Ivana c and stephen b OBGYN CORE content

disclaimer While this talk is as accurate as we could make it, we are students. Accordingly, there may be errors. Please do not rely on this talk when making clinical decisions. The AMSS and authors of this talk do not accept any responsibility or liability relating to the use of the information.

preparing for OBGYN mid-rotation assessment OBGYN end of rotation assessment End of year written qs and OSCE

outline Approaches to 5 core topics/presentations w specific details about some key ddx

approach to… 28F nulliparous. Presents to GP following positive home pregnancy test. What does pregnancy test measure? Where is marker this produced? How early can it be detected? How quickly does it usually increase? How can you confirm the pregnancy? Refer to PPG: ‘Normal Pregnancy, Labour and Puerperium Management Clinical Guideline’ Refer to PPG: ‘Normal Pregnancy, Labour and Puerperium Management Clinical Guideline’

On further history she has been trying to have a child with her husband for the last 3 months. She missed her last period (LMP 6 weeks ago). What methods can be used to calculate the EDD? What routine screening should be performed at this stage?

She now asks what further screening will be required throughout the pregnancy? Which routine screening is conducted during the: 1st trimester? 2nd trimester? 3rd trimester?

approach to… 34F. G3P2 at 27 wks. Presents to WAS with painless vaginal bleeding for the past 30 minutes. DDx? Immediate mx? Refer to PPG: ‘Antepartum haemorrhage or bleeding in the second half of pregnancy’ Refer to PPG: ‘Antepartum haemorrhage or bleeding in the second half of pregnancy’

The bleeding lasted for 30 minutes but has now stopped The bleeding lasted for 30 minutes but has now stopped. She estimates losing two teaspoons of blood. Obs stable, afebrile. CTG normal. IV access is obtained and initial blood tests sent (including group and hold and blood type). An USS reveals a low lying placenta. What would be required before discharge could be considered? Assuming this episode resolves without further difficulty, how will the pregnancy be managed in the long term based on these USS results?

Refer to PPG: ‘Preeclampsia’ and ‘Eclampsia’ approach to… 31F. G1P0 at 29 wks. Presents for routine check and is found to have BP of 160/95. DDx? What symptoms/signs would distinguish preeclampsia? Refer to PPG: ‘Preeclampsia’ and ‘Eclampsia’ Refer to PPG: ‘Preeclampsia’ and ‘Eclampsia’

BP 4 wks ago was 125/80. Ankle swelling over last 1-2 weeks BP 4 wks ago was 125/80. Ankle swelling over last 1-2 weeks. Denies headache, vision changes, abdo pain, easy bruising/bleeding and seizures. No significant PMHx. Role of urine dipstick at this point? If not dipstick, what other spot urine test? Cutoff point for 24 urine protein collection? What other Ix?

Her spot urine protein:creatinine ratio supports diagnosis of preeclampsia. Mx? Why not ACEI/ARB? What complications may prompt need for immediate delivery?

Approach to… 24F. G1P0. 38 wks gestation. Presents with abdominal cramping pain for 1 hour. How to determine true labour vs. false labour? Refer to PPG: ‘Normal Pregnancy, Labour and Puerperium Management Clinical Guideline’ Refer to PPG: ‘Normal Pregnancy, Labour and Puerperium Management Clinical Guideline’

Pain (contractions) are occurring every 10 minutes Pain (contractions) are occurring every 10 minutes. Cervix is dilated to 2 cm and soft. What are the stages of labour? How long are the different stages? What stage is she in? What rate of cervical dilation expected in each stage? Mx at this time?

4 hours later cervix is at 5cm. Pain is stable. What phase now? Mx? Options for pain mx if was inadequately controlled?

4 hours later PV exam to check progress. What would implication be if was at 5cm on this check? If so, Mx? Cervix is at 10cm. What stage now? What complications may occur in this stage?

2nd stage lasts 30 mins and is without complication 2nd stage lasts 30 mins and is without complication. Cord clamping is delayed and then cut. What medication given to mum after delivery of the anterior shoulder? Why? How would you know when placenta detached and ready to be expelled? How to assist w delivery of placenta? Why?

Placenta is delivered in 25 minutes. What to check on placenta + cord? Why? Immediate assessment + mx of baby (assuming no complications)? Why?

APPROACH TO… 32F. G4. P3. 37 wks gestation. Delivers 3.9 kg Male following 16 hour labour. Required oxytocin for failure to progress. Pregnancy was complicated by gestational DM and polyhydramnios. Nil other PMHx. Following delivery of placenta there is substantial ongoing blood loss. Volume of blood (and timeframe) that defines PPH? Top 4 ddx for PPH? Most common cause? Refer to PPG: ‘Postpartum Haemorrhage’, ‘Secondary Postpartum Haemorrhage’ Refer to PPG: ‘Postpartum Haemorrhage’, ‘Secondary Postpartum Haemorrhage’

Physical examination reveals a soft uterus Physical examination reveals a soft uterus. Inspection reveals intact placenta. Dx? Mx? Dx + causes if bleeding occurred 48 hrs after delivery rather than immediately?

Summary Approach to: Pregnancy “diagnosis” + Routine screening Antepartum haemorrhage (+ placenta praevia) Gestational hypertension + preeclampsia Routine management of labour PPH

sources for further reading PPG = South Australian Perinatal Practice Guidelines, Department of Health, Government of South Australia. Available at: http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+re sources/clinical+topics/perinatal/perinatal+practice+guidelines Callahan T & Caughey A, Blueprints Obstetrics and Gynecology, Lippincott Williams & Wilkins, Sydney. eMedici = http://www.emedici.com Uptodate = http://www.uptodate.com/home

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