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
Menopause
Take history Para, periods, age, fmhx, symptoms of menopause (hot flushes, night sweats, sleep, fatigue, irritability, vaginal dryness, dyspareunia) PPPPP PMHX, FMHX (cancer) Other history including social
Can give hormonal therapy - E and P
E for symptoms - P for protection of endometrium
DVT history, migraine with aura, smoking need to know these!!!
Side effects include breast tenderness, nausea and headaches
Benefits - relief of smpytoms, bone protection, osteopenia and osteoporosis, may protect against bowel cancer
Risks - DVT, after 5 years slight increase in cardiac symptoms and small risk of breast cancer (from the progesterone)
Jaundice in pregnancy
Planned or unplanned Pregnancy history Gravida and Para Ask about folate, vitamins, rubella, varicella, What symptoms? Screening tests? Gynae history, Paap smear, PMHX, PSHX SOCIAL MX, allergies SOCRATES, urinary symptoms and bowel symptoms HX of liver issues, IVDU
Examination: GI, Vitals CV RS exams Abdominal exam VE: Speculum - take pap smear
Investigations
Routine antenatal - B group, Rh, antibodies, FBC, rubella, varicella, MSU, HIV, syphilis,
Offer NIPT or CTFS, organise USS
LFT’s, Hepatitis serology, ?auatoimmune screen,
USS upper abdomen - gallstones?
Ddx - cholestasis of pregnancy, alcohol, NAFL, HELLP (pre-eclampsia) - not relevant asa early pregnancy
Hep B - no risk of transmission to son, need to get everyone who is a contact vaccinated.
Serial LFT checking, INR closer to delivery
NO EVIDENCE C SECTION is better than vaginal
NO RISK OF FETAL ABNORMALITIES DUE TO INFECTION
Avoid scalp blood sampling, avoid instrumental
Give passive and active immunisation with immunoglobulins and vaccination (after birth)
Serological testing at 12 months
Twin Pregnancy
Risks Antenatal maternal - Miscarriage rate increased, - Hyperemesis gravidarum - IDA - Exagerrated general symptoms - APH - Gestational hypertension - Pre-eclampsia - GDM - PROM - Premature delivery
Fetal risks -
- Congenital, IUGR, Perinatal mortality, Growth discordance
Intrapartum - increased need operative delivery, increased risk of trauma to both baby and mother
Post partum
Post-partum haemorrhage, breastfeeding difficult, financial, post natal depression
TTTS for monochorionic
Rapid abdominaal/uterine distension, reduce ability to palpate fetal parts due to massive polyhydramnios
USS every 2-4 weeks from 24-28 –> (growth discordance, polyhydramnios in recipient and opposite in donor)
Vaginal delivery requirements: Most only do C section but its agreeable to do vaginal Near term No compromise First needs to be cephalic Hospital, with experienced obstetrician - need paeds and anaesthetics Epidural/spinal IV access Continuous monitoring !!!!
Miscarriage
HISTORY, all normal antenatal stuff important SOCRATES ON BLEED - clots or products? Pain? - Current pregnancy symptoms When last eaten or drank Period history PPPPP Gynae history, Pap smear PMHX, Psych history, surgical history Home, social history Allergies, medications
Examination: GI, Vitals, Abdomen - Speculum Bimanual - size of uterus, position, adnexal masses, tenderness
Investigations: USS - pelvic Blood group and antibodies FBC BHCG
DDX - miscarriage, ectopic, molar, bleeding from cervix or vagaina
Give Anti-D if no antibodies and rhesus negative IV access (group and hold)
Management for miscarriage
Suction curettage under GA - need to get consent and inform of risks - 1-2% more treatment, infection, <0.5% perforation
Medical treatment - misoprostol 400mcg PV 4/24 hourly until delivery of products
Expectnat management - suction curette needed in case of excessive bleeding
15% miscarriage - 25-50% of WOMEN HAVE ONE IN THEIR LIFETIME
50-60% due to sporadic chromosomal defects
Smoking causes increase
Age also has increased risk, also diabetes, graves, hyperprolactin, genetic, uterine abnormalities, infection, thrombophilias, antiphospholipid , cocaine, chemical agents.
Needs check before and immunity and folate etc.
