Transcript Revision Lecture March 2014

O&G REVISION LECTURE
2014
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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•
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Menstrual problems
Pelvic pain
Vaginal discharge and infection
Incontinence, prolapse and basic
urogynaecology
• Gynae emergencies
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•
•
•
Miscarriage
ectopic pregnancy
Hyperemesis gravidarum
Gestational trophoblastic disease
• 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
• Diabetes / hypertension in pregnancy
• Screening in pregnancy
• Fetal growth problems: SGA, LGA
• Other common antenatal problems e.g. obstetric cholestasis
•
Labour Ward
• Pre-eclampsia, sepsis
• Other common life-threatening conditions e.g. pulmonary embolus
• Normal labour and common intrapartum problems
• Late pregnancy problems – e.g. reduced fetal movement, prolonged
rupture of membranes, IOL, post maturity
• CTG monitoring, Abnormal labour, Caesarean section
•
Puerperium
• Normal and abnormal puerperium
• Post natal depression
• Breast feeding
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
• Urogynaecology: incontinence & prolapse
GYNAE OPD
• Menstrual problems / abnormal vaginal
bleeding – common symptoms
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•
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Amenorrhea (primary & secondary)
Menorrhagia
Intermenstrual bleeding
Post coital bleeding
Postmenopausal bleeding
Menstrual problems and
abnormal vaginal bleeding:
• symptomatology
• 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 23 year old, BMI=32 presents with secondary
amenorrhea.
a) List 3 possible causes of amenorrhea in this case
(3)
b) List 4 investigations you would request
(4)
c) If the patient wishes to conceive without medical intervention
what would you advise?
(1)
d)Two years later, she returns and despite conservative measures
she has not conceived, what further investigation would you offer
the couple?
(2)
PMQ example
A 23 year old, BMI=35 presents with secondary amenorrhea.
a) List 3 possible causes of amenorrhea in this case
Pregnancy, PCOS, endocrine (thyroid, premature menopause), prolactinoma
(3)
b) List 4 initial investigations you would request on this patient
FSH, LH, Testosterone, sHBG, FAI, urine bHCG, TVS
(4)
c) If the patient wishes to conceive without medical intervention what would you advise?
(1)
weight loss
d) Two years later, she returns and despite conservative measures she has not conceived,
what further investigation would you offer the couple
(2)
Semen analysis, tubal patency tests (HSG, Saline ultrasonography, Lap & dye)
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.
a) What pathology must be excluded in this patient?
(1)
b) What investigation does she need to definitively exclude this diagnosis
(2)
c) A diagnosis of 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) If medical treatment fails, what surgical option could you discuss with her?
(1)
f) Name 2 risks or complications specific to the surgical treatment you have discussed
with her.
(2)
g) Name 1 routine mandatory post-op medication that you would prescribe for her
during her hospital stay?
(2)
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.
a) What pathology must be excluded in this patient?
Endometrial cancer
(1)
b) What investigation does she need to definitively exclude this diagnosis
Hysteroscopy and endometrial biopsy (gold standard)
(2)
c) A diagnosis of endometrial hyperplasia is made. What risk factor does she have that predisposes
her to this condition?
(1)
Obesity
d) What non-surgical treatment would you advise to treat her symptoms?
Mirena IUS
(1)
e) If medical treatment fails, what surgical option could you discuss with her?
Endometrial ablation / hysterectomy
(1)
f) Name 2 risks or complications specific to the surgical treatment you have discussed with her. (2)
Endometrial ablation – perforation uterus
TAH – damage bladder / bowel/ureter
g) Name 1 routine mandatory post-op medication that you would prescribe for her during her
hospital stay?
LMWH (clexane / enoxaparin / tinzaparin)
(2)
MCQ
• The following characteristically cause heavy
regular menses:
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•
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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:
• 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) HPV (human papiloma virus) triage has reduced the
number of invasive treatments for low grade lesions
• e) Hysterectomy is the first of 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?
(2)
b) List 5 investigations that you need request in this patient (5)
c) What treatment options are available for each of your differential
diagnosis?
(3)
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, serum 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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•
•
•
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a) Vaginal hysterectomy
b) Insertion of a ring pessary
c) Posterior colpoperrineoraphy
d) Transobturator transvaginal tape
e) Amitriptyline
FFFTF
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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•
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a) Osteomalacia
b) Coronary artery thrombosis
c) Deep venous thrombosis
d) Atrophic vaginitis
e) Cerebral haemorrhage
FFFTF
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 irregular
vaginal spotting in the first 6 months of use
e) Laparoscopic sterilisation of the female has a higher failure rate than
vasectomy in the male
FFTTT
CLINICAL CASE
• Obstetric / gynaecology patient
• Some history of note
• Complete history incl:
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gynae (cervical smears, contraception, menstrual history)
obstetric (previous pregnancies: gestations, MOD, BW, A&W)
medical, surgical, social
medications & allergies
• Obstetric examination: 4 manoevres
• General
• BP, Urinalysis
• Ask - Pinard, sonicaid
• Abdominal palpation:
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tender/non-tender
soft/rigid,
fundal height, lie, presentation,engagement,
FM, FH
Abdominal palpation:
Leopolds manouvers
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 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 singleton 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 this clinical situation in this patient
Prematurity, polyhydramnios , placenta previa, uterine abnormality, fetal
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 vaginal delivery
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
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/erbs/klumpke palsy)
• 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
• Underlying 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 / non-surgical:
• Drugs (e.g. Mirena)
• Pessaries
• Surgical:
• Must know indications, risks & complications
SURGERY: indications &
complications
• ERCP (evacuation of retained products of conception) /
surgical management of miscarriage
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Laparoscopy: diagnostic vs therapeutic
Laparotomy: phannelstiel or midline
Salpingectomy vs salpingostomy
Abdominal vs Vaginal hysterectomy
Colposuspension
Tension free vaginal tape
• (retropubic (TVT) or transobturator (TVT-O/TOT)
Drugs you should know:
•
Mifepristone: (RU486) antiprogesterone,
•
•
Uses: termination of pregnancy / missed miscarriage and IOL for stillbirths
Misoprostol: prostaglandin (prime the cervix and induce uterine contraction)
• missed / incomplete miscarriage, uterotonic for postpartum haemorrhage,
•
Methotrexate: folic acid antagonist,
• Uses: medical management of ectopic pregnancy
•
Propess: prostaglandin,
• Uses: prime the cervix and induce labour
•
Uterotonics: syntocinon, ergometrine, carboprost (Haemabate), misoprostol
• Uses: postpartum haemorrhage
•
Antihypertensives in pregnancy:
• methyldopa, b-blockers (labetolol), Ca channel blockers (Nifedipine)
•
Anti-virals:
• acyclovir, HAART, zidovudine
LAST THOUGHTS…
Read the question!
Think!
Be systematic in your approach
Engage with the patient
and…
GOOD LUCK!