Transcript O&G REVISION LECTURE 2012

O&G REVISION
LECTURE 2012
Dr Jacqueline Woodman
Consultant Obstetrician &
Gynaecologist
FPE
• three parts:
• a short answer written paper
• multiple choice written paper
• clinical examination
What you’ll be expected
to know:
• common presentations in O&G
• recognise how common conditions
present
• what investigations to do and why
• initial management
• a level which adequately informs
practice as an F1
GYNAECOLOGY: common conditions
• Gynae OPD
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Menstrual problems
Pelvic pain
Vaginal discharge and infection
Incontinence, prolapse and basic
urogynaecology
• Gynae emergencies
• Miscarriage and ectopic pregnancy
• Hyperemesis gravidarum
• Community, GUM & contraception
• Contraception
• Menopause and HRT
• GUM infections
• Oncology
• Common gynae cancers
• Cervical screening
• Reproductive Medicine
• Common presentations of
sub fertility – eg polycystic
ovarian syndrome, semen
analysis, endometriosis
OBSTETRICS: common conditions:
• Antenatal Clinic
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Diabetes / hypertension in pregnancy
Screening in pregnancy
Fetal growth problems: SGA, LGA
Other common antenatal problems e.g. obstetric cholestasis
• Labour Ward
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Pre-eclampsia, sepsis, pulmonary embolus,
Other common life-threatening conditions
Normal labour and common intrapartum problems
Late pregnancy problems – e.g. reduced fetal movement movement,
ruptures membranes
• CTG monitoring, Abnormal labour, Caesarean section
• Puerperium
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Normal and abnormal puerperium
Post natal depression
Speciality learning
• You may enjoy learning in more depth about
complex sub-specialty patients, but the exam
will concentrate on the common
presentations in the subspecialities e.g.
• Fetal medicine: twins
• Infertility: male factor, endometriosis, PCOS
GYNAE OPD
• Menstrual problems / abnormal vaginal
bleeding:
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Amenorrhea (primary & secondary)
Menorrhagia
Intermenstrual bleeding
Post coital bleeding
Postmenopausal bleeding
Menstrual problems and
abnormal vaginal bleeding:
• causes, investigations & treatment
• Amenorrhea
• infertility, PCOS, eating disorders
• Menorrhagia
• pelvic pain, fibroids, menarche, menopause, oncology
• Intermenstrual bleeding
• infections, oncology
• Post-coital bleeding
• infections, oncology / cervical screening
• Postmenopausal bleeding
• menopause, HRT, oncology
PMQ example
A 17 year old, BMI=16 presents with primary amenorrhea.
She has normal breast development.
a) List 3 most likely causes of primary amenorrhea in this case
(3)
b) List 4 investigations you would request
(4)
c) If all investigations are normal, what would you advise?
(2)
d) She returns in 2 years. Her BMI is 19, she is sexually active, on no
contraception and is still amenorrhoeic. She is planning a pregnancy
in the next 6 months. What treatment option would you discuss?
(1)
PMQ example
A 53 year old, BMI = 40 presents with heavy irregular bleeding
for 2 years. She is not sexually active. Her cervical smears have
always been normal. She is hypertensive and has type 2
diabetes.
a) What pathology must be excluded in this patient?
(1)
b) What investigation does she need to definitively exclude this diagnosis
(1)
c) A diagnosis of benign endometrial hyperplasia is made. What risk factor does she
have that predisposes her to this condition?
(1)
d)What non-surgical treatment would you advise to treat her symptoms?
(1)
e)She returns after 2 years with a 3 month history of heavy vaginal bleeding despite
your treatment. What 2 surgical treatment options would you discuss?
(2)
f) Name 1 risks or complications specific to each of the surgical treatments you have
discussed with her.
(2)
g) Name 3 routine mandatory post-op medicationsthat you would prescribe for her
during her hospital stay?
