TEALE FENNING

carpeaqua · Joined: 24 Sep 2006 Posts: 19

Dear all,

Again I need help re PROM question (saw online so that the wordings might not be correct)

The question was on young healthy woman with Term PROM without any problem during AN period.

2. After assessed as being Low-risk, what mx options would you discuss?

How would you get 6 (?) marks out of this? Do they want me to DISCUSS expextant and active managements? How do you do when they asked WHAT MX OPTIONS....?

3. Pt requested ACTIVE mx. Discuss methods available.

In HIGH RISK PREGNANCY, they show 3 options for PROM mx: expectant, active, and aggressive. However, in most of the UK books, the first two options are usually everything. What did they ask in this question? How should I understand ACTIVE mx in this question?

Let's assume that it was options including induction. Then, does 'the methods available' mean those Canadian group suggested? I Mean by Hannah et al...

Please help me....

Regards,
CarpeAqua

Nick Raine-Fenning · Posted: Mon Oct 23, 2006 8:51 am Post subject:

You are getting confused by a fairly straightforward question. I think this is due to the fact you are not UK based and you are reading a variety of texts.

It is essential that your answer reflects UK practice and as far as I am aware this is based on the Candian 'term PROM' study.

Expectant means 'no action' i.e. 'wait and see'.

Active means you do something whatever that maybe i.e. prostaglandins or oxytocin.

Obviously not all women are suitable for expectant management and there are certain things you need to consider to ensure the woman is managed appropriately. This all comes back to the basics that we keep on reitterating which are history, examination, investiagtion, and treatment.

When you discuss a treatment (and that includes the option of no treatment and alternative methods) you must address the advantages and disadvantages and descrive what the 'ideal patient' is for each. If appropriate you then need to balance these and say what is the best treatment for a given patient. You must refer to the evidence-base throughout.

What I want you to do is to think about the question and formulate an answer which we will correct (if needed).

Management options - discuss all that are appropriate for a low risk woman with term PROM.

Methods of active management - specifically discuss oxytocin versus prostaglandins.

... and in both you must discuss the advantages and disadvantages.

The difficulty here is deciding what to put in each section so as not to repeat yourself. The trick is to discuss 'active management' as a treatment in the first section and the 'types of active management' in the second.

Have a look at the NICE Guideline on the Induction of Labour - you want section 5.5 Smile

_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

carpeaqua · Joined: 24 Sep 2006 Posts: 19

Dear Sir,

Thank you for your kind reply.
Right, it's not easy to fake myself to think I'm in UK...

So, I still need to DISCUSS advantage/disadvantage when asked WHAT OPTIONS would you discuss... Right?

To learn how to 'discuss active mx' and to 'discuss types of active mx', I'd better write my answer soon. Will do that when I get home (safe environment!).

Again, thank you so much. Hope I can see you at one of your course soon.

Regards,
CarpeAqua

Nick Raine-Fenning · Posted: Mon Oct 23, 2006 4:39 pm Post subject: Re: Thank you!!

carpeaqua · Joined: 24 Sep 2006 Posts: 19

It will be much appreciated if you can spare some time to help me with this. Thank you in advance.

Regards,
CA

2.
Both expectant management and active management should be explained and offered to obtain informed consent. Expectant management includes no treatment, hospitalisation, administration of prophylactic antibiotics, and /or monitoring of patient and fetus. It may be justified as most of term PROM patients will enter labor within 24 hours. Hospitalisation may aid monitoring of temperature, pulse, liquor loss/color and uterine tenderness. Daily CTG and two-eekly growth scans will be of help as clinical assessment will be less reliable once membrane have ruptured. Antibiotic prophylaxis will reduce neonatal and maternal infection rate. The are in general non-invasive managements. Expectant management is not recommended more than 96 hours.

However, the chance of infectious morbidity increases as the latent period lengthens. Active management includes induction of labor with or without further augmentation or operative delivery. This may reduce the rate of infection in neonate and mother; however the absolute risks were small with either option. The outcome in terms of delivery method are not significantly improved with active management. This is also more cost effective and usually preferred by women.

3.
Active management can be offered as immediate induction with inravenous oxytocin or with vaginal PGE2 gel. Both reduces incidence of chorioamnionitis. Induction with oxytocin is the most cost effective method. PG, if initially administered, is associated with increased incidence of infection, longer interval to delivery and increased dose of subsequent oxytocin.

bronwyn · Posted: Tue Oct 24, 2006 4:59 pm Post subject:

Hi

Good answer.
Important to say why you are monitoring temperature, pulse, uterine tenderness and liquor colour (ie clinical signs of chorioamnionitis, meconium staining indicating fetal distress, blood staining & abdo tenderness indicating possible abruption)

A few other points:
Nice suggests PG tablets better than gel
Expectant management does not necessarily mean hospital admission
No difference in operative delivery rates between conservative and active management
Important to discuss risks/benefits of both and allow woman to make informed choice
LVS to screen for group B strep and offer prophylactic IV antibiotics in labour with PROM

Hope this helps
Razz

Bronwyn
_________________
Bronwyn Bell
SpR
Portsmouth

carpeaqua · Joined: 24 Sep 2006 Posts: 19

Dear BB,

Thank you for your kind inut. I will study more based on your input.

Thank you!

Regards,
CA

Nick Raine-Fenning · Posted: Wed Oct 25, 2006 3:58 pm Post subject:

carpeaqua · Joined: 24 Sep 2006 Posts: 19

Dear Sir,

Thank you for your input.

Do you mean that now I have to answer to such questions as if they were asking me to 'JUSTIFY, CRITICALLY APPRAISE, etc' management? For example, the question asked SIMPLY what options would you discuss?

Is that right?

Regards,
CarpeAqua

Nick Raine-Fenning · Posted: Thu Oct 26, 2006 8:17 am Post subject:

Exactly - justify everything!

sasiselvam · Joined: 16 Aug 2006 Posts: 13 Location: india

Hi carpeaqua,

Just one more point I would like to add:
As an overseas candidate I felt T.F Theory course ( both ie the technique and practice) were very useful.Nick and his team will tell you how to convert your knowledge in to marks.After the course you will find it easier to practice any type of question. So I suggest that you book for the course and arrange your leave and travel (if you have not yet done.) and attend both the theory course.

sasiselvam

carpeaqua · Joined: 24 Sep 2006 Posts: 19

Thank you for your kind suggestion.

Indeed, I am planning to do that. Not easy organising one but will try every means.

Again, thank you for your input and concern.

Regards,
CarpeAqua