2. List 3 Antiemetics (With Dose, Route, and 1 Disadvantage) in the Table Below

Obs and Blobs Q’s

SAQ 1

A 23 year female who is 7 weeks pregnant by dates presents to your tertiary ED with severe and recurrent vomiting. She has had no antenatal care or ultrasound thus far during the pregnancy. There is NO abdominal pain or PV bleeding at all.

1. List 4 clinical or laboratory features that would suggest SIGNIFICANT hyperemesis gravidarum

(4 Marks)

· .

2. List 3 antiemetics (with dose, route, and 1 disadvantage) in the table below.

(12 Marks)

Drug / Dose / Route / Disadvantage

3. List 3 alternative diagnoses in this patient

(3 Marks)

· .

4. List the criteria that would require the patient to be admitted to hospital

(4 Marks)

· .

SAQ 2

A 6 week pregnant woman, G1P0, presents to the emergency department with PV spotting and lower abdominal pain. She has had a positive blood BHCG 2 days ago. She is distressed, and is demanding an urgent ultrasound. Her only PMH is an appendicectomy, she is a current smoker.

1. Aside from ectopic, list 4 other common causes of PV bleeding in the first trimester of pregnancy

(4 Marks)

· .

2. What features on clinical assessment (Hx and exam) and laboratory tests will help to determine whether an urgent pelvic ultrasound is required today (or can wait till tomorrow)

(5 marks)

· .

3. The decision is made to order an USS as you feel unable to rule out an ectopic pregnancy. The BHCG is 1000. The sonographer tells you that there is “no point” doing a pelvic ultrasound as you wont see anything. How do you proceed?

(2 marks)

· .

4. The O&G reg comes to the bedside and is accredited to do pelvic ultrasound. She sees an IUP but no fetal heart. The patient is deemed well enough to go home. What other management, advice and follow up must be arranged prior to discharge?

(5 Marks)

· .

SAQ 3

A 40 year old female is in a subacute bed in ED. She underwent tubal ligation for sterilization 5 years ago and now presents with unilateral severe LIF and shoulder pain. She is married and has 3 children. No symptoms of urinary or gynaecological nature. She denies pregnancy and states that she has been sterilized. The nurse tells you that the urine BHCG is positive.

Obs P100, BP 120/90, Sats 98, RR 32, Afebrile

1. You perform a bedside ultrasound – shown below. What view is this and what does it show?

(2 Marks)

· .

2. A further 2 views are taken – what is the abnormality and what does this likely represent?

(2 marks)

3. List the immediate steps you will take to manage this patient now

(8 Marks)

· .

4. The ED RMO suggests that Methotrexate might be a good treatment for this lady, she read about it on Life In The Fast Lane last week. You explain to her that this is not appropriate for this patient and outline when MTX treatment of this condition is appropriate. What are they?

(4 marks)

· .

SAQ 4

A 28 week gestation multip (G3P2) presents to ED with epigastric pain and easy bruising. She has had uneventful pregnancies and deliveries in the past. This pregnancy has been uncomplicated until now. She has 2 grown up children. Her GP has sent her in as he is concerned about HELLP Syndrome

Obs

BP 140/85, P 100, Sats 100% RA, RR 24, T 37.1

1. What does HELLP stand for?

(3 Marks)

· .

2. Aside from HELLP what is your differential diagnoses

(6 marks)

· .

2. On examination she remains hypertensive over several hours, has swollen ankles and vomits twice. Her abdomen is tender in the epigastrium and RUQ. Her vomit has streaks of blood in it. If she has HELLP Syndrome, what might you expect to see on the following tests.

(8 Marks)

Hb/HCT
Plts
Coag Screen
DDImer
Blood Film
LFTs
EUC
LDH
Biliary/Liver USS

3. List 2 other investigations that you would like to perform

(2 Marks)

· .

3. She develops visual disturbance and her BP is now 160/100. Outline your management plan over next 1 hr and disposition. Be specific about drug doses/frequency/route.

(8 Marks)

· .

SAQ 5

A 34 year old female is BIBA after a home birth. Her baby is unwell and has been taken to the neonatal ICU. She is bleeding heavily (estimated 1L en route), is very drowsy and is unable to give any history. The midwife who delivered the baby at home is en route to the hospital.

Observations

BP 90/50

P 130

Sats 92%

RR 34

Temp 37.2

1. Outline the causes of primary PPH?

(4 Marks)

· .

2. She is in the resus bay and you have called for assistance from both O&G and anaesthetics, who are en route. You have a competent resus team present and she has 2 large bore lines inserted and all appropriate blood tests ordered. She doesn’t need immediate intubation. What is your immediate stepwise management?

(7 marks)

· .

Multiple Choice

With regards to Hyperemesis Gravidarum the follow statement are true:

A) It generally occurs on the first 12 weeks if it is going to happen

B) Ketonemia is NOT usually a feature

C) It occurs in approximately 7% of pregnancies

D) It may be a sign of gestational trophoblastic disease

E) Significant ketosis can be harmful to the fetus

A 23 year old woman who is 21 weeks pregnant in her first pregnancy presents with vomiting and abdominal pain.

A) The most likely cause is Hyperemesis Gravidarum

B) She should receive steroids in case she is in early labour

C) Gallstones are more likely in pregnancy

D) HELLP syndrome is more likely in a primip than a multip

E) If she is proven to have a UTI, Trimethoprim is a poor choice of antibiotic.

With regards to Gestational Trophoblastic Disease – True or False

A) It is more common in Caucasian than Asian women

B) Risk does not increase in subsequent pregnancies if a woman has had the disease before

C) Vaginal bleeding in the first or second trimester occurs in >75% of women with GTD

D) It should be suspected when the uterus is smaller than expected

E) Choriocarcinoma, the malignant form of GTD, can metastasise to lung, liver and brain

The following are associated with an increased risk of fetal loss due to spontaneous abortion

A) Teenage pregnancy

B) Type 1 Diabetes

C) Previous spontaneous abortion

D) Adenoviral infection of the upper resp tract

E) HIV

With a BHCG of 1000mIU/ml the following structures/abnormalities may be seen on a transvaginal USS

A) Interdecidual sac

B) Yolk Sac

C) Embryo with fetal heart

D) Tubal Ectopic pregnancy

E) Ruptured ectopic pregnancy

The following are recognised risk factors for ectopic pregnancy

A) Recurrent candida

B) Previous pelvic surgery

C) Laparoscopic Cholecystectomy

D) Smoking

E) First pregnancy

With regards to Pregnancy Induced Hypertension and pre-eclampsia

A) All antihypertensives cross the placental barrier

B) ACE inhibitors are safe in the second trimester of pregnancy

C) Labetalol can only be given intravenously

D) Pre-eclampsia can only be diagnosed after 24 weeks of gestation

E) Thrombocytopenia can be seen even in mild pre-eclampsia

The following factors predispose to PPH

A) Previous C-Section

B) Short third stage

C) Fetal Age <32 weeks

D) Preeclampsia

E) Protein C deficiency