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MRCOG PART 2 SBAs and EMQs

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EMQ1462
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Why my answer was not corrected

Why my answer was not corrected Posted by suad H.
Dear Dr. Paul Why my answer to assay 340 was not corrected, although answers posted after mine ,was corrected
Answer Posted by PAUL A.

Sorry we missed your answer - it will be marked and posted as a reply to this message today.

Answer Posted by PAUL A.

A

In view of her clinical history, the most probable cause of her present illness will be
Chorioaminitis and Septic Shock which associated with increased maternal /
fetal mortality and morbidity, but other causes also should be ruled out. Thus
initial management starting, by admitting the patient to the hospital, under multidisciplinary
team care including Obstetrician, physcian, neonatologist (1) , Check her ABC, O2 by
mask,2 wide bore cannula and collect blood for investigation. Careful history
taking regarding the time since fever started and how many times diarrhea/day
and whether there is any associated nausea or vomiting. Also If there are any
respiratory symptoms like cough; or urinary symptoms like dysurea. If there is  any associated vaginal bleeding; or offensive
vaginal discharge(1). Also enquire about the site, nature, radiation, aggravating
and releasing factor of her abdominal pain. Previous obstetric history and out
come, also social history (alcoholic, drug abuse)

And also check her handheld card for any previous admission notes (if present) and what treatment she received when she had PPROM, what type of antibiotic and whether she received steroid injection, and also any result for her previous and latest
investigations including CBC, CRP, HVS, etc. (No marks for etc. How will any of this alter your management?)

Thorough examination
should be done and checking her vital signs and pulse oxymetry (O2 Saturation).
Check her fundal height, presence of tightness (tenderness), any vaginal loss, and presence of fetal heart .I will do speculum examination (1) to check the color of the
liqure,smell and any associated discharge or bleeding and perform vaginal
examination to assist cervical dilatation if uterine contraction present. Then blood
should be sent for CBC, RFT, LFT, CRP, Blood c/s(1). Take vaginal swab for c/s ,
and do ultrasound for fetal wellbeing (which scan test?) and baseline CTG (1).

Initial treatment aim is to stabilise the patient's condition. Replacement of fluid and electrolyte by saline infusion, starting IV antibiotic with broad spectrum (3rd gen.
cephalosporin +  flagyl)(1)  and antipyretic (which one?).

Monitoring by early warning chart (1) her temperature, vital signs, input/output , and decide the plan for further management.



 

If suspected chorioaminitis, induction of labour (1) after assessing the bishop score should be done using prostaglandins (PGE2) or syntocenon augmentation (PGE2 may cause fever and loose motion, thus only given after stabilizing the patient's condition. otherwise syntocenon augmentation according to unit protocol can be used as first choice).

Before that, assess SCBU availability and if not, inuterotransfer the patient to another hospital (would you transfer this woman given how unwell she is? (-1)) and inform pediatrician and neonatologist about the patient and the need to council the parents about the prognosis of the baby if delivered at this age (preterm
delivery SCBU admission increase and prenatal mortality and morbidity). Offer
steroid injection if not given before as studies show it helps to reduce
prenatal mortality and morbidity as well as respiratory distress syndrome (WILL YOU DELAY DELIVERY?). It
also reduces intracranial hemorrhage and the need for SCBU admission (simple
fever not associated with systemic infection is not contraindicated for steroid
injection)

B

Maternal mortality from infection can be reduced by proper admission to the hospital when needed, offering antibiotic for prevention and treatment of infection, Immunization against H1N1 (1 Did you consider this as a possible diagnosis?), influenza virus or any other recommended immunization when traveling to endemic
areas if needed.

Advise the women to monitor any sign and symptom of infection, like after PPROM (fever, abdominal pain, and offensive vaginal discharge) and careful follow-up plan for monitoring patients with probability of infection, and early medical
advice-seeking if signs and symptoms of infection present. Also offer 24hour
access to the hospital with contact number and health education (1) with leaflet
information given to the patient can help in increasing the awareness of the
presence of infection. Audit and re-audit, as well as follow-up RCOG and NICE
guidelines and setup a unit protocol for managing patients with increased
probability of infection (PPROM) can help in reducing maternal mortality by
infection.