cabs with strangers or go home with strangers
111
Mother is in her 3rd stage of labour. Explain how you would best manage the third stage of labour in this Mother so as to ensure the best outcome?
1. After delivery of the baby, palpate the abdomen immediately to exclude the possibility of an undiagnosed twin.
2. 10 u of Oxytocin, IV
3. Control bleeding from episiotomy by applying pressure. Arterial bleeding points can be clamped.
4. Signs of Placental expulsion are now awaited:
° Lengthening of cord
° A sudden gush of blood from the vagina
° Contraction of the uterus
5. Placenta delivery by means of the modified Brandt-Andrew's method.
112
First antenatal visit. Mention 6 basic information you need to collect from her during physical examination.
1. Weight, height, MUAC
2. Respiratory system: Asthma
3. Thyroid: Goitre
4. Breast examination
5. Abdominal exam: SFH
6. External & Internal genitals
7. CVD
113
A 35 year old female primigravida is bought to the A&E by husband. She is 32 weeks pregnant. She is complaining of a severe headache, upper abdominal pain and problems with her vision. A quick assessment reveals an ill looking pregnant women. Her vital signs are as follows: BP= 160/110mmHg, PR=110, RR=18, TEMP=37C. On exam there is bilateral ankle oedema and brisk knee reflexes.
a) Describe 6 steps of a comprehensive plan for this patient Indicate the dosages of any medication. (6)
1. insert foley catheter (Monitor urine OP)
2. Check BP& reflexes every 15-30 mins
3. •MgSO4, IV, 4g in 200ml 0.9% N/S over 20 minutes.
• MgSO4, IM, 10g with( 1ml 2% lignocaine), giving 5g on each buttock.
4. Nifedipine, oral, 10mg
114
Female complaining of excessive vaginal bleeding during her menses. Following the complete consultation, she is diagnosed with Menorrhagia. She does not want to fall pregnant at this stage.
a) List two-drug treatments to arrest the active bleeding?
The patient returns after 5 months with normal amounts of bleeding during menses. She is now complaining of irregular menses.
b) State the most appropriate drug management to restore her normal menstrual cycle
a) 1. Norethisterone, oral, 5mg, 4 hourly until bleeding stops for a max of 48 hours
2. Tranexamic acid, oral, 1g, 6 hourly on days 1-4 of cycle
b) COCP, 1 tab daily for 6 months
115
25-year-old primigravida, 32 weeks pregnant. Saw water-like fluid draining from her vagina for 2 hours without abdominal pain. She has not attended ANC during her pregnancy.
a) Describe the 4 most appropriate monitoring steps for the management of this patient.
a) 1. Assess fetal well-being
2. Estimate fetal weight
3. Monitor for signs of infection (fever)
4. Monitor maternal VS
116
25-year-old primigravida, 32 weeks pregnant. Saw water-like fluid draining from her vagina for 2 hours without abdominal pain. She has not attended ANC during her pregnancy.
b) Describe 4 of the most appropriate investigation steps for the management of this patient
1. Booking investigations: Syphillis, HIV-test, Rhesus, Hepatitis B, Urinalysis: Protein & glucose
2. CTG: for foetal monitoring
3. CBC: Signs of infection
4. Ultrasound: To look for amniotic fluid index
117
A 20-year-old female complains of right breast pain and fever for 2 days. Three weeks ago, she had a normal spontaneous vaginal delivery. She has been breastfeeding without any difficulty until 2 days ago. She notices progressive pain, induration, and redness in her right breast. Her VS: BP=100/70mmHg, PR=110, RR=12, TEMP=38.8C. On exam her right breast has induration on the upper outer region with redness and tenderness. There is also significant fluctuation noted in the breast tissue.
a) Describe the 3 most effective next steps to manage this condition (3)
1. Compress and regular expressing of breast milk
2. Flucloxacillin, oral,500mg, 8 hourly for 5 days
3. Paracetamol, oral, 1g 4-6 hourly, when needed.
118
A 19-year-old female presents to OPD with vaginal bleeding and abdominal pain for 3 days. Her last normal menses were 3 months ago. She has no allergies, Her VS: BP= 88/54mmHg, PR=133, RR=24, TEMP=39C. On pelvic exam, the findings are: vulva is blood-stained, cervical os is open, blood with clots visible with a foul-smelling discharge.
a) Describe 3 initial management steps for this patient. Answer must include drug names, route, and dosage to prescribe.
1. Counselling
2. Urgent Evac
3. Oxytocin, IV, 20U in 1L N/S
4. Antibiotic: Amoxicillin/clavulanic acid, IV, 1.2g, 8 hourly.
119
Explain the possible mechanism that could lead to ectopic pregnancy?
