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History
OBSTETRICS - I understand that you’re here because you wanted to
discuss about home delivery. Are you pregnant at this
PRE-PREGNANCY AND PREGNANCY COUNSELING stage? When was your LMP? How did you confirm
pregnancy? How were your periods before? Did you
Unplanned Pregnancy see any doctor until now? Did you take any folic acid?
Do you have any history of hypertension, epilepsy,
Case: Jenny is 32-years-old and has attended your surgery for diabetes or asthma? Any past history of admissions?
routine checks for the past 3 years. She was last seen 6 months Do you know about your blood group? Were you ever
ago for pap smear which was normal. At the time of the last infected with Rubella? Is this is a planned pregnancy?
consultation, the BP was 130/70 and breast examination was SADMA? Social history? Do you have enough
normal. CVS and respiratory examination were normal. Jenny is support? Financial problems? Do you have other
married and has 2 sons, 10 and 8. kids? How far do you live from the hospital? FHx?

Patient Profile Physical Examination


- Name: Jenny Smith - General appearance
- DOB: 10/04/74 - Vital signs
- No allergy - Neck and breast
- Occupation: Nursing home receptionist - Chest and Lungs
- Family history: Nil - Abdomen
- Medication: Nil - Pelvic
- PMHx: antidepressant given for 2 months at the age - Urine dipstick, BSL and urine PT
of 20 years old; contraception: partner has vasectomy
2004 Management
- I appreciate your concern. Before we discuss options
Task about home delivery, I would recommend for you to
a History have regular antenatal care which is very important for
b Physical examination (BMI 24, PT +, urine dipstick you and your baby. As part of the routine, we will start
negative, BP with blood tests: FBE, Iron studies, blood group and
c Discuss essential issues with patient and Rh, TORCH, HIV, hepatitis B, syphilis, Pap smear if
management due, urine MCS, and BSL. At 18 weeks we will
organize an ultrasound to check the placenta and
History presence of abnormalities of fetus. Around 26-28
- Abdominal pain? SORTSARA? Reflux symptoms? weeks we will organize a sweet drink test for diabetes
N/V? change in bowel movements or urine? Vaginal mellitus and at 36 weeks we will do a swab to detect a
discharge? bug in the vagina. I would like to review you monthly
- Symptoms of depression? Symptoms of STD up to 28 weeks then every 2 weeks from 28 weeks up
(nocturia, pain, weight loss, unexplained fever) to 36 weeks then weekly until delivery.
- You would like to have a home delivery. It is a good
Physical examination idea because you will have your family members and
- General appearance would be more comfortable for you. Usually, there is a
- Vital signs 20-30% more chance of problems encountered during
- ENT: the first pregnancy and labor. During pregnancy, there
- Chest and lungs might be an increased risk of having increased blood
- Cardiac pressure, diabetes, antepartum bleeding, decreased
- Abdomen fetal movements of the baby, and chance of twin
- PV pregnancy. All these things are potentially risky and
- Urine dipstick and BSL can carry bad outcomes. That is the reason we are
doing antenatal care to pick them up early and
Management minimize the risk. Even with normal antenatal course,
- Offering appropriate treatment for nausea there are some unpredictable complications at the
- Medications, rest and fluids time of labor such as fetal distress,
- Explore patient’s attititude towards the situation intrapartum/postpartum hemorrhage, obstructed labor,
- Ensure support is available cord prolapse, shoulder dystocia, meconium
- Offer support aspiration, and such complications need urgent
- Followup management hospital setting with all medical staff and appropriate
- Plans for blood test and STD screening in the future equipments present. If you don’t like hospitals, there
are birth centers or family birthing suites or units which
Home Delivery are small and home-like, but they have midwife and
specialist if required. I would recommend you to have
Case: Your next patient in GP practice is a 24-year-old lady who a safe delivery at the hospital, but at the end, it is your
would like to discuss option of home delivery. choice. If you still want to go for home delivery, I would
advise you to stay near the hospital especially towards
Task the end of pregnancy. You must have ambulance
a. Relevant history (LMP 3months ago, confirmed by cover in case it is required and there should be
home PT) enough support at home. We will do regular antenatal
b. Examination findings care and if there are problems during the course of
c. Investigation and Management your pregnancy, then it is not recommended.
- Reading materials. Review.

Pregnancy Counselling Regarding Timing Of Admission


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- Arrange for followup with MW and may arrange for


Case: G1P0 female at 24 weeks AOG asking when to go to specialist consultation if requested
hospital for delivery
Pre-pregnancy counseling regarding a patient with epilepsy
Tasks:
a. Focused history Case: 26-year-old female presented in your GP who’s known to
b. Answer patient’s questions be epileptic and is treated by sodium valproate. Over the last 2
c. Counsel accordingly years, she had not fits and now in your GP clinic, asking for an
advice for her chances and preparation to be pregnant.
Focused History:
- Congratulate patient as it is her first pregnancy Task
- Informed consent a. Counsel patient (include risks)
- How is the pregnancy? Any problems?
- Any previous miscarriages (if yes: details on why, History:
when, AOG) - When were you diagnosed? When was the last fit?
- Is this a planned pregnancy? Description of fit (tongue bite, loss of consciousness,
- Regular antenatal checkups? wetting of clothes, pre-warning signs-aura), any
- Workups: blood tests? USD? – results? known triggers (alcohol, excessive effort, drugs?)
- PMHx: infections (esp TORCH), DM, HPN when was the last assessment by her neurologist?
- BLOOD GROUP Any known complications? Any hospital admission? All
- Location: how far do you live from the hospital? In current and previous medications used and if any
emergency cases, can anyone drive you to the complications? Any previous investigations (CT/EEG
hospital? Do you have relatives? Who do you live with and drug serum level)
at home? - Menstrual history: date of 1st period (menarche)?
- P/SHx: smoker? Alcoholic beverage drinker? Regularity of period? Description of cycle/period (no.
Recreational drug use? of days of cycle? Days of period) any painful period?
- Any medications being taken? Allergies? Any heavy bleeding or clots?
- Last pap smear? - Sexual history: are you sexually active? In a stable
- Gardasil vaccination relationship? Any contraception used? Any known
previous STIs?
Counselling: - Antenatal history: details of any previous
- Timing of delivery varies among women. Generally, at pregnancies? Any previous miscarriages?
40 weeks, women experience backache, tummy pain, - PMHx: any other associated systemic illnesses? DM?
and passage of mixture of water and blood from Hypertension?
vagina - Social hx: family hx? SMADMA? Previous pap smear?
- Labor pains result from strong uterine contractions Gardasil vaccination (14-26)? Blood group?
similar to period pain and are usually intermittent,
initially after 20-45 minutes  over a period of several Counselling tips:
hours grows stronger and lasts longer  time to go to - Remember to be positive!
the hospital and MW will measure the time for the pain - Tell criteria to be eligible for pregnancy
- Sometimes towards the end of pregnancy there are o For DM: HbA1c <7 for last 3 months
UC that give a feeling of false pain and it is important o Epilepsy: free of fit for 2 years
to recognize the pattern of labor pain o SLE: no active disease for the last 6 months
- If you develop serious symptoms (bleeding, passing of o DVT/PE: thrombophilia screen negative
blood clots, reduced fetal movements, or trauma)  - Mention fetomaternal risks associated with pregnancy!
report to the hospital ASAP - The management should be by multi-disciplinary
- Sometimes PIH can occur during 2nd and 3rd trimester. approach.
Sx are headache, visual problems, swelling  check - Are you alone? Would you like someone to be with
BP urgently and treat rising BP to prevent any us?
complications
- Duration of labor is not predictable because it Counselling
depends on several factors: - Although the outcome is successful for more than
o Size of the baby 90% of epileptic women to be pregnant, there is
o Position of the baby increased risk of fetomaternal risks during pregnancy.
o Age of the female - For the mother, there is increased risk of vaginal
o Size of maternal pelvis bleeding especially at the 3rd trimester, relapse of
o Any form of comorbid illness seizures more towards 3rd trimester and during labor.
o Usually: <12 hours for multiparous and 16- In 3rd trimester, level of absorption of medications is
18 hours for primipara reduced hence, there are higher chances of relapse
- Reassurance of support and pain relief throughout and bleeding.
duration of labor by the MW, MDs and nurses - For the baby, there is a risk of cleft lip, NTD, PTL, low
- Advise on regular antenatal checkups birth weight
o Monthly up to 28 weeks - But, you fit the criteria to be pregnant having no fits for
o Fortnightly from 28-36 weeks the last 2 years.
o Weekly >36 weeks until delivery - The management should be by multi-disciplinary
approach. I will refer you to a neurologist for review
o Check BSL (OGTT) at 28 weeks AOG,
and an obstetrician. I will also arrange for referral to a
vaginal swab to check for GBS at 34 weeks)
high risk pregnancy clinic in a tertiary hospital to look
– important to predict a spontaneous and
after you. The neurologist will review your medication
normal labor
as I don’t think sodium valproate is the best
- Give reading materials and write a script for vitamins
medication for you during pregnancy. I believe
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carbamazepine is less risky. Meanwhile, I will refer We will start you on LMWH on the 14th week of
you to an obstetrician to make sure everything is gestation as a prophylactic measure until 6 weeks
alright and he will follow you up during pregnancy as post delivery.
well. - It’s advised to wear elastic compression stockings
- All antenatal checkup tests will be done before during the day and avoid immobilization
pregnancy. - Labor will be in a controlled manner at 38-39 weeks.
- We will start you with 5mg of folic acid from 1st visit On the planned date, we will withhold the morning
attempting pregnancy (3 months before pregnancy up dose of heparin. After labor, warfarin would be given
to 1st trimester). for 6 weeks (safe in breastfeeding) and we will monitor
- Vitamin K to prevent bleeding especially 26th week INR everyday to begin with (INR 2-3).
onwards - If thrombophilia screen is positive: lifelong warfarin
- Post-delivery mother should nurse baby on the floor
surrounded by cushions. Breastfeeding is okay. Baby Critical issues: failure to do thrombophilia screen; failure to
will not be epileptic. Familial tendency doesn’t advise LMWH during pregnancy; and failure to advise about
increase. warfarin use in pregnancy
- Review of anti-epileptic medications will be done by
neurologist after delivery. Pre-Pregnancy Counseling of Obese Women
- High-risk pregnancy: combined 1st trimester screen
(blood plus usg looking for nuchal translucency and Case: You are a GP and a 30-year-old female came in because
nasal bone); if not high risk: 18-21 and 28-34 weeks she has been trying to conceive for the last 12 months. She
- All should deliver in tertiary hospital and shall have wants your advice on that matter. Height 1.5m, BMI 40, BP
planned labor when they have completed 37 weeks. Normal, BSL Normal

Pre-pegnancy DVT Counseling Task


a. History not more than 3 minutes (periods irregular, 5-6
Case: Your next patient is a 28-year-old woman. Her last weeks pain, stable partners, pap smear 1 year ago,
pregnancy was 18 months ago which was complicated by DVT junk food, no exercise)
and postpartum pulmonary embolism. She has come to see you b. Counsel regarding
for pre-pregnancy counseling. She has stopped warfarin 12 c. Advise Accordingly
months ago. There are no abnormalities on PE. She is not
overweight. Infertility
- >12 mos: investigation
Task - >24 months: infertile
a. Take relevant history (NSVD, episiotomy scar and
baby was normal; did not breastfeed; DVT happened History
postpartum and treated with warfarin x 6 mos) - I can see that you have been trying to conceive. Is
b. Management there anything in particular that concerns you? Do you
think you might be pregnant now? N/V/mood
History changes? Irritability? Breast tenderness?
- How was the previous pregnancy? When did the DVT - May I ask if you and your partner are aware of optimal
happen and how was it treated? Have you had any time for sexual activities? What contraceptives were
clotting episodes other than that? Do you have any you using before? How are your periods? Regular?
calf pains? Shortness of breath? Recent long Cycle? Any abdominal pain? Bleeding heavy?
immobilization? Any other bleeding problems (in the - Obstetric history: ever been pregnant? Miscarriages
family)? before?
- Contraception? Periods? Are they longer? Do you - I understand you are in a stable relationship. Any
bleed heavily during your periods? Blood group? history of STI in yourself or your partner? PMHx or
- Rubella status (vaccinate and avoid pregnancy for 3 Surgical conditions especially gynecologic surgery?
mos)? Thyroid problems? PCOS?
- FHx of bleeding disorders? - FHx: infertility? Gyne problems? Recurrent
- SADMA? miscarriages? Any pregnancy-related problems (CPD,
difficult delivery)
Management - Have you noticed any recent changes to weight? Hair
- Since you had a previous history of clotting during growth, acne? How is your appetite? Water work?
your first pregnancy, you have a high risk of having Bowel habits? How is your sleep?
another one. Pregnancy itself is a hypercoagulable - SADM (pills, steroid, anti-psychotic) A?
state because of the physiological and hormonal - I can see from your notes that your BMI is a bit high.
changes. Your pregnancy will be monitored by a Has it always been like this or is this a new change?
physican and obstetrician and GP. Anybody in family overweight?
- Before you get pregnant I would like to do some tests - Have you ever had BP, BSL, lipid level checked?
to exclude a group of disorders that can predispose to What was the result? Have you have ever had joint
clotting. This is known as thrombophilia screening. problem? How do you feel about your weight? How
There are 7 things in this screening: Protein C & S, does your weight affect your life?
factor V Leiden, antithrombin III, anticardiolipin,
antiphospholipid antibodies and anti-lupus Diagnosis
anticoagulant - First of all, it is very good that you have come for
- Rubella vaccination if not yet immunized some advice before falling pregnant. Apparently,
- Start taking folic acid 0.5mg OD 3 months before everything seems normal except your weight. The BMI
pregnancy and up to first trimester of pregnancy is an indicator of your healthy weight. The normal is
- During pregnancy, you would be managed by a team. between 18-24. If >35 it is morbid obesity that puts the
patient at a very high risk of developing obesity-
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related problems (heart disease, hypertension, stroke,


joint problems, DM, stress or depression).
- I can see that you are already worried about your Task
weight. The obesity affects out health generally as a. Counsel the patient (steroids but no longer taking it
well as related to pregnancy especially. Obese because she is symptom-free)
females have higher chance of developing menstrual b. Answer her questions
irregularities, problems with ovulation that can
sometimes lead to infertility. According to a study, SLE in Pregnancy
around 40% of obese females have problems - Does not seem to cause exacerbations of SLE
conceiving. Hence, it is very important for you to start - Can adversely affect pregnancy according to disease
losing weight now. severity
o Set a goal: 5-10% of BW in 6-12 mos - Complications:
o Make dietary changes – refer to dietitian o Increased incidence of spontaneous
o Increase energy expenditure by exercising abortions and stillbirth  related to lupus
regularly. I will give you some written anticoagulant and anticardiolipin antibodies
material regarding exercise o Preeclampsia
o Please keep a diary of your diet and weight o Prematurity
o Come for regular followup o IUGR
- I want you to be aware of certain obesity-related o Perital mortality
complications during your pregnancy, during labor and - Neonatal lupus syndrome: blood disorders and
afterwards. cardiac abnormalities in neonate
- During pregnancy, you are at risk of developing: - Increased maternal morbidity – kidney complications
o GDM and pre-eclampsia
o Pegnancy-induced hypertension - Management
o Sleep apnea o Preconception counseling  symptom free
o Problems with baby’s growth and for 6 months
development (IUGR is common). o Refer for review of drugs
- We will check your BSL at 26 weeks and regularly at o Corticosteroids
each visit. You will have regular ultrasound to check o Low-dose aspirin
growth of baby. Your antenatal visits will be more o Tests: lupus antibodies, APTI, FBE, RFTs,
frequent than other females. At 28-34 weeks, we will ultrasound
send you to specialist for anesthetic assessment o LMWH
because rate of CS is higher in obese females. We o Timed delivery
want to be prepared for that.
- During labor obese females have higher risk of Questions:
developing: - Can I become pregnant like other females?
o Shoulder dystocia - What are the risks for my baby?
o Non-progress of labor - How will my SLE be affected by pregnancy?
o Obstructive labor - Do I need some special medications during
o CS and its complication pregnancy?
o More difficult to monitor HR and activity (fat
obstructs signals) History
o Pain relief might be more difficult (more - When was it diagnosed? What symptoms did you
adipose, more unequal distribution) have? What treatment was given? For how long? Did
- What we will do is a planned delivery in a controlled you have any side effects from these medications?
environment under close monitoring by the specialist How many relapses have you had during the past 5
obstetrician. A normal vaginal delivery is encouraged years? Have you had regular checkups with
as much as possible, however, they will be prepared specialist? When was your last checkup? When was
for CS the last blood test done? At the moment do you have
- After labor, there is a higher risk for you to develop: any symptoms like skin rash, joint pain, problems with
o Wound infection waterworks? Are you on any medications at the
o Clotting problems moment? Which one and what dose (prednisolone
o Postnatal depression (more common) 5mg)?
- We will give you some meds to prevent clotting. You - When was your LMP? How are your cycles? Are they
will be encouraged to breastfeed child that helps you regular? How many days of bleeding? How many
to lose weight and to develop good bond with baby. days apart? Are you on any contraception at the
Come back after delivery and get wound checked. moment? Is this your first pregnancy? Any
Please be aware that elective CS is preferred because miscarriages before? How’s your general health? Any
it is hard to do emergency cesarean sections since it other medical conditions? Any FHx or SLE or
is difficult to move patient. It is more difficult to give recurrent miscarriages? When was your last pap
epidural anesthesia to predict effects of medication. smear? What is your blood group? SADMA?
Please bring your partner next time to discuss further
complications. Counseling
- Reading material - As you already know, SLE is an auto-immune disease
- Review which means that the body’s defense mechanism
becomes active against its own tissues. There is
Pre-pregnancy counseling of SLE usually inflammation of different tissues of the body
especially the skin, kidneys, and joints. The exact
Case: You are a GP and your next patient is a 24-year-old cause is still not known but certain genes and viruses
patient who is a diagnosed case of SLE for 5 years. She wants have been implicated as stimulants. It is very common
to become pregnant and is seeking your advice. in females of childbearing age (20-45).
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contraception are using? Any history of STI in yourself


or partner? Any other medical or surgical conditions?

- SLE unfortunately cannot be cured, but it can be very


well controlled with medications to prevent flare-ups. Any surgical/PM conditions? SADMA? What is your
The good news is that majority of females with SLE blood group? What is your partner’s blood group?
are able to have kids. It is important that they should Was the previous pregnancy with the same partner as
be symptom-free for at least 6 months before now? Did you receive any anti-D injections at that
conception. time? Any history of rubella infection before? Were
- There are certain risks associated with SLE: you tested for rubella? When was your last pap
o 40% have exacerbations/flare-ups however smear? What was the result? Are you vaccinated with
10% have remissions gardasil?
o Maternal risks: 20% develop pre-eclampsia,
2nd or 3rd (25%) miscarriages, Management
o Fetal risks: IUGR, prematurity (50%) - From the history the only problem that I noticed is that
o Lupus-like syndrome at time of delivery (5%) you have a blood group that might carry some
 rash and abnormalities of blood cell problems for you and your baby in the future. Let me
counts. This lupus like syndrome is not SLE. explain to you about blood groups. Usually in our
This is a temporary response in the baby blood, there are blood cells that carry oxygen to the
because of transplacental transmission of body. These cells carry proteins in the surface which
antiphospholipid antibodies from the mom to are named as A, B, O, AB as well as another factor
the baby. It usually resolves within the 1st 4 known as Rhesus factor (+ or -). The blood type is
weeks; determined depending upon the presence or absence
o congenital heart blocks: quite rare; only 2% of these proteins. Around 85% of the population is
positive for rhesus factor. The rest are negative. This
of pregnancies are complicated by this
is important if your partner is carrying it in his blood.
- SLE: small-vessel vasculitis which also deposits in the
There is a 50% chance that your baby will be Rh+.
placenta and small clots within the placenta  IUGR,
Sometimes, the baby’s blood cells cross the placenta
prematurity, death
either during pregnancy, miscarriage, with trauma, or
- We will consider this pregnancy to be a high-risk
even without any cause. In that case, the mother’s
pregnancy. You will be managed by the specialist
immune system produces antibodies against the
throughout the pregnancy. They will decide upon the
baby’s cells. This phenomenon is known as
best medications for you during pregnancy. Usually,
isoimmunization. If the mother does not receive any
steroids are safe but dose of steroids will be
anti-D injections and she becomes pregnant again,
managed. Sometimes, azathioprine may be used. All
there is a very high chance that these circulating
other cytotoxic drugs as we know are contraindicated.
antibodies reach the baby causing: hydrops fetalis,
- We will do some blood tests and ultrasounds before
hemolytic disease of the newborn, neonatal hemolytic
pregnancy and continue close monitoring throughout
anemia. This results from breakdown of the baby’s
your pregnancy. To prevent the risk of clotting
blood cells. The end result of the blood cell
problems or thrombophilia, the specialist might start
metabolism is bilirubin which can be checked within
you on ASA or LMWH that you will need to continue
the amniotic fluid to check the degree of hemolysis. At
after delivery (especially if anticardiolipin is positive).
the moment, what we can do is to do regular antenatal
- The mode of delivery and timing will be best decided
tests including your blood group and your partner’s
by the specialist according to the baby’s condition. If
blood group.
they have any problems with his growth, they might
- You need to start taking folic acid 0.5mg OD from now
intervene earlier.
onward. Once you become pregnant, at around 20
- I am going to write some blood tests for you: FBE,
weeks of gestation, we will do a test that is called
UEC, Blood group, rubella antibody status,
amniocentesis to check the level of bilirubin. If
anticardiolipin antibody, complete thrombophilia
required, we will give you Rhogam or anti-D
screen.
immunoglobulin, an injection to neutralize the
- Refer to obstetrician.
antibodies. We will also test your blood for the level of
- Reading material
antibodies to Rh group and titer. If titer goes beyond
- SLE association of Australia
1:8, we will do amniocentesis earlier, further followup
testing and anti-D injections.
RH-isoimmunization Counseling o Kleihauer test: determine how much
Rhogam is required. Tries to find out how
Case: You are a GP and a 25-year-old female comes to your
many fetal RBCs are present within the
clinic. She had a miscarriage 2 years ago and she wants to
mother’s blood.
become pregnant again.
o Coombs test/antiglobulin test: done to check
Task the level of antibody in mother’s blood.
a. History  Direct (checks the antibodies that
b. Relevant management are bound to RBC)
 Indirect (check the circulating free
History antibodies)
- When did you have it? What was the gestational age - Recommendations: For all RH (-) whose pregnancy
of the pregnancy? Why was it terminated? What progresses to 28 and 34 weeks and postpartum within
method was used? Where was the termination done? 72 hours will be given 625 Rhogam injections
Any complications afterwards? Any blood transfusions irrespective of antibody titers.
or further procedures were required? Have you been - If bilirubin too elevated: exchange transfusion
pregnant again since then? How are your periods? - Refer to obstetrician for possible assessment.
Are the cycles regular? Any bleeding in between? I - Reading materials regarding isoimmunization.
understand you’re in a relationship, what - Review
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- How are your cycles? How many days of bleeding?


How many days apart? Please tell me more about
your previous pregnancies? Have you had any kids up
to now with this partner or previous partners? When

RH ISOIMMUNIZATION INDICATIONS
All Rh(-) and unsensitized who requires or with:
INDICATIONS DOSE was your last pregnancy? How did you miscarry? Any
Abortion or requires D&C (give within 72 hours to 9- 250 IU IM trauma? Did you have a D&C during any of the
10 days) pregnancies? Did they do an autopsy on the products
CVS/amniocentesis 250 IU IM of conception? During the last 3 pregnancies, did you
Threatened abortion <20 weeks: 250 IU suffer from any infections? Fever? Did you have the
Antepartum hemorrhage IM antenatal blood tests done?
Abdominal trauma >20 weeks: 625 IU - How is your general health? Any history of diabetes,
External podalic version IM thyroid problems, immune-related diseases like SLE?
Bleeding during pregnancy History of gynecological surgery? Blood group? Last
@ 1st trimester single 250 IU IM pap smear? Were you on any contraceptives before
@ 1st trimester multiple 625 IU IM this pregnancy?
@2nd/3rd trimester 625 IU IM - SADMA?
@ Postpartum 625 IU IM
Pregnant women at 28 weeks 625 IU IM Investigations
34 weeks 625 IU IM - We need to do a pregnancy test on you to confirm if
Rh (+) baby (give within 72 hours of delivery) 625 IU IM you are pregnant. If it positive, I will refer you to the
high-risk pregnancy clinic. If negative, I will refer you
MISCARRIAGE AND ABORTION to a specialist clinic called recurrent miscarriage clinic
where they will do some tests on you to find out the
Recurrent Miscarriages possible cause of the miscarriages. They might ask
your partner to come in for a checkup as well.
Case: You are a GP and a young 26-year-old lady presents to - I would ask the examiner for the results of the blood
you in your GP clinic. She has had 3 miscarriages before. She tests including FBE, Blood group, Ultrasound to check
thinks she is pregnant again because she has not had her any defects of the uterus, ovaries, and fallopian tubes.
periods for the last 6 weeks. She has a family history of alpha I would like to run a complete thrombophilia screening
thalassemia. (Protein C, S, antithrombin III, anticardiolipin antibody,
factor V leiden – most common deficiency, blood
Task homocystein levels), TORCH, Thyroid function tests,
a. Counsel the patient BSL, urea and electrolytes. At the clinic they will order
HLA and karyotyping for both partners.
History (miscarriages x 3 episodes around 8-10 weeks, had - If PT (+): I will refer you to the high-risk clinic where
curettage once, irregular period 4-5weeks, Blood group B+) you will be seen by the specialist obstetrician.
Recurrent miscarriages affect 1% of all couples.
Case 2: You are a GP and a young 28-year-old lady presents to Sometimes, even with extensive investigations, no
you in your GP clinic. She has had 3 miscarriages before at cause can be found. You still have a very high chance
around 8-10 weeks and has had D&C done. You did some of a normal pregnancy. After the 1st miscarriages,
laboratory tests and she has come to collect the results. chances of successful pregnancy is 80%, 2nd (75%),
3rd (70%). I will ask the psychologist, midwife, and
Investigation: FBE, TORCH, chromosomal analysis, APAS, obstetrician to support you all this time whether or not
TFTs, PRL, LFTs, Hepatitis B&C, Urine microscopy and culture, you are pregnant.
FBS, HIV and STDs, thrombophilia, USD of uterus. - One of my friend got cervical stitch, should I have it
too? It is usually done in cervical incompetence where
Causes: the miscarriage occurs in the 2nd trimester. We can do
- Immune-mediated: APAS, SLE, HLA incompatibility ultrasound earlier this time.
between partners, thrombophilias, SLE - Referral letter
- Uterine abnormalities: cervical incompetence (2nd - Written material
trimester), gynecological surgeries, birth defects
(septate uterus) Threatened Abortion
- Infections: TORCH and STDs, Hepatitis B&C
- Endocrine: DM and thyroid Case: You are a GP and a 28-year-old female comes to you with
- Maternal age not a cause but risk factor; females vaginal bleeding after 8 weeks of amenorrhea.
who become pregnant after 40 years has 50% chance
of miscarriage within the 1st trimester Task
a. History (2pads, clots, regular periods, B+)
Definition b. Physical examination (moderate bleeding, clot, os is
- >3 consecutive pregnancies lost by a female closed, uterus is normal and not enlarged, (+) CMT)
c. Investigation
History d. Management
- I can see from the notes that you have a history of
recurrent or repeated miscarriages. At the moment, Case: You are a GP in a suburban GP practice. Your next
you think that you might be pregnant. Have you done patient is a 24-year-old Mrs. Jones with heavy PV bleeding for
a test to check for pregnancy? Do you have any the last 24 hours. She is 7 weeks pregnant by date and she is
symptoms like morning sickness, breast tenderness, concerned and seeks your care.
or irritability? I understand your LMP was 6 weeks
ago, any bleeding since then? Tummy pain or Task
discharge from down below? a. Focused history
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b. Physical examination - If pregnancy test negative: Most likely, this is a


c. Investigation delayed period. Sometimes, due to stress and with the
d. Diagnosis, management, and differential diagnosis use of the pill, your periods can become irregular. If it
continues for the next 2 or 3 cycles, you will need to
see the specialist gynecologist. She might decide to
start you on regular OCPs to regulate the cycle.

Differential Diagnosis Incomplete Abortion


- Ectopic Pregnancy: PV bleeding + b-hCG(+)+ os
closed + empty uterus Case: You are an HMO in ED and a 39-years-old female comes
- Threatened miscarriage: PV bleeding + b-hCG (+) + in complaining of vaginal bleeding and abdominal pain. LMP
os closed + intrauterine pregnancy was 8 weeks ago.
- Incomplete abortion + b-hCG(+) + os open +
intrauterine pregnancy + POC on examination Task
a. History (lower tummy, comes and go, started 12 hours
History ago; 4-5 pads/day; periods every 28-30 days, no easy
- Is my patient hemodynamically stable? bruisability or bleeding disorders)
- Please tell me more about the bleeding? When did it b. Physical examination (distress, pale and in pain; BP
start? How many pads did you use up to now? Did 80/50, os open with POC, PR:80  vasovagal shock;
you pass any clots? Do you have any associated size of uterus is 8 weeks, mobile, no adnexal
pain? Have you felt N/V/breast tenderness? Do you masses/tenderness; no CMT)
feel dizzy at the moment? Any fever or discharge from c. Diagnosis and management
down below? Possibility you might be pregnant right
now? When was your LMP? Are you periods regular? History
How many days of bleeding? How many days apart? - Is my patient hemodynamically unstable?
Have you ever had spotting in between? I understand - When did the bleeding start? What is the color of the
you are sexually active and in a relationship, what bleeding? How many pads did you used since then?
method of contraception do you use? Are you Were they fully soaked? Did you pass any clots or
planning to fall pregnant? Have you ever been pieces of tissue? Did you bubbles or grape-like
pregnant before? Any miscarriages? When was your tissues? Do you have any dizziness, SOB or fever? Is
last pap smear? What was the result? What is your it the first time?
blood group? Any past medical or surgical condition - Where is the pain? Is it there all the time or does it
especially any bleeding disorders, thyroid problems, come and go? Does it go anywhere? How severe is
gynecological conditions. FHx of bleeding disorders. the pain from 1-10? Anything that makes the pain
Have you or your partner ever been diagnosed with an better or worse? Any trauma or intercourse before the
STI? Any problems with waterworks like burning, bleeding?
frequency? How are your bowel habits? SADMA? - Are your periods regular? When was your LMP? How
many days of bleeding? How many days apart? Do
Physical examination you have heavy periods?
- General appearance - Are you sexually active? Are you in a stable
- Vital signs (postural drop) relationship? Any contraception used? Have you or
- Abdominal examination: distention, tenderness your partner ever been diagnosed with STDs? Any
especially on the RIF and LIF. Any visceromegaly, chance you could be pregnant? Do you know your
bowel sounds blood group? Have you ever been pregnant before?
- Pelvic examination: amount of bleeding, color of Any miscarriages? Do you have N/V/ or breast
blood, clots, discharge or signs of trauma? Sterile tenderness recently? When was your last pap smear?
speculum, check os whether open or close; POC; any - How’s your general health? Do you have any FHx of
mass or lesion over the cervix; bimanual examination bleeding/clotting problems or miscarriages?
checking for size, shape and position of uterus;
adnexal tenderness or mass; cervical excitation; Physical Examination
- Urine dipstick, BSL, pregnancy test - General appearance
- Vital signs
Diagnosis and Management - Abdomen
- If pregnancy test positive: most likely your condition is - Pelvic  remove POC immediately!!!
called threatened abortion/miscarriage. Your - Urine dipstick
pregnancy test is positive, but because of your
bleeding, we need to admit you to the hospital to do Diagnosis and Management
some tests which include FBE, U&E, blood group, - Admit the patient
USD of the pelvis to look for the presence of a fetal - Start IV fluids and take blood for grouping and
sac within the uterus and to check for cardiac activity. crossmatching
Depending upon the results, the OB might advise you - Give oxytocin or ergometrine or (Syntometrin) to stop
to take rest. Sometimes, because of the attachment of bleeding
the placenta to the womb, some bleeding can happen. - Refer to OB&Gyne registrar for curettage
In majority of cases (90-95%), this bleeding is quite - From history and examination, I am sorry to say that
harmless. It will stop on its own within a few days. this is a miscarriage. Most of the miscarriages occur
Your pregnancy will continue without any problems, without any obvious reason. Let me reassure you that
but you need to avoid stress, anxiety, and rigorous it is not your fault. You did not do anything wrong. So
physical activity for the rest of your pregnancy. We do please do not feel any sense of guilt. Most likely in the
not need to give you any medications as it has not first 14 weeks, the reason of miscarriage is due to
shown to alter the outcome in any way. If the bleeding chromosomal abnormalities. I have admitted you,
continues, we will repeat serial ultrasound to check for informed the registrar, and sent all the bloods for
fetal viability, but you will need to stay in the hospital necessary investigations. They will probably take you
until the bleeding stops.
8

to the theater and do a procedure called curettage. - When you miss your next period, please come and
They will empty whatever is left in the uterus to see me ASAP. We will do some tests including serial
prevent any complications. We will wait for your blood beta-hcg done starting day 5 of conception. We would
group report to come and if it is negative, we will give like to record the quantitative increase in beta-hcg
you an injection called anti-D.

which usually rises every 48 hours. If it doesn't, then


- Can I still get pregnant? Yes, you can still get pregnant we will do USG, progesterone (low) and CA-125 (rises
but it is advisable to wait for at least one normal period during impending rupture)
before you get pregnant again. - The gold standard for diagnosis remains to be
- I know it is a very hard time for you. Do you want me laparoscopy.
to call anyone for you? Do you have enough support? - If we find that the next one is ectopic as well,
- Being 38 years old puts you at a higher risk of your depending upon the fetal viability and damage to the
child having Down syndrome. So in your next tube, the specialist obstetrician might decide to inject
pregnancy, it is advisable for you to consider doing MTX within the gestational sac that will help in
Down Syndrome screening. resorption of the fetus protecting the tube.
- If you develop tummy pain, vaginal bleeding, episodes
Critical error: of fainting or dizziness, or back pain (interscapular
- Not considering anti-D area), please come to the hospital right away because
- Not taking out POC immediately these are symptoms of early ectopic pregnancy.
- Doing unnecessary investigations like beta-hCG and - The best option would be IVF if your opposite tube is
USD removed. Please be optimistic. You still have a very
high chance of having a normal pregnancy.
EXTRAUTERINE AND ECTOPIC GESTATION - General risk for ectopic pregnancy: 1%; chance of
recurrence: 10-20%
Ectopic Pregnancy
ANTEPARTUM AND OTHER COMPLICATIONS IN
Case: A 23 years old female has recently been discharged from PREGNANCY
the hospital after a procedure where the right Fallopian tube was
removed because of an ectopic pregnancy. The left ovary on the Antenatal Care:
ultrasound showed the presence of corpus luteum. The patient - Do beta-hCg (quantitative or qualitative)
wants to know why it happened to her. - Down Syndrome risk:
o @37: 1:200
Task o @40: 1:100
a. Talk to the patient and explain about ectopic o @45: 1:50
pregnancy and its causes. - Screening for down syndrome: HR: 1:200 or higher
o 1st tri: 80% predicted
- From the notes, I can see that you have recently  10-12 weeks: PAP-A and beta-
undergone a procedure to remove a right ectopic hCg;
pregnancy. How are you feeling at the moment? How  12-13 weeks: USG (nuchal
are you coping with the loss of this pregnancy? translucency  aneuploidy)
- I understand why you want to know why it happened o 2nd tri: 60-70% predicted
to you. Do you know what ectopic pregnancy means?  QUAD screen @14-20 weeks:
Usually, the egg from the mom and the sperm from
AFP, b-Hcg, estriol, inhibin A
the dad meet within the tubes to form the fetus. This
(ACEI)
fetus then travels and becomes attached to the wall of
- May do dating usg during first visit
the womb. Due to certain reasons, sometimes, the
- Amniocentesis (0.5%)/CVS (1%): risk of miscarriage
fetus implants within the tubes. It is then called an
- Blood group
ectopic or extra-uterine pregnancy. The size of the
o If (-): repeat blood at 28 weeks; then give
tube does not allow the fetus to grow therefore it may
anti-D; repeat blood antibody screen at 34
rupture and leads to a lot of bleeding and other
weeks (2nd injection of anti-D)  prevent
complications. For you fortunately, such complications
spontaneous transplacental hemorrhage
were prevented and the tube was removed. Please
 2nd tri: 12-15% fetal RBCs can be
don't worry. You still have a chance of normal
pregnancy. The risk factors for ectopic pregnancies found in maternal blood resulting
are: previous history of PID and STI (increases risk in isoimmunization
7x), previous surgeries of gynecologic nature  3rd tri: 20-30%
especially around the tubes, history of endometriosis, o Give anti-D after delivery
IUCD use, use of emergency contraception (causes - FBE: consider anemia (r/o hemoglobinopathy)
retrograde contraction of the Tubes), embryonal o Check the partner and check for trait
defects, previous history of ectopic pregnancy in the - Screen for infections: Rubella, HIV, Hepatitis,
opposite tube. hepatitis B&C, syphilis
- In most of the cases (97%), ectopic pregnancies are o If HbsAg (+) check partner for hepatitis b
found within the tubes. Sometimes, they can be found antibody; talk about safe sexual practice
in the ovary, peritoneal cavity, and on top of the uterus o For hepatits b&c  refer to infectious
- For your next pregnancy, the chances of conception specialist
are around 50%. Please remember that even one tube - MSU for micro&culture: asymptomatic bacteriuria (or
can catch the eggs from the opposite ovary. You need in 6-8%) (+) if >100,000 col/ml; tx because
to wait for at least 3-6 months before trying to increased likelihood of getting severe UTI (e.g.
conceive. Give yourself some rest and have a healthy pyelonephritis)
balanced diet. You can use OCPs but please avoid - Vitamin D levels: N: 70u; severe <20u
IUCDs, Emergency pill and POPs.
9

- 18-22 weeks: morphology scan to check for structural History


abnormalities - Mrs Hasim, Do you need interpreter? I understand you
- 28 weeks: check for anemia (FBE) – physiologic have come to see me regarding pregnancy. Is it your
anemia and GCT first pregnancy (Yes)? Was it planned (Yes)?
Congratulations!
- When was your LMP (8 weeks ago)?

