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PACES RevisionObstetrics and Gynaecology
Kindly sponsored by:
27/04/2012
AMR !A "A#ER$EE % O&A MAR' E( C)
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Plan for the morning
9-10.30 - Lecture + demonstration station10.30-11.00 - rea! 11.00-1".30 - #oc! P$%&' stations ()*
1".30-13.00 , Lunch
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utline of al!
bs / ynaeistory
&)amination%linical '!ills
2n estigations#anagement4ed 5lags
&thics and La6
%ommon P$%&' 'tations7emonstration 'tationips and $d ice
5urther 4esources
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2' 48
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he istory
!*e +ain ,art o- all PACES stations.. o not co+,ro+ise ont*is
P%P%ynae history bstetric istory
P#7
5''ystems re ie6
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he ynaecological istory
Periods• 7ysmenorrhoea• ligomenorrhoea
• $menorrhoea• #enorrhagia• #ittelschmer
isc*arge
• 'mell• %olour• %onsistency
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he ynaecological istory
!*in abo t se3• %ontraception• P accine
5ave se3• 7yspareunia• Post-coital bleeding
A-ter se3 catc*• ' 2;s• P , smears<• abies
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he ynaecological istory
"oys• 4egular• Protection , pregnancy and ' 2;s• =# clinic isits• Peer pressure• Legal
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he ynaecological istory
Obstetric 5istory 6 don;t forget Ps<
Conse ences o- c*ildbirt*• 'phincter dysfunction• 4ectal> aginal prolapse
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he ynaecological istory
Meno,a se• 'ymptoms• 4• Post menopausal bleeding<• aginal atrophy• 'e) life• ?uality of life
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bstetric istory
P%P%
%urrent Pregnancy @as this a planned pregnancyA&77 - scan or dates (L#PB #enstrual cycle%omplications2n estigations so far
Gravidity , number of times a 6oman has been pregnantB regardless of outcomeParity C (any li e or still birth after "* 6ee!s
S,eci-ic Sy+,to+s
#a sea / 8o+iting 9 if severe known as hyperemesis gravidarum:rinary -re ency 6 pressure on the bladder causes this – rule out UTI !iredness;etal Move+ents 9 usually felt at around 18-2 weeks gestation! earlier in multips
deas< Concerns % E3,ectations=
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bstetric istory
etails o- eac* ,regnancy7ate > 8earPlace of birth
estation
#ode of deli ery "aby , se"! weight! current healthProble+s d ring antenatal< labo r % ,ostnatal'ame PartnerA %onsanguinityA
#iscarriages / erminationsPre ious difficulty concei ing> assisted conceptionPlans for future pregnancies
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bstetric istory
#aternal: 7&$ P7iabetespre-&clampsia $naemia
hrombus
ypertensionPain
leeding2nfection
5etal#o ements'cans>tests
ospital admissions
5or each pregnancyB including the current one ifpregnantB as! about complications:
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bstetric istory %ont.
Past Gynaecological 5istory Contrace,tive se>
&ast Cervical S+ear , 6as the result normalA
Any gynae s rgery- Loop e)cision of transitional one (L& D - risk of cervical incompetence↑- Pre ious myomectomy - risk of uterine rupture #↑ placenta accreta #adhesions
Gynae investigations % treat+ent -or- 2nfertility - &ctopic , ↑ risk of future ectopics- P27 - chlamydia is most common cause – risk of ectopic↑
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he rest of the history
Past Medical 5istory and Past S rgical 5istory
r g 5istory Pregnancy +edication 9 folatesB ironB anti-emeticsB antacids!eratogenic dr gs 6 avoid at all costs - $%&i! 'etinoids! (odium )alproate! *ethotre"ate
O!C r gs - make sure to ask patient about these! to ensure nothing unsafe A&&ERG ES
;a+ily 5istory Medical conditions 9 gestational diabetes
n*erited genetic conditions 6 %+ Pregnancy &oss 9 recurrent miscarriages in mother , sisters
Pre9ecla+,sia 9 in mother or sister – increased risk
Social *istory S+o ing< Alco*ol< r g se&iving Sit ation BRelations*i, Stat sOcc ,ation
Syste+s revie?
