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Obstetrics & Gynaecology Dr Henry WillisQuestion 1: A 23-year-old woman presents to the emergency department with a two-day history of mild lower abdominal pain and vaginal bleeding. Her last menstrual period was 8 weeks ago. She has right iliac Given the likely diagnosis, what is the most fossa tenderness on examination. appropriate management? Obs: RR 16 A – Expectant management BP 125/75 HR 80 B – Laparoscopic Salpingectomy Sats 98% RAo C – IM Methotrexate Temp 37.3 C A urinary pregnancy test is positive and bHCG is 1200 D – Exploratory Laparotomy IU/L. E – CT guided IR Drainage You arrange a transvaginal ultrasound which shows an empty uterine cavity and a 30mm right sided adnexal mass. No foetal heartbeat seen.Question 1: A 23-year-old woman presents to the emergency department with a two-day history of mild lower abdominal pain and vaginal bleeding. Her last menstrual period was 8 weeks ago. She has right iliac Given the likely diagnosis, what is the fossa tenderness on examination. most appropriate management? Obs: RR 16 A – Expectant management BP 125/75 HR 80 Sats 98% RA B – Laparoscopic Salpingectomy o Temp 37.3 C C – IM Methotrexate A urinary pregnancy test is positive and bHCG is 1200 D – Exploratory Laparotomy IU/L. You arrange a transvaginal ultrasound which shows an E – CT guided IR Drainage empty uterine cavity and a 30mm right sided adnexal mass. No foetal heartbeat seen.T opic 1: Ectopic Pregnancy Key Differentials Risk Factors • Appendicitis Adhesions (ie PID, surgical), IVF, IUD • Migratory pain, nausea, anorexia, fever • Miscarriage Features: • ‘ectopic until proven otherwise’ Symptoms – abdominal pain, vaginal bleeding, • Infective cause ie PID / UTI / STI amenorrhea, ‘shoulder tip pain’ • Offensive discharge, urinary symptoms Signs – tenderness on internal examination, guarding Investigations: • Bedside • Obs, urinary sample + UPT Professional Practice • Bloods • ‘Pregnant until proven otherwise’ • FBC, U&Es, CRP, G&S, bHCG • Avoid internal examination unless necessary – no • Imaging need for ED F1 / ED reg / obs SHO to all examine • Transvaginal UltrasoundT opic 1: Ectopic Pregnancy Expectant Medical Surgical Size <35mm <35mm >35mm Foetal heartbeat? Not present Not present Present Symptoms? None Mild Significant bHCG? <1000IU/L <1500IU/L >5000IU/L Management Observe 48hrs, recheck IM methotrexate with Laparoscopic bHCG to ensure falling bHCG monitoring SalpingectomyQuestion 2: Which of the following statements is correct? A – MRI pelvis is the next appropriate investigation B – Multiparity increases your risk of endometrial A 69-year-old women attends her GP practice with 3 malignancy episodes of vaginal bleeding. Her last menstrual period was 15 years ago. A transvaginal ultrasound shows C – Long term combined oral contraceptive pill use increases this risk of endometrial malignancy endometrial thickness of 5mm. D - endometrial thickening is a normal finding in this age group E – topical oestrogen preparations are likely to improve symptoms in this patientAnswer 2: Given the differential diagnosis, which of the following statements is correct? A – MRI pelvis is the next appropriate investigation A 69-year-old women attends her GP practice with 3 B – Multiparity increases the risk of endometrial episodes of vaginal bleeding. Her last menstrual period malignancy was 15 years ago. A transvaginal ultrasound shows endometrial thickness of 5mm. C – Long term combined oral contraceptive pill use increases the risk of endometrial malignancy D - endometrial thickening is a normal finding in this age group E – topical oestrogen preparations are likely to improve symptoms in this patientT opic 2: Endometrial Cancers Risk Factors Lifetime oestrogen exposure – majority of tumours are adenocarcinomas arising from chronic oestrogenic endometrial stimulation Features: • ~90% present with post-menopausal bleeding • May report B symptoms ie weight loss etc, may have mass on examination external / internal Investigations & Treatment • tumour markers are not usually helpful • TVUS is gold standard investigation - >4mm • Uteroscopy with biopsy will lead to