- Average gestation: 40 weeks + 2 weeks; >42-43


weeks perinatal mortality doubles;
o Concern at 41-42 weeks: do fetal well-being - Period questions: Do you have regular cycles? How
USD measuring umbilical artery flow (SD long is the cycle? How long is the bleeding time? Any
ratio: difference between peak systolic flow spotting in between? Do you have excessive pain or
and end-diastolic flow), AFI and CTG bleeding during the period? How did you confirm your
pregnancy (I did pregnancy test at home)? Good on
Antenatal checkup you!
- Pregnancy symptoms: Do you feel tired, nausea?
Case: Your next patient in your GP practice is a 24-year-old Have you vomited? Breast tenderness? Tummy pain?
female who is 8 weeks pregnant. You saw her last week as a How’s your water work? Do you have regular bowel
part of her regular antenatal checks and ordered some blood function? Do you have unusual vaginal discharge or
tests. Today she is here to know about the blood results. Her bleeding?
health and pregnancy have been good so far. She is so excited - What type of contraception did you use before you got
about having a healthy baby by the end of her pregnancy. Her pregnant? Have you been diagnosed with STD?
results are as follows: When was your last PAP smear (If no for last 2years
FBE: Hgb 120, WBC 8000, Plt 170,000 do it now!)? Do you know your blood group? Have you
UEC: Na 145, K 4.4, Cl 130 had Rubella in the past or have you receive vaccine
LFTs: normal for it?
BSL: 4.3 - Any serious illnesses or surgeries in the past? (Heart,
Blood group: A-; Antibody screening test (-) HTN, DM, anemia.) Is your husband generally
IgG (+) for Rubella and Varicella healthy? Are you on any medication? Are you taking
Urine: MCS show GBS positive folic acid? Are you allergic to anything? Smoking,
HBV and HCV: negative Alcohol and drugs? How many cups of coffee do you
drink per day? What do you do for a living? When did
Task you migrate to Australia? Do you have any family
a. Explain result and advise on management members or close friends here? Has anyone in the
family had twin pregnancies? Has anyone in the family
Management had pregnancy complicated by DM, HTN, birth
- Congratulate on her pregnancy defects?
- Give anti-D at 28, 34 weeks and 72 hours after
delivery if child is Rh (+) and if there are bleeding Management
episodes - We need to order some routine lab tests to identify
- If antibody screening test positive: measure the titers any issue which needs to be addressed for the best
using ELISA (1:8 or 1:16 or 1:32 then check bilirubin outcome of your pregnancy.
by doing o FBE exclude anemia. Hb. Iron deficiency
o Amniocentesis: check bilirubin; Supplement.
o Umbilical cord sampling: Hct (25%) o Blood group and RBC antibodies. If you are
o MCA ultrasound: check velocity of blood Rh-you need anti-D immunoglobin
flow -- if there is hemolysis heart pumps prophylactically to prevent problem in future
faster then velocity increases; less invasive pregnancy. Repeat antibody test in
- Urine MCS: positive for GBS (asymptomatic 26weeks.
bacteriuria) -- treat with antibiotics because of risk of o Rubella status if you are not immunized to
developing pyelonephritis rubella, I recommend you receive rubella
(Cefalexin/Augmentin/amoxicillin) vaccination after delivery. (Contraindication
- Repeat culture after 1 week during the pregnancy)
- General advise for UTI o We will also do syphilis, Hepatitis B and C
- Check partner’s blood group and HIV screening.
- Advise on antenatal checkup o Vitamin D level.
- Dietary advice, smoking and alcohol o Midstream urine to check urinary tract
- Down syndrome screening  if older patient infection. Sometimes it can be
asymptomatic but need to be treated in
First Antenatal Check Up pregnancy. 30% of asymptomatic UTI can
become symptomatic.
Case: Mrs. Hasim a migrant from Sudan presents to your GP o There’s another test which we offer in every
clinic for her fist antenatal visit. women in Australia. It’s a Down’s syndrome
screening test. Would you like to do it?
Task  1st trimester: Pappa, beta HCG,
a. Take History Ultrasound
b. Your management in pregnancy  2nd trimester quad. Test(15-
18weeks): beta HCG, AFP,
She is a professional boxer for 10 years. “Can I do exercises?” oestradiol, inhibin A
“Can I eat sushi?” “How about weight gain?” o You also need 18-20weeks mid pregnancy
ultrasound to make sure baby develops
10

properly and to look for position of the - Do you have enough support? I understand you live
placenta. 80km away, how long does it take to go to the nearest
o At 28weeks we screen for Gestational hospital by car? Can anyone drive you to the hospital
Diabetics: sweet drink test/glucose in case of emergency? Do you have any friend or
challenge test. relatives who live near the hospital where you could
o At 36 weeks you will need to be advised to relocate a few days before the due date? Is there
do a low vaginal swab to check for a anyone at home who will look after your first baby
bacterial infection called GBS. If found you when you are in the hospital?
will be given antibiotics prophylactically
during delivery.

- You need to take folic acid 0.5mg for the 1st 3 months
of pregnancy because it decreases the occurrence of Counseling
neural tube defects. - The first pregnancy is usually longer as compared to
- Moderate exercise is good for you because it succeeding ones. However, there are some warning
improves cardiovascular and muscle strength. Best signs: if you have any contractions,any passage of
exercises are low impact aerobics, swimming, walking mucus or water, vagina bleeding, any reduction in fetal
and yoga. No contact sport because of risk of trauma. movements, any sort of tummy pain, headache, blurry
- Weight gain should be around 11-16kg during vision, cloudy urine, or other warning signs, you have
pregnancy. But it all depends on your pre-pregnancy to come to the hospital straight away.
state. Your diet is important, it should be well - The plan for your pregnancy is to come every month
balanced. Food rich in protein, dairy food, starch food until your28th week, then every fortnightly from 28-36
(potatoes) and plenty of fruits and vegetables. Best weeks and weekly after 36 weeks and until delivery. At
avoid a lot of sugary, salty and fatty food. Food 28 weeks, we will arrange a sweet drink test and
delicacies: uncooked meat, egg, soft cheese, shell fish around 34-46 weeks, we will do the vaginal swab to
and raw fish should be avoided as they are potential detect the bug called GBS.
sources of Listeria and Salmonella. - If there are no warning signs as discussed before, it is
- No smoking, alcohol and drugs. advisable to either relocate close to the hospital if you
- What about my sexual life? Sexual life is acceptable have friends or relatives or get admitted to the hospital
and normal during pregnancy just follow your normal a week or so before the due date.
desire. - Will I have a long labor this time as well? With regards
- Can I see a dentist? See your dentist in case any to your delivery, the exact duration of your labor is not
dental care is required and it can be carried out in the easy to predict as it depends on several factors at the
first half of the pregnancy. time of delivery such as medical conditions, size of the
baby, size of the pelvis, presentation of the baby, and
Timing of Admission to Hospital strength of the contractions. But usually, the duration
of labor in 2nd pregnancy is shorter compared to the
Case: your next patient in GP practice is a 24-weeks pregnant 1st.
lady who has just moved into your town. She has come to see - Right now everything sounds good. I will see you in
you as her first GP. She lives 80km from the main hospital one month time and give you a few reading materials.

Task Down Syndrome Screening


a. Relevant history (folic acid, regular checkup, normal
USD and blood tests; history of prolonged labor Case: A young woman at 10 weeks’ gestational age comes to
because of poor contractions; instrumental delivery) see you in your GP practice. She is concerned about having a
b. Advise when she immediately needs to attend the baby with Down syndrome as recently, her sister had a baby
hospital or midwife with Down syndrome.
c. Answer her question
Task
History a. Counsel patient
- Congratulations on your pregnancy. I can see that
you’re concerned about when you should go to the - Is this a planned pregnancy? Congratulations.
hospital for delivery. I understand that you live 80km - I understand from the notes that you are here to
away from the hospital. Before I address your discuss about Down syndrome screening. I appreciate
concern, is it okay if I ask you some questions? your initiative to do that. I understand your anxiety. I
- How is your pregnancy going so far? Was it a planned will give you all the information regarding the tests
pregnancy? Are you attending regular antenatal care? which can be done and how effective they are.
How were the blood test results? Anything significant? - How is your pregnancy going so far? Are you getting
Do you know your blood group? What about the 18 th your antenatal care? Are you done with your blood
week USD? Is it a single baby? Is the placenta in the tests? Any concerns or issues?
normal position? Any tummy pains or trauma so far? - Down syndrome is one of the common genetic
Any discharge or bleeding so far? Any leakage of fluid abnormality with trisomy 21. There are some
down below? Any headache, BOV, N/V? Any urgency, indications in doing Down syndrome screening in
frequency or smelly urine? Did you take folic acid? Is pregnant women:
your baby kicking well? Any previous pregnancy or o Increased maternal age (>30)
miscarriage? How was it? Was it term or preterm? Do o Previous down syndrome baby
you know the reason for the prolonged labor? How o History of down syndrome in the family
was the baby after delivery? Any complications? What - We have screening tests and confirmatory tests. In the
was the BW? Any previous medical or surgical issues first trimester, there is a triple test a blood test which is
like BP, DM? Any problem with your periods? Are you done at 9-13 weeks AOG. We check free beta-hCG
on any medications? SAD Pregnancy Associated Placental Protein-A. We
11

combine it with Ultrasound and it is done at 11-13 o Baby: Macrosomia, Multifetal gestation,
weeks AOG. Here we check for fetal nuchal Malpresentation (breech, face, brow,
translucency. Screening tests can also be offered in transverse lie)
the 2nd trimester between 15 and 17 weeks. These o Labor: Power, Passage, Passenger
tests are not 100% confirmatory. In high-risk
pregnancies, we can offer diagnostic tests: CVS or Eligibility: 1 previous LSTCS and NO contraindication
amniocentesis.
Induction of labor:
- Risk of uterine rupture especially if induction of labor
with prostaglandin E2, oxytocin + amniotomy and
misoprostol is used
o Classic (5%)
o LSTCS (0.5%)

- CVS
o done ideally at 9-11 (11-12 at clinical book)
weeks - Mechanical cervical ripening device may be used
o results within 24 hours safely
o more accurate - 1/5 of patients end up having cesarean section
o 1% risk of abortion
- Amniocentesis History
o Done ideally at around 14-15 - Congratulations. Is it a planned pregnancy?
o Longer (up to 3 weeks) and less accurate - What about first pregnancy? Was it your first? Was it a
o 0.5% risk of abortion planned pregnancy? Did you have regular antenatal
- 3 regimens: checkups? Complications of pregnancy (DM,
o PAPPA and free hCG at 9-13 weeks hypertension, bleeding)? Why was the CS performed?
o Nuchal thickness at 11-13 weeks (combined Was it an emergency? Do you know the type of
tests raises detection rate from 70 to 90%) cesarean section? Complications of surgery
o If calculated to be more than 1/200-250  (infections, bleeding, DVT)? CPD (height of partner
woman is offered CVS if gestation between and patient)? How was the baby at birth? Any
11 and 14 weeks or amniocentesis if at 15- resuscitation needed?
16 weeks - History of previous uterine surgeries or rupture?
o Combined test: AFP, unconjugated estriol - Are you taking folic acid?
- How is your general health? Any medical condition
and beta-hCG + Inhibin A at 15-20 weeks
you have at this moment? Why do you want to have
 increases detection rate from 65 to 75-
vaginal birth?
80% if inhibin A included
- If previous pregnancy was down syndrome, the risk of
Findings from Examiner
having Down syndrome in the next pregnancy
- Reason for cesarean section
increases by 1%.
- Classical or Low-segment cesarean section
- Age of gestation
Vaginal Birth After Cesarean Section (VBAC)
- Complications: anesthetic, infection, hemorrhage,
damage to the adjacent organs like bladder, large
Case: You are a GP and a 28-years-old lady with previous
intestine etc, DVT
cesarean section 2 years ago is in your GP clinic. She is now 7
- Baby: weight, apgar score, resuscitation done
weeks pregnant and she wants to have vaginal birth.
Management
Task
- At this stage we are not sure about the outcome of the
a. History (CS due to fetal distress, pap smear x 1 year
pregnancy as it depends on its progress. However, in
ago with
majority of cases and in your case, successful vaginal
b. Ask examiner for previous medical/surgical notes of
birth can be achieved safely. The success rate ranges
the LSTCS (obstructed 2nd stage of labor hence
from 55-85%. I will do antenatal screening tests and
underwent CS, Apgar 6,8 BW 3kg, no CPD)
will monitor you during your antenatal visits to look for
c. Discuss possibility of vaginal birth to patient
certain conditions which can pose a risk during vaginal
delivery or which can be an indication for cesarean
Predictors of successful VBAC (55-85%):
section. If any of these are present, you will be
- Non-recurring indication of CS (e.g. malpresentation)
managed as a high-risk pregnancy.
- PIH
- I will arrange an appointment with an obstetrician at
- Previous vaginal birth
26 weeks for discussion about possible mode of
- Institutions in which success rates is high
delivery and at 36 weeks for definite decision
- Onset of labor is spontaneous
regarding vaginal birth. The specialist will explain the
risks and benefits of the mode of delivery to you and
Contraindication
the final choice will be made according to your wishes
- Previous classic cesarean section birth
and advice of the obstetrician. If vaginal birth is
- Some uterine surgery (hysterotomy, deep
decided, it will take place in a well-equipped hospital
myomectomy, corneal resection and metroplasty)
under supervision of an experienced obstetrician
- Previous uterine rupture or dehiscence
because vaginal delivery can progress to cesarean
- Maternal or fetal reason for elective CS in current
section in 1/5 of the cases.
pregnancy
- Folic acid prescription
o Mother: PIH, Diabetes, Antepartum
- Reading material
hemorrhage (previa/abruptio)
- Review
12

- FBE, Serum beta HCG. U/S of pelvis and abdomen


Ovarian Cyst in Pregnancy looking at evidence of intrauterine pregnancy, rule out
ectopic pregnancy, ovarian cyst, fluid in the pouch of
Case: You are HMO in ED. 25yo female 8weeks pregnant c/o Douglas.
pain in the right lower abdominal pain. - Tumor markers: CA125, LDH

Task Diagnosis and Management


a. Take history
b. Ask for Physical Findings (All vitals stable. Healthy - From history and physical examination, most likely
looking. Abdominal examination: Tender in the right your pain is coming from a cyst within the ovary.
iliac fossa. No organomegaly. Per speculum: no Ovarian cyst is usually a benign condition where a
discharge, no bleeding, no poc, os is closes.) fluid filled sac is found near the surface of the ovary.
It’s quite common in female of reproductive age group
the exact cause is unclear. However, the hormonal

c. Ask for one relevant investigation findings ((U/S:


Intrauterine pregnancy, Cyst in the right ovary 5cm in changes during pregnancy can sometimes be
size, no fluid in the pouch of Douglas) responsible. Rarely certain types of nasty growth may
d. Talk about relevant management develop within that cyst however the chances are very
low at your age. The management depends upon the
Differential Diagnosis size of the cyst, your symptoms, and the opinions of
- UTI the obstetrician
- Ectopic pregnancy - According to JM
o If it’s a simple cyst <5cm reassess the
History patient clinically and with a U/S in about 6
weeks time.
- Is my patient haemodynamically stable? o If it’s a simple cyst >5cm recommend a u/s
- Pain questions: How bad? 5-6/10 dull kind of pain not guided aspiration.
radiated. Where? Go anywhere else? Does anything o Complex cysts irrespectively to size,
make it better or worse? When did it develop? Is this excision laparoscopically
the first time? Any associated symptoms eg fever, N/V, o Any symptoms or U/S evidence of torsion of
bleeding from down below, discharge from down cyst: laparotomy and removal of cyst
below? - For your case, because your cyst is still around 5cm
- Problems with water work: burning or frequency? and your symptoms are controllable (pain killers
Bowel habits: history of constipation? given). I’ll ask obstetrician to come to see you. Most
- I understand from notes you are 8 weeks pregnant. likely they will advice careful monitoring to lookout for
When was it confirmed? At the moment do you have any symptoms of torsion which are: severe pain all
symptoms like morning sickness, irritability, breast over the tummy, recurring pain, symptoms of shock
tenderness? Is this a planned pregnancy? Is this the (fainting, low BP). The risk of torsion is around 10-
1st pregnancy? Any miscarriages before? History of 15%. At the moment once your pain settles down we
ectopic pregnancy? LMP? Are they regular? When will send you home. However, you need to report back
was the last PAP? Result? to us if any symptoms develop most likely you will
- How’s your general health? PMHx: appendectomy. need to undergo surgery in that case. Usually
Have you or your partner ever dx with STD. History of laparoscopic surgery doesn’t affect early pregnancies.
pelvic infection or gynecological procedure done for However, slight increase risk of miscarriages. But we
yourself? will give you certain hormones to help maintain the
- SADMA? Blood group? Which contraception were you pregnancy (progesterone). Do the Surgery after
on before the pregnancy? Gardasil? 15weeks with progesterone therapy. I want you to be
aware of some other complication of ovarian cyst:
Physical Examination Infection: fever, and increasing pain, Cyst might
rupture, twist on its axis compromising the blood
- General Appearance: pallor jaundice dehydration supply to the ovary. However, around 80-95% of
- Vitals: ask all vitals. If suspect appendicitis ask for ovarian cyst that presents to us resolves
Pulse and BP. spontaneously.
- Abdomen: Any visible distension, mass, scars? - Review: in 6 weeks for U/S.
Palpate any tenderness especially McBurney’s point.
- Pelvic examination: Alcohol Excess in Pregnancy
o Inspection: Any discharge, bleeding?
o Sterile speculum: discharge, bleeding, POC, Case: Your next patient is a 10 weeks old pregnant lady who
OS came in for antenatal checkup. She is alcoholic beverage
o Bimanual: Any tenderness, adnexal mass, drinker and a smoker for the last 10 years.
position and size of the uterus
Task
Investigation: a. History (planned pregnancy; first pregnancy; not a
- U/S: Ovarian Mass binge drinker; drinks with partner; cannot go without
- Ask the examiner for Doppler U/S: To see the blood alcohol for one day
flow to the ovary(torsion), To determine the nature of b. Advise management
the cyst: homogenous mass(simple cyst) or a complex c. Focus on issues
cyst (malignant in nature).
13

History alcohol use in pregnancy. (Limit to 1 SD per week but


- Can you tell me a bit more about it? Is it a planned any reduction is important).
pregnancy? Is it your first pregnancy? - Suggestions on how to quit: It is important to
- I would like to ask you a few more questions understand the effects of alcohol and smoking and
especially with your smoking and drinking habits. Is it admit it as a problem for you and your baby. Strong
alright with you? motivation is the key to success. After making a
- For how long have you been drinking? How much do decision, establish clear and realistic goals and I will
you drink per week? What type of alcohol do you help you implement them to stop alcohol and smoking
drink? Do you drink a lot on the weekends? Do you altogether. Choose a quit date for both alcohol and
drink alone, with partner or with friends? Are you smoking to stop.
aware of the safe level of drinking? How long can you - I can arrange a family meeting to talk to your partner
go without alcohol? Do you need it to steady your and advise him to stay away from alcohol and
nerves? Does it help you go to sleep? Do you take a smoking. Avoid situation where you usually drink
drink in the morning when you wake up? Any alcohol like party and bars. Ask family and friends to
symptoms of agitation, sweating, nausea, or shakes if help you quit. Let your family members, friends, and
you don’t drink? coworkers know that you’re trying to stop drinking and
smoking.

- You can experience withdrawal symptoms like


- How’s your family life? Any problem at work or with headache, shaking, sweating, N/V, anxiety, tummy
family relations? Any financial issues? pain, diarrhea, problem with sleeping, high and low
- CAGE? Have you ever tried to cut down? Ever been BP, craving for alcohol and smoking. When you
annoyed? Do you feel guilty? Do you drink when you experience these symptoms, please immediately
wake up in the morning? Do you know about its contact me so appropriate treatment could be given.
effects in pregnancy? - Lifestyle modification: Deal with stress in a healthy
- How many cigarettes do you smoke per day and for way like exercise, sports, meditation and yoga.
how long? What is your pattern of smoking during the - I will refer you to alcohol anonymous. It is an
day? How soon do you have your first cigarette when organization composed of groups of people having
you wake up? Do you find it difficult to smoke in non- problems with alcohol and who desire to stop it. I will
smoking areas? Have you tried to quit smoking in the also refer you to support groups – quitline for smoking
past? Does your partner smoke? and give you some reading materials. I’m available for
- Any medical condition such as liver, gastrointestinal, you for ongoing management and support for follow-
heart? Any history of mental illness or depression? ups.
DM? Hypertension? - RWH:
- Are you on any medications? do you take folic acid? o Sometimes it is not possible to stop
Have you used illicit drugs? altogether.
o Avoid dehydration by drinking plenty of
Counseling water
- I would like to talk about the effects of smoking and o Vitamin D, iron and calcium
alcohol in pregnancy and I would also like to do supplementation
investigations that we do during the first antenatal o Folic acid for the first 3 months
checkup. o Nicotine replacement therapy shouldn’t be
- The effects of alcohol: In pregnancy, alcohol can pass used in pregnancy but may refer to
through the placenta to the baby and is broken down specialist for advice
more slowly than in adults leading to fetal alcohol o Medications for withdrawal: Acamprosate
spectrum disorders. On one extreme is fetal alcohol (champix) or naltrexone for 6-9 months;
syndrome which is main cause of mental retardation in
babies. The other effects include vision and hearing Pregnancy with IUCD
problems, learning, emotional and behavioral
problems, speech or language delays, low BW, and Case: A-26-year old female comes to your GP clinic complaining
birth defects including heart, face, eyes and other that her period is late. She has copper IUCD inserted.
organs of the body.
- In pregnancy, there is increased risk of miscarriage Task
and premature birth. After the birth of the baby, a. Take focused history
breastmilk production can also decrease. b. Ask for physical examination (size of uterus is 7
- Unfortunately, smoking exposes the baby to some weeks, no adnexal mass)
dangerous chemicals like nicotine, tar, and CO which c. Advice the management
decrease the amount of oxygen for the baby which
can affect his/her development. It can also damage Case 2: Same Scenario You can see the thread of the IUCD
baby’s lungs and can give rise to birth defects like cleft
lip and palate, low BW, and once baby is born, there is History:
increased risk of chest infection like asthma, - Hi. I know you are here to see me because you are
pneumonia, and ear infections.
concerned about your period. When was your LMP?
- In pregnancy, smoking is a risk factor for placental
Was it normal or light? Do you have regular cycles?
abruption and stillbirth. Also, there is an increased
How long is the cycle? How long is the bleeding time?
chance of SIDS if parents are smoking and drinking.
Any spotting in between? Do you have excessive pain
- I know you are quite worried about hearing all this, but
or bleeding during the period? When did doctor insert
the good news is that all of these can be avoided if
the contraceptive device? Did your period change
you stop smoking and drinking alcohol. The ideal
after the insertion? When was the last time you
situation is if you stop smoking and alcohol altogether
checked strings or thread?
if possible for you. The sooner you quit the better it is
- Pregnancy questions: Do you feel nausea, vomiting,
for you and your baby. There is no known safe level of
14

breast tenderness? Increase urinary frequency? Any


abdominal pain? Have you notice usually vaginal Case: 38 year-old woman who came in with a 2-week history of
discharge? Did you do pregnancy test? Have you ever nausea and vomiting. She is 8 weeks pregnant and her
been pregnant? Are you in a stable relationship? Have pregnancy is consistent with GA. She has no previous illness.
you ever been diagnosed with STD or PID? When
was your last PAP smear? Do you know your blood Task
group? a. History
- Are you generally healthy? Any pelvic Surgery, C- b. Investigations (1 only) -- MSU
section done before? Medication? Allergies? What c. Diagnosis and management
would be your intention if you are pregnant?
Differential diagnosis:
Physical Examination: - Multifetal pregnancy?
- General Appearance - Hydatidiform mole (complete/incomplete)
- Vital Signs - UTI
- Palpate abdomen: Distension, Tenderness, Masses - Infectious Gastroenteritis
- Brain tumor/Addison disease

- Pelvic examination:
o Inspection History:
o Speculum: Appearance of cervix, OS, The - IS MY PATIENT HEMODYNAMICALLY STABLE?
presence of the string - Congratulations on your pregnancy.
o Check vaginal discharge - How many episodes of vomiting did you have per
o Check if thread is present! day? Is it getting worse? Is it in the morning or
o Per Vagina: Size of the uterus (7weeks) throughout the day? What is the content? Do you
Consistency (soft) Adnexal masses and have fever? Diarrhea? How is your appetite? Are you
tenderness. still drinking eating or drinking? How is your
- Urine dip stick and Urine pregnancy test (+) waterworks? Any pain or burning sensation? Any
increased frequency? Any change in color of urine?
Diagnosis and Management Any loin pain? Did you eat outside?
- Jacky your pregnancy test is positive. And I can see a - Pregnancy: is this a planned pregnancy? How did you
string which means contraceptive device is in place. confirm your pregnancy? Any family history of twins?
How do you feel about it? Is the pregnancy natural or assisted? Any abdominal
- Unfortunately every contraceptive method has a cramps or vaginal bleeding?
failure rate. Effectiveness of IUCD is greater than 98% - Periods? Pills? Partner? Pap smear? Blood group?
but there’s still a chance for being ineffective. You - SADMA?
don’t need to make a decision now. You can go home
and discuss it with your partner. I will organize a pelvic Examination:
ultrasound for you to identify the exact position of - General appearance: tired, signs of dehydration
pregnancy and position of the device. If you decide to (tongue, skin turgor, CRT?
continue with pregnancy the device should be - VS: BP (check for orthostatic hypotension); PR
removed. (tachy), RR, T – normal
- Is it safe? The procedure doesn’t increase the - Chest, heart, abdomen – normal
miscarriage rate above that in population. (Every - No pelvic exam needed.
pregnancy carries 15-20% risk of miscarriage.) - Urine dipstick – nitrites, ketones (+), leukocytes
However if it is left inside it will increase the risk of o MSU: (+) for ketones! – admit!!!
miscarriage to up to 25% and increase risk of
ascending infection. If you decide not to continue with Investigations:
the pregnancy, I will refer you to a specialist for - MCU
termination and the device will be removed during the - Ultrasound examination
procedure. - Test for electrolytes, urea, LFTs

Case 2: NO thread Diagnosis and management:


- Jacky, your pregnancy is positive and I can’t see - You have a condition called hyperemesis gravidarum.
strings of device. Two options are possible. Either It means excessive nausea and vomiting in
uterus expels the device (because device is a foreign pregnancy. These are common symptoms during
body) or string loss and you are pregnant with device initial pregnancy. However, 1 in 1000 women will have
still in place. To find out I need to organize pelvic excessive vomiting and require hospitalization.
ultrasound. How do you feel about pregnancy? - On examination, you are dehydrated and this was
- What if device is still inside? We wouldn’t be able to confirmed in urine analysis, so we need to admit you. I
remove it if it still has strings but an attempt to remove will organize an ambulance. In the hospital they will
it will be made. But without strings it’s impossible to secure 2 IV cannulas, take the blood for FBE, U/E/,
remove the device safely without harming pregnancy. RFTs and LFTs because dehydration can affect the
However pregnancy can be continued but there’s high liver and kidney. We need to do MCS to rule out UTI
risk of miscarriage and ascending infection. If and USD to confirm intrauterine pregnancy, rule out
pregnancy will be successful device will be delivered multiple pregnancy and molar pregnancy.
with the placenta and membrane. If you decide not to - They will also give medications to stop the vomiting
continue with pregnancy I will refer you to a specialist (metoclopramide – mexalon, stemetil) and start IV
for termination. fluids and vitamin B6 (pyridoxine).
- We don’t know the exact mechanism behind it.
Hyperemesis Gravidarum However, it is usually due increased level of b-hCG
15

which is one of the pregnancy hormones. Once the - Vital signs


body has become used to the new environment, the - Cardiovascular examination and JVP
nausea and vomiting settles and this usually happens - Lungs
by 14 weeks. - Abdomen: FH, lie, presentation, FHT, tenderness
- You are a 38-year-old mother and that puts you at a - Neurological examination: Reflex
very high risk of having a baby with Down syndrome. - Peripheries: redness, warmth, tenderness in any
So I would like to offer you screening for Down areas
syndrome (during your 10th week – blood plus USD). - Urine dipstick and BSL

Critical Errors: Management


- Failure to recognize need for hospitalization - From history and examination, most likely you have a
- Failure to do ultrasound and urine examination condition called generalized edema of pregnancy. It
typically involves the lower extremities but
Generalized Edema in Pregnancy occasionally it can cause swelling of the face and
hands. There are a few reasons such as hormone-
Case: A 35-years-old primigravida who is 32-weeks-GA is in induced sodium retention, increase of blood volume
your clinic complaining of increased swelling in the body for the by 50% during pregnancy, and enlarged uterus may
last few days. compress the veins (IVC) when you’re lying down
obstructing blood flow and causing the edema.

Task - It can be reduced by intermittently lying on the left


a. History (both legs and face; decreased when lying and side, elevating the lower extremities intermittently,
on left lateral position; no headache, visual problems, wearing elastic compression stockings, and
tummy ache, had regular antenatal checkups, one decreased salt intake in diet. It usually resolves after
pregnancy, normal placenta, folic acid, sweet drink birth of the baby as the uterus returns to pre-
test normal, no contraceptive, 1st pregnancy, last pap pregnancy size and the hormones return to normal.
smear was one year ago and normal, no general - At this stage there is no need for investigations but if
medical health condition, no HTN; social support is ok there are changes in your symptoms or if patient is
and no financial issues; no problem with waterworks concerned: Do investigations  FBE for Hb, infection,
or BM? No fever? platelet, U&E, LFTs, TFTs, RFTs,
b. Physical examination (generally well, mild generalized - Red flags: headache, blurring of vision, tummy pain,
pitting edema of the especially both legs, BMI is 27, increased blood pressure, feeling unwell, baby not
PR 80, T37.6, BP 120/80, RR: 12, neck for thyroid kicking
swelling, no LAD, FH 32cm, lie longitudinal, cephalic, - Reading materials. Review.
FHR 120, pitting edema, urine dipstick proteinuria
negative, BSL normal) Stillbirth
c. Diagnosis and management
Case: You are a GP and a 26-year-old lady comes to you 6
Pregnancy/planned pregnancy weeks after the delivery of a baby. The delivery was a stillbirth at
- Antenatal checkup/infections/medications around 22 weeks of gestation. The patient is still very upset
- 18 weeks ULD – placental, baby, anomalies, liquor about her baby’s death and she wants to know if this will happen
volume, fibroid again.
- Sweet drink test
- Hemoglobin Task
- Pre-eclampsia a. Take history (had fever x 3-4 days continuously at 20
- Heart disease, HTN, DM, heart (CCF), liver, kidney, weeks, and started bleeding/discharge from down
severe hypothyroidism below; ruptured BOW; did tests and baby was already
dead; )
History a. Physical examination
- Is this a planned pregnancy? Congratulations? Is this b. Counsel accordingly
your first pregnancy? Where exactly is the edema
(swelling)? Did it come suddenly or gradually? Any
pain in your legs? Anything increasing or decreasing Approach to Patient Who has had Stillbirth
it? How is your pregnancy going so far? Have you had - Emotional support must be ensured by offering
regular antenatal checkups? Any infections? What appropriate resources or referral
was the result of your midgestation USD (baby, - Take detailed history focusing on obstetric, medical
placenta, anomalies, liquor volume, fibroids)? What and family history and conditions surrounding previous
was the result of your sweet drink test? What about stillbirth
your BP? Have you checked it recently? - Discuss anomaly screening with patient
- How’s your general health? did you have history of - Discuss uterine artery Doppler studies at around 22-
high blood pressure or diabetes? Do you have any 24 week
recent headaches, visual disturbance, tummy pain, - Discuss dating USD in 1st trimester
SOB, chest pain, or racing of heart? Do you have - Discuss lifestyle advice (smoking, alcohol, weight loss,
problems with your waterworks or bowel motions? Is diet)
your baby kicking? Do you have a kick chart? Any - Discuss Serial USD for fetal growth monitoring (28
history of heart problem, liver, kidney or thyroid weeks onward)
problems? Any previous DVT, surgeries or previous - Discuss fetal movement surveillance
hospitalization? Are you on medications such as - Consider timing of birth
steroids? SADMA? FHx of DM or HTN?
History
Physical examination - I am really sorry about the loss of your child. It is quite
- General appearance: pallor, dehydration, jaundice understandable that you feel upset about this. Would
16

you like someone (a partner or a friend) to attend this tube defects. Your pregnancy will be monitored very
discussion? How are you feeling at the moment? closely and around 12-14 weeks, the OB will assess
- I understand that you pregnancy was at around 22 you for possible cervical incompetence. We will make
weeks, did you have regular checkups until that time? sure that there is nothing that puts your next
Did you have blood tests, and USD? What was the pregnancy at risk. However, you need to make certain
result? Can you please tell me what exactly lifestyle changes like maintaining your weight within
happened? Did you have any symptoms like fever, normal limits, quit smoking, stop drinking, avoiding
rash, vaginal discharge, bleeding? Any problems like recreational drugs, healthy diet, and exercise.
headache, visual changes, or high blood pressure - The delivery will be in a controlled environment at
during the pregnancy? Any tummy pain? Were you around 38 weeks in the presence of a specialist
feeling the baby’s movement at that time? What obstetrician where we will prepare for the possibility of
happened afterwards? Where did the delivery occur? emergency CS.
Did the pain start by itself or was it induced? When the - The specialist/midwife will educate you regarding kick
baby was born, did they notice any abnormal charting for fetal movement and you need to inform us
features? Did they do an autopsy of the child? Was it if you develop any symptoms like fever, vaginal
your first pregnancy? Did you ever suffer from a discharge, bleeding, rash, or reduced fetal movement.

gynecological problem before that? Did you have any Intrauterine Fetal Death (IUFD)
gynecological surgeries done? Any D&C done? Have
you had regular pap smears? When was the last one? Case: You are an HMO in the ED and a 34-weeks pregnant lady
What was the result? Are you having bleeding now comes in with abdominal pain.
after the delivery? SADMA? Blood group? Gardasil?
- Any FHx of birth defects or stillborn babies? Task
a. History (dull, 2/10, similar to menstrual pain, started 2
Physical examination days ago, no N/V, relieved by paracetamol, no fever,
- General appearance and BMI no burning sensation, first pregnancy, blood group A+,
- Vital signs normal pap smear)
- Thyroid enlargement b. Physical examination (anxious, normal BP and HR,
- Chest and heart FHR is absent with handheld doppler, no discharge,
- Abdomen: size of uterus (involuted), tenderness, water leakage, bleeding, urine dipstick negative, BSL
organomegaly 5.5 mmol/L)
- Pelvic exam: discharge, bleeding, speculum c. Management
- Urine dipstick and BSL
Differential Diagnosis
Causes of Stillbirth - Placental abruption
- Unknown - Preterm labor
- Infections (TORCH) - Pre-eclampsia
- Cervical incompetence - Urinary tract infection
- Fetal growth restriction (IUGR) - Red degeneration of fibroid
- PIH - Appendicitis
- Placental insufficiency
- Thrombophilia defects in mother History
- FHx - I understand you have come to the hospital because
- Abruptio placenta you have abdominal pain. When did it start? Can you
- Chronic diseases in mom describe the pain? Does it come and go? Does the
pain travel anywhere? Can you recall any precipitating
Counseling factor such as trauma, exercise or sexual intercourse?
- Most probably, from the history and examination, the Do you have a fever, headache or blurred vision? Do
most likely cause of the stillbirth that you had was an you have N/V or back pain? Any burning sensation
infection that you developed at around 22 weeks. when passing urine? Have you noticed unusual
There are other causes as well like problems with vaginal discharge? Have you had any vaginal
placenta, poor growth of the baby, and certain bleeding or water leakage? Do you feel the baby’s
coagulation defects. It is important to find out the movements? When was the last time you felt the baby
exact cause before your next pregnancy. However, kick? Is this your first pregnancy? Have you had
sometimes, there is no cause that can be found. We regular ANCU? Any problems with your blood tests,
need to do some tests now after consultation with the midpregnancy USD, sweet drink test or blood
specialist gynecologist which includes FBE, cervical pressure? Do you know your blood group? SADMA?
smear and culture to rule out hidden infections, ANA Did anyone come with you today?
testing, VDRL, FBS to rule out diabetes, thrombophilia
screening, and USD to rule out any structural defects Physical Examination
of the uterus. Later on, the specialist might decide to - General appearance and edema
do a hysterogram. This is an xray of the womb that - Vital signs
helps to find out any defects of the shape of the uterus - Abdomen: uterus, fundal height, lie, presentation,
as well as any growths within the uterus. For your next engagement, palpate uterus if tender or hard/tense,
pregnancy, we will manage you in the high risk FHT
pregnancy clinic. You will have an early dating - Pelvic examination: discharge, bleeding, water
ultrasound at around 8-10 weeks. From then on, you leakage, cervical os, swabs (endocervical and high
will have serial ultrasound after every 2 weeks to vaginal)
monitor the baby’s growth. They will discuss with you - Urine dipstick and BSL
regarding screening for Down syndrome and neural
17

Counseling
Management - I’m not sure how this news will sound to you but the
- I’m sorry to tell you but I can’t hear the baby’s heart. report says it is a twin pregnancy. Don’t worry. We will
Most likely, your baby has died. I can see you’re very take care of you. We will do a multi-disciplinary team
distressed, do you know what we can do for you now approach which involves me as your GP, a specialist
or do you need some time? obstetrician, and pediatrician for your babies.
- First of all, we need to confirm this with an USD. We - History: how is your pregnancy going so far? Any
will also look for signs of placental abruption which is abdominal pain, bleeding, or discharge? Any
one of the possible causes for your presentation. excessive N/V? any headache, blurring vision, burning
- Why did it happen? We will try to find a cause. in urine or leg swelling? Do you know what your blood
However, in majority of cases the death is group is? Did you take folic acid during the early
unexplained. For now, I want to order some blood pregnancy? Is it an assisted or natural pregnancy?
tests for you. FBE, HbA1c, urine MCS, swabs, LFTs, Any PMHx? Any FHx of twins, DM, or hypertension?
U&E, TORCH infection screening, TFTs, ANA and SADMA?
lupus anticoagulant - We have two kinds of twins: dizygotic coming from 2
eggs and monozygotic which comes from one egg. In
your case, it is a dizygotic pregnancy with 2 sacs and
placenta. Twin pregnancies run in families or might be

- Medical problems are unlikely at least in the first 3 due to fertility medications. Is it risky? Yes. A twin
weeks after fetal death has been diagnosed and pregnancy is usually slightly high risk than the normal
usually, labor will start during this time. You may pregnancy. There are risks to both mom and the
choose to await spontaneous labor or to have labor babies. The maternal complications are exaggeration
induced. Either way you can have a family member or of signs and symptoms of pregnancy, preeclampsia,
friend during the delivery and we will give you premature labor, gestational DM, malpresentation,
adequate painkillers to reduce the pain of childbirth. If antepartum hemorrhage, increased incidence of CS.
you choose to await spontaneous onset of labor, you Fetal complications include PTL, IUGR, twin-twin
will need frequent blood checks. If labor wouldn’t start transfusion (more in monozygotic), malformations.
within 3 weeks, you will need to have labor induction. - Do not worry. You are in safe hands. We will do our
If your choice is immediate treatment, we can prepare best to manage you and prevent the complications. I
the cervix by using prostaglandin. If you or your will refer you to the high risk clinic. The specialist there
partner wish to bring clothes, see or hold the baby, it is will follow you up. You will need more frequent visits
possible. We strongly recommend an autopsy which (every 2 weeks until 28th week, weekly until delivery).
helps us to find a cause in up to 25% of cases. If You may need multiple ultrasounds starting from 28
you’re against autopsy, we can take a small sample of weeks (every 2-3 weeks). Babies will be monitored by
skin usually in the (axilla region) for chromosomal CTG from 34 weeks (2x a week). Aim to deliver the
study. Placenta will also be examined under the babies at 38 weeks.
microscopy and routine cord blood test. - Increased supplements (iron/folic acid), nutrition
- To suppress lactation after delivery, you need to wear requirements and rest
tight bra and use simple painkillers and ice packs in - Can I go for vaginal delivery? It is very early to
case of engorgement. comment at this stage, but it will depend on the
- We have a bereavement consultant and a social presentation of the first baby and your general health.
worker who can help you with funeral arrangements. If the first baby is cephalic, vaginal delivery is
- Technically, you can get pregnant when your periods possible. 70% (cephalic). If there are any
are back. However, it is important to be physically and complications, then specialist might consider doing
emotionally ready for the future pregnancy. cesarean section.
- We will also do active management of first stage of
MULTIFETAL PREGNANCY labor because of high chance of postpartum
hemorrhage due to overdistention of uterus.
Multifetal Gestation/Pregnancy - Referral/Review/Reading materials (support groups)
- Red flags: bleeding, abdominal pain, water leakage,
Case: A 28-year-old primi who is 18 weeks pregnant comes to headache, blurry vision, urinary symptoms
your GP clinic to collect her ultrasound report that shows twin
pregnancy with 2 placentas and 2 amniotic sacs. ANTEPARTUM HEMORRHAGE

Task Placenta Previa


a. Tell patient about diagnosis and findings
b. Focused history Case: You are an HMO in a hospital OBs-and-Gyne unit and
c. Advise on management your next patient is a 26-year-old 28 weeks pregnant who came
in due to PV bleeding for 1 hour. She has been following up
Complications regularly and there were no remarkable findings up to now.
- Maternal: anemia, symptoms of pregnancy (morning
sickness, varicose veins), preeclampsia x3, Task
antepartum and postpartum hemorrhage, a. Relevant history (x 1 hour)
malpresentation, cord prolapse, CS b. Physical examination (pale and stressed, BP:
- Fetal: increased risk abnormalities, preterm delivery c. Investigation
(PPROM), IUGR in one of the fetus, twin-twin d. Management
transfusion, perinatal mortality x 5; prematurity,
malformations x 2-4 Risk Factors
- Smoking
18

- Previous placenta previa o Total or partial: send to tertiary hospital and


- Previous cesarean section stay until delivery; most cases delivered via
- Multiparity CS
- Advanced maternal age o Marginal or low-lying and with minor
bleeding and bleeding has stopped: go
History home but needs to stay close to hospital;
- Is my patient hemodynamically stable? USG at 34 weeks; delivery: depends on
- When did the bleeding start? How many pads have USG at 34 weeks and specialist will decide
you used? How soaked were they? Any clots? Any on that; CS organized at 38 to 39 weeks
tummy pain? Headache? Dizziness? Sweating?
Palpitations (assess severity of bleeding)? History of o If with severe bleeding and with fetal
trauma? Any bleeding disorders (menstrual history/are compromise  immediate cesarean section
you bleeding from anywhere else)? - Refer, Review and Reading materials
- Pregnancy: how is your pregnancy going so far? Is it a - Red flags: bleeding, baby not kicking, water breaks,
single pregnancy? Planned pregnancy? Significant tummy pain
findings in 18 week ultrasound? How was your sweet
drink test? Is the baby kicking? Previous pregnancy?
How was placenta in previous pregnancy?
- Pills? Partner?

