2024 Oral Prep Flashcards
Hx of SLE +/- VTE - pre-con/antenatal
- HR preg/MDI - MFM/Obs Med/Haem
- R4U = lupus flare/lupus nephritis/VTE/PET
- R4B = FGR/PTB/SB/NL
- med safety + contraception till MDT
- FBE/UEC/uPCR/anti-DS DNA/C3/4 as baseline + aPL
- recheck every trimester + aPLs
- LDA+Ca from 12/40 till 37/40 (+/- LMWH if VTE)
- regular ANC w BP + urine dipstick at each visit
- anti-Ro/La antibody +/- Fetal echo weekly 16-26/40
- 4 weekly serial G/S from 28/40
mtx/myco/cyclopho = unsafe
**hydroxy/aza/pred/cyclosporine=safe
**VTE Hx - Haem rv LMWH + LDA
Prednisolone use in pregnancy
early OGTT
tertiary morph (early exposure teratogenic risk)
intrapartum hydrocortisone
Anti Ro/La+’ve on screen on bkg of SLE
FHR50s on fetal echo
(encounter 2)
HE - FM/RTS/CTG
- baby has NL is at risk of congenital heart block that can result HF/SB
- refer to MFM for opinion and rv
- in the absence of hydrops, can consider
1. dex or IVIG until end of preg
2. close monitoring with fetal echo/biometry scans - with worsening CHB (e.g. complete block) + hydrops - need emCS (can’t CEFM)
- paeds rv +/- steroid +/- mgso4
- alert paed cardiology
*anti-Ro/La +’ve, usually weekly foetal echo from 18-26 weeks
APLs on screen on bkg of SLE
R2U - PET/VTE
R2B - FGR/SB
Haem advice
LDA + Ca +/- LMWH
2 weekly serial G/S
Hx of T1DM/Renal transplant pre-con/antenatal
+/- insulin pump
+/- immunosuppressed
+/- retinopathy
High risk preg require MDI from MFM/Obs Med/Nephro/Transplant
R2U - hypo/DKA/worsen existing cx/graft failure/rejection/PET/emCS/injury
R2B - MC/congenital abn/FGR/LGA/PTB/SB
Medications are…need MD clinic +…contraception till MDT rv
Baseline bloods/urine check end-organ dysfunction FBE/UEC/HbA1c + MSU + uPCR
Diet/Monitor/Med compliance/LDA+Ca/4wkly MSU/UEC/HR ANC BP/urine/opthal rv
Tertiary morph +/- echo/serial 4wkly G/S/
statin/acei/cyclopho/myco/bisphosphonate = unsafe
cyclosporin/tac/aza = safe
*acute rejection rate is lower if transplant >12/12
**don’t forget extras if on pred
**CMV reactivation risk
N&V + Abdo pain + low UOP on bkg of renal transplant
+/- borderline BP +/- high Cr/uPCR etc…
(encounter 2-3)
HE - fever/chills/suprapubic pain/HA/visual/BP
- I’m concerned about acute renal failure
- FBE/UEC/LFT/CRP/uPCR to check renal function/exclude infection/PET
- MSU to exclude UTI
- Renal tract USS to exclude obstruction
- Formal Obs USS +/- CTG to check growth & wellbeing
- IVC + IDC - strict FB
- Refer to MFM/Obs med/Nephrology team rv
- Depending on results - expedite delivery or continue pregnancy
Expedite
- No reversible cause to treat/clinical deterioration
- Paeds rv +/- steroid +/- MgSo4
- Consent for emergency CS +/- classical with Tx team on standby
Continue pregnancy.
- Identify and treat reversible cause (e.g. abx-UTI, pred-rejection)
- monitor for improvement in renal function/UOP
- OP F/U to recheck renal function/resolution
nausea + vomitting
abdo pain on bkg of T1DM
(encounter 2)
Hx/Exam
- PO intake/fever/chills/diarrhea/sick contact
- compliance with insulin/monitoring
- vitals/BSL/ketones/CTG
I’m concerned about DKA which has many triggers
infection/starvation/insulin compliance/pump failure
DKA pose sig M&M for mum/baby - PTB/SB
- FBE/UEC/CMP/LFT/CRP - ?infection/electrolyte derangement
- MSU MCS - exclude UTI
- CTG and Obstetric USS to check fetal wellbeing
- Treatment in ICU - IVT + K correction then insulin infusion
- Identify and treat reversible condition (e.g. UTI)
- Consider expediting delivery if deteriorate paeds rv +/- steroid +/- MgSo4
- If stable, improving, DC home, OPC F/U + serial G/S
- 24/40 EFW5% NAFID on bkg of T1DM/renal transplant
- 25/40 EFW5% AFI5 on bkg of T1DM/SLE
- 23/40 EFW5% NAFID on bkg min antenatal care
- 28/40 EFW5% AC3% raised UPAI, reduced MCA PSV - hx of IUGR
(encounter 2-3)
HE
- LMP vs dating (? wrong dates) - how reliable
- FM/APH…/PET sx/aneuploidy/morph/vitals/BP
- EOIUGR - likely PI on bkg of medical condition (asymmetrical)
- +/- screen for PET or use PET risk predicting markers if BP normal
- +/-TORCH +/- amnio to exclude infection/aneuploidy (symmetrical)
- d/w MFM/admit/steroid/paeds/wkly doppler/+CTG/2 wkly scan
- monitor for PET (BP/urine dip)
- aim for 37/40/MOD individualized
*if AEDF - consider 2nd daily dopplers…
results of rpt doppler of EOIUGR show
- AEDF or REDF
- decreased MCA PI
- placental insufficiency -> hypoxia -> brain sparing
- timing/mod individualized
- discuss with MFM
*absent or raised DV indicates cardiovascular instability, sign of impending acidemia and death
HPV16/18 + LSIL on smear during pregnancy
On immunosuppression for T1DM/Renal transplant
- HR HPV/LR pre-cancer change
- Ref to Dysplasia -> colposcopy to exclude overt malignancy
- colp safe in preg/no bx unless ?invasive disease
- recheck 3/12 postpartum-ovestin if breast feeding
*indication for Colp in pregnancy
- HPV 16/18 irrespective of LBC -> Colp
- HPV Non16/18 pHSIL/HSIL/glandular lesion ->Colp
- Non16/18 –‘ve LBC/pLSIL/LSIL ->CST 12/12
- PI on bkg of dyspareunia/dysmeno
- PI on bkg of PCOS/high BMI
- PI on bkg of bilateral nipple DC
(encounter 1)
DDx
- ovulatory - PCOS/2ndary ameno
- transport - PID/Stenosis/Endometriosis
- implant - Fibroid/Asherman’s/Septum
HE
- HA/visual/menstrual/OGHx/PHx/Surg/SHx/vitals/BMI/breast/spec…
- rv separate - male - age/job/PHx
+/- bHCG
- D2-3 FSH/E2/mid-luteal phase P4/TFT/Prl/AMH
- pelvic USS - AFC/structural anomalies
+/- SBHG + T + FAI + DHEAS + 17OH (if clinical hyperT)
+/- OGTT/HbA1c (if PCOS suspected)
- Rub/HIV/HCV/HBV/syphilis serology
- FBE+/-Thal/G&S/MCS - MSU
- Semen analysis
Interim Mx
- await Ix result - f/u visit to discuss
+/- bring partner to review
- supplements/social teratogens
- PCOS/Infertility, preconception health + LS mod before offering OI
***2ndary ameno = absence of menses for > 3 cycle intervals, or 6 consecutive months, in a previously menstruating woman
primary infertility investigation
all normal except high prolactin level
(encounter 2)
HE - nipple dc/ha/visual field
- repeat prolactin
- organize MRB
- f/U to review result
+/- refer to endocrinologist +/- neurosurg
(prl still high, MRB showed microadenoma)
- benign tumor
- r2u - expansion/compression/reduced ovulation/infertility
- r2b - no impact on baby
- preg possible post treatment, cease during preg, monitor sx in preg, nil CI to BF
- use contraception during treatment/serum prl 1mo post rx then 12/12 post+MRB
- dopamine agonist (bromocriptine)/transphenoid surgery
- may need ovulation induction if cycle remains irregular
dopamine agonist can be used in preg if concern of tumor expansion/monitor sx +/- MRB, req MFM/Obs Med input
**risk of expansion in preg higher with macroprolactinoma
**don’t repeat prolactin in pregnancy
**cease dopamine agonist if breast feeding
PI bkg of PCOS/high BMI
LS modified, weight lost
still not pregnant
(encounter 2)
? change in Hx/Exam
OI Mx options
- 1st line = Letrozole vs Clomiphene + Metformin
- 2nd line = Gonadotropin (FSH) + USS monitor vs Ovarian drilling
- 3rd line = IVF
Risks
- OHSS/Multiple pregnancy (less so for letrozole)
Plan
- D1 menses bHCG
- D3-7 Letrozole 2.5mg/Clomid 50mg
- D10-12 TV USS to check for dominant follicle
- D10-20 IC alt day
- D21 P4
- Menses (if not do bHCG)
*letrozole is 1st line but still off-label
**Clomid sx - hot flushes/abdo discomfort
OI with clomiphene, follicle tracking showed multiple dominant follicles, dominant being 17-27mm, what now (encounter 3)
Dx
- multiple dominant follicles increase risk of multiple preg if IC
- risk to you include GDM/PET/operative delivery
- risk to baby include PTB/FGR/SB
Mx
- abstain from IC or use barrier contraception
- try letrozole for OI next cycle
Abdopain days post egg collection
Abdopain days post embryo transfer
HE
- F&C/U&B/SOB/vitals/cardioresp/abdopelvic - fluid shift/girth/peritonism
- RFs - Type of trigger/#Egg retrieved/type of transfer/PCOS/previous OHSS
DDx - OHSS/post procedure PID/bowel perforation/torsion/theca lutein cyst
FBE (hct)/UEC/LFT/Coag/bHCG
TV USS (ov size/ascites) +/- CXR
NBM whilst investigating
Admit/observe/RBU team rv +/- Resp
Analgesia/antiemetic
Drink to thirst +/- crystalloid/colloid
Daily weighs/abdo girth
VTE prophylaxis/Daily bloods
Feedback to fertility specialist
F/U with fertility specialist +/- dating scan
*mx of theca lutein cyst (excess bHCG - hyperplasia of theca interna cells) is essentially analgesia/antiemetic and observe +/- aspiration/pelvic USS to check for resolution/monitor for sx of torsion
dyspareunia/dysmeno
PI bloods/SA = NAD
(encounter 2)
? any change in hx/exam
Dx
- Bloods excludes ovulatory cause of PI
- History suggestive of endometriosis
- Endometriosis can result in anatomical distortion -> infertility
- Imaging such as HSG and HyCoSY can shed some light
- Can’t always reliably detect anatomical distortion, tubal patency, and exclude uterine anomalies (e.g. septum)
For the purpose of PI Ix, I would recommend
1. Diagnostic lap +/- rx of endometriosis w aim to restore anatomy
2. Hysteroscopy +/- polypectomy - ?fibroid/septum/remove polyp
3. Dye studies to check tubal patency
It is a day procedure, GA, General Risks - infection/bleeding/VTE/injuries… Specific risk - staged procedure…quick recovery, F/U post procedure
*endometrial biopsy is not routine infertility ix anymore!!! do a curette when there’s concern about hyperplasia/AUB…
PI, suspect endo
diagnostic lap
stage 4 endo/ovaries stuck on bowel
large endometrioma >4cm
tubes/uterus normal
discuss finding & ongoing mx
(encounter 2)
PI, dysmeno
suspect endo
diagnostic lap
stage 2 endo - right hydrosalpinx/endometrioma/patent left tube
rx endo = RS/right cystectomy/excision endo
histo confirmed endo
discuss findings & ongoing mx
(encounter 2)
Hx/Exam
- pain/bleeding/post op recovery
- vitals/scar healing
Endometrioma/hydrosalpinx/adhesion/distorted anatomy
All contribute to infertility and chronic pelvic pain
To improve fertility outcome + pain
- refer to MD Endo unit for Gynae/CR rv
- MDT for pre-op planning
- laparoscopic excision of endo/division adhesion/salpingectomy
- multi-D, GA, laparoscopy, path, follow-up
- risks include general/specific - reduce ovarian reserve/recurrence
- TCC 3-6/12, if fail then refer to CREI - IVF
Other modalities to complement surgery for pain mx if no fertility desired
- hormonal suppression with progesterone PO/Depo/Implant/IUS
- refer to pain specialist/pain psychology/PF PT
AMH should be done if planning to or post endometrioma excision
**consider CREI if reduced ovarian reserve (from endometrioma excision)+/- salpingectomy
**endometripma excision improve accesss
6/12 post severe endo excision
still can’t conceive, what next
(encounter 3)
? change in hx/exam
Mx
- Most effective form of ART for endo-related infertility is IVF
- Alt = OI alone, superovulation + IUI but limited evidence
- Refer to REI specialist for consideration of IVF
- IVF involves
1. ovarian superovulation with FSH
2. follicle tracking with TV USS/trigger/egg retrieval 38/24 post
3. fertilization/embryo culture
4. embryo transfer or embryo freezing, transfer on D3 or D5 + P4 pessary given for luteal support
- risk includes OHSS, multiple pregnancy
*trigger when follicle >18mm
**OI - also estrogen lvl tracking every 1-3 day from day 2 of cycle until HCG trigger
19/40 Pink PV discharge
Hx of 17/40 pregnancy loss
or
Short CL on scan 17/40 Twin preg
Hx of Cone biopsy for CIN3
or
P/w PCB around 22/40
Nil previous hx
HE
- trauma/F&C/U&B/STI/CST/aneuploidy/morph - plac/PHs/Surg
- vitals/abdo-uterus/spec - open/liquor
(open cervix or short cervix)
R2U - emergency delivery
R2B - PPROM/PTL/PTB/SB
Ix - FBE/CRP (exclude infection)/MSU/HVS (exclude UTI/BV - rx)/wellbeing scan
Admit/bed rest until mx plan/senior obs/paeds rv
PV P till 36/40 +/- cerclage
McDonald Cerclage multi-d/regional/non-absorbable/removal at 36/40 or if in labor/SROM
Ref to PTL clinic - surveillance/test till 26/40 +/-steroid when viable/serial 4wkly G/S
FFN indication - sx PTL btw 22-36/40, intact membrane, cervix <3cm
**FFN CI - ruptured membranes/cerclage/cervix >3cm/soap/gel/lub/disinfectant
**<10mm - consider cerclage to begin with
**pre-cerclage checklist - aneuploidy/morph/no PPROM, inserted btw 12-24/40
Hx of T2/3 pregnancy loss
high risk of recurrence
Refer to PTL clinic
PV progesterone from 16-36/40
Cervical surveillance till 26/40
Steroid loading when viable
Demonstrate and talk through how to perform a B-Lynch
(encounter 3)
- Senior obs present
- Use delayed absorbable (e.g. 1-0 vicryl)
- Hysterotomy (if VD)
- Transverse LUS (if CS)
- ## Check cavity empty
- exteriorize
- start 3cm below LUS/4cm from lateral
- enter Ut cavity, exit 3cm above
- go over fundus from front to back
- re-enter Ut cavity from posterior
- exit from contralat from inside ->out
- go over fundus from back to front
- re-enter 3cm above LUS/4cm from lat
- exit 3cm below
- pull tight whilst assistant compress
- double knot
- LUS/Hysterotomy closure
- continuous, 2-layer
PPH mx - at 1500ml after precipitate birth 37+4/40 (encounter 2)
- Obs Emergency
- Call for help - Code pink
- Required MDI
- x2 WB IVC - FBE/G&S/Coag - x-match
- IVT 3L max, warm, supine
- notify OT for EUA/activate MTP
- Tone - fundal massage/IDC/uterotonics - ergot/carborpost/txa
- Trauma - asx + repair
- Tissue - check plac/membrane
- Thrombin - anticipate DIC
- OT for EUA + Bakri insertion
- If high output Bakri - laparotomy -> B-lynch/Uterine art ligation/internal iliac ligation/UAE/Hysterectomy
- ICU/HDU postop
- debrief/Document
- repeat FBE +/- PRBC or Fe infusion
- OP F/U
vaginal DC or PVB 2/52 post hysterectomy
(encounter 2-3)
Hx/Exam
- pain/fever/chill/continuous/color
- vitals/abdomen/spec
Sx most likely due to vaginal cuff infection
Need to exclude vaginal cuff dehiscence/haematoma
- FBE/CRP to exclude systemic infection
- MCS - vault
- CTAP to exclude hematoma
Mx
- Admit for observation
- require MDI including ID
- expectant vs active (drainage)
- IVC + IV broad spec abx (ceft/met/gent)
- BC if febrile/VTE prophylaxis
- switch to PO Abx on DC
- F/U with USS + rv in OPC
PMB with or w/o USS findings
(encounter 1)
Hx/Exam
- urinary/bowel/fever/LOW
- menarche/menopause/parity/HRT/CST/MMG/FOBT
- Phx - breast ca/tamoxifen/DM/VTE/cardioresp
- abdopelvic surgery/FHx - EOC/BC/CR ca/SHx - support/SAD
- exam - vitals/appearance/BMI/cardioresp/abdopelvic
Mx
- Most likely atrophy or polyp
- Need to exclude EH/AH/EAC/Cervical ca
- Pipelle in room if able +/- CST
- W/L HDC to sample
+/- refer for anesthetic PAC if multiple co-morbidities
- Day procedure/GA/risks include…
- F/U for path +/- referral to GONC for Ix/Rx
HDC + CST for PMB
Cervical stenosis
False passage
Procedure abandon
CST = endometrial cancer
(encounter 2)
Hx/Exam
- postop recovery/pain/bleeding/fever/chills
- vitals…
- EAC cancer of uterus
- 5yrs >90% if stage 1 - disease confined to uterus
- more Ix required to stage disease - CA125/CXR/CTAP
- refer to GONC MDT/Rv
