O&G REVISION LECTURE 2014

1. O&G REVISION LECTURE 2014 Dr Jacqueline Woodman Consultant Obstetrician & Gynaecologist

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

3. 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

4. GYNAECOLOGY: common conditions • Gynae OPD • Menstrual problems • Pelvic pain • Vaginal discharge and infection • Incontinence, prolapse and basic urogynaecology • Gynae emergencies • 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

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 • 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

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 • Urogynaecology: incontinence & prolapse

7. GYNAE OPD • Menstrual problems / abnormal vaginal bleeding – common symptoms • Amenorrhea (primary & secondary) • Menorrhagia • Intermenstrual bleeding • Post coital bleeding • Postmenopausal bleeding

8. 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

9. PMQ example A 23 year old, BMI=32 presents with secondary amenorrhea. • List 3 possible causes of amenorrhea in this case (3) • List 4 investigations you would request (4) • If the patient wishes to conceive without medical intervention what would you advise? (1) • Two years later, she returns and despite conservative measures she has not conceived, what further investigation would you offer the couple? (2)

10. PMQ example A 23 year old, BMI=35 presents with secondary amenorrhea. a) List 3 possible causes of amenorrhea in this case (3) Pregnancy, PCOS, endocrine (thyroid, premature menopause), prolactinoma b) List 4 initial investigations you would request on this patient (4) FSH, LH, Testosterone, sHBG, FAI, urine bHCG, TVS 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)

11. 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)

12. 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) Endometrial cancer b) What investigation does she need to definitively exclude this diagnosis (2) Hysteroscopy and endometrial biopsy (gold standard) 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? (1) Mirena IUS e) If medical treatment fails, what surgical option could you discuss with her? (1) Endometrial ablation / hysterectomy 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? (2) LMWH (clexane / enoxaparin / tinzaparin)

13. 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

14. 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

15. 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

16. 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. • What are your two most likely differential diagnosis? (2) • List 5 investigations that you need request in this patient (5) • What treatment options are available for each of your differential diagnosis? (3)

17. 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. • What are your likely diagnosis? Ectopic pregnancy; miscarriage • List 5 investigations FBC, G&S, serum βhCG, serum progesterone & pelvic USS • What treatment options are available for your diagnosis? • Ectopic – Medical (MTX), Surgical (salpingectomy) • Miscarriage - expectant, medical (misoprostol), surgical (ERPC)

18. Urogynaecology

19. 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

20. MCQ • The following is a recognized treatment of urinary stress incontinence: • a) Vaginal hysterectomy • b) Insertion of a ring pessary • c) Posterior colpoperrineoraphy • d) Transobturator transvaginal tape • e) Amitriptyline FFFTF

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

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

23. 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

24. CLINICAL CASE • Obstetric / gynaecology patient • Some history of note • Complete history incl: • 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: • tender/non-tender • soft/rigid, • fundal height, lie, presentation,engagement, • FM, FH

25. Abdominal palpation: Leopolds manouvers

26. 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

27. 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

28. 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 • What is the definition of presentation in obstetric practice • List three possible reasons for the clinical situation • List 2 management options. • Name 3 contraindications to ECV. • List one fetal complication of breech presentation

29. 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

30. 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

31. 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. • What is most likely diagnosis? • Give 4 reasons to support the diagnosis. • List 2 other differential diagnosis? • What is your immediate management? • What investigation will confirm diagnosis?

32. 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. • 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

33. 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

34. 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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38. 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

39. SURGERY: indications & complications • ERCP (evacuation of retained products of conception) / surgical management of miscarriage • 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)

40. 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

41. LAST THOUGHTS… • Read the question! • Think! • Be systematic in your approach • Engage with the patient • and… GOOD LUCK!