- Period: are they too heavy or normal? Pap? Are you


aware of your blood group?
- Social history: how far are you staying from the Mild Abruptio Placenta
hospital and do you have enough support?
- SADMA? Case: You are an HMO in ED and a young primigravida who is
30 weeks gestational age comes to see you because of vaginal
Physical examination bleeding on examination, she is stable and vitals are normal.
- General appearance: pallor, dehydration and jaundice, Abdomen is not tense but slightly tender. FHT 140/min
signs of trauma
- Vitals: sitting and standing BP, RR, PR, T, oxygen Task
saturation a. Focused history
o If with postural hypotension: I would like to b. Explain condition to patient
insert 2 IV bore cannulas, take blood for c. Management
blood group and crossmatching and start IV
fluids Features
- Abdomen: FH (whether it corresponds to gestational - Separation of the placenta from the uterus
age), lie, presentation, tenderness of uterus, Revealed: bleeding
engagement/floating, FHR - Concealed: severe hypotension
- Pelvic exam: NO Per Vagina Exam!!! - Complications: IUFD, DIC (micro thrombi)
o Inspection: discharge, blood, clot, signs of - Types:
trauma o Mild - blood loss <500ml; no fetal
o Speculum: discharge, blood, cervical os (if compromise; USG to exclude retroplacental
open or close); clots; CTG; -- bed rest; ambulate slowly
- Urine dipstick and BSL once bleeding stops; if term then might do
labor induction by amniotomy
Placenta Previa: o Moderate - about 1/4 of placenta has been
- Total placenta previa (completely obstructs the detached; blood loss >1L; severe abdominal
cervical os) tenderness; shock; fetal compromise;
- Partial Placenta previa (partially obstructing the Admission and stabilize patient; if fetus alive
cervical os) then cesarean section
- Marginal (just at the beginning of the os) o Severe - more than 1500ml of blood, shock,
- Low-lying placenta severe tenderness, fetus is almost always
dead; DIC and coagulopathies are common
Diagnosis and Management - Risk factors
- Most likely, you have placenta previa. At this stage, I o Multiparty
would admit you, put 2 IV lines and take blood for o Hypertension in pregnancy
FBE, blood grouping and crossmatching, and o Smoking
coagulation profile. I will call the OBS&Gyne Registrar o Cocaine abuse
to come and have a look at you
o Trauma
- We need to organize an urgent USG to see the
position of the placenta and the obs and gyne registrar
might also consider doing CTG to check the status of Differential diagnosis
baby. - Placental abruptio
- Placenta previa is an obstetric complication that - Premature labor
occurs in the 2nd half of pregnancy. It can cause - Red degeneration of fibroids
serious complications in both mom and baby. - Trauma
Complications are fetal malpresentation, postpartum - Placenta Previa
hemorrhage, rebleeding, IUGR, isoimmunization
- Reassure History
- Further management: - Is my baby okay? I understand that you are stressed.
Before I answer your questions, I would like to ask you
a few details regarding your pregnancy. Are you still
19

bleeding? When did it start? What were you doing your case. It is a dangerous condition and can
when it started? How much is the blood loss? How seriously affect you and your baby.
many pads did you use? Was it fully soaked? Did you - I know you are feeling unwell. Your BP is low and your
pass any clots? What was the color? Any gush of pulse is fast. They are signs of hemorrhagic shock
water coming out with the blood? Any tummy pain? Do due to blood loss. Most likely you lost at least 30% of
you feel dizzy or palpitations? Do you have any your blood volume and you are still bleeding. It is an
bleeding disorders in you or the family? indication for blood transfusion to increase you and
How's the pregnancy so far? Are you regular with your your baby’s chance for survival. No doctor I still don’t
antenatal checkups? Do you remember your mid- want to be transfused.
gestation USG? How was your sweet drink test? - Miriam, it is your right to refuse the treatment.
Anything abnormal? Is your baby kicking? Is it However, it is important for me to explain the possible
reduced? Do you know blood group? Any previous outcomes so that you can make an informed decision.
pregnancies? Are you regular with your pap smears? Right now, we are doing important preparation for
Smoker? Illicit drugs? emergency cesarean section. Bleeding will stop after
we empty the uterus. However, the operation itself is
associated with blood loss (500ml) and may worsen
your condition if blood transfusion is not started. We
can replace fluids and use synthetic blood substitutes
(Haemaccel). They will reduce shock. However, if
blood loss exceeds 40% of blood volume, the biggest
problem is hypoxia or oxygen deprivation, which may
quickly lead to multiorgan failure/shutdown and death.

Diagnosis and management:

- You have a condition called a mild placental abruption. - Blood loss may also affect your baby’s condition in the
Draw diagram. I will need to organize some same way. Less blood will come to the baby and he
investigations to confirm the diagnosis and make sure will experience hypoxia.
the baby is alright. I will request for an USG to check - You are losing RBCs which have a very special
the degree of abruptio and request for CTG, full blood function to carry oxygen to all organs and tissues in
examination, UEC, crossmatching, coagulation profile, your body. The only way to restore that is by blood
indirect coomb test and kleihauer test. transfusion.
- Is this hospital a tertiary hospital? I would like to admit - No doctor I still don’t want to be transfused. Miriam, I
you. At this stage the bleeding has stopped but the understand and respect your wish. Can you please tell
condition is risky. I will call the OB registrar to come me if you fully understand all possible consequences
and have a look. Meanwhile I will secure IV lines and which may arise without blood transfusion?
collect blood for investigations. Because you are RH- - We will do our best to save you and your baby’s life
we will give you anti-D injection. We will consider without blood transfusion.
injection of Betamethasone 2 injections 12 hours apart
to help with the maturity of your baby's lung. Examiner: Summarize legal and ethical issue in this situation
- What about the delivery? At this stage, we cannot say. - Every competent patient has the right to accept/refuse
You are stable now. We have to wait for the results of treatment.
the ultrasound and CTG. However, if your baby - In this case, there is the potential to damage the fetus.
becomes distressed or the bleeding recurs, the In Australia, the fetus has no rights.
specialist might decide to do an emergency cesarean - Born babies can be transfused without parental
section. consent providing it is a life-saving procedure.
- Reassure.
- If in pain, IV pethidine. How would you manage this situation?
- I will continue monitoring mother and baby’s condition
Blood Transfusion Consent in APH until emergency cesarean section has been arranged.
- I need to continue fluid transfusion.
Book case 123: - I need to talk to senior doctor to help me.
- If husband is available, then can talk to husband.
Task
a. Ascertain patient’s view on blood transfusion Pregnancy with Road Traffic Accident
b. Explain risks and benefits of treatment to patient and
baby Case: You are an HMO in ED and a 23-year-old female comes
c. After six minutes, answer examiner’s question to you complaining of tummy pain. She is 32 weeks pregnant
and was in a car accident.
Counseling
- Hello Miriam, I want to explain your condition and Task
possible ways of management. You are having b. History
severe bleeding, and we call it antepartum c. Physical examination (B-, stable VS pallor,
hemorrhage. An emergency USD confirms placental generalized tenderness, FH=GA, cephalic, FHS +, no
previa. Placenta previa means the placenta is lying in bleeding, or contractions)
the way of the baby. This condition is a common d. Management
cause of bleeding in pregnancy. Thirty percent of all
APH is because of placenta previa. It usually presents History
with causeless, painless and recurrent bleeding. - Is my patient hemodynamically stable?
Sometimes, it can present with severe bleeding like in
20

- I would like to talk to my patient preferably in a o Serious trauma after second trimester where
resuscitation cubicle with all the necessary the patient requires fetal monitoring for 24
resuscitation equipment. hours or more
- How are you feeling at the moment? Let me reassure o Abnormal obstetric findings like vaginal
you that you are in safe hands. If you want, I can call bleeding
someone to be with you. - Keep admitted until all possible complications have
- I understand you have tummy pain? Where is it? How been ruled out such as fetal death, premature ROM
bad is it? What is the type of pain? Does it come and leading to PTL, abruptio placenta (can be delayed for
go or is it constant? Does it go anywhere else (back or up to 48 hours), amniotic fluid embolism, and
towards genitalia – to r/o pelvic organ damage)? Do chorioamnionitis
you think it is getting worse?
- Can I ask more about the accident? When did it Concealed Placental Abruption
happen? How? Who was driving? Were you in the
passenger seat/backseat? How fast was it going? Case: You are an HMO and a 25-year-old female who is 32
Were you wearing seatbelt? Do you have bleeding, or weeks pregnant came in due to sudden onset of severe
discharge from down below? Do you have headache, abdominal pain.
N/V? Did you hurt your head? Is there a wound
anywhere on your body? Did you lose consciousness Task
at any time? Do you feel the baby kicking? a. History (pain is 7/10, sharp pain, started 45 minutes
- Previous obstetric history? What is your blood group? ago, bending over decreases the pain, baby kicking;
Partner’s blood group? Did you receive any injection waterworks normal, ANC, USD, and sweet test
of anti-D during pregnancy? Any past history of normal)
bleeding disorders, clotting problems, illnesses? b. Physical examination (pale, anxious, sweating,
SADMA? increased HR, normal BP, RR, O2, Temperature, FH
appropriate for age, tender all over, mainly around
umbilicus, guarding +, cephalic, FHS+; pelvic no
bleeding or discharge; os closed)
c. Diagnosis and management

Physical Examination
- Full primary survey of the patient Differential Diagnosis
- Ensure her airway, breathing, circulation are not - Placental abruption
compromised - Placenta Previa
- Inspect for any visible signs of trauma all over the - Acute red degeneration of fibroid
body? Bruises? Pallor? Dehydration? - Preterm labor
- Vital signs especially BP - Appendicitis
- Secondary survey looking for signs of trauma to the - Bowel obstruction
bones, joints, vessels (pulses) - Torsion
- Abdomen: palpate any tenderness, guarding, rebound
and signs of ecchymosis, large bruise over lower History
tummy, fundal height, lie, presentation, FHS, uterine - Is my patient hemodynamically stable? I would like to
contractions take a history and I would like to ask for IV access.
- Pelvic exam: visible bleeding, discharge, signs of - Can you please tell me more about the pain? When
trauma, nitrazine test (if pH >5 normal; >5-7 amniotic did it start? How bad is it on a scale of 1-10? Can you
fluid) point out where exactly is the pain? Does it go
- B/E  preferable done by obstetrician at tertiary care anywhere else like towards the flanks or downwards
- Urine dipstick and BSL toward the pubic area? Did you hurt yourself in that
- Heart and chest area? Do you think this pain is associated with
N/V/headache/dizziness? Any bleeding from down
Management below? Vaginal discharge? Leaking of water? Do you
- I would like to ask for review by specialist obstetrician think the pain is continuous or does it come and go?
and I will arrange for blood tests such as FBE, U&E, Do you think this pain was related to sexual activity
BSL, crossmatching, D-dimer, coagulation profile, (placenta previa)? Do you have any associated
ABG, Kleihauer test to determine amount of problems with waterworks? Any history of constipation
fetomaternal hemorrhage to decide the amount of or bowel-related problems? Is this your first
antiD, ECG and xray of pelvic girdle. pregnancy? Any miscarriages before? Have you had
- Risk of fetal deformities are minimized during the third regular antenatal visits? Are you aware of the results
trimester and usual radiation exposure is very low of your last USD? What was the position of the baby?
o Typical pelvic xray – 0.10 mGyron Placenta? Can you feel the baby kicking? How often
o CT scan – 20-50 mGyron during the last 1 hour? How is you general health?
o Proven risk - >50-100 mGyron Any medical or surgical condition? Is this the first
- I would also like to do USD to assess for fetal viability, episode of pain? Do you have any fever along with the
size, gestational age, and position of baby, and any pain? What is your blood group? What is your
evidence of intraperitoneal fluid or hemorrhage. Also, I husband’s blood group? Have you received any anti-D
would like to hook you to continuous CTG for 24 hours injections up to now?
to look for any signs of fetal distress. - FHx of HPN, DM, bleeding disorders
o Indications for CTG: bleeding, previous CTG
is abnormal, trauma Physical examination
- Most likely, the obstetrician will advise anti-D IM - General appearance
dosage after the results of the Kleihauer test. - Vital signs: postural BP drop
- Criteria for admission
o FHR on CTG shows variable decelerations
21

- Abdomen: FH, lie/presentation, FHR, tenderness on (derealization)? Do you feel the baby kicking? Have
palpation, guarding, rigidity, tenderness especially you noticed any leaking from down below? Any
over the RIF/LIF? swelling of your ankles? Have you had all regular
- Pelvic: inspect for signs of bleeding, discharge, antenatal checkups? USD? Blood tests? Sweet test?
leaking; insert sterile speculum for bleeding, Are you generally healthy? Any medical or surgical
discharge, pooling of fluid, nitrazine test; os if it is condition? Before this pregnancy, have you ever been
open or closed diagnosed with high blood pressure, kidney problems,
- Bimanual examination is preferably avoided until an DM or any other conditions? FHx of similar condition?
ultrasound has been obtained SADMA? Blood group!

Investigations Physical Examination


- FBE, blood grouping, crossmatching and hold. I would - General appearance
like to do a CTG to assess fetal distress, coagulation - Vital signs
profile, LFTs, RFTs. If she is RH (-) I would like to do - Evidence of pedal edema (pitting or non-pitting)
kleihauer test to check fetomaternal hemorrhage. - Funduscopy for bulging of the disc
Also, I would organize an USD to check for fetal - Chest and heart
viability, position of placenta, and if there is any - Abdomen (FH, lie/presentation, FHT, tenderness)
abruption of the placenta and amount of blood. - Reflexes
- Urine dipstick and BSL
Management
- Unfortunately, what you have is a serious condition Management
called placental abruption. Basically, a part of the - I would like to put the patient on the left lateral position
placenta starts detaching from the wall of the womb and call for help. Check the airway. If there are
for some reason. The exact cause is not known. secretions wipe with clean cloth or suction. Put airway.
However, there are certain risk factors like trauma, Give oxygen by mask if possible. IV access. I would
smoking, high blood pressure in the mom, diabetes, like to start her on magnesium IV LD 4gms over 15
previous history of placental abruption, high parity, minutes diluted with NSS and continue with 1 gram
poor nutrition, and sometimes, it is unexplained. divided over 24 hours. IV hydralazine (5-10mg bolus
- This condition can be quite serious as there is a high given over 5-10 minutes then an infusion of 5mg/hr is
risk of PROM, PTL, fetal distress, maternal shock,
acute renal failure and sometimes, IUFD.

maintained. Aim is to keep the BP between 140/90


- I need to admit and you need to be urgently seen by a and 160/100; add beta-blocker if with tachycardia)
specialist obstetrician. We will start you on IV fluid and after the patient has been seen by the specialist.
monitor your urine output with the help of catheter. We - At GP clinic  methyldopa or nifedipine spray to
will send blood for crossmatching. If required, we lower BP
might need to transfuse you. We need to prepare for - I would inform the obstetric team to organize for
possible premature delivery. I will inform the theater to immediate delivery.
prepare for emergency cesarean section. We will give - I would like to monitor the patient by monitoring her:
you steroids to help with the maturation of baby’s urine output, continuous ECG, reflexes, vital signs.
lungs. - Investigation: FBE, U&E, LFTs, coagulation profile,
- Usually, with moderate to large placental abruption, blood grouping and crossmatching, USD, CTG,
there is a need to deliver the baby ASAP. We will also thrombophilia screening
give you anti-D injections to prevent any - Aim of treatment: prevent development of fits
incompatibility of blood groups. - Aim of treatment if with fits: deliver the baby
- If the baby is non-viable, if you are stable, we will - I would like to call in obstetrician. If the pregnancy is
induce and deliver the baby. But if not, emergency less than 34 weeks, we will give the patient steroids
cesarean section is performed. Betamethasone (Celestone) 11.4mg IM 2 dose 12
hours apart, stabilize patient, and monitor all
HYPERTENSIVE DISORDERS OF PREGNANCY symptoms. The patient remains at the hospital for
observation. If symptoms worsen, we deliver by CS.
Pregnancy-Induced Hypertension/Pre-eclampsia - If pregnancy is more than 34 completed weeks,
deliver by induction or cesarean section.
Case: You are a GP and a 30-weeks-pregnant primigravida - If platelets are going low  give FFP
comes to your clinic. She is complaining of headache. Her BP - If patient develops symptoms of pulmonary edema 
today is 170/110mmHg. It was the same on a previous give high-flow oxygen and diuretics.
occasion. - Complications: ARF, cardiac failure, cerebral
hemorrhages, DIC, IUD, HELLP syndrome,
Task
a. Relevant History Counseling of mom
b. Manage the case - What your daughter has had just now is a fit as a
consequence of a very high blood pressure. This
History condition is known as PIH. This can happen because
- Is my patient hemodynamically stable? I would like to of certain chemicals that are released by the placenta
know all the vital signs. that cause constriction of blood vessels and formation
- I would like to give the patient methyldopa now. of clots because of reduced supply to the brain
- If she develops fits while talking rectal diazepam 5-10 resulting to the fit. It is very important to control the
mg symptoms to prevent complications like liver failure,
- I would like to ask some history from the patient. heart failure, and kidney failure. That is why we are
Please tell me if you’re having symptoms like sending her to the hospital right away. She will be
headache, BOV, tummy pain, or bleeding from down seen by a specialist OB. They will lower her BP with
below? Any abnormal feelings that you have medications, but the cure is to deliver the baby.
22

a. History
CARDIOVASCULAR, RESPIRATORY, HEMATOLOGIC, b. Physical examination
NEUROLOGIC, GASTROINTESTINAL CONDITIONS IN c. Diagnosis and Management
PREGNANCY
History
Abdominal pain (Early Pregnancy)  Uncomplicated Cystitis - I understand that you’re here for your blood results
and it was found that you have iron deficiency anemia.
Case: You are an HMO in the ED and your next patient is a 12- This means that there is less oxygen delivered to the
week GA pregnant lady complaining of nausea and vomiting. tissues.
This is her first pregnancy. No complications so far. - Do you feel tired? Is there any dizziness, palpitations
or SOB?
Task - How is your pregnancy so far? Have you had regular
a. History (N/V with dull, nonspecific lower abdominal antenatal checkups? How are your blood tests and
pain x 2 days; malaise; tolerate meals) ultrasound? How about your pregnancies? Have you
b. Physical examination (T:37.6, BP: 115/80; soft, tender had blood loss? When was your last pregnancy?
in lower abdomen but not peritonitic signs; os is blue, - What about your periods? Did you have abnormal
closed, no secretions or bleeding; free adnexas; bleeding? What about your diet? Any bleeding
fundus expected high according to gestational age; disorders? Are you on any special diet? Is the baby
nitrites ++++, leukocytes +++, no blood, protein and kicking? Any other health problems?
sugar) - Blood group?
c. Diagnosis and Management
Physical examination
History - General examination: pallor, bruising, lethargy,
- Was it a planned pregnancy? Congratulations. When - Vital signs: postural drop
did it start? Are you able to tolerate meals? Do you - Lungs
feel tired? Do you have abdominal pain? What type of - Cardiac: murmur (systolic)
pain? Any discharges or bleeding? Fever? Pregnancy - Abdomen: FH (check for IUGR), abdomen soft or
checks? Did you have any tests done? Are you taking tense, FHT
folic acid? Did they mention your blood group? - Pelvic examination: bleeding, discharge
- Urine dipstick and blood sugar

- PMHx: any history of UTI;


- 5Ps: previous miscarriages; twin pregnancies? Diagnosis and Management
- You have a condition called iron-deficiency anemia. It
Physical examination: is the most common cause of anemia in pregnancy. It
- General appearance: pallor, dehydration is often asymptomatic and detected on screening as in
- Vital signs: stable except temperature 37.5 your case. There is high demand of iron during
- ENT/CVS/Lungs pregnancy and in your case, most likely the reason is
- Abdomen: tenderness of lower abdomen due to the inadequate gap.
- Pelvic: - There are some risks to you and your baby because
o Inspection of genitalia: bleeding, discharge; of this. Anemia can predispose you to infections,
o Speculum: no bleeding or discharge; os is excessive blood loss during pregnancy, and can affect
close; your heart. Because of this, there is reduced oxygen
o Bimanual examination: adnexa are free; supply to the baby which can lead to IUGR, fetal
uterus is expected high distress and in severe cases, stillbirth.
- Urine dipstick and BSL - We need to give you iron supplements. 200 mg 2x
daily. The hemoglobin level should increase by 1gm/L
per week. There are some side effects like nausea,
Diagnosis and Management
tummy pain, black stool, and constipation. We will
- You have a condition called UTI most likely what we
stop the medications 3 months after your hemoglobin
call cystitis. Do you know what it is? At this point, I am
levels become normal. I would also advise you to eat
happy to send you back home, but if the condition
more iron-rich foods such as iron-fortified cereals,
persists and you cannot tolerate foods or drinks, fever,
legumes, nuts and nut butters, seeds, wholegrain
chills and pain in the back, then go to the ED.
breads, green leafy vegetables, dried fruit, iron-
- I will need to send your urine for culture and sensitivity
enriched breakfast cereals, milo and ovaltine and liver.
and I am going to start you on amoxicillin 500 mg TID
Eating a lot of vitamin C rich foods to increase
or cephalexin 500 mg BID or nitrofurantoin 50mg QID.
absorption of iron;
If pyelonephritis: ceftriaxone IV 1g OD.
- Parenteral iron indications: if close to delivery and if
- I will review you in 3 days and we will either continue
cannot tolerate oral iron and Hgb <7g/L
your medication or change it according to the results
- Anemia: Hgb <110g/L in 1st trimester and <100g/L in
of your culture. I will prescribe paracetamol for the
late second or third trimester. Iron requirements
abdominal pain and metoclopramide for vomiting.
increased to 1300mg/day.
- Review after 2 weeks. Refer if not increasing.
Anemia in Pregnancy
- Reading material.
Case: You are a GP and a 28-year-old G4P3 20 weeks’
Asthma in Pregnancy
pregnant lady has come to see you to know the results of the
recent blood tests. The blood tests hemoglobin is low, MCV is
Case: A 26-year-old female who is 20 weeks pregnant comes to
low, transferrin is high, ferritin is low.
your GP clinic complaining of SOB.
Task
Task
23

a. History (had mild asthma and use ventolin PRN; asthma attack. Most likely you will be nebulized with
sudden, fever; with wet cough; greenish or yellow; ex- ventolin, ipratropium and IV steroids and treatment of
smoker and partner is a smoker) infection with IV antiobiotics.
b. Physical examination (in distress; audbible wheeze, - Which antibiotic would you like to use? Benzypenicillin
BP 120/80; T:38, RR26, O2 93, HR 100; RR or amoxicillin or erythromycin if with allergy
increased; increased work of breathing, retractions, - You will also be hydrated with IV fluid and have
increase vocal fremitus in right lung base; dullness on oxygen.
right lung base and decreased air entry on right lung - You will have some tests: FBE, ESR/CRP, blood
base and diffuse wheezing; FH 20cm, FHT 140, cultures, and U&E, sputum for microscopy and
uterus soft and non-tender) culture; CXR if indicated
c. Diagnosis and management - How long will I stay in the hospital? You will probably
stay for a few days. We need to control your
Differential Diagnosis pneumonia and asthma. If your temperature has
- Pulmonary embolism returned to normal for 48 hours and you are free of
- Asthma exacerbation asthma symptoms, you will be discharged and treated
- Spontaneous Pneumothorax as an outpatient.
- Heart failure
Pregnancy plus Cardiac Murmur
History
- I understand you have come to see me because of Case: You are a GP and a 32-year-old 10- week (or 20-week)
SOB? When did it start? Did it happen suddenly or pregnant lady came in due to shortness of breathing. She is a
gradually? Do you feel SOB at rest or only on primigravida.
exertion? Does anything make it better or worse? Is it
the first episode? Do you have a fever, shivers? Do Task
you have a cough? Is it dry or wet? What’s the
sputum? Did you notice blood in the sputum? Do you a. History (1st pregnancy; noted SOB x 1 month ago with
have chest pain or tightness? Is it worse with deep occasional palpitations, no chest pain, especially with
inspiration? Do you feel your heart is racing? Do you walking, + history of RF 6-7 years old,
feel nauseous? Have you been vomiting? Do you
have abdominal pain? Have you felt the baby kick?

Any Vaginal discharge or bleeding? Waterworks and


bowel? Calf tenderness or swelling? b. Physical examination (vital is normal, no thyroid
- Is it your first pregnancy? How’s your pregnancy so enlargement, no carotid bruits, no rashes or jaundice,
far? Any problems with blood tests? Any problems chest normal, apex is normal, tapping, auscultation
with USD? Do you know your blood group? low-pitch, rumbling diastolic murmur best heard with
- Can you please tell me more about your asthma? bell on the left lateral position; soft, nontender, no
When were you diagnosed? How often do you get hepatosplenomegaly; ankle edema)
attacks? Do you have symptoms between attacks? c. Diagnosis and management
Which medications are you on? Have you ever been
admitted to the hospital with severe asthma attack? History
Have you ever been admitted to the ICU or ever been - I know you have come to see me because you are
intubated? Do you know any precipitating factors short of breath. When did it start? Did it happen
(smoking, cold air, exercise, dust, pollen, infection)? suddenly or gradually? Do you have SOB at rest or
Other medical or surgical conditions in the past? Are only during physical activity? How far can you walk
you on any medications? Allergies? Smoking? (block)? Is it the first episode? Associated symptoms:
- What do you do for a living? Any recent history of fever, cough, noisy breathing, chest pain or tightness?
travel? Do you notice your heart is racing or beating
- FHx of asthma irregularly? Do you sleep flat? How many pillows do
you use when you go to sleep? Have you ever woken
Physical examination up at night SOB? Have you noticed swelling of your
- General appearance and peripheral cyanosis; signs of ankles? How’s your appetite? Do you feel tired? Do
respiratory distress you have N/V? Do you have abdominal pain? How’s
- Vital signs your waterworks? Any unusual vaginal discharge or
- ENT bleeding? History of travel?
- Chest: - I know it’s your first pregnancy, is it planned? Did you
o Inspection: use of accessory muscle; chest see any doctors regarding your pregnancy? How did
expansion; you confirm pregnancy? Do you know your blood
o Palpation: chest expansion; vocal fremitus group? When was your last pap smear?
o Percussion: dullness or hyperresonance - PMHx: Are you generally healthy? Any serious
o Auscultation: air entry; condition or surgeries in the past? Any heart or lung
o Peak-flow meter disease? Can you remember what type of treatment
- Heart did you receive? Did you have regular follow-ups?
- Abdomen: FH, FHT, uterus is soft and nontender Medications? Allergy? Smoking? Alcohol? Do you
have enough support? FHx of heart or lung problems?
Management
- According to your history and PE, it is most likely an Physical Examination
acute asthma attack secondary to chest - General appearance
infection/pneumonia. You need to be admitted in the - Vital signs: PR (regular)
hospital. You will receive treatment to control the
24

- CVS: peripheral/central cyanosis and pallor, JVP, The plasma glucose level was 9.2mmol/L (N<8mmol/L) after 1
inspection and palpation of precordium, apex beat, hour.
thrills, murmur
- Lungs: evidence of pulmonary edema or pleural Task
effusion a. Further history (FHx of DM, regular PNCU, no
- Abdomen: hepatomegaly, tenderness symptoms of DM)
- Legs: peripheral edema b. Explain the results
c. Examination (FH, FHT +, cephalic)
Diagnosis and Management d. Diagnosis and outline management
- According to your history and PE, I suspect heart
valve disease which is called mitral stenosis. Your History
heart has 4 chambers. Mitral valve separates the - How’s your pregnancy going so far? How was your
upper and lower chambers on the left side of the midpregnancy ultrasound? Is this your first
heart. Stenosis means the valve doesn’t open fully pregnancy? Have you ever been diagnosed with
restricting blood flow. Most likely, it’s the complication diabetes before? Recurrent thrush/candidiasis?
of rheumatic fever. Polyuria, polyphagia? Any other previous illnesses or
- I will refer you to the cardiologist for further surgeries? Any FHx of diabetes? Blood group? Are
assessment. You need to have ECG and echo to you regular with pap smear? Weight before pregnancy
confirm the diagnosis and assess the severity and and weigh now?
heart function. - Do you think your tummy is more distended than what
- Normal pregnancy is associated with significant you expect it to be? Any previous pregnancies or
hemodynamic changes (increased blood volume) and miscarriages? Do you have headache, frothy urine, or
your heart will need to work harder and may worsen blurred vision? SADMA? Social history?
your condition. That is why, for the best outcome of
your pregnancy, you will be managed in a high-risk Physical examination
pregnancy clinic. You will be seen by an OB, - General appearance: edema, BMI
cardiologist, midwives and GP. - Vital signs
- During the pregnancy you will have more frequent - Chest and heart
follow-ups and the cardiologist will make a decision - Abdomen: FH, lie or presentation, floating/engaged,
about treatment FHT
- Pelvic examination: discharge, spotting/blood, os,

- NYHA (Heart Failure)


o I – no symptoms but with signs of cardiac
damage Diagnosis and management
o II – symptoms comes with ordinary physical - I would like to organize some confirmatory tests
exertion; dyspnea, SOB, palpitations, because the GCT we did 2 days ago is one of the
tiredness; usually treatment not required in screening tests so I would like to do the oral glucose
pregnancy; monitor for deterioration tolerance test. In that test, you have to fast and we’ll
o III – asymptomatic at rest but symptomatic give you oral glucose and measure the blood sugar
with minimal physical exertion; treatment levels at 1 and 2 hours. In addition, I would also
required organize FBE, HbA1c, urine MCS, USD and CTG.
o IV – symptomatic at rest; admission to
hospital for treatment - From the history and examination, you have a
- Will I be able to deliver vaginally? Most women who condition called gestational diabetes. This means that
have heart disease have an easy spontaneous labor. during the pregnancy your blood sugar has increased
There is no indication for inducing labor. During labor, too much. Gestational diabetes is the result of the
you will need to be on your side or well-propped up to hormone called Human placental lactogen (HPL)
avoid compression of the major vessels (aorta) which produced by the placenta, progesterone, beta-hCG,
may cause marked decrease in BP. If there is a delay and cortisol. All these substances/hormones have
at the 2nd stage of labor, instruments (forceps/vacuum) anti-insulin effects.
will be used. If there is a need for medication to - Gestational diabetes increases the mother’s risk and
stimulate uterine contractions, oxytocin is the puts the baby at risk as well. Mother’s glucose crosses
preferable one. You will be closely monitored during the placenta, but insulin cannot and fetal pancreas
the delivery and after. gets activated and starts secreting additional insulin
- If heart failure needs to be treated, same drugs (beta- and because of that baby’s can become macrosomic
blocker, digoxin, diuretics) are given as for non- (large babies), hence we will do frequent USD. The
pregnant apart from ace inhibitors. baby may also develop jaundice and there is
- Do you have any questions? increased chance of premature delivery, which leads
to prematurity and hyaline membrane disease. There
ENDOCRINE DISORDERS OF PREGNANCY is also a risk of neonatal hypoglycemia because of
increased insulin, as well IUGR and IUFD.
Gestational Diabetes - Do not worry. You are in safe hands, but with good
monitoring done by the MDT these risks can be
Case: Your next patient in GP practice is a 28-year-old woman minimized dramatically. I need to refer you to a
who is 28-weeks pregnant. She returns to you for the results of diabetic physician/endocrinologist, obstetrician,
the GCT with 75 grams of oral glucose load done 2 days ago. dietitian and diabetic educator. Our main aim is to
25

maintain the BSL to <7mmol/L by dietary


modifications. You need to measure you BSL at least
3x a day. If the BSL is not controlled with the diet we
will start with insulin. I would advise you to maintain a
diary of your BSL. You might also need to be reviewed
by ophthalmologist and kidney specialist. We will
monitor you by doing the HbA1c and urine protein
(microalbuminuria).
- From 32 weeks of pregnancy, we will start doing CTG
to monitor the baby. If your sugar is well controlled, we
will do it once a week but if not, we will do 2x a week.
If euglycemia is achieved, the specialist may give you
a trial of labor/normal delivery. They will also organize
USD in the 3rd trimester to assess the growth of the
baby and we do a planned delivery at term (38
weeks). Depending on how your glucose levels are,
you might need intermittent insulin injections during
labor. If baby is big or any other complications
Immunized; safe to be pregnant
happen, the specialist might consider doing cesarean IgG +, IgM -
section.
- Don’t worry. We just have to control your blood sugar
level.
- Will I remain diabetic? Usually, the diabetes will not patient
Pregnant (b-hCg -) Vaccination and avoid pregnancy till the ne
resolve after delivery. However, there is an increased IgG -, IgM -
chance of recurrence in succeeding pregnancies and
30% risk of developing DM later in life. Hence, we
need to organize a followup GTT 6-8 weeks after
delivery and to be checked 2 yearly (every 5 years in Mild illness: symptomatic control; she can b
IgG -, IgM +
clinical book).
- Red flags: uterine contractions, leaking of water, etc.

Rubella Varicella
Vaccination No No
Immunoglobulin No Yes
Termination Yes if IgM (+) Never

- Complete damage of baby (>45%) if mother exposed


INFECTIONS IN PREGNANCY during the 1st trimester
- Further damage can result to deafness and cataract
Rubella exposure in pregnancy - Offer termination of pregnancy
- NO vaccination in pregnancy
Case: 28-year-old schoolteacher presented in your GP clinic - Can cause abortion, miscarriage, stillbirth, IUGR, fetal
concerned she was exposed to an 8-year-old student who was infection
confirmed to have Rubella infection. She is not sure if she is - Congenital rubella:
pregnant or not. LMP was 10 weeks ago. o Cataract, deafness, developemental delay,
irritability, mental retardation, microcephaly,
Task: neurologic (meningoencephalitis)
a. Talk to the patient o Heart: patent ductus arteriosus, tricuspid
b. Discuss her concerns stenosis
c. Answer her concerns
Chickenpox in pregnancy
History:
- I know that you are concerned about being exposed to Case: 25-year-old G3 female who is currently 10 weeks
a child with rubella and being pregnant. How long pregnant. She is worried because her son has chickenpox.
have you been exposed to this child? Have you had
any fever? Rash? Body ache? Did you have any Task:
previous vaccination against rubella or any chance a. Counsel the patient
you’ve been infected with rubella before? When was
your LMP? How frequent were your periods?
Immunized; safeDid
toyou
continue pregnancy
- Congratulate on pregnancy
IgG +, IgM -
check PT? Do you have signs of pregnancy? N/V? - I understand from the notes that your son is having
morning sickness? Tender breasts? Are you in a stage chickenpox. How is he? Is he feeling better? When
of having a planned pregnancy? exactly did he have the rash? Who diagnosed the
- Do you have any other systemic illnesses? Are you chickenpox? Is the rash becoming dry by now? Have
Pregnant patient using folic acid?
(b-hCg
Avoid +) Meds?
further Pap smear?
contact; can Blood group?pregnancy and repeat
continue youtest
had in
chickenpox
2-3 weeksbefore? At the moment are you
SADMA? IgG -, IgM - suffering from fever, rash or any other symptoms?
Were you vaccinated against chickenpox. Have you
Management had regular antenatal checkups up till now? Did you
have the
1st 8-10 weeks of gestation and this condition is called congenital rubella syndrome with lotsblood tests? USD?malformations.
of congenital Results? Offer patient r
- Do I have any examination findings?