Infection of the upper female genital tract leads to inflammatory damage, resulting in scarring, adhesions, and partial or total obstruction of the fallopian tubes.
This can result in loss of epithelial cells along the fallopian tube lining, resulting in impaired ovum transport and an increased risk for infertility and ectopic pregnancy.
120
What is the medical treatment for non-severe pre-eclampsia?
1. Methyldopa, oral, 250mg, 8 hourly as a starting dose.
AND/OR
2. Amlodipine, oral, 5mg daily.
121
Describe the MOA of COC
Combined oral contraceptive pills are composed of a mixture of synthetic estrogens and progestins or just progestins alone→ decrease GnRH release→ decrease in FSH and LH levels→ inhibition of follicular
development→absence of ovulation
122
What are the benefits of using COCP except for the prevention of pregnancy
Used to treat dysfunctional uterine bleeding, polycystic ovary syndrome, endometriosis, acne vulgaris, and dysmenorrhea.
Decreases the risk of ovarian
and endometrial cancer.
123
Explain the MOA of Oxytocin
Oxytocin is a hormone, produced in the posterior pituitary, which acts to stimulate uterine contraction as well as the contraction of the myoepithelial cells in the breast.
124
Mention 3 indications of oxytocin for maternal healthcare?
1. Induce labor
2. stimulate breast milk “let-down” in the new mother
3. Control postpartum uterine hemorrhage.
125
Mention 3 indications of oxytocin for maternal healthcare?
1. Induce labor
2. stimulate breast milk “let-down” in the new mother
3. Control postpartum uterine hemorrhage.
126
An 18-year-old mother delivered a 4.2kg baby following a 2-hour second stage of labour. She is now P6G6. She is discharged home from the community health care center 4 hours post-delivery. Three hours later she is brought to the district hospital by ambulance. PE is significant for cool extremities, confusion, pallor. Vital S: BP=70/40mmHg, PR=140, RR=18, O2 Sats=85% on room air.
1. State the most likely diagnosis
2. Describe the immediate pharmacological and non-pharmacological management of this mother that needs to be done in the emergency department. ( For drugs include name, dose, route and frequency)
1. PPH
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2. • Call for help
• Bi-manual compression of the uterus
• Assess for bleeding by inspection
• Insert for bleeding by inspection
• Insert foley’s catheter
• Monitor urine output
• Monitor VS
• Gain 2 large IV bore access
• Insert 2 IV fluids, NS 0.9% 1L one infused with 20u of oxytocin
• Give 100% oxygen 6-8L/min
• Ergometrine, 0.5mg, IV (if atonic)
• If the uterus is firm suture lacerations of the perineum, vagina, or cervix
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127
3. List 3 risk factors for the most likely diagnosis (PPH) in this patient
* Macrosomia
* Multi-parity
* Advanced maternal age
* > 2-hour long 2nd stage of labor
128
An 11-year old brought by her mother. She suspects that her daughter has been sexually abused 2 days ago. The girl told her mother that she is experiencing abdominal pain, a smelly vaginal discharge and pain on urination. On examination, the child is anxious and withdrawn and in pain. Sexual assault is suspected. There is no dedicated crisis centre for the management of sexual assault cases at the institution.
1. Discuss 3 biological (clinical) management steps as part of the plan for this patient
* Post-exposure prophylaxis
* Treat for STI
* Copper IUCD : Cu T380A within 5 days
129
A 11-year old brought by mother. She suspects that her daughter has been sexually abused 2 days ago. The girl told her mother that she is experiencing abdominal pain, a smelly vaginal discharge and pain on urination. On examination, the child is anxious and withdrawn and in pain. Sexual assault is suspected. There is no dedicated crisis centre for the management of sexual assault cases at the institution.
2. Discuss 3 psychological/social (individual/contextual) management steps as part of the plan for this patient
* Refer to a social worker
* Refer to psychologist
* Refer to counselling for HIV/AIDS testing the possibility of HIV infection.
* Encourage family support
* Encourage support groups
130
A 27-year-old female presents to district hospital with lower abdominal pain for 3 days. In addition, the patient experiences nausea and vomiting. There is no dysuria. Her last menstrual period was 10 days ago. VS: BP=120/80, PR=100, RR=16, TEMP=38. On examination, the patient is lying on the hospital bed clenching her abdomen. The abdominal exam confirms lower abdominal rebound tenderness. The pelvic exam confirms an adnexal mass on the right with cervical excitation tenderness.
1. Fully describe the most likely clinical diagnosis for this patient
2. State 3 clinical features/medical complications that specifically characterise the most severe stage of the most likely diagnosis stated above.
