Y4 Obs and Gynae

Question 1

When does jaundice in a neonate need to be investigated?

Answer 1

<24hrs
>14days

Question 2

Causes of jaundice in the first 24 hrs:

Answer 2

rhesus haemolytic disease
ABO haemolytic disease
hereditary spherocytosis
glucose-6-phosphodehydrogenase

Question 3

Causes of prolonged jaundice (14 days after birth)

Answer 3

biliary atresia
hypothyroidism
galactosaemia
urinary tract infection
breast milk jaundice
- jaundice is more common in breastfed babies
- mechanism is not fully understood but thought to be due to high concentrations of beta-glucuronidase → increase in intestinal absorption of unconjugated bilirubin
prematurity
- due to immature liver function
- increased risk of kernicterus
congenital infections e.g. CMV, toxoplasmosis

Question 4

Migraine prevention medication in women of child bearing age?

Answer 4

Propanolol

Question 5

What is meant by the term adenomyosis?

Answer 5

If endometrial tissue is present in uterine muscle, the term adenomyosisis used.

Question 6

Symptoms of endometriosis:

Answer 6

Cyclic pelvic pain!

Dysmenorrhoea, dyspareunia, dysuria, dyschezia (difficult, painful defecating), and subfertility.

Question 7

Findings from a bimanual exam in endometriosis:

Answer 7

• A fixed, retroverted uterus
• Uterosacral ligament nodules
• General tenderness
  
  • Note: An enlarged, tender and boggy uterus is indicative of adenomyosis.

Question 8

Endometriosis differentials for the OSCE:

Answer 8

Pelvic inflammatory disease
Ectopic pregnancy
Fibroids
IBS

Question 9

Investigations for endometriosis:

Answer 9

Gold standard laprascopy
Ultrasound

Question 10

Summarise the management of endometriosis:

Answer 10

1. Analgesia - NSAID’s / analgesic ladder.
2. Suppress ovulation - Low-dose COCP, injectable or mirena.
3. Surgery - laser ablation to remove ectopic endometrial tissue. Relapses will occur so hysterectomy is definitive.

Question 11

Describe endometriosis for an OSCE:

Answer 11

Endometriosis is a chronic condition where endometrial tissue is present at other sites other than the uterine cavity such as ovaries, pouch of Douglas, uterosacral ligaments, pelvic peritoneum, bladder umbilicus and lungs.
Patients may be asymptomatic. Signs and symptoms also include pelvic pain, dysmenorrhoea, dyspareunia and subfertility.

Question 12

Risk factors for pelvic inflammatory disease:

Answer 12

• Sexually active
• Aged under 15-24
• Recent partner change
• Intercourse without barrier contraceptive protection
• History of STIs
• Personal history of pelvic inflammatory disease

Pelvic inflammatory disease can also occur viainstrumentationof the cervix – inadvertently introducing bacteria into the female reproductive tract. Such procedures include gynaecological surgery, termination of pregnancy, and insertion of an intrauterine contraceptive device.

Question 13

Features of pelvic inflammatory disease:

Answer 13

• Lower abdominal pain
• Deep dyspareunia (painful sexual intercourse)
• Menstrual abnormalities (e.g menorrhagia, dysmenorrhoea or intermenstrual bleeding)
• Post-coital bleeding
• Dysuria (painful urination)
• Abnormal vaginal discharge (especially if purulent or with an unpleasant odour)

In advanced cases, women can experience severe lower abdominal pain, fever (>38° C), and nausea and vomiting.

Question 14

What is seen on vaginal examination in pelvic inflammatory disease?

Answer 14

On vaginal examination, there may be tenderness of uterus/adnexae or cervical excitation (on bimanual palpation). There may be a palpable mass in the lower abdomen, with an abnormal vaginal discharge noted.

Question 15

Explain what pelvic inflammatory is for an OSCE:

Answer 15

Pelvic inflammatory disease refers to an infective inflammation of the endometrium, uterus, fallopian tubes (salpingitis), ovaries and peritoneum.