IgG -, IgM +
26

- How much do you know about chickenpox? sepsis. Although only 1% gets it, it is a serious
- Chickenpox is a viral infection caused by varicella infection and carries serious mortality for the infected
zoster virus. It is a very common infection especially in baby.
school-going kids. From statistics, we know that 80% - There are some risk factors which can exaggerate the
of pregnant females are found to be immune or risk of infecting your baby:
protected either as a result of exposure in childhood or o Preterm delivery
from immunization. This immunity is lifelong. If you o Prolonged rupture of membrane
have had it before, the risk is minimal for you. o Maternal fever >38C during labor
- I will arrange some blood tests if you have antibodies o Previous GBS infection
in your blood. There are two types of antibodies that - Reassurance  don’t worry, it’s good we have picked
we check: IgG (if + that means you are immune and up at this stage and we will do our best
can continue with pregnancy without any problems); - We will give IV antibiotics (Penicillin 3G initially as LD
IgM (if + it indicates that you have been recently then 1.5 gms or erythromycin q4) during labor which is
exposed to this infection, but let me reassure you that started at least 4 hours before delivery
the risk to the baby within the first trimester is only - Baby will be assessed by pediatrician. If completely
0.4% and later on goes up to 2%. healthy, and no risk factors, no antibiotics will be
- The period of highest risk both for the baby and for given.
you is 1 week before and after delivery. Especially for - Give reading material and red flags arrange for review
the mother with an active chickenpox infection, there after 1 week
is a 10% chance of developing certain complications
e,g. encephalitis, pneumonia and hepatitis which can Critical Errors:
be fatal. - Failure to advise mother that it can be serious for the
- If baby is infected, he/she might be born with a baby
condition called congenital varicella syndrome - If you tell neonatal sepsis can be handled easily
where he might have a rash, similar to the chickenpox - Offering antibiotics now
rash, limb defects, IUGR, microcephaly, cataracts,
micropthalmia, MR (due to cortical atrophy), muscle Recurrent Herpes in Pregnancy
and bone defects
- If IgM+  give Immunoglobulins that can prevent and Case: You are a GP and 28-year-old primigravida who is 20
reduce severity of disease for mother. It is usually weeks GA comes in complaining of pain and ulcers over the
given via IM injections preferably within 4 days of vulva over the last 2 days.
exposure because efficacy is highest. If you develop
sx, we will give acyclovir that reduces the severity and Task
duration of chickenpox. a. History
b. Physical examination
c. Management at present and during labor

- Please don’t worry too much because the risk of History


infection and complications is low. I will write the order - Are you in a lot of pain? Would you like some
for you. Please come back tomorrow for review. painkillers? When did it start? How bad is it from 1-
- If IgM is positive then you have to proceed to the 10? What kind of pain? Burning? Stabbing? Shooting?
hospital for review by an obstetrician. Is this the first time? Do you have any problems with
your waterworks? Have you noticed any fever,
GBS In Pregnancy headache, any lumps and bumps in the body
especially in the groin area? Any vaginal discharge?
Case: Mrs. Mary Jones had her last antenatal visit at 37th week What about the ulcers? Did they come with the pain or
and vaginal swab for GBS was done which is positive. She is afterwards?
concerned to hear and wants to know the risks for the baby and - I understand you’re 20 weeks pregnant. How is it so
herself. far? Have you had regular antenatal checkup? Have
you had all the blood tests? Can you feel the baby
Task: kicking? Any bleeding or spotting down below? Any
a. Explain nature of disease and its appropriate tummy pain?
management - Are you in a stable relationship? May I ask how many
b. Answer patient’s questions partners have you had previously? Have you or any of
- Congratulate pregnancy your partners every suffered from an STI? What
- From the notes I understand that you are here to contraceptives were you using before this pregnancy?
discuss your results. Your vaginal swab shows the - How is your general health? When was your last
presence of bacteria called GBS. This is a bug. Before episode of genital ulcers? Did you have fever and
we go ahead, I would like to ask some question. Is it lumps in the body at the time? What treatment was
alright? given by your doctor? Did it help? Any problems?
- Ask for burning sensation in urine, smelly, increased SADMA?
frequency, lower burning pains, change in color of
urine Physical examination
- How is your pregnancy going so far? Any concerns? - General appearance
- Are you allergic to any medications? - Vital signs
- GBS are normal vaginal bacteria in healthy women - Abdomen: Fundal height, tenderness, rash in the
and is found in 18-27% of pregnant women. It will abdomen, blisters/ulcers (dermatomal distribution), lie
cause no harm to you, but we are concerned that if of baby and fetal heart sounds
present during labor, it can harm your baby. 40-50% of - Pelvic:
babies are colonized but only 1% develops neonatal
27

o Inspection: redness, discharge, ulcers o Treat baby with acyclovir after delivery
(unilateral – syphilis or bilateral – herpes; - If with 1st infection of herpes: risk to the baby is 50%.
weeping/wet –herpes; pus or discharge –
superimposed bacterial infection), vesicles, DISEASES OF PLACENTA AND MEMBRANES
warts
o Groin for tenderness and evidence of Molar Pregnancy Counseling
lymphadenopathy
- Urine dipstick and BSL Case: You are a GP and a 30-year-old female comes to
complaining of tummy pain, vaginal bleeding and passing grape-
ASHM (Australasian sexual health medicine) and RCOG like material with the bleeding. The ultrasound was done that
Differential Diagnosis for Genital Ulcer Disease has confirmed molar pregnancy.
- Herpes – until proven otherwise
- Syphilis – single, painless, wet ulcer Features:
- Allergy/scabies/vulvar (squamous cell carcinoma) - Bleeding + passage of grape-like debris
- Varicella – painful vesicles – ulcer with dermatomal - May be exagerrage symptoms of pregnancy
radiation (hyperemesis)
- Donovanosis – not common in Australia; - Uterus large for dates
Calymmatobacterium granulomatis)
- Trauma Investigations:
- Lymphogranuloma venereum – Chlamydia - FBC, blood group and cross-match, beta-hcG,
- Chancroid (Haemophilus ducreyi) – painful ultrasound (pelvic: snow-storm appearance), CXR
- Suction curette with oxytocin drip
Investigation - Hysterectomy if patient has completed family planning
- FBE, MSU (if indicated), swabs from ulcer to send for - Register in trophoblastic registry
PCR, antibody testing in the blood specific for herpes,
oral swabs Followup
- Offer full STD screening, and preferably the partner as - CXR
well - Weekly serum beta-hcG until zero (8-12 weeks) then
monthly for 12months
Management - Avoid pregnancy for 12 months after hcG levels are
- Most likely you are having recurrent genital herpes. As normal
you know, it is a viral infection that is usually acquired - OCP is appropriate
by sexual contact. This virus stays within the body
lifelong even after treatment of the first attack. It lives Task
within the nerve root. Whenever there is a period of a. Counsel patient regarding current and future
stress, like for example, a febrile illness, pregnancy, management
and in females, during periods, this virus becomes

activated and causes symptoms (e.g. pain, blisters,


ulcers, fever, swollen glands, and vaginal discharge). - Is my patient hemodynamically stable? How do you
- Unfortunately, this virus cannot be eliminated from the feel at the moment? Do you feel dizzy or do you feel
body, but treatment reduces the severity of symptoms, like lying down. I can see from the notes that you’ve
duration of illness, and prevents spread of infection. had some bleeding and tummy pain and that you’ve
- When you had the first infection, you were given oral noticed some grape-like material passing out from the
antivirals. This time, we will give you a cream vagina. From the investigation, you have a condition
containing acyclovir that you can apply locally. I will called molar pregnancy. This condition can be a
also write for you some topical lignocaine gel to serious problem. Unfortunately, there is no fetal tissue
reduce the pain. You can use warm salt water baths to that we can see. I understand that it might be
relieve the pain. It is important to avoid sexual contact shocking for you. Is it alright for me to continue?
until the ulcers heal completely. - Molar pregnancy occurs when the fetus is not able to
- Wash your hands immediately after touching or form completely. As you know, in a normal pregnancy,
scratching the area. Take oral analgesics as well. the sperm and the egg fuse to form the fetus. This
- During pregnancy, herpes infection can come again. If fetus carries equal genetic material from mother and
it happens within 6 weeks before EDD, we will give father. Sometimes, the egg is empty or it is fertilized
you oral antivirals. We will refer you to the specialist by 2 sperms at the same time. The resulting tissue
obstetrician who might offer you cesarean section lacks maternal genes, therefore only the placenta is
because there is a risk that with normal vaginal formed. This placenta grows and invades/erodes the
delivery, 5% of babies might get the infection and lining of the womb which causes bleeding. The
develop neonatal herpes. Neonatal herpes can be a placenta is also responsible for the production of a
serious infection for the baby. The baby might be born hormone called beta-hcg that gives the usual
prematurely, develop herpes of the eye, meningitis, symptoms of pregnancy such as nausea, vomiting,
and rarely, can be fatal within 1st 7 days. Some and breast tenderness. In a molar pregnancy, the
specialists recommend using continuous acyclovir placenta is abnormal and grows massively and it
starting from 36 weeks until delivery. contains fluid-filled sacs or cysts. The grape-like
- If insistent on NSVD: material that you have noticed is the same sac.
o Avoid fetal scalp pH monitoring, artificial Rarely, the placenta starts to grow and invade the
rupture of membranes and other invasive uterus. It travels within the circulation sometimes
procedures. reaching the lungs, brain, bones. We then label it as
o Acyclovir will be started as soon as labor is invasive mole or choriocarcinoma that can carry
established serious consequences for you.
28

- At the moment, I need to send you to the hospital Case: Your next patient in a small country town is a 26-year-old
urgently. They will admit you and call the obstetrician. Mrs. Jones who is 30-weeks-pregnant. She has recently moved
This pregnancy needs to be removed either by to this area. Her antenatal care up to now has been taken cared
dilatation and evacuation or by suction curettage. It of by one of your colleage. Midgestation USD is normal. 4
will be done under general anesthesia so you will not weeks ago her fundal height was 26cm, but today, it is 40cm.
feel any pain. She feels a bit tired and uncomfortable with a large tummy and
- After the procedure, they might decide to give you a wants you to take over her antenatal care. She recently traveled
form of chemotherapy (Methotrexate) as some cells overseas.
from the mole can reach the circulation. We will need
to do serial hcg monitoring every week until it touches Task
normal level and stays normal for the next 3 samples, a. Brief history (traveled to NZ, no fever or jaundice,
do monitoring hCg monthly x6 months then annually. single baby, 18 weeks USD, B+)
We will also do serial USD every 2 weeks. b. Physical Examination (FHT normal, FH 40, cephalic,
- If it remains elevated or persistently highly, we will head freely mobile, FHT, no tenderness, cervix closed)
need to check for the spread of the disease by doing c. Investigations
CT scans of the chest and abdomen. If anything is d. Diagnosis and management
detected, you will be referred to the cancer specialist.
- Once the treatment is completed, you need to avoid Causes
pregnancy for 1 year because the pregnancy - Wrong dating
hormones can induce recurrence of the cancer. - Multifetal gestation
- OCP: Yes. - GDM
- Regarding your next pregnancy, there is still a very - Chorioangioma
high chance that you might have a normal pregnancy, - Fetal abnormalities (NTD, UGI atresia)
but the recurrence rate is higher (1:80 compared to - TORCH (CMV and toxoplasmosis)
1:15,000 for general population). - Fibroids
- I will refer you to the counselor because you need a
lot of emotional support at this time. It is normal to be History
upset after losing a pregnancy. - Congratulations on your pregnancy. Is it planned?
How was it confirmed? Are you regular with your
Oligohydramnios antenatal checkup? Did you visit your GP before
leaving? Did you receive appropriate vaccinations
Case: Your next patient in your GP practice is a 28-year-old before leaving? Did you have any problems there or
primi who works as a nurse in the Renal transplant unit. You on flights? How was your midpregnancy USD?
have looked after her pregnancy so far, and all appeared normal Placenta? Single baby? How were your blood tests?
up to her last visit 4 weeks ago. When she was 30 weeks AOG Any FHx of congenital anomalies? How is your baby?
she had a SFH of 28cm. Today her SFH is 29 cm and there Is he kicking well? Did you maintain a kick chart? Is
appears to be less amount of liquor. this distended tummy giving you any problems like
SOB or day-day lifestyle? Any fever or signs of
infection in the last 3 months.

- Do you have any tummy pain? Is your tummy tender?


Any bleeding or discharge per vagina? How are your
Task: periods? Are they regular? Heavy or normal? Are you
a. Further relevant history regular with your pap smear? Do you know what your
b. Relevant Physical examination findings and blood group is? Any other symptom symptoms like
investigation headache, blurring of vision, polyuria or polyphagia?
c. Diagnosis and subsequent management plan Any chance of exposure to cats or dogs? Any past
history of uterine fibroids? Did you eat raw meat
Problem list recently?
a. Recognize and managem oligohydramnios - SADMA?
b. Management plan and appropriate investigations
c. Relieve patient concern regarding baby safety Physical examination
- General appearance
Differential diagnosis: - Vital signs
Maternal factors: - Chest and heart
- Wrong dates - Abdomen: FH (40cm), lie and presentation, head if
- Constitutional: small mother (hx, weight, parity, ethnic engaged or mobile, FHT/FHR
group) - Pelvic exam: inspection and speculum
- Medical: HTN, DM, Immunological (SLE) - Signs of edema
- Socioeconomic: nutritional factors – anemia
- Medication usage – steroids, warfarin, anti-epileptic Management
- Previous pregnancy with IUGR; FHx: IUGR - I have noticed that your pregnancy is larger than the
- Tobacco and substance misuse date. There are a number of causes for it. It could be
wrong date, multiple pregnancy but it is not your case.
Fetal factors: It could also be diabetes or abnormalities in the baby
- Genetic: chromosomal fetal defects or certain infections. It may also be due to uterine
- Multiple pregnancy (each child IUGR) fibroids. At this stage, I would refer you to the
- Fetal infections (TORCH) obstetrician and organize blood tests such as FBE,
- Placental insufficiency – placenta previa, abruption, blood group, TORCH, BSL, urine microscopy and
immunological culture, ultrasound, biophysical profile (AFI >25cm is
diagnostic of polyhydramnios).
Polyhydramnios
29

- We will also need to do CTG and GTT (even with - Contraindications for tocolytics: Chorioamnionitis,
normal GCT). cervix >5cm, IUFD, abruptio placenta
- Can it be risky? Don’t worry, we have picked it up
early. You will be seen by the specialist. Having said Preterm Labor
that, there are some complications like premature
labor, premature rupture of membrane, Case: Linda aged 34 years presents to a country hospital where
malpresentation, placental abruption, cord prolapse, you are working as year 1 HMO. Linda is 33 weeks pregnant
pregnancy-induced hypertension, and postpartum and since this morning she had noticed few contractions and
hemorrhage. That is why we will monitor you and your cramps in the lower abdomen. There is no vaginal discharge
baby very closely. and baby is moving well. Up till now, pregnancy has progressed
- How will they treat it? If the polyhydramnios is mild well and all investigations have been normal
and asymptomatic, we just do observation. However, if
it is moderate to severe, and you get SOB, you cannot Task
sit or lie down comfortably, and you are <35 weeks, a. History (started contractions a few hours ago,
the specialist might do amnioreduction up to 500 ml. if occurring every 5 minutes)
the pregnancy is >35, the specialist might do induction b. Physical examination (3cm open, 50% effaced)
of labor by artificial rupture of membrane. At this c. Probable diagnosis and management
stage, the specialist might consider giving
indomethacin to reduce urine production. Features
- Prophylactic steroid decided by specialist. - Gestational period is less than 36 completed weeks
- Red flags: bleeding, discharge, blurring of vision, - Uterine contractions preferably recorded on tocograph
SOB, tummy pain, kindly go to the ED of the nearest occur every 5-10 minutes, last for at least 30 seconds
hospital immediately. and persist for at least 60 minutes
- Reading material. Review, - Cervix is more than 2.5cm dilated and more than 50-
75% effaced
VARIATIONS IN DURATION OF PREGNANCY (PRETERM - Contraindications to tocolytics: APH, effacement
AND POSTDATISM) >75%, cervical dilatation >5cm

Preterm Labor Physical Examination


- General appearance
Case: Sarah is a 27 year old female and presents to a district - Vital signs
hospital where you work as HMO in ED. She is 32 weeks - Abdomen: FH, presentation, lie, contractions,
pregnant and noticed some pain in the lower abdomen since engagement
yesterday. She didn't break her water and the baby is kicking - Pelvic examination: inspection and speculum
well. examination; No IE done

Diagnosis and Management


- Investigations
o Cervical swab looking for pathogens

Task
a. History (spasms that are getting worse, all over, 8/10, o Nitrazine test or amnisure
no bleeding, good antenatal checkups, pap smear a o Fetal fibronectin (may be FP if had sexual
year ago) intercourse within 24 hours, bimanual
b. Physical examination (distressed and in pain, FH examination done)
consistent with GA, cephalic presentation, FHT (+), o Ultrasound (Abdomen):
nontender on palpation, pelvic examination: no o FBE: signs of infections
discharge, bleeding, bulging of BOW, normal cervix, o ESR/CRP
3cm dilated, 70% effacement) o Urine MCS
c. Advise on management
- Management
o Pain-relief Panadeine, Pethidine IM 25-
Preterm labor:
100mg, diazepam
- Gestational age <36 weeks, UC q5-10mins x 30 secs
o Tocolytic
in 60 mins, cervix >2.5cm dilated and 75% effaced
o Betamethasone 11._ mg 2 doses 24 hours
Physical examination apart
- Abdomen: lie, presentation, FH, head is engaged or - Refer to tertiary hospital
floating
- Pelvic: Premature Rupture of Membranes
o Inspection: discharge, bleeding
o Speculum: discharge, bleeding, cervical os, Case: 32 weeks GA pregnant female presented complaining of
passage of fluid 2 hours ago. She is 24 years old. She has cone
effacement, nitrazine test
biopsy done for abnormal pap smear and cervical suture is in
o IE: consistency, position, station
place. You are a GP in a rural area.
Management
Task
- CTG, fibronectin and nitrazine test
a. Relevant history
- Start tocolytics (nifedipine or salbutamol) -- nifedipine
b. Examination findings
10mg orally q20 then 20 q4
c. Management
- Betamethasone 11.4mg IV 24 hours apart
- Refer to metropolitan hospital.
Focused history:
30

- How much (how many pads? Is it soaked)? What is - Difficult deliveries (problems with molding)
the color (is it clear? associated mucus? Blood? - Increased risk of operative deliveries
Greenish material? How long? Is there any tummy - Increased risk of labor induction
pain? Contractions? Any other associated waterwork - Dystocia
problems (e.g. increased frequency of urination?), any - 4x increased risk of stillbirths
vaginal secretions? Fever? Hot flushes? Dizziness? - 3x increased risk of neonatal death
Vomiting? Heart-racing? Do you still feel the baby - 10x increased risk of neonatal seizures (within 1st 48
kicking? hours of life)
- Pregnancy: is this the first pregnancy? Previous
antenatal checkup? Any abnormalities on usd ? What History
is your blood group? Previous deliveries and previous - Is this a planned pregnancy? Congratulations! How is
gynecological problems? the pregnancy so far? Can you tell me how your
- Pap smear: what was the cause detected. For the pregnancy was confirmed? Have you had regular
cone biopsy, when and where did you have this done? antenatal visits? All blood tests? What were the
- PMHx: hypertension? DM? meds? SADMA? results? Any problems? Did you have the sweet drink
- How far do you live from here? Who can care for you test? Was it alright? When was your last ultrasound?
if we decide to transfer you to a tertiary hospital? What was the result? Is it a single baby? Weight?
Placenta? What was the expected date of delivery on
Physical examination: that ultrasound?
- General appearance: pallor, anxious, BMI - How’s your general health? Any past history of
- Vital signs: temperature, BP (postural drop), pulse, RR diabetes, high blood pressure? Currently do you have
- Urine dipstick any symptoms of headache, blurred vision, or swelling
- Rapidly I’d like to check chest and heart of the legs? Any bleeding or discharge from down
- Focus on the abdomen: general look abdomen. I’d like below? Any tummy pain? backache? Is the baby
to start with superficial palpation (tenderness means kicking alright? Have you counted how many times in
chorioamnionitis), feel fetal parts, check fetal position, how many hours? Do you have kick chart with you (10
gestational age, fetal heart sounds in 12 hours)?
- With the consent of the page, I’d like to go for pelvic - FHx of postdated deliveries? Big babies?
examination and ask consent for swabs. I’d like to - Have you had any gynecological surgeries or
inspect for fluids. Can I have a description of the fluid? procedures (adhesions)? What is your blood group?
Is it clear? Does it smell? Blood/mucus or other When was your last pap smear? Have you been
discharge. With complete aseptic condition, I’d like to vaccinated against gardasil? SADMA?
perform speculum examination (fluid at fornices). I’d - Do you have enough support at home? Any
like to collect cervovaginal swabs for MCS and collect problems? How far do you live from the hospital? Is
low vaginal and anorectal swabs for GBS. I’d like to there anyone who can drive you in case of an
confirm the diagnosis of PRM by nitrozine/lithmus test. emergency?
Remove cervical suture and send for MCS!
Physical examination
Investigations and Management - General appearance
- I’d like to arrange some investigations as soon as - Vital signs: BMI and height
possible: FBE, U/E, LFTs, CRP, CTG, USG, and refer
patient to hospital.

- Give her erythromycin 250 mg QD for 7 days and - Chest and heart
betamethasone 2 injections 24 hours apart. - Abdomen: FH, lie of the baby, presenting part,
- If there is no evidence of infection or no engagement, FHT, tenderness over the abdomen,
contraindication for tocolysis: nifedipine/salbutamol contractions
- Organize admission at local hospital and tertiary - Pelvic examination:
hospital by nets (neonatal emergency transfer o Inspection and speculum: discharge,
service). bleeding, presence of show,
nitrazine/lithmus test to detect amniotic fluid
Postdated Pregnancy in the vagina,
o Bimanual: position, size, and effacement of
Case: You are a GP and a 41-weeks primigravida comes to your cervix
clinic because she is worried when she will deliver. - Urine dipstick and BSL

Task Management
a. History - It seems like your pregnancy is advancing towards
b. Physical examination (FH 39, head just, engaged, lie postdatism. 5-10% of normal pregnancies can go
is longitudinal, FHT normal, speculum: no discharge, beyond 42 weeks something we call as postdated
bleeding or show; closed, long, posterior, no bulging of pregnancy. You are still within the normal range so
membranes) please don’t worry. However, I want you to be aware
c. Management of certain risks associated with postdated pregnancy,
for example, placental insufficiency, meconium
Definition: aspiration, fetal distress, difficult delivery with higher
- RWH: >41 weeks + 6 days risk of undergoing cesarean section.
- LJ: 40 + 2 completed weeks - What we need to do is monitor you very closely to
prevent postdated pregnancy. Starting from now, we
Risks: will do CTGs 2x a week to assess fetal distress. We
- Placental insufficiency will also do ultrasound once a week to check the
- Meconium aspiration baby’s growth (BPS). We will also check the AFI. Also,
- Fetal asphyxia
31

I will recommend a Doppler study of the umbilical cord bounces between the fingers, FHS usually loudest
to check the flow of blood to the baby. above the umbilicus, tenderness, FHT
At the end of all these tests, you will need to see the - Pelvic exam/Speculum: discharge, os
specialist obstetrician. They might give you options - Leg edema
which include elective induction of labor with the help - Urine dipstick and BSL
of prostaglandin tablets that are inserted within the
vagina to initiate contractions. The second option Diagnosis and Management
would be to continue the pregnancy but with regular - Your baby’s position is breech. Normally, the baby’s
CTGs, USD and Doppler studies. The third option is head is down and the bottom is up. In your case, the
elective CS that carries minimal risk in safe hands. baby’s butt/bottom is presenting down.
The decision is yours. Please bring your partner for - There are three kinds of breech
the next consultation so we can discuss it together. o Frank: hips flexed and knees extended
- Meanwhile please look out for signs of labor which o Complete: hips and knees flexed
includes bleeding, discharge, leaking of fluid, o Single or Double Footling: one of both legs
continuous/intermittent back or tummy pain. are completely extended.
- First of all we need to do USD to confirm the diagnosis
ABNORMAL PRESENTATIONS and exclude the causes of breech and to make sure
Breech Presentation that the baby is fine. In most of the cases of breech
near term or at the time of delivery, baby takes the
Case: You are a GP and a 25 year-old primagravida with breech normal cephalic presentation. If not, with your
presentation at 32 weeks’ GA came in for consultation. consent, the specialist obstetrician will try to turn your
baby in the normal position by gently pressing the
Task tummy. Do not worry. It is a painless procedure and it
a. History is done in a tertiary hospital.
b. Physical Examination (lower pole of the uterus is a - There are some complications which can be possible:
soft, smooth and with a rounded mass that bounces o Failure baby can come back to breech
between the fingers, position of heart sound is above presentation
the umbilicus) o Premature labor
c. Diagnosis and management o Bleeding
o Fetal distress if umbilical cord goes to the
Causes of Breech
neck (0.5%)
- Maternal
- Contraindications of ECV
o Polyhydramnios
o Oligohydramnios
o Uterine abnormalities (bicornuate, septate)
o Antepartum hemorrhage (placenta previa)
o Placental abnormalities (previa)
o Multiple pregnancy
o Multiparity
o Uterine structural abnormality
o Contracted maternal pelvis
o Fetal abnormalities
o SOLs (fibroids)
- What about the delivery? If the breech is complete or
- Fetal
frank, the specialist can offer a trial vaginal delivery
o Prematurity
but there are some risk to vaginal delivery which
o Fetal anomalies (neurological, includes fetal distress because of cord prolapse, hip or
hydrocephalus, anencephaly) shoulder dislocation, fracture of humerus, femur or
clavicle and asphyxia. If these develop during the trial

o Multiple pregnancy of labor the specialist will do cesarean delivery. If


o Fetal death footling, then do Cesarean delivery. We can reduce
o Short umbilical cord the risk of complications by 50% if we choose elective
cesarean section at 39th week. If you do decide to go
History on a trial with vaginal delivery, we will still do our best
- Is it a planned pregnancy? Congratulations on your to monitor you and your baby by doing regular CTG
pregnancy. How is the pregnancy so far? Are you and USD. It will be done in a tertiary hospital in the
regular with your antenatal checkups? How were your care of an experienced obstetrician.
tests? Ultrasound? Was it a single baby? What was - Is it a serious condition? Not really, but it makes
the position of the placenta? Amniotic fluid? Sweet NSVD difficult but not impossible. However, you are
drink test? Blood group? Have you taken folic acid? still at 32 weeks and there is a high chance that your
- Is the baby kicking normally? Are you maintaining a baby will still change its presentation
kick chart? Do you have any headache, dizziness, - Reading material. Referral.
BOV or leg swelling? Do you go to washroom quite - Red Flags: bleeding, tummy pain, blurring of vision
often? Do you drink a lot of water? Does your tummy
feel more distended than usual? Any vaginal bleeding, Transverse lie in Multigravida
discharge, tummy pain?
- How are your periods before? Were they very heavy? Case: You are an HMO working at a district hospital and a 38-
Were the cycles regular? Were you ever been weeks multigravida who lives 80 km from the tertiary hospital
diagnosed with fibroids or any other abnormality? was found that the baby had a transverse lie.

Physical examination Task


- General appearance a. Relevant history
- Vital signs especially BP b. Physical Examination (FH does not correspond to
- Abdominal: FH, bell shaped, lower pole of uterus is gestational, uterus is ovoid, fundus is empty and head
occupied by a soft, smooth rounded mass that lies in one of the flanks, no tenderness, FHT normal)
32

c. Management Management
- Your baby has a transverse lie which is different from
Case 2: Julia aged 35 years presents to your surgery for routine the normal or expected position during term. It is
antenatal checkup as advised by you last week. She is 38 uncommon. It occurs in 0.5 to 1% of women. There
weeks pregnant and till now her pregnancy has been are several reasons for that: placenta previa (placenta
progressing well. On routine questioning she tells you that today lying in the way of the baby and prevents the baby
she had uncomfortable feeling in her flanks and tense feeling from turning to normal position). We will need to do an
but no other associated symptoms. She had normal USD at 18 ultrasound to rule out this condition and
weeks and other blood tests performed during pregnancy. This polyhydramnios (or increased amniotic fluid in the
is Julia’s 2nd pregnancy. She had one abortion when she was 32 baby) which is also another cause of this abnormal
years old. Julia lives with her partner in an apartment close to position. The commonest reason is a relatively large
your surgery. She stopped smoking when she became pregnant and lax uterus after previous pregnancies. For now I
Doppler
but is still having a glass of wine here and there. will organize an ultrasound and CTG for you and
arrange for an obstetric assessment.
Differential Diagnosis - There(-) are
FHTtwo options to manage yourCTG
(+) FHT pregnancy.
- Labor Whichever you choose, you will need to stay here until
- Placental abruption delivery (Do we have a cesarean section unit in this
- UTI/Pyelonephritis hospital? If not, then transfer to tertiary hospital
because labor may commence soon).
Task - Why do I have to this stay in this hospital? The reason
a. Focused history (tense on both sides, no radiation, for that is if labor starts and the baby has transverse
baby kicking well) lie, it can quickly progress to obstructed labor which
b. Examination and investigation findings from examiner can lead to uterine rupture. Another risk is cord
(FH 36cm, transverse lie, FHT+, no tenderness, no prolapse (cord can slip into vagina) after membranes
discharge and os is closed on pelvic exam; urine rupture and it is a life-threatening condition for the
dipstick +1, BSL 4.6mmol/L) baby.
c. Probable diagnosis and management advise - If you agree, after ultrasound, an obstetrician can
rotate the baby to normal position. We call this
Risk factors external cephalic version. If it is successful and your
- Multiparity cervix is favorable, OB will rupture the membrane and
- Lax uterus  most common cause you will go to normal vaginal delivery. External
- Previous cesarean section cephalic version is quite a safe procedure. However,
- Polyhydramnios approximately 0.5% requires immediate cesarean
- Placenta previa section due to fetal distress or vaginal bleeding
- Uterine malformation (abruption). Your second option is elective cesarean
- Small pelvis delivery. Regardless of your decision, we are here to
help you.
History - Let me reassure you that you and your baby will be
- I found out from the notes that your baby’s position is closely monitored by the specialist. I will call the
different from the expected. Can I ask a few more ambulance for transfer.
questions? How is your pregnancy so far? Any
abdominal pain/contractions or water leakage?
Any vaginal bleeding? Do you feel the baby is
Normal

kicking? Are you maintaining a kick chart? Did you If patient not at term: Hypoxia
have regular antenatal checkups? How were the blood - Gentle cephalic version maybe attempted at 36-38
tests? What about the midpregnancy USD? Do you weeks if patient consents. If successful, may induce
remember what the doctor said about the baby and labor and go to vaginal delivery.
placenta (Single baby and position of placenta)? - Advise to report to hospital immediately when labor
Sweet drink test? Did you have a low vaginal swab IUFD starts or if social conditions are unfavorable
done (GBS)? Do you know your blood group? Do you - Elective cesarean section
feel your tummy is more distended than it should be?
Did you have any infection during pregnancy? LABOUR AND DELIVERY
- How many children did you have? What type of
delivery (2 normal and 1 CS)? Were they big babies? Reduced Fetal Movements
No fetal movement
Complications?
- How is your general health? Ever been diagnosed Case: You next patient in a country clinic is a 38 weeks
with fibroids or any uterine problems? FHx of gestational age lady with no fetal movements in the past 12
malpresentations? SADMA? hours.

Physical Examination Task


- General appearance a. History
- Vital signs b. Physical examination
- Chest and Lungs c. Diagnosis and management
- Abdomen: FH, FHT, broad transverse uterus with a
firm ballotable round head in one iliac fossa and a
softer mass in the other, assess AFI (very subjective
 abdomen tense and hard to palpate fetal parts)
- Pelvic: Inspection and Speculum: discharge, blood,
cervical os, nitrazine test, NO PV
33

Case: You are a GP and a 34-weeks pregnant female comes to


you asking for early induction of labor at around 37 weeks
because she wants her husband to attend the delivery and he’s
going on a business trip in about 4 weeks’ time.

Task
a. Counsel patient and answer her questions

Indications for Induction of Labor


- Maternal
o Postdated pregnancy
History o PROM
- I understand you have come to see me because you o IUGR/Oligohydramnios
haven’t felt your baby’s movement for the past 12 o Maternal Diabetes
hours. Is it the first time? Have you noticed that your o Pulmonary Embolism (shunting of oxygen)
baby is moving less in the last few days? Is it your first - Fetal
pregnancy? Did you have regular antenatal o Fetal abnormalities
checkups? How was your USD? Lab tests? Sweet
o Placental insufficiency
drink test? Did you have a low vaginal swab? How
o IUGR
was your BP throughout pregnancy? Do you know
your blood group? Did you have any infections or
febrile episodes? Do you have a fever? Headache or Contraindications
abdominal pain? How’s your waterworks? Have you - Fetal distress
noticed any unusual vaginal discharge or bleeding? - Placenta Previa
- General medical health? SADMA? - Malpresentation
- Where do you live and who you do you live with? Do - CPD
you have any family members or close friends with - Previous CS
you today?
Risk of Induction of labor
Physical examination - Fetal Distress
- General appearance - Postpartum hemorrhage
- Vital signs - High risk of operative delivery
- Abdomen: - Uterine rupture
o FH: 20-36 weeks = 32 +2, 36-40 = +3cm,
Counseling
>40 weeks = 4cm,
- Congratulations. Please tell me why you want to have
o uterus (soft, tender, contractions)
an early induction. Is there any way that your husband
o Speculum: nitrazine
can delay his trip?
o Per vagina: check the cervix (4cm, posterior, - How is your pregnancy so far? Any bleeding,
closed, station -3) discharge, tummy pain, headache, visual problems,
swelling? Did you have regular antenatal checks? Did
you have all the blood tests especially the sweet test?
When was your last USD? What was the result? Do
you feel the baby kicking? Is this your first pregnancy?

Diagnosis
- I can hear your baby’s heart sound and it is within Any miscarriages? Do you have any history of medical
normal range. There are two possible explanations for conditions like diabetes, or high blood pressure? Any
your presentation. The baby’s activity could be surgical conditions for example gynecological
different throughout the day and absence of baby’s surgeries like cervical biopsies? How are you feeling
movement could be due to rest or sleep. However, we at the moment? Are you sleeping well? Appetite?
need to exclude the other possible cause which is Bowel habits? Waterworks? Blood group? SADMA?
fetal distress due to hypoxia or lack of oxygen to the FHx of operative/difficult deliveries or fetal
fetus which makes your baby quiet. For this reason, I abnormalities? Do you know your height and weight?
need to send you to the hospital where CTG will be Do you have any family or friends to support you in
performed. It’s a simple and safe procedure. Two your husband’s absence? How far do you live from the
sensors will be placed on your abdomen to record hospital? Is there anyone who can drive you in case of
baby’s heart rate, uterine contractions and fetal emergency?
movements. You will also be assessed by an - As you know, elective induction of labor is a big
obstetrician. If the CTG pattern is normal, you might decision by itself. As a medical health practitioner,
have an ultrasound to assess the amount of amniotic there are certain indications where induction is
fluid around the baby. If everything is fine, you might necessary. This includes pregnancy extending beyond
go home after that and the doctor will explain a kick 42 weeks, chronic kidney or liver disease in the mom,
chart for you. If the CTG pattern is suspicious, the very small baby, and problems with placenta. There
doctor will most likely discuss induction of labor with also some contraindications which will make it
you. If the CTG is abnormal, you might need to have impossible for us to induce labor like if the baby is too
an urgent cesarean section. You made a right decision big to pass through mother’s pelvis, or if the baby
to come and see me today. develops any kind of stress because of insufficient
oxygen supply. Sometimes, we avoid induction in
Elective Induction of Labor those who have had a previous surgical procedure to
the tummy.
34

- There are some risks associated with elective NO2 and oxygen in a 50:50. This procedure
induction which includes high chance of bleeding from is very safe for both mom and the baby.
the womb, risk of rupture of the womb, and because o IM Pethidine injections  gives pain relief
the baby is delivered before term, he might suffer from for at least 2-3 hours. Effect comes rapidly
consequences of prematurity. You need to know that within 15 minutes. It is commonly used but it
not all inductions end up having NSVD. Sometimes, does have side effects (e.g. acidity and
we need to use instrumental deliveries such as reflux symptoms, drowsiness, and
forceps or vacuum, or ultimately cesarean section to respiratory depression in the baby)  we
deliver the baby. will adjust the dose according to side effects
- Induction of labor is usually done in the hospital where o Epidural analgesia  gives complete pain
cesarean section facilities are available. You will be relief in around 95% of patients; usually
seen by the obstetrician and they will assess the given by anesthetist into lower back
baby’s position and size. If there are no protecting the spine. Sometimes, patient-
contraindications, they might go through it. Please controlled epidural analgesia is given. There
understand that we prefer to leave the baby inside the are some side effects like headache,
womb until Mother Nature decides for delivery. It is dizziness, and shivering. Rarely, leakage of
important for the baby’s growth and maturity. If you spinal fluid (dural tap). It has been noticed
wish, I can arrange a meeting with the obstetrician. It that the use of epidural analgesia during the
would be preferable if you could bring your partner to 2nd stage of labor leads to higher risk of
the meeting. If you like I can give you a certificate for operative delivery for the patient
you husband which he can use to delay his trip. o IV pethidine analgesia  reserved for
- Reading material. Review. Referral. patients after cesarean section
- In the end, the decision is up to you. You can decide
with your partner after you discuss with the
obstetrician. High Mobile Head At Term

Pain Relief During Labor Case: You are a GP and a 40 weeks primigravida is referred to
you by a nurse because the baby’s head is still 5cm above the
Case: You are a GP and a 30-weeks pregnant primigravida pubic bone.
came to you asking about pain relief in labor.
Task
Task a. History
a. Counsel accordingly b. Physical examination
c. Discuss possible causes and management
- Congratulations! How is your pregnancy so far? I
understand from the notes that you want to know Differential Diagnosis
about pain relief. Do you know why there is labor - Passage:
pain? Actually, there is contraction of the uterus, o CPD – depends on age, nutritional status,
dilatation of the cervix, and distention of pelvic tissues type of pelvis; more common in
as well as pressure in certain organs. underdeveloped countries; risks involve
- There are many methods of pain relief including non- obstructed labor, shoulder dystocia,
pharmacological and pharmacological methods. increased risk of CS in primigravida, higher
- Regarding non-pharmacological methods: maternal morbidity and mortality, difficulty
with subsequent pregnancies
o Fibroids/Ovarian tumors
o Placenta Previa

o Adjusting the position brings comfort to the


mom (e.g. kneeling down or standing
upright)
o Hot or cold bags applied to the tummy, back - Passenger:
and perineum o Malposition especially occipitoposterior
o Relaxation or breathing techniques with or position
without a massage to encourage the mother o Fetal macrosomia (>95% percentile)
to tolerate the pain and reduce the anxiety. o Coil abnormalties (short coil/cord coil)
o Transcutaneous electrode nerve stimulation
(TENS) we place 2 electrodes parallel to History
your backbone. It is helpful by interrupting - How are you doing at the moment? I understand you
the transmission of pain to the nerves. The are 40 weeks pregnant. Any problems like bleeding,
frequency of the current can be modified discharge, or leaking of fluid? Tummy pain?
accordingly. contractions? Headaches or visual problems? Have
o Hydrotherapy departments within the you noticed swelling anywhere in the body? How has
hospital  hot showers to feel better your pregnancy been so far? Have you had regular
o Hypnotherapy antenatal checks, blood tests, and ultrasound? When
o Injection of sterile water in lower back was your last USG? What was the result? Do you
- Pharmacological remember the baby’s weight from the USG? What
o Inhalation of nitrous oxide gas which gives about the placenta? Was it normally located? How
pain relief for 20-30 secs. Patient can about the amount of fluid around the baby? Did you
administer the gas by herself through a have a sweet test (16-28)? What was the result? Is
mask during a contraction. The machine is this your first pregnancy? Any previous miscarriages?
called entonox which contains a mixture of - If not previous pregnancy: what was previous weight?
Any complications? Mode of delivery?
35

- Any medical or surgical history? How is your general a. History


health? Do you know your weight or BMI? May I ask b. Physical examination
how tall you are? Have you ever been diagnosed with c. Management
any problems like fibroids or growth within the
ovaries? Features: Expected speed
- SADMA? Gardasil? Blood group? Trauma to pelvic - Latent phase: 6hours up to 4cm
bones? FHx of difficult deliveries? - Active phase: 1cm per hour. Up to 6 hours.
- In this case now the expected speed: At least 3
Physical examination contraction in 10 mins lasting 30-90sec
- General appearance
- Vital signs: BMI History
- Abdomen: FH, lie, presentation, FHT, engagement - Hello Margaret. How are you? How long have you
(>36 weeks/floating), amount of liquor been having contractions (8 hours ago)? How often do
- Pelvic exam: they come (had 2 contractions in 10 min)? How long
o Inspection: bleeding, discharge, show, do they last (30seconds)? Are they painful? 0-10? Did
leaking of fluid you have something for the pain? Did it work? We can
o Speculum: cervical os, discharge, bleeding, adjust your pain relief in a few minutes. Have you
bulging of membranes, nitrazine test notice water leakage or bleeding (No)?
(leakage of amniotic fluid) - Just a few questions regarding your pregnancy: Did
o Bimanual examination: tenderness, position you have regular check-ups? Any problems with your
of cervix, length, mass blood test? Mid pregnancy ultrasound? Sweet drink
test (big baby)? GBS swab? Result? Do you know
Investigations your blood group?
- Ultrasound: look for fetal wellbeing, AFI, additional - What is your and your partner’s height (big husband
masses or abnormalities and small wife)? Are you generally healthy? PMHx:
DM? Surgeries? Pelvis bone fracture? Ever been
Management diagnosed with ovarian cyst or fibroid (occlude the
- From history and examination, it seems like there is pelvis)?
nothing that might be preventing the baby’s head from - If multi: How big was the baby? What was before?
engaging within the pelvic bone. It could be a normal
phenomenon where the head may go down within the Physical Examination:
next few days. You will then have the signs of labor - General Appearance: Is it just a delayed of 1st stage
which are abdominal contractions, leakage of water, + labour or obstructive labour
small amounts of bleeding - Vitals: tachycardia in obstructive labour
- What I want you to do is: - Abdomen: palpate the uterus and assess frequency
o Keep a daily kick chart for the baby’s and length of contractions, lie and presentation. How
movements (at least 10 in 12 hours) much of fetal head palpable per abdomen (5 fingers
o I will write a request for ultrasound with palpable head above the pelvic brim. 0 fingers means
Doppler the head is already in the pelvis)? FHR?
o Come for CTGs 2x/week until 42 weeks  - Pelvic: Per Vaginal examination: effacement dilated?
if during the 42nd week, condition remains How much? Is membranes intact or not (NO)? The
the same, the specialist might decide to position of the head: Try to find the fontanelle: Anterior
admit you for possible induction of labor with Fontanelle: diamond shape. Occipital bone: posterior
the help of artificial rupture of membranes fontanelle. Occipital anterior/ occipital
and the use of a vaginal gel (prostacyclin). posterior/transverse position/oblique. Stations: relation
to Ischial spine -5 to +5. Moulding and caput? Overlap
of the suture line.

