og lecture 2013 amrita

8/18/2019 Og Lecture 2013 Amrita

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PACES RevisionObstetrics and Gynaecology

Kindly sponsored by:

27/04/2012

AMR !A "A#ER$EE % O&A MAR' E( C)


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Plan for the morning

9-10.30 - Lecture + demonstration station10.30-11.00 - rea! 11.00-1".30 - #oc! P$%&' stations ()*

1".30-13.00 , Lunch


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utline of al!

bs / ynaeistory

&)amination%linical '!ills

2n estigations#anagement4ed 5lags

&thics and La6

%ommon P$%&' 'tations7emonstration 'tationips and $d ice

5urther 4esources


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2' 48


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he istory

!*e +ain ,art o- all PACES stations.. o not co+,ro+ise ont*is

P%P%ynae history bstetric istory

P#7

5''ystems re ie6


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he ynaecological istory

Periods• 7ysmenorrhoea• ligomenorrhoea

• $menorrhoea• #enorrhagia• #ittelschmer

isc*arge

• 'mell• %olour• %onsistency


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!*in abo t se3• %ontraception• P accine

5ave se3• 7yspareunia• Post-coital bleeding

A-ter se3 catc*• ' 2;s• P , smears<• abies


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"oys• 4egular• Protection , pregnancy and ' 2;s• =# clinic isits• Peer pressure• Legal


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Obstetric 5istory 6 don;t forget Ps<

Conse ences o- c*ildbirt*• 'phincter dysfunction• 4ectal> aginal prolapse


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Meno,a se• 'ymptoms• 4• Post menopausal bleeding<• aginal atrophy• 'e) life• ?uality of life


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bstetric istory

P%P%

%urrent Pregnancy @as this a planned pregnancyA&77 - scan or dates (L#PB #enstrual cycle%omplications2n estigations so far

Gravidity , number of times a 6oman has been pregnantB regardless of outcomeParity C (any li e or still birth after "* 6ee!s

S,eci-ic Sy+,to+s

#a sea / 8o+iting 9 if severe known as hyperemesis gravidarum:rinary -re ency 6 pressure on the bladder causes this – rule out UTI !iredness;etal Move+ents 9 usually felt at around 18-2 weeks gestation! earlier in multips

deas< Concerns % E3,ectations=


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bstetric istory

etails o- eac* ,regnancy7ate > 8earPlace of birth

estation

#ode of deli ery "aby , se"! weight! current healthProble+s d ring antenatal< labo r % ,ostnatal'ame PartnerA %onsanguinityA

#iscarriages / erminationsPre ious difficulty concei ing> assisted conceptionPlans for future pregnancies


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bstetric istory

#aternal: 7&$ P7iabetespre-&clampsia $naemia

hrombus

ypertensionPain

leeding2nfection

5etal#o ements'cans>tests

ospital admissions

5or each pregnancyB including the current one ifpregnantB as! about complications:


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bstetric istory %ont.

Past Gynaecological 5istory Contrace,tive se>

&ast Cervical S+ear , 6as the result normalA

Any gynae s rgery- Loop e)cision of transitional one (L& D - risk of cervical incompetence↑- Pre ious myomectomy - risk of uterine rupture #↑ placenta accreta #adhesions

Gynae investigations % treat+ent -or- 2nfertility - &ctopic , ↑ risk of future ectopics- P27 - chlamydia is most common cause – risk of ectopic↑


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he rest of the history

Past Medical 5istory and Past S rgical 5istory

r g 5istory Pregnancy +edication 9 folatesB ironB anti-emeticsB antacids!eratogenic dr gs 6 avoid at all costs - $%&i! 'etinoids! (odium )alproate! *ethotre"ate

O!C r gs - make sure to ask patient about these! to ensure nothing unsafe A&&ERG ES

;a+ily 5istory Medical conditions 9 gestational diabetes

n*erited genetic conditions 6 %+ Pregnancy &oss 9 recurrent miscarriages in mother , sisters

Pre9ecla+,sia 9 in mother or sister – increased risk

Social *istory S+o ing< Alco*ol< r g se&iving Sit ation BRelations*i, Stat sOcc ,ation

Syste+s revie?


