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PreMedEaz PreClinEazy y SurgEazy FinalsEazy THE OBSTETRIC STATION SESSION TIME: 1.5-2h • Obstetric History • Abdo Examination Today’s • PV/Speculum Examination Session • Example Stations • Spot Diagnosis Role Foundation Year 1 Doctor (FY1) Setting Emergency Department STUDENT Patient A 32 year old 22 week pregnant woman attends complaining of PV bleeding. Student tasYou have 7 minutes to take a focused history from the patient. some clinical questionsto present your differential diagnoses and answer INSTRUCTIONS Obstetric History Normal History GH PC HPC Smear history PMH Sexual history DH (Contraception FH Menstrual history) SH OH Extras Previous pregnancies Current pregnancy Safeguarding Mental health Rhesus statusINVESTIGATIONS MANAGEMENT BEDSIDE: INITIAL • Abdo examination MUM: • PV/speculum examination* • A-E (if acutely unwell) • Observations • Contact seniors • Urinalysis (infection, eclampsia) • Oxygen • ECG (if acutely unwell) • IV fluids (restrict in eclampsia) • Swabs • Anti-D if Rh - BLOODS: BABY: • FBC, U&Es, LFTs, CRP • Corticosteroids • Clotting (bleeding) • Magnesium sulphate • G&S, crossmatch (bleeding) ONGOING IMAGING MUM: • US (abdo/TV*) • Monitor obs • Synto if delivered SPECIAL • CTG BABY: • Doppler • ?Paedsreview Role Foundation Year 1 Doctor (FY1) Setting Emergency Department Patient A 32 year old 22 week pregnant lady attends complaining of PV bleeding. CASE 1 Student task You have 7 minutes to take a focused history from the patient. You will then be asked to present your differential diagnoses and answer some clinical questions DIFFERENTIALS INVESTIGATIONS MANAGEMENT • Placenta previa • Bedside: basic observations, • A-E if acutely deteriorates urine dip, blood glucose • ?Major haemorrhage protocol • Ectropion (depending on blood loss) • Bloods: FBC, U&Es, LFTs, CRP, • Contact seniors • Vasa previa TFTs, G&S, crossmatch, coagulation studies INITIAL • Miscarriage • CTG to monitor foetus • Imaging: abdominal US • Anti-D if Rh- • Adenomyosis • Steroids if <37w • Special: CTG • If unstable, emergency C • Placental abruption section • If stable, ?home with follow up ONGOING • Patient education • Placental abruption – IOL @ 37w • Placenta previa - monitor (C section if still there @37w)CAUSES OF APH Role Foundation Year 1 Doctor (FY1) Setting A&E Patient A 33-year-old woman at 24 weeks gestation presents to the clinic for a CASE 2 routine prenatal visit. Student task You have 7 minutes to examine the patient’s abdomen. You will then be asked to present your differential diagnoses and answer some clinical questions INTRO GENERAL INSPECTION HANDS, ARMS, FACE HANDS: CRT EXPLAIN PATIENT: Comfortable at rest Discolouration CONSENT Pain Temperature Scars Pulse Pallor OFFER TO CHECK BLOOD PRESSURE CHAPERONE FACE : Melasma MAINTAIN DIGNITY BEDSIDE: Medications Pallor Fluid balance Vital signs Jaundice Oedema LEGS & FEET ABDOMEN ABDOMEN INSPECTION CHECK FOR CALF PAIN (DVT) SPECIAL TESTS: PALPATION: Symphysis-fundal height Identify upper boarder and CHECK FOR ANKLE OEDEMA Foetal heat eat lateral edges of uterus LIE PRESENTATION ENGAGEMENT THANK PATIENT & RESTORE CLOTHING Role Foundation Year 1 Doctor (FY1) Setting A&E Patient A 33-year-old woman at 24 weeks gestation presents to the clinic for a CASE 2 routine prenatal visit. Student task You have 7 minutes to examine the patient’s abdomen. You will then be asked to present your differential diagnoses and answer some clinical questions DIFFERENTIALS INVESTIGATIONS • Gestational diabetes