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Hello, everyone. Er, welcome to the Obs and Gynae in the spotlight. I'll just give this a few more minutes, just more, some more people to join. Hi, everyone. Welcome again. Uh, this is session seven emergencies of Singin, um, run by the Scrubs team and the Obs Committee. Er, so today I will just be doing some SBA and SA Qs. Er, this is just a little disclaimer saying that I've written these questions and they've not been peer reviewed. So don't rely on these, er, for your revision, but, er, you can use it as a guide to help you and today I'll be covering ectopic pregnancy, preeclampsia, eclampsia and maternal sepsis. Ok. So the first question is, um, S AQ so an 18 year old female attends A&E with unilateral right, lower quadrant pain, which started four hours ago. She feels nauseous but has not yet vomited. What further questions would you like to ask when taking her history? So, if you can just write on the, on the chat and it should come up? Yeah. So these are all very good, um, questions. So, the nature of the pain, when was the last menstrual period is the patient sexually active. Any bleeding and yet could she be pregnant? Any aggravating or relieving factors? Does the pain radiate anywhere? So, yeah, very good. So, I've just got a few examples here. So you could do Kear on the patient. Um, ask whether she's had any cold sweats. Um, any history of trauma? Is she sexually active? Is she currently using contraceptives? Um, any history of miscarriages and then just the general rest of the history. So name four differentials, which co which you, which you could consider for this patient. So just as a reminder she has right, lower quadrant pain, which started four hours ago and she feels nauseous but not, has not yet vomited. Yeah, these are all really good examples. Ovarian torsion, ectopic pregnancy, appendicitis, obstruction, pyelonephritis, middle Schmitz as well. So just a few examples. So appendicitis, ovarian torsion, we've said UTI as well. P ID, endometriosis and diverticulitis as well. So the patient tells you that she's recently had unprotected intercourse two weeks ago. This prompts you to do a beta H CG which comes back positive. You suspect this is an ectopic pregnancy. What is the most likely location of an ectopic pregnancy? Oh I, yeah, that's correct. So, it's the ampulla. So, just a diagram here uh to demonstrate where that is. And as a bonus question, where is an ectopic pregnancy at highest risk of rupture? Yeah, that's correct. It's the isthmus which um you can see is orange on that diagram. So the patient tells you she doesn't understand how she ended up with an ectopic pregnancy as this has never happened to anybody in her family stage three risk factors which increase the risk of an ectopic pregnancy. So, very good answers. Uh So a past medical history of previous ectopic pregnancies or P ID. Um Both of these can cause inflammation and adhesions um as can endometriosis and also different types of contraception such as the IUD or the I US. Um The progesterone pill can um reduce ciliary motility and previous ligation or occlusion of a fallopian tube as well uh as well as pelvic surgery or IVF in the past. So, further investigations are performed based on the results. What are the next steps in terms of managing this patient? So, in case anyone's screen is lagging, the er in investigations are positive urine beta HCG uh serum be to H CG of 1200 an empty uterine cavity on ultrasound and a new score of zero er route. The site most likely to rupture was the isthmus, which is the site a bit closest to the actual uterine cavity. So, yeah, this one's a bit of a harder one. It, it's actually number three. So you retake the serum beta HCG in 48 hours. Uh The reason for this is if the initial beta HCG level is more than 1500 there's no intrauterine pregnancy, then you think you, you have to think this is an ectopic pregnancy. So then you would offer a diagnostic laparoscopy. If the beta HCG level is under 1500 the patient's stable, then you can check 48 hours later to see whether the beta HCG doubles or halves in 48 hours. If it doubles, then it's a viable pregnancy and you want to treat it as a miscarriage, uh then it's a viable pregnancy. And if it's a mess, if it divides every 48 hours, um, then it's a miscarriage. And this patient had a beta HCG of 1200 was stable because they had a new score of zero. So I hope that makes sense to everyone. The patient is offered medication to medically manage her ectopic pregnancy. Which of the following drugs would she have been offered? Yeah, excellent. It's methotrexate. So, Mifepristone and miSOPROStol, you would give that in the medical management of a miscarriage that was in utero methotrexate disrupts the folate dependent cell division and that prevents the fetal growth and that prevents er, the rupture of the fallopian tubes. So you would want to give methotrexate in this case. And as a bonus question, what must patients be advised to do 