O&G Flashcards
A 24 year old female comes to your GP practice and asks about different contraceptive methods. Discuss how you would counsel the patient.
History: menstrual, sexual, O&G, contraindications (pregnancy, migraine with aura, CVD risk factors, VTE, steroid-dependent cancers, liver disease, lactation/postpartum, PID, dysmenorrhoea, OP, organ transplant)
beta-hCG +/- STI screen/pap
Counsel
- non-hormonal: abstinence only 100%
- hormonal: COC, POC
- surgical
- need STI protection as well
A 27 year old female comes in with her 30 year old husband complaining of infertility despite “trying for a year”. How would you investigate and manage the couple?
DDx
- female: ovaries, tubes, uterus, systemic (weight, exercise, SNAP)
- confirm sex is helpful sex
- past obs hx for both
- male: genetics, infections/trauma, meds, SNAP
- female: anovulation, tubal impatency (ectopic, PID, endo), uterine anatomic abnormality (primary or secondary eg fibroids, polyps)
Ix
- sperm analysis
- OTC LH surge kit -> if now surge, midluteal progesterone -> if low, anov workup
- hysterosalpingogram (incl hysteroscopy)
- lap for endometriosis
Mx
- Lifestyle/behaviour
- clomiphene to make follicle grow (+HCG if not ovulating the big follicle)
- IUI
- IVF
- Correct uterine abnormality
- Counselling: psych, pregnancy prep
A 28 year old comes to your GP clinic to talk about having a baby. She has been on the pill for the past two years and stopped 2 months ago and has been trying to conceive since then. Discuss how you would counsel her.
Priorities
- identify risks (incl Ix) + minimise
- educate woman
*** med hx: chronic conditions and mx incl meds infections and vax fhx: genetic conditions shx: smoking and alcohol (plus other toxins) nutrition incl supplementation and foods to avoid exercise support
A 36 year old presents with a miscarriage. Discuss your investigations and management.
Priorities
- resus if necessary
- type of miscarriage (and patient)- does it req management and which kind (expectant, med, surg; F/U)
- does cause req investigation (more than 2)
- antiD
- counsel!
- F/U in 2 weeks
A 26 year old had 3 previous 1st trimester miscarriages. What is your management?
DDx - genetic: majority (underlying maternal conditions) - anatomic - immune (APS, thrombophilia) - endocrine: PCOS, DM, obesity, thyroid disease (acute maternal insults) - infections: TORCH, mycoplasma, listeria - trauma: maternal, amniocentesis, CVS - toxins
Priorities
- rule out genetic/anatomic/maternal disease/infectious cause
- check ovarian reserve
- educate, psych support
A 25 year old woman presents with severe lower abdominal pain and tenderness. Her last period was 6 weeks ago. How would you assess and manage her?
Priorities
- resus if necessary
- confirm ectopic, rule out miscarriage (AND NON-OBS)
- decide on expectant, med or surg mx
- after: antiD, counselling (incl wait 3 cycles before trying again)
***bhCG should double every 48 hours
A 25 year old G1P0 presents at 10 weeks gestation to an antenatal clinic. Counsel her about the lifestyle changes during pregnancy and discuss investigations and tests used to assess foetal well-being.
Priorities
- HoPC: LMP, pregnancy so far -?planned, ?method of conception, ?consanguinity
- PO&GHx: G, P, complications/issues
- PMHx: what conditions does she have, what vax has she had
- meds: what meds is she on, are they safe
- allergies
- FHx: any conditions to be aware of, any genetic testing to be done
- SHx
- -smoking: stop
- -nutrition: foods to avoid, supplements to take
- -alcohol and drugs: stop
- -PA: what’s safe, obesity counselling
- tests
- -baby screening: bloods @ 10 weeks, U/S @ 12 weeks, U/S @ 20 weeks
- -mother screening: initial bloods (GROUP, antibodies, FBC, vitamin D, serology, pap, MSU), 28 week bloods (FBC, antibodies, OGTT), 36 week bloods (FBC, antibodies, GBS)
- -appt monthly until 28 weeks, fortnightly until 36 weeks, weekly after
A 16 year old female came in to your GP practice asking for a referral for abortion. How would you counsel and manage the patient? Discuss time limits for abortion, ethical, legal aspects.
