O & G



O & G SAQ’s

SAQ 062

You are asked by one of your registrars to review an as yet untreated 30 year old diabetic woman with DKA. Her vital signs are as follows:

• P 120

• BP 80/60

• RR 30/min

• BSL 40

• GCS 13

She is 28 weeks pregnant. Outline your management.

ISSUES

1. Hemodynamically unstable, tachypnoeic (probable metabolic acidosis), ALOC - Volume resus priority

2. Physiological ∆s in pregnancy

- haemodynamics – at 28/40 BP ~ 90/60 - masks hypovolaemia; L tilt to remove gravid uterus from IVC

- reduced immunity – infection (?underlying cause)

- coag factors – DVT risk

- Interpretation of ABG: resp alkalosis is normal in pregnancy, pH 7.4 probably acidotic

3. DKA potentially life-threatening – harm to woman and foetus:

a. Fetal death risk during DKA = 50%

b. Best fetal care is good maternal care

c. Issue of any drug use in pregnancy

d. Viable fetus

4. Look carefully for underlying cause eg infection (UTI)

MANAGEMENT (Treatment, Supportive Care, Disposal)

1. TREATMENT

Monitored area, early fetal monitoring (CTG), right lateral position (wedge/pillow under right buttock)

a. Resuscitation

A monitor GCS

B high-flow O2 to keep sats > 95%

C 18g iv x 2 (send off bloods + venous gas)

Fluid deficit 5 – 10L

Aim to replace over 24 – 48h (otherwise cerebral edema)

1L stat, 1L q1h, 1L q2h

N/saline or N/2 saline if Na > 150

D monitor GCS, pupils, reflexes

E temp, underlying cause

b. Specific treatment

Insulin 50u /50ml saline

Infusion 6units/hour (0.1u/kg/h)

Monitor BSL: aim to decrease by 5u/hour

When BSL 15, change fluid to 5% dextrose

Continue until ketones cleared from urine

(Q1h BLS, pH, urine ketones)

Potassium K deficit ~ 200mmol

Commence when K < 5 and passing urine

60mmol/L bag or 5-10 mmol via CVL

Also monitor PO4, Mg

HCO3 not indicated

Dexamethasone not proven to prevent cerebral oedema

Consider DVT prophylaxis – heparin sc safe in pregnancy

c. Treatment of Complications

ALOC may need I&V anticipate difficult airway

GOR – sodium citrate

Kessell’s blade

Thiopentone

suxamethonium

Pulmonary edema/acute lung injury

Renal failure

Hepatic dysfunction

Ileus keep NBM, ?NGT

Premature labour salbutamol/ACE-inhibitor

Steroids for lung maturity

2. SUPPORTIVE CARE

Analgesia prn

Antiemetics prn

Strict fluid balance (?IDC)

Family/partner support

Diabetes education for patient

Departmental teaching opportunity

3. DISPOSAL

HDU monitor BSL, U&E (K), fluid balance, renal function

?CTG monitoring of fetus

Input from intensivist

Endocrinologist

Obstetrician (Emergency LUSCS if fetal distress)

Paediatrician

 

SAQ 098

Discuss the utility of ultrasound and b-hCG in the diagnosis of the patient with abdominal pain and vaginal bleeding in early pregnancy.

Beta-HCG

Bloods detects as small as 25 iu/ml

Home urine test >500 iu

Should double every 48 hrs

USS

Discriminatory Zones

TV 1500 - 2400

TA >3000 - 5000

PV bleeding & BHCG

High risk of ectopic - PID - embryo t/f

- previous ectopic - older

- sterilisation /IUD - smoker

ultrasound & admit

Level 1500 - TV ultrasound

BHCG can be low or normal

High risk ultrasound

Only definite finding is FH out of ultrasound

Suspicious findings - free fluid

- adnexal mass/cyst

- ‘bagel sign’ in adnexa

If empty uterus

? complete M/C

? early ectopic

May need laparoscopy to determine

SAQ 155

Discuss your approach to a patient with PV bleeding in the first trimester of pregnancy.

1. Stability – unstable and free fluids → ectopic → OT→ minimum volume resus

2. Location of pregnancy discriminatory zone BHCG

3. Viability of pregnancy – risk of ectopic

4. Age of pregnancy

5. Need for admission – pain, severe bleeding, ectopic, high risk for

6. Need for anti-D

7. Mx of 1st tri problems

Ectopic – methotrexate vs surgery

Incomplete MC – expectent vs D&C

Threatened MC – expectent mx @ home

SAQ 302

A 32 year old multiparous woman presents via ambulance with marked per vaginal bleeding following the precipitous delivery at home of her term infant 15 minutes previously. The infant is well and is under the care of the neonatal service. The ambulance service has been unable to establish intravenous access and her blood pressure is now unrecordable.

Outline your management of this patient.

The overall pass rate for this question was 51 / 64 (79.7%).