- likely need TH/BSO/SLND
- pre-op need anesthetic/SPAC - ref to medics to optimise
- mutli-D, GA, open or key hole, 6 week recovery, path, MDT, F/U
Stage 1a – surgery alone
Stage 1b -II – surgery + adjuvant radio
Stage III/IV – cytoreduction vs primary CCRt
Chemo = neuropathy/alopecia/infection
RT = cystitis/proctitis/colitis/vaginitis
Recurrent PMB
Hx of HDC
(encounter 2)
Hx/Exam
- previous HDC result/urinary/bowel/LOW
- vitals/appearance/BMI/cardio-resp/abdo-pelvic
Mx
- need to exclude EH/AH/EAC
- need to reinvestigate with
- TV USS +/- TMs (CA125/LDH)
- W/L for HDC to sample
etc…
68yo, smoker
HPV 16 on CST FI on PMB
Counsel on mx
(encounter 2)
Hx/Exam
- ongoing PMB/urinary/bowel/smoking cessation attempts
- previous dysplasia hx
Mx
- HPV16 is a high-risk HPV that increase risk for dysplasia/SCC
- To exclude dysplasia/cervical ca you will need Colposcopy
- Colposcopy involves …
- During colposcopy a biopsy … bx to path,
- Depending on Bx result, you may need further treatment
- Will require CST again in 12mo, x2 neg then 5yrly
- Smoking cessation is vital to management of HPV
*younger pts - consider vaccination if not vaccinated
68yo
Cervical adenocarcinoma on CST
CTAP -> 5cm mass
Offered CCRT, want to know SE of Rx
(encounter 3)
Hx/Exam
- any change in sx
Chemo
- peripheral neuropathy - numbness/tingling
- ototoxicity - hearing impairment
- nausea & vomiting
- myelosuppression - infection
- alopecia
RT
- urinary frequency
- diarrhea/dyschezia
- vaginal stenosis
*younger pt - consider fertility/ovarian insufficiency - VMS/GSM/osteo, dyspareunia
Post TAH/BSO
abdominal distension/no flatus
(encounter 3)
HE - pre-op RFs/cx intra-op/PF/BS/peritonism/UOP
DDx - ileus/bowel injury/intra-abdominal bleeding/urinary retention
- FBE/UEC- bleeding/infection/electrolyte
- AXR to exclude bowel obstruction
- NBM +/- NGT + IVC + IVT + FB + anti-emetic
- chew gum/VTE/ambulate
- surg rv + guide diet
*dilated small bowel loops + air in colon + rectum w/o transition point = ileus
TAH c/b bladder injury
Returned to ward post discharge from hospital with IDC for mx
(encounter 3)
or
Postop review, had emCS c/b bladder injury requiring IDC
Mild ID/explanation of surgery/complications/consequences
(communication)
or
Bladder perforation with TVT or vaginal hysterectomy
Bladder perforation at TAH/BSO for AH/left ovarian mass
Bladder perforation at TLH
HE
- recovery course - pain/bleeding/bowel
- vitals - wound check/IDC urine color
Intra-op (explanation to pt)
- cystoscopy - assessed the dome/trigone - UO
- double layer closure
- intravesical methylene blue to check leak
- pelvic drain + IDC
Post-op
- arrange cystogram to assess for leak
- discuss findings with Urology
- remove IDC + formal TOV
- outpatient F/U in 6/52
cx from bladder injury - decrease bladder capacity/urgency/incontinence/fistula
**intra-op with vaginal surgery: senior gyn/inform ano/call urology + cystoscopy ?trigone injury vs dome +/- removal of TVT - re-insert then re:cysto - admit/IDC/observe…
**intraperitoneal injury (e.g. trocher at TLH) - usually need open repair
**don’t forget hemostasis/completion of primary operation…
47yo nullip sx large pelvic mass
52yo multip sx large pelvic mass (on CTAP)
30yo LAP for 2/52
(encounter 1)
HE - PVB or PMB/bloating/LOW/U&B
PHx/Surg/Med/FHx - CR/EAC…SHx/BMI/vitals/abdopelvic
- DDx - uterine-Fibroids/LMS/EAC/ovarian/GIT
- FBE/UEC/LFT (baseline)
- +/-CTAP +/- Pelvic USS (need for RMI) +/- TMs (e.g. LDH vs CA125) +/- CXR
- Refer GONC MDT + Rv to plan for surgery - PAC
*PHx/Surg/SHx/BMI - key to perioperative planning
**Uterine - CXR cuz hematogenous spread
30yo P2 CTCAP show irregular mass LDH or ALP elevated
52yo GCT on histology post TAH/BSO (postmenopausal)
7yo precocious puberty - found on ix to have ovarian mass - RSO = GCT
HE - postop recovery
- Dysgerminoma - germ cell cancer of ovary
- GCT - stromal cell cancer of ovary
- Stage 1 >90% 5yrs
- GONC MDT/rv +/- RBU referral - oocyte/embryo/OTC
- Surg - Dx/Stage - fertility = USO + PW +Bx of contra +/- oment +/- appendix
- Path - MDT +/- adjuvant chemo (e.g BEP for OGCTs, BEP or plat/taxol for GCT)
- Ongoing postop surveillance with TM (e.g. CA125, LDH, inhibin)
most pts with OGCTs p/w stage 1A disease
1A/1B dysgerm/1A immature teratoma don’t req adj chemo (BEP)
*1A SCSTs (e.g. GCTs) don’t req adj chemo (Plt/taxol), if fert req - HDC exclude EH/AH
**gold std any ovarian ca = TAH/BSO/PW/Omentum/Appendix/Peritoneal bx/LN
***early stage OGCTs/GCT/1A EOC/BOT - fertility spare surg possible
**stage 1a =limited to one ovary (not ruptured), 1b both ovaries, 1c, breach of capsule/surface tumour/+’ve cells in PW/ascites
**EOC will req chemo
Elevated TMs post fertility sparing surgery + mass on USS
bkg of OGCT or SCSTs
- GONC MDT/rv
- rpt imaging - CTCAP
- biopsy to confirm
- BEP +/- RBU - oocyte/embryo cryo/OTC
- +/- TAH/BSO/resection of local deposit
*recurrence of BOT is generally treated with cytoreduction
**residual ovarian syndrome - a ddx, p/w asx pelvic mass post oophorectomy, also present as chronic pelvic pain, lack of menopausal sx post oophorectomy - ix include FSH/E2 + Pelvic USS, surgical excision if sx (e.g. CPP)
Nodule in vaginal vault post TAH/BSO for EAC
HE - previous CST result/distant met sx (cough/sob)/urinary/bowel
- Locoregional recurrence of EAC
- Bx/PO Abx/monitor sx +/- CA125
- GONC MDT rv of path
- PET-CT
- Pelvic radiation +/- Surgery
Cough/SOB post TAH/BSO for EAC
HE - fever/chills/haemoptysis
- distant mets
- FBE/CRP/ca125/CXR (exclude infective cause)
- GONC MDT rv
- PET-CT
- chemo/immune/hormone/radiation +/- surgery
N&V/abdo pain post pelvic clearance for EOC
HE - anorexia/bloating/U&B sx
- SBO 2nd to EOC recurrence
- Admit/NBM/NGT/Gen surg + MONC rv
- IVC - FBE/UEC/CMP + IVT +/- CA125 +/- MSU MCS
- CTAP exclude obstruction
- As per Gen Surg - expectant vs surgery (stent) vs palliation
- F/U post acute episode
- PET CT +/- guided biopsy -> MDT rv
- EOC recurrence rx = chemo +/- secondary cytoreduction
Pelvic mass with each of the following
⬆️LDH
⬆️AFP
⬆️hcg
⬆️inhibin
⬆️LDH = dysgerm
⬆️AFP=yolksac
⬆️hcg=choriocarinoma
⬆️inhibin = GCT
*multiple markers +’ve - consider mixed germ cell tumor, dysgerminoma mixed with yolk sac tumour = most common, mixed tumour may secrete LHD/AFP/hCG
Ovarian ca staging
stage 1 local ~90%
stage 2 adjacent organ-pelvis ~70%
stage 3 abdo ~30%
stage 4=distant mets ~15%
LMS on histology from TAH/BSO
(encounter 2-3)
HE - postop recovery
- uterine muscle cancer
- prognosis poor regardless of stage
- 5yrs survival - mitotic figures
- poor response to chemoRT
- refer to GONC - rv + MDT
- likely need PET-CT to exclude mets
- surveillance alone if stage I/II
- possible chemoRT if stage III/IV
24/40, PV discharge + known short CL with cerclage (encounter 1)
26/40, PV discharge + known short CL with cerclage (encounter 1)
19/40, fluid from vagina (encounter 1)
HE - fever/chills/vitals/spec - pool/RTS - presentation
Most likely PPROM need to exclude vaginal infection
- Amnisure to confirm or exclude
- FBE/CRP to exclude infection/as baseline
- MCS - HVS/LVS + MSU to exclude treatable infection->PTL
- Wellbeing scan +/- CTG
- R2U chorioamniotis/endometritis/sepsis
- R2B PH/Contracture/PTB - cx/SB/cord/MP
- Senior obs/Paeds to discuss long term outcome
- Continue preg & resuscitate vs TOP (more appropriate for extreme PPROM)
- admit observe/IV/PO abx - erythro/benpen/twice wkly bloods/hvs
- +/- steroid loading/paeds rv/2 wkly scans/IOL 37/40
- +/- cerclage removal -> need MgSo4
cerclage removal - reduce infection/tear risk if TPL, reduce latency -> PTL/PTB
**PPROM - liquor pooling/amnisure/continue leak/low AFI/pad check
**leave stitch in PPROM whilst steroid loading then remove
24/40 known PPROM + PVB
23/40 known PPROM + elevated WCC + lactate on F/U
29/40 PPROM LLP/previous CS - fever/chills
HE - pain/APH/fever/chills/vitals/uterine tender/spec-cervix/RTS or CTG
Ix - FBE/CRP/BC
Mx
- NBM/x2 WB IVC/IVT/triple abx-amox/gent/metro
- steroid/mgso4/expedite delivery
- inform con/ano/paeds/cord gas
- MCS plac/membrane/histology/continue abx/recurrence
MOD
- VD if birth imminent/no malpresentation/IOL may take too long/high mort PTB
- emCS +/- classical under GA esp if compromise fetus/malpresentation
D0 post classical emCS ~28+/40 for evolving chorio, c/b 1.2L PPH paged to rv
tachy + hypotensive + febrile + tachypneic
(encounter 2)
? change in Hx/Exam
- wound/peritonism/FB/UOP
Dx = sepsis - most likely chorio
DDx - wound/cystitis/pneumo..
Immediate mx
- Obs emergency
- Call for help - MET call
- Activate Sepsis pathway
- MDI - simultan- resus/ix/stabilisation
Resus
- ABC - O2/x2 WB IVC - IVT
- Broad spec abx - triple
Ix
- FBE/UEC/LFT/CRP/Coag/BC
- MCS - urine
- CXR
Stabilization
- analgesia/antipyretic
- VTE prophylaxis
- chase culture
- discuss mx with ID
- inform paeds re: mx
Ongoing mx
- aperients
- anemia correction
- daily bloods
- PPROM prevention next preg
- discuss risk of recurrence
request for labiaplasty for appearance (communication station)
Reason/indication/evidence
- double check reason for request
- indication
- discuss “normal” (birth/menopause)
- no evidence that it will improve
1. self-image
2. sexual function
Risks
- risks of procedure - general/specific
- scar/adhesion/permanent disfigure
- dyspareunia/altered sensation
Information & F/U
- summary of discussion
- info for reading and consideration
- follow-up to discuss further
- sexual health counselling (if request surgery to improve sexual function)
post myomectomy c/b 1.2 bleed
tachy+ poor UOP + pale + abdo pain (encounter 2)
post TAH, minimal UOP (encounter 2)
post lap endo, no UOP (encounter 2)
Hx/Exam
- operative difficulties
- vitals/peritonism/IDC patency
DDx
- hypovolemia/bleed/ureter-bladder injury
Ix
- FBE to exclude anemia/bleed
- UEC to exclude renal dysfunction
- G&S +/- Xmatch
+/- Bladder scan
- CTAP +/- CT IVP - collection/ureter
Results
…
Initial Mx
- postop emergency
- care requires MDI
- x2 WB IVC + IVT (fluid resus)
- NBM pending ix
Sheath hematoma
- Return to theatre
- Take down sutures
- Identify source
- Suture/diathermy/procoagulant
- Exclude intra-abdominal source
- Washout/Intra-abdominal drain
Ureteric injury
- Urology advice/Radiology +/- nephrostomy
- consent/cystoscopy + laparotomy
- Drainage of urinoma or uroperitoneum
- Identify injury +/- repair
Postop
- recovery in HDU or ICU
- IV abx + VTE prophylaxis
- FBE + anemia correction
- debrief/document
- F/U and M&M
Multi fully dilated, good labor progress
suspected face presentation
vs
Multi 4cm dilated, in labour, face + cord presentation
HE
- labor progress/urine/temp (?obstructed)
- VE - MA vs MP
- CTG (?NRCTG)/RTS
Scenario 1
- aim for VD if MA (MP = always CS)
- no ventouse/avoid forceps/if req only when face cause perineum to bulge
- senior obs/paeds/cord gases at birth
Scenario 2
- consider emCS - based on std obs indication at first!!!! see **
- NBM/x2 WB IVC - FBE/G&S + IVT + IDC + Tocolytic + CEFM
- avoid elevating PP if CTG =N -> may cause cord prolapse
- senior obs/paeds/cord gases/debrief/document
try VD with brow if detected early in labor w/o obstruct, brow rarely VD, instrumental usually CI, don’t augment brow - due to risk of obstruction
**obstructed/NRCTG -> automatic emCS
**cord presentation -> automatic emCS
**MP can rotate to MA or vertex - monitor closely then decide CS
21yo G1P0 40/40
APH 200ml settled
CTG normal
how do you manage?
(encounter 2-3, snap x plan, prioritization station)
HE - placenta location/FM/contractions/SROM/vitals - esp BP/uterus/spec/VE
- I’m concerned about undiagnosed previa & abruption
- if no hx, need to exclude abruption (assess RFs)
- APH @ term may be a sentinel event to abruption
- Most likely due to rapid cervical dilation
- I would recommend IOL for term APH
- IOL involves bringing labor on…
- Baby will need CEFM in case of fetal distress
- Youl will need IVC - FBE/G&S then synt, VE to check progress
…
HMO/MW Level can get IOL started
Pt p/w mastitis 2/52 postpartum, how do you manage? (encounter 2-3, snap mx plan, prioritization station)
HE - pain/redness/febrile/difficulty feeding + rv of delivery complications - PVB/pain/wound/mood/vitals - temp/rash/tender/fluctuant lesion
- You have an infection of the breast
- Without appropriate rx, you could become septic
- I recommend admission for ix/rx with MDI
- Start with IVC - FBE/CRP as a baseline
- Breast milk MCS
- Breast USS to exclude an abscess
- Commence on Fluclox + antipyretic + IVT
- I will refer you to Gen Surg + LC
- Inform my consultant of the plan
- Encourage ambulation/VTE propnhylaxis whilst I/P
HMO level can manage initially
40yo DUB 6/52, actively bleeding with Hb68, how do you manage? (encounter 2-3, snap mx plan, prioritization station)
DDx - rupture ectopic/menorrhagia undiagnosed condition
HE - pain/bleeding/LMP/contraception/CST/previous
ectopic/PHx/Surg/Med/vitals/abdo/speculum exam
- Gynae emergency, need MDI
- Call for help - MET call
- Simultaneous resus/ix/rx
- x2 WB IVC for urgent bloods
- bHCG to exclude pregnancy
- FBE/Coag - check level
- G&S & x-match x2 units
- Urgent pelvic USS +/- Pipelle +/- I/P HDC
- Txa + Primolut + Mefanemic acid
- NBM + IVT until investigations are complete
- Await results for definitive mx plan
ED/HMO level can manage resus initially
21yo septic, suspected PID
or
14yo LAP+febrile + N&V
DDx - TOA/PID/appendicitis
HE - pain/sexual hx/PID/STI/PV DC/bleeding/vitals/bimanual/spec/urine
- Call for help - follow sepsis protocol
- If HD unstable, call for help
- x2 WB IVC for
- bHCG/FBE/UEC/CRP/Lactate/BC as a baseline/check severity
- Endocervical PCR for chlam/gon/Mg
- Urgent pelvic USS to exclude TOA
- Commence fluid resus + Triple Abx - Ceftrixaon/Metro/Azithro
- Inform consultant/discuss with ID
- Antipyretic/analgesia/VTE prophylaxis
- Observation with clinical/biochemical improvement
- Chase MC +/- contact tracing, OP Rx/F/U plan
sex with minor -> involve SW -> mandatory DHS reporting
**underage don’t want to disclose to parents - assess Gillick’s competence/support self disclosing to guardian
**even if urine bHCG is neg - should do serum
Primip, 38/40
SROM - MSL, not in labor
suspected IUGR
(encounter 2-3, snap mx plan, prioritization station)
DDx - fetal distress/breech presentation
HE - time of SROM/fever/chills/FM/APH/AN course/EFW/Dopplers - GBS status/vitals/abdo/spec + pool or amnisure/VE/RTS
- MSL may be related to fetal distress or breech
- CTG to exclude distress, RTS to exclude breech
- Birth should be expedited -> need to start labor
- IUGR babies may not tolerate labor well - need CEFM
- I would recommend IOL in setting of MSL/IUGR
- Risk of operative delivery is high due to above
- IOL involves FW then synt +/- IAP (prolonged SROM or GBS+…)
- So you need an IVC then FBE/G&S, and syn started
HMO to counsel re: indication
MW level can get IOL started
30yo G3P2 GDM, planned IOL 38/40, cervix 3cm, head 4-5/5 above, CTG normal, how do you manage?