It is caused by the spread of bacterial infection from the vagina or cervix to the upper genital tract.

Chlamydia trachomatis and Neisseria gonorrhoea are responsible for approximately 25% of cases.

Features include: Umbilical pain, dyspareunia, post-coital bleeding, dysuria, vaginal discharge with odour. Fever is a late sign.

Question 16

PID Differentials for the OSCE:

Answer 16

• Ectopic pregnancy (a pregnancy test is mandatory to exclude this).
• Ruptured ovarian cyst
• Endometriosis
• Urinary tract infection

Question 17

Investigations for pelvic inflammatory disease:

Answer 17

1. Vaginal swabs to identify the organism.
2. Full STI screen (HIV, syphilis, gonorrhoea and chlamydia as a minimum).
3. Urine dipstick and culture to exclude UTI.
4. Pregnancy test.
5. Transvaginal ultrasound
6. Laprascopy - observe inflammatory changes and peritoneal biopsy.

Question 18

What are the different types of vaginal swab and what do they respectively test for?

Answer 18

1. Endocervical swabs - gonorrhoea and chlamydia.
2. High vaginal swab - trichomonas vaginalis and bacterial vaginosis.

Question 19

How is pelvic inflammatory disease managed?

Answer 19

1. Antibiotics (14 days broad spec)
2. Analgesics - paracetamol
3. Abstain from sex
4. Test any sexual partners in the last 6 months.
5. Consider hospital admission

Question 20

Talk through the use of antibiotics to treat PID:
- what’s used?
- when are they started?

Answer 20

Treatment is a14-day course of broad spectrumantibiotics with good anaerobic coverage. This should be commenced immediately, before the results of swabs are available. Options include:

• Doxycycline, ceftriaxone and metronidazole
• Ofloxacin and metronidazole

Question 21

When should a patient with pelvic inflammatory disease be admitted to hospital?

Answer 21

• If pregnant and especially if there is a risk of ectopic pregnancy.
• Severe symptoms: nausea, vomiting, high fever.
• Signs of pelvic peritonitis.
• Unresponsive to oral antibiotics, need for IV therapy.
• Need for emergency surgery or suspicion of alternative diagnosis.

Question 22

When should a patient with pelvic inflammatory disease be admitted to hospital?

Answer 22

• If pregnant and especially if there is a risk of ectopic pregnancy.
• Severe symptoms: nausea, vomiting, high fever.
• Signs of pelvic peritonitis.
• Unresponsive to oral antibiotics, need for IV therapy.
• Need for emergency surgery or suspicion of alternative diagnosis.

Question 23

Complications of pelvic inflammatory disease:

Answer 23

• Ectopic pregnancy– due to narrowing and scarring of the fallopian tubes
• Infertility– affects 1 in 10 women with PID.
• Tubo-ovarian abscess
• Chronic pelvic pain
• Fitz-Hugh Curtis syndrome– perihepatitis that typically causes right upper quadrant pain

Question 24

Describe bacterial vaginosis for an OSCE:

Answer 24

Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid-producing aerobic lactobacilli resulting in a raised vaginal pH.

Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women.

• Vaginal discharge: ‘fishy’, offensive
• Asymptomatic in 50%

Question 25

How is BV diagnosed?

Answer 25

Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present

• Thin, white homogenous discharge
• Clue cells on microscopy: stippled vaginal epithelial cells
• Vaginal pH > 4.5
• Positive whiff test (addition of potassium hydroxide results in fishy odour).

Question 26

BV treatment:

Answer 26

Oral metronidazole for 5-7 days

Topical metronidazole ortopical clindamycinare alternatives.

Question 27

Frothy green/yellow offensive discharge, strawberry cervix and vulvovagnitis.

• Diagnosis and treatment:

Answer 27

Trichomonas - treat with oral metronidazole.

Question 28

PPROM give what abx?

Answer 28

10 days erythromycin should be given to all women with PPROM