Counsel
- assess Gillick competence
- HoPC - LMP, sx, psychosocial stressors
- PMHx - contraindications
- non-directive pregnancy counselling: nothing, medical, surgical
- contraception counselling, psychosocial screen (depression, DV etc)
- opportunistic screening (later)
- F/U
Time limits
- albury: upto 9 weeks for med; upto 12 weeks for surg; then to melbourne
- law: upto 24 weeks in vic; in nsw crimes act (1900)
Ethical
- mother vs fetus’ ‘health’
Legal
- nsw act based on 1861 offences against the person act (england)
- case law: menhenitt (lawful when necessary and proportionate), levine (on physical/social/psych reasons), kirby (future health considered)
- barriers to access for mother incl safe zones and conscientious objectors
- resulting issues: distance, affordability, visibility, conscientious objectors, delays caused by admin
A 38 year old G2P1 is worried about the child having Down syndrome. What tests are available and how would you counsel the patient regarding possible results (i.e. risk figures for Downs Syndrome etc., risks of chorionic villus sampling and amniocentesis)?
Tests
- screening: bloods (PAPP-A, bhCG) and nuchal translucency (85-90%)-> modified risk
- **NIPT: 99% detection
- diagnostic: CVS (10-13w), amniocentesis (15-18w)-> miscarriage, infection, Rh sensitisation, false pos/neg
Result:
- genetic counselling
- continue pregnancy vs adoption vs termination
**risk
@30yo: 1/1000; @37yo: 1/200; @40yo: 1/100
A G1PO presents to antenatal clinic at 32 week gestation with a blood pressure of 180/110. Describe your approach to diagnosis and management.
Concern: pre-eclampsia/eclampsia
Priorities
- assess for pre-eclampsia - is there evidence of end-organ damage? (neuro, CV, liver, kidney, haem)
- assess risk factors: CVD, first preg/new dad, FHx, more placenta (multipreg, GDM, hydrops)
- was it pre-existing?
Management
- counselling
- drop blood pressure but not too low - labetalol
- monitor closely: just HTN weekly visits with monthly U/S; pre-eclampsia weekly proteinuria, fortnightly CTG; threeweekly U/S
- plan delivery (@36 weeks if HTN)
- postnatal r/v: check BP, CVD risk, aspirin + Ca for future pregnancies, contraception
A 30 week gestation woman is brought in by ambulance after a fit at home, witnessed by the husband. How would you manage her?
1) Resus
A: recovery position
B: O2
C: control HTN if >160-> labetalol; IDC
D: MgSO4
E: t
2) History and exam if stable - rule out other aetiologies
3) Plan delivery
- Emergency Caesar if fetal distress
- Caesar by 7 days if neuro sx, by 10 days if significant proteinuria
(induce if dead)
- steroids, MgSO4
4) Postop care
- monitor closely, continue MgSO4, DVT prophylaxis
- counselling: future risk - Ca, aspirin; CVD risk (5yearly assessment); contraception
A 28 year old pregnant woman is found to have a random BSL of 15mmol/L. Discuss diagnosis and management.
Priorities
- Confirm GDM: check for symptoms, fasting BSL; rule out first presentation T1DM/T2DM
- Assess baby: ?macrosomia, polyhydramnios, IUGR etc
Management: MDT
ANTENATAL
- lifestyle modification
- referral to diabetes education +/- dietitian
- consider insulin/OHG if poor control
- monitor baby closely
PERINATAL
- delivery asap after 38 weeks if evidence of baby affected - as normal if no evidence
- avoid hypos during labour by monitoring carefully
- monitor neonate carefully for hypos, jaundice, RDS
POSTNATAL
- education and counselling re: T2DM risk (OGTT at 6 weeks and then 2 yearly after), SNAP
- contraception
A 30 year old presents at 32 weeks with US finding of the foetus being less than 10% of predicted weight. What are the causes and what is the likely management? (IUGR)
DDx - nutrition, weight - toxin/infection - maternal chronic disease - multipreg, ART - fetal genetic/structural issue OR could be normal small or incorrectly aged
Priorities
- confirm correct dates - LMP, early U/S
- assess for potential causes
- confirm IUGR: fetal weight, growth velocity, doppler changes (esp UmA)
Management: deliver on the best day, in the best way (no later than 37 weeks)
- regular monitoring (CTG, AFI, BPP twice a week)
- deliver when Doppler/CTG become worrying - don’t forget steroids, modified bed rest, stop smoking
- Caesar unless multip near full term (with continuous CTG)
A lady is found to be carrying twins at her 12 week ultrasound. Counsel the patient regarding what she should expect in her pregnancy.
