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MRCOG PART 2 SBAs and EMQs

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Posted by H H.
Many thanks
Posted by Ir A.
Thank you, Dr Paul.
Posted by AMMAR A.
27 year old woman with sickle cell disease attends the antenatal clinic at 12 weeks gestation in her first pregnancy. (a) Discuss your clinical assessment [7 marks]. (b) Discuss the modifications that you will make to her antenatal care [8 marks]. (c) Discuss the modifications that you will make to her intra-partum care[5 marks].
firstly, thanks Dr. Paul
this patient ( at the gestational age she comes for care) has the risk of increase the frequency of crisis (pain crisis or avascular bone necrosis), also there is high risk of miscarriage, infection and thromboemboletic disease.
she should get her medical care in a joint clinic by obstetrician and haematologist who is expert in haemoglobinopathies. i\'ll do the routine investigations for her, complete blood count, blood sugar, urine test, urine culture and sensitivity, and blood group and Rh, with special attention to the detailed antibodies, as she surely had many blood transfusions already, and she may have got many antibodies, that may affect the cross-matching later.
the modifications that she should get: firstly i\'ll offer her the prenatal diagnosis and i\'ll explain to her that if she wants this it will need amniocentesis the will be done at about 15 weeks. i\'ll ask if she was / or still on chelating treatment, if se still, i\'ll advice her to stop them as they are contraindicated during pregnancy. i\'ll check if there is overload of iron, by doing ferritin. if it is elevated, echocardiogram and cardiac assessment should be done to exclude / confirm cardiomypathy.
i\'ll prescribe her folic acid 5 mg daily, and put her on prophylactic penicillin throughout the pregnancy to prevent infections,
haemoglubine and HbS should be monitored regularly.
renal and liver function tests should be done regularly in pregnancy as both may be impaired.
program for top-up transfusion and exchange transfusion if indicated should be put, thromboprophylaxis should be given throughout pregnancy, and postnatally.
regular assessment of fetal growth and placental function should be done.
nurses or lab technician should take care when having the samples to her, to keep at least one vein safe for access when needs transfusion.
aggressive treatment with antibiotics should be applied in infections, and advices should be given to avoid dehyeration , and avoid exposure to cold.
during labour: I fluids to avoid dehydration, and oxygyn to avoid hypoxia. analgesia , continous electronic monitoring to the fetus. continuoing thromboprophylaxis. although giving antibiotics in labour is cotoversal, but i prefer to give it as she will be on it throughout the pregnancy. vaginal delivery is encouraged, and caesarian section should be done for obstetric indications only, if there is need to it, general anaesthesia shold be avoided.
Posted by Despina  M.
(a)I would check the type of sickle cell disease,Hb level,BP,dipstick as increased risk of pre-eclampsia
I would screen partner for haemoglominopathies and counsel possible results,if positive for carrier-risk to fetus,possible diagnostic invastigations.
Dating scan is important for accurate dating,gestational age for management of pregnancy and timing of delivery avoiding iatrogenic prematurity.
counsel the effects of pregnancy on the sickle cell disease: increased risk of painful crisis,increased risk of sickling(what that means ),increased risk of infection(UTI,chest)
Counsel effects of disease on pregnancy- fetal risks are IUGR,miscarraige,preterm delivery,increased mortality by four fold,fetal distress. maternal risks are pre-E,placental abruption,thromboembolism,bone marrow embolism,avascular necrosis of bone c/s,increased mortality.
plan the care
frequent visits
(b)folic acid 5mg/day, partner screening haemoglominopathy implications if positive
detailed anomaly scan,regular growth scans as higher risk of IUGR,regular BP,urinalysis as higher risk of Pre-E and is important to detect early so plan of care and close monitoring and possible ealrier delivery if indicated.
Hb check,if below 8, if iron deficient- iron supplementation or blood transfusion only if clinically indicated,otherwise no benefit for prophylactic
no evidence to show benefit for prophylactic thromboprophylaxis-only if additional risk factors.
(c)Operative delivery or c/s as clinically indicated
FBC- blood transfusion of below 8
well hydration with IV hartmans,keep warm to prevent crisis
Continuous CTG as higher risk for fetal distress
avoid prolonged labour as increases risk of infection,dehydration and generalised stress that would prone for crisis
continue antibiotics.
check BP,sats

prophylactic antibiotics penicillin 250mg BD
Posted by AMMAR A.
Discuss the potential impacts of maternal diet and body mass index on pregnancy outcome [12 marks]. (b) Discuss the impact of nutritional supplementation on pregnancy outcome [8 marks].

