ࡱ> 8:567 bjbjΚΚ *dxxHHHHH\\\\ \\1@||||||& 0000000,46t40MH||40#HH||1###" H|H|0#0##.h/0xDۋ!*//101:/|-7#-7 /#H/<4040#1-7x :   O & G SAQs 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 Kessells 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 - repeat BHCG 48 hrs 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 benzos 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 <160/<105 Alternatives: labetolol 10-20mg q10min (dont use nitroprusside unless <30min to delivery) E temp, BSL b. Specific treatment DELIVER THE BABY 36/40 = viable, should not need steroids Vaginal delivery or LUSCS depending on patient stability c. Treatment of complications cerebral edema/hypoxic brain injury optimise secondary issues: PaCO2 35, PaO2 100, Na 150, normothermia, normoglycemia Monitor for: Renal failure Liver injury and rupture Intracerebral hemorrhage Cardiorespiratory arrest aspiration pneumonitis/acute pulmonary edema Portpartum hemorrhage DIC, HELLP 2. SUPPORTIVE CARE Fluid balance: IDC for UO aim 1-2ml/kg/h BSL, temp Analgesia prn (headache paracetamol/codeine, pethidine) Support family (partner) involve social worker Increased risk for future pregnancies Many need PICU if baby compromised contact retrieval team early Consider staff debriefing afterwards emotive issue 3. DISPOSAL Labour ward or OT for LUSCS Then ICU for mother risk of eclampsia remains high post-partum Monitor BP, hemodynamics, conscious level, renal function, gas exchange Input from: intensivist, obstetrician, paediatrician SAQ 229 A 20 year old woman arrives in your ED with a pre-hospital cardiac arrest (which occurred 5 minutes previously) following blunt trauma from a car crash. You are told that she is 28 weeks pregnant. She is in ventricular fibrillation. Outline your management. Call for HELP Paediatrics O & G other ED staff start perimortum CS Simultaneous continue resuscitation of M Blunt chest trauma and arrest nearly 100% mortality Mum - I&V - anticipate difficulty, continue CPR, left tilt - shock 150J Biphasic 150J 200J 200J Monophasic 200J 360J - iv fluid load 1000ml stat - Adrenaline 1mg IV 95min Perimortum CS can check viability with ultrasound - vertical incision xiphisternum to symphysis pubis - through linea alba - make a classical (vertical) incision in uterus from fundus to bladder reflection if find placenta, continue to cut through deliver baby, clamp and cut cord fetal survival with good neurological outcome 70% some reports of maternal survival SAQ 409 A 27 year old female presents after a high speed motor vehicle accident in which she was the front seat passenger. She is 28 weeks pregnant. Her pulse rate is 75 beats per minutes, blood pressure 100/60 mm Hg, peripheral perfusion appears normal and she is alert and orientated. Her only external sign of injury is a seat. belt mark on her chest and abdomen. Discuss the issues peculiar to pregnancy that should be considered in this patient's assessment, investigation and disposition. Trauma in pregnancy is a significant cause of morbidity and mortality for both mother and foetus. Fundamental issues relating to the pregnant trauma patient include 2 patients to consider mother and foetus viable at 28/40 altered baseline physiology will make assessment of haemodynamic state challenging investigations/pathology altered by pregnancy per se unique issues to pregnancy abruption, amniotic fluid embolus, uterine rupture/laceration, foetal injury/death, PROM/prem labour disposition including a period of CTG monitoring Assessment : As with any trauma patient Significant mechanism Manage in high acuity area with resus facilities O2/monitor IV access Primary survey followed by secondary survey including log roll and obstetric examination Analgesia Specific features on history: Ask if blood group known (assess need for anti-D if Rh ve) Single or multiple pregnancy PMHx/complications of pregnancy such as PIH/IUGR Foetal movements felt since MBA Uterine contractions felt Abdominal or pelvis pain Examination: At 28/40 to avoid IVC compression patient should be positioned in L lateral decubitus position If concerns re spinal injury on history or examination a wedge can be placed underneath the spinal board, or manually displace the uterus to R