Obs Gyn Osce Flashcards
Diabetic Mother
Find out Insulin / Mx
Take diabetic history, gynae, PMhx, PsHx, Social (life and home support)
Talk about importance of diabetic control –> foetal abnormalities and later pregnancy
Advise against pregnancy until controlled
Needs to visit diabetitcian, more Folate, MDT, Investigations
Needs specialist unit antenatally and for birth, frequent review, vaginal delivery but risk of shoulder dystocia
Baby needs to go to nursery
Rural PPH
Brief Hx - emergency
- Contractions, antepartum/medical issues, contraction, liquor, CTG, drugs given, type of delivery, agars, episiotomy, times of stages, Placenta
How much blood lost?
Examination - call for help, carry on
- Conscious state, haemodynamic
Initiate Resus
- 2 wide bore, Cross match and group and hold, FBC, Clotting screen
- Head down, O2, Saturations,
- Colloid IV
- Activate MTP if necessary
- Obs 10-15 mins
Causes - 4 T’s - Tone, Tissue, Trauma, Thrombin
- Tone - boggy, non contracted, enlarged
- Placenta and membranes fully out?
- Any lacerations on Sims speculum?, use sponge forceps to see cervical
- Clotting profile
MX:
Fundal massage, synto by bolus then infusion (10, 40), ergometrine (500mcg) half IM half IV
IDC
Misoprostol 2-4 tablets PV/PR
If MTP activated –> Surgical management
Operating theatre - GA, CV line,
Look for lacerations retained products
Give prostaglandin F2 alpha into 4 quadrants
Move to laparotomy –> uterine artery ligation bilaterally, internal iliac artery ligation
Consider B-Lynch suture
Uterine packing or balloon tamponade
Hysterectomy if all else fails
PPH risk factors
>500mL after delivery, or 1000mL if C section
Past PPH Prolonged labour Precipitate labour Prolonged Synto use APH/Abruption Grand-multiparity Uterine over distension - polyhydramnios, macrosomia Instrumental/operative delivery Fibroids Chorioamnioitis Trauma to uterus Haemostasis
NEXT LABOUR —> IV Access, group and hold at start, experienced accoucher, ergometrine and misoprostol should be available, and prostaglandin F2 alpha
Can cause - Shock, DIC, Sheehan’s
Fluids post op
Vitals every 15 mins for first hour, 30 mins next 3 hours, every hour for following 6 hours, 4 hourly thereafter Urine output - notify <30mL IV Give 3L - 2L saline, 5% dextrose DVT prophylaxis
Analgesia - add on PRN Paracetomol
Ice chips NBM
Antibiotics if infection
FBC, UEC, Albumin next morning
Subfertility
Gynae - cycles, contraception, STD’s, Pap smear, have they ever had children, MALE HISTORY, how often do you have sex, are they taking supplementation, substance use?, job’s, stable relationship
Examination:
Male - pattern of hair, etc. testicles and penis
Female - BP, BMI, Vaginal exam –> uterus position, size, tenderness, mobility, masses, pap smear to be formed and maybe sTD checked
Investigations - 2-4 FSH, LH, E2, Day 21 progesterone, TSH
Rubella, varicella
After this –> tubal laparoscopy, hysteroscopy, dye studies, D and C or hysterosalpingoram
ALWAYS DO SEMEN ANALYSIS AND IMMUNE BEAD TEST FOR ANTI-sperm antibodies
Substance use and pregnancy
Smoking –> fertility - (delay of conception, ovarian depletion), preterm, teratogenicity, spontaneous miscarriage, ectopic, harder IVF, if over 35 not allowed to take OCP.
Antenatal: placental abruption, premature, PPROM, placenta rpaevcia, low birth weight
Post partum: Brain tumours, perinatal mortality, SIDS, respiratory illness
Use patches and can use bupropion
Alcohol - FAS, IUGR, intellectual impairment and behaviour, cardiac, brain and spine defects, low set ears, small head, hypo plastic philtre, elongated flat mid-face, short palpebral fissures, intellectual impariment
Cocaine –> Abruption in particular
Post-menopausal Bleeding
How many episodes, clots or just blood, when menopause, hormone therapy?, pap smear, mammogram, GP status, PMHX and SDX, Allergies, Social, Family history
Examination - BP, breasts, chest (mets), abdominal, vaginal, speculum, pap smear, bimanual
FBC, UEC, LFC, CXR, ECG, Transvaginal USS, hysteroscopy D and C, Mammogram
USS features - thickness <4mm needed, morphology of ovaries, uterine size/dimensions
Surgical staging - hysterectomy, bilateral sapling-oopherectomy, +/0 pelvic lymph node sampling
HPV
NOT CANCER - low grade changes - means infection that has potential. it is very common –> pre-cancerous before finals cancerous.
