Professional Documents
Culture Documents
History
OBSTETRICS - I understand that you’re here because you wanted to
discuss about home delivery. Are you pregnant at this
PRE-PREGNANCY AND PREGNANCY COUNSELING stage? When was your LMP? How did you confirm
pregnancy? How were your periods before? Did you
Unplanned Pregnancy see any doctor until now? Did you take any folic acid?
Do you have any history of hypertension, epilepsy,
Case: Jenny is 32-years-old and has attended your surgery for diabetes or asthma? Any past history of admissions?
routine checks for the past 3 years. She was last seen 6 months Do you know about your blood group? Were you ever
ago for pap smear which was normal. At the time of the last infected with Rubella? Is this is a planned pregnancy?
consultation, the BP was 130/70 and breast examination was SADMA? Social history? Do you have enough
normal. CVS and respiratory examination were normal. Jenny is support? Financial problems? Do you have other
married and has 2 sons, 10 and 8. kids? How far do you live from the hospital? FHx?
Case: A 23 years old female has recently been discharged from ANTEPARTUM AND OTHER COMPLICATIONS IN
the hospital after a procedure where the right Fallopian tube was PREGNANCY
removed because of an ectopic pregnancy. The left ovary on the
ultrasound showed the presence of corpus luteum. The patient Antenatal Care:
wants to know why it happened to her. - Do beta-hCg (quantitative or qualitative)
- Down Syndrome risk:
Task o @37: 1:200
a. Talk to the patient and explain about ectopic o @40: 1:100
pregnancy and its causes. o @45: 1:50
- Screening for down syndrome: HR: 1:200 or higher
‐ From the notes, I can see that you have recently o 1st tri: 80% predicted
undergone a procedure to remove a right ectopic 10-12 weeks: PAP-A and beta-
pregnancy. How are you feeling at the moment? How hCg;
are you coping with the loss of this pregnancy? 12-13 weeks: USG (nuchal
‐ I understand why you want to know why it happened translucency Æ aneuploidy)
to you. Do you know what ectopic pregnancy means? o 2nd tri: 60-70% predicted
Usually, the egg from the mom and the sperm from QUAD screen @14-20 weeks:
the dad meet within the tubes to form the fetus. This AFP, b-Hcg, estriol, inhibin A
fetus then travels and becomes attached to the wall of (ACEI)
the womb. Due to certain reasons, sometimes, the - May do dating usg during first visit
fetus implants within the tubes. It is then called an - Amniocentesis (0.5%)/CVS (1%): risk of miscarriage
ectopic or extra-uterine pregnancy. The size of the - Blood group
tube does not allow the fetus to grow therefore it may o If (-): repeat blood at 28 weeks; then give
rupture and leads to a lot of bleeding and other anti-D; repeat blood antibody screen at 34
complications. For you fortunately, such complications weeks (2nd injection of anti-D) Æ prevent
were prevented and the tube was removed. Please spontaneous transplacental hemorrhage
don't worry. You still have a chance of normal 2nd tri: 12-15% fetal RBCs can be
pregnancy. The risk factors for ectopic pregnancies found in maternal blood resulting
are: previous history of PID and STI (increases risk in isoimmunization
7x), previous surgeries of gynecologic nature 3rd tri: 20-30%
especially around the tubes, history of endometriosis, o Give anti-D after delivery
IUCD use, use of emergency contraception (causes - FBE: consider anemia (r/o hemoglobinopathy)
retrograde contraction of the Tubes), embryonal o Check the partner and check for trait
defects, previous history of ectopic pregnancy in the - Screen for infections: Rubella, HIV, Hepatitis,
opposite tube. hepatitis B&C, syphilis
‐ In most of the cases (97%), ectopic pregnancies are o If HbsAg (+)Æ check partner for hepatitis b
found within the tubes. Sometimes, they can be found antibody; talk about safe sexual practice
in the ovary, peritoneal cavity, and on top of the uterus o For hepatits b&c Æ refer to infectious
‐ For your next pregnancy, the chances of conception specialist
are around 50%. Please remember that even one tube - MSU for micro&culture: asymptomatic bacteriuria (or
can catch the eggs from the opposite ovary. You need in 6-8%) Æ(+) if >100,000 col/ml; tx because
to wait for at least 3-6 months before trying to increased likelihood of getting severe UTI (e.g.
conceive. Give yourself some rest and have a healthy pyelonephritis)
balanced diet. You can use OCPs but please avoid - Vitamin D levels: N: 70u; severe <20u
IUCDs, Emergency pill and POPs. - 18-22 weeks: morphology scan to check for structural
‐ When you miss your next period, please come and abnormalities
see me ASAP. We will do some tests including serial - 28 weeks: check for anemia (FBE) – physiologic
beta-hcg done starting day 5 of conception. We would anemia and GCT
like to record the quantitative increase in beta-hcg
9
- Average gestation: 40 weeks + 2 weeks; >42-43 ‐ Period questions: Do you have regular cycles? How
weeks perinatal mortality doubles; long is the cycle? How long is the bleeding time? Any
o Concern at 41-42 weeks: do fetal well-being spotting in between? Do you have excessive pain or
USD measuring umbilical artery flow (SD bleeding during the period? How did you confirm your
ratio: difference between peak systolic flow pregnancy (I did pregnancy test at home)? Good on
and end-diastolic flow), AFI and CTG you!