- During your visit with the specialist, she might decide


to do a pelvic examination to assess for possible CPD
where the mother’s pelvis is not suitable for the baby’s o If mild moulding not concerned
head to engage into. It is done with the help of a o If severe moulding think of obstructive
bimanual examination. Sometimes, the specialist labour.
might do an Xray or a CT scan in doubtful cases. It
also depends on the mother’s height. If during Management
pelvimetry the specialist thinks that your pelvis is - Margaret I know you have been in labour for the past
insufficient for NSVD, they may offer you a trial of 8 hours. Unfortunately your last 4 hours are not very
labor, possibly followed by cesarean section. efficient. You are at active phase of 1st stage labour.
- Pelvimetry: AP <13, Oblique < 12, and tranverse Cervix should dilate more rapidly. Expected rate is
diameter <11  contracted pelvis 1cm per hour. The most likely cause for failure for
- Referral and review cervix to dilate is inefficient uterine contractions.
- What could be done? In this case management is
Prolonged First Stage of Labour artificial rupture of the membranes. With your consent
we will break your water. (Empty the uterus easy for
Case: A 25-year-old primigravida has been admitted for labour 4 uterine to contract). +/- Oxytocin or 1- 2hours of
hours ago. At that time vaginal examination showed cervix was observation.
effaced 4cm dilated. 4 hours later cervix is 5 cm dilated - We will monitor progress of labour closely.
Contractions will be assessed every 15-20min. Rate of
Task oxytocin infusion will be slowly increased and
36

adjusted. You will be on continuous CTG monitoring


once oxytocin is given. If in 4 hours the cervix fails to Case (Condition 125): Your patient is a 25yo primigravida who is
dilate by >4cm we will consider C-section. Abnormal in early labour at 41 weeks of gestation. She is in the local
CTG pattern or signs of obstruction will also be an district hospital where you are attending as a general
indication for C-section. Otherwise normal vaginal practitioner. The hospital has good facilities but a consultant
delivery is possible once contractions are efficient. I obstetrician is not available. Pelvic examination 30 minutes ago
will also organize pain relief for you. showed the cervix was 3cm dilated, well effaced, and well
applied to the presenting part. The cephalic presentation was
Meconium Stained Liquor position left occiptotransverse (LOT), at zero station, with no
caput or moulding evident. The membranes were still intact and
Case: You are in ED in a district hospital where facilities for C- allowed to remain so. Spontaneous rupture of the membranes
section and new born resuscitation are available. Your next then occurred and revealed profuse, thick meconium-stained
patient Mrs. Brown, is a 32-year-old G2P2L1 10days postdated. liquor. The pregnancy had been uneventful to date, and blood
She presents with a history of leaking water which is green in pressure and urine testing have been normal in labour. The fetal
colour. The pregnancy was uneventful, except for 36 weeks heart rate, as defined using auscultation, has been between 130
group B streptococcus positive. and 140/min.

Task Task
a. Take history a. Take any further relevant history you require.
b. Physical examination (Per abdomen: cephalic b. Ask the examiner about relevant findings likely to be
position, engaged , FHS: normal OS dilated 2 cm, and evident on general and obstetric examination
well effaced; CTG: normal) c. Advise the patient of the diagnosis and subsequent
c. Management management during and after delivery.

History History
- I understand it’s your second pregnancy. Could you - When your water break? Was it green in color? How
tell me more about it? Any pain? Any bloody long have you been in labor/When did the contraction
discharge? Is the baby kicking as usual? From your start? How often is your contraction? How long does it
notes your 36 weeks bug test was positive. The doctor last? Do you feel movements of the baby? Is your due
must have informed you. We will take care of that. Are date a week ago? Is that correct? I know your
you allergic to any med? What’s your blood group? If pregnancy has been uneventful, any problems with
the previous pregnancy was normal? blood tests, midpregnancy USD, or GBS swab? Do
- you know your blood group? I know you’re a bit
Physical Examination: overdue, have you had an USD and CTG last week?
- General Appearance - Are you generally healthy?
- Vital signs
- Chest and heart Physical Examination
- Abdomen: Size of the uterus, Lie of the fetus - General appearance
(longitudinal or transvers), presentation, head if mobile - Vital signs every 2 hours
or engaged. FHS - Abdomen: FH, fetal lie and presentation, uterine
- Pelvic: Inspection for discharge, blood; per speculum: contractions,
any discharge? Dilated? Effacement? Membrane - Pelvic examination: cervix, effacement, dilatation,
ruptured? Cord prolapse? presence of membranes, presence of cord loop,
station, position of fetal head, signs of caput/moulding
Diagnosis and Management
- Mrs Brown you are postdated by 10 days, and you Diagnosis and Management
have rupture of membranes. We have to admit you. - The baby has passed meconium which is the baby’s
We will do an ultrasound and CTG (continuous). Baby first stool. That is why your water looks green. It is
looks fine now, if these two tests are good labor will be common and often normal in post-term labor.
induced. You will be taken cared of by the OB However, it can also be an indirect sign of fetal

registrar. We will monitor the progress of the labour distress due to lack of oxygen. That is why we need to
and baby with CTG. If it progresses normally, we will monitor your baby closely. I will organize
allow you to have normal labour, but if not or if the cardiotocograph for you. CTG is a safe, non-invasive
baby isn’t well we will have to intervene, and use method commonly used during pregnancy and labor.
instruments to facilitate labour or you might need an We will place 2 sensors in your abdomen to record
emergency C-section if the baby goes into distress. baby’s movements, heart rate and uterine
Meconium stained liquor is quite common in postdated contractions. CTG will help us to assess your baby’s
pregnancy. Baby passes stool in the amniotic fluid and wellbeing.
it turns green. If CTG is normal we don’t need to worry - If CTG is normal and progression of labor is good, you
about the meconium. A pediatrician will be present will still be able to have vaginal delivery. If CTG shows
during the labour. They will suction the nose and small abnormalities, we will perform fetal scalp blood
mouth and remove the meconium. Then they will sampling to assess acidosis. If present, we will need
cover the baby, check the APGAR score. If the baby is to perform emergency CS because this is a sign of
in distress they might consider giving your baby a fetal distress.
stomach wash. - If your baby shows signs of distress in the 2nd stage of
- For the GBS infection: From the onset of labour IV labor (after full cervical dilatation). A pediatrician will
benzyl penicillin, 1.2g first dose at admission and then be present at your delivery. After birth, we will use
600mg 4-6hourly.
37

suction to clear the baby’s mouth and nose to prevent


particles of meconium to descend to the lungs. Physical Examination
o If CTG abnormal  oxygen to mom, stop - GA: any signs of dehydration?
oxytocin, left lateral position  check - V/S: BP: 115/65 Temp: febrile RR:20 sat: normal
monitor  if still abnormal  fetal scalp - Breast examination
blood sampling to check pH (<7.2) and - Heart and lung
lactate (>4.2)  emergency cesarean - Abdomen: Not distended, no signs of peritonitis, bowel
section sound heard. Slight tenderness in the suprapubic
- If hospital doesn’t have facilities for emergency CS, area. Renal angle tenderness (-)
then transfer patient to tertiary hospital. - Pelvic examination:
o Inspection: Any laceration, Any hematoma,
POSTPARTUM Any episiotomy cut infected bleeding any
discharge.
Postpartum Hemorrhage due to Endometritis o Speculum (OBD): OS, Bleeding, Discharge,
Case: A 30-year-old lady comes to GP clinic had her second laceration? Trauma to the vaginal wall? Any
baby 10 days ago. Now she comes of complaining increase blood discharge or tissue coming out from
bleeding per vagina the OS
o Bimanual Examination (TAC): Tenderness,
Task Adnexal, Cervical excitation, Uterine size:
a. History (6pads fully soaked with clots. Slight lower after delivery: 20weeks
abdominal pain. Full term vaginal delivery no  1day: 16weeks
complications. No fibroids. Skin delicate and easily  10days: 10 weeks or less
bruised. No breast tenderness, no swelling or legs or  2weeks: inside the pelvis
discoloration.)
- Calf pain/tenderness?
b. Physical Examination findings (GA: Well. A bit pale,
- Urine dip stick: blood +++
V/S: BP: low but within normal range. Tachycardia,
Neck is normal., Abdominal examination: No rigidity
Diagnosis and Management
but mild tenderness in the lower abdomen, Uterus 14
- Based on physical examination and history the most
weeks in size, Pelvic examination: No laceration, no
probable diagnosis is Endometritis. Do you know what
hematoma, Per speculum: Bleeding (+), OS: 2cm,
it is? The inner lining of the uterus is infected. But you
Bimanual examination: No cervical excitation, 2
can also have retained POC or some bleeding
fingers above the public symphysis)
problems. I’d like to do some investigations to rule out
c. Investigations
other conditions: FBC,CRP, ESR, Blood group and
d. Diagnosis and Differential Diagnosis
hold, If the temperature is about 38.5 we do blood
e. Management
culture, urine micro/cult and sensitivity, coagulation
profile, LFTs, U/S, Swabs(high vaginal swabs, wound
Differential Diagnosis
swabs, Endo cervical swab)
- Retained placenta
- If it’s mild Endometritis: Outpatient treatment: Panadol
- Bleeding disorder
or oral Amoxycillin plus Metronidazole.
- Endometritis
- This patient is allergic to penicillin: use Cephalexin or
- DIC
Erythromycin.
- Trauma
- If moderate or severe (Temp: 39, Dehydrated, Toxic
and tachycardia): hospitalize and IV antibiotics:
cephalosporins and Metronidazole 5~7days
History:
- Review: in 2 weeks’ time
- Is my patient is hemodynamically stable? If no:
- Red Flags: Increase temperature, chills and rigors,
DRABC
and increase in abdominal pain
- Bleeding questions: When did it start? How much?
- Retained POC: Antibiotics for 24 hours and D&C
How many pads are you changing? Are they
- Mastitis: Flucoloxacillin. Continue breast feeding with
completely soaked? Are there clots? Any smell? Is it
complete empty. Compresses(hot and cold) Follow up
bright red or dark bleeding? Any bleeding from
in 2 days.
anywhere else in the body? (DIC) Do you have any

fever? N/V? tummy pain? Any dizziness? SOB? Chest


pain? Any vaginal discharge? How about your water
Postpartum Pyrexia
work? Dysuria? Frequency? How’s the baby? How are
you coping?
Case: You are a GP and a 29-year-old female had a normal
- Pregnancy Questions: Was the pregnancy normal?
vaginal delivery 3 weeks ago. She had a baby boy who is
Any complications during pregnancy? Is this your first
healthy and doing well. Patient is complaining of fever and
baby? Was it a normal full term vaginal delivery? How
shivering.
long was the labour? Was it a normal or complicated
labour? Any PROM? Did you have episiotomy? Were
Task
there any instrumental or other assistant method used
a. History (fever since 2 days ago, decreased appetite,
during delivery? Was the 3rd stage of labour complete?
breastfeeding, NSVD, abdominal pain (+),
Was the placenta completely removed? Was there
b. PE: pulse: 106, T: 38.6; mild tenderness over lower
any complication after delivery? Were you discharged
umbilicus, uterus involuted, no mass or tenderness;
from the hospital early? Any bleeding or clotting
dipstick and BSL N; pelvic: no clots, discharge,
problem? Were you on any medications? Do you have
episiotomy scar healing, no mass and tenderness;
any chronic condition? SADMA?
fissured nipple, cracked and inflamed
38

c. Management common during initial breastfeeding period.


Sometimes, because of poor feeding technique, the
Mnemonic: After Uni, Every Woman Should Marry baby suckles on the nipple only. The nipple cracks
and bleeds and bugs from the baby’s mouth or mom’s
Atelectasis (0-1) skin enter the breast tissue and cause infection. At the
UTI (1-2) moment, I would give some antibiotics (flucloxacillin or
Endometritis (2-3) cephalexin for the next 7-10 days). I would give some
Wound infection (3-5) analgesics (PCT). It is important to keep the breast
Septic thrombophlebitis (5-7) drained by feeding or manual evacuation/expression.
Mastitis (7-21) - For soothing effects, refrigerated cabbage leaf. While
feeding, try to massage the breasts towards the nipple
Breast abscess: can happen anytime to help evacuation. There are ointments available to
help with cracked nipples. I will give you reading
Organism: materials regarding proper feeding techniques. You
- Staphylococcus aureus (from baby’s mouth or over need to rest and have ample fluids. We will perform
skin) USG of the breast and repeat 3 days later to see if
- E. coli abscess has developed.
- Candida - Red flags: If the redness/pain does not go away, if you
feel a swelling on the breast, fever persists, please
History come back or if very ill or high spikes of fever 
- Congratulations on your pregnancy and delivery. How admit for IV antibiotics
is your baby doing? Please tell me more about this - Endometritis: admit! Rehydrate (aminoglycoside +
fever? Since when? Chills? Severity? Is it continuous clindamycin + metronidazole)
or come and goes? Medicine? Did it help?
- Associated symptoms: cough? SOB? Chest pain? Mastitis
How are your waterworks? N/V? tummy pain?
Discharge from down below? How was the delivery Case 2: You are a GP and a 29-year-old woman came in
(Normal or CS)? Did you have an episiotomy? Does because of fever. She had cesarean section 3 weeks ago and
the wound hurt? was recovering well until 2 days ago when she becomes shivery
- Any leg pain? Redness over calf? Temperature? and cold.
Swelling? Case 3: A 25-year-old lady 4 days postpartum forceps delivery
- Are you breastfeeding the child? Tenderness/pain used, Temp 39, Redness and tenderness in right breast:
over the breasts? Redness over skin? Bleeding Task
around nipples? Is it painful while feeding? a. History
- PMHx: DM? Hypertension? b. Physical examination (flushed, T: 39, PR: 90,
- SADMA? Bp:125/75, axillary lymphadenopathy on the right,
obvious erythema of the right breast, tenderness on
Physical examination the RUOQ, well-healed CS wound,. BSL 6.6, urine
- General: Dehydration? Pallor? Jaundice? dipstick normal; pelvic examination: normal discharge,
- Vitals no tenderness )
- Chest: auscultation for air entry or added sounds c. Diagnosis and management
- Heart: visible localized swelling
- Breast: redness? Fissure? Cracked nipples? Palpate Causes of Pyrexia
for tenderness, engorgement of breast, change in - Genital
temperature over that area, local lymph nodes that are o Endometritis
enlarged o NSVD: infected episiotomy scar; infected
- Abdomen: tenderness especially suprapubic, size of laceration
uterus, loin tenderness (pyelonephritis) o CS: wound infection
- Pelvic: lochia, discharge, odor, color; episiotomy: - Non-genital
redness, edema, tenderness over wound; discharge o UTI
 swab for culture and sensitivity o Mastitis
- Leg: swelling, redness and tenderness o DVT
- Urine dipstick and BSL
History
- Congratulations on the birth of your baby. Is it your
first baby? Is everything going well at home?

Investigations
- FBE, CRP
- Urine MCS - I understand you have come to see me because
- Swabs if appropriate you’re feeling unwell. Did you measure your
- USG: retained POC temperature? Is it up and down or constantly high?
- USG of breasts if in doubt of abscess; mastitis: clinical How’s your appetite? Do you have N/V? Do you feel
diagnosis tired? Do you have loin or back pain? How’s your
waterworks? Do you have burning sensation when
Management passing urine? Has the color of your urine change?
- Postpartum pyrexia where patients develop fever Do you have abdominal pain? How is the wound
within 6 weeks of giving birth is due to a number of looking? Any discharge or redness? Do you notice any
reasons including infection of womb, UTI, or breast unusual vaginal discharge or bleeding? Tummy pain?
infections. On exam, I could see that your left breast is Do you have cough, runny nose, earache or sore
red and tender. Most likely you have mastitis. It is very throat? Are you breastfeeding? Any problems with
39

breastfeeding? Do you have breast pain? Have you Postpartum Issues:


noticed any changes in the color of breast skin? Any - Fever
lumps or swelling? Any swelling under the armpits? - Depression
Do you have calf pain or swelling? Did you have a - Psychosis
planned or emergency CS? Were you discharge from - Mastalgia
the hospital as expected? - Dyspareunia
- Are you generally healthy? Medications? allergies? - Contraception

Physical examination History


- General appearance - Congratulations! How does it feel to be a mother?
- Vital signs How is the baby? Does the nurse visit you?
- Lymphadenopathy: neck and axilla - Was it a planned pregnancy? How was the antenatal
- Breast: care? Anything significant? How was the delivery?
o Erythema, swelling, cracked nipples? Long labor? Any complications? Are there any pain
o Palpation: tenderness and lump (site, size, down below, discharge? Are you breastfeeding or
shape, surface, border, mobility, tenderness, bottlefeeding? Any breast pain or sore nipples? Any
fluctuation), temperature masses or lumps in the breast?
- Abdomen: scar, palpable uterus (no longer palpable - Is there any social support available to you?
by 2 weeks); renal angle tenderness - Pap smear? Pills? Periods?
- Pelvic: abnormal discharge; PV: size of uterus, - Partner: Are you sexually active now? Any problems
tenderness (bulky and tender if endometritis), adnexal with intercourse? Was there any bleeding after
masses and tenderness intercourse? STIs? Did you get your periods back?
- Calf tenderness What contraception were you using before? Have you
- Urine dipstick started taking any contraception?
- General health?
Diagnosis and Management
- You have a condition called lactational mastitis. Do Vital Signs
you know what it means? It is a common condition. - General appearance
About 20% of breastfeeding women in Australia will - Vital signs
face similar problems.
- Mastitis is an inflammation of the breast which is
commonly associated with bacterial infection - Breast examination
(staphylococcus). Commonly, breastfeeding is - Pelvic examination:
challenging and can cause cracked nipples, which is a o Inspection: discharge, lochia
painful condition that leads to milk stasis. It also o Speculum: check for dryness of vagina,
creates an access for bacteria which live on the skin episiotomy scar
to enter the breast tissue and cause inflammation. I
will order some blood tests (FBE, CRP and blood Postpartum dyspareunia
culture).
- You need to continue breastfeeding. Do you need the
HISTORY
help of a breastfeeding specialist? You need to keep
the affected breast well drained. You can have a hot
shower or put a face towel before breastfeeding. Cool
the breast after breastfeeding. Massage any breast Pre-existing Acquired
lump gently towards the nipple while feeding. Empty
the breast completely after breastfeeding (manual or
pump).
Refer to psycho-sexual therapist
- I will give you antibiotics (Flucloxacillin x 5 Non-organic Organic
days/Cephalexin/Clindamycin) and painkillers.
- If your condition does not improve in 24-48 hours or if
you have any concerns, please come back to see me.
We might need to do breast USD to rule out breast Episiotomy Scar IssuesVaginal dryness
abscess. Otherwise, I will see you in 2-3 days to
discuss results of your test.
- Initial: continue with breast feeding. If no response in
12-14 hours treat with Flucoloxacillin 500 QID OB referral Lubricant
- If allergic: Cephalexin oral 500

Postpartum Checkup
Diagnosis and Management
Case: Your next patient in GP practice is a 22-year-old lady for - On examination, we found that you have a dry vagina.
checkup after her first baby was born 6 weeks. Her pregnancy It can happen normally after childbirth. At this moment
was uneventful and the baby was delivered normally. you are breastfeeding that is why a hormone called
prolactin is high which inhibits estrogen, the lack of
Task which leads to a dry vagina and painful intercourse. It
a. Relevant history (dyspareunia) should be fine within a few months. In the meantime,
b. Physical examination you can use lubricants. If it becomes persistent, I
c. Diagnosis and management might need to refer you to the obstetrician.
40

- In terms of contraception, breastfeeding can be an there are retained products? Is the blood clotting? Is
effective form of contraception but you have to fulfill the patient bleeding from anywhere else (No)?
several criteria: exclusive breastfeeding in infant, child
<6months, you have not had your periods yet. Failure On arrival:
rate is 1-2%. There are other methods of - Check vitals, IV lines and catheter
contraception which are safe in lactation. Minipills or - Start syntometrin (Oxytocin + Ergometrine)
progesterone only pills. It is better to start after 3-6 o Ergometrin contraindication: heart disease
weeks and their efficacy is better. Another option is and hypertension
depo-provera. It is injected intramuscularly and needs - Massage uterine fundus
7 days before becoming effective. The efficacy is 98%. - Check placenta
Another option is implanon and it is better to start 3 - Do speculum examination to check for lacerations
weeks after delivery and can be used up to 3 years. - Call registrar
The last one is IUCD. These are devices inserted into
the uterus 6 weeks after vaginal delivery and 12 Management
weeks after cesarean section. IUCDs are effectively - I have called the registrar and they will take you to the
immediate, last for 10-12 years. Efficacy is 99%. theater to examine the uterus under anesthesia to
Higher chances of PID and ectopic pregnancy. check for any retained placental fragments. They can
Condoms. do bimanual compression of the uterus. If it doesn’t
- It is your choice. work, they will give you intrauterine prostaglandins to
- Reading material. promote contraction. If unsuccessful, they will go for
- Review. internal iliac artery ligation.
- If all measures fail, the last resort would be
Primary Postpartum Hemorrhage hysterectomy. However, we will do our best to prevent
this as this is only your first pregnancy.
Case: Your next patient is a 25-year-old primi who had a normal
vaginal delivery 20 minutes ago in one of the country district Secondary Postpartum Hemorrhage
hospital. You are an HMO on call. Pregnancy was normal. Labor
went for 14 hours and now the midwife calls you because the Case: You are an HMO in ED and your next patient is a 35-year-
patient has lost 1.5L of blood. She asks you to come and help old woman. She delivered her baby 5 days ago and she is
her. complaining of vaginal bleeding.

Task Task
a. Ask the midwife appropriate questions (BP 85/5-, pale, a. History (started 10 hours ago, soaked 7-8 pads,
blood clotting, uterine lax, no lacerations) NSVD, BS 3.2 kg, epistiotomy +, pain in stomach +,
b. Advise her on what to do until you arrive NSVD, full term, not a difficult labor)
c. Complete the management when you reach the b. Physical examination (pale, SOB, increased HR,
hospital fever, tachypneic, postural drop, + tender uterus, +
bleeding, scar okay, no laceration)
Types c. Management
- Primary: blood loss per vagina of more than 500ml in
the first 24 hour after delivery
History
- Is my patient hemodynamically stable? When did it
o Atonic uterus (insufficient contraction  start? How many pads have you used since then? Is
shortening and kinking of the uterine blood the pad fully soaked? Have you passed any clots or
vessels and prevent further blood loss) tissues? Are you bleeding from anywhere else like
o Retained placental fragments  prevent nose, gums, urine? Do you have SOB, palpitations or
placental site retraction dizziness? Do you think you have fever? Any other
o Laceration of genital tract vaginal discharge? Any tummy pains? How was the
o Uterine rupture delivery? Was the baby term? Was it a long or difficult
- Secondary: bleeding of more than 500 ml after 24 labor? Did they use forceps? Did they give you a cut
hours during delivery? What was the weight and size of the
o Retained products of conception (placenta) baby? Have you established breastfeeding? Any
o Birth trauma problems with breastfeeding? Any problems with
o Uterine infections (endometritis) waterworks? Are you aware of your blood group and
your baby’s blood group? Any pain in your legs?
History - Any other significant past medical history? do you
- What are the vitals (85/50, 130)? Is she have any FHx of bleeding problems?
hemodynamically stable? Can you please secure IV
lines, take blood for grouping and crossmatching, and
start IV fluids. Is she on a urinary catheter? If not, can
you please insert a catheter?

- Is she conscious (Yes)? Is she having SOB (yes)?


Can you please give her oxygen. What was the mode
of delivery (instrumental delivery with forceps)? Was it Physical Examination
a single baby or multiple? Any genital tear? Was - General appearance
episiotomy done? What is the weight of the baby and - Vital signs
how is the condition? Is the uterus lax or contracted - Abdomen: distention, uterus, masses, organomegaly
(lax)? Have you checked the placenta? Do you think
41

- Pelvic: episiotomy wound, check site of bleeding Primary amenorrhea(Constitutional Delay/Familial)


whether from wound, cervix or uterus, discharge;
lacerations, od open; uterus; adnexal masses Case: Your next patient is an 18-year-old girl with primary
- Urine dipstick and BSL amenorrhea. All secondary sexual signs have been present for
the past 3 years. She has not spoken about this to anyone, but
Diagnosis and Management is now in a relationship.
- From the history and examination, you are suffering
from a condition called secondary postpartum Task
hemorrhage which is bleeding after 24 hours of labor. a. Focused history
There could be a number of reasons for that but most b. Examination
likely, in your case, it is because of a small piece of c. Diagnosis and management
placenta which has been retained in your womb.
- At this stage, I will admit you, secure IV lines take
blood for FBE, coagulation profile, grouping and Differential Diagnosis:
crossmatching and start IV fluids. I will take some - Imperforate hymen
swabs from your vaginal area for any infections. - Genital malformations/Mullerian duct agenesis
- I will call the OB registrar and arrange an USD. If the - Excessive exercise
ultrasound confirms retained placenta, the specialist - Eating disorders
will do curettage. I will also start you on antibiotics - Pituitary tumors/Hyperprolactinemia
because the uterus might have been infected - Hypothalamic disorder (stress)
(ampicillin + gentamycin + metronidazole). - Turner syndrome
- Gonadal dysgenesis (ovaries)
- Thyroid disorders

History
- Ensure confidentiality
- HPI: how about your growth spurt (recently 2-3
years)? Do you think your breasts have developed?
Axillary and pubic hair? How is your height when you
compare it to your friends? Are you on a special diet?
Do you do excessive exercise? Do you take laxatives
or induce vomiting? Do you consider yourself
overweight? How do you feel when you look at
yourself in the mirror? Any change in your weight? Do
you have any weather preferences? Any lump in your
neck or change in your voice? How about your bowel
motion? Have you noticed any milk secretions from
your breast? Any problems with vision or headache?
Do you experience cyclical abdominal pain every
month? Any breast tenderness or early morning
sickness?
- Partner, Pills, Pregnancy, Pap
- Social: how are things at home? How’s the uni? Any
stressors (boyfriend, home)?
- FHx: do you know when your mom had her periods?
Do you have a sister? When did she have her
periods?
- SADMA
- Are you stressed or worried about this?

Examination
- General appearance: normal for age; BMI - normal;
hirsutism
o Puberty: 8-13 (F), 9-14 (M)
- VS: BP;
- ENT: thyroid swelling
- Breast: breast development; axillary hair
- Chest and heart: normal
- Abdomen: suprapubic mass (imperforate hymen)
- Pelvic exam: inspect external genitalia (tanner staging
– pubic hair development); speculum: hymen
- Urine dipstick, PT and BSL

Investigations:
GYNECOLOGY - FSH, LH, prolactin, estradiol
- Chromosome analysis
- Pelvic ultrasound
DISORDERS OF MENSTRUATION
42

Management o inspection and speculum: atrophic vaginitis


- You have a condition called primary amenorrhea. It is o size of uterus; palpate adnexa for masses
defined as failure to start menstruation by 16 years of and tenderness
age. In your case, it is most likely physiological or - DO pregnancy test: I understand that the likelihood of
constitutional or familial as your mom also had my patient being pregnant is low but pregnancy must
delayed periods, but there could be other causes as always be included.
well. So I would like to organize some investigations:
FBE, USD (abdominal), and hormonal studies, TFTs. Investigations:
- Reassure. But if persistent, I can refer you to a - FBE, U&E, LFTs
specialist gynecologist who may consider hormone - FSH, LH, estradiol, prolactin, TSH
challenge test. - Pelvic USD
- Review after reports are back. - BSL
- Bone density scan
Amenorrhea - CT/MRI if suspecting pituitary tumors
Case: 24-year-old female with a 1 year history of amenorrhea.
Management:
Task: - Kathy according to you history and PE, you most likely
a. Focused history have secondary amenorrhea due to excessive
b. Physical examination exercise? We will still run investigations to exclude
c. Investigations other causes like problems with the thyroid gland,
d. Management ovaries, and pituitary glands.
e. Differential diagnosis - Decrease amount of exercise to moderate and your
periods will come back to normal
Secondary Amenorrhea - Other options include OCP or HRT to prevent
- Natural: pregnancy/lactation/menopause osteoporosis thinning of your bones
- Metabolic: unstable DM, renal failure, hepatic - Increase calcium in diet or we can consider ca/vit D
failure, thyroid disorders supplementation
- Hypothalamic: eating disorders (anorexia),
emotional stress, excessive exercise (competitive Asherman syndrome after miscarriage
sports), drugs (GnRh
agonist/danazol/contraceptives) Case: 30-year-old lady who had a miscarriage 5 months ago
- Pituitary: tumors, micro and macro-adenoma, and has come to see you because she hasn’t had a period yet.
pituitary infarction (Sheehan syndrome) OTHER: after manual removal of placenta
- Ovaries: POF, PCOS Task
- Uterus: asherman syndrome a. History
b. Manage case
History:
- Can you please tell me when was your last menstrual History:
period? Did your period stop suddenly or gradually? - I understand that you have come to see me due to
- Period: Menarche? Were they regular? How long is absence of your period since 5 months.
the cycle? How long is the bleeding time? Did you - Did you experience any spotting? Sorry to ask but at
have excessive bleeding or pain during periods? which age of pregnancy did you miscarriage? Did you
Spotting in between periods? have curettage? Any problems after miscarriage
- Partner: are you sexually active? Are you in a stable (fever? Bleeding? Discharge?)
relationship? - 5Ps
- Pills: do you use any form of contraception? Which - Ho w many pregnancies have you had? Could you be
type? pregnant? Any gynecological procedures done in the
- Pap smear? Offer if >2 years. Was it normal? past?
- Pregnancy: Have you ever been pregnant? - Ask differential diagnosis questions
- Are you on a special diet? Have you been stressed for
the past year? Do you exercise regularly? And how Management:
often? - Sophie first we would do PT to exclude pregnancy. We
- Do you suffer from headaches? Visual disturbance? also would check your hormones, FSH, LH, estradiol,
Have you noticed milky discharge from your nipple? prolactin, TSH to exclude different causes
- Can you tolerate cold weather? Any change in weight - We will do pelvic usd. According to your history you
in the past year? Do you suffer from constipation? most likely have secondary amenorrhea due to
- Hot flushes? Dryness of vagina? Is intercourse asherman syndrome. It is the formation of adhesion or
painful? scar tissues inside the uterus. It is a well-recognized
- Do you notice any excessive hair growth? Acne? complication of curettage.
Deepening of the voice? - The ability of the inner lining of the uterus to recover is
- Are you generally healthy? Any gynecological reduced during the pregnancy. Together with surgical
procedures in the past? SADMA? procedure, it contributes to scarring inside the uterus.
- FHx: POF, thyroid disorders - There is a treatment for this condition. I will refer you
to a gynecologist. Most likely the doctor will perform
Physical examination hysteroscopy. Under anesthesia,a small flexible optic
- General appearance: BMI, hirsutism, acne tube is placed thru the cervix into the uterine cavity. It
- VS helps to see intrauterine adhesions and cut them.

- ENT: visual fields; palpate thyroid; do breast - Sometimes it’s not possible to see inside the uterus
examination including nipple discharge immediately, so contrast and xray study might be used
- Abdomen:
- Pelvic exam:
43

to find the uterine cavity and define all the scar HRT are usually used. These hormonal pills will
tissues. reduce your symptoms, prevent osteoporosis and
- After procedure, gynecologist will prescribe estrogen possibly, cardiovascular disease. Most experts agree
to increase the repair of the inner lining. that young women with POF should use hormonal
- As any surgical procedure, hysteroscopy carries some therapy at least until they turn 50.
risks. Complications are uncommon but it includes - HRT  if patient wants to get pregnant because of
anesthesia risk, infection, bleeding. Rarely, lower levels of hormones
perforation.
- It is effective treatment and most likely you can get Secondary Amenorrhea secondary to Polycystic Ovarian
pregnant again. Success depends on the extent of the Syndrome
disease and how difficult is the treatment.
Case: A 21-years-old lady has come to see you in your GP
Secondary Amenorrhea (Premature Ovarian Failure) clinic. She hasn’t had a period for a few months.

Case: 30-year-old presenting because she hasn’t had a period Task


for about 1 year. a. History (sexually active, stable partner, not on OCP,
amenorrhea x 6 months; menarche at 16, teacher, not
Task: so stressed; no headache, weakness, n/v, s/p
a. History appendectomy, goes to gym 2x a week, no weather
Physical examination preference,
b. Investigations b. Physical examination (BMI 27, increased hair on chin
c. Diagnosis and upper lip)
d. Management c. Investigations
d. Management
History: same as 1st 2 cases. Ask for differentials!!
- PMHx: autoimmune disease (SLE, DM, RA etc..) Features:
- Chemoradiotherapy or previous surgery - Roterdam criteria (2/3)
- Drugs (especially cytotoxic) o Anovulatory cycles (prolonged >40 days and
- FHx: 10% of POF run in family irregular)
o Clinical or biochemical of androgen excess
Physical examination: o PCO on USD (>12): necklace appearance
- General appearance: hirsutism, acne, BMI - Increased LH  increased androgen
- Vitals (androstenedione)  converted to testosterone
- Visual fields, Thyroid, breast - Decreased FSH  increased insulin secretion
- Abdomen
- Pelvic: Inspection – atrophic changes History
- Bimanual examination – size of uterus, adnexal - I understand you came to see me because you are
masses and tenderness worried about your periods? When was your LMP?
- Pregnancy test Did your periods stop suddenly or gradually?
- Periods: When was your first period? How many days
Investigations: of bleeding? How many days apart? Any bleeding in
- FSH (high), LH, estradiol, prolactin, TSH between?
- Pelvic USD (thin endometrium, few follicles growing) - Stable relationship? Sexually active?
- BSL - Are you on any contraceptives? When was your last
- Bone density scan pap smear? Was it normal?
- Have you ever been pregnant? Are you trying to
Management: conceive at the moment?
- According to your history and PE, you have secondary - Are you on a special diet? Have you been stressed
amenorrhea most likely due to premature ovarian recently? Do you exercise regularly? Have you
failure. POF is a condition in which ovaries stop suffered from headaches or any visual disturbance?
functioning normally in women who are younger than Have you noticed milky discharge from your nipples?
40. In women with POF, the ovaries stop releasing Can you tolerate cold weather? Any recent change in
eggs or release them only intermittently, and stop your weight? Any recent change in your weight? Do
producing the hormones estrogen, progesterone and you suffer from constipation? Do you have hot
testosterone or produce them only intermittently. flushes? Is intercourse painful? Have you noticed
- In the vast majority of cases, POF has no known excessive hair growth, acne, thinning of your hair or
cause. Some cases of the condition can be explained deepening of your voice?
by genetic abnormalities (Turner or fragile x - Are you generally healthy? Have you ever had any
syndrome), exposure to toxins and autoimmune surgeries or gynecological procedures? SADMA?
disorder. - FHx
- That’s why I would like to refer you to a gynecologist
for further assessment and management.
Physical Examination
- You also need to know that POF often interferes with
- General appearance, hirsutism, acne and BMI
a woman’s ability to get pregnant. Even so, between 1
- Vital signs
and 10% of women with the condition are able to
- Visual field, thryoid and breast exam
conceive normally as there is a chance of intermittent
- Abdomen
improvement of ovarian function.
- Pelvic exam: size of uterus, adnexal masses and
- However, if infertility is a problem, there is also
tenderness
effective an treatment for that, IVF with donor eggs.
- Urine dipstick and urine PT

- One of the main goals for POF is replacement of


Investigations
estrogen that the ovaries stopped producing. OCP or
44

- LH: FSH ratio = 3:1; estradiol, testosterone,


androstenedione, prolactin, TFTs, FBS, pelvic USD body down below? Do you know if your daughter is
sexually active? Any chance she could be pregnant?
Management Any bleeding disorder running in the family? How
- According to history and PE, you most likely have about the development of breast and pubic hair? Is
secondary amenorrhea due to Polycystic ovarian she on any kind of medications? Do you know her
syndrome. We will run investigations to confirm it and blood group? SADMA? Is her immunization up to
exclude other causes. date? Have you considered vaccination against HPV?
- PCOS is a condition that causes irregular menstrual
cycles because monthly ovulation is not occurring and Physical Examination
levels of androgens or male hormones are elevated. It - General appearance: distressed, pallor, dehydration,
is a very common condition. About 5-10% of women jaundice
are diagnosed with PCOS. The cause of PCOS is not - Vital signs: postural hypotension, tachycardia, RR,
completely understood. It’s believed that abnormal Temperature and oxygen saturation normal
levels of the pituitary hormone LH and high level of - Neck swelling (Thyroid) and LAD
androgen interfere with normal function of the ovary. - Tanner Staging
- Classic PCOS symptoms include absent or irregular - Signs of skin bruising
periods, abnormal hair growth, scalp hair loss, acne, - Chest and heart
weight gain, and difficulty becoming pregnant. - Abdomen: organomegaly, tenderness
Although PCOS is not completely reversible, there are - Pelvic exam: inspection for blood clots, signs of
a number of treatments that can reduce symptoms. trauma, sexual abuse; development of genitalia;
- What is your main concern? Periods and Hirsutism
o Lifestyle modification like healthy diet and Diagnosis and Management
regular exercise often help to normalize - Your daughter has a condition called pubertal
menstrual function. menorrhagia which is not uncommon. Because Jane
o We can also use oral contraceptives for 6 is not stable, and her BP is falling, I would like to
months plus hair treatment like laser therapy organize an ambulance, and start IV lines. They will
or electrolysis take blood for investigations: FBE, coagulation profile,
o If it’s not effective I will prescribe OCP plus PT, APTT, vWF screen (factor VIII assay, vWF
anti-androgen (spironolactone or antigen, ristocetin cofactorm PFA-100), urine
cyproterone acetate) – Yasmin and Diane Chlamydia, PCOS screen, 17-OH-P, platelet-function
- Pregnancy assay, iron studies, pregnancy test, TFTs, blood group
o Lifestyle modification and try to have regular and crossmatching.
sexual life for 6 months. If you cannot - At the hospital she will be seen by a specialist and
conceive, I will refer to gynecologist for they will start her on IV premarin for sometime plus
specific treatment. tranexamic acid to control the bleeding. Depending on
o Metformin (improves insulin resistance and the results, they might do blood transfusion. Once she
is stabilized, they would put her in
weight loss):
uninterrupted/continuous OCPs plus iron tablets until
o Clomiphene citrate – 50-70%
her hemoglobin is normal for at least 3 months.
o FSH injection
- Reassure.
o Surgery: drilling - If patient is hemodynamically stable: give oral
o IVF estrogen, do workup, continuous and iron tablets.
- Are there any complications of PCOS?
o Type II Diabetes Abnormal/Dysfunctional Uterine Bleeding
o Endometrial Hyperplasia and Cancer
o Sleep apnea Case: 43/F comes in with painless heavy periods for the last
o Metabolic syndrome four months. She is mother to 3 kids. Previously, some
o Depression investigations have been done including FBE, hormonal profile,
- Review once labs are in. Reading material. pap smear, diagnostic d&c and an endometrial biopsy. All results
are normal except for her hemoglobin which is 70.
Pubertal Menorrhagia (Metrostaxis)
Task: No further history taking allowed.
Case: Your next patient in GP practice is a 12-year-old who is a. Talk to the patient regarding diagnosis and future
having heavy periods for the last 10 days management
Task
a. History (vaginal bleeding 5-6 pads/day, soaked with Differential Diagnosis:
big clots; 1st period) a. Fibroids
b. Physical examination (distressed, pale, tenderness in b. Endometrial cancers
lower abdomen; postural hypotension; tachycardia) c. DUB
c. Diagnosis and management d. Bleeding disorders
e. Hypothyroidism
History f. Cystic hyperplasia
- Is my patient hemodynamically stable? g. PREGNANCY
- When did the bleeding start? How many pads per h. Drugs – anticoagulants, estrogen-containing
day? Are they soaked? Is it getting worse or better? preparations, anti-psychotics
What is the color of the blood? Any clots? Is it smelly? i. IUCD
Is she bleeding from anywhere else? Is this her first j. Trauma
period? Does she bruise easily from minor trauma? k. PID (Chronic)
Any dizziness, SOB, fainting or palpitations? Is there l. AVM
any tummy pain? Any possibility of trauma or foreign
45