(encounter 2-3, snap mx plan, prioritization station)
DDx - poor uterine tone/undiagnosed LLP
HE - placenta position/confirm presentation with RTS…
- concerns is high station
- risk of cord prolapse with ARM
- if there’s a cord prolapse, you will need an emCS
- need to have a controlled ARM
- i will ensure OT is available and have my consultant to support
- before starting RTS to confirm presentation, IVC - FBE/G&S
- to reduce the risk, start synt before hand
- have you in lithotomy/bladder empty/stabilize/ARM with fundal pressure
Reg/Consultant level to manage, in the setting of competing emergency, can wait as labor not started
35yo, 7/7 post lap+HDC FI of HMB/dysmenorrhea, histo result show clear cell EAC from bx in POD/Curettage. Otherwise fit/healthy, explain the results to her, don’t need to take a hx or do exam (communication station)
English speaking chinese woman, relatively isolated in Australia, nulliparous, didn’t have debrief postop, recalled urgently to clinic.
Opening sentence from SP “they told me this was urgent, is this about the results…
Do you have a support person with you today?
I’m afraid I have some bad news to share with you today.
We found cancer in the samples we took from surgery
*use ASSIST model to communicate
Acknowledge - this is devastating and unexpected news with life altering implications
Sorry - I’m so sorry
Story - allow time for pt to express thoughts/feelings
Inquire - allow time for pt to ask questions, let pt lead the conversation, offer additional information not covered by pt’s questions with their permission.
Solution - discuss future mx plan, provide some reassurance
Travel - I will organize F/U for you, refer you to Psych support, we will be here to help you through, I will provide you with our contact number, please reach out if there’s anything we can help with
21yo, G1P0, 3/52 post MTOP at 6/40, presented for F/U with USS result showing live IUP 10+2/40, bHCG97k, S:N, R:I, FHx of T2DM, no supplements, please assess and manage. (encounter 1)
Something didn’t work - always ask about how compliance
HE - how was MS2step taken/pain/bleeding/vitals…
- MTOP has failed
- The options are STOP vs continuing pregnancy
- I recommend STOP as misoprostol is teratogenic in T1
- ## STOP is performed under GA, day procedure, quick recovery, risks are … POC sentIf you want to continue the pregnancy, I would recommend
- counselling by MFM team re: risk of misoprostol exposure
- aneuploidy testing
- early morphology
- early OGTT due to FHx of T2DM
- tertiary morph in the setting of misoprostol exposure in T1
- repeat OGTT at 28/40
- anti-D 28 & 34/40 gestation
- vaccination whooping cough/influenza
21yo failed MTOP, still pregnant, with N&V
21yo confirmed IUP 14/40 w severe N&V
no multiple preg or GTD on early preg scan
(encounter 1-2)
DDx - HG/GTD/Multiple preg/Thyroid/Infection/Addisonian crisis
HE
- tolerate anything oral/weight loss/impact on life
———————————————————
- Admit for Ix/Mx
- IVC for FBE/UEC/CMP/LFT/TFT - exclude infection/electrolyte/thyroid
- Consider ECG if electrolyte disturbance
- MSU MCS
- fetal USS to check wellbeing
+/- any other AN care appropriate for that gestation
—————————————————–
- start with IVT + IV antiemetic to control your sx
- electrolyte replacement if deranged
- 1st line rx = doxylamine + pyridoxine + thiamine
- 2nd line rx = ondansetron + metoclopramide (limited)
- 3rdl line rx = prednisolone
- none-pharm alternatives - ginger/acupressure
- I will refer you to Dietician and clinical psychology for review
- I will also organize for you to have IVT weekly in ambulatory clinic
*Addisonian crisis presenting as severe N&V - usually have known PHx, it’s an emergency, requires MDI, fluid resus, identify/rx cause (infection/dehydration/trauma)
21yo G1P0 19/40
clear PV dc for 2 days
absent FM, left shift on bloods
rhesus negative, assess and manage?
(encounter 2-3)
or
25/40, PPROM from 20/40
steroid loaded
contracting/T37.9/HR110
breech presentation
(encounter 3)
HE - pain/ever/N&V/offensive dc/PVB/vitals/uterine tender/spec…
Aggressive mx of sepsis (ABC)
- x2 WB IVC - FBE/UEC/CRP/G&S +/-
- urine/genital MCS to identify pathogenic organisms
- Fluid resus with IVT + IV triple antibiotics
—————————————————————————–
Scenario 1 - chorio -> R2U, fetus not viable -> recommend TOP by IOL
Scenario 2 - chorio -> R2U/B -> Cat 1 GA/classical…
——————————————————————————
- placenta/membrane swabbed for MCS
- placenta also for histology
- I recommend:
1. postmortem to identify other issues that may have caused this
2. cabergoline for lactation suppression
3. +/- anti-D administration
4. de-escalation of IV Abx to PO when organisms isolated
5. discussion of contraception prior to DC
6. SW
7. Psychological support
——————————————————————————
- F/U discuss recurrence/ strategies (e.g. cervical surveillance, lifestyle modification - smoking cessation…)
10/40, RHD + Mod AS on TTE + NYHAII
24/40, RHD + Mod MS on TTE + SOBOE
Hx of rheumatic fever as a child
(encounter 1)
HE - SOB/ortho/lethargy/murmurs
- RHD -> heart dmg
- risk to you AF/VTE/APO
- risk to baby PTB/FGR
- ref to MFM/Obs Med +/- TTE to check function
- B-blocker/abx prophylaxis/TTE each trimester +/- LMWH if mechanical valve
- Tertiary morph/4 weekly G/S from 28/40
- IOL from 39/40 - VD if NYHA I-II, CS if NYHA III-IV
- CEFM/Telemetry
- epi/strict FB/short 2nd
- active 3rd/PPH avoid ergot
- HDU care post/strict FB/monitor APO
Uterine inversion
(encounter 2)
- Obs emergency
- Call for help
- MDI for simult resus/ix/rx
- Follow principles of ABC
For resus
- Oxygen/x2 WB IVC - FBE/G&S/Coag - X-match PRBC
- Fluid resus and consider activate MTP
- IDC insertion/track EBL
For inversion mx
- discontinue any uterotonics until replacement
- manual reduction by Johnson’s maneuver
- hand in vagina and push the fundus towards umbilicus
- other hand stabilize uterus externally
- if successful, give uterotonics (avoid ergot in setting of RHD)
- attempt MROP in OT possibly followed by Bakri insertion
—————————————————————————————-
- if unsuccessful, use GTN in OT before 2nd attempt under GA
- then surgical correction via laparotomy - Huntington’s procedure or Haultain’s procedure, if all fail then hysterectomy
—————————————————————————————-
- alternative is O’Sullivan’s maneuver hydrostatic reduction if failed 1st line and don’t have access to OT - laparotomy
———————————————————————————-
Post Mx - Abx prophylaxis/Bakri removal/HDU por ICU/VTE prophylaxis/debrief/document/RHD postpartum care
Describe the surgical mx of uterine inversion (encounter 2-3)
Huntington procedure - pulling on round ligament with assistant pushing on fundus from inside the vagina
Haultain procedure - 1.5cm incision to posterior surface of uterus to release the constriction ring then manually reduce uterine inversion - then interrupted sutures
Describe O’Sullivan’s maneuver (encounter 2-3)
- reverse Trendelenburg lithotomy position
- silastic ventouse cup in vagina
- manually seal labia
- run warm saline 2-5L at least 1m above pt by gravity or light pressure
Hx of RHD -> MS -> mechanical valve
On warfarin now
Preconception advice
(encounter 3)
- Mechanical valve = VTE risk
- Warfarin most effective VTE prevention
- Warfarin -> congenital abn use in T1
- LMWH not as effective but safe baby
- Dose adjust based on renal function/BMI/anti-Xa level
- high risk preg/MDI - MFM/Card/Hem
Strategy
- LMWH in T1
- Warfarin in T2 till 36/40
- LMWH from 36/40 till peripartum
- LMWH to UFH for quicker reversal
+ LDA
- warfarin recommenced PP, ok BF
*If onset of labour prior to cessation of warfarin, reverse with vitamin K/ prothrombinex or similar and deliver by CS
Hx of RHD w MS
prolonged labor
5L of NaCl
sudden CP/SOB, O2 saturating 90% (encounter 2-3)
Hx of RHD w MS
postpartum
SOB, tachyarrhythmia
(encounter 2-3)
? CP/EBL/UOP/BP/RR/WOB/O2 sat
- APO in setting of RHD/MS
- Obs/Medical emergency
- Call for Help - activate a MET call
- Require MDI, simultaneous resus/ix/rx
- Follow principles of ABC
- ABC - O2/x2WB IVC +/- IDC (if not already in)
Ix
- FBE/UEC/CMP/Coag/Troponin
- arterial blood gas
- ECG exclude ischemia
- urgent mobile CXR exclude APO
Stabilization +/- Delivery
- IV diuretics + strict FB
- NIV - CPAP
+/- B-blocker
+/- ionotropic support
- Expedite delivery
Ongoing mx
- Transfer to ICU
- TTE/VTE prophylaxis
- Cardiology OPC - TTE - precon counselling
Worried about SB, how to prevent
HE - identify RFs
Advice
- smoking cessation
- side sleeping from 28/40
- FH at each visit
- G/S where there are RFs for FGR
+/- optimize any medical conditions
- monitor FM
- avoid prolonged gestation (e.g. IOL for PD)
*maternal obesity, age >35yo, primiparity, low SES are some modifiable RFs in
DFM 36/40, bkg of GDM, no FHR, tell JR what to recommend (encounter 2)
DFM 35/40 bkg of ICP, BA>45, no FHR (encounter 2-3)
FDIU @morph 7/52 post uncomplicated laparotomy for dermoid
(encounter 3)
HE - itch/pain/bleed/VTE hx/vitals/fundal height/uterine tenderness
- COGU scan to confirm - 4 chamber/color doppler
- FBE/UEC/LFT/Coag/G&S
- Kleihauer - FMH
- HbA1c/BSL/TFT/aPLs/BA/TORCH
Expectant - unpredictable timing/infection/DIC/haemorrhage
Active - mife then miso 24-48/24 post in hospital/mife SE = pain/N&V/diarrhea, PV miso, analgesia options, delivery +/- MROP
Post delivery
- Plac MCS/histology +/- fetal karyotype
- PM with autopsy
- Cabergoline for lactation suppression
- Referral to SW/Bereavement service
+/-Referral to Clinical Psych
- Death cert + Funeral arrangement
- Contraception + preg interval
- OP F/U for Ix result + future preg care
will need to expedite delivery if unstable - e.g. coagulopathic or abruption -> haem opinion/Obs med input -> Vit K/FFP/Cryo -> hysterotomy…
**risk of recurrence is ~2.5%
**autopsy - yield may be low if sig time lapsed since death - tissue degeneration - maceration, same for co-twin death - autopsy of dead twin from earlier in gestation is of little value
Post FDIU F/U
Karyotype 47XX T21
HE - post delivery recovery
T21 likely cause of FDIU
1:1000 (30yrs), risk increase with age
Need karyotype of mother/father
higher risk if carrier of balanced translocation - Genetic counselling
If normal parental karyotype, recurrence rate is 1%
Explain value of PM and what’s involved (encounter 2-3)
- find cause - rx - prevent
- assist with grieving + alleviate guilt
- full or limited PM, full = gold std
- 50% time no cause found
- alt = full body xray/MRI = low yield
Pt referred to OP Urogynae with POP/SUI, p/w confusion in OPC
DDx = UTI -> delirium
Admission/delirium workup/medics
Test for UTI +/- empirical UTI rx
What are the symptoms of voiding dysfunction and how do you treat someone with voiding dysfunction?
Sx - difficulty emptying, hesitancy, weak stream, dribbling
DDx - detrusor underactivity or bladder outlet obstruction
- Exclude UTI -> retention
- UDS/renal tract USS
- no cure, symptom management
Mx options
- bladder training - double voiding
- pelvic floor exercise
- Intermittent self-catheterization/IDC/suprapubic
- muscarinic receptor agonist/alpha-antagonist
34yo G1P0 32+6, persistent/worsening central abdo pain, A-‘ve, hx of bowel resection, sinusoidal trace, firm abdomen, what do you do? (encounter 1),
sinusoidal trace + abdo pain = abruption
what’s RFs for abruption? concurrent mx issues (e.g. PET - PPH)
what was the previous bowel resection? lots of adhesion?
