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Disclaimer “These Sessions are designed and presented by us. They are supplementary materials and are not intended to be used as replacement for core lectures. These sessions and advice are based on our own experiences.” OSCE SERIES THE OBSTETRICS STATION Srinjay Mukhopadhyay PROUDLY IN COLLABORATION WITH Role Medical student Setting Obstetrics Ward Patient Janet Smith is a 35 year-old pregnant woman who has come in with per vaginal bleeding. STUDENT Student task Take a focused form this patient. INSTRUCTIONS At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis. History of Presenting Complaint: FOR ANY PRESENTING • Open Question: How can I help you today? COMPLAINT: • When did you notice the blood DOPT A • How much blood? Duration • What colour was it? ONSET PROGRESSION • Any Abdominal Pain? TIMING • Reduced Fetal Movements? ASSOCIATED Sx • Post coital? • Any injury to your stomach? Blood Group? • How many weeks into this pregnancy Systems Review: • Any changes to your vision, any headaches? • Any changes to your water works or bowel movements • Any Nausea or Vomiting? • Any fever or fatigue? • Have you felt lightheaded? • Any leg swelling?- Not specific to this case but good to ask in Obs Hx. Systems Review: • How may time have you been pregnant before? How many children do you have? I am sorry to ask, but have you had any still births? • How were your previous pregnancies? Any complications during previous births? • Cervical Screening Past Medical History: • Any conditions you see a doctor for? • Any Previous Hospitalisation • Any previous surgeries? • How have the scans been for this pregnancy so far? Drug History: • What medications do you take currently? Did you take any supplements for the pregnancy? Any Herbal remedies? Have you had your anti-D injection? • Any over-the-counter medications? • Do you have any drug allergies? Family History: • Any Family history of conditions? Social History: • Do you smoke? Or Have you ever smoked? If so how many cigarettes per day and for how long? • Do you drink? • Where do you work? • Who is with you at home? ICEE OBSTETRIC HISTORY SPECIFICS: 1. Establish Gestational Age! 2. Establish Gravidity and Parity 3. Past Sexual history 4. Cervical Screening 5. Abdominal pain 6. Fetal movements 7. Vaginal Bleeding/Discharge 8. Previous obstetric Hx: Any Complications? 9. Screen for Pre-Eclampsia 10.Screen of DVT/PE 11.Check immunisations Summarising The history Patient details, occupation I took a history from Janet Smith, a 33-year-old 28 week gestation, G3 P2 woman who came in & key presenting complaint with a PV bleeding She first noticed the bleed today in the morning, when her innerwear was blood stained. She describes History of presenting complaint it as dark brown. She also complains of severe lower diffuse abdominal pain. She also complains of reduced fetal movements. No trauma to the abdomen. Up-to-date with cervical screening. Pregnancy so far has been uncomplicated apart from a diagnosis of gestation HTN. She is Rh- and is due an anti-D injection this week. Previous pregnancies have been uncomplicated, and both her children are healthy. No significant past medical history. Had elective C-sections for both previous children. Currently takes Relevant PMH/PSH/SH/DH labetalol for G HTN, NKDA, consultant-led care due to gest HTN, BMI>40 and FH of pre-eclampsia. Lives with family and is well supported. Ideas, concerns & expectations Just hopes child is ok. Top differential & why My top differential is an acute Placental Abruption Other differentials that I would like to rule out include placenta previa, Vasa Previa. Other differentials PV Bleeding INVESTIGATIONS TEST JUSTIFICATION A-E For any acutely unwell patient always start with the A-E approach! Senior Support! Basic observations Assess for haemodynamic instability, hypoxia and fever BEDSIDE Pregnant Abdomen Examination Look to feel for contractions; hard woody uterus for placental abruption CTG Fetal Distress 12-lead ECG PE, pneumonia may cause ECG changes Full blood count (FBC) Assess for anaemia and signs of infection Liver function test (LFT) Assess for liver function Coagulation Profile Essential to detect coagulopathy. BLOODS Urea and Electrolytes (U&Es) Assess for electrolyte abnormalities & Acute kidney Injury Group and save/X match Essential!! C-reactive protein (CRP) Assess for infection IMAGING Ultra Sound Placenta Previa can be detected and graded. SPECIAL TESTS SPOT DIAGNOSIS A G4P3 32-week gestation lady presents to the Obstetric assessment unit with sudden per vaginal bleeding. She does not complain of any abdominal Placental Previa pain but mentions having a problem with her placenta in a previous antenatal scan. What is the most likely diagnosis? A G2P1 26-week gestation lady presents to the Obstetric assessment unit with severe headaches Pre-Eclampsia and blurry vision. She mentions here waterworks have looked slightly frothy over the past week. What's the most likely diagnosis? An G6P5 lady presents to A=E with severe shortness Pulmonary Embolism of breath and pleuritic chest pain. On examination the left calf looks swollen and red. What is the most likely diagnosis?Blood Results Name Janet Smith Age 33 Date of stu26/04/2023, 12:00 pm Hb 85g/l (115-160g/l) Urea 7.8 mmol/l (2-7mmol/l) Creatinine 145 umol/l (55-120umol/l) Obstetric Haemorrhage Antenatal Post-partum • Placenta Previa • 4 T’s: (primary PPH) • Placental Abruption • Tone • Vasa previa • Trauma • Thrombin • Tissue Major Haemorrgahe Protocol; 2222; inform Antepartum blood bank; 4 units of X matched blood ASAP Haemorrhage Conservative Medical Surgical • Counsel patient on diagnosis • Pain Relief and antiemetics • Abruption: • Consider corticosteroids based • If massive haemorraghe: • Fetus alive and > 36 weeks on gestation if premature trigger major haemorrgahe • no fetal distress: deliver vaginally delivery likely. protocol, get Operation • IV MgSO4 for child’s fetal distress: C-section Theatre ready for immediate • Fetus alive and < 36 weeks neuroprotection. delivery. • Monitor obs closely fetal distress: C-section No fetal distress: Observe Previa: Severe Bleed: C -section