No increased risk of miscarriage from working, normal activity, intercourse
No need for investigation unless 3 consecutive
Refer to counselling services ??? - not her fault
Slightly increased risk after 2 miscarriages and thereafter increases slightly
<20 weeks of <400 grams
In utero fetal death
History of pregnancy
History of antenatal investigations, fever/rash/illness, medical issues or past surgery
ALL OTHER HISTORY
SOCRATES what actually happened
Investigations - see if something to be worried about so can prevent, and if risk of occurring again
BG, ABO incompatibility FBC - low platelets means DIC Fibrinogen, APTT/INR Kleinbauer test - may be concealed abruption Phospholipid snydrome HBA1c TFT ANA Serology - TORCH
Send placenta/cord for histology, surface swabs for culture, examine cord for knots
PHOTOGRAPHS, karyotype, surface swabs, X-RAY (if not consenting for autopsy)
Advise for autopsy so can see future pregnancies
Need to do SPIKES -
No cause on history, need to await results
Expectaant management - risk of DIC but this is low unless >4 weeks in utero, ] C section (will affect future pregnancies) Induction of labour - use vaginal delivery with prostaglandins (low-dose misoprostol, or Prostin - prostaglandin E)
Seeing helps deal with grieving, naming, photos and footprints/handprints
Burial options
Counselling
SANDS - stillbirth and neonatal death support
SENIOR CONSULTAT TO GO THROUGH RESULTS AND FORM A PLAN
Abortion
Antenatal history Sexual activity, 5 P's Periods, cycles LMP PMHX, SX FMHX Social, allergies, medications
ASK WHY wants abortion - support, implications known
Surgical TOP -
Suction curette under GA or sedation - oxytoxcic used, 400microgral misoprostol 3 hours before
100mg Doxy 6 hours prior and 200mg orally 2 hours after
ANTI D MIGHT BE NEEDED
Risks - perforation (hence using misoprostol), haemorrhage (again miso helps), infection (antibiotics), no long-term sequelae
Mortality rate 1/100,000
Taken place until 14 weeks gestation - GA or paracervical block
Vacuum pressure used - sharp curette used to explore (empty uterus does not usually bleed)
Not allowed surgical TOP =6 weeks (can’t remove gestational sac)
NEEDS ONGOING CONTRACEPTION
IUD, implant, copper IUD - can be put in at the same time
CONDOMS - for sti though
<7 weeks MEDICAL TOP preferred and can be offered 7-9 weeks: RU486 200mg and 800 microgram MIsoprostol (vaginally - 48 hours later - reduces SE which are mainly GI) —> 5% need curettage, 1% will bleed heavily enough for a transfusion to be indicated, 1% failure
—> Abortion usually occurs within 6 hours in 90%
NEED TO FOLLOW ALL PATIENTS UP
SECOND TRIMESTER ABORTION:
Surgical - dilatation and evacuation with misoprostol 400microg 3 hourly for 3 doses vaginally before hand
Medical - PGE1/2, intramniotic or intramuscular PGs. Extra or intraamniotic compares well –> pessaries in posterior fornix every 3-4 hours (5-6 required to cause abortion)
Early complications - Perforation, haemorrhage,e lacerations, failure to complete due to too early
Late complications - retained products, anaemia, VTE and cervical stenosis. Mortality rate is 1:100,000 from infection, thromboembolism, haemorrhage and anaesthesia
Pelvic infection - prophylaxis with antibiotics against Chlamydia, BV help reduce morbidity
Second trimester slightly increased perforation
IF BLEEDING LAPARASCOPY +/- laparotomay
NO LATER FERTILITY FROM 1st trimester
UNKNOWN IF SECOND TRIMESTER DOES
MINIMAL PSYCHOLOGICAL sequelae - still need to address
Neonatal Resus
Dry and provide tactile stimulation to the baby
Provide warmth
Position airway - neutral or slightly extended
Check breathing, heart rate with stethoscope
PEEP - oxygen, self-inflating bag, T piece device (provides PEEP and ventilations at 60 per minute)
CHEST COMPRESSIONS - two thumbs -
90 / 30 ventilations in 1 minute 3:1
Reassess APGARS
Keep warm once good
Pain relief for labour
Medical conditions, allergies, medications currently taken
Drug free - mobilising, walking, rocking, position change (bean bag, floor mat, medical, hot packs, water based, bath, massage)
