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UL Obs And Gynae > Clinical Osce Cases > Flashcards

Clinical Osce Cases Flashcards

1
Q

What are three options to confirm the diagnosis of ruptured membranes?

A
  • Sterile speculum exam
  • Amnisure or nitrazine test
  • Ultrasound – oligohydramnios
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2
Q

What are three potential complications of ruptured membranes?

A
  • Pre-term labour
  • Chorioamnionitis
  • Placental abruption
  • Cord prolapse
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3
Q

List at least six steps for managing a patient with ruptured membranes.

A
  • 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
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4
Q

What important features should be assessed in the history of a woman with ruptured membranes?

A
  • Systemic illness – feeling flushed, shivery, abdominal pain
  • Change in colour of liquor or vaginal bleeding
  • Fetal wellbeing – feeling movements
  • Symptoms of labour
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5
Q

What important features should be examined in a woman with ruptured membranes?

A
  • Maternal HR/temperature
  • Abdominal exam – uterine tenderness/contractions
  • Inspect pads for liquor
  • WILL NOT PERFORM VAGINAL EXAM! – risk of chorioamnionitis
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6
Q

What investigations would you like to order for a patient with ruptured membranes?

A
  • FBC (for white cells)
  • CRP
  • CTG
  • U/S for liquor volume, presentation, estimated fetal weight
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7
Q

Who would you recommend the Progesterone-Only Pill (POP) for?

A
  • Smokers
  • > 35 years
  • Obese
  • Clotting disorder / Hx of stroke or clot
  • Migraine
  • Post-partum
  • Breastfeeding
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8
Q

How should a woman be counseled regarding the use of the Progesterone-Only Pill (POP)?

A
  • 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
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9
Q

When should a post-partum woman start taking the Progesterone-Only Pill (POP)?

A
  • 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
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10
Q

Who would you recommend the Depo-Provera Injection for?

A
  • Adolescent
  • Patients on anti-convulsants
  • Poor compliance
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11
Q

What counseling should be provided to a woman receiving the Depo-Provera Injection?

A
  • Irregular bleeds for the first 3 injections (every 12 weeks)
  • 40% - amenorrhea
  • 40% - hypoamenorrhea (light periods)
  • Needs barrier contraception for STI
  • Osteoporosis long term
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12
Q

Who would you recommend the Mirena (LARC) for?

A
  • Long-term contraception needs – up to 5 years
  • Menorrhagia
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13
Q

How should a woman be counseled regarding the Mirena (LARC)?

A
  • 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
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14
Q

What are the 4Ts that cause Post-Partum Haemorrhage (PPH)?

A
  • Tone: Uterine atony
  • Tissue: Retained placenta/products
  • Trauma of Genital Tract: Uterine, cervical, vaginal
  • Thrombin: Bleeding disorder
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15
Q

What are the initial steps in emergency care for a patient experiencing PPH?

A
  • 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
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16
Q

How can you control haemorrhage in PPH?

A
  • Uterine massage
  • Oxytocic agent
  • Transfer to theatre
  • EUA: Examination under anaesthesia for retained products & tears
  • Remove retained products & repair tears
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17
Q

What specific management options are available for PPH?

A
  • Balloon tamponade
  • B Lynch suture
  • Internal iliac ligation
  • Hysterectomy
  • Interventional radiology
  • Oxytocic agents (e.g., Syntocinon IVI, Ergometrine IM, Carboprost IM, Misoprostol PR)
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18
Q

What are the poor indicators for confirmation of early pregnancy failure?

A
  • Irregular gestational sac
  • Absent yolk sac in gestational sac
  • Retro-placental clot
  • Failure of the fetal pole to grow or develop over time
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19
Q

What are the initial steps for assessing a first trimester haemorrhage?

A
  • Stabilise
  • Pregnancy test (PT)
  • Serum βhCG level
  • US
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20
Q

How do you distinguish between failed pregnancy or ectopic pregnancy using serum βhCG levels?

A
  • Normal pregnancy → Doubling every 2-3 days
  • M/C → Falling (or plateauing)
  • Ectopic → Abnormal increasing
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21
Q

What are the characteristics of a complete mole?

A
  • Only trophoblastic tissue, all of which are abnormal
  • All chorionic villi are vesicular
  • No embryo/fetus
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22
Q

What are the risk factors for molar pregnancy?

A
  • Advancing age
  • Ethnicity (SE Asian, India)
  • Previous molar pregnancy
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23
Q

What management steps are taken for a molar pregnancy?