3 to 6 months after using the methotrexate? Yeah, both of these are, are correct. So you want to use contraception for the next 3 to 6 months. Um And you would also advise to afterwards to take folic acid, um, as you would normally do, um, for pregnancy, but you don't want to fall pregnant within that 3 to 6 month er, window. So question two, a 34 year old woman attends a routine antenatal clinic at 16 weeks gestation. She has no significant past medical history but suffers from occasional frontal headaches. She is noted to have a BP of 100 and 50/78. Your analysis shows protein zero and everything else. Zero and a ph of 6.5. What's the most likely diagnosis? So, this is actually a trick question. Um It is actually chronic hypertension and I'll explain why a gestational hypertension and preeclampsia can only be diagnosed after 20 weeks of gestation and this er lady is 16 weeks er pregnant. So it would be chronic hypertension, even if her protein was positive, it still wouldn't count as preeclampsia until she was 20 weeks pregnant. So, in normal pregnancy, you would affect, uh you would expect the BP to fall in the first trimester until around 20 to 24 weeks and then it normally goes back to normal levels. In gestational hypertension, you'd see an increase in the systolic over 140 or an increase a um above booking readings of over 30 and it would have to be above 20 weeks of gestation. Um This happens in around 5 to 7% of pregnancies and in gestational hypertension, you wouldn't get any proteinuria or edema. And after birth, it usually resolves and women with um P IH are at increased risk of future preeclampsia or hypertension later on in life. So it's, it's good to educate the patients on this as well. So two B, the woman has told her diagnosis of chronic hypertension and is advised to start an antihypertensive drug. She's also warned that she is at high risk of developing preeclampsia, which two drugs will she be started? Yeah, well done guys. So you would give labetalol that's first line um for pregnant women and aspirin, 75 to 100 and 50 mg. Er, this is recommended for women with one high risk factor or more than two moderate risk factors and should be continued from 12 weeks gestation. So, um on the same sort of topic, what are three other risk factors of developing preeclampsia? Sorry guys, I think my internet cut off. Um, can you hear me? Thank you. So yeah, some moderate uh some moderate risk factors are nly parity. Er, a maternal age of over 40 years. Um A high BM I A family history of preeclampsia which was mentioned in the comments, er, multiple pregnancy, a pregnancy interval of over 10 years and some high risk factors would be chronic hypertension, um hypertension or preeclampsia in previous pregnancy, diabetes or an autoimmune disease. So, to be diagnosed with preeclampsia, you need to have hypertension and proteinuria after 20 weeks, gestation and the mechanism of this is to do with poor placentation where you get placental ischemia, which leads to a cytokine release and um increases capillary permeability. And that makes the body respond by vasoconstricting, which increases BP. But the exact mechanism of this is not really that well known and uh to manage preeclampsia. So you would monitor by checking the patient's BP, urinalysis, blood tests and fetal growth scans. You would want to make sure that they, they've got VT E prophylaxis. So that's usually low molecular weight, heparin antihypertensives and which we've said was labetalol and delivery of baby is the definitive treatment. Sorry, I'm just struggling with the wifi for a bit. One second. Hi, everyone. Sorry about that. I just had some Wi Fi issues. Can you see the screen and hear me? OK. Again. Thank you. OK. So the next question, uh one of the complications of preeclampsia is the development of Hellp Syndrome. Uh What does this stand for? Yeah, well done. That's exactly it. So, hemolysis, elevated liver enzymes and low platelets. So that's why it's really important when a patient has preeclampsia that you check their LFT S that full blood count and using these because um they, they could be having Hellp Syndrome at, at any point during their pregnancy. Ok. Question number three, a 35 year old woman is admitted onto the Antenatal ward due to poorly controlled preeclampsia. She's 30 weeks pregnant with her first child while the F one is examining her alone in the room, she suddenly falls unconscious and starts having a seizure on the bed. Which of the following is the most appropriate step in the management of this patient. Yeah. Well, don't everyone. So it's number three. So you would give IV magnesium sulfate. So this is given as a 4 mg bolus and then continued for 24 hours after the seizures um to prevent further seizures from happening and it works by increasing the seizure threshold. Which of the following signs or symptoms is she least likely to have elicited the previous week. So a a negative question just as a hint, well done everyone. So it's actually hyperreflexia that