‐ Pregnancy symptoms: Do you feel tired, nausea?
Antenatal checkup Have you vomited? Breast tenderness? Tummy pain?
How’s your water work? Do you have regular bowel
Case: Your next patient in your GP practice is a 24-year-old function? Do you have unusual vaginal discharge or
female who is 8 weeks pregnant. You saw her last week as a bleeding?
part of her regular antenatal checks and ordered some blood ‐ What type of contraception did you use before you got
tests. Today she is here to know about the blood results. Her pregnant? Have you been diagnosed with STD?
health and pregnancy have been good so far. She is so excited When was your last PAP smear (If no for last 2years
about having a healthy baby by the end of her pregnancy. Her do it now!)? Do you know your blood group? Have you
results are as follows: had Rubella in the past or have you receive vaccine
FBE: Hgb 120, WBC 8000, Plt 170,000 for it?
UEC: Na 145, K 4.4, Cl 130 ‐ Any serious illnesses or surgeries in the past? (Heart,
LFTs: normal HTN, DM, anemia.) Is your husband generally
BSL: 4.3 healthy? Are you on any medication? Are you taking
Blood group: A-; Antibody screening test (-) folic acid? Are you allergic to anything? Smoking,
IgG (+) for Rubella and Varicella Alcohol and drugs? How many cups of coffee do you
Urine: MCS show GBS positive drink per day? What do you do for a living? When did
HBV and HCV: negative you migrate to Australia? Do you have any family
members or close friends here? Has anyone in the
Task family had twin pregnancies? Has anyone in the family
a. Explain result and advise on management had pregnancy complicated by DM, HTN, birth
defects?
Management
- Congratulate on her pregnancy Management
- Give anti-D at 28, 34 weeks and 72 hours after ‐ We need to order some routine lab tests to identify
delivery if child is Rh (+) and if there are bleeding any issue which needs to be addressed for the best
episodes outcome of your pregnancy.
- If antibody screening test positive: measure the titers o FBE exclude anemia. Hb. Iron deficiency
using ELISA (1:8 or 1:16 or 1:32 then check bilirubin ÆSupplement.
by doing o Blood group and RBC antibodies. If you are
o Amniocentesis: check bilirubin; Rh-you need anti-D immunoglobin
o Umbilical cord sampling: Hct (25%) prophylactically to prevent problem in future
o MCA ultrasound: check velocity of blood pregnancy. Repeat antibody test in
flow -- if there is hemolysis heart pumps 26weeks.
faster then velocity increases; less invasive o Rubella status if you are not immunized to
- Urine MCS: positive for GBS (asymptomatic rubella, I recommend you receive rubella
bacteriuria) -- treat with antibiotics because of risk of vaccination after delivery. (Contraindication
developing pyelonephritis during the pregnancy)
(Cefalexin/Augmentin/amoxicillin) o We will also do syphilis, Hepatitis B and C
‐ Repeat culture after 1 week and HIV screening.
‐ General advise for UTI o Vitamin D level.
‐ Check partner’s blood group o Midstream urine to check urinary tract
‐ Advise on antenatal checkup infection. Sometimes it can be
‐ Dietary advice, smoking and alcohol asymptomatic but need to be treated in
‐ Down syndrome screening Æ if older patient pregnancy. 30% of asymptomatic UTI can
become symptomatic.
First Antenatal Check Up o There’s another test which we offer in every
women in Australia. It’s a Down’s syndrome
Case: Mrs. Hasim a migrant from Sudan presents to your GP screening test. Would you like to do it?
clinic for her fist antenatal visit. 1st trimester: Pappa, beta HCG,
Ultrasound
Task 2nd trimester quad. Test(15-
a. Take History 18weeks): beta HCG, AFP,
b. Your management in pregnancy oestradiol, inhibin A
o You also need 18-20weeks mid pregnancy
She is a professional boxer for 10 years. “Can I do exercises?” ultrasound to make sure baby develops
“Can I eat sushi?” “How about weight gain?” properly and to look for position of the
placenta.
History o At 28weeks we screen for Gestational
‐ Mrs Hasim, Do you need interpreter? I understand you Diabetics: sweet drink test/glucose
have come to see me regarding pregnancy. Is it your challenge test.
first pregnancy (Yes)? Was it planned (Yes)? o At 36 weeks you will need to be advised to
Congratulations! do a low vaginal swab to check for a
‐ When was your LMP (8 weeks ago)? bacterial infection called GBS. If found you
will be given antibiotics prophylactically
during delivery.
