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Abik · Posted: Mon Feb 19, 2007 2:10 pm Post subject: teenage pregnancy

A fit & well 14 yr old comes to A&E on her own with PV bleeding. Abdominal exam reveals a pelvic mass and USS confirms a 26 week viable pregnancy.

a. What are the important immediate issues and how will you assess her?(8 marks)
b. What plan for her antenatal and intrapartum care will you make? (8 marks)
c. What plan will you make for her postpartum care? (4 marks)

knock yourselves out!!

I have done a marking scheme for this and the second stage question. If anyone wants a mark just yell. Cool

Nick Raine-Fenning · Posted: Mon Feb 19, 2007 5:45 pm Post subject:

Another brilliant, and very topical, question Abi.

You could change this to a woman aged 45 and have another good brainstorm but one at a time eh Wink

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

vani s · Century Club Joined: 20 Jan 2007 Posts: 141

a. What are the important immediate issues and how will you assess her?(8 marks)

no family/ friend/partner, anxious, pt , will need sympathy, support and non judgemental attitude.
might be her first AN visit.
amount of bleeding,? needs ?reuscitation/? intravenous fluids

ask about H/o pain, previous episode, any scan finding, (painless, recurrent - previa)
H/o trauma, headache, prev high BP( abruptio)
prev scan also useful for dating
ask about smoking, drugs, STD ,

Exam:

P, BP (low- excess bleeding... though cant be...as fetus ok.) high-PET, chr HT.

Per abd: ?gestation coresponding with dates contarctions/tenderness.

P/S rule out any local cause of bleeding like polyp..
Any vag discharge suggestive of infection

NO P/V

Inv:
FBC, Bld Grp, Urine protien, Baseline (U & E, LFT),
Swabs if suspecting STD's
USG: gestation, IUGR, placental location, not so good for clot. ( very rarely coexistant V Mole Rolling Eyes

shd not say? )
Bld lost can be tested if fetal ( vasa previa).
CTG no use at this early gestation.
for lung maturity etc
anti D if Rh neg. consider steroids

b. What plan for her antenatal and intrapartum care will you make? (8 marks)

decision whether IP or OP mx will depend on presence of bleeding,if Pl previa which gr?
If previa, may recede, and Normal del possible. else elective CS at 38wk.

serial (BP, protien, U & E, scans) if IUGR suspected.
Doppler for decision for delivery

general nutrition, alc, smoking, teratogens.

report if further bleeding.

vasa previa bleeding very risky, may lead to fetal death..

c. What plan will you make for her postpartum care? (4 marks)
[/b]

BF
Contraception
Psychological.....more depression etc.

vani s · Century Club Joined: 20 Jan 2007 Posts: 141

Dont ask me how long it took me to write this much............... Shocked

Abik · Posted: Tue Feb 20, 2007 10:53 am Post subject:

A very good bubbling.

Would you have been able to get all this in?

The main issue here is the teenage pregnancy and the PVB is really a side-line ( hence the word )viable.

In my marking scheme;

a. What are the important immediate issues and how will you assess her?(8 marks)

Social issues paramount. Was she aware/ family aware/ who are the family? who is the partner? Is she a mature or imature 14 yr old. Do you need to call parents? Social services
(1 mark)

There is an issue of consenting sex here also. She should be 'Gillick' competent in order for you to be happy about consent (even for your investigations) Is there any hint of abuse?
(1 mark)

Drug history and smoking history important in concealed pregnancy
(1 mark)

STDs important, well done!
(1 mark)

Differential diagnosis of the APH should be covered by Hx and Ex - I would argue with the No PV bit. It is probably not indicated here clinically but if it is - then she needs it (she managed to get pregnant!!)
(1 mark)

Blood pressure and urinalysis to demonstrate your knowledge that she is at risk of PET.
(1 mark)

This is a good time to do booking bloods- rubella, HIV, HepB Hb. Don't forget that she is not booked! (probably)
(1 mark)

Anti- D if Rhesus Neg
(1 mark)

b. What plan for her antenatal and intrapartum care will you make? (8 marks)

The concept here is risk. So...