Assess
- DCDA/MCDA/MCMA
- past pregnancies, any complications
- general history and exam
Management
- counsel about worries: GDM, HTN, pre-eclampsia, placenta praevia, PPH, growth restriction, congenital anomalies, prematurity
- increased surveillance:
- –DCDA: U/S every 4-6 weeks after 20 weeks and then weekly after 32 weeks (do BPP) and deliver at 38
- –MCDA: U/S every 2-3 weeks and then weekly after 32 weeks (do BPP) and deliver at 36
- –MCMA: U/S every 2 weeks and then biweekly from 24 weeks, admit at 28 weeks and delivery at 32-34
—caesar (unless uncomplicated vertex vertex dcda/mcda)
A 30 year old G3P2 presents at 24 weeks gestation with per vaginal bleeding. Describe your management.
DDx
- abruptio placenta
- placenta praevia
- placenta accreta, vasa praevia
- lower genital tract pathology
Primary survey and resus if necessary - prepare for deterioration even if not necessary
Assessment
- Assess mother and baby’s health: fetal movements, hard uterus, nonreassuring CTG tract
- Confirm source as from the uterus
- Bright and painless vs dark and painful
- Assess risk factors: vascular disease/uterus overdistension/infection/trauma vs multiparous/twins/previous surgery
- Investigations: U/S (?placenta where), FBC, G&H and antibodies, coags, ?Kleihauer
Management
(abruption)
- Wait and watch if no signs of fetal/maternal instability -> admit overnight, regular CTGs and U/S (2-3/w and every fortnight respectively), steroids, deliver at 37-38 weeks, - ANTI-D
- F/U: increased risk - close monitoring and no late delivery; contraception
(praevia)
- Caesar at 37-38 weeks if no haem instability - high risk of PPH, be careful
- counsel about representing; can continue normal activities if asymptomatic
A 34 year old Asian lady G2P1 24 weeks’ gestation is found to be Hep B +ve in her antenatal testing. What would be your management? What would be your concerns and follow-up for the foetus?
Concerns
- vertical transmission to fetus
- cirrhosis’ effect on fetus (IUGR, FDIU, prem)
- progression of disease
Assessment
- HoPC of hepatitis B
- Comorbidities, esp HCV, HIV, other STIs
Management
- monitor: HBV and LFT bloods 3monthly until 6 months postpartum
- antiviral treatment (tenofovir) if acute/chronic liver failure or high viral load at 28 weeks
- avoid unnecessary invasive procedures
- Hep B Ig and vax at birth for fetus
- can breastfeed (if both HBV Ig and vax given)
A 27 year old Spanish woman G3P2 36 weeks’ gestation is found to be group B strep positive. Discuss her management now and during labour.
Concern:
- chorioamnionitis, UTI -> low birth weight, preterm
- transmission to the baby in the birth canal -> sepsis, meningitis, pneumonia
Priorities
- full hx, exam: confirm GBS, find out any potential other risks to baby and likely delivery method
- mx now: monitor closely esp for PPROM
- in labour: prophylactic abx (benpen IV 3g, then 1.4g 4hrly until deliver - unless PPROM, in which case need broader spectrum = amp and erythro)
- counsel incl F/U postpartum
- **indications for GBS prophylaxis
- positive GBS on 36 weeks rectovaginal swab
- positive for bacteriuria during pregnancy
- past infant with GBS
- unknown GBS result but fever/prem/PPROM/positive PCR
Discuss the assessment and management of HSV infection during pregnancy.
Concern: transmission to baby in birth canal causing encephalitis and permanent neuro sequelae
=> higher risk if a) first episode; b) procedures that enable transmission (vaginal delivery, transcervical procedures, fetal scalp clips etc)
Priorities
- screen: STI screen at start of pregnancy, ask about symptoms at antenatal visits, inspect perineum and genitalia before VE/Ix
- determine if primary/non-primary first episode/recurrent (based on ulcer PCR and HSV antibody serology)
- antivirals (acyclovir 400mg TDS) at time of new lesion and from 36 weeks until delivery
- Caesar if lesions/prodromal sx/recent HSV new infection
- counsel mother on condum use/abstinence if partner pos but mother neg
Discuss the management of HIV infection during pregnancy.