10
‐ You need to take folic acid 0.5mg for the 1st 3 months Counseling
of pregnancy because it decreases the occurrence of - The first pregnancy is usually longer as compared to
neural tube defects. succeeding ones. However, there are some warning
‐ Moderate exercise is good for you because it signs: if you have any contractions,any passage of
improves cardiovascular and muscle strength. Best mucus or water, vagina bleeding, any reduction in
exercises are low impact aerobics, swimming, walking fetal movements, any sort of tummy pain, headache,
and yoga. No contact sport because of risk of trauma. blurry vision, cloudy urine, or other warning signs, you
‐ Weight gain should be around 11-16kg during have to come to the hospital straight away.
pregnancy. But it all depends on your pre-pregnancy - The plan for your pregnancy is to come every month
state. Your diet is important, it should be well until your28th week, then every fortnightly from 28-36
balanced. Food rich in protein, dairy food, starch food weeks and weekly after 36 weeks and until delivery.
(potatoes) and plenty of fruits and vegetables. Best At 28 weeks, we will arrange a sweet drink test and
avoid a lot of sugary, salty and fatty food. Food around 34-46 weeks, we will do the vaginal swab to
delicacies: uncooked meat, egg, soft cheese, shell fish detect the bug called GBS.
and raw fish should be avoided as they are potential - If there are no warning signs as discussed before, it is
sources of Listeria and Salmonella. advisable to either relocate close to the hospital if you
‐ No smoking, alcohol and drugs. have friends or relatives or get admitted to the hospital
‐ What about my sexual life? Sexual life is acceptable a week or so before the due date.
and normal during pregnancy just follow your normal - Will I have a long labor this time as well? With regards
desire. to your delivery, the exact duration of your labor is not
‐ Can I see a dentist? See your dentist in case any easy to predict as it depends on several factors at the
dental care is required and it can be carried out in the time of delivery such as medical conditions, size of the
first half of the pregnancy. baby, size of the pelvis, presentation of the baby, and
strength of the contractions. But usually, the duration
Timing of Admission to Hospital of labor in 2nd pregnancy is shorter compared to the
1st.
Case: your next patient in GP practice is a 24-weeks pregnant - Right now everything sounds good. I will see you in
lady who has just moved into your town. She has come to see one month time and give you a few reading materials.
you as her first GP. She lives 80km from the main hospital
Down Syndrome Screening
Task
a. Relevant history (folic acid, regular checkup, normal Case: A young woman at 10 weeks’ gestational age comes to
USD and blood tests; history of prolonged labor see you in your GP practice. She is concerned about having a
because of poor contractions; instrumental delivery) baby with Down syndrome as recently, her sister had a baby
b. Advise when she immediately needs to attend the with Down syndrome.
hospital or midwife
c. Answer her question Task
a. Counsel patient
History
- Congratulations on your pregnancy. I can see that - Is this a planned pregnancy? Congratulations.
you’re concerned about when you should go to the - I understand from the notes that you are here to
hospital for delivery. I understand that you live 80km discuss about Down syndrome screening. I appreciate
away from the hospital. Before I address your your initiative to do that. I understand your anxiety. I
concern, is it okay if I ask you some questions? will give you all the information regarding the tests
- How is your pregnancy going so far? Was it a planned which can be done and how effective they are.
pregnancy? Are you attending regular antenatal care? - How is your pregnancy going so far? Are you getting
How were the blood test results? Anything significant? your antenatal care? Are you done with your blood
Do you know your blood group? What about the 18th tests? Any concerns or issues?
week USD? Is it a single baby? Is the placenta in the - Down syndrome is one of the common genetic
normal position? Any tummy pains or trauma so far? abnormality with trisomy 21. There are some
Any discharge or bleeding so far? Any leakage of fluid indications in doing Down syndrome screening in
down below? Any headache, BOV, N/V? Any urgency, pregnant women:
frequency or smelly urine? Did you take folic acid? Is o Increased maternal age (>30)
your baby kicking well? Any previous pregnancy or o Previous down syndrome baby
miscarriage? How was it? Was it term or preterm? Do o History of down syndrome in the family
you know the reason for the prolonged labor? How - We have screening tests and confirmatory tests. In the
was the baby after delivery? Any complications? What first trimester, there is a triple test a blood test which is
was the BW? Any previous medical or surgical issues done at 9-13 weeks AOG. We check free beta-hCG
like BP, DM? Any problem with your periods? Are you Pregnancy Associated Placental Protein-A. We
on any medications? SAD combine it with Ultrasound and it is done at 11-13
- Do you have enough support? I understand you live weeks AOG. Here we check for fetal nuchal
80km away, how long does it take to go to the nearest translucency. Screening tests can also be offered in
hospital by car? Can anyone drive you to the hospital the 2nd trimester between 15 and 17 weeks. These
in case of emergency? Do you have any friend or tests are not 100% confirmatory. In high-risk
relatives who live near the hospital where you could pregnancies, we can offer diagnostic tests: CVS or
relocate a few days before the due date? Is there amniocentesis.
anyone at home who will look after your first baby
when you are in the hospital?
11
- CVS - Mechanical cervical ripening device Æmay be used
o done ideally at 9-11 (11-12 at clinical book) safely
weeks - 1/5 of patients end up having cesarean section
o results within 24 hours
o more accurate History
o 1% risk of abortion - Congratulations. Is it a planned pregnancy?
