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Obs and Gynae History TakingSession overview ●Open questions ●SObs/Gynae questions ●Systemic review Quick Recap - ●Past medical history Standard history ●Surgical history ●Drug history and allergies ●Family history ●Social history ●ICECase 1 Student briefing: You are a 4 year medical student on clinical placement in a District General Hospital Setting: Gynaecology outpatient department Patients details: Charlotte Brown is a 32 year old female who has been referred by her GP complaining due to worsening menstrual pain. Your task: You have been asked to take a history from the patient. At 7 minutes the examiner will ask you to present your findings. You will then be asked to interpret clinical data and answer questions relating to your clinical reasoning and clinical care for the patient. Differentials 32 year old female with worsening menstrual painKey Gynae Questions To Ask● Constant abdominal pain associated with menstruation (chronic dysmenorrhea) ● Pain on defecation ● 33 day menstrual cycle ● Very heavy periods ● Cannot use tampons as too painful ● No intermenstrual bleeding ● Sexually active with long term male partner, dyspareunia ● Not on contraception, have been trying to get pregnant for last 2 years (infertility) ● Previously on COCP, pain has worsened since coming off the pill ● No previous pregnancies, miscarriages or terminations ● Up to date with cervical smears● Systemic review - No N+V, no diarrhoea, no blood in stools, no dysuria, no increased urinary frequency, no fever, no weight loss ● ICE- no of her friends seem to have periods as bad as hers, pain becoming unbearable, wants some better pain relief ● PMH- Nil ● DHx - Ibuprofen and paracetamol. Not on any hormonal contraception. No herbal medications. NKDA ● FHx - Mother had breast cancer age 55 years old, now in remission ● SHx- works in retail, having to take 2-3 days off a week due to the pain, her boss is getting frustrated, lives with partner, no alcohol, non smoker, no recreational drug useDifferentials Top differentialsFurther investigations? B-BOXES ● Bedside: Full abdominal examination, including PR exam, examine hernia orifices and external genitalia, speculum exam if not too painful and bimanual vaginal examination again if not too painful, vital signs, urinalysis, pregnancy test, vaginal swab ● Bloods: FBC (to look for anaemia, infection), U&Es and LFTs (As baseline), Coag (due to heavy bleeding), CRP (inflammation) ● Imaging: transvaginal ultrasound, pelvic MRI ● ECG ● Special tests: gold standard for endometriosis diagnosis is diagnostic laparoscopyManagement of endometriosis Conservative Medical Surgical ● Patient ● Analgesia - 1st line NSAIDs, can ● Therapeutic information trial mefenamic acid (consider laparoscopy and PPI if long term use) regarding ● Tranexamic acid for menorrhagia excision of condition (only taking when menstruating) endometriosis ● Hormonal contraception 1st line ● Hysterectomy -if ● Gynaecologist COCP- but contra if trying to referral conceive severe and ● Fertility referral ● GnRH (gonadotropin releasing exhausted all other options/patients ● Lifestyle advice hormone) agonists e.g. weight loss ● If trying to conceive can consider wishes IVFCase 2 Student briefing: You are a 4 thyear medical student on clinical placement in General Practice Setting: GP Patients details: Jean Smith is 63 year old female presenting with urinary symptoms. Your task: You have been asked to take a history from the patient. At 7 minutes the examiner will ask you to present your findings. You will then be asked to interpret clinical data and answer questions relating to your clinical reasoning and clinical care for the patient. Differentials 63 year old female with urinary symptomsKey Gynae Questions To Ask● Sudden need to pass urine ● Gradually got worse over last 3 months ● Has not made it to the toilet on a couple of occasions - occurring more frequently, around once a week now ● No increased frequency, passing normal amounts of urine ● No symptoms when coughing/sneezing ● No dysuria ● No vaginal discharge ● Vaginal dryness and itching ● No abdominal pain, no dragging sensation or bulge ● Menopause 10 years ago. No HRT. ● Previously regular periods ● Cervical smears up to date ● Not sexually active ● 3x children, all SVD. No complications. ● G4 P3 - 1 termination● PMH: Asthma, HTN, anxiety ● Surgical history - appendicectomy as a child ● DHx- Salbutamol inhaler, amlodipine 10mg OD, no OTC/herbal, NKDA ● FHx- none of note ● SHx- lives with husband, office worker, non-smoker, drinks a glass of wine a night and drinks 4x coffees a day ● ICE- big effect on QOL, has been taking time off work due to embarrassment, has not been going out, affecting her mental health Differentials Top differentials Urge vs StressFurther investigations? B-BOXES ● Bedside: Full abdominal examination, including examining hernial orifices, bimanual examination, vital observations, urine dipstick and urine MC&S ● Bloods- FBCs, U&Es, LFTs (baseline), CRP (infection), HbA1c and glucose (check for diabetes) ● Orifices- bimanual examination, speculum, vaginal swab ● X-ray (imaging) - post void bladder scan ● ECG ● Special tests - bladder diary for 3 days doing normal activitiesUrge vs Stress Incontinence recap Urge Stress ● ‘’involuntary leakage accompanied by, or ● ‘’involuntary leakage on effort immediately preceded by, a or exertion, or on sneezing or sudden compelling desire to coughing’’ pass urine which is difficult to defer’’ ● Due to a rise in intra- ● Due to overactivity of the abdominal pressure and weakened/damaged urinary detrusor muscle (muscle surrounding the bladder) sphincter (muscle which prevents urination)Management of urinary incontinence - urge vs stress Urge Stress ● Conservative - reduce alcohol ● Conservative - reduce alcohol and caffeine and caffeine, weight loss ● 6 week bladder retraining ● 3 months supervised pelvic floor ● Medical - offer antimuscarinic muscle retraining e.g. oxybutynin or mirabegron ● Gynaecologist referral for ● Treat associated conditions e.g. surgical intervention e.g. colposuspension vaginal atrophy with intravaginal ● Medical - duloxetine 2nd line if oestrogen therapy surgical intervention refused/not suitableCase 3 Student briefing: You are a 4 year medical student on clinical placement in an District General Hospital. Setting: Obstetric assessment unit Patients details: Katy Brown is a 27 year old pregnant female presenting with abdominal pain. Your task: You have been asked to take a history from the patient. At 4 minutes the examiner will ask you to present your findings. You will then be asked to interpret clinical data and answer questions relating to your clinical reasoning and clinical care for the patient. Differentials 27 year old pregnant female presenting with abdominal painKey Obstetric Questions To Ask● 36 +3 weeks pregnant, single fetus ● G1P0 ● Sudden severe abdominal pain ● Associated with PV bleeding ● Regular fetal movements ● No urinary symptoms ● No clear loss of fluid ● Rhesus negative ● 2 scans so far with no complications however some spotting in early pregnancy but this was checked and no further issues ● First pregnancy (no prev terminations/miscarriages) ● No visual changes, headaches, leg swelling ● Up to date with cervical smears● PMH: Depression and anxiety ● DH: Sertraline, NKDA ● FH: No family history of note ● SH: Smoker (Around 10 year pack history), no alcohol in pregnancy, no recreational drugs, lives with partner and feels safe at home, works as teaching assistant ● ICE: No idea, but really scared, is the baby going to be okay>Differentials Top differentialsFurther investigations? B-BOXES ● Bedside: Full abdominal examination, vital signs including BP, check rhesus status, speculum examination, urinalysis ● Bloods: FBCs, U&Es, LFTs (baseline), Coag screen, crossmatch / G&S (due to bleeding) ● Orifices: Vaginal swab, speculum (contra if placenta previa) ● Imaging: Doppler US of fetus, cardiotocography (CTG), trasvaginal US (more useful for placenta praevia) ● ECG ● Special tests: Kleihauer test - quantify amount of fetal blood mixed with maternal blood to determine dose of anti -DAntepartum haemorrhage Bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby Placental Placenta Vasa praevia abruption praevia ● Pvaginal bleeding (fetal blood) ● Painful PV ● Painless PV ● Fetal distress - fetal bleeding bleeding bradycardia/tachycard ● Hard woody uterus ● Non-tender uterus ia ● Separation of the ● Placenta lies over ● Velamentous placenta from the cervical os umbilical cord uterus wall ● Facross the cervical os ● A-E approach ● Urgent involvement of obstetrics and paediatrics team ● Major haemorrhage protocol Management of ● Left lateral position ● 2x wide bore cannulas placental abruption ● IV fluids/blood resuscitation ● Consider beclomethasone if fetus <37 weeks ● Consider anti-D if patient is rhesus negative ● Close monitoring of the mother and continuous monitoring of the fetus ● If fetal distress- emergency C sectionCase 