Usually spontaneously resolve
REFER TO GUIDELINES
No role for current vaccine not prophylactic, but can get it for future
New nonavalent
Go to colposcopy if required - check transformation zone LOOK at vagina and vulva too
5% acetic acid –> dysplastic stain white due to different glycogen content.
Abnormal areas are biopsied
Lugols iodine used to identify dysplastic areas and –> examine vagina for evidence of dysplasia, helps further definition of abnormal and normal
Can use LLETZ or laser ablation
NEED CONE BIOPSY IF EVIDENCE OF INVASION
Endometriosis
LMP/cycles, IMB, DUB, Dyspareunia, Pain SOCRATES, Sexual activity, contrapcetion, PPPPP’s, URINARY sx, PMHX/SX, Pap smear
Explain:
Chronic, varying severity
Pain correlates little to severity
Management surgical and medical
Medical - hormones, surgical removal and normalising anatomy
If infertile hormonal treatment doesn’t help, need surgical treatment and/or IVF
EXAM:
POD nodules
Direct visualisation - blue/black powder burn type, may also be red, vesicular, polypoid, non-pigmented
Surgical treatments most effective
5-20% recurrence, 40% after 5 years
Emergency Contraception
Take a history, 5 P’s, consensual sex or not, LMP, periods, PMHXSX, FMHX, SX, allergies, PAP SMEAR
Few options: need to pregnancy test if delayed by 1 week
Levenogestrol method - 2x0.75mg immediately - 1-2% failure
Yzpe method - 100microg EE and 0.5mg LNG - 12 hours apart with antiemetic (high dose of oestrogen causes vomiting) - 2-3% failure, more side effects - theoretically can be used 5 days
Insertion of copper IUD 5 days after unprotected 2-3% failure. Contraindiciations are PID and STI’s, can be kept in for ongoing
RU486 - most effective can be used 5 days after –> causes cycle prolongation
A pregnancy test should be performed if the expected period does not occur within 3–4 weeks after taking emergency contraception. There is no evidence that failure of the LNG method is associated with an increase in congenital malformations or adverse pregnancy outcomes.
DIscuss termination of pregnancy if method fails
Adequate ongoing contraception so this is not regular
Instrumental Delivery
History:
GP, previous, antenatal testing, group and hold, PMHXSX, allergies, contractions, how long first stage and second stage, what is liquor, when did membranes rupture, what medication, CTG???
Examination:
General inspection, Vitals
Abdominal exam - term fundal height, contractions, lie, palpable head/engagement, metal heart rate
Vaginal - dilation, presentation, station, OP/PA etc., moulding, liquor, pelvis appearance
Prolonged - Need CTG, call paeds, call for help
CONDITIONS FOR FORCEPS: Fully dilated cervix Cephalic, can use for head in breech or face mento-anterior Station needs to be below ischial spines No part of head palpable above pubic symphysis Correct position of head No CP disproportion Empty bladder Adequate analgesia Requires episiotomy
Complications for mother
Lacerations, perineal injuries, anal sphincter, extension of episiotomy, urinary retention, PPH, Longer term (incontinence, dyspareunia)
Fetal complications: Scalp/face/bruising or lacerations Cephalhaematoma Subconjunctival haemorrhage Facial nerve injuries Skull fracture
TYPES OF FORCEPS: Outlet - visible head Low forceps - station +2 or more Mid cavity - 0cm High - NOT USED
Neville-Barnes - OA only
Kjelland - rotational
Wrigleys - outlet and C section (less traction than Neville Barnes)
Indications of less maternal exhaustion, prolonged second stage,
Fetal - fetal distress, cord prolapse
PCOS
History - age, menarche, periods, PPPPP, acne, hirsutism, how long problems for, voice deepening, body shape changing, clitoromegaly, balding
Weight, struggles?
