Obs/Gyn for AMC Clinicals IMG study Network Lecture 1

Case You are seeing 30 year old Mary who is complaining some vaginal bleeding since this morning. Her LMP was 10 weeks ago. Tasks: Take history not more than 2-3 mins Ask for PE findings from the examiner Advise further management.

History Can you tell me a bit more about the pain? (Open ended Q). Ask for vitals to the examiner. HOPI Can you tell me a bit more about the pain? (Open ended Q). Now can you tell me more about the bleeding. How many pads have you soaked? Any clots? Any discharge? Are you currently bleeding from down under? Any possible trauma? How is your water works? Bowels?

Menstrual history/ 5Ps. Are you in stable relationship right now? –if stable relationship need not ask sex or not I can see that your LMP was 10 weeks ago. Are you and your partner currently trying for pregnancy? Any symptoms like nausea/ vomiting in early morning? Breast heaviness and tenderness? (Pregnancy symptoms) Any prior pregnancies? Any miscarriages? Any surgical or gynecological/curettage done before? Have you ever been diagnosed with STIs before? Are you taking any pills? Any use of IUCDs in the past? Are you regular with your pap smears? Do you know your blood group?

PHYSICAL EXAMINATION Starts with general appearance. Any pallor, icterus, cyanosis, edema. Vital signs. (Temp, HR, RR, BP, SpO2). Next, Focused abdominal examination Inspection: Any bruises, scars, distension(non pregnant). Shape of the abdomen. Palpation: Any tenderness. Fundal height. Lie. Presentation. Any fetal movements? In late pregnancy check the engagement.

Auscultation: FHS. With patient’s consent and presence of a chaperone Auscultation: FHS. With patient’s consent and presence of a chaperone. PELVIC Examination. Inspection: Any rashes, discharge, lesions, bleeding. Speculum: Vaginal walls/any signs of tear/trauma. Bleeding? Discharge? Lesions around the cervix? State of the OS? Pooling of the liquor? Nitrazine test? Swabs. FFT.(Near term) BiManual : Size, mobility and position of the uterus? Adnexal masses. Cervical motion tenderness.

Any contraindications for PV/Bimanual examination? Young Virgin. Second trimester bleeding. PROM/ Active herpes lesions (minimize) Malpresentations? What’s your opinion? Office tests: RBS, Urinalysis. Pregnancy test (Depending).

MANAGEMENT Treatment vs Investigations? Give all the options to the patient. Respect Autonomy. Explanation From the history and examination, you most likely have_________. Have you heard about this before? There can be reasons as to why this happens. (Explain your differentials). But please don’t be alarmed you will be in good hands. (Reassurance).

Immediate management. Long term management. So for now I am going to admit you/ you can go home. We will do some tests, the CTG to check your baby’s status. USG to look for any bleeding/ check volume of liquor. You will be seen by the specialist, who will assess you again and ________. Long term management. The outcome is quite good. After your delivery we will have to repeat the OGTT again in 6 weeks as there is_________. Reassure. Review. Red flags.

WTS Explanation From the history and my assessment you mostly likely are pregnant and have what is called a threatened miscarriage. It is not uncommon and the cause is unknown. The good news is that in 90% of the time, you will carry on to have a successful delivery. Immediate management I shall be admitting you as of now as we need to make the baby’s alright and also to exclude other bleeding causes like placenta detachment. In the hospital you will be seen by specialist who will an USG to make sure your baby’s well. We will also do some basic tests like FBE, ESR/CRP, RFT, LFT, Coagulation profile.

Long term management As I said before there is high chance that your pregnancy will carry on. After you discharge we will begin with all your antenatal checkups. Please take ample rest and maintain good diet and avoid any stressors. You might need to take an early maternity leave.

Antenatal checkups

Case You are a GP seeing a 40 year old managing consultant Sarah who recently found out that she is pregnant via home pregnancy test. The repeat pregnancy in the clinic shows positive. This is her first pregnancy and her PE is unremarkable. Your Tasks: a) Take relevant history from the patient. b) Counsel her regarding the nature of her pregnancy.

History Sarah, Congratulations on your pregnancy. Was this is a planned pregnancy? Do you have any bleeding, discharge from down under? Any tummy pain? Any past medical h/o HTN,DM ? How is you support at home? Do you know your blood group?

Menstrual history/ 5Ps. When was you last menstrual period? Are your periods regular? Any bleeding in between periods? Are you taking any contraception? How about previously? Are you in a stable relationship? When was your last pap smear? Any abnormal result? Any family h/o congenital problems?

Advanced age pregnancy counselling/ WTS Explanation over the age 35 is considered as advanced age pregnancy and is associated with some risks to you and your baby as well. increase chance of having HTN, gestational diabetes, issues with the placenta like placenta previa. Biggest risks: Miscarriage. Risk of Down’s syndrome. Please don’t be alarmed as we have excellent management plan to follow through.