- Amniocentesis - What about first pregnancy? Was it your first? Was it a
o Done ideally at around 14-15 planned pregnancy? Did you have regular antenatal
o Longer (up to 3 weeks) and less accurate checkups? Complications of pregnancy (DM,
o 0.5% risk of abortion hypertension, bleeding)? Why was the CS performed?
- 3 regimens: Was it an emergency? Do you know the type of
o PAPPA and free hCG at 9-13 weeks cesarean section? Complications of surgery
o Nuchal thickness at 11-13 weeks (combined (infections, bleeding, DVT)? CPD (height of partner
tests raises detection rate from 70 to 90%) and patient)? How was the baby at birth? Any
o If calculated to be more than 1/200-250 Æ resuscitation needed?
woman is offered CVS if gestation between - History of previous uterine surgeries or rupture?
11 and 14 weeks or amniocentesis if at 15- - Are you taking folic acid?
16 weeks - How is your general health? Any medical condition
o Combined test: AFP, unconjugated estriol you have at this moment? Why do you want to have
and beta-hCG + Inhibin A at 15-20 weeks vaginal birth?
Æ increases detection rate from 65 to 75-
80% if inhibin A included Findings from Examiner
- If previous pregnancy was down syndrome, the risk of - Reason for cesarean section
having Down syndrome in the next pregnancy - Classical or Low-segment cesarean section
increases by 1%. - Age of gestation
- Complications: anesthetic, infection, hemorrhage,
Vaginal Birth After Cesarean Section (VBAC) damage to the adjacent organs like bladder, large
intestine etc, DVT
Case: You are a GP and a 28-years-old lady with previous - Baby: weight, apgar score, resuscitation done
cesarean section 2 years ago is in your GP clinic. She is now 7
weeks pregnant and she wants to have vaginal birth. Management
- At this stage we are not sure about the outcome of the
Task pregnancy as it depends on its progress. However, in
a. History (CS due to fetal distress, pap smear x 1 year majority of cases and in your case, successful vaginal
ago with birth can be achieved safely. The success rate ranges
b. Ask examiner for previous medical/surgical notes of from 55-85%. I will do antenatal screening tests and
the LSTCS (obstructed 2nd stage of labor hence will monitor you during your antenatal visits to look for
underwent CS, Apgar 6,8 BW 3kg, no CPD) certain conditions which can pose a risk during vaginal
c. Discuss possibility of vaginal birth to patient delivery or which can be an indication for cesarean
section. If any of these are present, you will be
Predictors of successful VBAC (55-85%): managed as a high-risk pregnancy.
- Non-recurring indication of CS (e.g. malpresentation) - I will arrange an appointment with an obstetrician at
- PIH 26 weeks for discussion about possible mode of
- Previous vaginal birth delivery and at 36 weeks for definite decision
- Institutions in which success rates is high regarding vaginal birth. The specialist will explain the
- Onset of labor is spontaneous risks and benefits of the mode of delivery to you and
the final choice will be made according to your wishes
Contraindication and advice of the obstetrician. If vaginal birth is
- Previous classic cesarean section birth decided, it will take place in a well-equipped hospital
- Some uterine surgery (hysterotomy, deep under supervision of an experienced obstetrician
myomectomy, corneal resection and metroplasty) because vaginal delivery can progress to cesarean
- Previous uterine rupture or dehiscence section in 1/5 of the cases.
- Maternal or fetal reason for elective CS in current - Folic acid prescription
pregnancy - Reading material
o Mother: PIH, Diabetes, Antepartum - Review
hemorrhage (previa/abruptio)
o Baby: Macrosomia, Multifetal gestation, Ovarian Cyst in Pregnancy
Malpresentation (breech, face, brow,
transverse lie) Case: You are HMO in ED. 25yo female 8weeks pregnant c/o
o Labor: Power, Passage, Passenger pain in the right lower abdominal pain.
Task Task
a. History a. History (had mild asthma and use ventolin PRN;
b. Physical examination sudden, fever; with wet cough; greenish or yellow; ex-
c. Diagnosis and Management smoker and partner is a smoker)
b. Physical examination (in distress; audbible wheeze,
History BP 120/80; T:38, RR26, O2 93, HR 100; RR
- I understand that you’re here for your blood results increased; increased work of breathing, retractions,
and it was found that you have iron deficiency anemia. increase vocal fremitus in right lung base; dullness on
This means that there is less oxygen delivered to the right lung base and decreased air entry on right lung
tissues. base and diffuse wheezing; FH 20cm, FHT 140,
- Do you feel tired? Is there any dizziness, palpitations uterus soft and non-tender)
or SOB? c. Diagnosis and management
- How is your pregnancy so far? Have you had regular
antenatal checkups? How are your blood tests and Differential Diagnosis
ultrasound? How about your pregnancies? Have you - Pulmonary embolism
had blood loss? When was your last pregnancy? - Asthma exacerbation
- What about your periods? Did you have abnormal - Spontaneous Pneumothorax
bleeding? What about your diet? Any bleeding - Heart failure
disorders? Are you on any special diet? Is the baby
kicking? Any other health problems? History
- Blood group? - I understand you have come to see me because of
SOB? When did it start? Did it happen suddenly or
Physical examination gradually? Do you feel SOB at rest or only on
- General examination: pallor, bruising, lethargy, exertion? Does anything make it better or worse? Is it
- Vital signs: postural drop the first episode? Do you have a fever, shivers? Do
- Lungs you have a cough? Is it dry or wet? What’s the
- Cardiac: murmur (systolic) sputum? Did you notice blood in the sputum? Do you
- Abdomen: FH (check for IUGR), abdomen soft or have chest pain or tightness? Is it worse with deep
tense, FHT inspiration? Do you feel your heart is racing? Do you
- Pelvic examination: bleeding, discharge feel nauseous? Have you been vomiting? Do you
- Urine dipstick and blood sugar have abdominal pain? Have you felt the baby kick?