Concern: vertical transmission to fetus
- increased by high viral load, cigarette smoking, recreational drug use, unprotected intercourse with multiple partners
Assessment
- viral load, risk of transmission
- pregnancy thus far
Management
- multidisciplinary care: ID
- counselling
- monitoring: regular viral load and CD4
- decrease viral load: HAART (ideally agents that are safe in pregnancy)
- prevent complications: dTPa, fluvax, pneumovax, HAV and HBV vaxx
- decide on best delivery: minimise fetal exposure to maternal fluids; if viral load >1000, elective Caesar at 38 weeks with intrapartum ART
- postnatally continue maternal ART and start fetal ART for 4-6 weeks and check HIV RNA PCR at 48 hours, 1-2/12; 3-6/12
- avoid breastfeeding if formula fine
A lady comes in with rupture of membranes at 38 weeks. Discuss the management of the 3 stages of labour
Three stages of labour
- contractions to fully dilated cervix (10cm) (passive = 0-3cm; active = 3-10cm - 1cm/hr is lowest acceptable)
- fully dilated cervix to baby delivered (passive = descent; active = flexion, internal rotation, extension, external rotation, restitution
- baby delivered to placenta delivered
First stage
- monitor closely: BP, temp, fetal HR (every 30 min) regular CTG, cervical assessment (every 4 hours) -> partogram
- analgesia
- hydration
- support
- prophylactic abx if necessary
Second stage: hands on vs hands off approach
- encourage pushing
(flexion, internal rotation)
- crowning
- hold perineum to prevent tearing when head comes through
- check umbilical cord not around neck
(extension, restitution)
- push down on head to pop out one shoulder, then the next
- pull baby onto prone position on mother’s chest
- delay cord clamping
Third stage
- give oxytocin
- gentle traction on placenta
- check placenta after it comes out
- check perineum for tears and repair
A woman presents with premature rupture of membranes at 32 weeks. How would you manage this? Discuss both premature rupture of membranes progressing to labour and not progressing to labour.
PPROM: concerned about prematurity, infection, placental abruption, cord prolapse, oligohydramnios
Priorities
- confirm ROM and rule out urinary incontinence/vaginal discharge, perspiration (history, visualising amniotic fluid on speculum (push/valsalva if not seen), consider vaginal pH testing/ferning
- assess risks of not delivering: fetal lung maturity (llamelar body count in amniotic fluid), GBS status, HSV/ gonorrhoea/ chlamydia and other infections, fetal wellbeing (U/S, CTG), risk of cord prolapse
- assess progression to labour: contractions, examine cervix, FFN
Management
- prepare for prematurity: steroids, prophylactic antibiotics
- if in labour, tocolytics for 2 days and ?MgSO4
- if emergency, deliver asap with induction (Caesar if cord prolapse)
- IF NO EMERGENCY, expectant management (monitoring) until induction at 34 weeks
- F/U: counsel on future pregnancy risk (30%) - risk factor modification (smoking, multipreg), progesterone, cerclage (if cervical insufficiency); contraception!
A 20 year old G1P0 asks about pain relief during labour and potential side effects. How would you counsel her?
Options PHARM - gas (entonox) - opioids - epidural/spinal NON-PHARM - massage - heat - active birth - vocalisation - water birth - TENS - water injections
Contraindications
- water birth: staff not trained
- opioids: opioid dependence
- epidural: local infection, systemic sepsis, coagulopathy, uncorrect hypovolaemia
A 32 year old G1P0 wants a Caesarean Section. What are the common indications and complications of caesarean section?
Indications
- fetal distress, failure to progress
- maternal disease making labour unsafe: eclampsia, placental abruption, placenta praevia, previous C-section, maternal herpes
- baby difficult to get out: breech, macrosomia (>4.5kg), mechanical obstruction
Complications
- short term: operative (anaesthesia, bleeding, infection, injury to local structures), prolonged recovery, post-op (infection, VTE, scar, adhesions)
- long term: uterine rupture if VBAC, abnormal placentation
A 27 year old has lost approximately 1 L of blood 30 min after delivery of the foetus and placenta. What is your immediate management? Discuss differentials.
DDx (PPH):
- tone
- tears
- tissue
- thrombin
Primary survey and resus with focus on B and C
- A
- B: O2 to sats, consider NIV and IV
- C: assess, two largebore IV cannulae, take bloods (incl septic screen), fluid resus and consider massive transfusion protocol; look for source of bleeding - uterus, vagina, U/S
- D: GCS, pupils, BSL
- E: temp, sites of bleeding
More thorough evaluation
- Assess for risk factors
- Look for soft uterus, tears, incomplete placenta
Definitively treat cause
- atonic: fundal pressure, catheterise bladder, oxytocin +/- ergometrine +/- misoprostol, bimanual uterine compression, Bakri balloon (tamponade), laparotomy, hysterectomy
- tear: achieve haemostasis and repair
- tissue: D&C
- thrombin: blood transfusion
A 30 year old G2P2 has just delivered her second baby and she appears well. 20 minutes after delivery you notice she has become acutely hypotensive and has marked respiratory distress. How would you assess and manage this patient?