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ther 2mportant ?uestions

o6 do her symptoms affect her life

@hat support does she ha e at home , do not

assume she is married<2s there anything else that you are 6orrying aboutA

2s there anything else that you;d li!e to as! meA


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aginal '6abs

Bug Swab Other Treatment

Candidaalbicans

High vaginalswab

Mycelial filaments onmicroscopy

Clotrimazole creamor oral fluconazole

Bacterialvaginosis

High vaginalswab

Whiff test positive cluecells al!aline pH

Metroni"azole orclin"amycin cream

Trichomonasvaginalis

High vaginalswab

Motile flagellate" protozoaon microscopy al!aline pH

Metroni"azole

Chlamydiatrachomatis

#n"ocervicalswab

$ucleic aci" amplificationtests %$&&Ts' eg( )C*

+o,ycycline orazithromycin

Neisseriagonorrhoea

#n"ocervicalswab

-ram negative "iplococci Ceftria,one


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%er ical screening programme

Ai+ : identification of %2E and initiating earlytreatment before the de elopment of cer icalcarcinoma

E a test for cancer< Age range :"F-*9 e ery 3 yearsF0-G* F yearly

G0+ if not screened since F0 or recent abnormal results!ec*ni e : 4otate brush in the e)ternal os to pic!up loose cells o er the D for liHuid based cytology


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%er ical screening programme

%ounselling and e)plaining the process>results>follo6 up<

DYSKARYOSIS:Cytology – smear

CervicalIntraepithelial

neoplasia: Histology - biopsy

anagement

mil! CI"#

Can spontaneo$slyregress

% month &ollo' $p( I&persists then colposcopy

mo!erate CI") Colposcopy * treatment

severe CI"+

Imme!iate colposcopy *

treatment


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2E &' 2 $ 2 E'


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2n estigations

General ti,s

2mportance of obser ations and bedside tests

7o not mention lists of in estigations unless you are able to Iustify 6hy you 6ant them

it the Iac!pot early (but don;t sho6 off

hin! outside the bo) , pregnant 6omen get non-pregnantdiseases


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2n estigations

Gynae :%er ical smears2nterpret hormone le els: 5' B L B 5 ;s

=rodynamics=ltrasound: endometrial thic!ness'urgery: endometrial biopsyB laparoscopyB lap + dye

%ontracepti e methods: 2=7ysteroscopy


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2n estigations

Obstetrics :Pregnancy test (in $+&

lucose olerance est

%ardiotocographsPartogram

Pel ic ='''creening tests $mniocentesis>chorionic illus sampling


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#$E$ &E


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#anagement

@hat e eryone does 6orst on<

on@t -orget4esus +

CO#SER8A! 8EME CA&

S:RG CA&

$nd 8ER importantly

AS' ;OR 5E&P.


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4&7 5L$ '


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4ed 5lags - bstetrics

Condition Sy+,to+s

Placenta ,raevia Painless P bleeding late in pregnancy

Placental abr ,tion Painful P bleeding late in pregnancy

BR ,t red ecto,ic ,regnancy &arly pregnancyB pel ic painB P bleeding +>- faintnessB shoulder-tip pain

Obstetric c*olestasis 2tchy hands and feet during pregnancy

S*o lder dystocia 7elayed deli ery after deli ery of thehead

Cord Prola,se =mbilical cord descends belo6 thepresenting part follo6ing rupture ofmembranes

A+niotic -l id e+bolis+ 7yspnoeaB hypotensionB hypo)iaB

sei uresB heart failure


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4ed 5lags , bstetrics cont.

Condition Sy+,to+s

:terine r ,t re $cuteB se ere pain during labour orB if epiduralBsudden maternal hypotensionB cessation ofcontractionsB fetal hypo)ia

:terine inversion Post-partum haemorrhageB pain and profound

shoc! Pre9ecla+,sia ypertensionB proteinuriaB oedema

Ecla+,sia Pre-eclampsia 6ith 4=? painB headachesB tonicclonic sei uresB blurred ision

PE ' B chest painB hypo)iaB cardiac arrest

8! $cute leg painB rednessB s6ellingB heatB +>-'

Pri+ary and Secondary PP5 Primary J F00 ml of blood loss 6ithin "* hoursof deli ery.

'econdary 9 abnormal or e)cessi e bleeding bet6een "* hours and 1" 6ee!s postnatally.


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4ed 5lags - ynaecology

Condition Sy+,to+s

Ovarian cyst torsion,acci!ent Severe pelvic pain associate" withhypovolaemic shoc!

n!ometrial carcinoma &bnormal uterine blee"ing especially)MB

Ovarian carcinoma $on.specific symptoms of ab"ominal"istension pain abnormal blee"ingweight loss

Cervical carcinoma /MB )CB )MB offensive vaginal"ischarge

.ID )0 "ischarge pelvic pain feverabnormal blee"ing


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% =E'&LL2E


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%ounselling

'hared decision ma!ing#7&mpathy

$cti e listening=se of silence $ oid Iargon2deasB concernsB e)pectations


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%ounselling cont.

