O&G REVISION LECTURE 2012

Dr Jacqueline WoodmanConsultant 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• 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

• 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, 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• 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:

• 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:

• 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) 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 emergenciesMiscarriage:

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

PMQAn 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 patientc) What treatment options are available for each of your differential diagnosis?

PMQAn 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 investigationsFBC, 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:• 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:

• 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

PMQMrs Turvey is a 28 year old woman and attends the ANC at 36 weeks gestation in her first pregnancy with a breech presentationa) 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

PMQA 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 WardA 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? Placenta Previab) Give 4 reasons to support the diagnosis. Painless bleeding;

Soft abdomen No fetal compromiseTransverse lie at term

c) List 2 other differential diagnosis? Placental abruptionlocal cause of bleeding

d) What is your immediate management? IV accessbloods-FBC, crossmatch 4 U, coagulation screenFetal monitoring (CTG)

e) What investigation will confirm diagnosis? USS for placental localization

PMQYou 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.

PMQYou 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? PEb) What important blood investigation would you perform? ABGc) What 2 features you would expect this test to show if your diagnosis was correct? Pco2-N

po2-lowa) List 3 other investigation you will perform & why?

CXR (excl. chest infection); ECG - tachycardia, S1Q3T3V/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)

1

23

45

6

7

8

910

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• 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

GOOD LUCK!

LAST THOUGHTS…

Think!Read the question!Re-read the question!Be systematic in your approach

and…