OBSGYN OSCE review Flashcards
what is included in a general gynecological history
- ID–> age, occupation, relationship status
- CC
- HPI–> onset, course, duration, OPQRST
- Menses
- Sexual history
- contraception
- PAP and mammography
- general gyne history
- PMH/past surgical history, meds, allergies
- social history
- family history
- obstetrical history
what questions do you ask on a menses history
LMP
menarche
regularity
frequency
interval
flow
spotting
PMS/dysmenorrhea
what should you ask on a sexual history
active?
age of coitarche
number of partners and gender
STI/blood born disease work up before?
what should you ask on history about contraception
method
duration
side effects
plans for future
what should you ask on a general gyne history
discharge
itching
dyspareunia
post coital bleeding
what is an outline for an obstetric history
- ID
- EDD my US/LMP, GA
- US dates
- LMP dates
- CC
- HPI–> 4 cardinal questions
- current OB history –> complications (diabetes, HTN), GBS status, blood type
- Past OB history –> SVD or C/S, reasons for C/S, miscarriages and abortions and their management and complications, PPH, transfusion required?
- past gyne history–> STI, paps etc
- PMHx, meds, allergies
- social history, family history
describe an approach to a focused gynecological physical exam
- inspection, vitals, stigmata of disease
- quick screen of HEENT, CV, Resp
- abdo exam–> IAPP, special maneuvers
- pelvic exam–> inspection, speculum exam, special swabs/pap, bimanual exam, rectovaginal exam
- testing for cervical/vaginal infections
- -GC/chlamydia culture testing (endocervical)
- -general swab for all other infections (posterior fornix) for gram stain (intracellular diplococci are gonorrhea and large gram positive rods are lactobacilli)
- -pH paper test (lateral vaginal walls)
- -whiff test with KOH
- -vaginal saline wet prep (trich vs BV)
- -vaginal saline wet prep plus KOH - bimanual exam–> vaginal walls, cervix, CMT, uterus (size, mobility), adnexa, uterosacral nodularity
- rectovaginal exam
what does large gram positive rods on endocervical swab indicate
lactobacilli
what does intracellular diplococci indicate on endocervical swab indicate
gonorrhea
what does a vaginal saline wet prep test for
trich vs BV
what does a vaginal saline wet prep plus KOH test for
yeast
describe an approach to the pelvic exam
- introduction and detailed explanation–> empty bladder–> abdo exam
- wash hands, sterile gloves, get all equipment ready
- give notice
- inspection–> vesicles, lacerations, rash etc
- speculum exam–> use hot water as lubricant instead of lube, comment on anatomy
- pap–> SHORT end of spatula and cytobrush (NEVER in pregnant women) –> wipe on slide and then fix
describe an approach to a focused obstetrical exam
- inspection, vitals, stigmata of disease
- quick screen of HEENT, CV, resp
- abdo exam–> IAPP
- -intro and explanation, empty bladder
- -examine on right side of patient
- -palpate the fundus for contractions
- -SFH
- -leopolds maneuvers - FHR–> baseline, variability, accels, decels
- sterile speculum exam
- vaginal exam (confirm no previa beforehand)
what are leopolds maneuvers
presentation–>
- fundus for whether head or bum
- lie–> longitudinal, oblique or transverse
- engagement
- attitude–> flexion/extension–cant assess unless head is engaged in pelvis
what are the cardinal movements of labour
- engagement and descent
- flexion
- internal rotation
- extension
- restitution/external rotation
- expulsion
describe the cardinal movement of labour:
engagement and descent
biparietal diameter (largest transverse diameter) of the fetal head passes through the pelvic inlet–> most commonly assumes OT position
describe the cardinal movement of labour:
flexion
descending fetal head meets resistance of pelvic floor and passively flexes to allow smallest diameter to present to the pelvis–> posterior fontanel in the center of the birth canal
remains OT
describe the cardinal movement of labour:
internal rotation
occiput rotates anteriorly to come under the symphysis–> OT into oblique position, OA or OP (OA most common)
describe the cardinal movement of labour:
extension