(a) diet of pregnant -like other people- should be balanced, with increased the total calories about 300-500 kcal to arrive 2400-2600 kcal/day, and the protein intake to 60-70 g/day.
maternal weight gain during pregnancy affects the birthweight of the infant.
women should gain 8-12 kg during pregnancy, (avarage 0.7 lb/week till 20 weeks, then 1 lb/week till term).
women with BMI > 29.9 should gain at least 8 kg trhoughout pregnancy, but those with BMI > 18.5 should gain 12-18 kg.
effects of BMI on pregnancy output:
BMI<18.5, gaining less than 16 lbs or being less than 50 kg increases risk of new born weight < 2500 g.
women with BMI 18.5-25 are healthy, 25-29.9 are considered overweight , and 30 or more are obese, the later is associated with increased risk on the pregnant herself, that includes: gestational diabetes (with its impact on the fetus) / OGTT with 75 g glucose should be done, venous thrombo embolism, vitamine deficiencies (folic acid and calcium noted at BMI > 27), difficulties in ultrasound scanning.
in addition, there are intrapartum risks include slow progress in labour, high caesarian rate, sholder dystocia, anesthetic difficulties, and postpartum complications including postpartum hemorrhage, and wound infection.
BMI 30 or more affects the fetus and the neonate: high risk of miscarriage, congenital anomalies (neural tube defects due to folate deficiency) , macrosomia, birth trauma, stillbirth , prematurity. neonatal death, difficulty in breastfeeding.

(b) folic acid should be started 5 mg / day (for BMI >30 and women on antiepiliptic drugs) , and 0.4mg/day for healthy weight one month before conceiving till end of 12 weeks, to decrease the neural tube defects, calcium 10 mcg/day as soon as getting pregnant (espicially for obese). iron addition is not obligatory, it is individual according to Hb value as it may be intolerable due to GI disturbances (but it is strongly recommended for vegitarians), all other vitamine and mineral additions should not be more than twice of the daily requiremants as they may be toxic, espicially fat solube vitamines, vit B6 overdose may cause neuropathy, and vit. A > 700 m iu may be toxic even in the food (liver).
Posted by AMMAR A.
Discuss the potential impacts of maternal diet and body mass index on pregnancy outcome [12 marks]. (b) Discuss the impact of nutritional supplementation on pregnancy outcome [8 marks].

(a) diet of pregnant -like other people- should be balanced, with increased the total calories about 300-500 kcal to arrive 2400-2600 kcal/day, and the protein intake to 60-70 g/day.
maternal weight gain during pregnancy affects the birthweight of the infant.
women should gain 8-12 kg during pregnancy, (avarage 0.7 lb/week till 20 weeks, then 1 lb/week till term).
women with BMI > 29.9 should gain at least 8 kg trhoughout pregnancy, but those with BMI > 18.5 should gain 12-18 kg.
effects of BMI on pregnancy output:
BMI<18.5, gaining less than 16 lbs or being less than 50 kg increases risk of new born weight < 2500 g.
women with BMI 18.5-25 are healthy, 25-29.9 are considered overweight , and 30 or more are obese, the later is associated with increased risk on the pregnant herself, that includes: gestational diabetes (with its impact on the fetus) / OGTT with 75 g glucose should be done, venous thrombo embolism, vitamine deficiencies (folic acid and calcium noted at BMI > 27), difficulties in ultrasound scanning.
in addition, there are intrapartum risks include slow progress in labour, high caesarian rate, sholder dystocia, anesthetic difficulties, and postpartum complications including postpartum hemorrhage, and wound infection.
BMI 30 or more affects the fetus and the neonate: high risk of miscarriage, congenital anomalies (neural tube defects due to folate deficiency) , macrosomia, birth trauma, stillbirth , prematurity. neonatal death, difficulty in breastfeeding.