A
  • 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
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24
Q

What should be included in the assessment of a patient post-hysterectomy?

A
  • 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
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25
Q

What initial assessments should be performed on a post-hysterectomy patient with low blood pressure?

A

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.

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26
Q

List possible causes for hypotension in a post-operative patient.

A
  • Post-op haemorrhage (abdominal or pelvic)
  • Inadequate fluid (underestimates blood loss)
  • Medication/anaesthesia related (analgesia, especially opiates, hypotension as side effect of epidural anaesthesia)
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27
Q

How would you manage a patient with BP 80/40 and HR 120 bpm post-hysterectomy?

A
  • 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
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28
Q

What are the possible causes of antepartum hemorrhage (APH)?

A
  • Placenta praevia
  • Placental abruption
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29
Q

Define placenta praevia.

A

Abnormal placental location with migration occurring after 28 weeks gestation when the lower segment of the uterus develops.

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30
Q

What are the types of placenta praevia?

A
  • Marginal
  • Partial
  • Complete
  • Low-lying
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31
Q

List the clinical features of placental abruption.

A
  • 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
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32
Q

What are the risk factors for placenta praevia?

A
  • Advanced maternal age
  • High parity
  • Scarring of uterus (history of D&C, myomectomy, previous C/S)
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33
Q

What is the management for complete placenta praevia?

A

Cesarean section.

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34
Q

What is the significant threshold for defining preterm delivery?

A

Less than 37 weeks gestation.

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35
Q

What are the causes of preterm delivery?

A
  • 1/3 follows PROM
  • 1/3 are medically/obstetrically indicated
  • 1/3 are spontaneous (idiopathic)
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36
Q

What is the strongest association for risk factors of preterm delivery?

A

Previous preterm delivery.

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37
Q

What assessments should be made for a symptomatic patient at risk of preterm delivery?

A
  • Are membranes ruptured?
  • Is there infection present?
  • What is the likelihood of delivery?
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38
Q

What is the management for threatened preterm delivery?

A
  • IV fluids
  • Analgesia (paracetamol or pethidine)
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39
Q

What corticosteroids are used in preterm labor management?

A
  • Betamethasone (12 mg IM daily x2 doses)
  • Dexamethasone (6 mg IM 6-hourly x4 doses)
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40
Q

What is tocolysis and when is it reserved?

A

Tocolysis is reserved for gestations less than 34 weeks to give steroids enough time to work.

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41
Q

What are the indications for GBS prophylaxis?

A
  • 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
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42
Q

What is PROM?

A

Rupture of membranes prior to the onset of labor, at any gestation.

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43
Q

What is the management for pre-term premature rupture of membranes (P-PROM) at 24-34 weeks?

A
  • Admit
  • Corticosteroids
  • Antibiotics (ampicillin, erythromycin, amoxicillin)
  • Blood tests (FBC, U&E, CRP)
  • Monitoring for signs of infection
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44
Q

What are the risks associated with P-PROM?

A
  • Prematurity and its complications
  • Infections/chorioamnionitis
  • Pulmonary hypoplasia
  • Abnormal presentation
45
Q

How should a patient with PROM at term (38 weeks) be managed?

A
  • Consider risk of infection
  • GBS prophylaxis
  • Elective induction of labor
46
Q

What are the complications of multiple gestation?

A
  • Preterm delivery/PROM
  • Hypertensive disorder
  • Gestational diabetes
  • Postpartum hemorrhage
47
Q

What criteria must be met for instrumental delivery with forceps?

A
  • Full analgesia/anaesthesia
  • No force
  • Os fully dilated
48
Q

What is the biggest single risk associated with pregnancy?

A

Hypertensive disorder

Other significant risks include gestational diabetes, complications of systems overload, postpartum hemorrhage, operative deliveries, and twin-twin transfusion syndrome.

49
Q

What is Twin-to-Twin Transfusion Syndrome (TTTS)?

A

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.

50
Q

What are the criteria for instrumental delivery using forceps?

A
  • 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.

51
Q

What is the initial management for a patient with mild pre-eclampsia?

A
  • Admit
  • Urinary protein:creatinine ratio
  • PET bloods: FBC, U&E, creatinine, LFTs

Mild pre-eclampsia is characterized by hypertension and proteinuria.

52
Q

What are the risk factors for developing pre-eclampsia?

A
  • Advanced maternal age
  • First pregnancy

Other risk factors may include history of hypertension or pre-eclampsia in previous pregnancies.

53
Q

What defines severe pre-eclampsia?

A

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.

54
Q

What are the treatment goals for managing severe pre-eclampsia?