DDx
- Hypovolaemic shock from PPH: tone, tears, tissue, thrombin
- Distributive: anaphylaxis to drugs, septic shock
- Cardiogenic: MI, PE, AFE, electrolyte disturbance
Primary survey and resus with focus on B and C
- A
- B: O2 to sats, consider NIV and IV
- C: assess, two largebore IV cannulae, take bloods (incl septic screen), fluid resus and consider massive transfusion protocol; look for source of bleeding - uterus, vagina, U/S
- D: GCS, pupils, BSL
- E: temp, sites of bleeding
Simultaneous brief history: AMPLE incl pregnancy complications (prolonged/precipitate labour, stretched uterus)
Definitively treat cause
- febrile, pain, known infection: empirical abx
- atonic: catheterise uterus to drain blood, fundal pressure, catheterise bladder, oxytocin +/- ergometrine +/- misoprostol, bimanual uterine compression, Bakri balloon (tamponade), laparotomy, hysterectomy
- tear: repair
- tissue: D&C
- thrombin: blood transfusion
- AFE: supportive
You are trying to deliver the baby and although the baby’s head has been delivered, you are having difficulty trying to get the shoulders out. What do you do
Shoulder dystocia:
-Risks: brachial plexopathy, clavicular/humeral fractures, HIE, death
Priorities
- Assess pregnancy and labour so far: any complications?
- Assess fetal and maternal wellbeing: any urgency?
Management
1) Call for help
2) Mother stops pushing
3) Make space: buttocks flush with end of bed, empty bladder, generous episiotomy
4) Apply manoeuvres: McRoberts (maternal thigh flexion), delivery of posterior arm (reach in and grab it), delivery of posterior shoulder (hook fingers under axilla and pull it out), clavicular fracture (what it sounds like), head replacement and Caesar
THEN manage third stage normally
A 16 year old girl comes in with her mother because she has not had periods yet. What are your differential diagnoses, investigations and management?
Primary amenorrhoea: central tells peripheral to make hormones which get uterus to bleed
DDx
-physiological, constitutional
-central hormonal issue: hypothalamus/pituitary
-peripheral hormonal issue: gonadal dysgenesis (eg Turners), PCOS
-structural abnormality eg mullerian agenesis
Assessment History - HoPC: any secondary sex characteristics, any stressors/illness/weight loss/exercise at the moment, any hirsuitism/acne/alopecia, any period-type symptoms (cylical pain, sore breasts, mood changes) - PMHx: any other medical conditions, any perinatal issues - FHx: family history including height - meds, allergies, SHx Exam - height, growth - secondary sex characteristics - abdo and vagina Investigations -U/S, FSH -LH, endo screen
Management
- functional: treat issue and wait
- Y chromosome present: oophorectomy after puberty
- POI: HRT
- PCOS: weight loss +/- OCP
- surgical: surgical correction
A 48 year old woman complains of heavy periods and fatigue. On examination, she looked pale and had palmer and conjunctival pallor. Abdominal and bimanual pelvic exams were normal. Her haemoglobin was 68 g/L. What are your differentials and what investigations would you do? What is your short term and long term management?
Issues
- menorrhagia: fibroids, adenomyosis, coagulopathy (might be cancer, polyp, contraception)
- anaemia
Priorities
- resus if necessary
- treat anaemia: transfusion, iron supplementation
- assess bleeding and treat cause
Assessment
- History: HoPC incl dysmenorrhoea, dyspareunia, bulk-related symptoms, menstrual history, other bleeding, cancer sx, contraception; PO&GHx, PMHx, meds and allergies, FHx, SHx
- Exam: anaemia + other bruising, abdo, bimanual and spec
- Investigations: ultrasound, hysteroscopy +/- lapscopy
Management
- anaemia
- consider TXA, contraception
- fibroids: consider resection
- polyp: polypectomy
- bleeding disorder: treat
A 28 year old presents with a 2 month history of dysmenorrhoea and dyspareunia. What are your differentials and what investigations would you do? What management would you initiate?
