Clinical Osce Cases Flashcards
What are three options to confirm the diagnosis of ruptured membranes?
- Sterile speculum exam
- Amnisure or nitrazine test
- Ultrasound – oligohydramnios
What are three potential complications of ruptured membranes?
- Pre-term labour
- Chorioamnionitis
- Placental abruption
- Cord prolapse
List at least six steps for managing a patient with ruptured membranes.
- Admit until delivery
- Antibiotics – erythromycin (chorioamnionitis)
- Corticosteroids – fetal lung maturity
- Deliver if signs of infection
- Genital culture for GBS, chlamydia, gonorrhoea
- Inform pediatric team re potential premature delivery
- Deliver at or after 34/40 if still pregnant
What important features should be assessed in the history of a woman with ruptured membranes?
- Systemic illness – feeling flushed, shivery, abdominal pain
- Change in colour of liquor or vaginal bleeding
- Fetal wellbeing – feeling movements
- Symptoms of labour
What important features should be examined in a woman with ruptured membranes?
- Maternal HR/temperature
- Abdominal exam – uterine tenderness/contractions
- Inspect pads for liquor
- WILL NOT PERFORM VAGINAL EXAM! – risk of chorioamnionitis
What investigations would you like to order for a patient with ruptured membranes?
- FBC (for white cells)
- CRP
- CTG
- U/S for liquor volume, presentation, estimated fetal weight
Who would you recommend the Progesterone-Only Pill (POP) for?
- Smokers
- > 35 years
- Obese
- Clotting disorder / Hx of stroke or clot
- Migraine
- Post-partum
- Breastfeeding
How should a woman be counseled regarding the use of the Progesterone-Only Pill (POP)?
- Take at the same time every day
- There is no break in taking pills - 28 tablets in blister pack, go from one pack straight into the next
- There will be breakthrough bleeding initially from day 21-28
When should a post-partum woman start taking the Progesterone-Only Pill (POP)?
- Normally first day of period - but BF post-partum woman might not have a period
- Begin any time, but use barrier protection for 7 days; should be protected afterwards
Who would you recommend the Depo-Provera Injection for?
- Adolescent
- Patients on anti-convulsants
- Poor compliance
What counseling should be provided to a woman receiving the Depo-Provera Injection?
- Irregular bleeds for the first 3 injections (every 12 weeks)
- 40% - amenorrhea
- 40% - hypoamenorrhea (light periods)
- Needs barrier contraception for STI
- Osteoporosis long term
Who would you recommend the Mirena (LARC) for?
- Long-term contraception needs – up to 5 years
- Menorrhagia
How should a woman be counseled regarding the Mirena (LARC)?
- 5 years max
- But if > 40 yrs - up to 10 yrs
- Very effective - as good or better than sterilisation
- Breakthrough bleeding for first 3 months
- 80% will resume fertility as soon as it’s removed
- Should check the string once a month
What are the 4Ts that cause Post-Partum Haemorrhage (PPH)?
- Tone: Uterine atony
- Tissue: Retained placenta/products
- Trauma of Genital Tract: Uterine, cervical, vaginal
- Thrombin: Bleeding disorder
What are the initial steps in emergency care for a patient experiencing PPH?
- Call for help
- Resuscitation (ABCs)
- Oxygen
- IV access: 2 wide bore cannulas
- Fluids/blood (2 units O neg)
- Baseline bloods: FBC, coag, group and crossmatch (4-6 units)
- Catheterise: Foley catheter
How can you control haemorrhage in PPH?
- Uterine massage
- Oxytocic agent
- Transfer to theatre
- EUA: Examination under anaesthesia for retained products & tears
- Remove retained products & repair tears
What specific management options are available for PPH?
- Balloon tamponade
- B Lynch suture
- Internal iliac ligation
- Hysterectomy
- Interventional radiology
- Oxytocic agents (e.g., Syntocinon IVI, Ergometrine IM, Carboprost IM, Misoprostol PR)
What are the poor indicators for confirmation of early pregnancy failure?