23
Any Vaginal discharge or bleeding? Waterworks and b. Physical examination (vital is normal, no thyroid
bowel? Calf tenderness or swelling? enlargement, no carotid bruits, no rashes or jaundice,
- Is it your first pregnancy? How’s your pregnancy so chest normal, apex is normal, tapping, auscultation
far? Any problems with blood tests? Any problems low-pitch, rumbling diastolic murmur best heard with
with USD? Do you know your blood group? bell on the left lateral position; soft, nontender, no
- Can you please tell me more about your asthma? hepatosplenomegaly; ankle edema)
When were you diagnosed? How often do you get c. Diagnosis and management
attacks? Do you have symptoms between attacks?
Which medications are you on? Have you ever been History
admitted to the hospital with severe asthma attack? ‐ I know you have come to see me because you are
Have you ever been admitted to the ICU or ever been short of breath. When did it start? Did it happen
intubated? Do you know any precipitating factors suddenly or gradually? Do you have SOB at rest or
(smoking, cold air, exercise, dust, pollen, infection)? only during physical activity? How far can you walk
Other medical or surgical conditions in the past? Are (block)? Is it the first episode? Associated symptoms:
you on any medications? Allergies? Smoking? fever, cough, noisy breathing, chest pain or tightness?
- What do you do for a living? Any recent history of Do you notice your heart is racing or beating
travel? irregularly? Do you sleep flat? How many pillows do
- FHx of asthma you use when you go to sleep? Have you ever woken
up at night SOB? Have you noticed swelling of your
Physical examination ankles? How’s your appetite? Do you feel tired? Do
- General appearance and peripheral cyanosis; signs of you have N/V? Do you have abdominal pain? How’s
respiratory distress your waterworks? Any unusual vaginal discharge or
- Vital signs bleeding? History of travel?
- ENT ‐ I know it’s your first pregnancy, is it planned? Did you
- Chest: see any doctors regarding your pregnancy? How did
o Inspection: use of accessory muscle; chest you confirm pregnancy? Do you know your blood
expansion; group? When was your last pap smear?
o Palpation: chest expansion; vocal fremitus ‐ PMHx: Are you generally healthy? Any serious
o Percussion: dullness or hyperresonance condition or surgeries in the past? Any heart or lung
o Auscultation: air entry; disease? Can you remember what type of treatment
o Peak-flow meter did you receive? Did you have regular follow-ups?
- Heart Medications? Allergy? Smoking? Alcohol? Do you
- Abdomen: FH, FHT, uterus is soft and nontender have enough support? FHx of heart or lung problems?
Task Management
a. History - It seems like your pregnancy is advancing towards
b. Physical examination (FH 39, head just, engaged, lie postdatism. 5-10% of normal pregnancies can go
is longitudinal, FHT normal, speculum: no discharge, beyond 42 weeks something we call as postdated
bleeding or show; closed, long, posterior, no bulging pregnancy. You are still within the normal range so
of membranes) please don’t worry. However, I want you to be aware
c. Management of certain risks associated with postdated pregnancy,
for example, placental insufficiency, meconium
Definition: aspiration, fetal distress, difficult delivery with higher
- RWH: >41 weeks + 6 days risk of undergoing cesarean section.
- LJ: 40 + 2 completed weeks - What we need to do is monitor you very closely to
prevent postdated pregnancy. Starting from now, we
Risks: will do CTGs 2x a week to assess fetal distress. We
- Placental insufficiency will also do ultrasound once a week to check the
- Meconium aspiration baby’s growth (BPS). We will also check the AFI.
- Fetal asphyxia Also, I will recommend a Doppler study of the
- Difficult deliveries (problems with molding) umbilical cord to check the flow of blood to the baby.
- Increased risk of operative deliveries At the end of all these tests, you will need to see the
- Increased risk of labor induction specialist obstetrician. They might give you options
- Dystocia which include elective induction of labor with the help
- 4x increased risk of stillbirths of prostaglandin tablets that are inserted within the
- 3x increased risk of neonatal death vagina to initiate contractions. The second option
- 10x increased risk of neonatal seizures (within 1st 48 would be to continue the pregnancy but with regular
hours of life) CTGs, USD and Doppler studies. The third option is
elective CS that carries minimal risk in safe hands.