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ther 2mportant ?uestions
o6 do her symptoms affect her life
@hat support does she ha e at home , do not
assume she is married<2s there anything else that you are 6orrying aboutA
2s there anything else that you;d li!e to as! meA
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aginal '6abs
Bug Swab Other Treatment
Candidaalbicans
High vaginalswab
Mycelial filaments onmicroscopy
Clotrimazole creamor oral fluconazole
Bacterialvaginosis
High vaginalswab
Whiff test positive cluecells al!aline pH
Metroni"azole orclin"amycin cream
Trichomonasvaginalis
High vaginalswab
Motile flagellate" protozoaon microscopy al!aline pH
Metroni"azole
Chlamydiatrachomatis
#n"ocervicalswab
$ucleic aci" amplificationtests %$&&Ts' eg( )C*
+o,ycycline orazithromycin
Neisseriagonorrhoea
#n"ocervicalswab
-ram negative "iplococci Ceftria,one
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%er ical screening programme
Ai+ : identification of %2E and initiating earlytreatment before the de elopment of cer icalcarcinoma
E a test for cancer< Age range :"F-*9 e ery 3 yearsF0-G* F yearly
G0+ if not screened since F0 or recent abnormal results!ec*ni e : 4otate brush in the e)ternal os to pic!up loose cells o er the D for liHuid based cytology
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%er ical screening programme
%ounselling and e)plaining the process>results>follo6 up<
DYSKARYOSIS:Cytology – smear
CervicalIntraepithelial
neoplasia: Histology - biopsy
anagement
mil! CI"#
Can spontaneo$slyregress
% month &ollo' $p( I&persists then colposcopy
mo!erate CI") Colposcopy * treatment
severe CI"+
Imme!iate colposcopy *
treatment
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2E &' 2 $ 2 E'
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2n estigations
General ti,s
2mportance of obser ations and bedside tests
7o not mention lists of in estigations unless you are able to Iustify 6hy you 6ant them
it the Iac!pot early (but don;t sho6 off
hin! outside the bo) , pregnant 6omen get non-pregnantdiseases
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2n estigations
Gynae :%er ical smears2nterpret hormone le els: 5' B L B 5 ;s
=rodynamics=ltrasound: endometrial thic!ness'urgery: endometrial biopsyB laparoscopyB lap + dye
%ontracepti e methods: 2=7ysteroscopy
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2n estigations
Obstetrics :Pregnancy test (in $+&
lucose olerance est
%ardiotocographsPartogram
Pel ic ='''creening tests $mniocentesis>chorionic illus sampling
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#$E$ &E
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#anagement
@hat e eryone does 6orst on<
on@t -orget4esus +
CO#SER8A! 8EME CA&
S:RG CA&
$nd 8ER importantly
AS' ;OR 5E&P.
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4&7 5L$ '
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4ed 5lags - bstetrics
Condition Sy+,to+s
Placenta ,raevia Painless P bleeding late in pregnancy
Placental abr ,tion Painful P bleeding late in pregnancy
BR ,t red ecto,ic ,regnancy &arly pregnancyB pel ic painB P bleeding +>- faintnessB shoulder-tip pain
Obstetric c*olestasis 2tchy hands and feet during pregnancy
S*o lder dystocia 7elayed deli ery after deli ery of thehead
Cord Prola,se =mbilical cord descends belo6 thepresenting part follo6ing rupture ofmembranes
A+niotic -l id e+bolis+ 7yspnoeaB hypotensionB hypo)iaB
sei uresB heart failure
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4ed 5lags , bstetrics cont.
Condition Sy+,to+s
:terine r ,t re $cuteB se ere pain during labour orB if epiduralBsudden maternal hypotensionB cessation ofcontractionsB fetal hypo)ia
:terine inversion Post-partum haemorrhageB pain and profound
shoc! Pre9ecla+,sia ypertensionB proteinuriaB oedema
Ecla+,sia Pre-eclampsia 6ith 4=? painB headachesB tonicclonic sei uresB blurred ision
PE ' B chest painB hypo)iaB cardiac arrest
8! $cute leg painB rednessB s6ellingB heatB +>-'
Pri+ary and Secondary PP5 Primary J F00 ml of blood loss 6ithin "* hoursof deli ery.
'econdary 9 abnormal or e)cessi e bleeding bet6een "* hours and 1" 6ee!s postnatally.
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4ed 5lags - ynaecology
Condition Sy+,to+s
Ovarian cyst torsion,acci!ent Severe pelvic pain associate" withhypovolaemic shoc!
n!ometrial carcinoma &bnormal uterine blee"ing especially)MB
Ovarian carcinoma $on.specific symptoms of ab"ominal"istension pain abnormal blee"ingweight loss
Cervical carcinoma /MB )CB )MB offensive vaginal"ischarge
.ID )0 "ischarge pelvic pain feverabnormal blee"ing
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% =E'&LL2E
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%ounselling
'hared decision ma!ing#7&mpathy
$cti e listening=se of silence $ oid Iargon2deasB concernsB e)pectations
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%ounselling cont.