History:
- HPI: Since when? Are your periods regular? How - Therapy:
many days do you bleed for? How many pads do you o Medical (controls up to 70% of cases):
in a day? Are they soaked? Any clots? Any associated Mefenamic acid (500mg TID) 4 days before
discharge with the bleeding? When was your last next period  tranexamic acid (1g OD on
period? Any spotting or bleeding in between your D1 of menses)  OCP  Danazol (anti-
periods? Any pain during periods? What was your age estrogen) GnRh agonist (zoladex and
at menarche? Do you have symptoms like n/v synarel)
headache, irritability, swelling of your body before o Surgical: D&C (high recurrence)
periods? Are you sexually active? Stable relationship? endometrial ablation (laser/cautery)
May I ask do you have any problems related to uterine artery ligation/embolization 
intercourse, e.g. pain/bleeding? What contraception hysterectomy
do you use? What type and since when? Have you - Give iron supplements: ferrous sulfate 325mg TID
used IUCD? Have you ever been diagnosed with STIs - Prognosis is good with medical therapy. Up to 70%
or other pelvic infections? success rate.
- I understand you have 3 kids, age of last child? Mode
of delivery? Dysfunctional Uterine Bleeding
- Have you ever suffered from a bleeding disorder, DM,
thyroid? Any previous gynecologic sx? Have you lost Case: Reena, aged 41 years presents to your clinic. She tells
weight recently or change in appetite? Any night you that she had heavy periods for the last few months and
sweats or prolonged fever? describes them as a nightmare. Previously she had regular
- SADMA? Pap-smear? periods but for sometime, they have becomes excessively
- FHx: bleeding, thyroid heavy. She feels tired and has to put herself to bed every month
for at least one day. She works as an accountant in a busy
Physical examination: company and has to take a few offs every month due to which
- General appearance: pallor, jaundice, dehydration, her boss is not happy and she is at risk of losing her job. She
BMI lives at home with her partner and two children.
- VS: BP (postural)
- Skin: bruises or purpura Task
- Stigmata of hyperandrogenism: acne, hirsutism, a. Further history
central obesity, pigmentation, change of voice, male- b. Physical examination
pattern baldness c. Differential diagnosis and management
- Palpate thyroid for enlargement and LN
- Auscultate chest/heart Differential diagnosis
- Palpate abdomen and check for tenderness especially - Fibroids
the R/L iliac fossa; palpable mass; - Contraceptives (depo-provera)
- With patient’s consent, I would like to ask for the - Endometriosis
pelvic exam. On inspection, I would like to quantify - IUD
bleeding (soaked pads), any clots or associated - Bleeding disorders and warfarin
discharge? With a sterile speculum I would like to look - Miscarriage and ectopic pregnancy
at the cervix for any signs of trauma, ulcerations, - Endometrial cancer
lesions, and polyp. Take swabs of vagina and culture - Thyroid disorders
to check for infections. Do bimanual examination
looking for any signs of cervical excitation, size and History:
shape of uterus, and any pelvic mass I can feel. - 5Ps. Signs and symptoms of thyroid disorders,
bleeding disorders, weight loss
Investigations:
- FBE, U,C/E, coagulation profile, blood grouping, LFTs, Physical examination
TFTs, iron studies, complete hormonal assay including - General appearance
serum b-hcg, pap smear, TVS (fibroids and check - Vital signs
thickness of endometrium).
- Chest and Lung
- Hysteroscopy w/ or w/o endometrial sampling –
- Abdomen: masses
visualization of uterus
- Pelvic examination
- CT/MRI may needed
- DO PREGNANCY TEST!
Management Investigations
- Most likely from your history and PE, you have a - FBE, TFTs, LFTS, UEC
condition called DUB where you have bleeding without - Abdominal and vaginal ultrasound
an apparent cause in spite of complete investigations. - D&C
It is a very common condition, the cause of which is
- Endometrial sampling
usually not known. It is suggested that disturbances of
- D&C
the normal brain axis leads to hormonal changes.
- Hysteroscopy
Sometimes there is a problem within the vasculature
of the endometrium, which is the lining of your womb,
Treatment
(there is reduced vasoconstriction of endometrial
- Aim is to reduce the amount of blood loss
vessels and increased prostaglandin E1 and
- Give hormone replacement (progesterone), anti-
prostacyclin)
prostaglandin medication (NSAID) or blood clotting
- It is a diagnosis of exclusion. The therapy is a step-
and reduce bleeding (tranexamic acid)
ladder therapy. We start with medical intervention,
- Options: OCP, progesterone tablets, progesterone
reserving the surgical intervention for resistant cases.
releasing IUD, tranexamic acid (most effective
therapy; reduce bleeding by 50% 4x a day for 4 days)
- Keep a menstrual diary
- Rest as much as possible
46

- Take iron supplements - Pelvic examination


- Eat well-balanced diet o Inspection: discharge, bleeding, clots
- Avoid aspirin o Pelvic examination: evidence of ectropion
(seen as very red patch over cervix which
Postcoital Bleeding (Cervical Cancer) bleeds upon touching), cervical os
o Bimanual examination: palpate mass,
Case: You are a GP and a 40-year-old female comes to you tenderness, whether os is open or close,
complaining of vaginal bleeding after intercourse for the last 7 cervical excitation, adnexal mass that I can
days. She is a mother of 4 kids. Her husband passed away 2 feel?
years ago and she has a new partner recently. - Urine dipstick and pregnancy test

3 cases about cervical cancer: Diagnosis and Management


- From the history and examination, my concern is a
Task mass we have noticed to be arising from the pelvis.
a. Relevant history (2 pads/day x 2days; no clots; last Unfortunately, it seems like this mass is probably a
pap smear x 14 years ago) nasty growth of the cervix.
b. Physical examination findings: abdomen: non-tender - Do you understand what I’m saying? Do you want me
mass palpable and uterus enlarged to 12 weeks; to call someone for you? Are you alright to continue?
inspection: (+) bright red blood on speculum, os - The first step would be to confirm the diagnosis with
closed and (+) mass probably originating from the the help of a procedure called colposcopy and biopsy.
cervix; speculum: small ulcer on the cervix It will be done by the specialist gynecologist. We will
c. Management also do some blood tests before the biopsy including
FBE, LFTs, UEC, TFTs, MSU for MCS. Once the
Presentation: postcoital bleeding in a female smoker who does diagnosis is confirmed, they will do CT scans of the
not have regular pap smears chest, abdomen and pelvis to find out at which stage
the disease is at. Depending upon the staging, the
Differential Diagnosis treatment options are cone biopsy (reserved for stage
- Atrophic vaginitis 1), total hysterectomy, chemotherapy and
- Cervical ectropion radiotherapy.
- Cervical polyp - Staging
- Cervical cancer o I – confined to cervix
- Endometrial cancer o II – involves the uterus but not the lower 3 rd
- Bleeding disorder of vagina
o III – extends to the pelvic walls including the
History lower 1/3 of vagina
- Is my patient hemodynamically stable? o IV – distant metastasis
- Please tell me more about the bleeding? Was it
- Refer to gynecologist for further management
related to intercourse the first time you had bleeding?
- Please don’t worry. There is still a lot of hope for you.
How many pads are you using for the bleeding at the
- Support groups. Counselor.
moment? Any clots? Any discharge apart from the
- Review
bleeding? Any itchiness? Any problems passing
- Reading material.
water? Any bleeding from anywhere else in the body
- If pregnant:
(nose, gums)? When was your LMP? Any possibility
o <20 weeks: offer termination
you might be pregnant at the moment?
Contraception? o >20 weeks: may still offer termination but
- At the moment do you have any dizziness, N/V, usually induction of labor done after 35
lightheadedness? How are your cycles? Are they weeks gestation
regular? Any bleeding in between cycles?
- I understand you have 4 kids. When was your last Postmenopausal bleeding
delivery? Any complications during any of the
pregnancies or deliveries? Case: Your next patient in your GP practice is a 52-year-old lady
- How is your general health? Any history of high blood who complains of bleeding PV. She initially noticed brownish
pressure, DM, bleeding disorders, thyroid problems? staining of her underpants a week ago and came to get a
- When was your last Pap smear? What was the result? checkup.
May I ask why you didn’t have any pap smears?
- SADMA? Investigations ordered:
- FHx: gynecological cancers, bleeding - bHcG – normal
- Do you have any weight loss? night sweats? - FBE – Hb 12m/L, wbc 8500
- Abdominal USG
Tiredness? Any pain anywhere in the body? Any
o Normal uterus, tubes and ovaries
lumps you have noticed?
o Endometrium 12 mm thick (4-8mm)
Physical examination
- General appearance Problem list:
- Vital signs: postural BP - Hemodynamic stability
- Abdomen: obvious abdominal distention, tenderness - History to r/o differential diagnosis
on palpation, mass (can I find out if it is uterine or o Hormones – estrogen content of HRT
ovarian in origin) is it tender? Mobile? Percussion o Vaginal /uterine atrophy
note? Any other viscera that is enlarged? Ausculate o Uterine cervical polyps
bowel sounds? o Endometrial hyperplasia
- Lymph nodes especially inguinal lymph nodes o Cancer (uterus, cervix, vagina)
- Heart and lungs
47

Risk factors: when she gets the abdominal pain. Paracetamol does not
- Nulliparity relieve the pain. Yesterday her mom gave her strong analgesia
- Early menarche, late menopause with codeine (endone) which relieved the pain but she slept for
- Unopposed estrogen therapy (OCP/HRT) the remainder of the day. Mary’s menarche was at 13 years of
- DM age. Her cycles were irregular for the first 6 months but now are
- Obesity regular every 28 days lasting about 7 days. She is otherwise
well. Her mother suggested Mary to see you because she is
Task: concerned that the severity of pain might indicate that there is
a. Take a further history required something serious with Mary.
b. Ask the examiner relevant examination findings
c. Discuss further management plan with the patient Task
a. History (menses started yesterday, 1 pad/day, every
Physical examination 28 days, sexually active and uses condoms, not on
- General appearance: BMI, OCPs)
- Vitals: BP, RR, PR, Temperature b. Physical examination
- Abdomen: scars, masses, striae, masses, c. Investigation
organomegaly, FHT, lateral grip, pelvic grip, FHT d. Diagnosis and management
- Gynecological exam:
o informed consent - Ensure CONFIDENTIALITY at all times!!!!!!
o inspection: discharge, ulcers, lesions, warts, - Consent:
scratch, atrophic changes; speculum  o legal age: 18 y.o
cervix, atrophic changes; do PAP and o sexual activity: 16 y.o.
endometrial sampling where possible o mature minor: >12 y.o.
- Scale PAIN!
Atrophic vaginitis – dx usually done using speculum examination - Sexual history: are you sexually active? How long
seen as thin, friable vaginal wall which may bleed to touch. have you been active? Are you in a stable
Typically, history will be a 10-year-postmenopausal lady relationship? How long? How many sexual partners
complaining of a yellowish-brown vaginal discharge or just have you had? Do you practice safe sex?
mucus. (+) dyspareunia; tx: topical estrogen cream initially and - SADMA?
systemic estrogen/progesterone (if uterus intact) - Other bleeding problems

Cervical polyps – diagnosis usually made in speculum Dysmenorrhea Differential diagnosis:


examination – seen as red protrusion from the cervical os; tx:
attempt removal by grasping it with sponge forceps and twisting Primary dysmenorrhea
the pedicle - Menstrual pain associated with ovular cycles without
any pathologic findings; usually commences within 1-2
Endometrial polyp – usually identified on hysteroscopy where years after menarche and becomes more severe with
the polyp is directly visualized; typical history of a 50-year-old time up to about 20 years.
female with bleeding PV; estrogen dependent (incidence - 50% of women and up to 95% of adolescents
decreases after menopause. History of tamoxifen use; tx: - Features:
removal during hysteroscopy and send to pathology o Low midline abdominal pain
o Pain radiates to back or thighs
Endometrial hyperplasia – diagnosed on hysteroscopy; TVS is o Varies from a dull dragging to a severe
more accurate. Two types: simple (proliferative endometrium) cramping pain
or complex (proliferative endometrium with atypical changes and o Maximum pain at beginning of the period
if left untreated will progress to cancer in 2 years); tx: high-dose o May commence up to 12 hours before the
progesterone with frequent reassessment; definitive tx: menses appear
hysterectomy with oophorectomy o Usually lasts 24 hours but may persist for 2-
3 days
Endometrial CA – 5th most common cancer in women in
o May be associated with nausea and
Australia. Px complains of vaginal bleeding or irregular
postmenopausal bleeding; (+) hx of anovulatory cycles or vomiting, headache, syncope or flushing
abnormal endometrial cells on pap; tx: surgical removal (Total o No abnormal findings on examination
hysterectomy  bilateral salpingo-oophorectomy  bilateral - Investigations:
pelvic and para-aortic LAD  peritoneal cytology) and staging o MSU
during surgery; good prognosis if diagnosis is made early; - Risk factors:
consider RT for deeply invasive tumor o Obesity
o Smoking
DYSMENORRHEA AND ABDOMINAL PAIN o Early age at menarche
o Longer periods
Dysmenorrhea o Alcohol
o Lack of exercise
Case: Mary is 14 years old presents to your GP clinic while her o Anxiety, stress, depression
mother is outside in the waiting room. You know her for 6 years. - Management:
She complained of severe central lower abdominal pain with her o Lifestyle modification
periods for the past few menstrual cycles. The pain gradually o Avoid smoking/alcohol
begins on day one of her menses and becomes very severe o Relaxation techniques (yoga)
within a few hours. She gests nauseated and sometimes vomits o Avoid exposure to extreme cold
and sometimes she feels a nagging ache at the top of her thighs
o Place a water bottle over the painful area
48

- Medication
o ASA or PCM Differential Diagnosis
o Prostaglandin inhibitors (Mefenamic acid) - Ectopic pregnancy
o NSAIDS (Naproxen or ibuprofen)  start 1 - PID
day before the period then continue for the - Ruptured ovarian cyst
next couple of days - Ovarian torsion
o Thiamine 100mg - Mittelschmerz
o Low-dose OCP - UTI
- Initially during first 1 or 2 years of period, you don’t - Acute appendicitis
produce eggs and therefore you don’t experience
pain. However, when eggs become produced, History
chemicals (prostaglandin) are released which increase - Is my patient hemodynamically stable? I understand
the contraction of the uterus (womb) producing pain. you came to the ED because of abdominal pain.
When did it start? Can you show me with one finger
Secondary dysmenorrhea: menstrual pain for which an organic where is the pain? Has it always been there or did it
cause can be found; begins after menarche, after years of pain- start somewhere else? Can you describe the type of
free menses; >30 years of age; begins 3-4 days before menses pain? Does the pain travel anywhere else? Can you
and becomes more severe during menstruation. May have recall any precipitating factors? How bad is the pain
intermenstrual pain, dyspareunia, etc. on a scale of 1-10? Does anything make it better or
- Causes: worse? Is it the first episode? What happened last
o PID time? Do you remember any investigation result and
o Endometriosis what doctor said? Are there associated symptoms like
o IUCD fever, nausea or vomiting? How’s your waterworks?
Any stinging or burning sensation? Has the color of
o Submucous myoma
urine changed? How are your bowel movements?
o Intrauterine polyp When was the last time you opened your bowels?
o Pelvic adhesions - When was your LMP? How long is your cycle? How
long is the bleeding? When was your first period? Any
Investigations excessive pain or bleeding during the periods? Are
- FBE you sexually active?
- MSU - How’s your general health? Any surgeries in the past?
- Pregnancy test SADMA?
- USD - Whom do you live with at home? Any problems at
- Hysteroscopy, D&C, HSSG home or in school?
- FHx
Mittelschmerz
Physical Examination
Case: You are an HMO in ED and a 14-year-old girl comes - General appearance
complaining of severe lower abdominal pain. - Vital signs and growth chart
- Abdomen:
Task o Inspection
a. History (severe right lower quadrant pain, 7/10, for 2 o Palpation: guarding, rigidity, rebound
hours, 3rd time for 2 months relieved by panadeine tenderness, tenderness at McBurney point,
forte, 2nd episode went to hospital, workup done was Rovsing sign, Psoas sign (pain on extension
normal, can’t remember what doctor said, and of hip), obturator sign (pain on internal
discharged after being pain-free, periods regular 28- rotation of hip)
30 days, not sexually active, FHx of DM and MI; LMP o Auscultation
2weeks
- Urine dipstick
b. Physical examination (BMI 17, mild tenderness of
deep palpation on RIF, hymen intact)
Investigation: Transbadominal USD + Doppler (helps exclude
c. Investigation if relevant
torsion)
d. Diagnosis and management
Diagnosis and Management
Features
- According to your history and PE, most likely you have
- Rupture of Graafian follicle  small amount of blood
a condition called mitteschmerz syndrome. Have you
mixed with follicular fluid released into pouch of
ever heard about it? The word means “middle pain”
Douglas  peritonism
because this pain is typically felt during the middle of
- Features: onset of pain in mid-cycle, deep pain in one
the menstrual cycle. This pain coincides with
or other iliac foosa (RIF>LIF), often described as
ovulation. It’s a very common condition. As many as 1
“horse-kick pain”; tends to move centrally; heavy
in 5 women experience mittelschmerz pain. Some
feeling in pelvis; relieved by sitting or supporting lower
every cycle, some intermittently. It is more common in
abdomen; lasts for fe minutes to hours
young women under 30. There are a number of
- Patient otherwise well
theories why women experience this pain.
- Sometimes can mimic acute appendicitis
o The ovaries have no opening. At ovulation,
- Management
the eggs break through the ovary wall and
o Explain and reassurance
causes pain.
o Simple analgesics
o Hot water bottle
49

o At time of ovulation, blood is released from - Physical symptoms: headache, dizziness, hot flushes,
ruptured egg follicles and may cause breast swelling and tenderness, abdominal
irritation of the abdominal lining. bloatedness, constipation
o There is also contraction of fallopian tubes
and some other contributory factors leading Management: Diary/CBT/Lifestyle modification/Relaxation 
to spasm and pain antidepressants

- Usually pain appears suddenly in the middle of the


cycle and subsides within hours. It is not harmful and
doesn’t signify presence of disease. - Diary: write her symptoms for at least 2-3 months
- You need to have rest. Drink plenty of fluids. Take period.
panadol or ibuprofen or Panadeine or Panadeine - CBT
forte. You can use local heat applications or warm - Lifestyle modification (exercise, diet)
baths. - Relaxation
- If pain is severe and doesn’t respond to simple - Medication
painkillers, your doctor might consider OCP to block o Nil or negative: evening primrose oil, gingko
ovulation. biloba, progesterone, OCP, bromocriptine
o Weak: magnesium, calcium, vitamin E, vitex
PREMENSTRUAL SYNDROME angus
o Moderate: pyridoxine vitamin b6 (mild-
Premenstrual Syndrome (PMS) moderate), st. john’s wort, spironolactone
o Strong (for PMDD): SSRI and clomipramine,
Case: Nancy aged 32 years visit your surgery and tell you that GnRH agonists, danazol
she frequently feels irritable, tearful and bloated before her - PMDD: fluoxetine 20mg mane for 10-14 days before
periods every month. This has been going on for last couple of anticipated onset of menstruation or sertraline 50 mg
years. Her menses are regular lasting for about one week and daily
symptoms completely resolve within 1-2 days of onset. Her
menses occur every month and she considers they are not Pre-menstrual Dysphoric Disorder
painful and are not heavy. She has no bleeding in between her
menses or after intercourse. She is a school teacher and lives PMDD Criteria: (A) Symptoms must occur during the week
with her husband at home. She had two children aged four and before menses and remit a few days after onset of menses; five
six years of age. of the following symptoms must be present with at least one
being 1-4 and should be symptom free for one week:
Task - Depressed mood or dysphoria
a. History - Anxiety or tension
b. Physical examination - Affective lability
c. Diagnosis and further advice - Irritability
- Decreased interest in usual activities
Predisposing factors: - Concentration difficulties
- Mental illness - Marked lack of energy
- Alcoholism - Marked change in appetite, overeating or food
- Sexual abuse cravings
- Family history - Hypersomnia
- Stress - Feeling overwhelmed
- Other physical symptoms
Precipitating factors - B. Symptoms must interfere with work, school, usual
- Cessation of OCP activities or relationship
- Tubal ligation - C. Symptoms must not merely b an exacerbation of
- Hysterectomy another disorder
- D. Criteria A, B and C must be confirmed by
Sustaining factors prospective daily ratings for at least 2 cycles
- Diet – containing caffeine, alcohol, sugar
- Smoking CONCEPTION CONTROL
- Stress
- Sedentary lifestyle Natural methods of contraception

Differential diagnosis Case: A 19-year-old females comes to your GP clinic to consult


- Psychologic: Depression about contraception as she is now going to start sexual relations
- Thyroid disorders with her boyfriend. She is not interested in barrier methods or
- PCOS hormonal contraceptives and wants to know about natural
- Mastalgia contraception.
- Menopause syndrome
Task
History a. Focused history : 5Ps (gardasil vaccination) and
- Rule out anxiety and depression question general health
- Home situation b. Explain methods
- Ask about psychologic symptoms: Insomnia,
Moodiness, Irritability, Anxiety, Tension, Depression, Natural: They require regular periods and high motivation.
Confusion, Food cravings These methods will help determine when to avoid intercourse
during your cycle, meaning your safe and unsafe periods.
50

- Bibasal temperature: relies on measurement of your boyfriend 6 months now, and wants to discuss the OCP with
body temperature you.
o Check temperature every morning before
getting out of bed or any activities. Task:
Temperature rises slightly during ovulation. a. take a further history required
o 0.2-0.5C increase in temperature indicates b. ask for relevant findings
ovulation  avoid sexual contact for up to c. discuss OCP with the patient
72 hours after the change in temperature

o You must note the temperature on a chart to Problem list:


compare changes from day-to-day. Avoid a. confidentiality and consent
sexual contact from the first day of period up b. social/ethical aspect (boyfriend’s age)
to 72 hours after rise in temperature c. 14-year-old minor – Gillick’s test
o 99% effective if done correctly and d. Discuss OCP – r/o contraindications; usage
consistently; instructions and adverse effect
o Benefits: no side effects
HEADS (psych history)
o Limitations: tedious and should be
Home situation
motivated; unsuitable if woman has fever or
Education/employment
other health condition; period of abstinence
Activity/alcohol
of longer
Depression/drugs
- Calendar/Rhythm Method:
Suicidality/smoking
o Monitor 6 (at least 12) cycles and select the
shortest and longest cycle. Management
o Shortest Cycle (– 21) and Longest cycle - Partner's age: >2 years age difference is not
(10) acceptable;
 14-6 = 8 (Sperm viable for 6 days) - Gillick's test: if you are able to show me that you're
 14+2 = 18 (Egg viable for 2 days) able to understand what you are saying, and at the
o Avoid sexual contact on the unsafe days. end of the conversion you are able to understand what
o 95% effective if used correctly I said, then I can give you the script. (how are you
o Benefits: No side effects, no cost, and do going to use the OCP? What will you do if you missed
not require any special device the pill?)
o Limitations: must monitor length of - Will not protect against STIs.
menstrual cycle for 6 months; - Advise on 7 days row. Use other contraceptive
- Billings Ovulation Method methods for the first 7 days. If you missed the pill or
o Based on careful observation of the nature have had any nausea, vomiting, diarrhea then use
of mucus so that ovulation can be barrier method
recognized - Reading materials
o Fertile mucus is wet, clear, stringy and - Review again for 3 months
increased in amount and feels lubricated
due to estrogen Breakthrough Bleeding with OCPs
o Last day of this type of mucus is peak
mucus day which is followed by abrupt Case: Your next patient in GP practice is a 22-year-old female
change of thick mucus associated with who started using Microgynon 30 because she wants to start
secretion of progesterone sexual relationship with her partner in the near future. She has
o Infertile phase: 4 days after peak mucus day had some per vagina spotting over the last 4 weeks and is
concerned.
o Intercourse is avoided from the first
awareness of increased clearer wet mucus
Task:
until 4 days after maximum mucus
a. History (spotting x 2-3 for 4 weeks)
secretion.
b. Diagnosis
o Most effective method if done correctly;
c. Management
failure rate is 1-2/100 women-years
o Failure: women are only able to detect 3- History
4days of wetness prior to the peak moisture - Could you talk more about it? Do you take the pills at
day and still have sex 4-6 days prior to a regular time? Have you skipped or missed a pill?
ovulation when sperm survival is still Smoking? STDs? Are you taking any other
possible medications (anti-epileptics/antibiotics)? Recent
- Coitus interruptus: male withdrawal before ejaculation; diarrhea or vomiting?
least effective - Any chance you could be pregnant? Partner? Pap
- NOT EFFECTIVE AGAINST SEXUALLY smear?
TRANSMITTED INFECTIONS
Factors for breakthrough bleeding:
Counseling about OCP - Not taking pills at the same time (decreases efficacy)
- Missed pill
Case: 14-year-old girl who seems to be mature for her age - Smoking
came to you for contraceptive advice. She is your regular - Medications
patient, is generally healthy. She has been with her 15-year-old - AGE
51

o Active liver disease


Management o Pregnancy
- What you have is a case of breakthrough bleeding o Undiagnosed vaginal bleeding
which occurs in between periods. It could be a light o Otosclerosis? Intermittent porphyria
spotting in your case or a heavy bleeding. It is a
common side effect of OCPs. Investigations: FBE, LFTs, BSL, Lipid profile, U/C/E, TFTs,
- There are several reasons why breakthrough bleeding Estrogen/FSH/LH
can happen: if not taking pills at the same time (15
minutes), should not skip pills, smoking, medication or Management:
STDs, or AGE. For some women, the low-dose pill - From the history, you are not a candidate for HRT.
does not contain enough estrogen to maintain the However, I would like to request for some medications
stability of the endometrium (lining of the uterus) to check if you’re already reaching menopause. HRT
which causes breakthrough bleeding. is not a contraceptive method. Both HRT and OCPs
do not prevent STIs.

- It also depends on the type of progesterone.


- At this stage, I would recommend for you to continue - Menopause is a natural phenomenon. One of the
for 4-6 months and if it does not stop after that, then things I am concerned about menopause is
we might consider changing your OCP dose to a osteoporosis and heart disease. It is advisable to
higher estrogen-containing pill or different change lifestyle: maintain healthy weight, adequate
progesterone. relaxation and exercise, do pelvic floor exercises
- Review and Reading materials. regularly, reduced smoking, caffeine, alcohol intake,
- Red flags: severe bleeding, nausea/vomting, etc… increased exposure to sunlight.
- Some other methods of contraception: barrier, IUCD,
Indications for high-dose estrogen OCPs implanon, injectables, etc… during next consultation
- Uncontrolled menorraghia
- Taking other enzyme inducing (p450) drugs such as Additional information:
anti-epileptics - Ways to know: organize LH and FSH (30-40)  most
- Low dose pill failure
likely menopausal; if FSH and LH are that high 
On OCP wants to change to HRT stop OCP and get symptoms  HRT; require regular
follow up.
A 45-year-old lady came to your GP clinic and she is on OCP. - 45  too early; but requires support; usually high
She wants to change to HRT because she has heard about it dose HRT given;
from her friends.
OCP-Induced Hypertension
*48-year-old px with irregular periods and husband had
vasectomy; Case: You are a GP and a 26-year-old female comes to your
clinic asking about the chances of becoming pregnant within the
*53-year-old with amenorrhea for last 2 days (years)/with history next 6 months
of breast cancer.
Case Before: Patient coming to you who is a heavy smoker and
Task has hypertension. She is on OCP.
a. History
b. Management Task
c. Answer her questions a. History (regular 2-3 days, 28 days, on the pill, pap
smear n, no previous pregnancies/miscarriages, non-
History: smoker, social drinker, mom with DM)
- 5Ps: b. Physical examination: BP 155/95,
- Vasomotor symptoms: hot flushes? Night sweats? c. Diagnosis and management
Palpitations? Lightheadedness/dizziness? Migraine?
- Urogenital: dyspareunia? UTI? Vaginal dryness? History
Decline in libido? Bladder dysfunction (dysuria)? - I can see from the notes you wish to become pregnant
Stress incontinence/prolapse? in the near future. Congratulations on your decision.
- Psychogenic: irritability, depression, anxiety/tension, - Please tell me more about your periods? Are they
fearfulness, loss of concentration, tearfulness, loss of regular? How many days of bleeding? How many
concentration, poor short term memory, unloved days apart? Are your periods heavy? Are they painful?
feelings, mood changes, loss of self-confidence Any spotting in between?
- Frequent headaches? Migraine? FHx: CVS, cancers, - I understand you’re sexually active, since when? What
osteoporosis? Breast lumps? History of heart form of contraception do you use? What type of pill
disease? Hypertension? Unusual bleeding? Pills? Any are you on? Since when? Have you had any side
weight gain? Nausea/vomiting? effects from the pill (nausea, weight gain,
- SADMA: smoking? Medications: steroids? intermenstrual spotting)? Have you or your partner
- FHx: Premature menopause ever been diagnosed with a STI? At the moment, do
you suffer from any vaginal discharge? Any bleeding
- Contraindications of HRT: or itchiness down below? Have you ever had pelvic
o Estrogen-dependent tumor (endometrial, infections before? Have you had any
breast cancer) pregnancy/miscarriages/gynecological surgeries
o Recurrent thromboembolism before?
- When was your last pap smear? What was the result?
o Acute IHD (absolute)/history of CHD
Have you had gardasil?
(relative)
o Uncontrolled hypertension
52

- PMHx: diabetes, hypertension, kidney disease,


infections, liver? History of clotting problems in you or Task
your family? a. History (on the pill, periods stopped GRADUALLY,
- SADMA? b. Physical examination
- How’s your appetite/sleep? Any recent history of fever, c. Diagnosis
cough, diarrhea, tummy pain? How do you consider d. Management
your weight to be? Do you know your blood group?
- Any FHx of fertility problems? Pregnancy related Secondary Amenorrhea
problems? Diabetes? High blood pressure? - Pregnancy (breast tenderness, spotting, early morning
- Headache: how frequent, since when? Have you N/V)
noticed any association with particular food or time of - PCOS (weight gain, acne, hirsutism, irregular periods)
day? What do you take to relieve pain? Any - Hypthyroidism (weather preference, puffy face,
associated N/V/abnormal sensations/visual edema, mood)
disturbance? - Eating disorder/exercise induced
- Hyperprolactinemia (breast discharge, medications,
headache, nausea and vomiting

Physical examination
- General appearance and BMI - Asherman syndrome (gynecological procedures/D&C)
- Vital signs - Stress
- Dysmorphic features of cushing syndrome, PCOS - Premature ovarian symptoms
- Palpate thyroid - Post-Pill Amenorrhea
- Auscultate chest and heart
- Abdomen to palpate renal or suprarenal mass and History
listen to bruit - I understand you have not had your menses for the
- Pelvic exam: last 2 months. Any chance you might be pregnant?
o Inspection: discharge, bleeding What’s your LMP? Do you have symptoms like breast
o Bimanaual exam: position and size of pain, N/V, spotting?
uterus, tenderness, cervical excitation - Pills: any problems with that? Do you think you might
- Urine dipstick, pregnancy test and BSL have missed your pill anytime? Are you taking it
regularly? Did you have any diarrhea or vomiting? Are
Management you on any other medications?
- From the history and examination, the most important - Review of systems: hirsutism
finding is that of a high blood pressure. Have you ever - Partner? Pap? Gardasil vaccination?
had your blood pressure checked before? Usually, at - Any previous pregnancies?
your age, having a high blood pressure can be due to - Any Family history of premature ovarian failure or
a number of causes. Most likely, it can be related to cancers?
the use of the pill as the headaches that you have - SADMA? PMHX
started along with the use of the pill. I still need to rule
out other causes of hypertension such as smoking, Physical Examination
any problems with the blood supply to the kidneys, - General appearance
certain growths in the adrenal gland related to the - Vital signs and BMI
kidney, cardiac problems, and the like. I would do - Visible hirsutism, acne, puffy face or edema
some investigations like FBE, U&E, Urine MCS, ECG, - Vision: visual fields, funduscopy, visual acuity
uric acid level, lipid profile, LFTs, TFTs, blood group, - Neck: thyroid enlargement
rubella antibody, infection screening. - Breast examination: nipple discharge
- We still need to check your BP during the next visit. - Abdomen: masses, tenderness
However, I want you to please stop using the pill. - Pelvic exam:
Around 2% of females, especially those who have o Inspection: discharge, atrophic vagina
family history of high BP, those who are overweight, o Speculum: cervical os, bleeding
>35 years old, and smokers can develop high blood o Bimanual: size of uterus, adnexal masses,
pressure due to OCPs. Some women get high BP CMT
from the progesterone component of the pill. Usually, - Urine dipstick, BSL, Pregnancy Test
this rise in blood pressure is only seen with the
systolic component. The good news is that it is Diagnosis and management
completely reversible. However, you need to stop - There is no abnormality on physical examination.
smoking and adopt a healthy lifestyle to reduce this According to your history, the most likely cause of not
risk to minimum. Meanwhile, you may use another having the periods is endometrial atrophy secondary
form of contraception, probably condoms. Becoming to the pill.
pregnant at this stage might further complicate your - However, we need to rule out pregnancy. The only
condition, so my advice is once the results are back possible reason is one of the hormones
and your BP is normalized, you can plan for the (progesterone) in the pill is causing thinning of the
pregnancy. I would like to see you in one week’s time lining of the womb.
with the results of the tests. Please come back if you - DIAGRAM
develop further headaches, visual problems, fainting - Do not worry. It is a reversible condition. At this stage,
or dizziness. we will stop the Microgynon 30 and you can use other
forms of contraception at this time or I can shift you to
Post-pill amenorrhea?? Microgynon 50 or we can use the triphasic pills. Most
likely your periods will return. In case you don’t or
Case: Your next patient in GP practice is a 30-year-old woman. you’re really concerned, I can refer you to the
She did not have periods for the last 2 months. She is on gynecologist for further investigation.
MIcrogynon 30. - Reading material. Referral. Review.
53

equally worried if your daughter suffered from any of


Request for sterilization for a disabled person/Contraceptive the complications of this surgery which includes
advise for disabled complications with anesthesia, bleeding, infections,
and long-term effects on her bone growth and
Case: You are a GP and a mother of 13-year-old child comes to hormonal imbalances.
you. She is intellectually disabled and epileptic. She is on - I gave the consent appendicectomy. Why can’t I do it
carbamazepine. She wants your advice because the child goes now? Appendectomy is a medical emergency where
to school for both boys and girls. She is worried about the decision is taken on medical grounds. If you like,
contraception and the risk of pregnancy. you can contact the family court or the guardianship
board. They have the legal authority to allow this kind
Task of procedure.
a. Relevant history
b. Address mother’s concerns

History Depo-Provera Counseling


- Can you please tell me, what is your main concern?
Do you think your daughter has started her periods? Case: A 25-years-old female is in your GP clinic and who wants
Did you notice any breast development? Since when? to have depo-provera.
Have you noticed any hair growths in the armpits over
the pubic area? Since when? I understand she is on Task
phenytoin/carbamazepine? Any side effects? Who a. Advise about depo-provera
takes care of her medications? Since when did she
last see her neurologist. Counseling
- Please tell me more about her mental retardation. - It is the only injectable IM contraceptive available in
Was she born this way? How would you describe her Australia and it has progesterone in it. The dose is
mental age to be? Is she able to do daily life activities 150mg by deep IM injection in the first 5 days of
like eating, dressing, and going to the toilet? Does she menstrual cycle and same dose is given every 12
need partial or complete supervision? Who takes care weeks.
of her most of the time? Do you experience any - Do you have any migraine? Stroke? Cancer? Any
difficulties while taking care of your daughter? How is undiagnosed vaginal bleeding? Hypertension? Heart
her school performance? Any problems at school? Is it disease? Diabetes? Lipids? Liver disease?
a special school? Do you think she might already be - 5Ps: periods, pap smear, do you want to be pregnant
sexually active? Have you discussed anything with her in the next 12 months?
like Periods? Contraception? Previous medical or - When the woman has depo-provera in the body her
surgical illnesses? Any concerns about her growth? own hormone production is switched off. Because of
Do you have enough support at home, from family this the ovaries will not release eggs thus pregnancy
friends and partner? Financial problem? is prevented. It is a highly effective method of
contraception more effective than the combined pill
Counseling and failure rate is 1%.
- I understand from the history that your daughter has - The advantages of depo-provera are: It is highly
not had her periods up till now. However, some degree effective and therefore has low failure rate. It can
of breast development has occurred so we might relieve pre-menstrual tension and period pain. It is
expect that she will start menstruating soon. It is very also likely to cause some reduction in risk of ovarian
good that you have come at this time to discuss and endometrial cancer, and endometriosis. As it is
contraception. However, no form of contraception is given every 12 weeks, no other effort or remembering
required until periods start. Usually, we recommend is required.
oral contraceptives that might be most suitable for her. - The disadvantage is that you have to take injection
Because she is on antiepileptic medications, we might every 3 months. Once the injection is given, the
need to give her a pill with high dose of estrogen. hormone cannot be removed and if you want to stop
Please understand that the pill prevents pregnancy depo-provera you have to wait for the hormone to
only and not STDs. If you find that giving a pill wear off. In some women, it can take 6-12 months for
everyday is inconvenient, we can give her injections of periods to return. There is a concern about the risk of
depo-provera every 3 months. However, with thinning of bones if woman is using depo-provera for a
prolonged use, it will produce side effects including long period of time.
reduced density of bones as well as problems with - Side effects may include reduced periods due to low
periods. There are other options as well like implanon level of hormones. After 2-3 injections, most women
and IUCDs. However, the management is better will have no periods at all because there is no lining
suitable for females who can look after themselves. building up to shed. Some have intermenstrual
- Can we remove her womb instead? The oral pill is the bleeding which is usually light and irregular or have
best option for your child because you are already heavy bleeding which can be controlled by hormone
giving her some medications and you just need to add treatment. A small amount of weight gain can occur.
one more. Regarding permanent sterilization, it is There can be headache, abdominal discomfort and
usually not allowed for girls under the age of 18 years mood changes. Women who have increased
without approval from the court. Please understand incidence of depression can have reduced interest in
that being mentally disabled does not deprive your sex.
daughter from the right to be treated just like other - Contraindications
people. We, as doctors, only prescribe something if it o Bleeding disorders or taking anticoagulant
is in the best interest of your daughter. I understand medication
you are concerned; however, I am sure you would be
54

o Undiagnosed vaginal bleeding Task


o History of some forms of cancer a. Explain methods of emergency contraception
o Serious medical conditions b. Manage the case
o Already pregnant or those who want to
become pregnant within 12 months Case: Rosie aged 24 years presents to the ED of the local
- Not recommended for greater than 2 years. hospital where you are working as an intern. She tells you that
she was sexually assaulted by a person to whom she met in a
Implanon Counseling pub. She is very distressed and teary. On further questioning
she discloses that she doesn’t know this person and had never
Case: Your next patient is a 19-year-old female previously on met him before. He offered her a lift home and then stopped the
OCP and now requests implanon. car in a lonely place and assaulted her. Rosie is an overseas
university student and lives in a shared accommodation and had
Task no other medical or any surgical problems.
a. Relevant history (friend mentioned; no problems
except missed pill) Task
b. Advice patient and answer questions a. Further relevant history
b. Physical examination
c. Management advice

History - I understand from the notes that you are here for
- Why do you want to change? Who suggested emergency contraception which is available OTC. Is
implanon? Any side effects of OCP? Any chance you there some special reason to see me today?
are pregnant now? Did you have previous STIs? Pap - I am sorry to hear that, but don’t worry there is a lot of
smear support and you are not alone at this moment of crisis.
- Previous pregnancies/miscarriages? How are your - Confidentiality statement.
cycles? When was your LMP? Any medical conditions - Would you like to take any legal action? (No doctor.
and FHx of hypertension, diabetes? This man is known to my family and I don’t want to
- SADMA? make a fuss about it.) I respect your decision but I
would like to get samples and keep it in the hospital
Counseling just in case you will change your mind later.
- The implanon, as you know, is a small device that - Were you injured anywhere else?
goes below the skin in the non-dominant upper arm - Menstrual history: When was your LMP (3 weeks
under local anesthesia. It contains a certain hormone ago)? How are your periods? Are they regular? What
(etonogestrel) that will cause 2 things: inhibits is the cycle? Bleeding? How many days apart?
ovulation and increases the viscosity of the cervical - Sexual history: Do you know if the man suffered from
mucus. It is a very safe contraceptive method. The any STIs (No)/Did you see any discharge on his
failure rate is <1% and it lasts for 3 years. private part? Are you sexually active? Are you in a
- Upon removal, most women will ovulate during the stable relationship? Are you using any form of
first month. The procedure needs to be done by a contraception? Have you or your partner ever been
trained personnel. diagnosed with STIs? Pap smear
- Advantages: convenience, rapid reversibility, available - Any history of clotting, hypertension, migraine,
at low cost through the PBS systems, suitable for undiagnosed vaginal bleeding, breast cancer?
women with CI to estrogen
- Absolute contraindications: pregnancy, undiagnosed Examination
vaginal bleeding, active thromboembolic disease, - General appearance
present or history of severe liver disease, - Vitals
progestogen-dependent tumors, breast cancer, - Pelvic examination with consent
hypersensitivity to components of implanon o Inspection: sign of injury, vaginal secretions,
- Relative contraindications: long-term use of liver consent to take low and high vaginal swabs
enzyme inducing drugs, past or family Hx of for STD screening
thromboembolic disease, obesity (>100kg  efficacy - Chest, heart, abdomen to check signs of assault
is less), women for whom regular periods are - Urine dipstick
important
- Side effect: Menstrual disturbance is the most Management
common reason for removal - We need to take blood samples for HIV, syphilis,
o bleeding approximating normal (35%), Hepatitis B&C, HSV and take urine sample for PCR
and Chlamydia
infrequent bleeding (26%), amenorrhea
- I would give you antibiotic coverage: Azithromycin 1g
(21%), frequent or prolonged bleeding
SD
(18%)
- I would like to refer you to a psychologist or counselor
o breast tenderness, fluid retention, weight
for support (rape crisis team).
gain, skin disorders (improve), mood change
- Let’s talk about emergency contraception. The first
- Effective immediately if inserted during day 1-5 of the
method is levonorgestrel (Postinor). This is a POP. 2
patient’s menstrual cycle; if not, then important to pills (0.75mg each)  12 hours apart or 1 pill (1.5mg)
ascertain the patient is not pregnant and alternative
given up to 5 days but most efficient if taken within 72
contraception should be used for 7 days after
hours. Efficacy is 85%.
insertion.
- The next method is combined pills or Yuzpe method
75% efficacy ([50mcg estrogen and 250 mcg
Emergency Contraception after Rape
progesterone] 2 tablets now then 2 tablets 12 hours
apart) or copper IUDs with a failure rate of <1% if
Case: You are a GP and 18-year-old Samantha came to your
used within 72 hours.
clinic asking for emergency contraception and advice.
- There are chances of getting pregnant even after
taking the emergency pills. Therefore, I would like to
55

review you after 2-3 weeks to do pregnancy test - CLOSURE: I would recommend you to go home and
especially if you miss you period. discuss what we have talked about today and if you
- Most common side effect is nausea and vomiting. If have decided, I will give you a referral letter.
she develops it, she needs to take the drug again.’
- Reading material Vasectomy