definitive diagnosis • Surgical treatment (TAH + BSO usually) +/- chemo if metastatic diseaseT opic 2: P ost Menopausal Bleeding Key features Investigation Treatment Atrophic Vaginitis Post coital - Topical oestrogen bleeding, vaginal preparations dryness Uterine Liomyoma Heavy + painful TVUS + Levogesterol IUS (fibroids) menstruation, hysteroscopy Myomectomy abdominal mass Hysterectomy Endometrial - TVUS + Progesterones hyperplasia hysteroscopy + biospy Endometrial Polyp - TVUS + Curetage hysteroscopy + biopsy Cervical Malignancy Post-coital bleeding Culposcopy + LLETZ punch biopsyQuestion 3: A 26-year-old nulliparous woman attends her GP Given the likely diagnosis, what is the most surgery with persistent painful periods over the last 6 appropriate next step? months. She has a regular 28 – 30 day cycle with bleeding usually lasting 4 days. Pain often starts before A – Urgent referral to gynaecology under 2WW menstruation, and ibuprofen does not ease symptoms. She has recently been investigated for inflammatory B – Routine referral to gynaecology bowel disease. C – Request a Transvaginal Ultrasound scan Examination, observations, and initial bloods including FBC are all within normal range. D – Offer a trial of hormonal contraception Urinalysis is unremarkable and a urinary pregnancy test E – Advise to continue simple analgesia and to return in is negative. 3 months if still symptomaticAnswer 3: A 26-year-old nulliparous woman attends her GP Given the likely diagnosis, what is the most surgery with persistent painful periods over the last 6 appropriate next step? months. She has a regular 28 – 30 day cycle with bleeding usually lasting 4 days. Pain often starts before A – Urgent referral to gynaecology under 2WW menstruation, and ibuprofen does not ease symptoms. She has recently been investigated for inflammatory B – Routine referral to gynaecology bowel disease. C – Request a Transvaginal Ultrasound scan Examination, observations, and initial bloods including FBC are all within normal range. D – Offer a trial of hormonal contraception Urinalysis is unremarkable and a urinary pregnancy test E – Advise to continue simple analgesia and to return in is negative. 3 months if still symptomaticT opic 3: Endometriosis Risk Factors Management Nulliparity, early menarche / late menopause, white • First line ethnicity, low BMI, smoking • simple analgesia +/- hormonal contraception – usually COOP is offered Features: • Imaging may be appropriate if positive Symptoms – chronic (6 months +) pelvic pain, examination findings dysmennohrea, dyspyrunia (pain during intercourse) • Second line Signs – usually normal examination, may find • Refer to specialist if not tolerated after 3 – 6 abdominal masses / visual vaginal endometriotic months • Laparoscopic ablation – improves fertility, pain, lesions ~10% reoperation rate Investigations: • Bedside • Obs, urinary sample • Bloods • FBC, U&Es, CRP – note CA-125 not useful Professional Practice • Imaging • Many women take months / years to reach diagnosis • TVUS may be useful • Urine MCS with recurrent UTI! • Diagnostic laparoscopy + biopsy is gold-standard • Refer to specialist endometriosis centreQuestion 4: Which of the following statements are correct? A – This patient will need a repeat smear in 12 months, A 29-year-old woman who moved to the UK from Nepal with return to normal recall if HPV is negative 6 months previously attends her GP to discuss her cervical smear results. She has not had a smear test B – Every sample is sent for cytology before. C – HPV 6 & 11 are strongly linked to the development of cervical carcinoma Smear results: - HPV+ D – Women should be invited for smear tests every 5 - Cytology – no abnormal cells identified years from the age of 25 E – Treatment is often indicated with low grade dyskaryosis (CIN 1)Question 4: Which of the following statements are correct? A – This patient will need a repeat smear in 12 months, A 29-year-old woman who moved to the UK from Nepal with return to normal recall if HPV is negative 6 months previously attends her GP to discuss her cervical smear results. She has not had a smear test B – Every sample is sent for cytology