Is birth imminent - cervix opened? - if VD not possible then CS
————————————————————–
- Obs emergency
- Code green GA emCS
- MDI essential
- Inform Senior Obs - expect adhesion, may need CR team
- x2 WB IVC - FBE/G&S-xmatch/Kleihauer
- NBM + IVT
- Cord gas/placenta for path/assess for features of abruption
- Paeds at birth
- Anti-D postpartum
- Document/Debrief
- postpartum F/U to discuss RFs and prevention
—————————————————————-
*BP/drugs/thyroid/fibroid
34yo, D2 post cat 1 emCS for placental abruption on bkg of previous bowel surgery, not PF, with worsening abdominal pain, uterus FC, minimal PVB, distended abdomen
DDx - ileus/ogilvie/intra-abdominal bleed
Focused hx
- Uterus position/PVB - F+C/min PVB - not intra-abdo bleed
- N&V - see if pt needs NGT
- RFs for either of above - bowel handling/hemoperitoneum…
———————————————————–
- NBM with IVT +/- NGT
- Urgent bloods include FBE/UEC/CRP/LDH - infection/electrolyte/LDH elevated in Ogilvie
- Urgent AXR to exclude BO/risk of bowel perforation - caecum
- Inform consultant/Refer to Gen Surgery for advice
- Analgesia/Antiemetic +/- ABx
- Chew gum/VTE/ambulation
- Serial AXR to check for resolution
- Gradual upgrade of diet as per Gen Surg
*Ogilvie may require neostigmine +/- decompression
26/40, sudden onset RIF pain
- USS showing a 7cm suspicious ovarian cyst
- USS showing ovarian cyst with torsion
HE - onset/N&V/fever/chills/U&B/vitals/abdo/spec - cervix/FFN
- I’m concerned about either torsion/appendicitis
- need to also exclude abruption/rupture/TPL
- FBE/UEC/CRP to exclude acute infection
- consider CTAP vs TV USS to exclude appendicitis
- inform con/refer gen surg for opinion
- NBM + IVC - IVT/analgesia/antiemetic +/- steroid
- await investigation +/- surgery
TMs not be useful in pregnancy
**suspicious mass - USO+PW+peritoneal/omental bx
**torsion - detorsion/cystectomy +/- USO if necrotic (need to consent well pre-op)
**COCP to reduce risk of cyst in future
26/40, 12/24 post lap detorsion/cystectomy
abdominal pain/low BP/tachycardic
HE - pain/PF/UOP/pallor/BS/peritonism
- I’m concerned about an intra-abdominal bleed
- need to also exclude anemia/dehydration/ileus
- FBE/UEC/LFT/CRP/G&S to check for Hb/inflammatory markers
- CTAP to exclude intra-abdominal bleed/RTS - fetal wellbeing
- NBM/x2 WB IVC + IVT + analgesia + IDC
- await Ix +/- RTT
26yo G1P0 26+3/40, sudden onset RIF pain with USS showing a 7cm suspicious ovarian cyst on USS, LR AN course, RSO during same admission, results returned stage 1c EOC, elevated CA125, negative washings. (encounter 2)
- recovery hx - change in sx
- you have ovarian cancer
- it’s early stage, prognosis is ~90% 5yrs
- you will need further surgery + chemo to complete rx
- surgery will involve TAH/LSO/omentectomy
your options are:
1. continue pregnancy
2. continue pregnancy + chemo and complete surgery PP
3. terminate pregnancy and proceed with surgery/chemo
risks to pregnancy is high if you continue, risks can include
- chemo can be used in pregnancy but can cause FGR/PTL/PTB
- chemo have a range of SE for you too (N&V/risk of infection…)
- you will need MDI - MFM/GONC - rx/RBU - if fertility preservation
investigations you will need include:
- 4 weekly G/S to check wellbeing
treatments you will need include:
- anti-emetic/steroids to help with sx
- hydrocortisone in labor
30yo G1P0 10/40, hx of RA on pred, LR AN Ix, please manage. (encounter 1)
HE - std AN/neck/hip issues/vitals…
R2U - PET
R2B - FGR/PTB/NLS
Pred exposure
- MFM/Obs med
- LDA+ca+reg OPC+BP+uPCR
- early OGTT/tertiary morph/hydro
- anti-Ro/La +/- fetal echo
- 4wkly G/S from 28/40
- ano rv if neck issue
- MOD if hip issues
- 24/40, EFW10%,180/100
(encounter 1)
HE - HA/visual/RUQ/vitals/clonus/reflex
- HTN crisis - MET call - MDI
- NBM + x2 WB IVC + IDC + strict FB
- FBE/UEC/LFT/uPCR/coag +/- hemolytic screen to exclude PET or HELLP
- Anti-HTN PO vs IV/check response - transfer to ICU for MgSo4 if unresponsive
- Steroid loading +/- delivery planning (CS consent +/- classical)
- Post CS -> ICU/continue MgSo4/BP control/education/VTE prophylaxis…
*maternal indications del - uncontrolled HTN, eclampsia, HELLP, persistent neuro/epigastric sx, worsening haem/biochem
**fetal indications for del - FGR/NRCTG/abruption
D0 post emergency classical
no UOP
(encounter 2)
Surgical cause vs Pre-renal cause
Hx/Exam
- OP cx/EBL/abdo pain/fluid balance
- HR/BP/IDC/abdo - fundus/peritonism
DDx
- ureteric/PET related - fluid shift/AKI
Ix
- FBE/UEC to check Hb/renal function
+/- renal tract USS ? post renal cause
+/- CT IVP ? post renal cause
Mx (ureteric)
- MDI - Urology rv/IR
- NBM pending Ix
- ? nephrostomy vs RTT
…
Mx (PET-hypovolemia/AKI)
- MDI - Obs med opinion
- judicious use of IVT + monitor for APO
- repeat bloods + monitor UOP
- correct any anemia
- cease nephrotoxins (e.g. ACEI)
+/- alter clexane dosing
+/- diuretics
32/40 in ANC
BP160/95
(encounter 2)
Hx/Exam
- HA/visual/FM/APH/SROM/TPL
- uterine tender/clonus/reflex/FHR/FH
DDx - PIH/PET/HELLP
Exclude abruption
Ix
- FBE/UEC/LFT/uPCR to screen for…
- CTG to check for fetal wellbeing
- Obs USS to check for FGR
Initial mx
- anti-HTN and check response
- admit for observation and BP optim
- inform con/consider steroid loading
Ongoing mx
- DC with PO anti-HTN
- weekly ambulatory monitoring
- weekly OPC with bloods
- timing/MOD depends on progress
known PET from 32/40,
now 33/40, BP180/100 in ANC
- uPCR 1000
- Plt 120
- AST210 ALT170
(encounter 3)
HE - HA/visual/FM…vitals/clonus/reflex/VE
- HTN crisis = DDx - PET/HELLP
- Call for help - MET
- MFM/Obs med/Haem
- ABC - x2 WB IVC + IDC
- FBE/UEC/LFT/Coag/G&S/CTG
- Requst con/ano/paeds rv
- Treat and monitor in HDU
- Anti-HTN + Steroid loading +/- MgSo4
- NBM + CS consent +/- classical
(indication = HELLP)
Postpartum
- HDU/rpt plt/VTE prophylaxis
- strict FB/BP control/education
- discharge with anti-HTN/titration w GP
- 6/52 postpartum OP rv
- Hx of SLE - high BP in OPC
- Hx of SLE - scan show EFW24 AC10
(encounter 1)
HE
- FM/APH/SROM/TPL/usual flare sx - rash/joint pain/photosensitivity
- vitals/BP/uterus +/-FH +/- spec
(DFM, 145/95, discoid rash, urine protein 3+, FH=Date)
DDx - lupus flare vs PET
- FBE/UEC/uPCR, LFT/sFLT-PLGF (rising) to exclude PET
- anti-DS DNA (rising)/C3&4 (falling) to exclude lupus flare
- consider TORCH screen to exclude viral infections
- CTG +/- formal obs USS to check fetal wellbeing
- MFM/Obs Med input
- lupus flare will require high dose pred or aza +/- BP rx
- PET - anti-HTN +/- delivery vs OP F/U
- if delivery planned - need to consider
*BP can also be result of lupus flare - LN ->renal dysfunction -> BP, uPCR/BP are not helpful distinguish btw lupus flare & PET
How do you tell PUPPS rash from PG rash?
PUPPS - Sole/palms/peri-umbi spare, start from striae
PG - Sole/palms/peri-umbi
*PUPPS - reassurance is important - resolution post delivery
Suspected PG
HE - sole/palms/peri-umbi
R2U - discomfort
R2B - FGR/PTB/SB
Derm review + Bx to confirm
MFM/Derm input - fetal monitoring + timing of delivery
Rx = steroids - topical -> oral + antihistamines/emollient
Paeds review postpartum
*treatment same for PUPPS except the fetal monitoring and early delivery
**don’t forget SLE + TORCH infections as a cause of a rash
UI
Hx/Ex
- urge/nocturia vs cough/sneeze
- coffee/tea/smoking/diuretics
- PHx/Surg/Med/Screen - CST/MMG/Bowel
- SHx - living situation/work/finance
- urogenital atrophy/POP-Q
Ix
- MSU to exclude UTI
Mx
- BD/BT/PFE/modify RFs - cough/constipation/smoke/tea/coffee/etoh/fluid intake
- incontinence nurse referral
- topical E2/Review in 3 months +/- UDS
Surgery - SUI - MUS/Burch/Bulkamid
Medical - UUI - anticholinergic/b3 adrenoreceptor antagonist
Surgery - UUI - sacral nerve stimulation/bladder graft/diversion
SUI - fix cough/constipation
UUI - fix fluid/diuretic intake
64yo vaginal lump
HE
- cough/constipation/fullness/difficult void/defecate - can’t empty/sex
- UI - stress vs urge-nocturia
- quality of life/PMB
- VMS/CST/MMG/FOBT
- PHx/Surg/SHx-sup/BMI/POP-Q
FBE/UEC/LFT (baseline)
Urine - MCS
Pelvic USS (exclude uterine/adnexal abno)
Mx - LS + PFE + Pessary - pessary is…F/U to rv in…
cough - asthma/copd/smoking
**occupational - lifting
**constipation
Describe Pessary as a treatment option for POP
- to reduce vaginal/uterine prolapse symptoms
- if want to avoid surgery, not fit for surgery, not finished family
- need to change/expect discharge/can have ulcers
Apical prolapse (uterus, cervix, vault) surg options.
- Colpocle - close vag/minor op/quick recover/not if SA/can’t test
- Hyster - remove ut/major op/slow recover/ok SA/no mesh
- Hyster options = VH v TAH v TLH - VH = safer/quicker recovery/short vagina
*SSF if vault prolapse
*Sacro hysteropexy is uterine preserving, not fertility preserving
UUI Med/Surg Options
- failed conservative mx (encounter 2)
- confirmed OAB, failed medical mx (encounter 3)
Hx/Exam
- change in sx
- compliance with conservative mx - cut down smoke/etoh/tea/coffee etc…
- compliance with medical mx - meds…
Medical
- anticholinergic/b3 adrenoceptor agonists
- daily tabs, effective
- SE: dry mouth/constipation/palpitations
- trial and F/U in 3mo
Surgery
1. Botox injection
- day procedure under GA
- cystoscopy with botox injection
- antibiotics intra-op, trial of void
- quick recovery/effective/ no systemic SE
- risks - need repeat/UTI/retention - ISC
2. sacral nerve stim (implant in pelvis stim bladder nerve)
3. augmentation cystoplasty (bowel graft to improve bladder func)
4. urinary diversion (ileal conduit/stoma)
*CI to anticholinergic - narrow angle glaucoma
**CI to mirabegron - poorly controlled HTN
also think about cost assoc with medical rx options
Describe MUS
- tape support bladder neck
- day procedure done under regional or GA, antibiotics pre-op
- 3 incisions -either side of lower abdomen and vagina
- tape passed through to support bladder neck
- scar tissue form over time to hold tape in place
- cystoscopy at the end to exclude blader injury
- trial of void (if fail - ?IDC and return TOV vs RTT - too tight) and OP F/U
- effective, quick recovery
- risks include surgical cx + mesh cx
*RFs for poor healing - smoking, would recommend against
Describe Burch
- lift bladder neck
- done under GA
- open or keyhole
- side of vagina attached to ligament behind pubic bone with sutures so bladder neck lies in a hammock
- cystoscopy at the end to exclude bladder injury
- trial of void and OP F/U
- as effective as MUS, no mesh
- risks include surgical cx, longer surgery, slower recovery
Describe Bulkamid
- works by narrowing urethra
- day surgery under regional or GA
- cystoscopy to look inside urethra & bladder
- bulking agent inject near internal opening of urethra to bladder
- trial of void and OP F/U
- quick recovery, doesn’t use mesh
- risk include repeat procedure, ISC
Describe SSF aka Sacrospinous colpopexy
(encounter 2)
or
Return post conservative mx for vault prolapse
want surgery
(encounter)
HE - change in sx and POP-Q
Options = SSF vs SCP (non-mesh vs mesh) + cystoscopy +/- VR
SSF
- suspend vaginal vault to sacrospinous ligament on one side
- under GA, alone (e.g post hyster vault prolapse) or as part of a hysterectomy
- vag approach, delayed absorbable sutures to SSL then to vaginal vault unilat
- low recurrence/quick recovery/restore vaginal length
- general risks include…
- specific risks include buttock pain/dyspareunia/de novo SUI or worsen SUI
SCP
- mesh to vault to sacrum
- under GA, lap approach
- low recurrence
- general risks
- specific risks - mesh exposure/erosion/OM/dyspareunia/de novo SUI or worsen
Describe AP repair (encounter 2)
- risks include general/specific - de novo UUI
- ga/IV abx/lithotomy/prep/drape
- LA infiltration/sharp dissect bladder or rectum from vagina mucosa
- fascial plication with PDS - double layer continuous
- cystoscopy (anterior only) to check…
- remove excess vagina mucosa skin vicryl
- vaginal pack/catheter postop/TOV
Buttock pain post SSF (encounter 3)
HE
- analgesia requirement/intra-op cx/vitals
- perineal exam - loss of sensation vulva/LL weakness to exclude pudendal neuropathy
DDx: hematoma/pudendal nerve entrap/small n traction & injury
- inform consultant
- consider FBE+/-CTAP to exclude hematoma
- Hematoma - Observe + IV Abx +/- IR vs RTT
- Nerve traction/injury - reassure, NSAIDs, gabapentin, enema, OP F/U
- Pudendal nerve entrapment - NBM+IVT, RTT to release
Dyspareunia post VH/AP repair (encounter 3)
Hx/Exam
- bleed/discharge/fever/type of fixation/time since op/vitals/spec
DDx: granulation tissue/infection/dehiscence
Ix
- FBE/CRP to exclude active infective process
- Vault MCS
Mx
Granulation tissue
- Silver nitrate
- OP F/U +/- rpt
Infection/Dehiscence
- Admit/observe + IV Abx
+/- RTT - debride/repair
No cause found
- treatable but takes time
- 1st lubrication + topical E2 ->dilator therapy ->systemic anxiolytic
Consider EUA - division of adhesion and injection of LA/steroids
Abdominal pain post TVT (encounter 3)
Hx/Exam
- analgesia requirement/UOP/intra-op cx/vitals
DDx: retention/retropubic hematoma/tape too tight
Ix
- bladder scan to check PVR
- FBE/coag/G&s/CTAP to exclude hematoma
Mx
- NBM + IVT until Ix returned
- Inform consultant
- Rx depends on cause…
Hematoma
- observe with serial Hb +/- IR - embolization
- consider 1g Txa
- ensure adequate analgesia
- alternative is to RTT
Urinary retention
- IDC/MSU MCS +/- antibiotics
Tape too tight
- loosen within 14/7 beyond which would need removal & reinsertion vs split the tape
*confined space, bleeding should tamponade, observation reasonable for hematoma
Watery discharge post hysterectomy
(encounter 3)
or
Watery discharge post lap SCP
(encounter 3)
HE - bleeding/fever/chills/intra-op cx/vitals/speculum - dehiscence/fistula