BEDSIDE: • Observations • Polyhydramnios • Urinalysis (UTI) • OGTT • Twin-twin transfusion syndrome BLOODS: • FBC, U&Es, LFTs, CRP • Congenital anomaly • Glucose, HbA1c IMAGING • US (abdo/TV) SPECIAL • CTGGlucose measured on fasting, then 75g glucose drink given, glucose measured 2h later OGTT Normal values: o Fasting <5.6 o At 2h <7.8 DIFFERENTIALS INVESTIGATIONS MANAGEMENT • Gestational diabetes BEDSIDE: CONSERVATIVE • Observations • Capillary glucose monitoring • Polyhydramnios • Urinalysis (UTI) • US Scans • OGTT • Twin-twin transfusion MEDICAL syndrome BLOODS: • Diet & exercise • FBC, U&Es, LFTs, CRP • Metformin • Congenital anomaly • Glucose, HbA1c • Insulin • Glibenclamide IMAGING • US (abdo/TV) IF FASTING GLUCOSE >7 • Insulin +/- metformin SPECIAL • Glibenclamide • CTG SURGICAL (Delivery) • IOL or C section @37w • Monitor glucose hourly • Dextrose + insulin infusion (if glucose not 4-7) Gestational Diabetes Complications MATERNAL FOETAL Macrosomia Pre-eclampsia Cardiomegaly/myopathy LT maternal T2DM Erythropoiesis Polyhydramnios Pre-term delivery Jaundice Post-delivery: Instrumental delivery (tears) hypoglycaemia, tachypnoea• Good control pre-pregnancy • 5mg folic acid (until 12w) • 75mg aspirin (12w until birth) • Target levels same as in gestational diabetes • T2DM – only use metformin +/- insulin Pre-Existing • Retinopathy screening • Planned delivery 37 - 38 +6 weeks Diabetes • Sliding-scale insulin labour for women with T1DM or poorly controlled T2DM/GDM Role Foundation Year 1 Doctor (FY1) Setting A&E Patient A 31-year-old woman who is 29 weeks pregnant has come to A&E CASE 3 complaining of headache. Student task You have 4 minutes to take a focused history from the patient. You will then be asked to present your differential diagnoses and answer some clinical questionsPatient nameSarah Age: 31 Date: Today FBC Hb 115g/l (120-160) Platelets 120* 109g/l (150-400 * 109g/l) WBC 8.7 * 109g/l (4.0-11.0* 109g/l) TEST RESULTS LFTs Bilirubin 90 µmol/L (3-17 umol/L) ALP 540 u/l (30-100 umol/L) ALT 120 u/l (3-40 iu/L) γGT 130 u/l (8-60 u/L) Albumin 35 g/l (60-80 g/L) INR 1.0 DIFFERENTIALS INVESTIGATIONS MANAGEMENT • Pre-eclampsia BEDSIDE: INITIAL • Ophthalmology MUM: • HELLP syndrome • Neuro exam • A-E • Abdo exam • Contact seniors (emergency C- • Eclampsia • PV/speculum exam section) • Observations (BP) • IV labetalol • Gestational hypertension • Urinalysis (proteinuria) • IV MgSO 4 • Fluid restrict • Migraine BLOODS: • FBC, U&Es, LFTs, CRP BABY: • Tension headache • Clotting • Corticosteroids IMAGING ONGOING • US (abdo/TV) MUM: • Counsel patient SPECIAL • Education • CTG • Stop or switch antihypertensive BABY: • ?Paedsreview Pre-Eclampsia Risk Factors HIGH RISK MODERATE RISK >40y Pre-existing hypertension BMI >35 Previous hypertension in pregnancy >10y since previous Existing autoimmune conditions (SLE) pregnancy Diabetes Mellitus Multiple pregnancy Chronic kidney disease First pregnancy FH pre-eclampsia Where are you calling from? S Who is the patient? Why are you calling? Brief HPC, including key negatives B Significant PMH/DH Rhesus status HANDOVER Examination findings Key observations A Any initial test results Top differential What you have done/are going to do R What you want them to do and why A B C D E • ABCDE – stabilise mother • IV MgSO 4 manage seizures ECLAMPSIA • IV labetalol / hydralazine – manage HTN • Continuous CTG – monitor foetus • HDU care until stable – monitor mother (at ACUTE MANAGEMENT least 24h), fluid balance to prevent pulmonary oedema or AKI • Deliver baby – definitive