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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?
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
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
7
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.
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.
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
- 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
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
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.
- 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!
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
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?
- 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,
Rubella Varicella
Vaccination No No
Immunoglobulin No Yes
Termination Yes if IgM (+) Never
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
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
- 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.
- 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
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
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.
Task
a. Counsel patient and answer her questions
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
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
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
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?
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
- 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.
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
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
- 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
- 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
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
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
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
- 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
- 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
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
- 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?
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
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
- 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
Atrophic Vaginitis