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
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