DDx: VVF/worsening incontinence - masked SUI/infection
Ix
- vag fluid/serum Cr to confirm nature of fluid
- FBE/UEC/CRP to exclude biochem signs of infection
- MSU MCS to exclude UTI
- HVS MCS to exclude genital tract infection
- CT IVP to identify VVF
(VVF confirmed…)
- VVF is communication btw bladder/vagina
- risks include cystitis/urosepsis
- d/w Urology re: ongoing mx - await expectant vs surgical
- if small likely defunctioning IDC + abx then cystogram -> TOV
- if big likely EUA/debride/repair either within first 48/24 or 6/52 - post repair will need IDC then cystogram pre-removal + Urology F/U
*small RVF can also be healed by 2ndary intention
PV/PR bleeding post posterior vaginal wall repair (encounter 3)
HE - pain/fever/intra-op cx/vitals/speculum - dehiscence/offensive dc/PR
DDx: dehiscence/endometritis/RVF
- FBE/UEC/CRP to exclude infective process
- HVS MCS to identify bacteria
- Admit + IVC + IVT
- Broad spectrum IV antibiotics + Observe
- If worsening -> EUA + Debride + Repair
- VTE prophylaxis
- Transition to oral on DC with OPC F/U
*if RVF - CR opinion - not repair during active infection, diet mx, bowel prep/repair 6/52/fistulectomy/reapproprixmation/transvaginal-transperineal vs transabdominal…
post posterior repair
febrile, unwell
(encounter 2-3)
HE - pain/bleed/discharge/vitals/spec…
Admit + IVC + Bloods + MCS
IV ABx + Observe + CR opinion
No repair when acute infection
?spont resolution after rx of acute infection
F/U +/- Plan for OT 6-8/52
Bowel prep - transvaginal/transperineal vs transabdominal (if high)
May need stoma
Delirium post gynae surgery in elderly (encounter 3)
Hx/Exam
- pain/bleeding/fever/UOP/flatus/bowel motion/vitals/assess wound/IDC if in-situ/Bladder scan - PVR
DDx: pain/retention/constipation/infection
Ix
- FBE/UEC/CMP/LFT
- MCS - MSU/HVS
- ECG/CTB
Mx
- MDI involving Medical team
- Adequate analgesia/aperients
- Empirical broad spectrum abx if suspected infection
- VTE prophylaxis
- Vulval pain & dyspareunia bkg of recurrent infection (e.g. thrush) (encounter 1)
- vulval pain on IC, no obvious cause
Quickly ask for info not given in stem e.g. Menstrual/OGHxPHx/Surg/SHx…
Briefly address any unexpected issues as you go e.g. CST overdue
Dx/Prognosis
- trigger -> inflammation -> more nerve endings -> lower pain threshold -> heightened sense of pain
- treatable, takes time, impacts fertility
Exam/Ix
- Q-tip test
- HVS/LVS MCS to exclude thrush
+/- bx +/- PCR if suspicious lesions
Interim Mx
- await results & F/U
- Psych support
Mx
- MDI - PT/Psych/Sexual health/RBU
- CBT/PF exercise for pelvic floor spasm
- SSRI/SNRI/TCA/Gabapentin
- Dilator therapy
- Lignocaine gel with IC
- Botox injection to levator ani
- ART - IUI/IVF
*vulvodynia trigger - recurrent thrush, HPV/HSV/trauma/surgery
Pre-pregnancy counselling (general)
Hx/Exam
- Menstrual hx
- OGHx - Contraception/CST if on - stop, if overdue - do now
- PHx/Surg
- Med - if none - need folate/vitamins/iodine
- SHx
1. if SAD - need to stop/offer support
2. if toddler - aware of CMV - prevention strategies
- BMI - if high - need diet/exercise
- Cardio-resp/Thyroid
Ix
- FBE/Ferritin/+/- Thal + G&S/HIV/HCV/HBV/Rubella/Syphilis
- MSU MCS
+/- Carrier screen
Suspected molar pregnancy on USS
(encounter 1)
Quickly ask for info not given in stem e.g. Menstrual/OGHxPHx/Surg/SHx…
Briefly address any unexpected issues as you go e.g. CST overdue
Dx
- abnormal development of embryo
- pregnancy is not viable and you’re at risk of hemorrhage
Ix
- FBE/bHCG/G&S - baseline/rhesus + x-match 2units of PRBC
- +/- confirm o tertiary or COGU TV USS
Mx
- Admit - NMB+IVC+IVT
- Inform consultant/theatre/request Anesthetic rv
- D&E under USS - POC to path fresh
+/- anti-D postop
+/- conservative mx of theca lutein cyst - monitor sx of torsion, can be drained if large and high risk of torsion
- OP F/U pending histology results
+/- molar registry referral for bHCG tracking
Rising bHCG at F/U for histo confirmed mole
(encounter 2)
or
persistent PVB 10/52 postpartum
(encounter 3)
HE - …
Scenario 1 DDx = new preg vs GTN
Scenario 2 DDx = GTD/GTN/RPOC
- bHCG/FBE/UEC/LFT/TFT/G&S as a baseline as may need chemo (e.g. MTX)
- Tertiary or COGU TV USS to confirm & exclude new preg/RPOC/theca lutein cyst
- Consider CXR +/- CT head/CAP -> work out FIGO score
(vascular tissue on USS or choriocarcinoma on USS)
- likely GTN = persistent GTD, risk of malignant transformation
- prognosis is good - 85% cure rate
- high risk of uterine perforation if D&E again
- as need chemo, no need to repeat D&E unless bleeding
- uterine curettage is not required for dx, if not bleeding, no need for POC to confirm dx as risk of perforation is high
- Referral to GONC MDT/OP rv
- FIGO stage/WHO prognostic score determine type of chemo
- single (mtx) vs multi-agent (actinomycin + etoposide+mtx)
- chemo until bHCG is negative
- monthly bHCG, 12mo with effective contraception (P4, not IUS)
(ok for COCP/Depot/Implanon/Filshie/Salpingectomy) - future pregnancy: recurrence, no impact on future pregnancy, early preg USS, plac to histo postpartum, bHCG 6/52 postpartum
if need D&C, should go in with hysteroscopy to locate persistent focus
GTN is a clinical dx based on elevated serum bHCG/uterine enlargment w lesion/bilateral theca lutein cysts/metastatic disease
*whether to do brain - would be based on sx too
**IUS ok after complete resolution
**GTN can be benign (persistent GTD) or malignant - prognosis >90% even with mets (eg. met chorio), responds well to chemotherapy
MTX SE
GIT upset
Mucositis
Conjunctivitis
Neutropenia/thrombocytopenia
LFT derangement
RUQ pain + N&V + Hypertension in pregnancy
(encounter 2-3)
Also present with fever
HE - VE - ?IOL or CS
DDx = AFLP/HELLP/PET
Ix:
- FBE/UEC/LFT/Coagulation Profile/uPCR/BSL
Results:
- ⬇️Hb/Plt/⬆️AST/ALT (AFLP vs HELLP)
- Hypoglycemia/DIC - ⬇️fibrinogen ⬆️PT/APTT- (AFLP)
Dx/Prog
- AFLP sig M&M to baby/mother
- untreated, can lead to liver failure/mat/fetal death
Mx
- Obstetric emergency
- MDI - urgent paeds/anaesthetic rv/advice from Haem/Gastro
- Treatment in ICU to correct abnormalities before delivery
- Correct hypoglycemia w 50% glucose
- Correct coagulo FFP/cryo/albumin/Vit K
- Stabilize BP with anti-HTN
- Expedite delivery via emCS +/- classical
+/-Steroid +/- MgSo4 loading
- GA>regional, PPH - txa/uterotonics, Hematoma - drain/staples
- remain in ICU postpartum
- FU 6/52 obs med postpartum/LFT
*other rx = ventilation/dialysis/plasmapheresis/NACT or liver Tx
**for a multi with an open cervix, ?IOL vs CS, depends on maternal and fetal status, either AFLP is not going to get better baby still needs to be born
talk to an angry patient re: mx plan (angry re: mx plan suggested by another staff)? Communication
- You look unhappy about…
- Tell me about…
- I’m sorry that…
- How would you like me to help…
- There are other options (risk mitigating strategies - pros/con)…
- Would you like a second opinion…
- Thanks for sharing your concern and listening…
- 35yo G0, referred from FCC, BRCA1
- request for pre-menopausal oophorectomy to reduce cancer risk (encounter 2)
? any change to Hx/Exam
- Lifetime risk of EOC ~2%
- germline mutations make it higher
- EOC in relatives increases risk
Initial ix/mx
- Referral to FCC for rv/testing
- Pending results discuss RRBSO alone or as part of another surgery for benign gynae issue
Results
- Mutation vs No mutation
—————————————–
Dx
- BRCA2 risk of EOC/breast = 20/40
- BRCA1 risk of EOC/breast = 40/60
- no reliable screening for EOC
- RR surg reduce risk (e.g. 90% for EOC)
Initial Ix
- Pelvic USS +/- CA125
Mx
- Refer to Breast Onc -? mastectomy
- Refer to GONC - pros & cons of RRBSO
- Refer to Menopause clinic - risks & mx of early menopause
- RRBSO can be offered from 35yo when family complete
- RRBSO - day surg, GA, key-hole, pelvic washing, path, OP F/U, risks of surgery/early meno - sx/CHD/osteo
No mutation
- Risk of early menopause (CHD/Osteo) > Bkg risk of EOC
- No reliable screens, but would not recommend BSO
- Alternatives = long term use of COCP vs BS -50% reduction vs hyster alone
———————————————-
inheritance of BRCA, autosomal dominant, 50%, genetic counselling, PDG+IVF or prenatal dx +/- TOP vs donor egg vs adoption
**if someone needs to have a child before RRBSO - help with preconception planning
**onset of EOC after 40yrs for BRCA1, after 50yrs for BRCA2
Tubal ca on RRBSO sample, confined to FT
(encounter 2-3)
HE - postop recovery - pain/PVB…
- stage 1 FT cancer/prog (90%)/rx like stage 1 EOC
- refer for GONC rv + MDT + discuss additional ix req
- likely need CT CAP or PET CT + CA125
- likely need cytoreduction (TH/Omentum/LN) + stage + adj chemo
- also ref to menopause/sup grp/psych
- lifestyle modification where applicable in setting of iatrogenic meno
*refer for genetic testing (in case of completely incidental finding)
care post RRBSO (encounter 2-3)
care post inadvertent BSO at emergency surgery
HE - menopausal sx +/- open disclosure
- risks of early meno = CHD/Osteoporosis
- range of sx - VMS/GSM/myalgia/arthralgia/cognition
- care require MDI - meno/GP
- LS + HRT + Screens
- LS - cease smoke/min etoh/wt bear ex/ca/vit/dexa
- HRT - till meno age w f/u/risk of VTE/BCA/CVA/benefit - osteo/CVD reduce
- Non-pharm (CBT) + Non-hormonal (SSRI/SNRI/Gaba) options
*no HRT in hormone sensitive tumors/VTE/CVA, HRT ok if just BRCA+ no ca
FHx of BC/EOC/early onset CRC
No testing yet
Genetic counsellor said
5yr colonoscopy + yrly MRI brst
Want to discuss screen vs RR surg
(encounter 1)
FHx of BC/EOC
No testing yet
Want to discuss RRBSO
(encounter 1)
HE - menstrual hx/CST/fertility/bowel habit/PHx/SurgHx/SHx/breast lump
- FHx = strong risk of heritable mutation
- BRCA - EOC/BC (20/40/40/60)
- MMR - EOC/EAC/CRC (10/40/50)
Mx
- ref FCC- MMR/BRCA test/counsel
- type of RR surg depend on mutation
- RR surg pros & cons (menopause)
- alternatives to RR surg
- screen FRT ca - TM/Imaging/EB
- screen not proven for FRT ca
- screen for breast/GIT - MMG/C-scope
- need referral to breast or CR
confirmed Lynch
requesting RR surgery
hx of midline laparotomy + peritonitis (encounter 2)
HE - change in sx
- MMR mutation = Lynch syndrome
- Risk for EOC/EAC/CR 10/40/50
- ref GONC MDT/rv +/- TV USS + CA125 pre-op
- most definitive RR = TH + BSO + PW +/- Omental bx w Gen Surg support
- PAC/multi-D/GA/path, MDT, post-op F/U
- general risks…specific risks
- alt = BSO+HDC for EOC > COCP > BS
- screening not proven for EAC/EOC (e.g. USS+TMs+EBs)
- postop - refer to menopause +/- HRT/sup grp/breast/CR - MMG/G&C scope
- lifestyle mod - exercise/SAD/sup due to iatrogenic menopause
*Hasson vs Palmer’s w CR team avail avoid Veress or DOE via umbilicus
checklist for starting anyone on HRT
- uterus in-situ?
- hx hormone sensitive tumour/VTE/CVA
- not >60yo
- no more than 10 years of HRT
- f/u arranged?
40yo on HRT for POI
p/w SOB/pleuritic CP
DDx - PE vs infection
- VTE ix/rx
- VTE confirmed -> change from HRT
- non-HRT options for mx of VMS - pharm vs non-pharm
- non-HRT options for mx of osteo & cardiovascular risks
intra-op detection and mx of suspected ureteric injury (e.g. transection) (encounter 3)
? change in Hx/Exam
- ensure hemostasis
- pause surgery
- notify anesthetist
- call urology for opinion/assistance
- ask for IV methylene blue
- whilst waiting for urology support
ways to identify injury includes
1. visual inspection
- urine/visible defect in operative field
- hematuria + bubbles in IDC
- extravasation of methylene blue
- also check injury to bladder + contralateral side
- ureteral evaluation
- identity proximal, trace it
- look for peristalsis - cystoscopy
- assess bilateral UO jets
- no jet = obstruction or transection
- stent if thinking obstruction
intra-op mx
- kinked ureter - release suture +/- stent
- transection - re-anastomosis vs re-implantation, if can’t repair immediately - need nephrostomy until able to repair
postop
- IDC/Urology rv/plan
- Open disclosure/M&M/FU
Borderline BP + proteinuria …T2-T3, on bkg of T1DM/Renal Tx and FGR (encounter 3)
? change in Hx/Exam
evolving PIH/PET
DDx - renal failure/UTI
Ix
- FBE/UEC/LFT/uPCR to exclude PET
- MSU to exclude UTI
- CTG + Obs USS
Results
….PIH/PET….
Mx
- High risk/MDI
- BP opti to prolong vs Expedite delivery
- Deliver - Paeds+/-steroids+/-MgSo4
- BP opti - meds/monitor/scans/plan
*monitor - bloods/baby/sx
rashless pruritis @33/40 (encounter 1)
HE - FM/APH/SROM/TPL/vitals/FH…
Rashless pruritis = ICP
- FBE/UEC/LFT/Peak BA (non-fasting)
+/- hepatitic screen
+/- coagulation profile
+/- liver USS
- ICP a problem in liver
- R2U = pruritis/coagulopathy
- R2B = PTB/MSL/SB
- Obs Med opinion
- 2-4 weekly BA + LFT
- Urso +/- antihistamine +/- ointment +/- vitamin K
- IOL depends on BA (e.g. 37-39 BA<40…)
- no E2 contraception
- see GP to recheck liver function in 6/52
- recurrence 80-90%
*BA 40-99 36-37/40
*BA >= 100 36/40
Hx of FGM
previous re-infibulation
anterior epis, now post NVB
request re-infibulation
(communication station)
- ask why…
- safety/coercion
- safety of children from FGM
- follow the women’s response
Relevant clinical info
- cut/remove, no clinical reason = FGM
- FGM = illegal
- re-infibulation also illegal
- taking someone overseas = illegal
- risks of re-infibulation
1. painful
2. PP - infection/obstruct - urine/DC
3. gynae - UTI/CST
4. future pregnancy
Hx of FGM
- HE - impact on life ?UTI ?sexual dysfunction ?CST ?menstruation
- FGM clinic referral
- De-infibulation under LA antenatal or intrapartum
- gynae health - CST/reduce UTI/sexual function
- obstetric - allow FSE to monitor baby/VE to check labour progress/reduce risk of obstructed labour/CS/PPH/OASIS
- expect faster micturition/vaginal discharge + surgical risk - infection/pain/bleeding
Young nulliparous woman requesting hysterectomy for HMB, failed medical mx.