treatment (must REASSESS THE PATIENT IF ANY stabilise mother first), C section INTERVENTION IS PERFORMED REVIEW INVESTIGATION RESULTS AS SOON AS THEY ARE AVAILABLE CALL FOR HELP EARLY USING SBAR AND MUST CONSIDER ICU REFERRAL Role Foundation Year 1 Doctor (FY1) Setting Labour ward Patient A 26 year old woman who gave birth 1h ago attends complaining of PV CASE 4 bleeding. Student task You have 7 minutes to take a focused history from the patient. You will then be asked to present your differential diagnoses and answer some clinical questions DIFFERENTIALS PPH 2 to OTHER TONE VAGINITIS TISSUE MALIGNANCY TRAUMA ECTROPION THROMBIN POLYPS/EROSIONSA Maintaining own? If not – airway adjuncts and contact ITU 15L O2 via non-rebreather B Assess compromise – cap refill, HR, BP, ECG PPH Insert 2 wide bore cannulas – take off bloods (including G&S and crossmatch) C Resuscitation – start with IV fluids until blood products available (then up to 4 units of O - or crossmatched blood) ACUTE MANAGEMENT Monitor GCS Check BM D Keep patient warm REASSESS THE PATIENT IF ANY INTERVENTION IS PERFORMED REVIEW INVESTIGATION RESULTS AS Expose to check for any other abnormalities SOON AS THEY ARE AVAILABLE E Identify cause CALL FOR HELP EARLY USING SBAR AND MUST CONSIDER ICU REFERRAL Role Foundation Year 1 Doctor (FY1) Setting A&E Patient A 21-year-old woman who is 30 weeks pregnant has come to A&E CASE 5 complaining of discharge. Student task You have 4 minutes to take a focused history from the patient. You will then be asked to present your differential diagnoses and answer some clinical questionsName: Cara Smith Age: 21 Date: Today Collection sample: High vaginal swab TEST RESULTS Culture results: Moderate growth of Group B streptococcus Penicillin S Clindamycin S Doxycycline R DIFFERENTIALS INVESTIGATIONS MANAGEMENT • PPROM BEDSIDE: INITIAL • Abdo examination MUM: • Infection • PV/speculum examination* • Contact seniors • Observations • Admit for 24h obs • Urinary incontinence • Urinalysis (UTI) • Prophylactic ABx • High vaginal swabs • Normal vaginal secretions BABY: BLOODS: • Corticosteroids • FBC, U&Es, LFTs, CRP • G&S ONGOING MUM: IMAGING • Patient education • US (abdo/TV*) • Expectant management • IOL @34w SPECIAL • CTG BABY: • Neonatal team INTRO GENERAL INSPECTION PV EXAM EXPLAIN BEFORE: Confirm consent POSITION: Heels to bottom Lubricate gloved fingers Knees fall to sides CONSENT DURING: Separate labia INSPECTION: Ulcers Gently insert index & CHAPERONE Discharge/bleeding middle fingers Scarring Rotate 90o MAINTAIN DIGNITY Masses Rashes SPECULUM SPECULUM PV EXAM DURING: Inspect cervix (including os) BEFORE: Confirm consent DURING: Vaginal walls Erosions/ulcers Masses Lubricate speculum Cervix Fornices Discharge DURING: Separate labia Uterus Gently insert sideways Ovaries AFTER: Remove slowly Rotate 90 Cover patient AFTER: Remove & inspect fingers Open slowly Cover patient Tighten Thank patient THANK PATIENT & RESTORE CLOTHING CTG DR: Define risk C: Contractions Bra: Baseline rate V: Variability A: Accelerations D: Decelerations O: Overall impression SPOT DIAGNOSES A 25y woman who is 32 weeks pregnant with… PV bleeding Painless Placenta previa Painful Placental abruption PV discharge (gush) PPROM Abdo pain Headache Pre-eclampsia Reduced foetal movements Miscarriage/stillbirthSBAs Q U E S T I O1N A 38-year-old female has a BP of 155/103 in the third A HELLP syndrome trimester of her first pregnancy. A 24 hour urine collection shows 0.5g protein. B Foetal prematurity Which complication would indicate progression to eclampsia? C