All other history, including FMHX Cardiac
Examination:
GI, vitals
Hair, acanthuses nigerians, pink abdominal striae, other examination, look for goitre, check CVS, visual fields (pituitary adenoma), bushings, abdomen masses, pelvic, pap smear
Investigations:
FSH, LH, prolactin, testosterone, DHEAS, TSH, Pelvic USS, OGTT, Lipid, SBHG, 17-OHP
MX:
Weight and exercise
Hirsutism - shaving, depilatory creams, electrolysis, laser
Hormonal treatments - OCP +/- anti-androgen
Pill helps with endometrial growth, inhibition of androgens, helps with lipids, helps with free androgens (inhibits sex binding globulin, DHEAS)
Daily dose of EE –> sufficient SHBG production
Progestogen ensures withdrawal bleed
IUD also provides good endometrial protection
Metformin and/or clomiphene helps ovulation
OI with gonadotrophin, daily injections of FSH, until follicular response
Use rotterdam criteria
DDX CAH, androgen secreting tumours, Cushings
> 12 follicles 2-9mm in diameter in at least one ovary +/- >10mL volume stroma
Clinical signs of androgen - acne, hirsutism (ferryman-gallwey scoring), male-pattern baldness, virilisation, clitoral, breast atrophy, increased muscle bulk
INSULIN resistance, CV disease, endometrial hyperplasia and cancer risk, GDM risk, recurrent miscarriage and IUGR (may be BMI not PCOS), sleep apnoea, endometriosis, breast cancer risk
ROM
Gush of fluid, soaked bedsheets No contractions Fetal movements Past obstetric history - ask about it all Current pregnancy history, blood group, medical issues PMSX FMHX Medications, Social
Examination:
Vitals
Abdominal examination - uterus, lie, presentation, engagement, fetal movements, fetal HR
Speculum - liquor, cord?, cervix, vagina, aamnicator
Investigations/Management:
CTG
- Induction of labour - confirm forewataers with forceps and start IV synto, continuous CTG, PROM (>18 hours) needs IV antibiotics
- Await onset of labour, temperature twice daily, foetal movements, daily normal CTG, no colour of liquor, no fever or abdominal pain, oral antibiotics, needs IV antibiotics due to PROM, after 96 hours HAVE TO INDUCE
Meconium liquor, needs CTG –> induction, this should be continuous, IV penicillin due to PROM, suctioning of airway/treachea after delivery of head
FEATURES OF CHORIO:
Fever, tender uterus/abdomen, change in colour of liquor from clear, raised CRP, rise in WCC, CTG with foetal tachycardia
IF CORD PROLAPSE, CHORIO and fetal distress excluded –> CAN DO CONSERVATIVE OTHERWISE HAVE TO
Ovarian Cancer
SOCRATES
N+V, early satiety, reflux?, Urinary symptoms
Recent diarrhoea
GYNAE HX - periods, para, pap smear, surgeries
MX, Allergies
FMHX, SOCIAL
Exam: General inspection Vitals Head and neck, lymph nodes CVS, LUNG Breast Abdominal - nodes, palpation Vulva/Vagina Speculum PV/PR - mass?
Investigations: FBC, UEC, LFT CA125, 15.3, 19.9, LDH, CEA CXR Pelvic USS CT chest, abdomen, pelvis
• FBE, U+E+Cr, LFTs: normal
• CA125: 1205 U/mL (<45 U/mL)
• CA15.3: 11 U/mL (<30 U/mL)
• CA19.9: 45 U/mL (<39 U/mL)
• CEA 6.4 μg/L (non-smokers <3.5; smokers < 6.5 μg/L)
• LDH 225 U/L (100-230)
• CXR: small pleural effusion in R lung field
• Pelvic ultrasound: Bilateral solid and cystic ovarian masses with low
resistance blood flow. Small uterus, endometrial thickness 3 mm,
ascites, normal kidneys
• CT scan: Large solid, cystic mass arising from pelvis, ascites, omental
thickening, no lymphadenopathy
Explain cancer of ovaries - complex masses, tumour marker and ascites
Spread - majority do spread when noticed
Surgery - cytoreduction –> chemo
Pre-eclampsia
BP, protein, other system - >/=2 diagnosis
BP, Previous HTN, any previous HTN, FMHX Pre-eclampsia, Any medical illnesses, or secondary causes of HTN (CREED), connective tissues diseases or IDDM predispose
Current symptoms:
Headache, visual disturbance, epigastric pain, oedema, foetal movements, PV bleeding
SOCRATES
Examination: BP, height Lie, presentation Heart Bishop score
Needs to be admitted, investigations for severity, check foetus, need to check for need of delivery, give possible anticoagulants
IX:
Maternal:
FBC, UEC, LFT, COAGS, Uric acid, 24 protein (if >0.3g per 24 hours)
Fetal:
USS, CTG, Liquor, Dopplers
GIVE - Methyldopa or labetalol, second line is nifedipine.
Induction of labour if indicated