A
  • 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.

55
Q

What medication is preferred for seizure prevention in pre-eclampsia?

A

Magnesium sulfate

Magnesium sulfate slows neuromuscular conduction and decreases CNS irritability.

56
Q

What is the therapeutic range for magnesium levels?

A
  • 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.

57
Q

What are the first-line antihypertensive medications for severe pre-eclampsia?

A
  • IV labetalol
  • IV hydralazine
  • Oral alternatives: nifedipine, methyldopa

The goal is to maintain maternal diastolic BP between 90-110 mmHg.

58
Q

What are the delivery decisions for severe pre-eclampsia?

A
  • Vaginal delivery preferred
  • C/S for: continuous seizures, fetal distress, unfavorable cervix, severe prematurity

Anesthesia considerations include platelet counts for epidural or general anesthesia.

59
Q

What is the most common cause of postpartum infection?

A

Endometritis

Endometritis typically occurs after cesarean section and can present with fever and uterine tenderness.

60
Q

What are the clinical features of endometritis?

A
  • Fever
  • Uterine tenderness
  • Foul-smelling lochia
  • Tachycardia

Endometritis can lead to serious complications if not treated promptly.

61
Q

What is the management for endometritis?

A
  • 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.

62
Q

What distinguishes mastitis from engorgement?

A
  • 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.

63
Q

What are the top causes of direct maternal death?

A
  • Hemorrhage
  • Venous thromboembolism
  • Hypertension
  • Sepsis

Cardiac disease is the leading cause of direct maternal death overall.

64
Q

True or False: Maternal sepsis & infection often presents early due to physiological changes of pregnancy.

A

False

Physiological changes can mask signs of sepsis, making it difficult to detect.

65
Q

What is the first-line investigation for menorrhagia?

A

Exclude pregnancy

Pregnancy must always be considered in women of reproductive age presenting with abnormal bleeding.

66
Q

What are the causes of abnormal menstrual bleeding summarized by PAADD?

A
  • Pregnancy
  • Anatomy
  • Anovulation
  • Diseases
  • Dilation

Each category includes various potential conditions contributing to abnormal bleeding.

67
Q

What does the PAADD mnemonic stand for in relation to causes of abnormal bleeding?

A

Pregnancy, Anatomy, Anovulation, Diseases, Drugs

68
Q

What is the first test that must be conducted to exclude pregnancy in reproductive-age women experiencing abnormal bleeding?

A

Pregnancy Test (PT)

69
Q

What are common causes of bleeding from the vulva?

A
  • Excoriations
  • Dysplasia
  • Atrophy
70
Q

What are the causes of bleeding from the vagina?

A
  • Vaginitis
  • Atrophy
71
Q

What is ectropion, and how does it typically present?

A

Normal eversion of the transformation zone associated with OCP use, typically presents with post-coital spotting

72
Q

What are the signs of cervicitis?

A
  • Intermenstrual spotting
  • Post-coital spotting
73
Q

What are the common causes of cervicitis?

A
  • Gonorrhoea
  • Chlamydia
  • Dysplasia
74
Q

What is a cervical polyp?

A

Benign, polypoid neoplasm of the endocervical canal

75
Q

What are the symptoms associated with uterine fibroids?

A
  • Heavier menstrual flow
  • Prolonged menses
  • Intermenstrual spotting
  • Pelvic pain
  • Pressure
  • Dyspareunia
76
Q

What is adenomyosis?

A

Extension of endometrial glands into the uterine muscle

77
Q

What are the histological variants of endometrial hyperplasia and their cancer risk?

A
  • Simple hyperplasia: 1%
  • Complex hyperplasia: 3%
  • Simple hyperplasia with atypia: 10%
  • Complex hyperplasia with atypia: 27%
78
Q

What are the drug causes of abnormal bleeding?

A
  • Contraceptive pill
  • Copper IUD
  • Depo-Provera
  • Hormone Replacement Therapy (HRT)
  • Steroids
  • Chemotherapy
  • Anticonvulsants
  • Antipsychotics
79
Q

What is the significance of high BMI in the context of abnormal bleeding?

A

It is a risk factor for endometrial hyperplasia and malignancy

80
Q

What is the purpose of a Day 21 progesterone level test?

A

To assess if the patient is ovulating

81
Q

What imaging methods are used to diagnose anatomical causes of abnormal uterine bleeding?

A
  • Ultrasound
  • Endometrial biopsy
82
Q

What are the treatment options for abnormal bleeding due to systemic disease?