1. • PID Stage 3
2. • Tubo-ovarian abscess,
• Septicaemia
• Generalized peritonitis
131
A 27-year-old female presents to the district hospital with lower abdominal pain for 3 days. In addition, the patient experiences nausea and vomiting. There is no dysuria. Her last menstrual period was 10 days ago. VS: BP=120/80, PR=100, RR=16, TEMP=38. On examination, the patient is lying on the hospital bed clenching her abdomen. The abdominal exam confirms lower abdominal rebound tenderness. The pelvic exam confirms an adnexal mass on the right with cervical excitation tenderness.
3. Outline the five most important initial management steps for the patient. Include pharmacological and non-pharmacological management steps as well as investigations that need to be done for the patient.’
* Admit patient
* Ultrasound
* Cef, 1g, IV, daily
* Metronidazole, IV, 500mg 8 hourly
* Frequent monitoring of abdominal and pelvic signs
* Offer pregnancy test for sexually active patient and screening STI’s & HIV
132
Define placenta accrete?
This is a condition in which the placenta implants deeply into the walls of the uterus
133
Except infertility, mention 4 possible complications of uterine fibroids
* PPH
* Recurrent spontaneous abortion
* Endometrial cancer
* Iron deficiency
* Urinary retention
134
Mention 4 mechanisms of how uterine fibroids may predispose a patient to infertility (4 marks)
* Broad ligament fibroids may stretch or distort the tubes.
* Cornual fibroids may obstruct the uterine end of the tube
* Sub-Mucosal-Fibroids act as a foreign body interfering with implantation
* Cervical fibroids may obstruct the cervical canal
* Associated endometriosis or endometrial hyperplasia
135
Mention 2 mechanism of action for MgSO4
* Slows rate of SA node impulse formation in the myocardium and prolongs conduction time
* Promotes movement of calcium, potassium, and sodium in and out of cells and stabilizes excitable membranes
* Depresses CNS, blocks peripheral neuromuscular transmission, produces anticonvulsant effects, decreases the amount of acetylcholine released at end-plate by a motor nerve impulse.
136
What are the indications of MgSO4 in maternal care in South Africa?
* Prevention of Eclampsia
| * Hypomagnesemia
137
List 4 possible complications of abruptio placenta
* Haemorrhagic shock
* Foetal death
* Disseminated intravascular coagulation
* PPH
* ARF
* Foetal distress
138
Mention 4 foetal factors that may contribute to delayed progress of labour.
* Hydrocephalus
* Breech presentation
* Macrosomia
* Shoulder dystocia
139
List 3 conditions that must monitor during the active phase of labour for pregnancy at full term. Give at least 2 examples of each
1. Foetal condition:
• Foetal heart rate
• Liquor
2. Maternal condition:
• Vital signs
• Urinalysis
3. Progression of labour:
• Cervical dilation
• Cervical effacement
140
Outline 4 measures that could be useful in reducing the incidence of cervical cancer in South Africa.
* Human papillomavirus vaccination
* Screening for Cervical cancer (Pap smear)
* Encourage the use of barrier contraceptives
* Avoid multiple sexual partners
141
A 25-year-old primigravida at 35 weeks of gestation, presents to the maternity ward with severe pre-eclampsia. Mention 2 symptoms and 2 physical examination findings using the table below. (2 marks)
SYMPTOMS
1. Severe Headache
2. Epigastric pain
3. Breathlessness (pulmonary oedema)
SIGNS
1. Oedema of the face, fingers, and feet
2. Hyperreflexia, clonus
142
A 30-year-old female with a Bartholin’s abscess came to OPD, list 4 complaints that she may present with. (4 marks)
* Pain on the vagina (unilateral)
* Dyspaurea
* Swelling
* Erythema
* Painful when walking
143
A 25-year-old sexually active female presents to the hospital with abdominal pain for two days/ After clinical assessment the CA made a diagnosis of PID stage 1.
1. What is the most appropriate management for her condition (drug name, route, dose and frequency)?
* Cef, IM, 250mg, stat as a single dose
* Azithromycin, oral, 1g, stat as a single dose
* Metronidazole, oral, 400mg, 12 hourly for 7 days
144
A 35-year-old female was referred from the clinic for probable pre-eclampsia
a) Write 3 criteria needed to make a diagnosis of pre-eclampsia
b) Mention 4 risk factors of pre-eclampsia
c) She is diagnosed with mild pre-eclampsia. What is the drug management for her condition?
* Elevated BP>140/90 with gestation > 20 weeks
* Proteinuria 1+
* Oedema of the face, fingers, and feet.
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b)
• Hx of Pre-eclampsia
• Age < 20 and > 35 years
• Primigravida
• Chronic hypertension during pregnancy
• Obesity
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c) Methyldopa, oral, 250mg, 8 hourly
AND/OR Amlodipine, oral,5mg daily