(Communication station)
- double check reason for request
- impact of problem on life
- explore why med mx failed
(?SE ?compliance…) - check understanding of
1. process of surgery/recovery
2. general risks of surgery
3. impact on fertility
4. impact on ovarian function - knowledge of alternatives
- recommend 2nd opinion
- follow-up visit to discuss
16yo primary amenorrhea
(encounter 1)
HE - anosmia (Kallman)/cyclical pain(imperf)/PHx/Surg/FHx/HEADSS/tanner
Ix - bHCG/E2/FSH/LH/Prl/TFT/Free T/SBHG/DHEAS/17OHP/Pelvic USS+/-Karyo
+/- rpt FSH/LH/E2/P/AMH (thinking POI) +/- anti-thyroid/ovarian/adrenal
primary ameno = no menses by 16, no menses 2yrs after breast develop
**Repeat FSH >40/E2 <50, TSH/Prl =N, in 4 weeks confirms POI
**HEADSSS - home/employ/activity/drugs/sex/self harm/safety
primary amenorrhea
normal hormonal profile
USS show no uterus
Karyotype 46XX
(encounter 2)
- MRKH = congenital abnorm
- missing uterus/cervix/part of vag
- risk: infertility/sexual dysfunction
- no general health risk
- care req MDI - PAG/psych/sexual health/fertility
- ongoing f/u/sup grp/vag dilator/vaginoplasty/adoption/surrogacy
primary amenorrhea
normal hormonal profile
USS show no uterus
Karyotype 46XY
(encounter 2)
- CAIS = Androgen receptor mutation
- male genotype/female phenotype
- no male reproductive tract
- risk of gonadoblastoma/infertility
- risk of CVD/Osteo post gonadectomy
- care req MDI - PAG/psych/fertility
- ongoing f/u/sup grp
- gonadectomy post puberty to allow breast development
- low dose E2 after gonadectomy
- adoption/surrogacy w partner sperm
- vaginal dilator therapy (1st line) -> vaginoplasty (2nd line)
*gonads may not be seen on USS, can be in inguinal canal or labia
primary amenorrhea
normal hormonal profile
USS shows uterus/streak gonads
Renal USS = horseshoe kidney
Karyotype 45XO
(encounter 2)
alternatives
- precon counselling Hx of Turner’s
- secondary amenorrhea - POI
- absent or mosaic X
- risk infertility 10% chance of spont/early meno -cx - osteo/cvd/VMS…
- general health risks = HTN/HypoT/cardiac/renal/IBD/Coeliac
- preg risk - aortic dissect/GDM/PET/FGR
- dysgerminoma risk (if 45XO/45XY)
- care req MDI - PAG/endo/psych/fertility
- screen for end-organ dysfunction - bloods/imaging*
- screen for visual/deafness (opthal/audiology)
- puberty induction with E then COCP
- ongoing f/u/sup grp/annual HbA1c/lipids
- donor oocyte/surrogacy/adoption
pregnancy = HR/MDI-MFM/Obs Med/Genetics
TTE pre-preg/early OGTT/LDA+Ca/tertiary morph/4wkly G/S
FBE/UEC/LFT/IBD/Coeliac/TTE/renal USS/DEXA
**+/- ref to surg for gonadectomy if 45X0/45XY
**aortic root 55mm - need repair, high risk for dissection, pregnancy CI - if someone had this u would offer TOP, otherwise, regularly echo/card/MFM/ctrl HTN if an issue and screen for PET/MOD=CS
primary amenorrhea
normal hormonal profile
USS shows uterus
Karyotype 46XY
(clinical or communication)
- Swyer’s = Absence or mutation in SRY gene
- no AMH or T, FRT not regressed, no MRT
- risk of infertile/meno/dysgerminoma
- care req MDI PAG/endo/meno/paed surg/psych/SW/sup grp/fertility
- puberty induction w E then COCP (HRT - osteo/CVD) + LS mod + DEXA…
- gonadectomy w Paed surg
- ongoing f/u/sup grp
- donor oocyte/embryo/surrogacy/adoption
*Girls and women typically have two X chromosomes (46,XX karyotype), while boys and men typically have one X chromosome and one Y chromosome (46,XY karyotype). In Swyer syndrome, individuals have one X chromosome and one Y chromosome in each cell, which is the pattern typically found in boys and men; however, they have female reproductive structures - a woman who is genetically male
Adult Dysmenorrhea +/- AUB
(encounter 1)
HE
- U&B/pressure/menstrual hx/dys’s
- IMB/PCB/CST/STI/PID/contraception
- OGHx - G&Ps/fertility plans
- PHx/Med/Surg/FHx - endo/SHx
- mobility/nodularity/spec
DDx - Endo/STI/Fibroid/adeno
- STI screen
- TV Pelvic USS
- trial of COCP + Mefanemic acid
- other agents available - cyclical P/IUS
- follow up visit
+/-diagnostic lap
*Epilim is sodium valporate - no interaction
Adolescent
Ix for dysmenorrhea
USS result = bicorn + non-communicating horn
(encounter 2)
Diagnostic lap for dysmenorrhea
Intra-op finding of bicorn + non-communicating horn
(communication)
? change Hx/Exam
Dx
- congenital malformation
- risk of endometriosis
- MC/ectopic/PTB/FGR/rupture/malpres
Ix
- MRI - characterize anomaly
- Renal USS - assoc renal anomalies
Initial Mx
- Ref PAG for consideration of surgery
- Likely need hemi-hysterectomy
- Procedure involves…
Ongoing mx
- F/U postop
- High risk preg care
emergency mx of preterm APH (26-28/40)
setting - rural vs tertiary
+/- previous CS
+/- previous hx of PTB
HE: pain/SROM/morph?LLP/rhesus/PET/BP/uterus/EBL/spec-cervix
Ix: FBE/G&S/Kleihauer/RTS/CTG +/- USS - VP/MAP/PAD
Mx: NBM/IVC/IVT/Steroid+/-MgSo4/+/-anti-D/paeds +/- Piper/tertiary care till 32/40/tert LLP rescan/decide MOD
*if abruption/APH uncontrolled - deliver 1st before transfer, would be an emergency classical
**previous cs/hx of PTB important to address as part of mx plan in setting of preterm APH
LLP or Placenta Previa on USS
(encounter 1)
Extra issues
- BMI 35-38
- previous CS
HE - preg sx + missing RANC
- Placenta near or over cervix
- R2U - APH/Admission/CS/PPH
- R2B - FGR/PTB/malpresent
- avoid IC/vigorous exercise/travel
- tertiary USS 24-26/40 to exclude VP/PAD +/- MRI
- 4 weekly serial G/S from 28/40
- optimize hematinic + MDT for peri-op planning
- 38/40 elCS - complex CS/MOD depends on resolution of LLP/previa
consider closer to hospital ~34/40, FFN/CL to gauge risk
**previous CS make it less likely for LLP to resolve by 32/40
**if no resolution by 32/40, 50% can still change, but if not 36/40, very unlikely
Known LLP
USS confirmed VP
Rural patient
(encounter 2)
Hx/Exam
- FM/PPROM/APH/TPL/FHR
- vessel in the membrane
- risk of admission/CS
- risk of FGR/PTB/SB
- confirm VP COGU TV USS
- tertiary care
- 2-4 weekly serial G/S to check for FGR
- admission from 32/40 - risk of PTB ->SROM ->rupture vessels
- steroid loading + Paeds rv + CS consent
- optimization of hemantinics
- daily CTG/IVC/Valid G&S/monitor sx
- elCS from 36/40
Known MAP Sig APH 30/40
(encounter 2)
HE - painful or painless/EBL (1L)/vitals/spec/RTS or CTG
- Immediate Delivery/Code Green
- x2 WB IVC - FBE/UEC/Coag/G&S/Kleihauer + x-match 4U/IVT/IDC
- GA/Trendelenburg/Midline/Classical with senior Obstetrician
- Immediate cord clamp/gaes/paeds in OT
- Placenta to histology/assess for abruption
- ICU or HDU postpartum/debrief/document +/- anti-D/anemia correction
*Electively, MDT pre-op planning, optimize hematinics, elective admission, steroid loading (pre-CS), elCS on complex CS list 38/40, cell saver, PRBC…
Known LLP mild APH 30/40
HE - FM/SROM/contractions/spec/RTS
Inpatient plan
- Inform con
- Admit/observe
- NBM/IVC+IVT
- FBE/G&S/Kleihauer
- Daily CTG
- Steroid loading + Paeds rv
- Formal Obs scan - growth/wellbeing
- regular pad check
On DC
- live close to hospital avoid…
- recurrent APH -> consider longer admission
- organize serial G/S + check resolution
Known LLP -> PAD
Sig APH 30/40
(encounter 2)
Hx/Exam
- pain or not/FM/PPROM/contractions
- vitals/EBL/Spec
- RTS-FHR/position/presentation/CTG
- Obs emergency
- Call for help - Code pink -> green
- MDI for simultan resus/ix/del
Resus
- ABC - O2 Hudson/x2 WB IVC/IVT/IDC +left lateral
Ix
- FBE/UEC/Coag/G&S/Kleihauer + x-match 6 units
Delivery (uncontrolled bleeding)
- NBM + CEFM
- Notify con/anesthetic/paeds
- Request GONC support
- Urgent TF to OT +/- MTP
- GA+Trendelenberg+Midline+Classical
+/- hysterectomy
- immediate clamp + cord gases
- paeds at birth
Postpartum
- HDU 24/24
- debrief/document
- anemia correction
- +/- anti-D
*Electively, pre-op MDT, MDI - urology/IR, optimize hematinic, consent for hysterectomy, internal iliac arterial balloon, discussion about fertility +/- RBU referral, admission, steroid loading, complex elCS 38/40, CVC/ART, cell saver, PRBC…
Known LLP
USS confirmed VP
32/40 requesting care rurally
(encounter 3)
- FFN/CL to assess risk of PTB
- case discussion with rural center
- check emCS and NICU capacity
- admission from 30-32/40
- standard I/P VP Mx
Known LLP
APH emergency -> CS
Suspected or confirmed PAD
(encounter 3)
Hx/Exam
- baby delivered or not
- hemodynamically stable or not
- level of support available
Mx (baby not delivered, no support)
- senior obs input/PIPER opinion
- close uterus/CEFM
- transfer urgently to deliver elsewhere
Mx (baby delivered, stable, no support)
- senior obs input/opinion
- inform anesthetic team
- withhold synt/leave plac in-situ
- close uterus/RTT when support available for hyster
Mx (baby delivered, stable, supported)
- senior obs input/opinion
- inform anesthetic team
- withhold synt/leave plac in-situ
- close uterus/hysterectomy vs MTX
- or exterorize - remove - oversew - tamponade with bakri
(question is how do you know how deep the invasion is if this is unexpected - defect might be through the wall…)
Mx (baby delivered, unstable, bleeding)
- obs emergency
- request senior obs support
- inform anesthetic team +/- pt (if awake in unexpected situation)
- convert to GA, central lines
- attempt to remove placenta +/- tamponade with Bakri …sequence of surg mx
- activate MTP + commence PPH mx - Txa/Uterotonics…
- ICU postop/debrief/document/routine PP care/anemia correction
Hx of multiple CS
tertiary morph to exclude LLP/previa/PAD
AMA
R2U GDM/PET
RR4U early OGTT/LDA/Ca
RR2B aneuploidy - 1:40 (40), 1:10 (45)/FGR/SB
RR4U MFM-screen vs diagnostic/4 wkly G/S from 28/40 to identify FGR
IOL from 39/40 to prevent SB assoc with PI
UPSI
(encounter 1)
HE - time since/LMP/reg/cycle length/partners/STI/PID
- R2U = unplanned pregnancy/STI
- EC options - Cu/LNG/Ulipristal +/- long term options
- HBV/HCV/Syphilis/Chlam/Gon/MG/Trich
- inform con/D/W ID team re: prophylaxis +/- empirical PID rx
- await Ix result to target rx & contact notification
- Cu = 5d, spermicidal/embryotoxic, insert/string/LARC/ cramp/PVB/expulsion
- LNG = 3d, delay ov, PO single dose/OTC, no long term contra/GIT sx/PVB
- Ulipristal = 5d, delay ov, PO single dose/OTC, no long term contra/GIT sx
- Long term contraception - start pill or discuss other options
- F/U in 2-3 weeks - ?menses +/- bHCG
HCV carrier
(encounter 1)
HE - IVDU/transfusion/less likely sexual/dx/rx/F/U
- transmission/cirrhosis/liver ca
- LFT + USS to check severity
- Gastro Ref - antiviral rx + VL F/U
HIV exposure
(encounter 1)
HE - partner VL/rx/F/U
- refer to ID for advice on mx
- likely need HIV PEP prophylaxis + HBIG
- recommend barrier contraception in future
- F/U +/- rx of any STI identified
HIV detected on antenatal serology
(encounter 2)
- human immunodeficiency virus -> AIDS
- R2U GDM (from cART)/PET (from immune reconstitution syndrome)
- R2B FGR/PTB
- need cART (protease inhibitor) - MFM/ID input
- screen for GDM/PET - early OGTT +/- LDA+Ca
- screen for co-infection (HCV)
- regular VL/CD4/LFT
- VL>400 copies/ml @36/40 -> plan for CS
- avoid prolonged SROM/AN/Intrapartum invasive procedures
(FSE/FBS/instrumental/epis) - cord blood/paeds/PEP/Formula feed safer than BF/HIV service
low CD4 - risk of pneumocytis pneumo/toxo reactivation
**folate 5mg if on co-trimoxazole for pneumo prophylaxis
**if PPROM - d/w ID/Paeds ?VL, MTCT vs prolonged gestation
**MTCT <1% if undetected VL - can have VD
Unsighted pregnancy w PVB
(encounter 1)
HE - hx of ectopic/smoke/IUD/tubal surgery & path/IVF/spec - ?POC
- MC/ectopic pregnancy/normal preg
- NBM + IVC + IVT +/- analgesia
- bHCG - baseline/FBE/UEC/LFT - in case need MTX/G&S - Rh +/- STI screen
- COGU TV USS to site the pregnancy
- D/W consultant/Await Ix results
TA USS if unable to tolerated TV
**nothing on USS -> rpt bHCG In 48/24 +/- rescan if >1500
**if bHCG falling, track to 0
**if severe pain/bleed - laparoscopy
Non-consensual IC (sexual assault)
HE
- pain/bleeding/injuries
- circumstances/assailant/police
- comprehensive OGHX/med hx
- vitals …
- refer to CASA - forensic examination/evidence/counselling
- refer to SW
- +/- refer to Police (if patient agree) +/- psychiatry input
- Preg risk - EC/FU in 3/52 serum bHCG
- STI - bloodborne/STI/d/w ID/PID abx/HIV or HBV PEP
- Chase result/F/U in 1 week
if can’t examine & acute bleeding, need EUA +/- repair
**empirical PID rx = ceft/doxy/metro
**initial blood borne may be normal - but need to recheck
- UPSI -> declined EC, bHCG2700, asx, 2cm left tubal mass
- CS scar on TA USS in ED -> CS scar TV COGU USS (when asked)
- UPSI -> failed EC, cervical ectopic
- +’ve bHCG on urine at IUD clini
(encounter 2)
HE - pain/bleed/vitals/peritonism
Ix - bHCG/FBE/UEC/LFT/Rhesus/TV USS
Ectopic pregnancy is not viable
R2U - rupture/bleed/surgery/death
Expectant
- asx, bHCG <1000, not live, can f/u
- bHCG track/monitor sx
- early pregnancy USS next preg
Medical
- asx, bHCG<3500, not live, <35mm, f/u
- MTX, d4-7 aiming for >15% drop
+/- anti-D
- if fail, 2nd inj, weekly bHCG till 0
- SE: GIT upset/agranulocytosis/liver…
- contra3mo/avoid NSAID/etoh/folate
- early pregnancy USS next preg
Surgery
- sx, b>=3500, live, >=35mm, cant f/u
- day case, lap, GA, salping, histo..
- risks gen/specific…15% drop in fertility
+/- anti-D
- postop F/U in 6/52
- early pregnancy USS next preg
Cervical - suction/hysteroscopic resection vs intra-sac asp + systemic MTX
**CS scar - lap wedge (exogenic) vs suction/hysteroscopic resection (endogenic) > intra-sac asp +systemic MTX > expectant
**Interstitial - lap wedge vs intra-sac asp + systemic MTX vs expectant
**MTX is only appropriate for someone who can attend F/U and is HDS
cervical ectopic post MTX - p/w PVB/Pain
(encounter 3)
HE - pale/hypotensive/tachycardic/peritonism
Mx
- I’m concerned about a ruptured ectopic causing internal bleeding
- Gynae emergency
- Call for help = MET call
- Require MDI for simultan resus/ix/rx
- ABC - O2 hudson/x2 WB IVC + bolus IVT + IDC + Keep warm
- FBE/UEC/Coag/G&S + X-match 2units
- Inform consultant/anesthetic/OT
- Arrange for urgent transfer to OT for laparoscopy +/- laparotomy rx of ectopic
- Intra-op 1g Txa/specimen to path
- HDU/ICU postop + repeat bloods & correction of anemia
- Debrief/document postop/OP F/U
Laparoscopy for rx of ectopic
Bleeding from anterior abdo wall from LIF port insertion
(encounter 3)
- injury to inferior epigastric artery
- stop operation/tamponade
- inform anesthetist/consultant for support
- request foley catheter/insert through port site and inflate to tamponade
- percutaneous suture to close port site/check with IAP lowered
- ports out under vision
- intra-abdominal drain and monitor OP
- postop open disclosure/document/MDT/anemia correction
50yo
sudden onset RIF pain
N&V
(encounter 1)
Hx/Exam
- fever/chills/dysuria/diarrhea/last BO/LOW/analgesia req
- OGHx - parity/MOD/menopause/CST/PID/dysplasia/ca
- PHx - appendix/Surg/med/FHx - BC/CR/EAC/SHx - support/SAD
- V/A/B/abdopelvic - bimanual/cervix
- I’m concerned about an ovarian torsion 2nd to unknown ovarian mass
- also need to exclude ectopic pregnancy/appendicitis/diverticulitis/BO
- NBM + IVC for FBE/UEC/LFT/CRP/G&S/bHCG+ IVT
- Urgent TV USS to exclude uterine/ovarian mass/doppler signs of torsion
+/- TMs - including CA125/CEA/CA19.9 - Where sx persist/worsen, consider theatre for diagnostic lap +/-…
partially workup mass/suspicious - seek GONC opinion/assistance/frozen
**desire fertility = USO+PW +/- Omentectomy
**peri/postmeno = USO vs BSO vs TAH/BSO + PW +/- Omentectomy
50yo, sudden RIF pain
USS show 6cm right adnexal mass pending TMs at time of surgery
Post Laparoscopy + USO + PW
Pathology = BOT(borderline) , cytology = N
(encounter 2)
24yo, torsion
CA125 - 52
Pathology = BOT mucinous
(encounter 2-3)
Hx/Exam
- pain/bleeding/fever/chills postop
- wound review
- TM results
