TEALE FENNING

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

A 22- year-old primigravida with no other complications is found to have a heamoglobin of 7.8 g/dl at 28 wks gestation.
A] Discuss her further investigations.[ 10 Marks ]
B] What is your plan for management? [ 10 Marks ].

Nick Raine-Fenning · Posted: Thu May 24, 2007 3:12 pm Post subject:

Very good question EMAK. This is exactly the type of question you can expect - very basic and something you should know how to deal with but not something you will necessarily revise. Good work.
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 973

may i split the question further?

A 22- year-old primigravida with no other complications is found to have a heamoglobin of 7.8 g/dl at 28 wks gestation.

1. what will you like to know in history? 4 marks

2. what examination findings do u expect and how will you investigate? 4 marks

3. how will you manage her antenatally? 6 marks

4. how will you manage her in labour? 3 marks

5. what advice will you give her for next pregnancy? 3 marks

try this...

Smile

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Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

Raj. I really appreciate your work but don't you think that you give 12 Mark for the management and only 2 marks for investigations .!!
Investigation is a big branch in aneamia,,, don't you think so ? Idea

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 973

emak,

this is one of the possible splits for the topic, u could come up with many more.

also this is a O&G exam and not haematology exam so for me the management has more importance than investigations.

u can finish the investigations in -- FBC, electrophoresis, iron studies, vit B levels, bone marrow and liver profile..

for me even if you know that these are available as a O&G it's enough, the hemat people will interprete them.

try n answer this. you can also post ur split questions n their model answer if you want.

remember, the college is free to ask you anything....... 12 marks on management or 12 marks on investigations.... it does not make a difference what i or you feel about their questions

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

Nick Raine-Fenning · Posted: Sat May 26, 2007 8:00 am Post subject:

The key investigation(s) here is to critically evaluate the FBC.

If the haemaglobin is th only abnormality you need to discuss macrocytic and microcytic pictures and the most common causes.

Iron deficiency anaemia and abnormalities of haemaglobin synthesis will cause a microcytic picture. Serum ferritin and the total iron binding capacity (TIBC) may be helpful in establishing the severity of the former but are not often required. Sickle cell and thalassaemia would have been known before pregnancy or following electrophoresis at booking.

Whilst pregnancy itself causes a macrocytosis, folate deficiency and pernicious anaemia (B12 deficiency) must be excluded if there is megalablastosis. A normocytic picture may be seen if there is a mixed cause.

The FBC should be compared to any previous samples. At least one prior test should be available from booking. This will identify chronic anaemia.

The blood film should be examined to exclude haemolysis which, although rare, may be associated with acute fatty liver, pre-eclampsia etc. There may be associated thrombocytopaenia.

If all values are reduced bone marrow failure should be excluded. A consultant haematologist should be involved and bone marrow biopsy considered.
_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

rpwalavalkar wrote:

1. what will you like to know in history? 4 marks
Smile

We ask the patient about any previous chronic disease taht may cause iron deficiency like maleabsorption, renal disease or poor nutrition.
also we ask her if she develops any bleeding duriing pregnancy and whether she take any medication or replenishment and also if she has good compliance with treatment.
We should enquire also about any family history of haemoglubinopathy or other blood disease or blood malignancy,

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 973

to complete the history ---

gyn h/o -- previous menorrhagia

obst h/o --- ( not applicable here but...) multigravidity, previous pph, previous placental probs

present complaints --- SOB, tiredness, ....

other h/o --- easy bleeding

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

Nick Raine-Fenning · Posted: Tue May 29, 2007 2:59 pm Post subject:

Emak - I cannot tell you how pleased I am.

That last post clearly demonstrates a huge improvement in your writing style from when you first arrived here in the Forum.

You have justified yourself and written very short, factual sentences. This is exactly what you need to do.

You may have provided too much information but this is 10 times better than providing too little and not justifying yourself. The key now is to decide which infomation is the most important - this comes back to planning.

Also, do not neglect basic points, such as pallor, tachycardia, glossitis, angular stomatits, as these often socre more than the rare problems liek hepatosplenamegaly. You included these as well so well done.

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

Thanks a lot Nick
for sure , the forum allowes broader discussion with Tealefennger,,
your advices are always taken in consideration
I am sure that your courses are full of MRCOG tricks=helps=hints=for success...
I appreciate your encouragement Surprised

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

Shinelkimo · Joined: 25 Apr 2007 Posts: 55

B) plan for management:

From investigation above, we differentiate diagnosis her as IDA/ Folate deficiency anaemia/ Sickle cell anaemia/ Thalassaemia. Then we go into our management for her.

For IDA, her iron level, Ferritin will be low (Ferritin < 15), TIBC will elevated. Blood film will be hypochromic and microcytic. Diet like meat, fish, egg , spinach will be encouraged to increase intake. Our daily iron requirement in pregnancy will be 4mg. Although about 25mg iron in our daily diet, only 10% can be absorbed. So, iron, Vit . C can be prescribed for her.

For folate deficiency anaemia, will present with macrocytic RBC in blood film. Folic acid 5-15mg daily can be given.

Sickle cell anaemia are diagnosed by electrophoressis. Patients with sickle cell anaemia will always cause risk of preterm delivery, fetal growth restriction, preeclampsia, miscarriage, both perinatal and maternal mortality
For high risk population, routine Hb electrophoresis is indicated.
Sickle crisis always develope in 3rd trimester and around delivery. Patients with Hb -SC should be very cautious of it. If it does happened, hydration, oxygenation, treatment of infection, even exchange transfusion are needed. Rountine transfusion (3-4 units PRBC) every 6 weeks should be considered.

Thalassaemia is diagnosed via globin chain of synthesis studies or DNA analysis of nucleated cells. Thalassaemia will also present with low MCV and MCH. MCHC will be normal or slightly reduced. For these patient, iron and folate supplements can be given safely in a+ and a0 thalassaemia. Folate only is given in HBH disease. Parentreal iron supplement is contraindicated because of the risk of iron overload. Transfusion may be required.