occiput comes into direct contact with inferior part of maternal symphysis and swivels under the bone, extending the head as it comes clear… chin delivers last
check nuchal cord after this
describe the cardinal movement of labour:
restitution
head restitutes to the original position before internal rotation–> transverse position to bring fetal shoulder in line with AP diameter of pelvic outlet
describe the cardinal movement of labour:
expulsion
anterior shoulder comes under symphysis, folloed by posterior shoulder, distends peritoneum
what is the shortest diameter of the pelvis
interspinous diameter
how do you manage the placenta after expulsion of the neonate
signs: sudden gush of blood, lengthening of the cord, uterus is globular and firm
check for 3 vessels, attachment point of cord, succenturiate lobe, is it complete
describe an approach to a vaginal exam in labour
general inspection
assess cervix
- -location
- -consistency
- -effacement
- -dilation
- -membranes
assess fetus
- -presenting part (cephalic/breech)
- -position (triangle is OA)
- -station (NOT assessable in blue box)
- -caput (NOT assessable in blue box)
what are the causes and risk factors for PPH
PREVIOUS history of PPH
tone
tissue
trauma/tears
thrombosis
what kinds of things can cause uterine atony leading to PPH
inversion
overdistended uterus–> macrosomia, multiples, poly, multiparity
exhausted uterus from prolonged labour, rapid labour, augmentation, chorioamnionitis
what kinds of tissue problems can cause PPH
retained POC
incomplete placenta
invasive placenta–accreta
what kinds of trauma and tears can cause PPH
hematoma
uterine rupture
lacerations (cervix, vagina, episiotomy)
assisted delivery
what kinds of thrombotic events can cause PPH
coagulopathy
anticoagulant tx
intravascular hemolysis and DIC
severe preeclampsia/eclampsia
how would you manage a PPH
- call for help
- ABCs, vitals
- two large bore IVs, start NS
- lab–> group and screen, crossmatch and coag profile
- foley catheter to monitor urine volume
- assess and manage TONE
- -bimanual massage
- -oxytocin 40 U IV in 1 L NS–> fast infusion
- -misoprostol suppository/hemabate/ prostin/ methergine/ ergotamine - assess and manage TISSUE
- -check placenta–manual removal of retained
- -express uterus for clots - assess and manage trauma/tears
- -repair - assess and manage thrombosis
- -replace missing factors according to coag results
- -packed RBCs, platelets - surgical management
- -Bakri balloon insertion
- -D and C
- -ligation of uterine/ovarian artery (main branches of internal iliac)
- -embolization
- -hysterectomy
how much/how would you administer oxytocin in the context of a PPH
40 U IV in 1 L NS fast infusion
what are some ways to prevent PPH
10 U of oxytocin IM after anterior shoulder delivery
breast feeding ASAP to cause uterine contraction
if has risk factors, be ready with IV etc
what are complications from PPH
anemia
Sheehans–> unable to breastfeed due to low PRL–> check other hormones
what is the ddx for AUB/menorrhagia that presents as a heavier than normal period
fibroid
adenomyosis
endometrial polyp
coagulopathy
could also be…
endometrial hyperplasia or cancer
cervical polyps or cancer
what is the ddx for AUB/menorrhagia that presents as intermenstrual bleeding
breakthrough bleeds from OCP/IUD
cervical polyp/ectropion
infection (endometrial, cervical or vaginal)
endometrial hypertrophy or cancer
what is the ddx for AUB/menorrhagia that presents as post coital bleeding
cervical polyp
cervical friable lesion
cervical cancer
what are some “other” causes for AUB/menorrhagia
trauma
lacerations
instrumentation
thyroid problem/prolactin problem
what history should you ask, beyond normal gyne history, in the setting of AUB/menorrhagia
intermenstrual, menstrual or post coital?
associated symptoms–fever, pain, discharge?
pregnancy?
family history of coagulopathy or cancers?
constitutional sx?
menopausal sx?
risk factors for endometrial cancer
what are the risk factors for endometrial cancer
early onset of menarche
late menopause
nulliparity
diabetes
obesity
exogenous estrogen use
chronic anovulation (irregular periods)
personal history
family history
lack of OCP use
HTN
what physical exam should you do for AUB/menorrhagia
inspection/vitals
height and weight
signs of anemia?