DDx
- PID
- endometriosis, adenomyosis
- fibroids, polyp
- IUD
Priorities
- determine cause: history of infectious sx, unsafe sex, endo sx, fibroid sx, IUD; Ix
- rule out pregnancy
- treat cause eg endo you severity stratify and then give pain relief and hormonal contraception OR GnRH agonist/aromatase inhibitor/lap excision
- counsel re: protection and prevention of pregnancy
A 22 year old sexually active female complains of vaginal discharge. How would you investigate and manage the patient?
DDx
- physiological
- vaginitis: BV, trichomoniasis, candidiasis
- cervicitis: chlamydia, gonorrhoea
- non-infectious inflammation: foreign body, irritant/allergen
Priorities
- determine cause of discharge and treat
- STI screen
- rule out pregnancy
- contraception
Assessment
- history: HoPC - smell of discharge, associated symptoms, sexual, menstrual history
- exam: abdo, speculum, bimanual (CET, adnexal mass)
- ix: high vaginal swab MCS and tricho PCR (first do pH, microscopy - saline and KOH wet mound, sniff test); endocervical swab PCR and MCS; HBV/HIV/syphilis serology; bhCG
Management: treat the infection you find
- BV: met
- tricho: met
candida: clotrimazole - counselling re: protection and contraception
**BV: Amsel criteria
A 30 year old female presents with 7 day history of pelvic pain and dyspareunia. On examination, she had a temp of 38.5 C and a tender left adnexal mass. What is your provisional diagnosis and management?
DDx
- tubal abscess and PID
- ectopic
- other abscess - appendiceal
(others: ruptured ovarian cyst, ovarian torsion, endometriosis)
Priorities
- acute stabilisation and resus if necessary - ?septic
- confirm diagnosis on hx, exam
- Ix: infection bloods, STI screen, abdo U/S (CT if considering surgery), RULE OUT PREGNANCY WITH bhCG
Management
- Treat infection: abx (cef, met, ‘atypical’ cover) +/- surgical drainage of abscess
- Counselling re: fertility, ectopics, protection, contraception
A 25 year old female presents with 5 year history of irregular periods, worsening facial hair and infertility. What is the likely diagnosis and management?
PDx: PCOS
DDx: thyroid disease, hyperPRL
Priorities
- Rotterdam criteria: oligo/amenorrhoea, hyperandrogenism, PCO
- rule out differentials
- assess for metabolic syndrome
- treat metabolic syndrome: weight loss, consider metformin
- treat hirsuitism: OCP/spironolactone/cyproterone
- treat periods: weight loss, contraception
- subfertility: weight loss, ovulation induction (clomid, ovarian drilling)
A 52 year old postmenopausal woman complains of hot flushes and irritability, she wants to commence HRT. Describe options in management of menopause and risks and benefits of HRT.
Background
- symptoms: hot flushes, night sweats, mood swings, sleep disturbance, loss of self-confidence, myalgia, arthralgia
- HRT options:
- —E +/- P (because endometrial cancer)
- —PO, patch, gel, vaginal cream, pessary
- —continuous or cyclical (if worried about breakthrough bleeding)
- benefits: alleviate vasomotor symptoms, preserve bone health, treat mood, reduce vaginal dryness
- risks: breast cancer, stroke/DVT/PE, gallbladder disease, dementia, urinary incontinence
- –> benefits > risks for <60yo
Priorities
- decide on HRT regimen
- assess and treat CVD risk
An asymptomatic 30 year old woman presents for a pap smear and on examination a firm mass is felt to be part of the uterus. Ultrasound demonstrated a 3 cm uterine mass, likely to be a fibroid. What is your management?
Assess
- confirm fibroid, rule out differentials (leiomyosarcoma, polyp, pregnancy)
- assess severity of symptoms: bleeding and anaemia, pain, bulk symptoms
- treat according to severity: expectant (counsel and monitor), medical (mirena), surgical (myomectomy, ablation, hysterectomy, embolisation)
A 35 year old woman has an abnormal pap smear result. Discuss the management of this.
Priorities
- elicit patient’s understanding
- determine patient’s risk: result, past results, sympatomatology, past and family history, smoking
- examine for masses, LN
- explain cervical cancer
- explain pap smear test and result
- explain management from here: LSIL - repeat in a year (unless high risk = over 30 and recent non-reassuring result); HSIL - colposcopy
- explain colposcopy procedure and management from there: CIN1 nothing; CIN2-3 ablation or excision
- F/U: repeat colposcopy and pap in 6 months; repeat pap in 12 months and annual until normal; then to normal program
- opportunistic STI testing, protection and contraception counselling
ISSUE
- changing to HPV testing
A 48 year old woman presents with post-menopausal bleeding. Discuss how you would assess and manage this patient.