Social services? Family/GP/ and a good Comm MW to be informed and plans to see her regularly. NCT classes are a good idea as this baby is at higher risk of neglect also. There are some parenting classes specifically for the very young also.
(2 marks)

Growth scans as risk of IUGR
(1 mark)

F.A.R.T. (folate/alcohol & smoking/rubella/teratogens). always woth a look in!!
(1 mark)

Depression risk so be alert
(1 mark)

Monitor BP and urine closely as risk of PET
(1 mark)

Aim for SVD - she is not too young and there is no indication for LSCS. Discuss a birth plan with her - or get MW too and plan for birth partner, analgesia. Lots of encouragement and reassurance (likely to just spit it out!!)
( 2 marks)

c. What plan will you make for her postpartum care? (4 marks)

Mention breastfeeding. Will need help, plan for admission to PN ward even if SVD
(1 mark)

Risk of isolation, depression, neglect or harm to baby. Close liason with community MW and Health visitor and GP.
( 1 mark)

Contraception always good for a bonus!
( 1 mark)

And the important last mark for neat handwriting!!!!

So Vani, I would give you about 5 for the first (depending on how you wrote it out), 2 for the second - too much focus on the APH and what about IP???, and 3 for the end. Can't judge the handwriting!!

10/20.

Comments?

vani s · Century Club Joined: 20 Jan 2007 Posts: 141

hey, NO p/V was from bleeding pt of view

vani s · Century Club Joined: 20 Jan 2007 Posts: 141

abik,

GOOD scheme form ur side But BAD score from my side... Crying or Very sad

I dont even realize I miss out things.. and that too in bubbling.
I didnt write about Intrapartum... though i did think.....
And this is in Bubling....what about full essay.
anyway, thanks for the mind blowing exercises
Laughing

Abik · Posted: Tue Feb 20, 2007 1:27 pm Post subject:

Don't panic -it's much easier when you're writing the question!
Just practice,practice, practice - it's all in your head already you don't need to read. Just practice. I promise it works Smile

vani s · Century Club Joined: 20 Jan 2007 Posts: 141

Nick Raine-Fenning · Posted: Tue Feb 20, 2007 8:58 pm Post subject:

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

i'll also add 'adoption' as an point on stem 3. -

if patient does not wish to keep baby, contact adoption services/social services in advance,
seperate mum and baby to avoid bonding,
allow expressed breast milk initially,
if decided to not breast feed then milk supression.
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Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Nick Raine-Fenning · Posted: Sun Mar 04, 2007 8:30 am Post subject:

It's a good point.

Adoption is something most of us forget to mention especially in infertility cases. If you mention donor gametes then you should mention adoption.
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Abik · Posted: Sun Mar 04, 2007 10:13 am Post subject:

Good point but no marks
Too much detail Raj - just cos she's 14!
If you have discussed social services & the parents involvement that covers those issues. Lets face it, I'm sure we could write a book on it - but you'll only have three lines cos there's only four marks.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

well, it's 4 marks on this question split, rephrase the question and my adoption point becomes 'very' important. Wink

the reasons these questions are on the forum is for people to brain storm and think of different bubbles and as nick says have your bubbles / points ready and then expand / contarct them as need be.

Laughing

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

Abik · Posted: Sun Mar 04, 2007 11:44 am Post subject:

Just remember to focus Raj.
You can beat us all in the bubbling but keep to the important points is all I'm saying - I know you know this cos you're much better at it now.
Maybe adoption is worth a mention but only at the end if time and space allow!!
Wink

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

agree whole heartedly. just still wish they should allow the 3 of us to do our exams together. Laughing

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

Abik · Posted: Sun Mar 04, 2007 2:09 pm Post subject:

Professor walavabiverine!!
Laughing

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

really like the name, we should start using it. Laughing

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

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

It sounds like treatment for IBS...

vani s · Century Club Joined: 20 Jan 2007 Posts: 141

Can you all believe what I did.. Laughing

I didnt remember that this was an old essay ( thought was 1 of the new once i havent bubbled...) so just read the question and bubbled ... and when saw further down and saw my bubbling.. Rolling Eyes

it was so different...
all i had bubbled this time was ... teenage preg n negligible .... previa n abruptio bit...( so less.. could even loose points badly)
Strange.. same question, same person.. so different responses... Confused

.thinking about it,..... can we discuss whether she wants to continue with the pregnancy or not? (if it's her first visit)
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