A

Treat underlying disease

83
Q

What is Depo-Lupron and its effects?

A

GnRH agonist that shrinks fibroids by 40-60%, causes menopause, and is used short-term

84
Q

What are the surgical options for managing fibroids?

A
  • Hysteroscopic polypectomy
  • Endometrial ablation
  • Uterine artery embolization
  • Myomectomy
  • Hysterectomy
85
Q

What is congenital varicella syndrome?

A
  • Circular limb scarring
  • Limb contractures
86
Q

What complications can arise from Zika virus infection during pregnancy?

A
  • Guillain-Barre syndrome
  • Meningo-encephalitis
  • CNS ischaemia
87
Q

What is the risk of fetal injury if a pregnant woman is exposed to varicella before 20 weeks of gestation?

A

< 2% risk of fetal injury

88
Q

What are the key points regarding Hepatitis B in pregnant women?

A
  • Screen for HepB at booking
  • Immunoprophylaxis may not be fully protective
  • Vaginal delivery is possible if viral load is low
89
Q

What is the management for a pregnant woman who has been exposed to chickenpox?

A
  • Check booking bloods for IgG
  • If IgG negative, give VZIG if non-immune
90
Q

What is the expected duration for the normal puerperium process?

A

6 weeks

91
Q

What happens to the uterus during involution post-delivery?

A

It shrinks and becomes non-palpable by day 12 postpartum

92
Q

What are the potential problems and pathologies during the puerperium?

A
  • Haemorrhage
  • Thromboembolism
  • Infection
93
Q

What is the term for the vaginal discharge that occurs after childbirth?

A

Lochia

Lochia refers to the discharge of blood, mucus, and uterine tissue following childbirth.

94
Q

When does menstruation typically resume after childbirth?

A

Resumption of menstruation occurs after childbirth

The timing can vary widely depending on factors like breastfeeding.

95
Q

How long does it typically take for cardiac output and blood pressure to normalize postpartum?

A

By 2 weeks

This indicates a return to pre-pregnancy cardiovascular function.

96
Q

What happens to fibrinolysis postpartum?

A

Normal within 30 minutes

This indicates a quick return to normal clot breakdown processes.

97
Q

What is the status of pro-coagulant factors postpartum?

A

Pro-coagulant state remains

This means that clotting factors are still elevated after childbirth.

98
Q

What happens to insulin resistance immediately after childbirth?

A

Goes immediately

This suggests an immediate improvement in insulin sensitivity.

99
Q

What are the two types of haemorrhage that can occur postpartum?

A

1º or 2º

1º refers to primary postpartum hemorrhage, while 2º refers to secondary postpartum hemorrhage.

100
Q

Name two thromboembolic complications that can occur postpartum.

A
  • DVT (Deep Vein Thrombosis)
  • PE (Pulmonary Embolism)

These conditions are related to blood clots that can form after childbirth.

101
Q

List four types of infections that can occur postpartum.

A
  • Sepsis
  • Endometritis
  • Wound infection
  • UTI (Urinary Tract Infection)
  • Mastitis

These infections can complicate recovery after childbirth.

102
Q

What are two hypertensive disorders that may arise postpartum?

A
  • Pre-eclampsia
  • Eclampsia

These conditions are characterized by high blood pressure and can pose serious risks.

103
Q

What lactation problems can occur postpartum?

A
  • Failure to establish breastfeeding
  • Mastitis
  • Breast abscess

These issues can hinder successful breastfeeding.

104
Q

What types of perineal trauma can occur postpartum?

A
  • Haematomas
  • 3rd/4th degree tears
  • Episiotomy breakdowns
  • CS (Cesarean Section) wound infections

These complications can affect recovery and comfort.

105
Q

What urinary complications may occur postpartum?

A
  • Retention
  • Infection
  • Incontinence

These issues can arise due to the physical changes of childbirth.

106
Q

What psychological issues can arise during the postpartum period?

A
  • Puerperal psychosis
  • Post-natal depression
  • Baby blues
  • Suicide

These mental health concerns can affect new mothers significantly.

107
Q

What are two types of perinatal loss that can occur?

A
  • Stillbirth
  • Neonatal death
  • Malformations

These tragic events can have profound emotional impacts on families.

108
Q

What are the two contraindications to breastfeeding?

A
  • HIV positive status
  • Radiotherapy

These conditions pose health risks to both mother and infant.

109
Q

Is breastfeeding possible during chemotherapy?

A

Possible

However, mothers may need to ‘pump and dump’ to manage medication timing.

UL Obs And Gynae (14 decks)

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