Physiological changes in pregnancy: SBP and DBP fall by 10 15 mmHg in second trimester Cardiac output progressively increases by up to 45% at term- patient in hypervolaemic state and may lose a significant volume of blood before it becomes clinically evident Evaluation of haemodynamic state may be very difficult HR increases by 15 20 bpm over pregnancy Therefore need to keep these changes in mind. At present this patients vital signs are stable, but need to be vigilant in assessment of bleeding as vital signs will be late to change. Use other clinical signs in assessment such as perfusion and capillary refill. trend in signs over time mechanism of injury Due to the uterus assessment of abdominal injury may be difficult and localised signs of peritonism may be hard to detect. Also should have CTG monitoring and obstetric/PV exam. Investigations: Bloods to do FBC, U&E, creat, gp and hold, Kleihauer, +/- ABG Expect dilutional anamia with Hb < 12 Leucocytosis of up to 18,000 in 2nd and 3rd trimester Mild respiratory alkalosis normally present due to increase in tidal volume Kleihauer test should performed assess occurrence and magnitude of any foeto-maternal haemorrhage and the need for anti-D if mother Rhesus ve ECG : due to cephalic displacement of heart left axis deviation can occur T wave inversion or flattening in III, V1 and V2 Radiological assessment should proceed as needed as risk to fetus is reduced at 28/40 and radiation exposure with plain films is minimal On Hx this patient may need Cx spine and CXR +/- pelvis with abdominal shielding. On CXR AP diameter of chest and mediastinum may be increased due to pregnancy. Other investigations include Doppler USS at bedside to assess foetal HR USS to assess foetus/liquor volume and possibility of abruption even in the absence of physical signs of a problem CTG monitoring while patient in ED Early liaison with Labour Ward and Obstetricians with ideally PV examination and obstetric examination by them. Injuries specific to the pregnant patient include Abruption Amniotic fluid embolus Uterine rupture Laceration of palcenta or cord Foetal injuries PROM Premature labour These injuries need to be kept in mind when assessing this patient. Clinical examination and USS will alert to the possibilities. CTG monitoring is more sensitive than USS to diagnose abruption. Disposition Will depend on injuries found If patient otherwise well and no injuries detected patient needs admission/observation for at least 4 hours to a labour ward setting for CTG monitoring. PHYSIOLOGICAL CHANGESAirwayLarge breastsPotentially difficult airwaysphincter tonerisk aspirationgastric pressureBreathingtidal volumerespiratory reserveFRCVC, RR sameO2 consumptionRespiratory alkalosis normalCirculationSUPINE HYPOTENSION SYNDROME (IVC compression by gravid uterus)Left tilt or wedge under right buttockBlood volume  by 50% Masks hypovolemiacardiac output, relative anemia (Hb 11)Flow murmurBP 10-15mmHgWCC, coag factorschest complianceCPR more difficultAbdominalGI motilitysphincter toneGORCephalad displacement or organsBladder intra-abdominalMore likely to be injuredDilated renal pelvis and uretersUterine blood flow  by 100xTYPICAL INJURIESPlacental abruptionFetal injuriesFetomaternal hemorrhage:Amniotic fluid embolismPROMFetal anemiaUterine rupturePremature labourFetal deathPlacenta/cord lacerationRh isoimmunisationTWO PATIENTSMotherBest approach to fetal survival is to ensure maternal survivalMaternal shock 80% fetal mortalityBabyEarly CTG monitoring and obstetric USSEstablish fetal age and viabilityMay require early deliveryMay need peri-mortem C-section- maternal arrest - within 4 minutesRHESUS FACTORRh neg motherKleihauer testAntiD: 1ml = 625iu and neutralises 6ml of fetal bloodINVESTIGATIONSLimited wrt:RadiationcontrastEMOTIVE ISSUESupport of mother/patient and familyCritical incident stress debriefing for staffDISPOSALOTTrauma teamLabour wardobstetricianPaeds/PICUpaediatricianRetrieval teamICUintensivist A 32 year old lady is brought in by ambulance. She was the driver of a car T-boned from the right side at high speed. She complains of neck and lower abdominal pain . Her BP is 85/65, PR 110, RR 28. You note there is PV bleeding. Outline your management. Multi-trauma in pregnant lady Viable fetus by gestational age Likely injuries/priorities: Airway and cervical spine (difficult airway) Maternal shock (in setting of physiological hypervolaemia) Secondary to ?abruption, pelvic injury, abdomen Fetal distress likely Maternal recuss (fluids, positioning +/- theatre ) initial priority Need for trauma team and additional obstetrician /paediatrician Management as per EMST guidelines Preparation Primary survey A B C neglect position bad news D E IDC/ bloods Radiology and secondary survey. XR U/S CT Fetal monitoring CTG Analgesia Anti-D Disposition Theatre or delivery suite. 