- Irregular gestational sac
- Absent yolk sac in gestational sac
- Retro-placental clot
- Failure of the fetal pole to grow or develop over time
What are the initial steps for assessing a first trimester haemorrhage?
- Stabilise
- Pregnancy test (PT)
- Serum βhCG level
- US
How do you distinguish between failed pregnancy or ectopic pregnancy using serum βhCG levels?
- Normal pregnancy → Doubling every 2-3 days
- M/C → Falling (or plateauing)
- Ectopic → Abnormal increasing
What are the characteristics of a complete mole?
- Only trophoblastic tissue, all of which are abnormal
- All chorionic villi are vesicular
- No embryo/fetus
What are the risk factors for molar pregnancy?
- Advancing age
- Ethnicity (SE Asian, India)
- Previous molar pregnancy
What management steps are taken for a molar pregnancy?
- Suction D&C (ERPC) – need to be sent to lab to confirm
- Check β-hCG weekly until negative, then monthly for 6 months to 1 year
- Follow-up is essential due to risk of malignant transformation to choriocarcinoma
What should be included in the assessment of a patient post-hysterectomy?
- Check colour/consciousness
- Ask re pain/lightheadedness/feeling cold
- Check BP, HR, RR, temp, cap refill
- Check urine output
- Examine abdomen for distension or haematoma
- Check/inspect PV bleeding/clots
What initial assessments should be performed on a post-hysterectomy patient with low blood pressure?
Check colour/consciousness, ask about pain/lightheadedness/feeling cold, check BP, HR, RR, temp, cap refill, check urine output, examine abdomen for distension or haematoma, inspect PV bleeding/clots, check drug chart for opiates, check for epidural/spinal anaesthesia effects, check operative records for estimated blood loss and complications.
List possible causes for hypotension in a post-operative patient.
- Post-op haemorrhage (abdominal or pelvic)
- Inadequate fluid (underestimates blood loss)
- Medication/anaesthesia related (analgesia, especially opiates, hypotension as side effect of epidural anaesthesia)
How would you manage a patient with BP 80/40 and HR 120 bpm post-hysterectomy?
- Elevate end of bed
- Increase fluids (colloid/crystalloid)
- Additional venflon
- FBC, G&H, U&E, coags
- Crossmatch if suspecting haemorrhage
- Administer oxygen
- Ask reg to attend
- If haemorrhage suspected: inform theatre staff, inform consultant on call, may need HDU
- Explain situation & management to patient and reassure
- Inform next of kin
What are the possible causes of antepartum hemorrhage (APH)?
- Placenta praevia
- Placental abruption
Define placenta praevia.
Abnormal placental location with migration occurring after 28 weeks gestation when the lower segment of the uterus develops.
What are the types of placenta praevia?
- Marginal
- Partial
- Complete
- Low-lying
List the clinical features of placental abruption.
- Painful bleeding
- Tetanic hard uterus
- Possible abnormal fetal heart rate
- Increased symphysis-fundal height
- Bleeding may not be revealed
- HCT not correlated with blood loss
What are the risk factors for placenta praevia?
- Advanced maternal age
- High parity
- Scarring of uterus (history of D&C, myomectomy, previous C/S)
What is the management for complete placenta praevia?
Cesarean section.
What is the significant threshold for defining preterm delivery?
Less than 37 weeks gestation.
What are the causes of preterm delivery?
- 1/3 follows PROM
- 1/3 are medically/obstetrically indicated
- 1/3 are spontaneous (idiopathic)
What is the strongest association for risk factors of preterm delivery?
Previous preterm delivery.
What assessments should be made for a symptomatic patient at risk of preterm delivery?
- Are membranes ruptured?
- Is there infection present?
- What is the likelihood of delivery?
What is the management for threatened preterm delivery?
- IV fluids
- Analgesia (paracetamol or pethidine)
What corticosteroids are used in preterm labor management?