you would typically find in eclampsia and also poorly controlled preeclampsia. Another negative question. What is not a known fetal complication of preeclampsia? Yeah. So you would expect to see a potential intrauterine growth restriction, placental abruption or also neonatal hypoxia. But you would unlikely see uh fetal hypertension and last of the negative questions, which is not a likely maternal complication of preeclampsia. Yeah, well done everyone. It's for obstetric cholestasis is not a complication of preeclampsia. So the final case, a 30 year old primi Paris woman at 19 weeks, gestation presents to the maternity unit with a rupture of membranes. She's admitted for observation on the labor ward, but 24 hours have now passed with no onset of contractions occurring on examination. Maternal observations are normal and fetal ctg is reassuring. What complication is she most at risk of if she goes home. Yup, we're done guys. So, uh possibly she could get chorioamnionitis, which is an infection of the membrane in the uterus that could also make her become septic and potentially miscarry, which antibiotic is given as prophylaxis against chorioamnio. So, you would be giving this patient prophylactic Erythromycin four times a day for 10 days if they're less than 36 weeks pregnant. Um for er those who thought it was benzylpenicillin, that's the one you would give for GBS. The way I like to remember is the B in GBS for benzylpenicillin. If that helps, what are the typical signs and symptoms of chorioamnionitis? And why is it a concern in cases of pe prom er Hannah? The antibiotic for chorioamnionitis was Erythromycin and then for GBS, it Benzyl penicillin. And yeah, it's number three. So, headache, visual disturbance and leg swelling. Um you would expect that in preeclampsia that was just to throw everybody off. A week later, she is admitted into hospital with the following obs based on her observations, how would you manage this patient? So, yeah, you would initiate the sepsis six protocol and perform a fetal H CG. Er This patient has very low ss um her heart rate is slightly elevated but she's also got a elevated temperature as well. So you decide to initiate the sepsis six protocol. What is the sepsis? Six? Yeah. Well, done everyone. So you give three and you take three. So give oxygen, um, take blood cultures, give IV antibiotics, give IV fluids and you would want to do a, a stat bolus to increase her BP. Um, you would want to check the lactate and measure the urine output. And specifically for this lady because she's pregnant, you want to monitor er, the fetus and consider expediting delivery. Um, she is 19 weeks pregnant at the moment. So it would likely cause uh not be viable to life if, if that were to happen a few hours later, the mother is stabilized. A pelvic ultrasound is performed several days later after this which unexpectantly finds no fetal heartbeat in the fo in the fetus in the uterus. Um At 19 weeks gestation, the cervical Os is closed. What type of miscarriage is this? Yeah, we're all done everyone. So it would be classed as a missed miscarriage. So, just to explain the types of miscarriages. So, miscarriages happen in roughly 20 to 25% of pregnancies. Um So it is quite common. Um, unfortunately, uh so a threatened miscarriage would be if there's any pain or bleeding in uh in a baby that's less than 24 weeks gestation. And if the heartbeat were present and the cervical os is closed, mis miscarriage as in as with this case, is diagnosed with ultrasound only. So it would be when they do an ultrasound scan and the gestational sac contains uh features that has no heartbeat and it's before 20 weeks without the symptoms of expulsion. So, the cervical os in this case would have to be closed. An inevitable miscarriage is when the cervix is open. Um And not all of the fetus has passed, but it inevitably will. But um uh none of the fetus has passed but inevitably will. And an incomplete one would be when some of the tissue remains in the uterus. A complete miscarriage is when all of the tissue pregnancy, um, has passed and the OS is open. And if the miscarriages happen for more than three consecutive pregnancies with the same partner, um, it would be classed as a recurrent miscarriage. And in this case, you would want to do further investigations to try and find out why the lady is having so many miscarriages. So you would do some tests, um, including antiphospholipid checking for antiphospholipid syndrome and any uterine anomalies which she has. And that's the end of the session guys. Thank you so much for attending and for commenting the answers. I hope it was helpful and, uh, good luck with er, all your exams coming up. Uh, please, would you be able to feed, uh, do the feedback form for us? So if you just scan this QR code, it would be very helpful. Um, so Hannah has kindly put the link on the chat as well. So if you could do the feedback form on there. I'd be very, very grateful and have a lovely rest of your evening guys. Thank you so much.