1. A pregnant 17 year old girl has been brought to your ED after a hypoxic episode related to deliberately inhaling paint (chroming). She has had several similar episodes in the past. Her GCS is now 15. Discuss the management options. Issues 1. Approach patient with tact and care as she is highly likely to abscond, have support people in attendance, eg nurses, social worker Highly likely not to attend follow-up so have her seen whilst in hospital eg antenatal, drug and alcohol, social work 2. Patients current health/state of intoxication Look for pulmonary, neurological, cardiovascular signs acute (or chronic) toxicity CXR (with lead shielding), neuro exam (esp cerebellar), ECG Oxygen and supportive care 3. Unborn childs status/health. What stage of pregnancy? Obstetric/sexual/gynae/medical history Examine/investigate appropriate to gestational age 1st trimester - (hCG, USS, fetal heart 3rd trimester fetal heart, ?CTG 4. Any antenatal care? If not, initiate basic tests and arrange follow-up in high risk obstetric clinic Other high risk factors eg IVDU, risk STDs, Initiate HepB, C, HIV testing if high risk after informed consent from patient 5. Substance abuse in pregnancy High risk of other / poly-substance abuse eg alcohol (F.A.S), opiate, cocaine Needs drug and alcohol service follow-up Drug withdrawal can be as dangerous as substance abuse itself 6. Social issues Any family/guardian supports? Home circumstances? Homeless? Partner? Abuse? Physical or sexual pregnant as a result of rape? Forensic issues then an issue Social services already involved? Own case-worker Offer admission if any medical or social concerns to sort out the medical/drug/ pregnancy/social issues raised 7. Multi-disciplinary approach Medical if acute issues Obstetric/antenatal Drug and alcohol Social services 7.) You are asked to write guidelines to help fast-track the emergency department care of women with first trimester PV bleeding. a.) Outline these guidelines. (50%) b.) How would you track the effectiveness of the new guidelines? (50%) 3.) A 23 year old lady is brought in by ambulance. A GPs letter says. Mrs. Green is 30 weeks pregnant and has a 2/24 history of vaginal bleeding and right sided abdominal pam. HerBP is 90/65. pulse 110. RR 28. Outline your assessment. 3.) A 30-year-old lady who is currently 35 weeks pregnant is brought in to your tertiary hospital ED from a high speed car accident. The ambulance officers tell you she was the driver and that the car struck a pole on the passengers side. There were no other occupants. She is complaining of neck, abdominal and pelvic pain and has mild PV bleeding. Her BP is l00/65,P105 andRR 24. Outline your assessment and initial management. SAQ 1 Write a guideline for the assessment of first trimester bleeding. (100%) The overall pass rate for this question was 45/81 (55.6%). Successful responses in this question addressed definitions, inclusion/exclusion criteria, quantification of bleeding/pain, haemodynamic status, abdominal/vaginal examination findings, B HCG levels, ultrasound indications and Rh status. Failed answers suggested inadequate history/examination/tests or strayed into management issues SAQ 6 A 28 year old woman who is 32 weeks pregnant is brought in by ambulance to your base hospital. She complains of seeing flashing lights and having headaches. At triage, her vital signs are: - Pulse rate 80 beats/minute - Blood pressure 135/95mmHg - Glasgow Coma Score of 15/15 As you start to assess her she has a grand mal seizure. Describe your management of this patient. The overall pass rate for this question was 43 / 69 (62.3%). Examiners expected that an answer to this question would include an awareness of the importance of the left lateral position, the role and dosing of magnesium which is now an accepted mainstay treatment, awareness that airway management may be difficult in this situation and require expert assistance, addressing of the issue of blood pressure control, consideration of foetal well being and addressing eclampsia complications such as aspiration and DIC. Candidates who failed tended not to address these issues in particular that the blood pressure was abnormal and in doing so displayed tentative obstetric knowledge in an area clearly of relevance to the general emergency physician. 2008.2 SAQ 8 A 32 year old woman who is 33 weeks pregnant is referred to your emergency department because of a blood pressure of 140/95 and right upper quadrant pain for 24 hours. One hour after arriving in the emergency department, the patient begins to have a grand mal seizure. Describe your management. (100%) 1. A 20 year old woman presents to your ED with one day of lower abdominal pain and light vaginal bleeding. She is G0 P0 M0, and it is 5 weeks since her last menstrual period. On examination, she appears pale, with the following observations. HR 100/min BP 95/60 mmHg supine Temperature 370 C Describe your assessment 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 Kessells 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 - repeat BHCG 48 hrs 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 benzos 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 <160/<105 Alternatives: labetolol 10-20mg q10min (dont use nitroprusside unless <30min to delivery) E temp, BSL b. Specific treatment DELIVER THE BABY 36/40 = viable, should not need steroids Vaginal delivery or LUSCS depending on patient stability c. Treatment of complications cerebral edema/hypoxic brain injury optimise secondary issues: PaCO2 35, PaO2 100, Na 150, normothermia, normoglycemia Monitor for: Renal failure Liver injury and rupture Intracerebral hemorrhage Cardiorespiratory arrest aspiration pneumonitis/acute pulmonary edema Portpartum hemorrhage DIC, HELLP 2. SUPPORTIVE CARE Fluid balance: IDC for UO aim 1-2ml/kg/h BSL, temp Analgesia prn (headache paracetamol/codeine, pethidine) Support family (partner) involve social worker Increased risk for future pregnancies Many need PICU if baby compromised contact retrieval team early Consider staff debriefing afterwards emotive issue 3. DISPOSAL Labour ward or OT for LUSCS Then ICU for mother risk of eclampsia remains high post-partum Monitor BP, hemodynamics, conscious level, renal function, gas exchange Input from: intensivist, obstetrician, paediatrician SAQ 229 A 20 year old woman arrives in your ED with a pre-hospital cardiac arrest (which occurred 5 minutes previously) following blunt trauma from a car crash. You are told that she is 28 weeks pregnant. She is in ventricular fibrillation. Outline your management. Call for HELP Paediatrics O & G other ED staff start perimortum CS Simultaneous continue resuscitation of M Blunt chest trauma and arrest nearly 100% mortality Mum - I&V - anticipate difficulty, continue CPR, left tilt - shock 150J Biphasic 150J 200J 200J Monophasic 200J 360J - iv fluid load 1000ml stat - Adrenaline 1mg IV 95min Perimortum CS can check viability with ultrasound - vertical incision xiphisternum to symphysis pubis - through linea alba - make a classical (vertical) incision in uterus from fundus to bladder reflection if find placenta, continue to cut through deliver baby, clamp and cut cord fetal survival with good neurological outcome 70% some reports of maternal survival SAQ 409 A 27 year old female presents after a high speed motor vehicle accident in which she was the front seat passenger. She is 28 weeks pregnant. Her pulse rate is 75 beats per minutes, blood pressure 100/60 mm Hg, peripheral perfusion appears normal and she is alert and orientated. Her only external sign of injury is a seat. belt mark on her chest and abdomen. Discuss the issues peculiar to pregnancy that should be considered in this patient's assessment, investigation and disposition. Trauma in pregnancy is a significant cause of morbidity and mortality for both