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O&G REVISION LECTURE 2012 Dr Jacqueline Woodman Consultant Obstetrician & Gynaecologist.

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Presentation on theme: "O&G REVISION LECTURE 2012 Dr Jacqueline Woodman Consultant Obstetrician & Gynaecologist."— Presentation transcript:

1 O&G REVISION LECTURE 2012 Dr Jacqueline Woodman Consultant Obstetrician & Gynaecologist

2 FPE three parts: a short answer written paper multiple choice written paper clinical examination

3 What youll 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

4 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

5 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

6 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

7 GYNAE OPD Menstrual problems / abnormal vaginal bleeding: Amenorrhea (primary & secondary) Menorrhagia Intermenstrual bleeding Post coital bleeding Postmenopausal bleeding

8 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

9 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)

10 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)

11 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

12 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

13 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, Wernickes, thrombosis, Mallory Weiss, weight loss

14 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?

15 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)

16 Urogynaecology

17 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

18 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

19 Community, GUM and contraception Contraception: Indications Contra-indications Menopause and HRT Benefits vs risks GUM infections: HIV, Hepatitis B

20 MCQ Hormone replacement therapy protects postmenopausal women against: a) Osteomalacia b) Coronary artery thrombosis c) Deep venous thrombosis d) Atrophic vaginitis e) Cerebral haemorrhage

21 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

22 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

23 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

24 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

25 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

26 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

27 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?

28 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?Placenta Previa b) Give 4 reasons to support the diagnosis.Painless bleeding; Soft abdomen No fetal compromise Transverse lie at term c) List 2 other differential diagnosis?Placental abruption local cause of bleeding d) What is your immediate management?IV access bloods-FBC, crossmatch 4 U, coagulation screen Fetal monitoring (CTG) e) What investigation will confirm diagnosis?USS for placental localization

29 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.

30 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

31 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

32 Hypertensive disorders in pregnancy Essential hypertension (pre-existing) Pregnancy induced hypertension (PIH) - usually late 2 nd /3 rd 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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36 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

37 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)

38 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

39 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

40 Abdominal palpation: Leopolds manouvers

41 GOOD LUCK! LAST THOUGHTS… Think! Read the question! Re-read the question! Be systematic in your approach and…


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