- No medications, no needles, no risk of sedation for anyone, multiple options, patient in control, partner involved
- May not be adequate enough, can’t use water based if continuous CTG needed (and for other movement options)
Patient controlled - nitrous oxide
- Rapid onset and offset, used for many hours, controlled, no overdose/sedation, reasonable analgesia
- Nausea, dry mouth, dizziness, mask claustrophobic, not adequate for some women
Patient controlled - TENS
- No sedation, no nausea
- not to be used with water-based, limited benefit analgesically
Prescribed analgesia
- reasonable level, routinely available, no IV
- N/V, ALOC/sedation for mother and foetus (respiratory compromise too), local pain/haemotoma at injection site, rare risk of nerve damage, not for herion addicts
Anaesthesia
- Usually excellent
- Requires anaesthetist
- Rare risk of complications - abscess, haemataomaa, nerve injury
- Risk of failure, incomplete, requires iV access, CTG monitoring, IDC
- Loss of mobility, maternal hypotension
- Headache, pruritus
- Increased requirement for synto AND INSTRUMENTAL DELIVERY
- Contraindicated in some illnesses or diseases
Some people use CSE -
In general epidural the best but most side effects and complications
Genetic counselling
TAKE HISTORY Gynae, past history Meds Family history SOCIAL
Genetic testing recommended
HNPCC, BRCA1 and 2 are syndromes
IF HNPCC - colonoscopy for bowel cancer (no screening for endometrial)
BRCA - mammography, CA125, pelvic USS, prophylactic mastectomies and prophylactic BSO (ovary)
Placental Abruption
MED, SURG, FMHX, MEDICATIONS, ALLERGIES, pap smears, progress of pregnancy to date, any complications
MOVE ON QUICK
SOCRATES - how much blood since when and how did it happen
IS there any pain, ROM?, Uterine activity?, Fetal movements?!?!
GI, Vitals
Abdominal exam - height, tenderness, lie, presentation, heart rate, time tightenings, bleeding
Speculum - clots?, fresh bleeding, EXCLUDE Lower tract causes
Mx
IV bung, IV fluids - colloid/crystalloid to replace loss
Cross match, Kleihauer, APPT/INR, Continuous CTG
Fast while bleeding - notify senior, prepare for delivery if fetal distress or ongoing haemorrhage.
Urgent USS
Incontinence/Prolapse
Dragging sensation or lump Urinary Sx, urge, coughing/straining causing it? Pads, How many episodes, how many times a day Bowel symptoms PPPPP Caffeine, alcohol, social Para, menopause?, bleeding, therapy Pap smear? Mammogram PMHX, PSHX, Allergies, SOCIAL
Examination: GI, Vitals Chest, breast Abdomen Vulva - Sims speculum - see grade of prolapse, cervix, vagina, see if stress incontinence after reduction of uterus
Investigations:
Mid stream MCS urine
Urodynamics
ECG, CXR - suitability for surgery
Mx:
Ring pessary, surgery (mesh for vagina with tension free tape or sling), hysterectomy
Reduce coffee and alcohol, improve bladder control in this way
Obesity reducing
Need to be screened regularly
Failure to progress
Take a history
HISTORY OF labour
When admitted, membrane status, contractions, what are the frequency of contractions and how are they changing, fetal movements, fetal heart rate
What type of analgesia
Exam:
Vitals
Abdominal - fundus, lie, cephalic, engagement, fetal heart rate, contractions
Vaginal - cervix, membranes, position, station, presentation, pelvis - BISHOPS SCORE
If progressing normally - continue with intermittent fetal auscultation, no need for anything else, vaginal exam in 4 hours
DECELERATIONS
- tachograph, baseline heart rate 100-160, variability 5-10 bpm is reassuring, 2 accelerations of at least 15bpm for 15 seconds over 20 minute, absence of decelerations
SLOW PROGRESS:
Assess power, passenger and pelvis
Power - contractions
Passenger - abdominal and vaginal exam
Pelvis - from vaginal exam
If passenger or pelvis abnormal need to do C section otherwise as below
ARM +/- synto - reassess 4 hours - may consider C section
REASSES PAIN RELIEF - IM pethidine or epidural
COCP
PPPPP
Normal history
Gynae history, pap smear, periods etc.