Tubal ligation Case: A couple comes to your GP clinic. They have completed
their family and want to discuss with you about vasectomy.
Case: 32-year-old lady comes to you in your GP practice. She
has 3 kids and would like to go ahead with tubal ligation. Task
a. Relevant history (family complete, and wife doesn’t
Task: want to take OCPs
a. Counsel the patient regarding ligation b. because of side effects)
b. Answer patients questions c. Explain the procedure
d. Complications
e. Follow up

Counseling
- REVEAL THE CONCERN: why have you decided Relevant history
that? - How much do you know about vasectomy? Did you
- Are you in a stable relationship? Have you completed make this decision after discussing with your wife?
your family? How’s your general medical health? Any What is your age? Are you married? How many
medical/surgical problems in the past. children do you have? What are the ages of your
- WARNING: I would like to inform you that reversal children?
can be done, but has a very low successful rate, and - How is your general health? Any previous medical
tubal ligation is considered a permanent form of conditions (DM, breathing disorder, hypertension??
sterilization Previous operations especially in your private parts?
- COUNSELING: I will tell you what the method is SADMA?
about, advantages and disadvantages, and other - Any problems or issues with your personal life?
alternative methods. Tubal ligation can be done by 2 - If person is unmarried, <35 years of age, says he
methods done by specialist under general anesthesia. doesn’t have a children, emotional crisis or spouse is
The first method is either the specialist can cut the not involved  be very careful
tubes and tie them together so that the sperm and ova
do not meet, or can put clips. Success rate is more Procedure
with the first method, whereas with the second - I would like to explain the procedure to you, its
method, there are chances that clips may dislodge. complications, how effective it is and important issues
Failure rate is 1:300 which means one in every 300 regarding reversibility.
women who gets the procedure gets pregnant. - It is the most common method of sterilization in men.
Disadvantages of tubal ligation: a. reversal rate is low, It is a simple operation that can be done under local or
and reversal is not covered by medicare, b. general anesthesia. It usually takes about 30 minutes.
anesthesia risk/complication, c. ectopic pregnancy, d. Two small cuts are made on each side of the back of
will not protect from STIs. the scrotum or one cut is made in the middle. The
- How long in hospital; 1-2 days. tube that carries the sperm (vas deferens) which lies
- ALTERNATIVES: I would like to give you some just below the skin is picked up and cut. About 1 cm of
information about the other methods you can use such it is removed. The ends are tied off and burned with a
as IUDs, implants, depo-provera where compliance is hot needle. This blocks the flow of sperm so when you
not a major issue. For men, there is also a procedure ejaculate, the semen will be free of sperms.
called vasectomy. The advantages are: a. simple, b. - What happens to the sperm? They are still produced
done under local anesthesia, c. less complications, d. in the testicles and lie around the blocked tubes for
lower failure rate around 3 weeks. After that, they become non-
- QUESTIONS: functional and absorbed.
o Will it affect my sexual life? No. It makes it - How effective is it? 1 in 500 vasectomies fail because
better because you’re not scared about the tubes somehow manage to rejoin.
pregnancy. - Complications: bruising, hematoma, bleeding,
o When can I resume sexual life? Once infection  but usually settles very quickly. You will
effects of operation is over. be given pain killers. The sperm granulomas, which
o Is there any effect on my periods? Not really, are brought about by blockage of the semen usually
but there are some studies which have clear up by themselves.
shown that if more of the fallopian tube is - It can take about 15-20 ejaculations to clear all the
cut, it leads to heavier bleeding. Not yet sperms from the tubes above the cut. About 2-3
proven. months after the operation, you will have 2 separate
o Will I gain weight? No. sperm counts to make sure semen has no sperm.
o What if I need kids later? The cut tubes may Until that time, it is important to use some form of
contraception.
be rejoined by microsurgery, but there is no
- When to start sexual activity? Normal sexual activity
guarantee of reversal of fertility. Pregnancy
can be started 4-8 days after vasectomy.
rate after reversal varies from 30-80% and
- Can it be reversed? Consider it to be permanent and
that depends on the technique. The simple
irreversible procedure. The cut tubes can be rejoined
clip method gives better chance of reversal.
by microsurgery but there is no guarantee of regaining
Regardless, it is considered a permanent
fertility. Only 40% chance that it can lead to
method and shouldn’t be entered lightly.
pregnancy.
56

- Written permission of the wife is preferable. Discuss procedures? Have you ever used any method of
other methods briefly. contraception? What was it? Any problems because of
- Is it going to affect my sexual function? NO. It will that? Any history of diabetes, thyroid or increased
make no difference. Rather, it can be improved blood pressure? Any FHx of infertility from your side or
because the worry of conception is removed. Before your partner’s side? Any issues with your married life?
you go for the procedure you can take your time to How often do you have intercourse? Are you aware of
reconsider it and avoid strenuous activity for 4-7 days your fertile/infertile days? Any stress? Are you a happy
after the procedure. couple? Do you have problems with your waterworks
- There is no known association with prostate or or bowel? Do you exercise a lot? SADMA?
testicular cancer. Vasectomy doesn’t help to prevent
STIs. Management
- I could not find anything positive in the history other
than the frequency of your intercourse which could be
the cause of not having a baby. Do you know which
days you are fertile? If your cycles are regular we can

calculate it, or check your temperature, or observe the


INFERTILITY consistency of mucus (time of maximum vaginal
wetness corresponds to day of ovulation) to know the
Primary Infertility time of ovulation. At this time, it is recommended you
have more frequent intercourse or at least 3x a week.
Case: Your next patient in GP practice is a young couple who - Still, I would like to organize some investigations to
comes to you because they have been trying to conceive for the rule out the other causes of infertility. I would advise
last 15 months. They are happily married for 3 years and have for your partner to have semen analysis. For you, we
not sought any medical attention before. will start with FBE, TFTs, hormonal assay like
midluteal phase progesterone, FSH, LH, prolactin,
Task estrogen, sperm antibody screen, TVS, and if
a. History (26 year old, no medical problems, most of the required, the specialist might consider doing
time in overseas, sexual contact 1x/week, menarche hysterosalpingography (HSSG) or hysteroscopy. I
13 years old, on pills, STDs, surgeries or would refer you to the gynecologist/infertility clinic for
gynecological problem) further evaluation and management.
b. Counsel patient about management - Do not worry. I understand that it is a very difficult time
for you but I am here to help. Even if we find
Causes something, a lot of options can be done for you: ICSI,
- Male factor IVF, surrogacy, or adoption.
- Ovulatory (PCOS, HPA, POF) - Reading material. Referral. Review.
- Tubal (PID, tubal damage, pelvic adhesion)
- Maternal age (rate of fertility declines >30) ENDOMETRIOSIS AND ADENOMYOSIS
- Endometriosis
- Coital problems (frequency, erection, problems, Endometriosis
psychological factors)
- Cervical (mucus) or uterine factors (adhesions, polyps Case: A 30 years old lady comes to your GP clinic complaining
or myomas) of dysmenorrhea for the last 3 months. She tried using OCP but
- Unexplained was not relieved.

Investigation Task
- Hormones: FSH, LH, midluteal progesterone, TFTs, a. History
estrogen, b. Physical examination
- TVS for structural abnormalities c. Investigations and management
- HSSG
Differential diagnosis
History - Endometriosis
- Confidentiality - Chronic PID
- Have you ever been pregnant before? Any history of - Adhesions (previous surgery)
miscarriages? Pregnancy from any previous - Fibroids (submucous myoma)
relationships? How long have you been trying to - Uterine polyps
conceive? Does your husband have kids from - Ovarian masses
previous relationship? - IUCD
- Periods: menarche, regular, how many bleeding, how - PCOS
many days apart? How is the flow? Do you pass
clots? Any bleeding in between period? When was Location
your LMP? Do you get any severe pain when you - Ovaries: 60%
have your periods? Any pain on intercourse? Have - Uterosacral ligaments: 60%
you noticed any abnormal hair growth on your body? - Pouch of Douglas: 28%
Have you gained weight recently? Have you noticed - Causes adhesions and fibrosis and during
any milky discharge from the breast? Any problem menstruation would cause bleeding as well due to
with your vision? Have you ever been diagnosed or hormonal stimulation;
screened for STIs? Any history of pelvic infections?
Any history of previous surgeries or gynecological
57

- Symptoms: dysmenorrhea, dyschezia, dyrsuria, as well. Now, on examination, everything is normal except there
dyspareunia, infertility is mild erythema of vulva and vagina. Urine dipstick is clear.

History Task
- Can you tell me more about the pain? (dull tummy a. History
pain before menstruation and more severe during b. Diagnosis and management
menses for 6 mos; tried ocp prescribed by gp but not
relieved severity 4/5; may radiate to thigh/back) Differential Diagnosis
SORTSARA? Mass in tummy? Previous history of - Vulvovaginitis
PID? Previous surgery? Fever? Vaginal discharge? - Foreign body
5Ps; any painful intercourse, or defecation? Urine? Do - Child abuse
you have any kids (no but been trying to conceive); - Allergy
Pap smear? Any unprotected intercourse? Any - Infestation of pinworm
previous STD? Past history of pelvic surgery? HOW - Type I diabetes Mellitus
IS THE PAIN AFFECTINGYOUR LIFE? SADMA? FHx - UTI

Examination
- Anxious; vital signs normal; focused examination on History
abdomen: no visible/palpable mass or tenderness in - Describe the discharge? Is it thick or thin? Is it foul-
abdomen; inspection and speculum normal; smelling? What about the amount? Any fever?
uterosacral nodularities and tenderness on bimanual Frequency of urination? Any change in color of urine?
examination; may have fixed retroverted tender uterus Is it a smelly urine? Is she toilet-trained? Any change
- Pelvic examination: in toilet training (bed wetting)? Is she drinking more
o inspection: discharge, bleeding, redness, water than usual? Who looks after her? Does she go
lacerations, mass, ulcers, to childcare/kindergarten? Do you think she might
o speculum: Vagina and cervix: cervical have put something in her private area? Any abnormal
motion tenderness (PID/ectopic pregnancy); behavior like sexual plays or playing with the
cervical os (miscarriage) genitalia? Is it possible that she is left unattended or
o bimanual examination: site, size, shape, unsupervised? Does she scratch her bottom at night?
consistency, mobility, and adnexal Have you changed her soap recently? Does she take
masses/tenderness a bubble bath? Does she go for swimming?
- BINDS
Investigation and management: - FHx of asthma or allergies
- Most likely you have a condition called endometriosis.
Did you ever hear it before? Examination:
- Explain retrograde menstruation and draw diagram. - General appearance
The tissue lining your womb is deposited in unusual - Vital signs and BMI
locations by backing up of menstrual flow into - Abdomen: distention, mass, scratch marks, sign of
Fallopian tube, ovaries, abdominal cavity or other abuse
organs of the body. These abnormally located tissues - Genital inspection: redness, discharge, scratch marks
form nodules and adhesions that respond to your - Urine dipstick and BSL
hormones during periods causing pain.
- Start with painkillers Management
- Refer to OB gyne for usd but gold standard is - Your child has an inflammation of the private part
laparoscopy. It is a tube with camera for direct called vulvovaginitis. It is a common condition in this
visualization of your tummy to see these nodules to age group (2-8 years). In this age, there is lack of
make a definite diagnosis estrogen so the mucosa (lining) of the vagina is thin
- Treatment Options and irritable. When the child scratches, it becomes
o Medical: stop hormone production infected easily. It usually resolves by itself. I would
also like to do urine microscopy and culture and take a
(progesterone oral/IM); GnRh agonist x 6
swab of the discharge.
months; danazol - treatment of choice
- There are risk factors: FHx of eczema, bubblebaths or
according to JM;
salt baths, nappies, irritating soaps, wet swimsuits,
o Surgical: laparoscopy -- definitive
sand from the sandpit, and overweight
investigation and laser surgery performed
- It is not a serious condition. Avoid bubblebaths, use
when needed; laparotomy;
cotton underwears and loose clothing, general vulval
- Pregnancy: helpful because it creates a state of
hygiene, wipe bottom from front to back to avoid
menopause
infection, warm shallow bath with a cup of vinegar,
- Support groups
advise zinc cream or castor oil to relieve redness
- Family meeting and refer to counselor
- When to refer: if foreign body is suspected and if
- Reading materials; review; general measures fail and condition is persistent
- Complications: vulvar adhesions, UTI
INFECTIONS OF THE GENITAL TRACT - Reading material
- Review
Vulvovaginitis
Trichomonas Vaginitis
Case: A father came with her 4-year-old daughter who has had
a 2nd episode of painful urination over the last year. During the Case: You are a GP and young female came in with greenish
first episode, the daughter had some yellow vaginal discharge vaginal discharge.
58

- Infections in male are asymptomatic


Task: - Diagnosis is by visualizing the organism within the
a. Focused History vaginal secretion under the microscope
b. Physical Examination - Treatment:
c. Management o Metronidazole 2g SD (+ antiemetic – due to
SE of N/V, metallic taste) or 400 mg BD x 5
Vaginal discharges: days
- Whitish, curd-like – candida albicans o Alternative for pregnant women:
- Grayish – bacterial vaginosis Clotrimazole
- Brownish – atrophic vaginitis - Important to prevent complications: UTI, PID,
- Greenish – trichomoniasis Recurrent trichomoniasis – infertility
- Higher chances of developing other STIs especially
Focused History: HIV  important to test for other STIs (consent)
- When did the discharge start? Continuous? - Practice good genital hygiene – wash vaginal area
- Describe the consistency (sticky or watery), color and before and after intercourse
smell - Do not share towels
- How many pads do you use per day? Are they - Remember to shower after swimming
soaked? - Practice safe sex with condoms
Advise to bring partner for consultation and treatment

- Associated features: fever, bleeding, tummy pain, Vaginal Discharge


itching?
- Relation to periods? Trichomonas vaginalis Candida vagin
- LMP? How many days? How many days apart? Itchy + +
Bleeding inter-menstrually? Dyspareunia + +
- Are you sexually active? Are you in a stable Discharge fishy frothy and green curdy
relationship?
- Is your partner suffering from any STI?
Vaginal Swab Organism Hyphae
- Method of contraception? Number of previous sexual
partners? Other investigation
- History of previous STIs?
- How are your waterworks? Burning? Frequency on In pregnancy Very dangerous safe
urination? Cause: preterm labour,
- Have you been pregnant before? Any chance you are premature rupture of
pregnant now? membrane
- PMHx: DM, HPN, previous gynecological Treatment Tinidazole Local Clotrimox
surgery/procedure
Pregnancy: (pessary)
- Recent use of cream or pessaries (consider allergic
rxn) Metronidazole
- Latest pap smear? Treat partner + -
- Meds taken? Steroids?
- Vaccination (gardasil) Gonorrhea Chlamydia
- Smoke/drink/recreational drug use Mucopurulent + +
Investigation 1st void urine PCR or same
Physical Examination: endocervical swab
- General appearance: pallor, jaundice, dehydration, In pregnancy PROM same
BMI Pneumonia
- VS: temperature, PR, RR, BP (postural drop) Ophthalmia
- Ausculation of chest/heart Treatment Ceftriazone + Azithromycin 1 dose
- Abdominal examination: tenderness (posterior fornix
Azithromycin 1 g stat
of the vagina), organ enlargements, mass, bowel
Treat partner + +
sounds
- Inspection of pelvic area – bleeding, discharge (color,
quantity, and smell), scratch marks, warts Recurrent Moniliasis/Candidiasis
- Bimanual palpation – adnexal mass, cervical
excitation, check size/position of uterus and cervix Case: You are a 25-year-old lady complaining of recurrent white
- Sterile speculum examination – check where the vaginal discharge. She was diagnosed with monilial infection
discharge is coming from and position/condition of the and was given treatment for that. She has now come to you for
cervix; take a swab and send for culture and wet further advice.
mount
- Get urine dipstick/finger BSL/PT Task
a. History (on-and-off for the last 3 months, given vaginal
Management tablets by GP without relief, on OCP, not pregnant, no
- Most likely from the history and PE, what you have is history of long-term use of steroids or antibiotics, or
a vaginal infection called trichomonas vaginitis obesity)
- Caused by a parasite called T. vaginalis, usually b. Examination (+ whitish curd-like discharge with vulvar
transmitted thru sexual contact erythema)
- Most common STI worldwide c. Diagnosis and management
- Common in females of child-bearing age
- Possible to carry organism without signs and Differential Diagnosis
symptoms - Candidiasis
- Gives symptoms like itching, burning of urine, watery - Trichomonas vaginalis
greenish discharge with fishy smell - Foreign body
59

- Atrophic vaginosis remission or long-term prophylaxis we can give


- Cervical ectropion weekly fluconazole for a few months.
- Malignancy - Before taking any antibiotics, advise GP that you are
undergoing treatment.
Risks - Wear loose undergarments. Keep the area dry and
- Long-term OCP thoroughly dry after bathing. Don’t use any creams or
- Diabetes perfumes in the vagina/vulva. Advise vaginal douche
- Pregnancy

- Long-term use of steroids and antibiotics (1tsp bicarbonate in 1 L water). Bathe genital area
- Obesity gently 2-3x a day for symptomatic relief. Thoroughly
- Wearing tight clothing cleanse vagina including recesses between rugae and
fornices, and also the folds around vulva. Avoid
History wearing pantyhose, tight jeans, or using tampons.
- I understand that you have recurrent white vaginal Avoid having intercourse or oral sex during infected
discharge. When did this episode start? What is the period. Do not use vaginal douches, powders or
color of the discharge? Any blood stains? Is it smelly? deodorants or take bubble baths.
Is it itchy? Is it sore down below? How many attacks?
How was it diagnosed? Did you take anything for that? Pelvic Inflammatory Disease
Which treatment were you on? Is the discharge
related to your period or intercourse? Any tummy Case: You are an HMO in the Emergency Department and a 24-
pains? year-old female comes in due to pain in the RIF for 1 day.
- Are you sexually active? Are you in a stable
relationship? Have you or your partner ever been Task
diagnosed with STDs? What contraception are you a. History (getting worse, not related to change in
using? Do you have any problems with the OCPs? position, feverish, vaginal discharge, smoking 10
Does your partner have any symptoms? cigarettes per day, LMP 2 weeks ago)
- Periods: LMP? Are they regular? How many days of b. Physical examination (in pain, pale, feverish (39), BP
bleeding? how many days apart? 110/70, PR 104, tenderness at RIF, yellowish
- Pregnancy: Any chance you can be pregnant now? discharge on undergarments and vagina, cervical
Any previous pregnancies? excitation and adnexal tenderness on right side, no
- Pap: Are you regular with your pap? mass and uterine size normal)
- Any possibility of using local perfumes or local creams c. Investigation
down below? Some people use sexual toys, do you d. Provisional and Differential diagnosis
happen to use them? e. Management
- PMHx: Any medical history of long-term use of steroid,
diabetes or any long-term antibiotics? Differential Diagnosis
- What is your profession? Do you wear tight jeans? - Pelvic inflammatory disease
- FHx: diabetes, cancers? - Ectopic Pregnancy
- SADMA? - Acute appendicitis
- Ruptured ovarian cyst
Physical Examination - Torsion of ovary
- General appearance and BMI
- Vital signs History
- Chest and heart - Is my patient hemodynamically stable? I would like to
- Abdomen: masses or RIF/LIF tenderness interview the patient in the resuscitation table. Where
- Pelvic examination: nature of discharge, color, smell, is the pain? How severe is the pain? Character?
thick, blood stain, vulvar erythema; per speculum Associated symptoms like discharge, bleeding,
cervix is healthy with discharge; per vagina waterworks, N/V/ fever? When was the last time you
examination for any CMT, adnexal masses opened your bowel? History of constipation or
- Urine dipstick, BSL, pregnancy test (optional) diarrhea? Is this the first episode of pain? Have you
had surgeries done previously?
Diagnosis and Management - When was your LMP? Are your cycles regular? Do
- From the history and examination you have a you get pain or spotting in between your periods? Any
condition called recurrent moniliasis or candidiasis. It complaints of excessive pain on day 1?
is a fungal infection caused by Candida albicans. It is - Are you sexually active? Are you in a stable
a common condition and there are some risk factors relationship? What contraception do you use? How
leading to repeated attacks. The risk factors are long- many sexual partners have you had previously? Have
term use of OCPs, DM, pregnancy, obesity, long-term you or your partners ever been diagnosed with an
use of steroids, antibiotics and wearing tight clothings. STI? Have you ever been pregnant before? Any
- At this stage, I would like to check the BSL, FBE and possibility you might be pregnant now? Have you had
do swab. I would advise you to stop OCPs and I can gardasil vaccinations? Pap smear?
book another appointment to discuss the alternative - How is your general health? SADMA?
methods of contraception. Until then, I would advise
you to use condoms. It is not STD but it is best to Physical Examination
abstain from intercourse until the condition resolves. - General appearance
- I will shift you to oral antifungals with fluconazole - Vital signs and orthostatic hypotension
50mg or Itraconazole 100 mg OD for up to 2 weeks - Abdominal: distention, tenderness, guarding, rigidity,
(up to 6 months depending on the severity) or vaginal Rovsing, mass, bowel sounds, hernial orifices
Nystatin if not comfortable with oral formulation. For
60

- Genital: discharge (color, quantity, smell), bleeding, - How long have you been suffering from this? Do you
signs of itching, trauma; sterile speculum looking for currently have ulcers? Have you ever had them
discharge, bleeding, condition of the cervix like checked? Did you notice any precipitating symptoms
redness; bimanual for size and position of uterus, like periods, stress, pregnancy? At the moment, are
cervical excitation, adnexal mass and tenderness you having any pain? Any vaginal discharge? Fever?
- Urine dipstick, pregnancy test, and BSL Body aches? Body pain? Urinary symptoms? Are you
sexually active? Do you have a steady partner? Have
you had unprotected sexual intercourse? Any history
of sexually transmitted disease? Have you ever been
screened for STI? Does your partner have similar
symptoms? Are you regular with your pap smear? Did
you get the gardasil vaccination?

Investigations
- FBE, urine for MCS, U&E, USD of abomen (fluid in the - Period: menarche, LMP, regular?
adnexa or in sac or normal), complete STD screening - Pills? Do you use condoms?
(urine PCR for Chlamydia and Herpes, Pap smear, - Have you ever been pregnant?
high vaginal swab for wet film preparation for - PMHx or FHx? Social history? SADMA?
Trichomonas, endocervical swab for Chlamydia and
Gonorrhea, syphilis with VDRL and RPR, Hepatitis B Physical examination
serology, HIV, throat swab or anorectal swab if - General appearance
indicated, urethral swab if indicated) - Vital signs and BMI
- Rashes or ulcers anywhere else in the body
Diagnosis and Management - Pelvic:
- My most likely diagnosis is PID. It is the infection of o Inspection: ulcers, bleeding, painful,
pelvic organs caused by bugs that are usually discharge,
acquired through sexual contact. The most common o Swab
ones are Chlamydia and Gonorrhea. These infections - Abdomen/chest/heart
are very common in young sexually active females. - Urine dipstick and BSL
The usual symptoms are high-grade fever, severe
tummy pain, and tenderness of the cervix. Diagnosis and management
- It is important to treat this infection carefully because - Most likely your ulcers are caused by a virus called
there are a number of complications both short- and herpes simplex virus. This virus stays in one of the
long-term. nerve roots of your body and under certain conditions
- Short-term complications are abscess formation and such as menstruation, pregnancy, or low immunity, it
peritonitis reoccurs and forms ulcers.
- Long-term complications include a 10% chance of - Usually the first attack is most severe. This is a
damage and obstruction of the fallopian tube after first sexually transmitted disease and I am afraid that you
episode of PID and 30% after second episode, and have acquired the virus from unprotected sex. At this
75% after 3rd episode, infertility, ectopic pregnancy, stage, I would like to organize some investigations. I
chronic pelvic pain and infection. would like to take a swab and send it for culture and
- That is why, we need to admit you and start you on IV sensitivity and I would also like to screen you for other
antibiotics most likely ceftriaxone IV 250 mg SD along STIs. I will give you some strong pain killer and local
with Azithromycin 1gm oral and later one switch to oral gels (lignocaine) to apply.
medications that you will need to continue for the next - Acyclovir within 72 hours of onset of rash.
2 weeks (doxycycline + metronidazole). - Rest. Warm salt baths. Do not scratch ulcers because
- Please avoid sexual activity until you are completely you can spread it in other parts of the body. Please
free of symptoms. Practice safe sex. If not already wash your hands if you scratch them. Wear loose
done, get yourself vaccinated with gardasil. We might clothings and clean cotton underwear all the time.
need to trace the contacts if required. Do not worry. Avoid tight jeans.
With IV antibiotics, the recurrence is quite low, but you - Sexual abstinence until the active lesions clear and
need to be careful and practice safe sex in the future. please practice safe sex (condoms + washing of
genitals before and after intercourse).
Recurrent Ulcers (Herpes) - I would also like to recommend for your partner to
come and see me or his GP to organize STD
Case: your next patient in GP practice is a 30-year-old lady screening as well.
complaining of recurrent vulvar ulcers. - Reading material. Review.
Task STI Screening
a. History (4x in that last year, went to dr gave
medications and occur again, painful, discharge Case: Suzie aged 20 years presents to your surgery for the first
yellowish no fever, 6/10, sexually active and affects time. She has recently started working at a local brothel and her
sexual activity, pap smear normal) employer has told her she needs to have a 3-monthly health
b. Physical examination (irritated and distressed, vitals checkup and get a certificate. Suzie lives independently in a
normal, no mouth ulcers, pelvic: ulcers few 3-4, shared accommodation and had no other medical or surgical
discharge +, not offensive, vulvar region, tenderness) problems.
c. Diagnosis and management
Task
History a. Further history
- To help you today, I need to ask you some questions b. Examination
and some of them might be sensitive, is it alright with c. Management advise
you?
61

Further history o Bimanual examination: uterine size, shape,


- Since when? What type of sexual practices do you tenderness, adnexal masses, mass in fornix
do? Are customers practicing safe sex? Any vaginal (can I remove the mass) cervical motion
discharge? Are you on any contraception (OCP)? tenderness (+ in ectopic pregnancy, PID,
Have you had any STIs? Did you have your pap endometriosis)
smear? Have you had gardasil vaccination?
Management:
Management - From history and PE, you have retained tampon which
- STI Screening: Chlamydia, gonorrhea, syphilis, HIV, got infected which I already removed. Since you don’t
HBV, HCV (if with history of IV drug abuse); hepatitis A have signs of infection such as fever, no need for
(MSM) antibiotics at this stage.
- Doctor is it legal? If the place is licensed, then it is - I would like to give you advice to prevent further
legal. recurrence

- What are the risks? There are more risk of sexually o Personal hygiene
transmitted infection, physical or sexual abuse, o Change tampons 3-4x a day
pregnancy, drug and alcohol abuse o Use external pads at night
- I will give you a medical clearance once we have the o Red flags: fever, muscle aches, pains,
results. dizziness,
- Offer gardasil vaccination - Advise to review after 3 days to see if there is any
infection
Retained Tampon - Give reading material
- If with fever or signs of TSS: Call ambulance and
Case: 35/F presenting with offensive vaginal discharge. admit. Start IV fluids and IV antiobiotics (flucloxacillin x
5-7 days) and should not use tampons in the future at
Task: all.
a. History - If with fever only: clean with povidone iodine 3x/day
b. Physical examination for 2 days and oral flucloxacillin; send blood and urine
c. Diagnosis for culture; vaginal and cervical swab for culture
d. Management
Bartholin Abscess
DIFFERENTIAL DIAGNOSIS
- Bacterial vaginosis Case: You are a GP and a 35-year-old lady comes in with a
- Trichomonas infection lump in the vulva which she finds uncomfortable.
- Foreign body (tampon/condom)
- Cervicitis Task
- Cervical ectropion a. History (very painful lump, (+) yellowish to reddish
- Neoplasm discharge, can’t sit or walk comfortably, periods
- Atrophic vaginitis regular, sexually active, in stable relationship x 1 year,
on pills)
History b. Physical examination (irritable, BMI 28, VS normal,
- I understand from your notes that you have offensive vulva: left labia majora, pea size, no redness but with
vaginal discharge. I might need to ask some sensitive discharge, no ulcer, tender, hot to touch; urine
questions. Is that okay? dipstick, BSL, normal)
- When? Describe the discharge. Color? consistency? c. Diagnosis and management
Continuous/on-and-off? Related to coitus or menstrual
cycle? Itchy or painful down below? Pain in your History
tummy? Fever? - When did you notice the lump? Does it come and go
- Has it happened before? or is it there all the time? Is it increasing in size? Any
- Periods: regular? Amount? Duration? Painful? discharge? What is the color? Is it painful? How is it
Menarche? LMP? Do you use tampons or pads? Have affecting your life? Have you noticed any lump in any
you recently lost/missed a tampon part of your body? Any rash or vesicle in your private
- Partner: are you sexually active? Do you have a part? Is it the first time? Do you feel feverish? Any
stable partner? Does your partner have symptoms? problem with your waterworks? Bowel habits?
Have you or your partner been diagnosed with STIs in - 5Ps
the past? - Any past medical or surgical history? Are you on any
- Pills: what contraceptives do you use? Any history of medications? SADMA?
unprotected sex?
- Pregnancy: how many? Ask for details if required Physical examination
- Pap smear: when? Any abnormal results? - General appearance and BMI
- General history: water works and bowel movement? - Vital signs
- PMHx/FHx/SADMA
- Chest and heart
- Abdomen
Examination
- Pelvic:
- General appearance: pallor, BMI,
o Inspection: site, size, shape, discharge and
- Vitals: BP, Temperature, RR, PR, O2 saturation
- Quick chest/heart if smelly, color
- Abdomen: masses/tenderness o Palpation: temperature, tenderness,
- Focused pelvic exam: ask for informed consent consistency, fluctuant
o Ask about discharge – color, amount, o Speculum examination
consistency, smell, blood, redness, scratch o Bimanual examination
marks - Lymph nodes
62

- Urine dipstick and BSL


Urinary Tract Infection/Prescription Writing
Diagnosis and Management
- You have a condition called bartholin abscess. There’s Case: You are a GP and your next patient is a 23-year-old
a gland called bartholin gland located on each side of female who complains of lower abdominal pain.
your vaginal opening and there is a collection of pus in
the small duct. Because it is blocked, the secretions Task:
and pus are trapped causing a painful swelling. It a. History: dull constant, not related to menses; LMP: 6
usually appears within 2-3 days and causes severe weeks
pain on walking and sitting. It is usually caused by a b. Physical examination: suprapubic tenderness;
bug E. coli, Streptococcus, Staphylococcus. c. Diagnosis
d. Management and write script

- Can it be STD doctor? It is unlikely, but it can also be


caused by gonorrhea. Therefore, with your History
permission, I would like to ask you to undergo STD - Can you tell me where exactly is the pain? How bad is
screening and swab the discharge. it on a scale of 1-10 (4)? Does it go anywhere? Can
- I would advise you to have Hot Sitz bath 4x a day, you describe the character? Is it a dull ache or sharp
give you pain relief, and refer you to a gynecologist pain? Any aggravating or relieving factors like
ASAP to drain the pus. This procedure is called movement? Any associated nausea, vomiting, fever or
marsupialization where a cut is done at the center, roll vaginal discharge? Bleeding or spotting? Any history
it and stitch it outside that leads to a permanent of constipation or change in bowel habits? How are
opening. I would also give you Azithromycin and your waterworks? Any burning or frequent passing of
Ceftriaxone. urine? Have you noticed any blood in the urine? Is this
- I would advise you to wear loose clothing, maintain the first time to have it? When did you have it? What
good personal hygiene, and practice safe sex. were the symptoms? What test? What treatment was
- Can it happen again doctor? Yes, there is a 10% given? Any problems? When was the last episode of
chance of recurrence but prognosis is good and UTI?
recovery is excellent. - Partner/Pills: Are you sexually active? Are you in a
- Reading material. Referral. Red flags. stable relationship? How many partners have you had
previously? Do you always practice safe sex by the
Cystitis use of condoms? Any history of STIs? What method of
contraception do you use?
Case: You are a GP and a 24-year-old female Melissa comes in - Period: When was your LMP? Are they regular? How
complaining of pain on micturition with frequency, urgency, and is the cycle like? Any chance that you might be
lower abdominal discomfort for 2 days. She is married, a non- pregnant?
smoker, and has had appendectomy 10 years ago. - SADMA? PMHx

Task Examination
a. History (terminal dysuria, no fever/N/V) - General appearance: pallor, jaundice, dehydration
b. Physical Examination (mild suprapubic tenderness, - Vital signs
urine dipstick: ++++ RBC, ++ leukocytes) - Chest/heart
c. Investigation - Abdomen: distention? Tenderness on palpation
d. Management especially in the RIF/LIF. Any mass palpable? Organ
enlargement? Bowel sounds? Hernia?
Differential Diagnosis - Pelvic exam: Inspection (bleeding, discharge, scratch
- Cystitis marks, ulcers); speculum (bleeding, discharge,
- PID position of cervix); bimanual (size and shape of
- STDs uterus, cervical excitation, adnexal mass/tenderness)
- Urine dipstick (leukocytes and nitrates), pregnancy
History test and BSL
- Pain questions: SORTSARA?
- 5Ps  especially Periods (LMP) and sexual history Management
- FHx of kidney problems - As previously you had another attack of UTI, do you
- Allergies? Previous history of UTIs know what it is? At the moment, I am sending a
sample of your urine for culture and microscopy. You
Physical Examination need to drink ample fluids especially cranberry juice.
- General appearance After passing water and stools, please wipe from front
- Vital signs Name to
of back.
patientI will write some antibiotics for you.name
Doctor’s
- Abdomen: tenderness, masses, CVA tenderness Trimethoprim or Cephalexin (500mg 2x a day for 5
- Urine dipstick, urine PT days or amoxicillin + clavulanic acid
DOB/age (500mg/125mg
Address
2x a day for 5 days (especially if pregnant)
Management Address Telephone number
- Lifestyle modification
o Drink ample fluids Prescriber no.
o Voiding post-intercourse
o Cranberry juice PBS/Private
o Hygiene: wipe from front to back
- Medications: trimethoprim/amoxicillin/cefalexin
- Review after 3 days to check for sensitivity to drug

Tab Trimethoprim

300 mg x daily for 3 days


63

- Caffeine
- Constipation
- Chronic cough
- Multiparity
- Menopause

History
What do you mean by losing urine? Is it small or
large? Do you lose urine when you laugh, cough,
exercising or just normal? Do you lose a lot of urine
when you try to reach the toilet? Any feeling of
masses down below?
- Any burning in urination? Frequency? Frothy urine?
Change in color of urine? Polyuria? Polydypsia or
polyphagia?