before. C – HPV 6 & 11 are strongly linked to the development of cervical carcinoma Smear results: - HPV+ D – Women should be invited for smear tests every 5 - Cytology – no abnormal cells identified years from the age of 25 E – Treatment is often indicated with low grade dyskaryosis or CIN 1T opic 4: Cervical Cancer Fast Facts • Causal link with HPV 16, 18, 33 • Children vaccinated against all strains including low • 90% reduction of cervical cancer cases in vaccinated womenTopic 4: Cervical CancerT opic 4: Cervical Cancer Fast Facts • High grade dyskaryosis / CIN 2+ treated with large loop excision of the transformation zone (LLETZ) • If LLETZ carried out, recall in 6 months for test of cure • If low grade / CIN1, recall in 12 months to ensure no further change / change to baselineTopic 4: FIGO StagingQuestion 5: A 36-year-old woman who is 22 weeks pregnant Given the likely diagnosis, what is the most presents to ED with light vaginal bleeding and mild appropriate management? lower abdominal pain which has now resolved. On examination she has a fundal height appropriate for A – Reassure and discharge, with safety netting to dates and mild lower abdominal tenderness. She has return if further bleeding spotting on her maternity pad. Speculum examination shows no blood in the vaginal B – Immediate delivery by caesarean section fornix and closed, long cervix. C – Administer dexamethasone and begin induction of labour Obs and bloods are within normal range. D – counsel the patient that she is having a miscarriage Bedside ultrasound is performed showing a foetus with a HR of 145 (normal range 100 – 160). E – Admit the patient for observationQuestion 5: Given the likely diagnosis, what is the most A 36-year-old woman who is 22 weeks pregnant presents to the labour ward with vaginal bleeding and appropriate management? lower abdominal pain which has now resolved. On examination she has a fundal height appropriate for A – Reassure and discharge, with safety netting to dates and mild lower abdominal tenderness. She has return if further bleeding spotting on her maternity pad. B – Immediate delivery by caesarean section Speculum examination shows no blood in the vaginal C – Administer dexamethasone and begin induction of fornix and closed, long cervix. labour Obs and bloods are within normal range. D – counsel the patient that she is having a miscarriage Bedside ultrasound is performed showing a foetus with a HR of 145 (Normal range 100 – 160). E – Admit the patient for observation, and discharge in 48 hours if no further bleedingT opic 5: Miscarriage Cervix TVUS Management Threatened Miscarriage closed normal Watch and wait Inevitable Miscarriage open May be normal / abnormal Allow 7-14 days to complete spontaneously Complete Miscarriage closed No products of conception - seen Incomplete Miscarriage open Residual pregnancy tissue in Single dose misoprostol uterus Missed Miscarriage closed Pregnancy tissue, no foetal Single dose mifepristone, heartbeat followed by misoprostol Surgical removal is under • Septic miscarriage general anaesthetic Indications for Surgery? • Haemodynamic instability transcervical vacuum aspiration • Unsuccessful medication management Give anti-D to Rh negative women who have surgical mxQuestion 6: What is the most appropriate initial management? A 36-year-old women G1P0, 30/40 is seen on the labour ward following a community blood pressure reading of 150/98. She is asymptomatic. She has a A – admit for 48 hours inpatient blood pressure background of type 2 diabetes. Clinical examination is monitoring, no initial treatment necessary unremarkable. B – Reassure and discharge with home blood pressure BP profile on review: monitoring, to return if over 150/100 148/92 C – give labetalol PO, discharge with regular follow up 146/90 148/95 D – ramipril PO, discharge with regular follow up CCG is unremarkable. E – magnesium sulfate IV, admit to the labour wardAnswer 6: Given the likely diagnosis, what is the most A 36-year-old women G1P0, 30/40 is seen on the appropriate initial management? labour ward following a community blood pressure A – admit for 48 hours inpatient blood pressure reading of 150/98. She is