History The decision is yours. Please bring your partner for
- Is this a planned pregnancy? Congratulations! How is the next consultation so we can discuss it together.
the pregnancy so far? Can you tell me how your - Meanwhile please look out for signs of labor which
pregnancy was confirmed? Have you had regular includes bleeding, discharge, leaking of fluid,
antenatal visits? All blood tests? What were the continuous/intermittent back or tummy pain.
results? Any problems? Did you have the sweet drink
test? Was it alright? When was your last ultrasound? ABNORMAL PRESENTATIONS
What was the result? Is it a single baby? Weight? Breech Presentation
Placenta? What was the expected date of delivery on
that ultrasound? Case: You are a GP and a 25 year-old primagravida with breech
- How’s your general health? Any past history of presentation at 32 weeks’ GA came in for consultation.
diabetes, high blood pressure? Currently do you have
any symptoms of headache, blurred vision, or swelling Task
of the legs? Any bleeding or discharge from down a. History
below? Any tummy pain? backache? Is the baby b. Physical Examination (lower pole of the uterus is a
kicking alright? Have you counted how many times in soft, smooth and with a rounded mass that bounces
how many hours? Do you have kick chart with you (10 between the fingers, position of heart sound is above
in 12 hours)? the umbilicus)
- FHx of postdated deliveries? Big babies? c. Diagnosis and management
- Have you had any gynecological surgeries or
procedures (adhesions)? What is your blood group? Causes of Breech
When was your last pap smear? Have you been - Maternal
vaccinated against gardasil? SADMA? o Polyhydramnios
- Do you have enough support at home? Any o Uterine abnormalities (bicornuate, septate)
problems? How far do you live from the hospital? Is o Placental abnormalities (previa)
there anyone who can drive you in case of an o Multiparity
emergency? o Contracted maternal pelvis
o SOLs (fibroids)
Physical examination - Fetal
- General appearance o Prematurity
- Vital signs: BMI and height o Fetal anomalies (neurological,
hydrocephalus, anencephaly)
31
o Multiple pregnancy of labor the specialist will do cesarean delivery. If
o Fetal death footling, then do Cesarean delivery. We can reduce
o Short umbilical cord the risk of complications by 50% if we choose elective
cesarean section at 39th week. If you do decide to go
History on a trial with vaginal delivery, we will still do our best
- Is it a planned pregnancy? Congratulations on your to monitor you and your baby by doing regular CTG
pregnancy. How is the pregnancy so far? Are you and USD. It will be done in a tertiary hospital in the
regular with your antenatal checkups? How were your care of an experienced obstetrician.
tests? Ultrasound? Was it a single baby? What was - Is it a serious condition? Not really, but it makes
the position of the placenta? Amniotic fluid? Sweet NSVD difficult but not impossible. However, you are
drink test? Blood group? Have you taken folic acid? still at 32 weeks and there is a high chance that your
- Is the baby kicking normally? Are you maintaining a baby will still change its presentation
kick chart? Do you have any headache, dizziness, - Reading material. Referral.
BOV or leg swelling? Do you go to washroom quite - Red Flags: bleeding, tummy pain, blurring of vision
often? Do you drink a lot of water? Does your tummy
feel more distended than usual? Any vaginal bleeding, Transverse lie in Multigravida
discharge, tummy pain?
- How are your periods before? Were they very heavy? Case: You are an HMO working at a district hospital and a 38-
Were the cycles regular? Were you ever been weeks multigravida who lives 80 km from the tertiary hospital
diagnosed with fibroids or any other abnormality? was found that the baby had a transverse lie.
Risk of Induction of labor Case: You are a GP and a 30-weeks pregnant primigravida
- Fetal Distress came to you asking about pain relief in labor.
- Postpartum hemorrhage
- High risk of operative delivery Task
- Uterine rupture a. Counsel accordingly
Task Task
a. Take any further relevant history you require. a. History (6pads fully soaked with clots. Slight lower
b. Ask the examiner about relevant findings likely to be abdominal pain. Full term vaginal delivery no
evident on general and obstetric examination complications. No fibroids. Skin delicate and easily
c. Advise the patient of the diagnosis and subsequent bruised. No breast tenderness, no swelling or legs or
management during and after delivery. discoloration.)
b. Physical Examination findings (GA: Well. A bit pale,
History V/S: BP: low but within normal range. Tachycardia,
‐ When your water break? Was it green in color? How Neck is normal., Abdominal examination: No rigidity
long have you been in labor/When did the contraction but mild tenderness in the lower abdomen, Uterus 14
start? How often is your contraction? How long does it weeks in size, Pelvic examination: No laceration, no
last? Do you feel movements of the baby? Is your due hematoma, Per speculum: Bleeding (+), OS: 2cm,
date a week ago? Is that correct? I know your Bimanual examination: No cervical excitation, 2
pregnancy has been uneventful, any problems with fingers above the public symphysis)
blood tests, midpregnancy USD, or GBS swab? Do c. Investigations
you know your blood group? I know you’re a bit d. Diagnosis and Differential Diagnosis
overdue, have you had an USD and CTG last week? e. Management
‐ Are you generally healthy?