%ongenital abnormalities e.g. 7o6nsB urnerssyndrome

%er ical smear results

&ctopic pregnancy #iscarriage%ontraception


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L$@ $E7 & 2%'


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La6 and &thics

& eryone ignores but is ery important<#ost sued specialty &)tremely sensiti e issues: culturalB religiousB personal

2mportant principles:illic! competencehe $bortion $cthe #ental %apacity $ct


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La6 and &thics

& eryone ignores but is ery important<#ost sued specialty &)tremely sensiti e issues: culturalB religiousB personal

2mportant principles:illic! competencehe $bortion $cthe #ental %apacity $ct


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he $bortion $ct

Permits termination of pregnancy by a registeredpractitioner subIect to certain conditions.#ust be performed by registered medical

practitioner in an E ' hospital or 7o appro edlocation (e.g. ritish Pregnancy $d isory 'er ice%linics $n abortion may be appro ed for the follo6ing

reasons:


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$ he continuance of pregnancy 6ould in ol e ris to t*e li-e o- t*e,regnant ?o+an greater than if the pregnancy 6as terminated.

he termination is necessary to ,revent grave ,er+anent inD ry to the physical or mental health of the pregnant 6oman.

% he continuance of the pregnancy 6ould in ol e ris!B greater than ifthe pregnancy 6ere terminatedB of inD ry to t*e ,*ysical or+ental *ealt* of the ,regnant ?o+an .

7 he continuance of the pregnancy 6ould in ol e ris!B greater than ifthe pregnancy 6ere terminatedB of inD ry to t*e ,*ysical or+ental *ealt* of any e3isting c*ildren of the family of thepregnant 6oman

& here is a substantial ris! that i- t*e c*ild ?ere born it 6ouldsuffer from ,*ysical or +ental abnor+alities as to be

serio sly *andica,,ed B or in emergencyB certified by the operatingpractitioners as immediately necessary

5 o save t*e li-e o- a ,regnant ?o+an

o pre ent grave ,er+anent inD ry to t*e ,*ysical or +ental*ealt* of the ,regnant ?o+an .


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he uman 5ertlisation / &mbryology $ct 1990

'ection 3 of the 5&$ made changes to the 19Gabortion act:

ime limit of abortion is "* 6ee!s under statutory

grounds % and 7'tatutory grounds $B and & are no6 6ithout timelimit


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5raser uidelines ( illlic! %ompetence

hose 1G may be prescribed contraception 6ithout parentalconsent if:

hey nderstand the doctor;s ad ice

he young person cannot be ,ers aded to in-or+ t*eir,arents that they are see!ing contracepti e ad ice

hey are li ely to begin or contin e interco rse 6ith or 6ithout contracepti e treatment

=nless the young person recei es contracepti e treatment their ,*ysical or +ental *ealt* is li ely to s --erhe young ,erson@s best interests reHuire that the doctor

gi es ad ice and>or treatment 6ithout parental consent


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& &M$#


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Fth 8ear P$%&'

* domains of mar!ing:

1. %linical s!ills

". 5ormulation of clinicalissues3. 7iscussion of #anagement*. Professionalism andPatient centred approach


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Past stations: bstetrics

1 year old ?anting !OPMissed +iscarriage F s,ec l +Pre9ecla+,sia

8"AC co nselingRec rrent +iscarriages F anti,*os,*oli,id syndro+e5 8 and ,regnancy Bin + lti,le circ itsPE in ,regnancy Bcon- sed a lot o- ,eo,le

Gestational diabeteso?n@s syndro+e screening

S+all -or dates9 yo ng s+o er $lcohol and pregnancy #ultiple pregnancy $bnormal lie and &% %ounseling a patient 6ith molar pregnancy P discharge in pregnancy %ontracepti e ad ice post-pregnancy Pre-term rupture of membranes

yperemesis gra idarum $ntenatal chec!


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Past stations: ynaecology

$bnormal bleeding#enopause $menorrhoea and infertility =nderage>pressured se)

'e)ually transmitted infections=rogynae , incontinenceB self esteem aginal dischargePel ic pain'ubfertility %ontraception

ynae oncology &thics

og lecture 2013 amrita

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