mother and foetus. Fundamental issues relating to the pregnant trauma patient include 2 patients to consider mother and foetus viable at 28/40 altered baseline physiology will make assessment of haemodynamic state challenging investigations/pathology altered by pregnancy per se unique issues to pregnancy abruption, amniotic fluid embolus, uterine rupture/laceration, foetal injury/death, PROM/prem labour disposition including a period of CTG monitoring Assessment : As with any trauma patient Significant mechanism Manage in high acuity area with resus facilities O2/monitor IV access Primary survey followed by secondary survey including log roll and obstetric examination Analgesia Specific features on history: Ask if blood group known (assess need for anti-D if Rh ve) Single or multiple pregnancy PMHx/complications of pregnancy such as PIH/IUGR Foetal movements felt since MBA Uterine contractions felt Abdominal or pelvis pain Examination: At 28/40 to avoid IVC compression patient should be positioned in L lateral decubitus position If concerns re spinal injury on history or examination a wedge can be placed underneath the spinal board, or manually displace the uterus to R Physiological changes in pregnancy: SBP and DBP fall by 10 15 mmHg in second trimester Cardiac output progressively increases by up to 45% at term- patient in hypervolaemic state and may lose a significant volume of blood before it becomes clinically evident Evaluation of haemodynamic state may be very difficult HR increases by 15 20 bpm over pregnancy Therefore need to keep these changes in mind. At present this patients vital signs are stable, but need to be vigilant in assessment of bleeding as vital signs will be late to change. Use other clinical signs in assessment such as perfusion and capillary refill. trend in signs over time mechanism of injury Due to the uterus assessment of abdominal injury may be difficult and localised signs of peritonism may be hard to detect. Also should have CTG monitoring and obstetric/PV exam. 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On CXR AP diameter of chest and mediastinum may be increased due to pregnancy. Other investigations include Doppler USS at bedside to assess foetal HR USS to assess foetus/liquor volume and possibility of abruption even in the absence of physical signs of a problem CTG monitoring while patient in ED Early liaison with Labour Ward and Obstetricians with ideally PV examination and obstetric examination by them. Injuries specific to the pregnant patient include Abruption Amniotic fluid embolus Uterine rupture Laceration of palcenta or cord Foetal injuries PROM Premature labour These injuries need to be kept in mind when assessing this patient. Clinical examination and USS will alert to the possibilities. CTG monitoring is more sensitive than USS to diagnose abruption. Disposition Will depend on injuries found If patient otherwise well and no injuries detected patient needs admission/observation for at least 4 hours to a labour ward setting for CTG monitoring. PHYSIOLOGICAL CHANGESAirwayLarge breastsPotentially difficult airwaysphincter tonerisk aspirationgastric pressureBreathingtidal volumerespiratory reserveFRCVC, RR sameO2 consumptionRespiratory alkalosis normalCirculationSUPINE HYPOTENSION SYNDROME (IVC compression by gravid uterus)Left tilt or wedge under right buttockBlood volume  by 50% Masks hypovolemiacardiac output, relative anemia (Hb 11)Flow murmurBP 10-15mmHgWCC, coag factorschest complianceCPR more difficultAbdominalGI motilitysphincter toneGORCephalad displacement or organsBladder intra-abdominalMore likely to be injuredDilated renal pelvis and uretersUterine blood flow  by 100xTYPICAL INJURIESCCCCCC $Ifgdg?wkd#$$If\Jk !;8622 l4aytg?CCCCD>D $Ifgdg?wkd8$$$If\Jk !;8622 l4aytg?CDDDD@DBDDDFDHDJDjDlDnDpDrDtDvDxDzD|D~DDDDDDDDDDDDDDDDDDDDDDDDDDEEEEEE E۽ۊ۽ۊ۽ۊ۽ۊ۽ۊ5hV8h56B*CJOJQJ\]^JaJph/hV8h5B*CJOJQJ\^JaJphhV8hCJaJ%hV8hB*CJOJQJaJphhV8hB*CJaJph)hV8hB*CJOJQJ^JaJph6>D@DDDHDlDpD $Ifgdg?wkd$$$If\Jk !;8622 l4aytg?pDrDvDzD~DD $Ifgdg?wkd%$$If\Jk !;8622 l4aytg?DDDDDD $Ifgdg?wkdf&$$If\Jk !;8622 l4aytg?DDDDDD $Ifgdg?wkd '$$If\Jk !;8622 l4aytg?DDEEE E $Ifgdg?wkd'$$If\Jk !;8622 l4aytg? 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