stable?
quick HEENT/CV/RESP/GI screen (rule out other sources of bleeding
abdo exam–> IAPP and special maneuvers
pelvic exam–> inspection, speculum, bimanual
what labs should you do for AUB/menorrhagia
pregnancy test
CBC
TSH, PRL, FSH
coagulation workup–> INR, PTT, fibrinogen
androgen workup if hirsutism suspected
pap smear
cultures for STI
endometrial biopsy
hysteroscopy if you have one
pelvic U/S or transvaginal U/S for endometrial thickness
HSG (MRI)
treatment for uterine bleeding due to fibroids
NSAIDS
provera
danazol
GnRH agonists for 3-6 mo to shrink fibroids
uterine artery embolization
hysteroscopic/lap/abdo myomectomy
hysterectomy
treatment for uterine bleeding due to adenomyosis
hormonal regulation
endometrial ablation
hysterectomy
treatment for uterine bleeding due to endometrial hyperplasia
progestin therapy
D and C
hysterectomy
treatment for uterine bleeding due to endometrial cancer
TAHBSO
how do you manage mild to moderate uterine bleeding
OCP
how do you manage severe uterine bleeding
admit
stabilize
premarin IV then to oral estrogen when bleeding stops
NSAIDS, OCPs, progestin, danazol, IUD, D and C, endometrial ablation, hysterectomy
ddx for oligomenorrhea
PCOS
pregnancy
anovulation
hypothyroid/
hyperprolactinemia
hypo hypo–> stress, anorexia, exercise
anovulatory
ddx of PCOS/hirsutism
PCOS
metabolic syndrome
cushings
androgen secreting tumour
CAH
androgen drug exposure
theca lutein cysts
stromal hyperplasia/
hyperthecosis
idiopathic hirsutism due to high 5 alpha reductase activity
history to ask for PCOS/hirsutism
onset and signs of hyperandrogenism –> if rapid with virilization–> consider androgen secreting tumour
signs of virilization
physical exam for PCOS and hirsutism
focus on clinical signs of virilism/hirsutism –>
male pattern balding
acne
oily skin
truncal obesity
acanthosis nigricans
pubic hair distribution
deepening of voice
increased muscle mass
clitoromegaly
breast atrophy
male body habitus
cushinoid features
labs to order for PCOS/hirsutism
CBC
serum testosterone
DHEA-S
serum 17-OHP
dexamethasone suppression test and 24 hour urine cortisol
FSH, LH, PRL, TSH, beta hCG
cholesterol panel
DM screen
pelvic U/S or transvaginal U/S
endometrial biopsy
treatment for PCOS
lifestyle mods
screening/monitoring for endometrial cancer, HTN, dyslipidemia, DM, sleep apnea
if trying to conceive–> weight loss, clomiphene citrate, metformin, FSH injection, ovarian drilling or IVF
if not trying to conceive–> weight loss, OCP/progestin and anti-androgens
how do you diagnose gestational DM
SCREEN with 50 mg glucose load at 24-28 weeks–> measure 1 hour later
- -if above 7.9 mmol/L, confirm with 75 g OGTT test
- -if above 10.3 mmol/L, diagnosis is made
DIAGNOSE with 2 hr 75mg OGTT after overnight fast–2 or more abnormal values is diagnostic
- -fasting above 5.1 mmol/L
- -1 hour above 10 mmol/L
- -2 hour above 8.5 mmol/L
if GDM is diagnosed, then have to do a 75g OGTT at 6-12 weeks post partum
what complications are associated with GDM
fetal macrosomia
birth injury
neonatal hypoglycemia
hypocalcemia
hyperbilirubinemia
polycythemia
how do you manage GDM
- nutritional counseling
- -BG self monitoring
- -count carbs (200-220 g carbs per day)
- -aim for fasting BG less than 5.3, post prandial less than 7/8 - start insulin therapy if targets not reached within a matter of 1-2 weeks
- serial assessment of fetal wellbeing especially if insulin treatment
- -fetal movement counting daily
- -U/S for growth, fluid, dopplers, NST, BPP
what is the starting dose of insulin for GDM
4U short acting/rapid acting insulin before meals
4U intermediate acting at bedtime (NPH)
