O&G REVISION LECTURE 2012

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 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 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. • List 3 most likely causes of primary amenorrhea in this case (3) • List 4 investigations you would request (4) • If all investigations are normal, what would you advise? (2) • 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. • What pathology must be excluded in this patient? (1) • What investigation does she need to definitively exclude this diagnosis (1) • A diagnosis of benign endometrial hyperplasia is made. What risk factor does she have that predisposes her to this condition? (1) • What non-surgical treatment would you advise to treat her symptoms? (1) • She returns after 2 yearswith a 3 month history of heavy vaginal bleeding despite your treatment. What 2 surgical treatment options would you discuss? (2) • Name 1 risks or complications specific to each of the surgical treatments you have discussed with her. (2) • 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, Wernicke’s, 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. • What are your two most likely differential diagnosis? • List 5 investigations that you need request in this patient • 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. • What are your likely diagnosis? Ectopic pregnancy; miscarriage • List 5 investigations FBC, G&S, βhCG, serum progesterone & pelvic USS • What treatment options are available for your diagnosis? • Ectopic – Medical (MTX), Surgical (salpingectomy) • 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 • 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

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; fetaldistress

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. • 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?

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. • 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. • What is the most probable diagnosis? • What important blood investigation would you perform? • What 2 features you would expect this test to show if your diagnosis was correct? • List 3 other investigation you will perform & why? • How should she be treated? • 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. • What is the most probable diagnosis? PE • What important blood investigation would you perform? ABG • What 2 features you would expect this test to show if your diagnosis was correct? Pco2-N po2-low • List 3 other investigation you will perform & why? CXR(excl. chest infection); ECG - tachycardia, S1Q3T3 V/Q scan or CTPA (to confirm the diagnosis) • How should she be treated? LMWH s/c, Warfarin (PO) • 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 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)

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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 vssalpingostomy • 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: Leopoldsmanouvers

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