asymptomatic. She has a monitoring, no initial treatment necessary background of type 2 diabetes. Clinical examination is unremarkable. B – Reassure and discharge with home blood pressure monitoring, to return if over 150/100 BP profile on review: 148/92 146/90 C – give labetalol PO, discharge with regular follow up 148/95 D – give ramipril PO, discharge with regular follow up CCG is unremarkable. E – give magnesium sulphate IV, admit to the labour wardT opic 6: Pregnancy Induced Hypertension Features: signs / symptoms of pre-eclampsia: • Oedema • Headaches • Visual disturbance / papiloedema • Brisk reflexes • Epigastric pain Investigations: Management • Aspirin from 12 weeks if 1 high risk factor or 2 moderate • Indication of pre-eclampsia:n wards’ risk factors • Rise in ALT • Oral labetalol +/- nifedipine • Proteinuria – (high urinary protein / creatinine • Hydralyzine second line ratio) • If severe pre-eclampsia / eclampsia: • MgSO4 + delivery of babyQuestion 7: A 24-year-old woman at 38/40, G2P1, is being induced on the labour ward for reduced foetal movements. She What is the definitive management in this scenario? has had one previous caesarean section. A – give STAT IV fluid resuscitation The alarm bell rings as she has a large volume vaginal bleed with sudden worsening abdominal pain. Her most recent examination revealed a fully effaced cervix B – Transfer immediately to theatre for category 1 caesarean section at 10cm dilation, with an engaged foetal head. C – Transfer immediately to theatre for instrumental Obs: delivery BP 90/60 HR 120 D – Continue induction of labour with oxytocin IV RR 28 Sats 97% RA Temp 36.8 E – Stop the oxytocin infusion to reduce contractions, and continue to monitor progress in labour The CCG indicates foetal distress.Answer 7: A 24-year-old woman at with an uncomplicated pregnancy,G2P1, is being induced on the labour ward at 38/40 for reduced foetal movements. She has had What is the definitive management in this scenario? one previous caesarean section. A – give STAT IV fluid resuscitation The alarm bell rings as she has a large volume vaginal bleed with sudden worsening abdominal pain. Her B – Transfer immediately to theatre for category 1 most recent examination revealed a fully effaced cervix caesarean section at 10cm dilation, with an engaged foetal head. C – Transfer immediately to theatre for instrumental Obs: delivery BP 90/60 D – Continue induction of labour with oxytocin IV HR 120 RR 28 Sats 97% RA E – Stop the oxytocin infusion to reduce contractions, Temp 36.8 and continue to monitor progress in labour The CCG shows foetal bradycardia.T opic 7: Antepartum Haemorrhage Time of presentation Key exam tricks Management Ectopic Pregnancy 6-8 weeks ‘shoulder tip pain’ As discussed Hydatidiform mole Late 1 trimester Hyperemesis, big for dates Vacuum aspiration (GA) Vasa praevia 3rd trimester / may be ‘bleeding – membrane Delivery by caesarean picked up on US rupture – fetal distress’ section /observe Placenta praevia Likely to be picked up at 20 Painless antepartum Delivery by caesarean week US bleeding section /observe Placental abruption 3 trimester, weeks ‘woody’ / tense uterus Delivery by caesarean preceding birth section / observe Uterine rupture During labour Prev C section, oxytocin Delivery by caesarean augmentation section +/- hysterectomyT opic 7: P ostpartum Haemorrhage Always start with A – E Resuscitation Primary PPH ”500ml+ within 24hrs” Mechanical Palpate fundus • T one Catheterise to prevent bladder distension and monitor • Uterine atony output • T rauma • Ie. Perianal tear • T issue Pharmacological • Retained placenta Oxytocin – ergometrine (HTN) - carboprost (asthma) – • T hrombin misoprostol • Clotting disorders Usually role for TXA Secondary PPH is any bleeding up to 6 weeks and is Surgical almost always caused by retained products or Balloon tamponade endometritis B-lynch suture HysterectomyT opics not covered Gynaecology Obstetrics Prolapse VTE Urinary dysfunction Normal labour ‘Abnormal discharge’ Intrahepatic cholestasis of pregnancy Menopause Hyperemesis Subfertility Diseases of vertical transmissionThank you! Please fill out feedback for free slides