Pregnancy/preconception :: PLAB 2 Symptomatic Differential Stations
- examiner mla
- Mar 22
- 5 min read
**Rule out preeclampsia in late pregnancy
**Rule out ectopic pregnancy/missed miscarriage in early pregnancy
Suspected missed miscarriage at 7wks GA
Presenting complaint:
Fetal pole present but FHR not detected on US
No pregnancy symptoms (nausea, vomiting initially present but not recently)
PMAFTOSA:
Current pregnancy
Planned
Any treatment to get pregnant
Previous pregnancies/miscarriages
Examination:
GPE, vitals
BMI
Abdominal exam
PV
UPT
Diagnosis:
Do it like BBN
There is a chance that the pregnancy has stopped growing
We will repeat ultrasound in another week to confirm
Management:
Involve senior
Once confirmed,
Medical
Surgical
Safety netting:
Severe abdominal pain
Vaginal bleeding
1st antenatal visit 6wks GA - concerned about miscarriages, 2 previous miscarriages at 10wks
Presenting complaint:
2 previous miscarriages
Normal pregnancy symptoms
PMAFTOSA:
DM, HTN, thyroid problems
PE, DVT, PCOS
Family history
Smoking, alcohol, drugs
Examination:
GPE, vitals
BMI
Abdominal exam
PV
UPT
HIV, Hep B, syphilis tests
USG
Diagnosis:
Equal chance as anyone else to have a normal pregnancy (3 consecutive miscarriages has a higher risk)
Management:
Reassure
Lifestyle advice
Exercise
Dont over-exert: As a general rule, you should be able to have a conversation while you exercise
Alcohol
Smoking
Diet
Folic acid
Vitamin D
Safety netting:
Severe abdominal pain
Vaginal bleeding
Followup:
12 week ultrasound
Down’s screening
First antenatal visit 14 wks GA - IV drug user, Rubella non-immune, Rh-ve, father unknown
Presenting complaint:
Routine visit
PMAFTOSA:
Living situation
Smoking, alcohol, drugs
STI history
Examination:
GPE, vitals
BMI
Abdominal exam
Diagnosis:
Normal pregnancy
Management:
Reassure
Rh negative:
if you have a baby who is rhesus positive your body can form antibodies to fight the blood cells of the baby this is likely to happen in the future pregnancies and to prevent this we offer a medication called anti-D immunoglobulin which neutralizes the antigens that enter the mother’s body and this can stop the body from forming the antibodies, so this is administered routinely during the 3rd trimester
Social groups for support
Financial and home support
Lifestyle advice
Exercise
Dont over-exert: As a general rule, you should be able to have a conversation while you exercise
Alcohol
Smoking
Diet
Folic acid
Vitamin D
Safety netting:
Severe abdominal pain
Vaginal bleeding
Followup:
Follow up to discuss drug problem
Pre-eclampsia
Presenting complaint:
High BP
Headache
Feet swelling
Red flags:
Abdominal pain
Blurry vision
Fits
PMAFTOSA:
DM, HTN, thyroid problems
PE, DVT, PCOS
Family history
Smoking, alcohol, drugs
Examination:
GPE, vitals
Abdominal obstetric exam
PV
Diagnosis:
Pre-eclampsia
It is a dangerous condition that is common in late pregnancy and can lead to seizures/death if left untreated
Management:
Admit and monitor
CardioTocoGraph
If baby in distress, C-section
Labetalol IV, MgSO4 IV
Water birth not recommended
Safety netting:
Severe abdominal pain
Blurry vision
Fits
Chickenpox exposure in pregnancy
Presenting complaint:
Son has chickenpox
When diagnosed? By whom?
When illness started?
Contact during the illness?
Asymptomatic
Rash? Fever? Headaches? nausea/vomiting?
Chickenpox in the past?
PMAFTOSA:
DM, HTN, thyroid problems
PE, DVT, PCOS
Pregnancy history
Examination:
GPE, vitals
Abdominal obstetric exam
Head-to-toe exam
Diagnosis:
Management:
>36 weeks pregnancy
If she has had chickenpox in the past:
Reassure
Can play with the child
Even if the baby gets affected, it will be treated and won’t develop any complications of chickenpox
If she has not had chickenpox/not sure:
Test for varicella IgG
Negative
Positive
Involve senior for immunoglobulin prophylaxis
Reassure
Can play with the child
Even if the baby gets affected, it will be treated and won’t develop any complications of chickenpox
How did you know about that?
Safety netting:
Severe abdominal pain
Blurry vision
Fits
Rash, fever
Preconception counselling: Wants Male Child: wants an abortion if not male child
Data gathering:
Is there any particular reason for wanting a male child in specific?
Are you under pressure to have a male child?
Before I proceed can I ask you some questions just to have some background information?
Obstetric history:
Current pregnancy
Previous pregnancies
Did you attempt to have a male child?
If yes, what remedies have you tried?
How did you know about that?
PMAFTOSA
Sexual history:
How many times a week?
Do you know your fertile window?
Explanation:
At the moment there is a very little that can be done in terms of having a male child specifically as there is no medical way of knowing you are going to have a male child or not in the UK
Regarding having sex in standing position; there is no scientific or medical evidence that suggests it would increase your chances of having a male child
Regarding abortion if you find out it is a girl; the abortions are not conducted on basis of gender
You should be mentally prepared that if you get pregnant you might have a girl, and I suggest that you discuss this with your husband so you can both be prepared to keep the child if you have another girl
Abortions is allowed in the UK but it needs to fulfill a certain criteria to be performed
Most abortions in the UK are carried out before 24 weeks of pregnancy,
They can be carried out after 24 weeks in very limited circumstances such as;
if the mother's life is at risk or the child would be born with a severe disability
If they went for abortion,
most women will not experience any problems,
but there is a small risk of complications, such as:
infection of the womb (uterus),
some of the pregnancy remaining in the womb,
excessive bleeding,
damage to the womb or entrance of the womb (cervix)
Lifestyle advice
Exercise
Alcohol
Smoking
Diet
Folic acid
Vitamin D
Preconception counselling: CF - worried planned baby will have CF (pen and paper provided)
Data gathering:
Why are you worried about cystic fibrosis?
Ask about her brother and how is he doing?
Do you have any family history other than your brother?
Have you ever been diagnosed with cystic fibrosis?
Have you ever been tested for cystic fibrosis?
Do you have any medical problems?
Does your partner have any medical problems?
Do you have any children?
PMAFTOSA
Explanation:
Cystic fibrosis is caused by a defect in a gene, and there is risk about 1 in 4 to transmit the affected gene if both parents are affected
This disease is inherited and transmitted through what we call autosomal recessive by that I mean you need to inherit 2 affected genes to have cystic fibrosis
So there are 3 scenarios it could either be:
You're a carrier and your husband is normal - chance of CF is zero
Your husband is a carrier and you are normal - chance of CF is zero
Both of you are normal - chance of CF is zero
Both of you are carriers:
Chance of inheriting cystic fibrosis is 1 in 4
Management:
The only way to know if you are a carrier is by genetic testing
You can test it before you get pregnant,
Both you and your partner need to be tested
This done by doing a mouth wash or blood test
During pregnancy:
We can do what is called amniocentesis (chorionic villous sampling) where we take a sample from your baby and send it to lab to see if there is cystic fibrosis
After birth:
We can do a heel prick test for the baby to take a blood sample for genetic counseling
Refer for genetic counseling and testing
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