total daily doses–> 0.6U/kg before 6 weeks, 0.7U/kg 6-18 weeks, 0.8U/kg from 18-26 weeks, 0.9U/kg from 26-30 weeks, 1U/kg from 36-40 weeks
how do you manage delivery in GDM
check level q1-2 hours and give IV insulin infusion/dextrose infusions if glucose levels exceed 6.5mmol/L
early induction of labour at 38-40 weeks
avoid forceps/vacuum due to increased risk of shoulder dystocia
prophylactic C/S for macrosomia (i.e above 4500-5000 g)
how do you manage GDM post partum
6-12 weeks post partum, do 75g 2 hour OGTT
annual fasting glucose to screen for T2DM
lifestyle mods
what is the workup for HELLP
CBC–platelets, HgB– plus diff
lytes
AST, ALT
albumin
bilirubin
workup for DIC/hemolysis
INR
PTT
fibrinogen
LDH
peripheral smear
renal workup
Cr
Uric acid
BUN
UA
24 hour protein urine
how do you manage an acutely elevated BP in a pregnant woman (including dosages)
treat immediately if sBP above 160 or dBP above 110 –> try and get it below this
- nifedipine (10 mg q45 min)
- labetalol (20 mg IV q 30 min)–contraindicated in asthma or heart failure
- hydralazine (5 mg IV q 30 min)
4 for seizure prophylaxis–> MgSO4 4g STAT over 20 min then 1g/hr–> antidote is calcium gluconate
how do you manage chronically elevated BP in a pregnant woman
goal is sBP 130-135 and dBP 80-105
- methyldopa
- labetolol/nifedipine XL 30 mg daily at 18:00
- diuretics if have special indications
avoid ACEi, angtiotensin II receptor antagonists, atenolol
how do you manage HELLP acutely
- order blood products, including platelets
- platelet transfusion prior to vaginal delivery/C section if count is below 20
- consider corticosteroids if count is below 50
- Mg prophylaxis (4 g stat over 20 min then 1g/hr)
- stabilize and deliver at all GA
how do you manage eclampsia acutely
call for help
ABC
stabilize
deliver
MgSO4 2g IV STAT to control seizures then 1.5g/hr plus valium
what BP meds are safe for breastfeeding (to control HTN post partum)
nifedipine
labetalol
methyldopa
captopril
non gyne ddx for PID
appendicitis
diverticulitis
bowel perf
inflammatory bowel disease
gyne ddx for PID
ectopic
ovarian torsion
tubo-ovarian abscess
hemorrhagic cyst rupture
TB salpingitis
what should you ask on history for PID
- how old are you (15-25 yo is highest risk)
- age at first coitus
- form of contraception
- sexual history–how many sexual partners recently?
- new partner?
- prior history of PID/pelvic infections or STDs? worked up for STDs in the past?
- smoker?
- recent instrumentation like IUD insertion, D and C etc
what elements to look for on physical exam for PID
unstable vitals, may have high fever
abdo tenderness with or without rebound tenderness and peritonitis
Fitzhugh curtis syndrome
increased vaginal discharge with abnormal odour, abnormal bleeding
adnexal tenderness, uterine tenderness
what is Fitzhugh curtis syndrome
inflammation of the liver capsule due to PID leading to adhesions
what tests should you order for PID
CBC
ESR
chlamydia and gonorrhea cervical gram stain
beta hcg
LFTs
kidney function
lactate
blood culture
pelvic U/S
do a diagnostic lap if appy cant be ruled out
how do you manage PID
if stable–outpatient with follow up in 48-72 hours
hospitalize if indicated
when should you hospitalize with IV abx for PID
- unstable vitals, severe V and V, high fever, septic
- if surgical emergency i.e appy cant be excluded
- pregnant
- likely to be non compliant at outpatient
- unresponsive to oral therapy
- known tubo-ovarian abscess
- presence of IUD
- immunodeficient or HIV positive
- peritonitis present in upper quadrants
what is the oral abx tx for PID
ceftriaxone 250 mg IM plus doxycycline 100 mg PO BID for 14 days with or without metronidazole 500 mg PO BID for 14 days