(2)
MCQ
• The following characteristically cause heavy
regular menses:
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a) Endometrial carcinoma
b) Adenomyosis
c) Cervical carcinoma
d) Endometriosis
e) Granulosa cell tumour of the ovary
FTFFF
MCQ
• The following statements relating to cervical
intra-epithelial neoplasia (CIN) are correct:
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a) Screening for CIN should start at the age of 22 years
b) It is associated with a history of multiple sexual partners
c) It arises in the squamo-columnar junction of the cervix
d) Diathermy large loop excision of the transformation zone (LLETZ)
is the treatment of choice for persistent CIN I
• e) Hysterectomy is the first line treatment for CIN III
FTTTF
Gynae emergencies
Miscarriage:
Complete: closed cervix, no POC in uterus
Incomplete: open cervix, POC in uterus
Inevitable: open cervix, IUP in uterus
Missed: closed cervix, non-viable IUP
Threatened: closed cervix, viable IUP
Ectopic pregnancy:
pregnancy implanting outside the endometrial cavity
Pregnancy of unknown location (PUL):
positive pregnancy test with no ultrasound location of pregnancy
Hyperemesis gravidarum:
Management: IV fluids, anti-emetics, thiamine, thromboprophylaxis, gastric
protection (ranitidine, gaviscon etc), steroids
Complications: electrolyte imbalances, dehydration, Wernicke’s,
thrombosis, Mallory Weiss, weight loss
PMQ
An 23yr old woman presents to gynae admission with
history of abdominal pain of 4 hours duration and PV
bleeding, seven weeks of amenorrhea and a positive
pregnancy test.
a)What are your two most likely differential diagnosis?
b) List 5 investigations that you need request in this patient
c) What treatment options are available for each of your differential
diagnosis?
PMQ
An 23yr old woman presents to gynae admission with history of
abdominal pain of 4 hours duration and PV bleeding, seven
weeks of amenorrhea and a positive pregnancy test.
a) What are your likely diagnosis?
Ectopic pregnancy; miscarriage
b)List 5 investigations
FBC, G&S, βhCG, serum progesterone & pelvic USS
c)What treatment options are available for your diagnosis?
a)Ectopic – Medical (MTX), Surgical (salpingectomy)
b)Miscarriage - expectant, medical (misoprostol), surgical (ERPC)
Urogynaecology
Urogynaecology: Management
• Prolapse:
• VH, AR, PR (pelvic floor repair)
• Stress incontinence:
• Lifestyle advice & PFE
• Medical: Duloxetine (SSRI)
• Surgery: TVT / TOT / Colposuspension
• Urge incontinence:
• Lifestyle advice & Bladder training
• Anticholinergics (Amitryptaline, Imapramine, Oxybutinine, Detrusitol,
Trospium, Solifenicin, etc)
• Botulinum toxin
• Mixed incontinence: as above
• Overflow incontinence: CISC
MCQ
• The following is a recognized treatment
of urinary stress incontinence:
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a) Vaginal hysterectomy
b) Insertion of a ring pessary
c) Posterior colpoperrineoraphy
d) Colposuspension
e) Amitriptyline
Community, GUM
and contraception
• Contraception:
• Indications
• Contra-indications
• Menopause and HRT
• Benefits vs risks
• GUM infections:
• HIV, Hepatitis B
MCQ
• Hormone replacement therapy protects
postmenopausal women against:
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a) Osteomalacia
b) Coronary artery thrombosis
c) Deep venous thrombosis
d) Atrophic vaginitis
e) Cerebral haemorrhage
MCQ
• The following statements about contraception are
correct:
• a) The combined oestrogen/progestogen contraceptive pill usually
increases menstrual blood loss
• b) Inflammatory bowel disease is a recognised contraindication to the
combined oestrogen/progestogen pill
• c) The progestogen-only contraceptive pill is recognised to cause
intermenstrual bleeding
• d) The intrauterine contraceptive device is associated with a higher
risk of pelvic inflammatory disease than oral contraception
• e) Laparoscopic sterilisation of the female by Falope rings can be
successfully reversed in over 90% of cases
FFTTF
OBSTETRICS
• Antenatal
• Diabetes in pregnancy
• Hypertensive disorders
• Screening in pregnancy
• Fetal growth problems: SGA, LGA
• Other common antenatal problems e.g.