%ongenital abnormalities e.g. 7o6nsB urnerssyndrome
%er ical smear results
&ctopic pregnancy #iscarriage%ontraception
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L$@ $E7 & 2%'
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La6 and &thics
& eryone ignores but is ery important<#ost sued specialty &)tremely sensiti e issues: culturalB religiousB personal
2mportant principles:illic! competencehe $bortion $cthe #ental %apacity $ct
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La6 and &thics
& eryone ignores but is ery important<#ost sued specialty &)tremely sensiti e issues: culturalB religiousB personal
2mportant principles:illic! competencehe $bortion $cthe #ental %apacity $ct
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he $bortion $ct
Permits termination of pregnancy by a registeredpractitioner subIect to certain conditions.#ust be performed by registered medical
practitioner in an E ' hospital or 7o appro edlocation (e.g. ritish Pregnancy $d isory 'er ice%linics $n abortion may be appro ed for the follo6ing
reasons:
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$ he continuance of pregnancy 6ould in ol e ris to t*e li-e o- t*e,regnant ?o+an greater than if the pregnancy 6as terminated.
he termination is necessary to ,revent grave ,er+anent inD ry to the physical or mental health of the pregnant 6oman.
% he continuance of the pregnancy 6ould in ol e ris!B greater than ifthe pregnancy 6ere terminatedB of inD ry to t*e ,*ysical or+ental *ealt* of the ,regnant ?o+an .
7 he continuance of the pregnancy 6ould in ol e ris!B greater than ifthe pregnancy 6ere terminatedB of inD ry to t*e ,*ysical or+ental *ealt* of any e3isting c*ildren of the family of thepregnant 6oman
& here is a substantial ris! that i- t*e c*ild ?ere born it 6ouldsuffer from ,*ysical or +ental abnor+alities as to be
serio sly *andica,,ed B or in emergencyB certified by the operatingpractitioners as immediately necessary
5 o save t*e li-e o- a ,regnant ?o+an
o pre ent grave ,er+anent inD ry to t*e ,*ysical or +ental*ealt* of the ,regnant ?o+an .
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he uman 5ertlisation / &mbryology $ct 1990
'ection 3 of the 5&$ made changes to the 19Gabortion act:
ime limit of abortion is "* 6ee!s under statutory
grounds % and 7'tatutory grounds $B and & are no6 6ithout timelimit
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5raser uidelines ( illlic! %ompetence
hose 1G may be prescribed contraception 6ithout parentalconsent if:
hey nderstand the doctor;s ad ice
he young person cannot be ,ers aded to in-or+ t*eir,arents that they are see!ing contracepti e ad ice
hey are li ely to begin or contin e interco rse 6ith or 6ithout contracepti e treatment
=nless the young person recei es contracepti e treatment their ,*ysical or +ental *ealt* is li ely to s --erhe young ,erson@s best interests reHuire that the doctor
gi es ad ice and>or treatment 6ithout parental consent
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& &M$#
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Fth 8ear P$%&'
* domains of mar!ing:
1. %linical s!ills
". 5ormulation of clinicalissues3. 7iscussion of #anagement*. Professionalism andPatient centred approach
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Past stations: bstetrics
1 year old ?anting !OPMissed +iscarriage F s,ec l +Pre9ecla+,sia
8"AC co nselingRec rrent +iscarriages F anti,*os,*oli,id syndro+e5 8 and ,regnancy Bin + lti,le circ itsPE in ,regnancy Bcon- sed a lot o- ,eo,le
Gestational diabeteso?n@s syndro+e screening
S+all -or dates9 yo ng s+o er $lcohol and pregnancy #ultiple pregnancy $bnormal lie and &% %ounseling a patient 6ith molar pregnancy P discharge in pregnancy %ontracepti e ad ice post-pregnancy Pre-term rupture of membranes
yperemesis gra idarum $ntenatal chec!
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Past stations: ynaecology
$bnormal bleeding#enopause $menorrhoea and infertility =nderage>pressured se)
'e)ually transmitted infections=rogynae , incontinenceB self esteem aginal dischargePel ic pain'ubfertility %ontraception
ynae oncology &thics