- Betamethasone (12 mg IM daily x2 doses)
- Dexamethasone (6 mg IM 6-hourly x4 doses)
What is tocolysis and when is it reserved?
Tocolysis is reserved for gestations less than 34 weeks to give steroids enough time to work.
What are the indications for GBS prophylaxis?
- GBS bacteriuria in any concentration during current pregnancy
- Previous birth of an infant with GBS disease
- Positive GBS vaginal-rectal screening culture in late gestation during current pregnancy
- Unknown GBS status at the onset of labor with GBS risk factors
What is PROM?
Rupture of membranes prior to the onset of labor, at any gestation.
What is the management for pre-term premature rupture of membranes (P-PROM) at 24-34 weeks?
- Admit
- Corticosteroids
- Antibiotics (ampicillin, erythromycin, amoxicillin)
- Blood tests (FBC, U&E, CRP)
- Monitoring for signs of infection
What are the risks associated with P-PROM?
- Prematurity and its complications
- Infections/chorioamnionitis
- Pulmonary hypoplasia
- Abnormal presentation
How should a patient with PROM at term (38 weeks) be managed?
- Consider risk of infection
- GBS prophylaxis
- Elective induction of labor
What are the complications of multiple gestation?
- Preterm delivery/PROM
- Hypertensive disorder
- Gestational diabetes
- Postpartum hemorrhage
What criteria must be met for instrumental delivery with forceps?
- Full analgesia/anaesthesia
- No force
- Os fully dilated
What is the biggest single risk associated with pregnancy?
Hypertensive disorder
Other significant risks include gestational diabetes, complications of systems overload, postpartum hemorrhage, operative deliveries, and twin-twin transfusion syndrome.
What is Twin-to-Twin Transfusion Syndrome (TTTS)?
A condition that only affects monochorionic twins, requiring consideration of complications in multiple gestation
TTTS is a serious condition that can occur in pregnancies with twins that share a placenta.
What are the criteria for instrumental delivery using forceps?
- Full analgesia/anaesthesia
- Os fully dilated
- Ruptured membranes
- Adequate contractions
- Episiotomy required
- Empty bladder
- Known position of fetus
- Adequate pelvis
- Skilled operator
Vacuum delivery does not require an episiotomy.
What is the initial management for a patient with mild pre-eclampsia?
- Admit
- Urinary protein:creatinine ratio
- PET bloods: FBC, U&E, creatinine, LFTs
Mild pre-eclampsia is characterized by hypertension and proteinuria.
What are the risk factors for developing pre-eclampsia?
- Advanced maternal age
- First pregnancy
Other risk factors may include history of hypertension or pre-eclampsia in previous pregnancies.
What defines severe pre-eclampsia?
Symptomatic presentation with significantly elevated blood pressure and possible neurological symptoms
A diagnosis of severe pre-eclampsia is made when the patient presents with severe hypertension and symptoms such as headache.
What are the treatment goals for managing severe pre-eclampsia?
- Prevent seizures
- Lower BP to prevent cerebral hemorrhage
- Expedite delivery, balancing maternal condition and fetal maturity
It is crucial to manage the mother’s condition while considering the health of the fetus.
What medication is preferred for seizure prevention in pre-eclampsia?
Magnesium sulfate
Magnesium sulfate slows neuromuscular conduction and decreases CNS irritability.
What is the therapeutic range for magnesium levels?
- Normal: 1.3 - 2.6 mg/dL
- Therapeutic: 4 - 8 mg/dL
- Loss of patellar reflex: 8 - 10 mg/dL
- Somnolence: 10 - 12 mg/dL
- Respiratory depression: 12 - 17 mg/dL
- Paralysis: 15 - 17 mg/dL
- Cardiac arrest: 30 - 35 mg/dL
Monitoring magnesium levels is essential to prevent toxicity.
What are the first-line antihypertensive medications for severe pre-eclampsia?