obstetric cholestasis, breech presentation
MCQ
• Amniocentesis…
• Has a higher complication rate than chorionic
villus sampling
• Is a screening test for spina bifida
• Is a diagnostic test for trisomy 21
• Has a miscarriage rate of 1%
• Has has a risk of vertical transmission in HIV
patients
FFTTT
PMQ
Mrs Turvey is a 28 year old woman and attends the
ANC at 36 weeks gestation in her first pregnancy
with a breech presentation
a) What is the definition of presentation in obstetric
practice
b) List three possible reasons for the clinical situation
c) List 2 management options.
d) Name 3 contraindications to ECV.
e) List one fetal complication of breech presentation
PMQ
Mrs Turvey is a 28 year old woman and attends the ANC at 36
weeks gestation in her first pregnancy with a breech
presentation
a) What is the definition of presentation in obstetric practice
The part of the fetus that is at the pelvic inlet/lower pole of the uterus
b) List three possible reasons for the clinical situation
Prematurity, multiple pregnancy, polyhydramnios ,placenta previa, uterine
abnormality
c) List 2 management options.
C/S; ECV; vaginal breech delivery
d) Name 3 contraindications to ECV.
Multiple pregnancy, Antepartum haemorrhage, placenta previa
e) List one fetal complication of breech presentation
Birth trauma- head entrapment, fractures; cord prolapse; fetal distress
Labour Ward
• Pre-eclampsia, sepsis, pulmonary embolus,
• Other common life-threatening conditions e.g.
antepartum & post partum haemorrhage
• Normal and abnormal labour and common
intrapartum problems
• Late pregnancy problems – eg reduced fetal
movement movement, ruptures membranes,
• CTG monitoring
• Caesarean section
PMQ
A 25 yr old G5P4 is admitted at 38 weeks gestation with
sudden onset of painless vaginal bleeding. She lost 400ml
blood. Her P88/min BP= 105/65. On abd. exam- abdomen
is soft , non tender. The fetus is lying transversely and fetal
trace is normal with a baseline of 140bpm.
a) What is most likely diagnosis?
b) Give 4 reasons to support the diagnosis.
c) List 2 other differential diagnosis?
d) What is your immediate management?
e) What investigation will confirm diagnosis?
Labour Ward
A 25 yr old G5P4 is admitted at 38 weeks gestation with sudden onset
of painless vaginal bleeding. She lost 400ml blood. Her P88/min BP=
105/65. On abd. exam- abdomen is soft , non tender. The fetus is lying
transversely and fetal trace is normal with a baseline of 140bpm.
a) What is most likely diagnosis?
b) Give 4 reasons to support the diagnosis.
c) List 2 other differential diagnosis?
d) What is your immediate management?
e) What investigation will confirm diagnosis?
Placenta Previa
Painless bleeding;
Soft abdomen
No fetal compromise
Transverse lie at term
Placental abruption
local cause of bleeding
IV access
bloods-FBC, crossmatch 4 U,
coagulation screen
Fetal monitoring (CTG)
USS for placental localization
PMQ
You are called to see a 25 yr old who is 3 days postnatal and
has developed chest pain. She complains of lower left sided
pain. She is slightly breathless. Her BP= 150/89, pulse=
98/min. She had uncomplicated forceps delivery.
a) What is the most probable diagnosis?
b) What important blood investigation would you perform?
c) What 2 features you would expect this test to show if your
diagnosis was correct?
d) List 3 other investigation you will perform & why?
e)How should she be treated?
f)List 2 pre-pregnancy risk factors.
PMQ
You are called to see a 25 yr old who is 3 days postnatal and has developed chest
pain. She complains of lower left sided pain and breathlessness. Her BP = 150/89,
pulse = 102/min. She had uncomplicated forceps delivery.
a) What is the most probable diagnosis?