UTEROVAGINAL PROLAPSE AND INCONTINENCE


Urinary (Stress) Incontinence
- Was it difficult labor? Assisted labor? Assisted
Case: A 50-year-old woman who had 3 kids aged 29, 25 and 22 delivery? Symptoms of menopause? Hot flushes?
came to your GP clinic complaining of leakage of urine. Dyspareunia? Mood swings? Pap smear? Partner?
Task Stable relationship? Any previous history of STDs?
- History Have you started with mammography?
- Appropriate investigations - Any medical history? Chronic cough or constipation?
- Diagnosis and management Joint problems?
- SADMA? BMI?
Causes of incontinence (DIAPPEERSS)
D – elirium Examination
I – infection of UT - General appearance: BMI, dehydration, pallor,
A -trophic urethritis jaundice
P – harmacological (diuretics) - Vitals
P – sychological (acute distress) - Chest/heart: chronic infections
E – ndocrine (hypercalcemia) - Abdomen
E – nvironmental (unfamiliar surrounding) - Pelvic examination: rule out prolapse (cystocele)
R – estricted mobility - Ask examiner for any demonstrable stress
S – tool impaction incontinence (ask patient to cough and check for
S – hincter damage or weakness leakage of urine)
- BSL and Dipstick

Drugs Causing Incontinence Diagnosis and Management


- Antihypertensives/vasodilators - (ACEI, prazosin, - You most likely have a condition called stress
labetalol, phenoxybenzamine) incontinence. When the urethra is no longer in the
- Bladder relaxants – (anticholinergics, TCAs) pelvis, there is an increase in intra-abdominal
- Bladder stimulants – (cholinergic, caffeine) pressure, which affects both bladder and urethra
- Sedatives – (antidepressants, antihistamines, increasing the bladder pressure more than the urethral
antipsychotics, hypnotics, tranquilizers) pressure, resulting to involuntary loss of urine.
- Others: alcohol, loop diuretics, lithium - I completely understand that it is a very frustrating
condition for you, but let me assure you that we can
Incontinence: manage it.
- Stress: small amounts of urine; involuntary during - Stress incontinence is highly associated with UTI so I
coughing, straining, laughing, etc; due to weakening of would like to order urine microscopy and culture (ask
muscles in the pelvis  increasing intra-abdominal examiner for results).
pressure results in leakage of urine - I would advise you to maintain a bladder diary. Avoid
- Urge: large amounts of urine; want to go to bathroom too much physical stress, lifestyle modification (weight
but cannot control; problem with detrussor or nerves reduction, smoking cessation, decrease caffeine
intake), avoid constipation and coughing
Investigations - Start pelvic floor exercises (contract pelvic muscles as
- MSU!!! if your lifting your pelvis or holding urine 40-50x daily
- Urodynamic studies (measure pressure in the bladder at 3 months)
and urethra) - Refer to gynecologist regarding vaginal pessaries.
o Urge incontinence: pressure in bladder They may consider giving you HRT and urodynamic
increases very fast reducing bladder studies but will be decided upon by the specialist.
capacity; - Surgery will only be indicated if conservative
o Stress incontinence: intravesical pressure measures fail. Bladder neck suspension, suburethral
does not increase when urine fills; bladder rings, and local injection of collagen.
capacity is normal - For urge incontinence: bladder training and anti-
cholinergic medications (oxybutynin, propantheline,
Risk factors: imipramine, tolterodine) refer to physiotherapist
- UTI - Review and Reading Material
- Obesity - Stress incontinence: MSU for urine and culture
- Smoking - Postmenopausal bleeding: Transvaginal
Ultrasound
64

frequent recurrent UTIs. It can also affect the wall of


Post-hysterectomy Prolapse the bowel causing constipation. Sexual functioning
may be affected and might cause pain and discomfort
Case: You are a GP and a 52-year-old female comes to your during intercourse.
clinic complaining of something coming out from her vagina - The treatment will be tailored according to your
especially after straining wishes, but you will need to see a specialist
gynecologist. The first option is conservative
Task management which includes pessaries along with
a. History pelvic floor exercises. Usually, this suitable for old,
b. Physical examination females who are not fit for surgeries. The second
c. Management option is the surgical approach. It is called vaginal wall
suspension surgery (sacrocolpopexy). The surgeon
History will attach the upper part of the vagina to the strong
- Please tell me more about your problem? Since when tissues within the pelvis usually to the lower backbone
have you noticed this lump? Is it present all the time or or sacrum. There are 2 options regarding the
does it come and go? Any changes with change in approach: laparoscopic or keyhole surgery OR
position like prolonged standing or lying down? Do abdominal approach best decided by the surgeon.

you have associated tummy pain or heavy/dragging


kind of sensation in the lower tummy? Any urinary - The recurrence rate after the surgery is very low
complaints like frequency, burning or leaking of urine? therefore the surgery is mostly curative.
Any loin pain? Any history of prolonged cough, - Review. Reading material.
constipation, asthma or respiratory problems? Do you - Pelvic floor exercise (kegel): done to strengthen the
have any problems emptying the bowels? Any muscles of the pelvic floor. The exercise can be done
complaints of discharge or bleeding from down below? either sitting or lying down. The patient needs to
Any fever? Itching? When was your LMP? Any empty the bladder before exercise. Contract the pelvic
problems during or after menopause? muscles, hold contraction for at least 5 seconds,
- When did you have the hysterectomy? Why did you release it slowly and repeat 3-4x and gradually build
have it? Any complications afterwards? Was it done at up duration for up to 10 seconds. She must not
a tertiary care center? After the surgery, did you do contract the abdominal, thigh or buttock muscles.
pelvic floor exercises? Any other surgeries that I Exercises must be repeated 3x a day as many times
should be aware of? Did you take any HRT as possible. Results are usually apparent within 8-10
afterwards? weeks. Safe to be done during pregnancy
- May I know are you sexually active at the moment?
Any complaints of pain or discomfort during sex? How Uterine Prolapse
many kids have you had? Any history of big babies?
Difficult or instrumental deliveries? Case: An a 80-year-old lady comes to your GP clinic
- SADMA? complaining of mass protruding down below and rash around
- Have you recently noticed weight loss? Change in the private area for several months.
appetite? Night sweats? Lumps and bumps in the
body? Pap smear? Mammogram? Task
a. Relevant history
Physical examination b. Physical examination (BMI 29, maculopapular rash
- General appearance around introitus and inside of thigh, urine dipstick +
- Vital signs sugar, BSL 11.3mmol/L
- Chest and Lungs c. Diagnosis and management
- Abdomen: for tenderness
- Pelvic exam History
o inspection: Obvious lump, discharge, ulcer, - I read from your notes that you have something
redness, discharge bulging from your private area. Since when? Can you
o Sterile speculum examination asking the tell how it happened? Is it increasing? Do you feel any
patient to strain looking for any visible lump abdominal discomfort? What is the effect of this
while straining; sims left lateral position bulging on your life? Is this swelling affecting your
(knee-chest position)  gradually withdraw waterworks? Do you leak urine while you strain,
while asking a patient to strain  cough, etc? Do you have a strong urge to void on the
lump/bulge in the vagina (best way to detect way to the toilet or do you leak a large amount of urine
cystocele and rectocele) on the way to the toilet? Any discharge down below?
- Urine dipstick and BSL Constipation? Waterworks?
- Rash? Since when? Is it itchy? Can you describe the
Diagnosis and Management rash for me?
- Most likely what you have is prolapse of the vaginal - Period: When was your last period? Any irregular
wall after hysterectomy. Once the uterus is removed, bleeding after that? Hot flushes? Mood swings?
the upper part of the vagina loses its anatomical Breast pain? Irritable?
support. Usually, during hysterectomy, the surgeon will - Pregnancy: how many pregnancies? Were they big
secure the upper part of vagina with the help of babies? Did you have any difficult labor or prolonged
ligaments attached to the backbone and pelvic wall. labor?
Some of these ligaments become loose because of: a. - Partner: are you sexually active? Do you have a
loss of estrogen b. prolonged straining/coughing c. stable partner? Do you have painful intercourse?
putting on weight. Have you or your partner ever been diagnosed with
- This phenomenon is quite common after STDs?
hysterectomy. Up to 30% of patients might develop - Pap smear: When was your last pap smear? Result?
this. It can affect the urinary system leading to - Mammography?
- Past medical history: chronic cough, diabetes, asthma
65

- FHx: Osteoporosis, MI Task


- SADMA a. History
b. Physical examination
Physical Examination c. Explain management
- General appearance
- Vital signs History
- Abdomen - I understand you have come because you are worried
- Pelvic examination: about a lump that is coming out from your vagina.
o Inspection for morphology of the rash When did you first notice it? Does it come and go or is
(maculopapular rash around the introitus it present all the time? Did you notice that it appears
and groin area), scratch marks, discharge, when you’re straining? Do you have a dragging
obvious bulge sensation or heaviness in the tummy? Any unusual
o Speculum: wall of vagina, rash, discharge, vaginal discharge or bleeding?
blood, ask patient to cough (cervix comes - Do you have chronic cough? How’s your waterworks?
up to the introitus), leakage of urine, cervix Have you noticed increased frequency or feeling that
o PV: adnexal masses, CMT, your bladder is emptying incompletely? Do you have
urine leakage during coughing, straining or laughing?
Do you have regular bowel movements?

- PR: differentiate between cystocele and rectocele


- BSL and Urine dipstick
- When was your LMP (menopause risk factor)? Any
Diagnosis and Management spotting or bleeding after that? Are you sexually
- You have a condition called uterovaginal prolapse with active? Does this problem cause difficulty or pain with
stress incontinence and candidiasis, intercourse? When was your last pap smear? Was it
- Menopause resulting to lack of estrogen, difficult labor, normal? How many pregnancies have you had? How
big babies and constipation leads to the laxity of the many children do you have? Do you remember the
pelvic floor ligaments. It is a common condition among birth weight (>4kg)? Did you have NSVD? Did you
females in your age group. have instrumental delivery?
- At this stage, I would like to refer you to the - Are you generally healthy? Surgeries? Medications?
gynecologist. I would advise you to start with pelvic Smoking? What are you doing for a living?
floor exercises (contract pelvic floor muscles as if
trying to hold urine). Physical examination
- The specialist might insert a pessary which is a device - General appearance
inserted into the vagina to support the uterus. They - Vital signs and BMI
need to be changed every 3-6 months. They also - Abdomen: masses and tenderness
advise topical estrogen to improve the discomfort. - Pelvic:
- Will it affect intercourse? Pessaries will not interfere o Inspection: evidence of prolapse and
with your sexual performance. atrophic changes; can you please strain or
- If conservative measures do not work, the specialist cough (for 2nd degree prolapse)?
might consider doing surgery to fix the ligaments. o Speculum (left lateral position): using sims
- How long will I be in the hospital? Usually 3-5 days. speculum prolapse, check for cystocele or
You can go home once you’re feeling well and once rectocele, degree of prolapse, atrophic
you have started urinating without problems. changes, discharge, appearance of cervix,
- Postop advice: For the first two weeks, restrict your o Bimanual examination: any pelvic masses
activities. Rest. Avoid heavy lifting. Avoid sports and palpable, size of uterus, and adnexa; ask
swimming. For 1st 6 weeks abstain from sexual patient to squeeze to fingers to assess of
intercourse. pelvic muscle strength
- Driving: It is not advisable to drive for the first 2 - Urine dipstick and BSL
weeks.
- Complications: Pain, bleeding, injury to nearby Degree of prolapse
structures, anesthesia complications - I – cervix protrudes/sits into lower 1/3 of vagina
- For the candida, I will prescribe you antifungals. It - II – cervix protrudes on straining outside of vagina
might be related to high blood sugar. I will give you - III – cervix/uterus lies outside of the vagina
referral to physician to investigate further
- Lifestyle modification: normal BMI, stop smoking, Diagnosis and Management
high-fiber diet - You have a condition called uterine prolapse. Have
- Referral to specialist obstetrician. Reading material. you ever heard about it? The uterus, bladder and
Review. bowel are supported by a tight hammock of muscles
- Advise OGTT. slung between the tail and pubic bone. These muscles
are known as pelvic floor muscles. Ligaments also
Prolapse: anchor uterus in place. If these tissues are weakened
- I: cervix remains within vagina or damaged, the uterus can slip down into the vagina.
- II: cervix comes up to introitus We call it uterine prolapse.
- III: most of uterus lie outside vagina - Common causes of uterine prolapse include vaginal
childbirth especially if baby was large or delivered
Uterine Prolapse quickly or if there was a prolonged pushing phase or
instrumental delivery. Another group of risk factors is
Case: A 58-year-old lady comes in your GP clinic complaining of being overweight, having chronic cough, constipation,
lump from the vagina. and heavy lifting which are factors that increase intra-
66

abdominal pressure. The last predisposing factor is a  Needle vaginal drainage by USD
low level of estrogen after menopause. for simple larger cyst
- I will refer you to a gynecologist for further  Laparoscopy: complex cysts, large
assessment and to discuss treatment options. cysts, or external bleeding
- Treatment depends on age, degree of prolapse, and - Ovarian torsion
patient preference. o Mainly from dermoid cysts
- Meanwhile, I will arrange a meeting with a o Symptoms: severe cramping lower
physiotherapist who will teach you pelvic floor abdominal pain, diffuse, pain may radiate to
exercises (effective for 1st and 2nd degree). I also
recommend for you to have lifestyle modification. Try
to keep your weight within the ideal range, have a
balanced diet, regular exercise, and smoking flank, back or thigh; repeated vomiting,
cessation. exquisite pelvic tenderness, patient looks ill
- The most effective treatment is surgery which is o Signs: smooth, rounded mobile mass
vaginal hysterectomy. Sometimes before surgery or if palpable in abdomen; may be tenderness
woman is not fit for surgery, or if woman does not and guarding over the mass
want surgery, a vaginal pessary can be used which is o Investigation: USD + color Doppler
a donut-shaped device inserted into the vagina and
o Management: Laparotomy
positioned to prop the cervix and uterus. It should be
changed every 6 months. Side effects include irritating Differential Diagnosis
discharge and increased risk of ulceration as well. - Ectopic Pregnancy
Local estrogen can be used to decrease the side - Ruptured ovarian cyst/torsion
effect. - PID

BENIGN TUMORS
- Acute appendicitis
Ovarian Torsion/Ruptured Ovarian Cyst
- Acute mesenteric ischemia
- Renal colic
Case: Julia aged 35 years presents to ED of local hospital
where you are working as year 1 RMO. She had severe right
History
sided abdominal pain for the last 1-2 hours associated with
- Since when? SORTSARA? Associated features like
nausea and vomiting. She had similar pain a few months ago
fever? Nausea? Vomiting? Any discharge from below?
but lasted only for a few minutes and was relived with panadol
Any problems with waterworks or bowel movements?
and neurofen. She had no other significant medical or surgical
- 5Ps:
problems. She had known allergies and is not on any regular
o Period: LMP? How many days of bleeding?
medications. Julia works as a business consultant in a local firm
and lives with her partner. She smokes about 10 cigarettes per How many days apart? Any bleeding in
day and is a social drinker. between? Any chance you might be
pregnant?
Task o Pills
a. Further history (10/10 in severity, tried panadol and o Partner: stable relationship? Ever been
neurofen but did not work; RLQ, no fever, no rash, no diagnosed with STIs? Partner?
problems with bowel motions or waterworks; periods o Pap smear
are regular, LMP 3 weeks ago) o Pregnancy
b. Physical examination (uncomfortable but fully - PMHx: Surgery or any medical illnesses?
conscious and oriented, PR 84, BP: 100/70, T and RR - FHx:
normal; no LAD, no lumps and bumps, chest and
heart normal; inspection normal; no distention; palpate Physical Examination
tender at RIF but no rebound or guarding/rigidity, no - General appearance
palpable mass; no organomegaly; pelvic examination: - Vital signs
normal; PR normal; urine PT negative, urine dipstick; - Abdomen and inguinal orifice
FBE normal U&E normal; USD pending) - PR
c. Diagnosis and management - Pelvic examination
- Urine dipstick, urine PT, BSL
Features
- Ovarian Cysts: Diagnosis and management
o Common in women under 50 years of age - Refer to OB registrar
o Best defined by TVS - Start IV line and take bloods
o Symptoms: pain, pressure symptoms,
menstrual irregularities Uterine Fibroid
- Ruptured ovarian cyst:
o 15-25 years Case: A 35-year-old female comes to your GP clinic complaining
o Symptoms: Sudden onset of pain in one or of heavy menstrual flow for several months. she has 2 children 6
other iliac fossa; No systemic signs; Pain and 8 years. She still wants to have a baby in the future. Her
usually settles within a few hours FBE showed low hemoglobin.
o Signs: tenderness and guarding in iliac
fossa, PR: tenderness in rectovaginal pouch Task
o Investigation: USD + color Doppler a. History (x6 months, change pads every 3 hours, 4-5
pads/day, 9-10 days, feel pressure and fullness in
o Management
lower tummy and sometimes has difficulty passing
 Explanation and reassurance
urine, urinary frequency)
 Conservative: simple cyst <4cm, b. Physical examination (Specific findings will be given
internal hemorrhage, minimal pain only when asked) – uterus 12 weeks size and irregular
67

c. Investigation are small and not causing symptoms, we may just


d. Management observe. For the large fibroids, we can use drugs to
shrink prior to surgery and these drugs are danazol
History (GnRh agonist) or medroxyprogesterone. The surgical
- Are you bleeding now? Since when did you have the options are uterine artery embolization. It is done
heavy periods? How many times do you have to under local anesthesia. A fine tube is passed via an
change a pad in a day? Are the pads fully soaked? Do artery in the arm of leg into the main artery supplying
you pass any clots as well? What is the duration of the fibroids. Fine particles like sand are then injected
your periods? Do you feel dizzy, palpitations, fainting? into the artery to block its blood supply. The fibroids
Any pain during your periods? Do you have bleeding slowly die and symptoms should settle over a few
between periods? Do you have any bleeding months. The whole process is monitored by xray.
disorders? LMP? Any chance you could be pregnant? Another option is hysteroscopic myomectomy. The
- Are you sexually active? Are you in a stable gynecologist can pass a tube via the cervix and
remove the fibroid. They can also choose to do
laparoscopic myomectomy which is a key-hole
relationship? Are you on any contraceptive? Have you surgery through abdomen. Very less likely, they will go
or your partner ever been diagnosed with STDs? for open surgeries especially if the fibroids are very
- Previous pregnancies? Pap smear? big. The last option is hysterectomy. This is done
- Any problem with your waterworks? Do you have any especially if the woman has completed her family. The
burning while urinating? one disadvantage of having open surgery is that
- FHx of bleeding disorders or gynecological cesarean section is more likely done in succeeding
tumors/cancers? pregnancies because of the weakening of the
abdominal and myometrial wall.
- Iron therapy.
- Reading material. Referral.

Physical Examination
- General appearance Acute Urinary Retention secondary to Fibroids
- Vital signs
- Abdomen: Visible masses, organomegaly, tenderness Case: A 45-year-old woman comes to you in your GP clinic
- Pelvic Exam: discharge, bleeding, cervical os complaining of difficulty to pass urine.
close/open, enlarged irregular uterus about the size of
12 weeks’ GA. No palpable adnexal masses. CMT Task
negative. a. History (3children, NSVD, pap smear >2 years
- Urine dipstick, BSL, urine PT normal, USD GB normal, + discomfort during sexual
intercourse, regular bowel movement)
Diagnosis and Management b. Physical examination (BMI 25, vital signs normal, soft,
- From the history and examination, the most likely no distention or masses, no discharge or bleeding,
cause of your heavy periods is uterine fibroid or bimanual normal, pelvic mass which is hard to
myoma. However, I need to do some investigations to distinguish if it arises from uterus or adnexa, urine
confirm the diagnosis. The investigations are beta- dipstick and BSL)
hcg, iron studies, coagulation profile, urine MCS, and c. Management
TVS. On TVS, there is a large 10 cm hypoechogenic
region in the fundus of the uterus. Causes
- A fibroid is a benign tumor which is formed inside the - Pelvic Mass (Fibroids or ovaries)
uterus. It is very common in the reproductive age - Pregnancy
group. Let me reassure you that it is not a cancer. The - Herpes simplex
exact cause is unknown, but it is suspected that the - Prolapse
sex hormones, estrogen and progesterone, play a - Neurologic problems
significant role. That is the reason why fibroids rarely - Renal stones
grow in pre-pubescent girls and postmenopausal - Constipation (elderly)
women. Pre-existing fibroids stop growing and even - Medications (antidepressants/antipsychotics)
shrink once a woman passes menopause. Fibroids - Males: Prostate enlargement
often cause no problems but occasionally, it can be
associated with: History
o Anemia - because of excessive menstrual - I understand you came to see me because you can’t
blood loss and cause fatigue, pallor and pass urine? For how long? Are you comfortable
breathlessness enough for me to ask you a few questions or you want
o Urinary problems - because large fibroids me to address this problem first?
can bulge the uterus against the bladder - Is it the first time? Can you recall any precipitating
causing a sensation of fullness or discomfort factors like trauma to the back or pelvis? Have you
and the need to urinate often noticed change in urination or frequency before? Do
o Infertility - presence of fibroids can interfere you have any bowel problems? Do you have difficulty
with the implantation of fertilized egg in a or discomfort when you try to urinate? Did you have
number of ways making successful leakage of urine while laughing, coughing or
implantation difficult sneezing? Have you noticed any rash in your private
o Miscarriage and premature delivery – can area? Have you noticed any unusual vaginal
reduce blood flow to placenta or may discharge? Have you noticed any lump coming out of
compete for space with the developing baby your vagina?
- I will need to refer you to the gynecologist for further - When was your LMP? Is it regular? Any excessive
assessment and management. Treatment depends on pain or bleeding? Have they always been heavy or is
the location, size, and number of fibroids. If fibroids it something new? Are you in a stable relationship?
68

Have you ever been diagnosed with STD? Do you - Let me acknowledge your pain and your concern
have pain or discomfort during sexual intercourse? about the breast lumps. I know you’re worried about
What type of contraception do you use? How many your mom’s condition, but before we go ahead I would
pregnancies have you had? How many children do like to ask you some questions.
you have? Type of delivery? BW? When was your last - Some of the questions might be sensitive, is that
pap smear? Was it normal? okay?
- Are you generally healthy? Ever been diagnosed with - When did you start having pain in your breast?
renal stone? Any medications? Allergies? Severity (1-10), site (both breasts/single)? radiation?
Aggravating factor (periods)? Associated factors? How
Physical examination is it affecting your life? Any previous history of similar
- General appearance problems? Any previous breast problems in general?
- Vital signs and BMI Nipple discharge? Changes in breast? Swelling and
- Abdomen: palpate distended bladder (smooth, firm, erythema? Any lumps and bumps in the body?
oval dull suprapubic mass) Back/bone pains? Any cough or other chest
- Pelvic exam symptoms? Headache, N/V, or visual changes?
o Inspection: any evidence of prolapse - Do you drink too much coffee? Do you have bra
o Speculum in left lateral position with sims problems?
speculum - 5Ps: pregnancy: any chance you could be pregnant at
the moment? Partner, pills, periods (regular?
Bleeding? Clots duration of cycle? Menarche); pap
o Bimanual examination: size of uterus, smear: any abnormal pap so far?
contour, consistency, adnexal mass - FHx: other cancers? PMHx
- Urinary catheter and take urinary sample for
microscopy and culture. After emptying bladder, can I
palpate any abdominal masses?
- Urine dipstick and PT

Diagnosis and Management


- You have an acute retention of urine and on PE, I Management
found a pelvic mass which can arise from the uterus - With respect to your worries about the cancer, let me
or the ovaries. You need to have a pelvic USD to reassure you that the pain and lump sensation is due
establish the diagnosis. I need to refer you the to a benign condition called cyclical mastalgia. Most
hospital where you will be assessed by the likely, it is because of hormonal changes during
gynecologist. menstruation. It usually starts a couple of days before
- The gynecologist will arrange further investigations menstruation and relieved during the commencement
including FBE, U&E, CA-125, and TVS/TAS. of menstruation, but let me reassure you that it is not
- If this problem is due to fibroid which is a benign tumor cancer. It is very common in women aged 30-40 years
of the uterus, the treatment will depend on site, size - Advise weight reduction
and desire for pregnancy. You have an acute - Reduce caffeine intake (not >1-2 cups/day) and low
presentation and most likely it will require surgery, fat
laparoscopic or open. - Stop smoking
- If it is benign ovarian cyst or tumor, cystectomy can be - Wear good quality comfortable brassiere
performed. However, in women above 40, bilateral - Prescribe analgesics
salpingo-oophorectomy plus total hysterectomy is - If not responsive, then add mefenamic acid, vitamin
preferred. A gynecologist will discuss diagnosis and b1 and b6.  evening primrose oil  danazol
all available options. - Because of your concern about your mom’s condition,
- A catheter should stay in the bladder until a cause for which increases your risk of having a breast cancer
your presentation has been identified and treated. (1:14 to 1:10), I will refer you to a specialist who will
order further investigations like mammography (every
BREAST 2 years from now) and annual examination by GP and
monthly self-breast examination.
Cyclical Mastalgia - Exercise (aerobic upper exercises)
- See his sister
Case: A 40-year-old woman comes to see you in your GP - Cause: Estrogen
practice. She complains of cyclic pain in both breasts. On
examination, there are some lumps in her breasts on the upper Nipple discharge (Intraductal Papilloma)
outer quadrant. She was not able to tolerate OCPs because of
vomiting and her mother was diagnosed with breast cancer Case: Marion aged 51 years presents to your GP clinic in a busy
when she was 60 and was treated with radical mastectomy. afternoon and tells you that she is quite worried about her nipple
discharge. The discharge is from right nipple describing it as
Task pinkish. The discharge is spontaneous and she had also noticed
a. History discoloration on her nightie. It happened last night and also last
b. Diagnosis week. It is of small amount, leaving a stain about the size of 20
c. Management cent piece on her clothing. She never had any breast problems
before and is very concerned. Marion is a mother of 3 who she
Risk factors: bottlefed. She had paternal grandmother who had mastectomy
- Caffeine intake although she doesn’t know any more details. She had attended
- Inappropriate brassieres a breast screen clinic about six months ago and was all OK. She
- Obesity is still menstruating but her cycles have become quite irregular
and scanty over the last year.
History
69

Task - FSH/LH increase and estradiol decrease


a. Further history - Symptoms:
b. Physical examination o Bleeding: oligmenorrhea/menorrhagia
c. Differential diagnosis and management advise o Hot flushes: heat centered on the face and
spreads to neck and chest; accompanied by
DISCHARGE DIAGNOSIS vasodilation and sweating; episodes last 2-4
Blood Intraductal papilloma minutes happening several times a day;
Cancer should be fine after 70 years
Green Duct ectasia o Sleep disturbance
Mammary dysplasia o Vaginal dryness (estrogen deficiency which
Yellow Mammary duct ectasia can lead to vaginal atrophy and
Abscess dyspareunia; pale vagina; pH which is
usually <4.5 in reproductive years increases
Carcinoma
to 6-7 and hence more prone to infections)
White Lactation cyst
o Sexual dysfunction: low libido and
Hyperprolactinemia
decreased vaginal lubrication; elasticity of
Drugs: chlorpromazine wall decreases and vagina may become
Straw-color Fibroadenoma shorter; continuing sexual activity may
Serous Carcinoma prevent changes
o Incontinence
Abnormal: o Breast pain and tenderness in early
- Color of discharge (serous, blood) menopause
- Spontaneous discharge o Skin changes
- Discharge coming from nipple o Osteoporosis
o Cardiovascular problems
Differential Diagnosis
o Dementia
- Ductal papilloma
o Anxiety, tearfulness, blues, loss of
- Infiltrating ductal carcinoma
- Medications (metoclopramide, SSRIs, OCP, cocaine) concentration are NOT menopausal
symptoms

- Paget disease of nipple


- Breast eczema
- Management
Features
- Benign hyperplastic lesions within large mammary o Education
ducts and not premalignant o Investigations
- Present with nipple bleeding or blood-stained o Healthy lifestyle (diet, exercise, pelvic floor
discharge and must be differentiated from infiltrating exercise)
carcinoma o Consider HRT
- Involved duct and affected breast segment should be  Relieve flushes and vaginal
excised  ductectomy symptoms
 Induce feeling of wellbeing
Triple Test for Lumps  Prevent osteoporosis
- History and physical examination  Improve skin
- Imaging (USD or mammography)  Efficacy regarding
- Biopsy (Fine needle or core biopsy) cardioprotection is controversial
- Itchy, bitchy, sweaty, sleepy, bloated, forgetful and
MENOPAUSE psycho

Menopause Investigations History


- Ask menopausal symptoms: problems with bleeding?
Case: Your next patient is a 54-year-old female who had her last Hot flushes? Sleep disturbance? Dyspareunia?
period 18 months ago. Now, she has mood swings, sweating, Sexual dysfunction? Incontinence? Breast pain and
and dyspareunia. She also has FHx of osteoporosis. She has 3 tenderness? Skin changes? Osteoporosis (bone pain,
children and her mother has osteoporosis. backaches)? CV problems? Signs of dementia?
Differentiate mood swing from depression? Any
Task change in weight or appetite?
a. History - 5Ps: pills, pregnancy, partner (history of STD), Pap
b. Physical Examination: dry vagina smear, mammography? Periods (postmenopausal
c. Investigation bleeding)?
d. Management - How is it affecting your life?
- Contraindications for HRT: ever been diagnosed with
Features stroke, TIA, migraine, hypertension, thyroid disease,
- Cessation of menses for >12 mos. clots in legs or lungs, undiagnosed vaginal bleeding,
- Pre-menopausal – 5 years before the onset of last liver disease, personal or FHx of breast or endometrial
menstrual period cancer?
- Perimenopause – the time when menses become - SADMA?
irregular (2 years before)
- Postmenopause – women who have not experienced Investigations
menstrual bleeding from a minimum of 12 months and - FBE with iron studies
up to 5 years after menopause - Urinalysis
70

- U&E, Ca and Vitamin D levels o Speculum: discharge, vaginal wall for pallor,
- LFts, TFTs, Lipid profile dryness, thin, atrophic, rectocele or
- Pap smear cystocele or prolapse, pap smear
- Mammography (all women before or after 3 months on o PV: cervical motion tenderness, adnexal
HRT) masses
- Hormone levels: FSH, LH, estradiol, progesterone, - Urine dipstick and BSL
testosterone, PRL,
- Coagulation profile Diagnosis and Management
- TVS to check for endometrial thickness - You have a condition called atrophic vaginitis. It is a
- DEXA scan common condition in postmenopausal women
- Diagnostic hysteroscopy and endometrial biopsy (if because at this age, there is lack of estrogen and the
with undiagnosed vaginal bleeding or increased vaginal wall starts to have atrophic changes because
thickness) of that.
- Urodynamic studies for incontinence - For this I will give you local estrogen creams.
- Also, we need to further assess the womb lining. I will
Management refer you to a gynecologist and arrange an ultrasound
- I have organized the investigations for you. At this to rule out any nasty changes in your womb.
stage, since you have dry vagina, I will give you - Lifestyle modification. More calcium.
estrogen creams. I would advise to have a healthy - Reading material.
lifestyle including exercises 30 minutes a day 5 days a - Review.
week, healthy diet with lots of calcium, pelvic floor
exercises, smoking cessation, advise on safe levels of Lichen Sclerosus et atrophicus
drinking
- Use evening primrose oil for breast tenderness You are a GP and a 68-year-old female came to your GP
- For social issues: handle accordingly practice complaining of itching of the vulva for 1 year.
- I would like to refer you to a gynecologist who may
consider starting you on HRT and I would like to Task
review you once all the investigations are back and we a. History: chronic itching x 1 year with pain/discomfort
may need to change some of the management b. Diagnosis based on picture given
depending on the results. c. Investigations and manage the case

Biopsy: chronic Inflammatory changes dermatoses -- lichen


sclerosis
r/o MALIGNANCY!

Atrophic Vaginitis

Case: You are a GP and a 60-year-old female comes in


complaining of vaginal discharge. History
- Please tell me more about the problem? Is it present
Task all the time or does it come and go? Does it wake you
a. History (vaginal discharge x 5 days, brownish, up at night? Any bleeding? Discharge? Any problem
menopause 5-6 years ago, no HRT) with passing water like burning sensation, frequency
b. Physical examination (thin and dry; pale, discharge) of urination, any problems with the stream (scarring
c. Diagnosis and management due to LS may cause problems with urination?
Previous infections or surgeries down there? Skin
History allergies? Have you ever been diagnosed with DM?
- When did you notice it? What’s the color? How much? Or prolonged steroid use? When was your LMP? Did
Is it smelly? Is it itchy? Does your partner have similar you have symptoms of menopause like flushing,
complaints? palpitations, irritability, dry vagina? HRT use? For how
- Periods: menarche, LMP, menopause? Are you long? Any problems with that? Did you have any
sexually active? Are you in a stable relationship? Do bleeding or spotting since then? When was your last
you have problems with sex? Have you or your pap smear? Are you sexually active? Stable
partner ever been diagnosed with STIs? relationship? Any problems during intercourse? Did
- Pregnancies? Pap smear? When was the last one? you have a mammogram recently? How many
Mammography? children do you have? All NSVD? Complications?
- 4B and 2Ps in a postmenopausal woman: Change in weight? Appetite? Lumps around body? Do
o Bladder, bowel, breast, bone you feel tired most of the time? Any FHx of
o Prolapse and Postmenopausal symptoms gynecological cancers or similar conditions? Any
(mood swings, hot flushes, irritability, PMHx or surgical conditions? SADMA?
dyspareunia, bleeding) Picture: white shiny plaques on both vulva with lace-
- FHx: cancers like patterns w/ or w/o bleeding; may bleed when
- How is your general health? SADMA scratched

Physical Examination Investigations


- General examination - BSL, pap smear, swab if with discharge
- Vital signs and BMI - Multiple punch biopsy of lesion
- Breast examination for lumps
- Pelvic examination Differential diagnosis
o Inspection: discharge, color, amount, smell, - lichen sclerosis
scratch marks, visible prolapse, - candidiasis
- atrophic vaginitis
- vulvar Cancer
71

- psoriasis  If (+) LSIL à colposcopy and


- diabetes biopsy
- paget disease  If colposcopy shows LSIL à
- leukoplakia ablation (laser, cryotherapy,
- vulvovaginitis diathermy or surgical excision)
- trauma  HSIL
- Eczema  Moderate to severe dyskariosis
 Do Colposcopy and biopsy
Management  If colposcopy shows intracellular
- You have a condition called lichen sclerosis (genital (LSIL) lesions à ablation (laser,
pruritus + genital soreness+ white wrinkled plaques). It cryotherapy, diathermy or surgical
is a chronic inflammatory skin condition. The exact excision)
cause is unknown, but there is a genetic pattern and it  If colposcopy is positive for
is linked to certain immune-mediated conditions, e.g.
invasive lesion à do cone biopsy
Autoimmune thyroid disease, vitiligo, psoriasis,
o NO cone biopsy in pregnancy
pernicious anemia, alopecia
 Complications: bleeding, cervical
- Please don't worry. This is not an infection and this is
not cancer. It is not contagious. It usually presents as incompetence, cervical stenosis
itching, vulvar pain, bleeding with scratching,  May affect further pregnancy:
sometimes blister formation. premature labor or premature
- It is important to treat the condition to prevent rupture of membranes
scarring. 5% of these patients may develop cancers o In pregnancy:
within the scar.  If LSIL à wait and can do ablation
- Is it because of my menopause? (up to now there has after pregnancy
been no association proven between lack of estrogen  If HSIL:
and appearance of the condition)  <20 weeks: offer
- Treatment with steroids (clobetasol propionate) -- termination and
apply 2x a day for x 1 month, then once every night x aggressive cancer
1 month then 2x weekly x 3 months then once weekly treatment
until asymptomatic then PRN  >20 weeks: up to
- Inform about risk of steroid therapy: thinning of skin, mother to decide
redness, fungal infections  >35 weeks: continue
pregnancy and do
cesarean section and
aggressive cancer
treatment
- Any active problems with cervix/abnormal pap smear
in pregnancy is a contraindication to vaginal delivery

- 95% of patients improve with this treatment. Maintain


good genital hygiene. Avoid using any other creams in
that area. Try to avoid scratching. If required, you may HPV
use emollient to keep the area moist - Around 200 types
- If not relieved, may use retinoids, tacrolimus, UV - 40 are found within anogenital area
therapy - Spread by sexual contact and skin-to-skin contact
- Refer to gynecologist for treatment and followup - Type 6 and 11: low-risk HPV  responsible for 90%
of genital warts; not related in any way to cancers
ABNORMAL PAP SMEAR - Types 16 and 18: high-risk HPV  responsible for
70% of cervical cancers all over the world
LSIL with HPV - Causes microabrasions within cervical epithelium
- Are extremely common within the first 10 years of
Case: You are a GP and 24-year-old female came to find out the sexual life but majority are transient
result of her pap smear. This showed low-grade intraepithelial - Body is able to get rid of the virus on its own but might
squamous lesion and HPV infection. take up to 12 months to clear the infection
- Also known as “common cold” of sexual activity
Task
a. Explain result to patient Counseling
b. Management accordingly - I have the results of the test with me. May I ask a few
relevant questions?
Guidelines for Pap Smear Results for Asymptomatic Females - When did you have your last pap smear? What was
Results Action the result? I understand you are sexually active, are
Negative Repeat x 2 years you in a stable relationship at the moment? How many
LSIL Repeat in 1 year partners have you had previously? Did you always
HSIL Colposcopy and biopsy practice safe sex with the use of condoms? Have you
Unsatisfactory Repeat in 6-12 weeks or your partner ever been diagnosed with a STI
Glandular cells Colposcopy and biopsy (warts)? At the moment, do you have any symptoms,
vaginal discharge, bleeding, or itching? Any pain
 LSIL during intercourse? Any chance you might be
o Mild dyskariosis/dysplasia or HPV infection pregnant now? Have you ever been pregnant before?
o Repeat in 12 mos Any miscarriages? When was your LMP? Cycles
 If normal à repeat in 12 mos. à if regular?
normal then every 2 years
72

- How is your general health? SADMA? Do you have a Management


family history of gynecological cancers or breast - Offer HPV vaccination
cancer? - Repeat after 1 year (or 6 months if age >30 and pap
smear >2 years ago)
Counseling - Counsel against risk factors and safe sex
- As you know, pap smear is a screening test for early
asymptomatic cervical cancer. We usually detect for Abnormal Pap smear with Actinomyces
the presence of abnormal cells in the cervix. At the
moment, your results showed that there are some Case: You are a GP and a 38-year-old female comes in with pap
cells that look different from normal. We call it LSIL. smear showing abnormal cells + Actinomyces. She has IUCD
Basically it means that there are minor changes within for 5 years.
the lining of the cervix, which could be because of the
presence of a coexisting infection with HPV. This virus Task
induces temporary changes in the lining of the cervix. a. History (periods regular, IUCD checks monthly,
What is important is that LSIL has a very low but 2children, NSVD, STI -, DM + Grandmother,
definite risk of transforming into cancer. We need to b. Physical examination (can see string of pap smear
repeat the test within 12 months time. There are two BSL 5.5)
possibilities: If pap smear is normal, we will repeat it c. Diagnosis and Management
again in 1 year time and if still normal then go back to
2-yearly regime. The other possibility is persistent History
LSIL or HSIL. If this happens, I will have to refer you - I know you have come to see me because you want to
to a specialist for colposcopy and biopsy. It is a discuss your pap smear result.
process where we introduce a small tube with a - Prior to our discussion, can I ask a few symptoms?
camera into the cervix to look at the lining. If there is a How are you feeling? Have you noticed any low
suspicious lesion, then a piece of tissue will be taken abdominal pain or discomfort? Any unusual discharge
out. If not, acetic acid will be applied and a suspicious or bleeding?
area will turn white and a sample will be taken. - Periods:
- Regarding HPV infection, the body will be able to clear - Are you in a stable relationship? Have you ever been
off the infection in majority of cases. It is very difficult diagnosed with STD or PID? Is it your first IUCD?
to find out how and when you got this infection What type of IUCD do you have? Have you ever been
because it can happen even in stable relationships. It pregnant? How many children have you had? Have
is important for you to be vaccinated with gardasil to you ever had an abnormal pap smear in the past
protect you from the other 3 subtypes of HPV. If you (No)? When was it? What was it? What was done for
like, we can check you for other STDs. that? When was your last pap smear apart from this
one? How’s your general health? SADMA?
- FHx

- We are planning to have a baby, can I fall pregnant?


There is a 10% that the baby might acquire the Physical examination
infection during labor only. It usually goes into the - General appearance
baby’s throat (respiratory papillomatosis) causing - Vital signs
warts. The baby may or may not be able to get rid of - Abdomen: tenderness and masses
the infection on its own, but we can give certain - Pelvic: inspection/speculum: appearance of cervix,
medications to help him. It is important to practice safe any abnormal discharge, thread of IUCD? PV: size of
sex from now onwards. uterus, adnexal masses/tenderness, cervical
- Review. Reading material. excitation/CMT
- Urine dipstick and BSL
Pap Smear (CIN I)
Diagnosis and Management
Case: Katharin aged 25 years presents to your surgery for result - Your pap smear result showed abnormal cells and
of her Pap smear which you did last week. The result shows actinomyces. Actinomyces is a gram positive bacteria
changes consistent with CIN 1. Her last Pap test was two years and is relatively common to find smears positive for
ago and that was normal. She is otherwise well and had no
previous medical or any surgical problems. Katharine lives by
herself and works in a local bar. She smokes on average 10-15
cigarettes per day and drink socially.
Actinomyces in women who use IUCDs. I want to refer
Task you to a gynecologist for further assessment and
a. Explain result of pap smear management. Usually, with symptomatic Actinomyces,
b. Further relevant history IUCD should be removed, threads cut, and IUCD sent
c. Management for microscopy and culture. If it is positive, prolonged
antibiotic treatment with penicillin for 6 weeks is done.
History After treatment, pap smear should be repeated in 6-12
- Multiple partners? Smoker? What age of coitarche? weeks because it might be due to the coexisting
Practicing safe sex? Promiscuity? What is your work? infection with the bug.
Low socioeconomic status? FHx of cancers?
Gardasil Vaccine
73

vaccination is severe allergic reaction (anaphylaxis)


Case: You are a GP and your next patient is a 45-year-old Mr. following a previous dose of the vaccine.
Walker wants to know about Gardasil vaccination. His 15 year - Gardasil contains virus-like particles which are non-
old daughter will receive vaccine in school and he is worried that infectious and do not have any cancer-causing
it will encourage early sexual life. potential. This vaccine is generally safe and well-
tolerated.
Task - Possible side effects: Injection site pain, swelling, and
a. Respond to patient inquiry redness.

- Hello Mr. Walker. I understand you have come to see


me to discuss Gardasil vaccine. How much do you
know about this vaccine? Have you ever heard about
HPV infection?
- Gardasil vaccine was designed to prevent HPV
infection and it doesn’t promote early sexual life. - Gardasil vaccine does not protect against other STDs.
Gardasil is effective against 4 types of HPV. There are It doesn’t encourage girls to start sexual life earlier.
40 types of HPV that affect the genital tract. This The main purpose of the HP V vaccine is to protect
vaccine is against types 16 and 18 causative agents in them against cervical cancer and genital warts.
70-80% of all cervical cancer and types 6 and 11, However, it doesn’t give 100% protection. All girls
which are associated with 90% of genital warts. HPV need to be screened for cervical pathology using pap
infection is transmitted by sexual intercourse. That is smear from the age of 18 or 2 years after they
why this vaccine is given to young girls (9-26) since become sexually active (whichever comes later).
most of them hasn’t started sexual life and haven’t - Can be given to boys but not included in the
been infected and thus will benefit the most. However, immunization program.
even sexually active girls can benefit from gardasil - Pregnant women? No, but you can give them after
vaccine. Majority of them will not yet be infected, or labor even while breastfeeding.
may be infected by 1 or 2 types and get protection - It is no longer beneficial after the age of 27.
against others.
- Gardasil vaccine is part of the school immunization
program. It is free and given within 6 months. It is
administrated by intramuscular injection usually in the
shoulder. The only absolute contraindication to HPV

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