4 Student briefing: You are a 4 year medical student on clinical placement in an District General Hospital. Setting: Obstetric assessment unit Patients details: Eloise Parks is a 33 year old pregnant female presenting with reduced fetal movements. Your task: You have been asked to take a history from the patient. At 4 minutes the examiner will ask you to present your findings. You will then be asked to interpret clinical data and answer questions relating to your clinical reasoning and clinical care for the patient. Differentials 33 year old pregnant female presenting with reduced fetal movementsKey Obstetric Questions To Ask● 34 +5 weeks pregnant, single fetus ● G2P1 ● Not felt the baby move for over 12 hours which is unusual for her, confirm regular fetal movement pattern ● General fatigue ● Itchy (pruritus), especially palms of hands and soles of the feet and worse at night ● No rash, just scratch marks from itching ● No PV bleeding, no loss of fluid, no swelling, no headaches/visual changes, no dysuria, no fevers ● Had 2 scans, no complications so far ● 1x previous pregnancy 7 years ago - emergency C-section due to failure to progress, developed postnatal depression ● Up to date with cervical smears ● Rhesus positive● PMH: Anxiety and depression, including previous post natal depression following traumatic birth ● DHx- citalopram, NKDA, took folic acid up to 12 weeks, not taking aspirin ● FHx- no family history of note - does not know anyone in the family who has had pre-eclampsia ● SHx- lives with partner and child (7 y/o), feels safe at home, no alcohol during pregnancy, ex-smoker ● ICE- is it related to all this itching? Very concerned baby has died! Differentials Top differentials Autoimmune liver disease, Drug induced liver disease, Polymorphic eruption ofyndrome, pregnancyObstetric cholestasis ● AKA intrahepatic cholestasis of pregnancy ● Characterised by reduced outflow of bile acids from the liver, commonly resolves after delivery of the baby ● Relatively common complication of pregnancy, occurring in around 1% of pregnant women ● Usually develops later in pregnancy (after 28 weeks) ● The buildup of bile acids in the blood results in the classic symptoms of itching (pruritis) ● It is associated with an increased risk of stillbirthFurther investigations? B-BOXES ● Bedside: Immediate handheld Doppler to assess for fetal heartbeat, Vital signs including BP, urinalysis, speculum ● Bloods: FBCs (Anaemia/infection), U&Es (baseline), LFTs and bile salts, coag screen, non invasive liver screen, Crossmatch and G&S ● Orifices: Speculum, vaginal swab ● Imaging: Doppler to assess fetal heartbeat, CTG, US Abdo ● ECG ● Special tests: NA ALT, ALP and bile salts will all be elevated/abnormal in obstetric cholestasis ● A-E approach and inform senior ● Confirm fetal heartbeat initially ● Monitor for 48 hours ● Medical Mx - Ursodeoxycholic acid ● Pruritus Mx - piriton and calamine lotion Management of ● Regular monitoring of LFTs up until obstetric cholestasis delivery ● Due to increased risk of stillbirth with bile salt levels >100 book for category 3 C- section at 35-36 weeks gestation ● Consider beclomethasone if <37 weeks gestation ● Consider Vitamin K if steatorrhoea/ prothrombin time deranged Other gynaecological ● PCOS ● STIs/PID conditions to revise in your ● Miscarriage ● Vaginal prolapse own time (list is not exhaustive) ● Cancer - endometrial, ovarian, cervical ● Pre-eclampsia ● Preterm premature rupture of Other obstetric conditions to membranes ● Chorioamnionitis revise in your own time ● Gestational diabetes (list is not exhaustive) ● Hyperemesis gravidarum ● Post partum haemorrhage ● (UTI- don't forget common things are common!)Thank you for listening! Any questions?References ● https://www.nice.org.uk/guidance/ng73/chapter/Recommendations#endometriosis- symptoms-and-signs ● https://www.nhs.uk/conditions/endometriosis/ ● https://www.nhs.uk/conditions/urinary- incontinence/#:~:text=stress%20incontinence%20%E2%80%93%20when%20urine%20leaks ,to%20pee%2C%20or%20soon%20afterwards ● https://cks.nice.org.uk/topics/incontinence-urinary-in-women/background- information/definition/ ● https://patient.info/doctor/gravidity-and-parity-definitions-and-their-implications-in-risk- assessment ● https://zerotofinals.com/obgyn/antenatal/placentalabruption/ ● https://zerotofinals.com/obgyn/antenatal/placentapraevia/ ● https://zerotofinals.com/obgyn/antenatal/vasapraevia/ ● https://www.rcog.org.uk/media/pwdi1tef/gtg_63.pdf ● https://zerotofinals.com/obgyn/antenatal/obschole/