Examiners felt that the important issues to cover were early involvement of obstetric services, resuscitation with an awareness that coagulopathy may be present and O-negative blood appropriate, alternative IV access sites, treatment of uterine atony with massage and oxytocics, and removal of the placenta. Failures related to limited attention being paid to the specific obstetric issues rather than the general resuscitation issues.

ALTERNATIVE QUESTION

A 30yo G3P2 woman who is two hours post partum after a home birth arrives at your dept accompanied by her midwife. She complains of excessive PV blood loss and dizziness. Outline your approach to her management.

ISSUES

(Primary) post partum hemorrhage – hemodynamically unstable – life threatening.

DDx for cause:

Uterine retained placenta

Atony

Cervical laceration

Check for products in os (cervical shock)

Vaginal/Perineal laceration/teat/episiotomy bleed

?Underlying coagulopathy/HELLP/pre-eclampsia

MANAGEMENT (Treatment, Supportive care, Disposal)

1. Treatment (resuscitation, specific treatment, treatment of complication)

A Resuscitation

Resuscitation area, full non-invasive monitoring, resus team approach including early call to O&G service (may need OT for definitive treatment) and to blood bank (O negative blood), OT and ICU.

Address immediate life-threats.

A Monitor airway for patency and protection.

NB still physiologically pregnant potentially difficult airway

Low respiratory reserve

High aspiration risk

Altered hemodynamics

B high flow O2 for sats > 93%

C 2 x 16g cannulae in antecubital fossae

Send off bloods incl VBG (Hb), FBE, U&E, glc, urgent cross match 6u PC

N/saline in 1L boluses

Endpoints: SBP > 100, PR < 100, good cap refill

After 2L N/saline commence packed cells (cross-matched/grouped/O neg)

Identify and stop the bleed:

Control external hemorrhage with direct pressure +/- sutures

Speculum examination of cervical os to remove any products (will need good suction at hand)

Uterine atony: rub up fundus, Syntocinon 10u stat then 40u in saline over ~ 2h

Retained placenta: urgent OT for manual evacuation

D monitor GCS

E keep warm

Monitor BSL

b. Specific treatment

As above re stopping bleeding

May need OT for:

Retained placenta

Repair of large perineal tear

Hysterectomy is necessary for ongoing uncontrollable bleed

Contact O&G, OT, anaesthetist early.

c. Treatment of complications

Massive blood transfusion can lead to coagulopathy:

Keep warm

FFP 6u, platelets 6u, cryoprecipitate 6u

Consider activated factor VII 80mcg/kg

Monitor resp and renal function (maintain fluid balance, UO 1-2ml/kg/h)

2. SUPPORTIVE CARE

Fluid balance

Monitor BSL

Keep warm

Anti-D if O negative

Support and reassure patient and family – involve social worker

3. DISPOSAL

Unstable urgent OT

Stable and source of bleed identified and addressed maternity ward

Stable but with potential for further bleed HDU/ICU

Monitor hemodynamics, gas exchange, renal function

 

SAQ 356

A 37 week pregnant woman presents with a history of severe headache accompanied by abdominal pain. Examination reveals a blood pressure of 180/120 mm mercury. There is tenderness and guarding over the right hypochondrium. She is afebrile.

a) What is the provisional diagnosis? How would you confirm this?

b) Outline your management plan.

ISSUES

Life-threatening illness: (Pre)eclampsia*

Two patients: mother and fetus (viable)

Best fetal care is good maternal care

Mainstays of therapy:

1. Stabilise mother Mg and benzo’s

2. Prevent recurrent seizures Mg 2 – 3 g/h (Magpie trial)

3. Treat severe HT (>160/>105) hydralazine 5mg or labetalol 10 – 20mg

4. Deliver fetus vaginal/LUSCS

*Consider other causes: epilepsy, infection, overdose (sympathomimetic toxidrome), metabolic/hypoglycemia, trauma

MANAGEMENT (Treatment, Supportive care, Disposal_

1. TREATMENT (Resuscitation, Specific Treatment, Treatment of Complications)

a. Resuscitation

Resus team incl obstetrician, anaesthetist (difficult airway), paediatrician

Notify OT, ICU +/- PICU

Address immediate life threats:

A unprotected if seizing +/- vomiting or GCS low post-ictally

ETT

Anticipate difficult airway

Pregnant – GOR, elevated diaphragm

Large breasts

Physiological changes: ↑RR, ↓FRC

Thiopentone + suxamethonium

Kessell’s laryngoscope

Difficult airway box

Anaesthetic back up

B note physiological changes

C left tilt or wedge under right buttock

2 x 18g cannulae

N/saline to endpoints SBP > 100, PR < 100, good cap refill

D STOP THE SEIZURE

MgSO4 2g iv push, repeat Q15min prn, upto 6g

End point: seizure terminated

Then: infusion 2-3g/h

Decrease rate if becomes hyporeflexic, monitor Ca (follow local protocols)

continue intil 24-48h post partum

Adjuncts midazolam/diazepam iv 5mg doses prn, upto 20mg

Thiopentone iv 5mg/kg

BP CONTROL

Hydrallzine 2.5 – 5mg iv boluses q20min

Aim ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download