Immediate management Start your antenatal check ups now. Start folic acids. This helps to prevent NTD defects in the baby. healthy diet, take some light exercise and if possible take an early maternity leave. Attend every antenatal checkups. Long term Arrange Down’s screening. 9-13 weeks bHCG, Pappa and USG to measure the baby’s nape. 15-17 weeks we will do blood tests to measure 4 hormones bHCG, inhibin A, AFP, estriol. Confirmatory tests. CVS done at 11-14 weeks. Amniocentesis is done at 15-18 weeks. invasive and have slight risks for miscarriage 1:100 and 1:200 respectively. the choice is yours Reassure.

Case You are seeing 22 year old Gemma in an ED who is complaining of tummy pain and some vaginal bleeding that started this morning. She says she hasn’t had any periods for the last 9 weeks. She is not sure if she pregnant. On her charts, her blood group is A –ve. Your Tasks: a) Take relevant history from the patient b) Ask physical examination findings from the examiner c) Explain your diagnosis/ses and immediate management

Early pregnancy bleeding Ectopic pregnancy Miscarriages Molar pregnancies Cervical lesions Bleeding diathesis

HISTORY HOPI Can you tell me a bit more about the pain? (Open ended Q). Cover site/severity, onset, location, duration, character, associated symptoms, relieving factors/radiation, exacerbating factors, first time pain? (SOLDCARE1). Now can you tell me more about the bleeding. How many pads have you soaked? Any clots? Any discharge? Are you currently bleeding from down under? How is your water works? Bowels?

Menstrual history/ 5Ps. Are you in stable relationship right now? I can see that your LMP was 9 weeks ago. Are you and your partner currently trying for pregnancy? Any symptoms like nausea/ vomiting in early morning? Breast heaviness and tenderness? (Pregnancy symptoms) Any prior pregnancies? Any miscarriages? Any surgical or gynecological/curettage done before? Have you ever been diagnosed with STIs before? Are you taking any pills? Any use of IUCDs in the past? Are you regular with your pap smears? Do you know your blood group?

Management/WTS Explanation. many reasons for bleeding from the vagina. (Give D/Ds).Given your circumstances and from my evaluation I am sad to say that you are pregnant and you have most likely have miscarried. Empathise Provide Knowledge. When I examined you I found lot of clots which suggests fetal tissues. We exactly do not know the cause but it could be due to some abnormality within the fetus itself. Immediate management Admission, IV fluids, removing the product of conception. FBE, CRP, RFT, Na/K, coagulation profile, order and cross match. I/M oxytocin Anti-D 250IU. Consult Obs/gyn registrar, she will do curettage to empty your uterus. This is to confer and stop bleeding source. Reassure.

Case Your next patient is a 28-year-old primigravida Mary who works as a teacher. You have been looking after her pregnancy since the first trimester. You are seeing her in a general practice setting in a shared care arrangement with the local obstetric hospital team. All appears to be normal up to now and including her last visit at 30 weeks of gestation, when the symphysis-fundal height was 28 cm. Today, four weeks later at 34 WOG, the symphysis-fundal height is 29cm. Other PE is unremarkable. Her blood group is B+, Rubella immunity +,OGTT normal. Yours tasks: a) Advise the patient of the diagnosis. b) Advise subsequent management including any further investigations you would want to arrange.

Small for gestational age(SGA) Maternal factors Infections. Constitutional. Smoking. IDA. HTN. DM. Thrombotic conditions. Fetus Malformed. Congenital problems. IUGR. Placenta Oligo. Insufficiency.

Investigations to order FBE, ESR/CRP, RFT, LFT. Coagulation profile. Thrombophilia screening. TORCH immunoglobulins. Ultrasound, CTG. Doppler studies

WTS Explanation Hi Mary it’s good that you are here today. Now looking at the results and your condition. Your baby is basically small for its gestational age(SGA), that means your baby is small than what is expected for his/her gestation age right now. It could be due to issues with you such as conditions like HTN, DM, SLE, some infections, clotting problems. Your baby might have some issues with the kidneys and other organs. And lastly the womb where there is some bleeding called abruptio placenta, oligohydramnios meaning less liquor around the womb. So to find out what’s the cause we have to do few tests.

MANAGEMENT Immediate management Long term management refer to the hospital to do an USG and CTG. We will do some other tests like FBE, ESR/CRP, RFT, LFT to see your health is in check. Some coagulation and clotting studies to investigate the cause. In the hospital the specialist will also do a Doppler scan to assess the blood flow in the placenta. Long term management monitored regularly. MDT team. CTG every week and USG every 2 weeks to monitor the baby’s growth. delivery will be in a controlled environment and most likely you will deliver at 37 WOG. This is because the outcome of the baby with SGA is best at 37 WOG.