Differential Diagnosis
Physical Examination - Retained placenta
‐ General appearance - Bleeding disorder
‐ Vital signs every 2 hours - Endometritis
‐ Abdomen: FH, fetal lie and presentation, uterine - DIC
contractions, - Trauma
‐ Pelvic examination: cervix, effacement, dilatation,
presence of membranes, presence of cord loop,
station, position of fetal head, signs of caput/moulding History:
- Is my patient is hemodynamically stable? If no:
Diagnosis and Management DRABC
‐ The baby has passed meconium which is the baby’s - Bleeding questions: When did it start? How much?
first stool. That is why your water looks green. It is How many pads are you changing? Are they
common and often normal in post-term labor. completely soaked? Are there clots? Any smell? Is it
However, it can also be an indirect sign of fetal bright red or dark bleeding? Any bleeding from
anywhere else in the body? (DIC) Do you have any
37
fever? N/V? tummy pain? Any dizziness? SOB? Chest Postpartum Pyrexia
pain? Any vaginal discharge? How about your water
work? Dysuria? Frequency? How’s the baby? How are Case: You are a GP and a 29-year-old female had a normal
you coping? vaginal delivery 3 weeks ago. She had a baby boy who is
- Pregnancy Questions: Was the pregnancy normal? healthy and doing well. Patient is complaining of fever and
Any complications during pregnancy? Is this your first shivering.
baby? Was it a normal full term vaginal delivery? How
long was the labour? Was it a normal or complicated Task
labour? Any PROM? Did you have episiotomy? Were a. History (fever since 2 days ago, decreased appetite,
there any instrumental or other assistant method used breastfeeding, NSVD, abdominal pain (+),
during delivery? Was the 3rd stage of labour b. PE: pulse: 106, T: 38.6; mild tenderness over lower
complete? Was the placenta completely removed? umbilicus, uterus involuted, no mass or tenderness;
Was there any complication after delivery? Were you dipstick and BSL N; pelvic: no clots, discharge,
discharged from the hospital early? Any bleeding or episiotomy scar healing, no mass and tenderness;
clotting problem? Were you on any medications? Do fissured nipple, cracked and inflamed
you have any chronic condition? SADMA? c. Management
HISTORY
o Atonic uterus (insufficient contraction Æ
shortening and kinking of the uterine blood
vessels and prevent further blood loss)
Pre-existing Acquired o Retained placental fragments Æ prevent
placental site retraction
o Laceration of genital tract
Refer to o Uterine rupture
Non-organic Organic
psycho-sexual ‐ Secondary: bleeding of more than 500 ml after 24
therapist hours
o Retained products of conception (placenta)
Episiotomy Vaginal o Birth trauma
Scar Issues dryness o Uterine infections (endometritis)
History
‐ What are the vitals (85/50, 130)? Is she
OB referral Lubricant hemodynamically stable? Can you please secure IV
lines, take blood for grouping and crossmatching, and
start IV fluids. Is she on a urinary catheter? If not, can
you please insert a catheter?
40
‐ Is she conscious (Yes)? Is she having SOB (yes)? Physical Examination
Can you please give her oxygen. What was the mode ‐ General appearance
of delivery (instrumental delivery with forceps)? Was it ‐ Vital signs
a single baby or multiple? Any genital tear? Was ‐ Abdomen: distention, uterus, masses, organomegaly
episiotomy done? What is the weight of the baby and ‐ Pelvic: episiotomy wound, check site of bleeding
how is the condition? Is the uterus lax or contracted whether from wound, cervix or uterus, discharge;
(lax)? Have you checked the placenta? Do you think lacerations, od open; uterus; adnexal masses
there are retained products? Is the blood clotting? Is ‐ Urine dipstick and BSL
the patient bleeding from anywhere else (No)?
Diagnosis and Management
On arrival: ‐ From the history and examination, you are suffering
‐ Check vitals, IV lines and catheter from a condition called secondary postpartum
‐ Start syntometrin (Oxytocin + Ergometrine) hemorrhage which is bleeding after 24 hours of labor.
o Ergometrin contraindication: heart disease There could be a number of reasons for that but most
and hypertension likely, in your case, it is because of a small piece of
‐ Massage uterine fundus placenta which has been retained in your womb.
‐ Check placenta ‐ At this stage, I will admit you, secure IV lines take
‐ Do speculum examination to check for lacerations blood for FBE, coagulation profile, grouping and
‐ Call registrar crossmatching and start IV fluids. I will take some
swabs from your vaginal area for any infections.