(b) folic acid should be started 5 mg / day (for BMI >30 and women on antiepiliptic drugs) , and 0.4mg/day for healthy weight one month before conceiving till end of 12 weeks, to decrease the neural tube defects, calcium 10 mcg/day as soon as getting pregnant (espicially for obese). iron addition is not obligatory, it is individual according to Hb value as it may be intolerable due to GI disturbances (but it is strongly recommended for vegitarians), all other vitamine and mineral additions should not be more than twice of the daily requiremants as they may be toxic, espicially fat solube vitamines, vit B6 overdose may cause neuropathy, and vit. A > 700 m iu may be toxic even in the food (liver).
Posted by SARO K.
Sickle cell disease and pregnancy:
I will take a detailed history about treatment of sickle cell disease like drug intake -Hydroxy urea and desferroxamine, repeated transfusions,factors leading to sickle cell crisis and repeated infections and how she has been managed so far.I will ask about previous miscarriage,any treatment done for the conception .Also history of consanguinity.
I will asses her general condition by checking height,weight,pulse rate ,BP ,Look for pallor ,icterus ,routine systemic and per abdomen examination.
I will advise her to do the routine blood tests -Hb to rule out anemia and white cell count to rule out infections and urine dipstick to rule out proteinuria,blood grouping and antibodies as she already had lot of tranfusions followed by serology to look for Bloodborne virus infections HIV,Hepatitis B and HCV.I wil do an usg to confirm dating and viability.I will offer amniocentesis as prenatal diagnostic test as sickle cell disease is an Autosomal recessive disease if the partner is having sicklle sell disease /trait.serum ferritin to rule out Iron overload.If levels are high advised to do echo.Also urine culture and sensitivity to rule out asymptomatic bacteriuria.
She should be taken care by multidisciplinaryteam of obstetrician ,hematologist ,consultant anesthetist and neonatogist.
She should be started on folic acid 5mg ,stop hydroxy urea and desferroxamine.Iron supplements if indicated as it causes GI side effects.I will do a detailed anomaly scan at 20 weeks.I will follow her BP at each visit to find out preeclampsia and SFH and serial scan to rule out IUGR.
I will counsel her about the effect of disease on pregnancy like miscarriage,preterm delivery,preeclampsia,IUGR and increased perinatal mortality and morbidity.Also about the effects of pregnancy on disease like increased sickle cell crisis,infections of urinary tract and chest.I will advise her to take good diet with adequate fluids as dehydration provokes thrombosis .Risk assessment of thrombosis done and if needed to be started on prophylactic LMWH.If patient develop sicle cell crisis ,she should be admitted and managed with IVF and antibiotics folowed by blood transfusion.
Intrapartum care is by a team of obstetrician, anesthetist and neonatologist.save adequate blood if patient in labour.Operative intervention for obstetric indication.No role of prophylactic tranfusion.Patient is kept warm and adequately hydrated .Early Iv line access as it is difficult to get access due to repeated transfusion.Regional is preferred over GA as it provokes sickling.Continous fetal monitoring to pick up fetal distress.Steps taken to avoid prolonged labour.Prophylactic antibiotics to prevent infections and avoid catheterisations.Active management of third stage followed by cord blood sent for Hb electrophoresisand repeat after 3 months as beta Hb is present in HbA. Early mobilisation and Prophylactic LMWH for 6 weeks to prevent thrombosis.Contraceptive advise should be given.Depoprovera is prefered .IUCD is avoided due to infection.

Posted by Bushra  A.
PRESERVATION OF REPRODUCTIVE POTENTIAL IN MALINGNANCY
Management depends on the stage of the disease at which she presents . If she comes with CIN, management options will be either local ablative or excisional processes for the cervix and conserving the uterus and cervix . And shd have strict follow up. Ablative procedures includes cryo therapy, electrocautery, and excisional options are LLETZ/LEEP ,laser conisation , surgical conisation.
For stage 1and 2a Tt of choice will be modified wertheim hysterectomy with conservation of ovaries after counselling the patient .This involves the removal of uterus with parametrium L.N, pelvic L.N , AND upper one third VAGINAL CUFF .Ovaries can be in future for producing ovum in IVF . Subsequent manage ment depends on the HPE of L.N ,if positive then shd receive adjuvant RT , which will have the risk for damaging the ovaries .and to prevent the risk of radiation exposure ovaries are suspended on to the lateral wall of the pelvis at the time of surgery or latter laproscopically if not done priorly . Or recently can have adjuvant chemotherapy for positive L.N.
Recent developement is Radical Trachelectomy with pelvic L.N dissection , and subsequent management is acc to the HPE of L.N .Although premilinaries results are encouraging but no long term folow up reports available till now , therefore patient should be thoroughly counselled before going for this treatment option .
Recent developements in adjuvant chemotherapy has promising results and can be one option for a young female who wants to conseve fertility ., esp if she has positive L.N after surgery and can bypass the sideeffects of RT.