Start active pill on day 1 of period –> ensures immediate protection
(If start non-active need 7 before safe)
NEED TO TRY TAKE SAME TIME EVERY DAY
SE- - nausea, headaches, breast tenderness, breakthrough bleeding - usually disappear by 3 months
7 day rule for missed pills also applies if vomiting, diarrhoea or antibiotics
STILL NEED TO USE DOMMIES FOR STIS
Benefits - 99% effective, periods lighter in some - less anaemia, less ovarian cysts, decreased risk of ovary and endometrial cancer, decreased bacterial STI, fewer fibroids and endometriosis
Risks - DVT, Gallbladder disease, no increase in breast cancer (maybe tiniest bit), small increase in cancer of cervix (regular screening), some small cardiac risk
RISK OF MI IF OVER 35 AND SMOKE, low dose no risk of stroke
The absolute contraindications to the COCP include suspected pregnancy, thromboembolic disorders, cerebrovascular or coronary artery disease, markedly impaired liver function, a history of cholestatic jaundice, suspected breast cancer or other E-dependent neoplasia, herpes gestationis, a history of otosclerosis with known deterioration during pregnancy, undiagnosed abnormal vaginal bleeding, smokers over 35 years. A contraindication to the OCP is usually a contraindication to pregnancy. - Migraine with aura
Relative contraindications include migraines, uncontrolled hypertension, epilepsy (depending on the drugs used), sickle cell disease and active gall bladder disease. Provided there are no contraindications, a woman may use a low dose COCP until she reaches menopause.
MISSED PILL IS >12 hours later then they lose protection or two are missed - take forgotten pills and use alternative for next 7 days
The P component suppresses LH and prevents ovulation and the E component suppresses FSH and prevents selection of a dominant follicle. The E provides stability to the endometrium and potentiates the action of the P component. The P component causes an atrophic endometrium, thick cervical mucus and decreases tubal motility. There is no evidence for a delay to return of fertility when the COCP is ceased.
Down syndrome risk
Take a normal history
Down syndrome is the most common chromosomal abnormality, resulting in intellectual disability, characterised by trisomy 21 (3 copies of chromosome 21).
Increasing maternal age is a major risk factor (roughly 1 in 1,500 at 20 y.o.; 1 in 300 at 36 y.o.; 1 in 100 at 40 y.o.; 1 in 40 at 44 y.o.).
Ninety-five per cent are sporadic mutations (non-dysjunction of maternal chromosomes during meiosis), but up to 5% are due to unbalanced translocations or mosaicism.
USS low sensitivity
OFFER NIPT OR CFTS with USS
Second trimester screening offered as well
DO NOT RULE OUT COMPLETELY - decides whether invasive test is needed
Anything more than 1/300 is high risk
Can give CVS (11-14 weeks, 1% miscarriage risk)
Amniocentesis 15-18 weeks (0.5% risk of miscarriage)
NEED ANTI-D COVER FOR INVASIVE
STI’s
Normal history
LMP, Periods, Post-coital bleeding, pain, urinary symptoms, PCB before, IMB, DUB, Dyspareunia, discharge??????
PPPPP
Other history
Investigations:
Pap smear, colposcopy exam required if post coital bleeding
High vaginal swab for MCS, endocervical swab for NAAT, first catch urine for chlamydia/gonorrhoea
GIVE treatment as per ETG flashcards
Doxy best taken with food
Counsel on how to tell partner - partner must be treated
Educate about STI’s - need to abstain for 7 days after single dose regimen or completed full regimen for other types
Can only have sex again after this and all partners have been treated
Reinforce safe practice, serology for HIV, hepatitis, spyhilis now and in 3/12
Continuous re-screening
Antenatal care
BG and ABO
FBC - anaemia and infection
Syphilis - congenital infection
Hep B - transmission
Rubella - congenital defects
HIV - transmission
Urine MCS - often asymptomatic –> reduces risk of miscarriage and ppROM
Vitamin D/calcium - muslims and others at risk
Down syndrome screening - need to offer this
Heavy menstrual bleeding
Take gynae history - how much blood, how long for, clots, tired, pain?, contraception, procedures, pap smear
PMHx, PsHx, OTHER HISTORY
Examination - signs of anaemia, vitals Thyroid exam Breast exam CV exam Abdominal exam Vulva exam Speculum - take pap smear, cervix, pipette sample of endometrium Bimanual - bulky?, masses?, anteverted?,
Investigations
FBC, Iron studies, UEC, LFT, TFT, Pelvic USS
If no pipette taking need to do D and C if endometrium is thickened
Medroxyprogesteroneacetate:10mg/dayfor14dayspermonth OR • MirenaIUDinsertion Side effects of medroxyprogesterone acetate: • Headaches • Breasttenderness/pain • Moodswings/irritability • Abdominalbloating • Irregular/breakthroughbleeding Side effects of Mirena: • Irregularbleedingforfirstfewmonths