PDx: endometrial cancer until proven otherwise
DDx: atrophy (atrophic vaginitis), tumour (endometrial hyperplasia, endo polyps), infection
Assessment
- History: bleeding, cancer sx, cancer hx, HRT, hyperestrogen
- Exam: BMI, abdo, bimanual, spec
- Investigations: TVU/S (>=5mm worrying), STI screen if indicated, biopsy (endometrial pipelle or hysteroscopy and curettage)
- Staging (CT-PET, CXR) - but surgical staging
Management: MDT
- atrophic vaginitis: topical estrogen, moisturiser
- hyperplasia: progestins/hysterectomy
- cancer: staging surgically (FIGO), exploratory laparotomy +/0 adjuvant radiotherapy, hormone therapy if receptor positive
- follow up
58 year old woman presents with abdominal distension and discomfort. She has had significant weight loss over the last 3 months. She is unmarried and has no children. Discuss your approach to this lady in terms of diagnosis and management.
Concerned about malignancy
- ovarian
- others unlikely due to lack of symptoms: liver, other GI
- others: chronic disease, malnutrition
Assessment
- HoPC: bloating, nausea, vomiting, early satiety, dyspepsia; GI/breast cancer sx
- PMHx: BRCA1/2, FHx (incl Lynch), nulliparity
- Exam: abdo, bimanual, spec, ?pleural effusion
- Investigations: initial evaluation to determine whether malignancy, then presurgical evaluation to decide whether to operate (including to stage) or not
- –initial (RMI): imaging (TVU/S), tumour markers: ca-125, paracentesis cytology
- –pre-surgical: CT abdo pelvis, bloods
Management
- early: intraoperative frozen section and then whole total extrafascial hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymph node dissection
- late: debulking
- ~all: chemo - platinum + taxane
***Ca-125 also rises with fibroids, endo, PID and appendicitis
A 70 year old female comes in with utero-vaginal prolapse. What are your options in management?
Assessment
- HoPC: lump, dragging pain, dyspareunia, bowel/bladder sx
- Rest of history incl childrearing
- Exam: BMI, abdo, pelvic - cough test => POPQ
- Investigations: consider urodynamics - ?incontinence
Management
- non-operative: pelvic floor exercises, estrogen cream, neotonus chair, pessaries
- surgical: anterior/posterior colporraphy, vaginal hysterectomy, colpoperineorraphy
- counsel incl risks: normal op risks, damage to structures, narrow/short vagina, voiding difficulties + constipation (usually improve, failure
A 55 year old female complains of urinary incontinence. What are the types of urinary incontinence and how are they diagnosed and managed?
Types
- stress
- urge
- mixed
- neurogenic (overflow)
- detrusor overactivity
Factors
- pelvic floor damage: pregnancy, raised intraabdominal pressure
- neuro disease
- meds
Assess
- symptoms to determine what kind of incontinence, associated symptoms, contributing factors, effect on life
- check bladder, masses, leakage, prolapse, estrogenisation on exam
- Ix: bladder diary, urine dipstick, urodynamic studies
Management CONSERVATIVE - urge: normalise fluid intake, avoid constipation, bladder drill, antichol (oxybutinin) - stress: PFE, estrogen - other conservative: continence aids SURGICAL (stress): can lead to urge incontinence - tension-free vaginal tape - transobdurator sling - mini-sling
A 12 week pregnant lady (G3P1) comes in with blood group results O-. What are the risks to the patient and fetus and what prophylactic measures are there?
Risks to fetus
- haemolysis -> hydrops fetalis -> death
Risks to mother
- future pregnancies affected
Prophylactic measures
- assess antibodies, and before giving any anti-D
- give anti-D when any transplacental fetomaternal haemorrhage (250 IU in first trimester, 625 IU in second or third trimester, guided by Kleihauer after delivery)
- give anti-D prophylactically at 28 weeks and 34 weeks
Management
- if antibodies established, close monitoring (MCA-PCV, liver length, fetal Hb) and deliver after 32 weeks
30yo 40 weeks pregnant with questions about managing post-term pregnancy without spontaneous labour. Discuss induction and augmentation.