- IV labetalol
- IV hydralazine
- Oral alternatives: nifedipine, methyldopa
The goal is to maintain maternal diastolic BP between 90-110 mmHg.
What are the delivery decisions for severe pre-eclampsia?
- Vaginal delivery preferred
- C/S for: continuous seizures, fetal distress, unfavorable cervix, severe prematurity
Anesthesia considerations include platelet counts for epidural or general anesthesia.
What is the most common cause of postpartum infection?
Endometritis
Endometritis typically occurs after cesarean section and can present with fever and uterine tenderness.
What are the clinical features of endometritis?
- Fever
- Uterine tenderness
- Foul-smelling lochia
- Tachycardia
Endometritis can lead to serious complications if not treated promptly.
What is the management for endometritis?
- IV antibiotics: Clindamycin/Gentamycin, may add Ampicillin
- Re-evaluate if no response in 24-48 hours
Prophylactic antibiotics may be administered during cesarean sections to prevent endometritis.
What distinguishes mastitis from engorgement?
- Mastitis: sudden onset, unilateral, intense localized pain, systemic symptoms
- Engorgement: gradual onset, bilateral, generalized pain
Mastitis can occur post-partum and may require treatment while continuing breastfeeding.
What are the top causes of direct maternal death?
- Hemorrhage
- Venous thromboembolism
- Hypertension
- Sepsis
Cardiac disease is the leading cause of direct maternal death overall.
True or False: Maternal sepsis & infection often presents early due to physiological changes of pregnancy.
False
Physiological changes can mask signs of sepsis, making it difficult to detect.
What is the first-line investigation for menorrhagia?
Exclude pregnancy
Pregnancy must always be considered in women of reproductive age presenting with abnormal bleeding.
What are the causes of abnormal menstrual bleeding summarized by PAADD?
- Pregnancy
- Anatomy
- Anovulation
- Diseases
- Dilation
Each category includes various potential conditions contributing to abnormal bleeding.
What does the PAADD mnemonic stand for in relation to causes of abnormal bleeding?
Pregnancy, Anatomy, Anovulation, Diseases, Drugs
What is the first test that must be conducted to exclude pregnancy in reproductive-age women experiencing abnormal bleeding?
Pregnancy Test (PT)
What are common causes of bleeding from the vulva?
- Excoriations
- Dysplasia
- Atrophy
What are the causes of bleeding from the vagina?
- Vaginitis
- Atrophy
What is ectropion, and how does it typically present?
Normal eversion of the transformation zone associated with OCP use, typically presents with post-coital spotting
What are the signs of cervicitis?
- Intermenstrual spotting
- Post-coital spotting
What are the common causes of cervicitis?
- Gonorrhoea
- Chlamydia
- Dysplasia
What is a cervical polyp?
Benign, polypoid neoplasm of the endocervical canal
What are the symptoms associated with uterine fibroids?
- Heavier menstrual flow
- Prolonged menses
- Intermenstrual spotting
- Pelvic pain
- Pressure
- Dyspareunia
What is adenomyosis?
Extension of endometrial glands into the uterine muscle
What are the histological variants of endometrial hyperplasia and their cancer risk?
- Simple hyperplasia: 1%
- Complex hyperplasia: 3%
- Simple hyperplasia with atypia: 10%
- Complex hyperplasia with atypia: 27%
What are the drug causes of abnormal bleeding?
- Contraceptive pill
- Copper IUD
- Depo-Provera
- Hormone Replacement Therapy (HRT)
- Steroids
- Chemotherapy
- Anticonvulsants
- Antipsychotics
What is the significance of high BMI in the context of abnormal bleeding?
It is a risk factor for endometrial hyperplasia and malignancy
What is the purpose of a Day 21 progesterone level test?
To assess if the patient is ovulating
What imaging methods are used to diagnose anatomical causes of abnormal uterine bleeding?
- Ultrasound
- Endometrial biopsy
What are the treatment options for abnormal bleeding due to systemic disease?