OVARIAN MALINGNANCY

Usually ovarian maling in young females are germ cell tumours , which are usually unilateral and we will do conservative surgery for this patient so before surg detailed inv shd be carried out knowing exactly the extension of the malingnancy and distant metastaes . Do thorough councelling of the patient , telling her about the nature of the tomour , its implications ,and the possibilities of change of status of tumour on laprotomy and possibilities of mangement accordingly .
Definitive management is laprotomy by a gynecological oncologist. Aim will be to preserve the uterus and the another ovary. --- If U/L ovary is involved and the capsule is intact -- do U/L oophorectomy , biopsy of the omentum ,biopsy of paraaortic L.N , biopsy of C/L ovary.
If U/L ovary is involved and there is suspicion about another ovary or there is ascites -- do U/L oophorectomy and send C/L ovarian biopsy and ascitic fluid for urgent frozen section and cytology and deal according.
If B/L ovaries are involved B/L oophorectomy with omentectomy with L.N removal is the tt , preserving the uterus for donated ova and IVF in future .

CHEMOTHERAPY is another option esp new platinum based CT drugs which have good tt profile . these tumours are usually radioresistant and radiotherapy is damaging ovaries so it has very limited role.
Intensive follow up and regular screening shd be emphasised , she do regular clinical examination ,TVS, tumour markers testing . And once family completed shd have TAH B/LSO
but recently it is not must to remove and she can keep ut. and ovary .

ATYPICAL ENDOMETRIAL HYPERPLASIA
The options available will be progestogens,either locally or systemic .prog is Locally released concentered to the endometrium by LNGIUS -- MIRENA , it releases 20microgram per day ,it is very effective and by pass the systemic side effects of progesterone
Systemic prog can be given either orally / injectables . MPA or norethisterone can be given orally in high doses for 6 months
injection depo provera can be an another option .
Regular follow up with TVS for endometrial thickness and biipsies
shd be advised after a period of tt. And once family is completed TAH B/LSO should be done.
Posted by Bushra  A.
SICKLE CELL DISEASE

CLINICAL ASSESSMENT
Take detailed history ,asking about blood transfusions , how often she receives BT . Ask about any drug history , surgical history . Ask about hospital admissions for chest complications , sickle crisis , infections of chest or renal tract .
Ask about family history as this is an autosomal disorder and inherited in recessive manner . Take consanguinity history , ask whether husband has been investigated or not.
Next examine the patient for signs and symptomds of anemia ,look for pallor , any limb deformity [ avascular necrosis ] , look for stigmata of excessive erythropoesis. Check pulse , B.P ,temp., pedal oedema .Take bodyweight and look for signs df malnutrition and associated iron def. anemia , and signs of iron overload . Do liver examination , splenic area palpation and of any suspicion of heart involvement ask for physician advice.
Regarding preg. take full obs. and menstrual history .B/P, weight , urine for urine albumin , examine P/A
if needed P/S , P/V examination .

MODIFICATION IN ANC CARE
Management should be multidisciplinary involving obs ,hematologist, physician . Councel and inform her about the implications and risks associated with SCD and prepare her for strict compliance to the modified and extra care in preg . If she is anxious regarding the risks for her baby , answer her and quqntify the chances of inheriting the disease in the baby .
Do inv for anemia ,send CBC ,IRON STUDIES ,S.FE ,TIBC .She may also have associated iron def.anemia .Do urine examination for routine microscopic and culture sensitivity .Do LFT, KFT , Heart assessment if indicated . If husband carries genes for SCA offer prenatal diagnosis for the baby .
Advise her to prevent dehydration , to take plenty of fluids .Avoid any infection ,if any focus take extra efforts to remove or tt it like oral cavity hygiene . If there is recurrent renal or chest inf ection consider prophylactic AB\'S .Pt is at increased risk for PTL /IUGR / IUFD so be vigilant for any suggesting signs and symptoms for these problems . Do serial USG for fetal well being and fetal growth . For anemia manage ment there are two schools -- either give prophylactic BT and keep Hb above 10 % or give BT only when Hb falls below 8 gm%, or when pt is having symptoms , follow your unit protocol .
Advice folic acid supplementation , multivitamin supplementation . Give oral iron if associated def anemia , parental iron is contraindicated as there is risk for iron overload. Pain killers are usually required in the form of paracetamol or opoids . Thromboprophylaxis is considered if required.

INTRAPARTUM CARE
Good pain relief is essential inthe form of opoids in the early stage of labour and epidural analgesia in active labour . Avoid dehydration ,allow oral fluids , give IVF , keep I/O chart .Give broad spectrum AB\'S covering Grampositive ,Gramnegative , anerobic .
Thromboprophylaxis should be advised for LSCS cases , and in certain situations like prolonged labour and in post natl all cases .
LSCS is indicated only for gynecological indications otherwise NVD is preferrable .Postdelivery encourage breast feeding , prescibe pain killers , discuss contraception -- OCP\'S are indicated , progesterone only methods are safe . Give follow up in PNC and for baby in pedia clinic .