Tonic clonicseizures D Transverse myelitis E Visual disturbance ANSWER ON THE ZOOM POLL Q U E S T I O1N A 38-year-old female has a BP of 155/103 in the third A HELLP syndrome trimester of her first pregnancy. A 24 hour urine collection shows 0.5g protein. B Foetal prematurity Which complication would indicate progression to C Tonic clonicseizures eclampsia? D Transverse myelitis E Visual disturbance Q U E S T I O2N A 41 -year -old, who has recently had a positive A Aspirin 75mg daily from 12w until birth pregnancy test, comes into the GP for some advice regarding her pregnancy. This is her B Aspirin 75mg daily from now until birth second pregnancy. She has a BMI of 22 and T2DM. C Folic acid 5mg from now until birth What advice should be given? D Folic acid 400mcg from now until 12w E No supplement needed ANSWER ON THE ZOOM POLL Q U E S T I O N 2 A 41 -year -old, who has recently had a positive A Aspirin 75mg daily from 12w until birth pregnancy test, comes into the GP for some advice regarding her pregnancy. This is her B Aspirin 75mg daily from now until birth second pregnancy. She has a BMI of 22 and T2DM. C Folic acid 5mg from now until birth What advice should be given? D Folic acid 400mcg from now until 12w E No supplement needed Q U E S T I O N 3 A 28 -year -old women who is 36 weeks A Labour pregnant presents to ED, complaining of severe continuous abdo pain with a small amount of B Placental abruption bloody discharge. Examination reveals a firm, woody uterus, which is tender, HR 110bpm, BP 98/65. C Placenta previa What is the most likely diagnosis? D Vaginitis E Vasa previa ANSWER ON THE ZOOM POLL Q U E S T I O N 3 A 28 -year -old women who is 36 weeks A Labour pregnant presents to ED, complaining of severe continuous abdo pain with a small amount of B Placental abruption bloody discharge. Examination reveals a firm, woody uterus, which is tender, HR 110bpm, BP 98/65. C Placenta previa What is the most likely diagnosis? D Vaginitis E Vasa previa ANSWER ON THE ZOOM POLL Q U E S T I O N 4 A 24 -year -old who is 37w pregnant comes in A Abdominal examination complaining of painless PV bleeding, which examination/investigation should be avoided B CTG initially? C PV examination D US abdomen E Doppler ANSWER ON THE ZOOM POLL Q U E S T I O N 4 A 24 -year -old who is 37w pregnant comes in A Abdominal examination complaining of painless PV bleeding, which examination/investigation should be avoided B CTG initially? C PV examination D US abdomen E Doppler ANSWER ON THE ZOOM POLL Q U E S T I O5N Following vaginal delivery, a 23 -year -old A Retained placenta female, with no significant PMH, has lost 700ml of blood. What is the most likely cause? B Coagulation disorder C Tear D Reduced uterine tone E Thromboprophylaxis ANSWER ON THE ZOOM POLL Q U E S T I O N 5 Following vaginal delivery, a 23 -year -old A Retained placenta female, with no significant PMH, has lost 700ml of blood. What is the most likely cause? B Coagulation disorder C Tear D Reduced uterine tone E Thromboprophylaxis • Obstetric History • Abdo Examination Today’s • PV/Speculum Examination Session • Example Stations • Spot Diagnosis TOP TIPS • Before station: form a list of differentials • After station: forget the previous one • Hx: red flags • Ix: bedside, bloods, imaging, special tests • Mx: A-E, initial and ongoing, consider both mum and baby • Be confident in yourselvesou’ve done the hard work, go in and do your bestJ PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK! @OSCEazyOfficial @osceazyofficial OSCEazy Osceazy@gmail.com