PE
b) What important blood investigation would you perform?
ABG
c) What 2 features you would expect this test to show if your diagnosis was
correct?
Pco2-N
po2-low
a) List 3 other investigation you will perform & why?
CXR (excl. chest infection);
ECG - tachycardia, S1Q3T3
V/Q scan or CTPA (to confirm the diagnosis)
a) How should she be treated?
LMWH s/c,
Warfarin (PO)
b) List 2general pre-pregnancy risk factors.
Thrombophillias,
Obesity
Family History
Diabetes in pregnancy
• Pregnancy is a diabetogenic state
• Pre-existing diabetes (type 1 & 2) vs GDM
• Risk factors for developing gestational diabetes: obesity,
PCOS, ethnicity, family history, previous macrosomia,
previous GDM
• Risks for fetus: congenital anomalies (type 1), macrosomia,
IUGR, stillbirth, birth trauma (shoulder dystocia)
• Risks for mother: hypertension, retinopathy (type 1),
nephropathy (type 1)
• Diagnosis of GDM: GTT
• Management: Diet, Metformin, Insulin
Hypertensive disorders
in pregnancy
• Essential hypertension (pre-existing)
• Pregnancy induced hypertension (PIH) - usually late 2nd /3rd trimester)
• Pre-eclampsia (PET): pregnancy induced hypertension with proteinuria
and / or oedema
• Underling pathology: endothelial damage
• Symptoms: headache, epigastric pain, visual disturbances
• Investigations: FBC (platelets), U&E (creatinine), Uric acid, LFT (raised
transaminases), LDH (haemolysis), urinalysis,
• Treatment: deliver the placenta
• Management dilemmas:
• HELLP syndrome: liver haematoma, DIC
• Fluid balance: fluid restrict to 85ml/r (oliguria vs pulmonary oedema)
• Premature fetus – give steroids
• Uncontrollable BP – antihpertensives (stroke)
• Fulminating PET/ eclampsia – MgSO4 (prophylaxis and therapeutic)
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MANAGEMENT in
general:
• Conservative:
• Wait & see (e.g. miscarriage)
• Lifestyle advice: smoking, weight loss, PFE (e.g.
incontinence)
• Medical:
• Drugs
• Surgical:
• Must know indications, risks & complications
SURGERY: indications &
complications
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ERCP (evacuation of retained products of conception)
Laparoscopy: diagnostic vs therapeutic
Laparotomy
Salpingectomy vs salpingostomy
Abdominal hysterectomy
Vaginal hysterectomy
Colposuspension
Tension free vaginal tape
• (retropubic (TVT) or transobturator (TVT-O/TOT)
Drugs you should know:
• Mifepristone: (RU486) antiprogesterone, termination of pregnancy
• Misoprostol: prostaglandin used to prime the cervix and induce
uterine contraction, missed / incomplete miscarriage, uterotonic for
postpartum haemorrhage,
• Methotrexate: folic acid antagonist, medical management
of ectopic pregnancy
• Propess: prostaglandin, used to prime the cervix and induce labour
• Uterotonics: syntocinon, ergometrine, carboprost, misoprostol
• Antihypertensives in pregnancy
• Chemotherapy
• Anti-virals: acyclovir, HAART
CLINICAL CASE
• Obstetric patient
• Some history of note
• Complete history incl:
• gynae (cervical smears, contraception)
• obstetric (previous pregnancies), medical, surgical, social
• medications & allergies
• Obstetric examination:
• General
• BP, Urinalysis
• Ask - Pinard, sonicaid
• Abdominal palpation:
• tender/non-tender
• soft/rigid,
• fundal height, lie, presentation,engagement, FM, FH
Abdominal palpation:
Leopolds manouvers
LAST THOUGHTS…
Think!
Read the question!
Re-read the question!
Be systematic in your approach
and…
GOOD LUCK!