- BOT is not cancer but have unknown malignant potential
- Chance of BOT in the other ovary, early stage = 95% 5yrs
- Refer to GONC MDT/clinic for discussion of further mx
+/- anesthetic PAC - Usually does not need chemo but may require completion surgery to stage
- Options likely involve surveillance vs pelvic clearance
- Surveillance involves 6-12 monthly CA125 + TV USS
- As you’re peri/postmenopausal, pelvic clearance is recommended
- Involving TH/BSO+/-omen+/-LN - multiday stay, GA, open or lap, path
- MDT rv of path + OP F/U
- SW/Counselling
appendicectomy if mucinous BOT
**pts with unilateral stage I BOT, USO + PW + omental bx + bx of any peritoneal lesion rather than full staging for ovarian cancer
**intra-op frozen sections can help with making decisions about appendicectomy or not
**BOT needs life long F/U until pelvic clearance
28yo, G1P0, 15/40
Hx of Maternal Marfan’s
(encounter 1)
Hx/Exam
- preg sx/AN care/Ix/OGHx…
- Marfan’s dx/cx/med/sx
- PHx/Med/Surg/FHx - Marfan’s/SHx…
- AVB/cardioresp - murmur/FHR
- medications are you’re on are…
- risk to you includes aortic root dissection/rupture/HF
- risk to baby includes congenital heart disease
To reduce risk to you
- TTE to check aortic root diameter + valve function (baseline + recheck)
- refer to MFM/Cardiology for care
- continue or commence b-blocker
- MOD depends on aortic root diameter
- intrapartum - epidural/short 2nd/minimize Valsalva
- postpartum TTE + cardiology rv
To reduce risk to baby
- genetic counselling re: risk of congenital heart disease
- tertiary morphology + fetal echo
*Root diameter <40mm = normal, >45mm = elCS
28yo, G1P0
maternal Marfan - mitral regurg + aortic root38mm
TTE = N, on metoprolol
Precipitate birth 36/40
Emergency buzzer - PPH
(encounter 2)
Hx/Exam
- 3rd stage/placenta/symptoms - SOB/chest pain (plac in-situ, SOB)
- vitals - HR155 BP100/70 ?RR ?temp
- PPH is an Obs emergency - likely 2nd to precip birth
- Call for Help - Code Pink
- MDI for resus/ix/stabilisation
- ABC - hudson o2/x2 WB IVC/IVT/IDC
- FBE/UEC/LFT/Coag/G&S + x-match 2 units
- Active 3rd stage (avoid ergot due to cardiac condition)
- Attempt CCT +/- Dublin’s - assess plac/membrane
- Assess for tears +/- repair
- Uterotonics (avoid ergot)…carbprost/Txa/40IU synt infusion/misoprostol
- Ongoing PPH -> urgent OT T/F…
- In the setting of mitral regurg + tachycardia
- I’m concerned about sudden SOB may be 2nd to APO
- need also to exclude aortic root dissection/rupture
- urgent mobile CXR to exclude APO
- seek opinion from CTS re: CT-aortogram
- once resuscitated, strict fluid balance, judicious use of fluid, rate control
- once stabilized pending other ix -> HDU for monitoring
- debrief - risk of PTB/PPH/document/routine PP care - correction of anemia
- TTE and F/U with Cardiology on DC
- ref for irregular menses
- ref for irregular menses/PCOM
- ref for irregular menses/obesity - PI
(encounter 1)
Rotterdam criteria - PCOS
Impact - fertility, general health, pregnancy
Fertility
- weight loss + metformin (MDT wt loss mx clinic - diet/exercise/meds/surg
- TTC - F/U if unsuccessful then try
- OI/IUI/IVF - Clomid/Letrozole/ovarian drilling (CREI)
General health
- BSL/lipid/HbA1c
- Endometrium - COCP - wt based vs cyclical P/mirena
- Hirsutism/acne - cosmetic - electrolysis/wax/topical rx
- MH/OSA - psychology/resp physician
Pregnancy
- early OGTT to detect GDM
*COCP - caution BMI >=30, CI for BMI>=35
**pre-menopause ET - highest 16mm in secretory, if oligo, don’t know which stage of cycle, borderline ET/high BMI - consider sampling
28yo, known PCOS on bkg of high BMI (high 30s)
Seen initially for irregular menses
Return to F/U for rv
(encounter 2)
Hx/Exam
- weight loss/hirsutism rx
- cycle regulation/compliance with meds
- other issues
- exam - BMI/hirsutism
Info provided from Hx/Exam
- BMI increased to 40s
- use COCP for limited time
- TCC for 9/12 no success
- oligomenorrhea
- want assistance with fertility
- PCOS/anovulation likely the main cause of sub-fertility
- Need to exclude other causes
- E2/LH/FSH/P4/TFT/Prl/AMH
- Pelvic USS to exclude EH/SMF + antral follicle count
- HyCoSy to check tubal patency
- also bring in partner for rv in F/U visit for hx/exam + SA
- PCOS/high BMI increase risk for pregnancy/fetal development
- weight loss is critical prior to conception
- refer to MD Wt loss clinic - med - GLP1-receptor ag/Bariatric surg
- need contraception whilst attempting weight loss
- once BMI optimized - need preconception supp (high FA) + Ix
- with BMI optimized and infertility ix completed, no cause
- if unsuccessful with TCC, would recommend OI
- 1st line letrozole…
*important to cover other long term aspects of PCOS - BSL/Lipid/Cardiovascular health with GP
PCOS risk to mum/baby in preg
BMI risk to mum/baby in preg
PCOS
risk to mum - high GWG/GDM/PET/emCS
risk to baby - MC/FGR/PTB
BMI
risk to mum
risk to baby
9/40 thrombocytopenia
(encounter 1)
HE - bleed/bruise/previous hx/VTE/meds/BP/rash
- I’m concerned about ITP/contact Haem for advice
- need to exclude other causes include GTP/SLE/APLS/PET/HELLP/DIC/Autoimmune
- FBE/blood film + UEC/LFT/Coag/Hemolysis screen/uPCR/ANA/aPLs
*sepsis can also be a cause
**sepsis -> TTP -> manifest with flu-like/diarrheal illness -> fever + thrombocytopenia + hemolysis -> seizures +/- BP
Flu-like sx/HA/Fever +/- BP
Thrombocytopenia
Hemolysis
High bilirubin/LDH
Normal LFT
- TTP/PET/evolving HELLP
Hx of VTE in pregnancy
New thrombocytopenia in pregnancy 18/40
DDx - most likely APS but need to exclude the others
DDx - can be APS + concurrent ITP
(PET/SLE screen -‘ve, APS screen +’ve)
Haem advice - complex area
Mx is about = rx of thrombocytopenia vs anticoagulation for VTE for low plt
Thrombo does not reduce VTE risks
Still need LMWH, safe to give plt >50-60 if no active bleeding
Peripartum/postpartum anticoag plan made antenatally
e.g. cease 24/24 before IOL, stop when labour commences etc…
Rx of thrombocytopenia 2nd to APS + concurrent ITP
IVIG/dexamethasone
Plt count monitoring
APS in preg
Baseline bloods - FBE/UEC/LFT/uPCR
HR MFM + Haem care
LDA + Ca from 12/40 PET risk
Reg OPC - BP/urine dip to screen for PET
+/- LMWH to prevent VTE
Serial G/S from 28/40 FGR risk
IOL from 39/40 SB risk
ITP confirmed
(encounter 2)
ITP = autoimmune/ab against plt
R2U = APH/PPH
R2B = neonatal thrombocyto 5-10%, small risk of ICH antenatal/intrapartum
RR4U
- MFM/Haem ref
- monitor plt regularly 2-4/52
- plt transfusion +/- IVIG/Pred when plt <20, symptomatic, or plan procedure
- aim >80 for regional, >50 for NVD or CS or IM injection
- optimize anemia + active 3rd stage +/- anticipate PPH +/- x-match
- rpt plt postpartum + F/U with Haem
RR4B
- no VE/FBS/FSE
- cord blood FBE + daily FBE to monitor for plt nadir
- neonatal review +/- rx with IVIG +/- cranial USS to exclude ICH if plt <20
anemia in setting of ITP - need to optimize anemia
**home birth request in setting of ITP - don’t recommend, need to birth where 24/24 blood bank -> plt availability
**if thrombocytopenia and concurrent LDA for PET prevention, consider stopping
Early GDM
early GDM, need to exclude pre-existing T2DM
risk to mum - PIH/PET/operative delivery/DM
risk to baby - MC/congenital abnom/polyp/PTB/LGA
To reduce risk for you
- check HbA1c to exclude T2DM
- regular 2 weekly high-risk clinic with BP/urine dipstick
- refer to endo/DNE for rv/education - BSL monitoring
To reduce risk for baby
- tertiary morph +/- fetal echo
- 4 weekly serial G/S from 28/40
*gliclazide is not used in pregnancy
34/40 SOL
Presumed ITP on pred
(encounter 2)
HE - frequency/duration/SROM/spec-cervix/RTS-cephalic
- inform con/paeds/haem/ano
- urgent FBE/G&S + check plt availability
- plt <50 = transfusion, >80 for regional
- hydrocort intrapartum if on pred/active 3rd stage/daily FBE post
- CEFM in labor/IV benpen/avoid VE/FBS/FSE/high forceps/cord blood FBE/paeds rv
*cranial USS to exclude ICH if plt <20
60yo
Vulval itch
(encounter 1)
Side issues
- FHx of Osteo
- Menopausal sx mx
- Missing CST
Hx/Exam
- SA/dyspareunia/impact on life
- PMB/urinary/bowel sx/VMS
- OGHx - parity/MOD/CST/MMG/FOBT
- PHx - autoimmune/atopy/Surg/Med/FHx- osteoporosis
- SHx - support/SAD
- AVB/external/vulvoscopy w AC - plaque/loss architecture/bx/cellulitis/inguinal lymph nodes/spec - vagina - sparing/cervix
menopausal sx - LS/Mx options briefly
not done CST - will perform today
FHx of osteoporosis - vit D/Ca/Dexa +/- Endo +/-bispho
fissure/erythema/white papules/left labial lesion 3cm
————————
- I’m concerned about LS, need to exclude VIN/SCC
- need to confirm on vulvoscopy + bx + MCS to exclude bacterial infection
- autoimmune/incurable/risk of ca transform - need lifelong f/u
- ultrap top steroid (clobetasol) vs high dose diprosone ointment
- avoid soap/detergent/use emollient/loose clothing
- chase histology +/- refer to Vulval Derm vs GONC
- need F/U in 3mo to check effectiveness then annually
*if rx (LS mod/steroids) not effective for sx improvement - consider anti-histamine, topical E2, TCA, pain modulator, vulvectomy (last line)
**risk for osteo - early meno/vit d def/FHx
60yo vulval itch, bx performed in OPC
home with high dose diprosone awaiting Ix result
histology = SCC w dVIN
(encounter 2)
Hx/Exam
- sx improvement with ointment
- healing of bx site
- SCC is skin cancer + dVIN is the precancer component
- Prognosis is good if confined to skin, no nodal disease 90% 5yrs vs 60% if node +
- Urgent ref to GONC MDT/RV
- Likely need additional Ix - CTAP/FBE/UEC…
- Likely need WLE + SLND, PAC - anesthetic/SPAC
- Multiday, GA, aim to remove and assess spread, path
- GONC MDT/FU rv, if +’v LN, likely need adj RT
- post rx, will need surveillance with GONC for many years
60yo vulval itch, bx performed in OPC
home with high dose diprosone awaiting Ix result
histology = dVIN vs uVIN
(encounter 2)
Hx/Exam
- sx improvement with ointment
- healing of bx site
- dVIN is precancer, related to LS
- 50% of ca transformation, 50% recurrence
- untreated dVIN -> SCC, average 2-4yrs
- vulval derm referral for rv/mx plan
- options include
1. surgical- WLE (recommended) as high risk for ca transformation
2. medical - imiquimod/ablation - laser when multi-focal - laser is usually under GA
F/U
- lifelong F/U (dVIN)
- likely need F/U 6-12/12 for 5yrs (uVIN post surgery)
uVIN - same treatment options (surg > laser > imiquimod), but usually laser preferred esp if multifocal, as is HPV related, HPV vax, smoking cessation, reg CST
**imiquimod SE - flu like sx, fever/lethargy, 3 weekly - 12-20 weeks of rx
**uVIN/HSIL - usually multifocal young women, 12% resolve in spont12/12, average 7 yrs to SCC if untreated, 50% also develop CIN/VAIN/AIN +/- SCC
26yo G2P1-1
P1 27/40 PTL emCS abruption - HIE - CP (L3 support)
SOL 26/40 7cm dilated
not wanting steroids/active mx/resus
(communication station)
Intro
Acknowledge
Sorry
Story
Solutions
Support
Second opinion
Relevant clinical information
- role of steroid = reduce risk of RDS/ICH/NEC
- role of MgSo4 = neuroprotection
- recommended MOD = emCS > VBAC, can’t monitor baby intrapartum & VBAC hx
- survivability of PTB = 22/40 10%, 24/40 60%, 27/40 90% 34/40 = full term
- disability of PTB = <24/40, very high chance, 40% will have long term health cx
Second opinion
- Paed rv
- Obs Consultant rv
30yo, G1P0 31/40
Moderate speed MVA in rural hospital ED
(encounter 1)
Hx/Exam
- Details of MVA
- FM/APH/SROM/TPL
- AN care/Ix - Hb/rhesus +/- antiD/S/R/Aneuploidy/Morph/OGTT/G/S
- OGHx - parity/mod/pelvic surgery
- PHx/Surg/Med/SHx - support/SAD
- vitals/seatbelt sign/abdo/uterine tenderness/contractions
- CTG/RTS - presentation
MVA - ? abdo trauma
Abdo trauma can result in placental abruption/uterine rupture
Risk to you = internal bleeding/emCS
Risk to baby = PTL/PTB/FMH/SB
- care require MDI
- trauma survey by ED/trauma team
+/- left lateral if supine with spinal precautions.
+/- empirical anti-D 625IU if rhesus -‘ve - kleihauer sent to exclude FMH + 4 hours CTG monitoring
- if stable, for DC home with OP Obs USS to check fetal wellbeing + OP F/U
*same rx as above for suspected pelvic # except liaise with ortho - implications - mobility/ROM of hip - elevated VTE risks in preg + may alter MOD
**CTAP or CTPA - low risk for fetal anomaly, theoretical risk of childhood cancer, pros vs cons
30yo, G1P0 31/40
Moderate speed MVA in rural hospital ED
Cleared from ED
Sent to BC to complete CTG/Monitoring
Developed constant abdominal pain + PVB
Rhesus -‘ve
(encounter 2)
Hx/Exam
- FM/contractions
- vitals/abdo palp (woody)
- CTG (fetal tachy+lates)/presentation (breech)/speculum (closed)
- abruption/uterine rupture 2nd to MVA
- this is an obs emergency
- call for help - code pink/green
- MDI for resus/ix/delivery
- ABC - o2 hudson/x2 WB IVC/IVT/IDC
- FBE/UEC/LFT/Coag/G&S/Kleihauer + x-match 2 units
- Cat 1 emCS +/- classical under GA vs Transfer (31/40 rural hospital)
(D/W with PIPER ?likely delivery then transfer, unlikely to have time for steroid loading with NRCTG and needing Cat 1 emCS)
- assess for clots in uterus/rupture/plac to histo
- Cord gases + blood group/Paeds at birth
- HDU postpartum/Debrief/Document
- Anemia correction + CS check
- Anti-D according to FMH
24yo, G1P0 28/40
P/W fever/chills/coryzal sx/SOB
(encounter 1)
Hx/Exam
- N&V/fever/chills/cough/coryzla/sick contact/rash
- Preg sx..
- AN ix/care…
- OGHx…PHx-asthma…SHx..SAD…
- vitals - RR/sat/cardioresp ?creps/FH/CTG/RTS
(fever/chill/N&V etc…not vaccinated, smoker, desat/tachycardic)
I’m concerned about influenza/covid on bkg of RFs
risk to you includes pneumo/resp failure/ICU/emCS
risk to baby includes PTL/PTB/Hypoxia/fetal distress
To establish severity and find a cause
- FBE/UEC/LFT/CRP +/- ABG +/- BC (if febrile)
- Nasopharyngeal Viral PCR to identify pathogen
- Sputum MCS if expectorating
- CXR to exclude pneumonia
- ECG to exclude tachyarrhythmia
To reduce risk for you
- Admit for observation/treatment (isolation)
- MDI from Obs Med/ID/PT - chest physio
- O2 + salbutamol neb + broncholytic
- IVT + antiemetic + antipyretic
- VTE prophylaxis (consider clexane) +/- antiviral +/- antibiotics
- if HR/RR remains high despite rx -> consider CTPA to exclude PE
- if deteriorating -> ICU support +/- delivery if unable to stabilize
To reduce risk for baby
- obs USS to check wellbeing
- daily CTG
- steroid loading +/- Paeds rv if decompensating and need delivery
If stable DC, ongoing AN care involves…
*COVID rx = steroid/mab/antiviral, clexane - beware if need urgent delivery
24yo, G1P0 28/40
COVID + on resp ward
on O2 + monoclonal ab
ATSP re: deterioration
(encounter 2)
alternative scenario with influenza with resp compromise
Hx/Exam
- SOB/FM/APH/SROM…
- vitals/WOB/cardioresp/spec -cervical dilation/CTG
HR130 BP110/70 RR35 Sats 85% on 4L o2 T39
check crackles/increase WOB at rest
cervix long closed, reduced variability with decels (not in labour)
- I’m concerned about resp failure and imp for mum/baby
- this is a medical & obs emergency
- call for help - MET
- req MDI for simultaneous resus/ix/stabilisation +/- delivery
- ABC - increase flow on hudson mask to 10L/x2 WB IVC/IVT/IDC
- rpt bloods FBE/UEC/LFT/CRP/BC/ABG/G&S, continue CTG
- fetal distress likely 2nd to mat hypoxia
- aim is to stabilize and improve oxygenation
- without improvement on resp - will need to consider cat 1 del
- inform con/request ano/paed rv
- NBM + steroid loading +/- MgSo4 if need to expedite Cat 1 Del
- consent for GA emCS +/- classical
- cord gases/paeds at birth, ICU for resp support postpartum
*postpartum COVID - refer to guideline for VTE prophylaxis
30yo
Transgender
XX - identify as male
Referred by GP for mx of HMB wanting to preserve fertility
Unremarkable Hx
Normal Pelvic USS
no menstrual hx included
Humiliated by ward clerk in waiting area.
Embarrassed from events in waiting area.