Treat underlying disease
What is Depo-Lupron and its effects?
GnRH agonist that shrinks fibroids by 40-60%, causes menopause, and is used short-term
What are the surgical options for managing fibroids?
- Hysteroscopic polypectomy
- Endometrial ablation
- Uterine artery embolization
- Myomectomy
- Hysterectomy
What is congenital varicella syndrome?
- Circular limb scarring
- Limb contractures
What complications can arise from Zika virus infection during pregnancy?
- Guillain-Barre syndrome
- Meningo-encephalitis
- CNS ischaemia
What is the risk of fetal injury if a pregnant woman is exposed to varicella before 20 weeks of gestation?
< 2% risk of fetal injury
What are the key points regarding Hepatitis B in pregnant women?
- Screen for HepB at booking
- Immunoprophylaxis may not be fully protective
- Vaginal delivery is possible if viral load is low
What is the management for a pregnant woman who has been exposed to chickenpox?
- Check booking bloods for IgG
- If IgG negative, give VZIG if non-immune
What is the expected duration for the normal puerperium process?
6 weeks
What happens to the uterus during involution post-delivery?
It shrinks and becomes non-palpable by day 12 postpartum
What are the potential problems and pathologies during the puerperium?
- Haemorrhage
- Thromboembolism
- Infection
What is the term for the vaginal discharge that occurs after childbirth?
Lochia
Lochia refers to the discharge of blood, mucus, and uterine tissue following childbirth.
When does menstruation typically resume after childbirth?
Resumption of menstruation occurs after childbirth
The timing can vary widely depending on factors like breastfeeding.
How long does it typically take for cardiac output and blood pressure to normalize postpartum?
By 2 weeks
This indicates a return to pre-pregnancy cardiovascular function.
What happens to fibrinolysis postpartum?
Normal within 30 minutes
This indicates a quick return to normal clot breakdown processes.
What is the status of pro-coagulant factors postpartum?
Pro-coagulant state remains
This means that clotting factors are still elevated after childbirth.
What happens to insulin resistance immediately after childbirth?
Goes immediately
This suggests an immediate improvement in insulin sensitivity.
What are the two types of haemorrhage that can occur postpartum?
1º or 2º
1º refers to primary postpartum hemorrhage, while 2º refers to secondary postpartum hemorrhage.
Name two thromboembolic complications that can occur postpartum.
- DVT (Deep Vein Thrombosis)
- PE (Pulmonary Embolism)
These conditions are related to blood clots that can form after childbirth.
List four types of infections that can occur postpartum.
- Sepsis
- Endometritis
- Wound infection
- UTI (Urinary Tract Infection)
- Mastitis
These infections can complicate recovery after childbirth.
What are two hypertensive disorders that may arise postpartum?
- Pre-eclampsia
- Eclampsia
These conditions are characterized by high blood pressure and can pose serious risks.
What lactation problems can occur postpartum?
- Failure to establish breastfeeding
- Mastitis
- Breast abscess
These issues can hinder successful breastfeeding.
What types of perineal trauma can occur postpartum?
- Haematomas
- 3rd/4th degree tears
- Episiotomy breakdowns
- CS (Cesarean Section) wound infections
These complications can affect recovery and comfort.
What urinary complications may occur postpartum?
- Retention
- Infection
- Incontinence
These issues can arise due to the physical changes of childbirth.
What psychological issues can arise during the postpartum period?
- Puerperal psychosis
- Post-natal depression
- Baby blues
- Suicide
These mental health concerns can affect new mothers significantly.
What are two types of perinatal loss that can occur?
- Stillbirth
- Neonatal death
- Malformations
These tragic events can have profound emotional impacts on families.
What are the two contraindications to breastfeeding?
- HIV positive status
- Radiotherapy
These conditions pose health risks to both mother and infant.
Is breastfeeding possible during chemotherapy?
Possible
However, mothers may need to ‘pump and dump’ to manage medication timing.