Concern:
- induction: balancing risks of induction (tachysystole, uterine rupture, AFE) with risks of post-term pregnancy (macrosomia, dysmaturity, fetal death; perineal tears, PPH, infection) -> at 40-41 weeks equivocal, at 42 weeks risks of continuing pregnancy higher
- augmentation: balancing risks (above) with risks of slow labour (fetal hypoxia -> HIE, seizures, mortality; maternal operative labour/Caesar, tears, PPH, chorioamnoitis,, urinary retention)
Induction
- cervical ripening (if Bishop score <8): prostin gel, balloon catheter
- straight to induction (if Bishop score >8): ROM, oxytocin
Issues
- tachysystole: stop oxytocin
- prolonged first stage (>3 min apart contractions at 24 hours): Caesar
Augmentation: if too slow (first stage cervix < 0.5cm/hr; second stage > 2hr for primip or >1hr for multip)
- ROM
- oxytocin
30yo G3P2 with BP70/30 HR120 in prolonged labour. What is your approach?
Shock:
- hypovolaemic: placetal abruption, placenta praevia, uterine rupture
- cardiogenic: AFE
- distributive: septic shock
Primary survey and resus with focus on circulation CALL FOR HELP - A: - B: O2 if necessary - C: assess, two largebore IV cannulae, fluid bolus and resus, consider massive transfusion protocol; assess for causes - examine uterus, vagina, U/S - D: GCS, pupils, BSL - E: temp, bleeding site - F: asses fetus
Treat definitively
- Theatre for emergency Caesar unless mother recovers
G2P1 mother, 32 weeks, comes in with active first stage of labour, breech presentation. How would you assess and manage?
Concern
- prolonged labour, fetal distress and hypoxia, trauma, death
Assess
- Ease of vaginal delivery: what kind of breech (frank, complete, incomplete), fetal size
- Staff experience with breech vaginal delivery
- Other Caesar indications/contraindications: maternal comorbidities, previous Caesar
Management
- optimise premature birth: steroids, MgSO4, tocolytics
- unless normal breech with normal size/term/experienced staff, Caesar - incision possibly with uterine relaxant, gentle and atraumatic delivery, paeds present
- F/U - baby DDH; maternal recurrence, contraception
29yo D2 postpartum with a temperature of 38.5 degrees Celsius. What are the likely causes and how would you manage?
DDx
- infection: endometritis, wound infection, UTI, C diff
- non-infectious less likely due to height of fever: DVT/PE, aspiration pneumonia, drug fever
Priorities
- Primary survey and resus if necessary - likely focus on C
- Assess pregnancy and delivery for risk factors: mode of delivery, retained products, abx perinatally
- Determine cause of fever - possible symptoms; head to toe exam; septic screen bloods and various MCS
Management depends on source of fever
- endometritis: amox and met
- SSI: open wound, drain, washout, debride and abx only if systemic (fluclox)
- UTI
- C diff
36yo woman presents with postcoital bleeding, weight loss and anorexia. How would you assess and manage?
PDx: cervical cancer
DDx: cervical ectropion, cervical polyps, cervicitis
Assess
- risk of cancer: symptoms, pap smear results, smoking
- risk of STIs: symptoms, sexual risk factors
- check for anaemia
- examination: abdo, speculum, bimanual
- ix:
- –cancer dx: pap smear, STI screen; colposcopy and biopsy
- –cancer staging: CT pelvis, CXR, skeletal survey, IVP/EUA/cystoscopy
- –anaemia: FBC, Fe studies
Management
- cervical cancer: resect if early (modified radical hysterectomy +/- adjuvant RTx/chemoradiation); primary chemoradiation if locally advanced
- F/U: post-treatment surveillance
- cervicitis: abx depending on bug
- cervical polyps: polypectomy
- cervical ectropion: cryotherapy +/- electrocautery
- opportunistic counselling re: protection and contraception
24yo woman presents with bleeding in between periods. What is your approach?
PDx: polyp
DDx: fibroids, contraception, other endometrial or cervical path (cancer, infection)
Priorities
- confirm diagnosis, rule out differentials on hx and exam
- assess for anaemia
- investigate: U/S, beta-hCG, FBC, STI screen if indicated, consider colposcopy/hysteroscopy
- treat condition eg
- –polyp: polypectomy
- –fibroids: expectant - counsel and monitor; medical - Mirena; surgical - myomectomy/ablation/hysterectomy (/embolisation)