Opens with concern “am i crazy for still wanting a child”
Intro
Acknowledge
Sorry
Story - HMB, fertility desires
Solution
Support
Second opinion
Summary
Second visit
Relevant clinical
- HMB ix/mx options
- Fertility options - spont/IVF
29yo, G3P1 25/40
acute joint pain
Hx/Exam
- which joint/fever/chills/rash/coryzal/sick contact/VTE
- FM/APH/SROM/TPL/PET sx
- AN Ix/care/OGHx…/PHx…
- vitals/malar rash/joint swelling/lymphadenopathy/FH/RTS-FHR
- I’m concerned about SLE
- Need to exclude infection/RA
- FBE/UEC/LFT/ANA/anti-DS DNA/C3-4/RF/anti-CPP/ESR/CRP
- TORCH + Chlamydia/Syphilis
- Formal Obs wellbeing scan
- Obs Med opinion re: cause/additional ix/rx
- Avoid NSAID, can have paracetamol
- If it’s SLE, and joint pain is related to flare, pred is the rx
29yo, G3P1 37/40
earlier dx with SLE in preg (hypothetical)
flare of joint pain
P1 twin emCS 32/40 for abruption
P2 VBAC
(Encounter 2)
HE - joint/rash/FM/APH/SROM/PET sx/vitals/BP/Fundus/CTG
- PET vs Lupus flare
- check severity of flare/exclude PET - FBE/UEC/LFT/anti-DS DNA/C3/4/uPCR
- check fetal well-being - Obs USS
- pregnancy exacerbate SLE -> more flares
- refer to Obs Med re: flare treatment options - likely pred
- discuss with MFM re: timing of delivery ?IOL for worsening joint pain
- IOL would increase risk for VBAC cF to SOL
- VBAC likely to be successful given previous CS indication & VBAC
Multiparous woman
D10 postpartum
Pt BIBA in COMA
post grandmal seizure
bkg of peripartum PET
In ED, CTB shows cerebral vein thrombosis (CVT)
(encounter 2)
Hx/Exam
- collateral re: postpartum recovery/events preceding seizure
- vitals - BP…
- CVT blood clot in vein in brain, likely associated with PET
- risk to you from CVT include more clots/seizures/infarct/bleed/raised ICP
- risk to you from PET uncontrolled hypertension - CVA
- require MDI from ICU/MFM/Obs Med/Neuro/Haem
To reduce maternal risks
Immediately
- initial anticoagulation with LMWH
- seizure prophylaxis with anti-epileptic vs ?MgSo4*
- BP control to avoid other CVA
Ongoing
- Reduce VTE risks DOAC or warfarin 3-12/12/Avoid COCP as contraception
- Reduce neuro risks driving restrictions/neurology F/U FI of seizure
- Reduce risk of postpartum PET - Obs Med F/U
- Ensure adequate support for family and newborn
- Prophylactic LMWH throughout next pregnancy/postpartum
*seizure likely from CVT > PET (usually during preg <48/24 post delivery)
26yo multi 21/40
p/w RUQ/Epigastric pain
(encounter 1)
Hx/Exam
- N&V/colicky in nature/fever/chills/urine/bowel
- FM/APH/SROM/contractions
- AN Ix/care - S/R/FBE/rhesus/aneuploidy/morph
- OGHx…parity/MOD…PHx/Surg/Med/SHx…
- vitals/jaundice/Murphy’s/contraction/spec - cervix/liquor
- I’m worried about cholecystitis
- need to also exclude PET/HELLP/AFLP/Abruption/Uterine rupture
- FBE/UEC/LFT/CRP/uPCR/BSL +/- hemolysis +/- LDH + hepatitic screen
- Upper abdomen USS to exclude cholecystitis
- RTS -FHR and formal Obs USS to check fetal welbeing
- NBM/x2 WB IVC/IVT
- simple analgesia +antiemetic +/- antibiotic
- inform consultant and discuss with Gen Surg for rv/opinion
26yo multi 21/40
p/w RUQ/Epigastric pain
confirmed cholecystitis
failed medical mx
general surgeon recommend lap chole
explain risk and benefit
(encounter 2)
Benefit
- doesn’t increase the risk of PTL/PTB cF gen pop
- equally safe and more effective than expectant/supportive med mx
Risk
- surgical risks - injuries to surrounding organs…
- anesthetic risks - reaction
- postop recovery - VTE
26yo multi
treated with cholecystitis ~21/40
contracting 33/40
(encounter 3)
Hx/Exam
- FM/APH/SROM/onset of contraction
- vitals/abdo - contraction/tenderness/spec or VE/CTG
(CTG = sinusoidal trace)
- Sinusoidal trace preterminal trace suggestive of underlying anemia
- Obs emergency
- requires immediate delivery
- Call a Code Green
- Urgent TF to OT for Cat 1 emCS under GA
- NBM/x2 WB IVC/FBE/GS/Kleihauer/x-match 2units
- Inform Paeds to attend birth
- Intra-op
1. immediate clamp
2. Assess for rupture/abruption - volume
3. Placenta to histology
4. Cord gases - Postop
debrief
document
identify any potential RFs
organize F/U OPC
35yo G4P3
10/40
p/w PVB
(encounter 1)
Hx/Exam
- onset of PVB/pain/fever/chills/discharge/urine/bowel
- type of conception/plan
- AN ix/care - R/S/FBE/Rhesus/dating scan - aneuploidy booked…
- OGHx - parity/mod/cx/CST/PID/STI
- PHx/Surg/Med - folate/SHx - sup/SAD
- AVB/cardioresp/abdopelvic - spec cervix
(uterine prolapse on examination)
PVB
- PVB may be related to POP
- need to exclude miscarriage/STI/dysplasia/UTI
- MSU to exclude urinary tract infection
- +/- endocervical swab STI screen +/- CST (if not done)
- early pregnancy USS to check pregnancy viability
POP
- risk to you - discomfort/infection/PVB/urinary retention/labor dystocia
- risk to baby - PTL/PTB/FGR
To reduce your risk
- refer to pelvic floor physio for PFE
- seek opinion from Urogynae team ? pessary in pregnancy
- pessary ring or space occupying to reduce POP, need F/U & change
- consider elCS at term instead of VD if sig POP
- consider surgery postpartum - sacrohysteropexy vs hysterectomy…
To reduce risk for baby
- consider steroid loading when viable
- 4 weekly serial G/S from 28/40
35yo G4P3 13/40
known uterine prolapse
abdominal pain
(encounter 2)
Hx/Exam
- location/onset/fever/chill/voiding difficulties/bowel
- vitals/abdopelvic - fundus not palpable…spec…severe anterior displaced cervix…uterine prolapse…
(not passed urine, tender supra-pubic, fundus not palpable, really anterior cervix)
Urinary retention
- I’m concerned about urinary retention
- immediate mx is to insert IDC for relief
- urinary retention likely second to incarcerated retroverted uterus
- need to exclude cystitis with MSU MCS and consider empirical UTI rx
- UEC + renal tract USS to exclude renal dysfunction/hydronephrosis
- Discuss with Urogynae team re: timing of TOV and advice on prevention
Incarcerated uterus
- dx on clinical +/- TA USS findings
uterus trapped in pelvis
- risk to you - discomfort/urinary retention/uterine rupture
- risk to baby - PTL/PTB/FGR/
To reduce risk for you
- expectant/manual reduction (sx, 14-20/40)/surgical
- as you’re sx - manual reduction is recommended 1st line
- day procedure, GA/regional, uterine relaxant, USS guided, posterior fornix - pressure fundus, RTS post to ensure fetal wellbeing, F/U and check
- if persist beyond 20/40 or failed reduction, asx, closely monitor +/- ISC or IDC, elCS from 36/40
To reduce risk for baby
- if can’t reduce, steroid load when viable
- 4 weekly serial G/S from 28/40
*surgical
1. colonoscopy reduction
2. intravaginal balloon
3. laparoscopic reduction
35yo G4P4 now
uterine prolapse in preg
returned to OPC postpartum with ongoing POP sx
(encounter 3)
Hx/Exam
- postpartum recovery/POP sx/incontinence
- vitals/abdopelvic - POP-Q
- consider RFs from Hx
Mx
- LS mod - cough/smoke/lift/BMI
- Conservative mx - PT - PFE
- as important as surgery
Ut sparing
1. Lap sacrohysteropexy - mesh around cervix to sacrum, mesh cx, contra
2. Lap USL suspension - USL sutured to apex of vagina, no mesh, ureteric injury
- +/- PAC, multi-day, GA, 4-6/52 recovery
- general surgical risks of…specific risks of
Ut removal - TH + vault suspension (e.g. SSF)
- TH is performed by…VH/TLH/TAH…specific risks include…
- SSF is performed by…specific risks include…
- +/- PAC, multi-day, GA, 4-6/52 recovery
- general surgical risks of…
+/- AP repair +/- continence surgery + cystoscopy can be part of Ut sparing or Ut removing surgeries
*https://www.yourpelvicfloor.org/conditions/uterine-preservation-surgery-for-prolapse/#What%20preparations%20are%20needed%20before%20the%20surgery?
Primip
TF rural to tertiary
Post SD c/b 4th degree
Baby in poor condition in NICU
(Communication station)
Intro
Acknowledge
Sorry
Story
Solution
Support
+/- Second opinion
Summary
Relevant clinic info
- SD -> HIE - monitoring/testing/paed team provide update
- 4th - antibiotic/analgesia/aperients/OP F/U/anal USS/discussion re: future MOD
*expectation form this station is to provide a distressed woman with clear information regarding ongoing care
25yo multip
acute PVB post recent suction for missed ab
hx of low plt been investigated for lupus
hx of Hashimoto thyroiditis
(encounter 1)
Hx/Exam
- fever/chills/offensive dc/urine/bowel
- reason/details/circumstances around suction ?histology result
- details for ix for low plt and lupus
- OGHx - mod/parity…CST/STI/IC-contraception
- PHx/Surg/Med/FHx/SHx - sup
- vitals/EBL - abdo/spec - ?POC
(suction for missed ab on nuchal 13/40)
- I’m concerned about RPOC
- need to exclude GTD->GTN/endometritis/new preg
- bleeding worsened by low plt
- FBE/UEC/CRP/bHCG/G&S to check hb/plt/infection
- TV USS to exclude RPOC
- Chase histo for previous POC
25yo multip
acute PVB post suction for missed ab
repeat TV USS show theca lutein cyst
ERPOC = partial mole
(encounter 2)
GTD
- GTD is a tumor of placental tissue with malignant potential
- Definitive management is evacuation of POC + bHCG tracking
- Refer to molar registry for bHCG tracking until 0/contraception
- no impact on future preg, recurrence risk is low
- early preg USS, and placenta histo, bHCG 6/52 postpartum
- if bHCG plateau/rise, concern for GTN
- referral to GONC for MDT/OP
- will need CXR +/- CTCAP + FBE/UEC/LFT (if thinking chemo)
- single (MTX) vs multiagent chemo till bHCG = 0
Theca lutein cyst
- conservative mx if no sx of torsion and small
- lap drainage if large due to risk of torsion
partial tracking weekly till 3 consec 0 then no more
**complete weekly till 3 consec 0 then monthly 6/12
**GTN is hematogenous spread then CXR first
28yo
Infertility
Hx of LLETZ for CIN3
(encounter 1)
Hx/Exam
- duration of TCC/IC/frequency
- menstrual - length/duration/regularity
- details of LLETZ/recovery
- OGHx - rpt CST post CIN3/STI/PID…contraception
- PHx/Surg/Med/SHx - SAD - vax
- Hx about partner - PHx/trauma/infection…
- AVB/thyroid/cardioresp/abdopelvic - spec - cervix ? stenosis
(not had repeat CST post CIN3…)
- I’m concerned about cervical stenosis
- need to exclude other causes of PI…
- D2-3 FSH/LH/E2/Midluteal P4…AMH/TSH/Prl…
- TV USS +/- HyCoSy…
- Repeat CST
- bring partner to next visit + SA
28yo
Infertility
Hx of LLETZ for CIN3
PI Ix
- Bloods = N
- Uterine septum on USS
- LSIL on CST
(encounter 2)
Hx/Exam
- change since last visit
Uterine septum
- uterine septum is a RF infertility
- risk for implantation failure/recurrent MC
- refer to tertiary gynae
- hysteroscopic resection of septum
LSIL on CST
- on bkg of previous CIN3
- need repeat Colp +/- Bx…
Further mx
- plan for Colp + HDC +Diagnostic lap + Dye studies for Ix of PI
- HDC can confirm imaging findings before planning resection
- day procedure, under GA, risks include…
- alternative = HyCoSy ?structural abn + tubal patency & perform Colp as OP
28yo G2T1
p/w amenorrhea on bkg of mirena
mirena string missing on exam
USS show IUP 12/40 + IUS in abdomen
(communication station)
Intro
Acknowledge
Sorry
Solution
Support
Summary
Second opinion
Second visit
Relevant clinic
- IUS abdomen - laparoscopic retrieval
- IUP - continue vs TOP - suction
- plan for diagnostic lap/IUS retrieval + STOP + mirena reinsertion vs implanon…
Expectation is to communicate finding and discuss options available
22yo
p/w vaginal pain/bleeding
on bkg of unplanned pregnancy
(encounter 1)
Hx/Exam
- abdo pain/dysuria/bowel/fever/chills/?contraception
- unplanned ? desire to continue
- LMP/regular/length/dysmeno/CST/STI/#partners
- OGHx - G&Ps…/PHx/Surg/Med/SHx - SAD…
- AVB/EBL/cardioresp/abdopelvic - bimanual/spec - cervix/POC
Bleeding
- likely MC but need to exclude ectopic
- FBE/UEC/LFT/G&S/bHCG exclude infection/rhesus status/baseline bHCG + suitability for MTX if ectopic confirmed
- TV USS to exclude ectopic pregnancy
Vaginal pain
- need to exclude STI
- endocervical PCR for chlam/gon/MG/HVS for BV/trich
- NBM + x2 WB IVC + IVT whilst await Ix
- in case significant PVB requiring OT
TOA not resolving
Need OT
what to do to optimise mx
preop - IVabx/ano rv/consent
intraop - entry technique/senior/txa/adhesio/drain postop
postop - ICU/HDU/IV abx/ID/observe/PO switch/OP f/u
22yo
p/w vaginal pain/bleeding
on bkg of unplanned pregnancy
TV USS show incomplete or inveitable MC
Chlamydia infection on PCR
(encounter 2)
Incomplete MC or missed ab
- risk of pain/bleeding, common 20%, no impact on future preg
- options - expectant/medical/surgery
- expectant/medical - mife/miso, SE = pain/nausea/bleeding, risk is need for admission +/- further procedure, timing unpredictable, done at home, support, antiemetic/analgesia, access to hospital, F/U bHCG or USS
- surgery - suction, day procedure, GA, quick recovery, risks include…specific - asherman/RPOC/uterine perf/POC to path to exclude GTD
- +/- LARC insertion (with STI screen +/- treated - not for insertion if symptomatic with STI infection - ie PID)
Chlamydia infection
- chlam is an STI +/- screen other STI if not done
- risk of transmission to others/PID -> CPP/infertility
- treatable with antibiotics (doxy or azithro), retest in 3mo
- notify partner, test, treat with GP
- no IC until 1/52 after both are treated
- use barrier contraception in future to prevent
- TOC in 4/52 not req unless preg, test for reinfection in 3/12 req
Unplanned pregnancy - long term contraception
- consider menstrual hx/previous contraception/pt preference
- hormonal vs non-hormonal…overall reliable, systemic vs local SE
- implanon vs IUS @time of suction for MC vs OP
*indication for suction curettage - heavy PVB/pain/infective signs/RMC - POC for testing/large G/S+CRL
22yo represented with abdo pain/fever/chills/offensive PV dc
post D&C for incomplete MC, on bkg of chlam (treated previous admission)
(encounter 3)
15yo chlamydia+ & TOA on pelvic USS in setting of Ix of LAP w vaginal discharge
failed medical -> had laparoscopy -> intra-op goal/F/U
(encounter 2-3)
Hx/Exam
- ?UPSI again/?partner rx/fever/urinary/bowel
- vitals/abdopelvic - peritonism/bimanual/spec - cervix - dc
(cervical excitation…)
- I’m concerned about PID 2nd to chlam
- need to exclude new pregnancy-ectopic/cyst accident/non-gynae
- FBE/UEC/CRP/bHCG/BC
- HVS MCS +/- STI screen (depending on timing from last)
- TV USS to check for TOA
(pelvic USS confirms TOA)
- TOA is…risk include adhesion-infertility/CPP
- admit+ IVC + IVT + VTE prophylaxis + anti-pyretic
- IV antibiotic - azithro+metro+ceftr - aiming 48/24 afeb-> PO
- seek opinion from ID re: choice and duration of abx
- monitor clinically/biochemically for improvement +/- drainage
- need F/U with USS 2/52 prior to OPC w Gynae/ID - to decide duration of abx
- subsequent F/U USS to assess resolution + TOC + barrier contraception
- contact tracing - test/rx
consider drainage if >9cm TOA, postmenopausal, unresponsive to IV ABx - clinical or biochemical deterioration, decision to drain is a difficult one, benefit must overweigh the risks - high risk injury to organs/bleeding due to adhesion
**surgical approach to TOA should be conservative - ie. drainage for source ctrl rather than extensive adhesiolysis, must discuss long term implications post-op
**send MCS from wash out sample
vaginal lump in preg
(encounter 1)
alternative
Hx/Exam
- fullness/drag/PVB/DC/dyspareunia/difficult urine/bowel/fever/c
- preg sx (gestation dependent)
- AN care/ix - sup/vax/r/s/fbe/rhesus/aneuploidy/morph/ogtt/GS
- OGHx - parity/MOD/cx/CST…PHx/Surg/Med/SHx - sup/SAD
- AVB/cardioresp/abdopelvic/external inspection - vulva/spec - urethra/cervix/POP/cyst/+/- RTS+/-CTG
(small, not overtly symptomatic, no impact on life)
Lump in vagina
- Lump is a vaginal wall cyst - likely Gartner’s cyst
- It is not a POP/Bartholin’s cyst/Skene’s duct cyst
- This is a benign congenital growth of FRT
- confirm with TV USS or MRI
- exp mx, and intrapartum if obstructing - aspirate
- postpartum review in OPC for mx
+ gestation appropriate RANC
*Skenes duct cyst if large enough can cause bladder outlet obstruction/recurrent UTI - rx = expectant/medical/surgical - antibiotics for UTI, surgical = aspiration vs ID+marsupilisation vs excision