Management ‐ I will call the OB registrar and arrange an USD. If the
‐ I have called the registrar and they will take you to the ultrasound confirms retained placenta, the specialist
theater to examine the uterus under anesthesia to will do curettage. I will also start you on antibiotics
check for any retained placental fragments. They can because the uterus might have been infected
do bimanual compression of the uterus. If it doesn’t (ampicillin + gentamycin + metronidazole).
work, they will give you intrauterine prostaglandins to
promote contraction. If unsuccessful, they will go for
internal iliac artery ligation.
‐ If all measures fail, the last resort would be
hysterectomy. However, we will do our best to prevent
this as this is only your first pregnancy.
Task
a. History (started 10 hours ago, soaked 7-8 pads,
NSVD, BS 3.2 kg, epistiotomy +, pain in stomach +,
NSVD, full term, not a difficult labor)
b. Physical examination (pale, SOB, increased HR,
fever, tachypneic, postural drop, + tender uterus, +
bleeding, scar okay, no laceration)
c. Management
History
‐ Is my patient hemodynamically stable? When did it
start? How many pads have you used since then? Is
the pad fully soaked? Have you passed any clots or
tissues? Are you bleeding from anywhere else like
nose, gums, urine? Do you have SOB, palpitations or
dizziness? Do you think you have fever? Any other
vaginal discharge? Any tummy pains? How was the
delivery? Was the baby term? Was it a long or difficult
labor? Did they use forceps? Did they give you a cut
during delivery? What was the weight and size of the
baby? Have you established breastfeeding? Any
problems with breastfeeding? Any problems with
waterworks? Are you aware of your blood group and
your baby’s blood group? Any pain in your legs?
‐ Any other significant past medical history? do you
have any FHx of bleeding problems?
41
Investigations:
GYNECOLOGY ‐ FSH, LH, prolactin, estradiol
‐ Chromosome analysis
DISORDERS OF MENSTRUATION ‐ Pelvic ultrasound
Physical examination
- General appearance: BMI, hirsutism, acne
- VS
42
- ENT: visual fields; palpate thyroid; do breast - Sometimes it’s not possible to see inside the uterus
examination including nipple discharge immediately, so contrast and xray study might be used
- Abdomen: to find the uterine cavity and define all the scar
- Pelvic exam: tissues.
o inspection and speculum: atrophic vaginitis - After procedure, gynecologist will prescribe estrogen
o size of uterus; palpate adnexa for masses to increase the repair of the inner lining.
and tenderness - As any surgical procedure, hysteroscopy carries some
- DO pregnancy test: I understand that the likelihood of risks. Complications are uncommon but it includes
my patient being pregnant is low but pregnancy must anesthesia risk, infection, bleeding. Rarely,
always be included. perforation.
- It is effective treatment and most likely you can get
Investigations: pregnant again. Success depends on the extent of the
- FBE, U&E, LFTs disease and how difficult is the treatment.
- FSH, LH, estradiol, prolactin, TSH
- Pelvic USD Secondary Amenorrhea (Premature Ovarian Failure)
- BSL
- Bone density scan Case: 30-year-old presenting because she hasn’t had a period
- CT/MRI if suspecting pituitary tumors for about 1 year.
Management: Task:
- Kathy according to you history and PE, you most likely a. History
have secondary amenorrhea due to excessive Physical examination
exercise? We will still run investigations to exclude b. Investigations
other causes like problems with the thyroid gland, c. Diagnosis
ovaries, and pituitary glands. d. Management
- Decrease amount of exercise to moderate and your
periods will come back to normal History: same as 1st 2 cases. Ask for differentials!!
- Other options include OCP or HRT to prevent - PMHx: autoimmune disease (SLE, DM, RA etc..)
osteoporosis thinning of your bones - Chemoradiotherapy or previous surgery
- Increase calcium in diet or we can consider ca/vit D - Drugs (especially cytotoxic)
supplementation - FHx: 10% of POF run in family
Case: Your next patient in your GP practice is a 52-year-old lady Endometrial CA – 5th most common cancer in women in
who complains of bleeding PV. She initially noticed brownish Australia. Px complains of vaginal bleeding or irregular
staining of her underpants a week ago and came to get a postmenopausal bleeding; (+) hx of anovulatory cycles or
checkup. abnormal endometrial cells on pap; tx: surgical removal (Total
hysterectomy Æ bilateral salpingo-oophorectomy Æ bilateral
Investigations ordered: pelvic and para-aortic LAD Æ peritoneal cytology) and staging
- bHcG – normal during surgery; good prognosis if diagnosis is made early;
- FBE – Hb 12m/L, wbc 8500 consider RT for deeply invasive tumor
- Abdominal USG
o Normal uterus, tubes and ovaries DYSMENORRHEA AND ABDOMINAL PAIN
o Endometrium 12 mm thick (4-8mm)
Dysmenorrhea
Problem list:
- Hemodynamic stability Case: Mary is 14 years old presents to your GP clinic while her
- History to r/o differential diagnosis mother is outside in the waiting room. You know her for 6 years.
o Hormones – estrogen content of HRT She complained of severe central lower abdominal pain with her
o Vaginal /uterine atrophy periods for the past few menstrual cycles. The pain gradually
o Uterine cervical polyps begins on day one of her menses and becomes very severe
o Endometrial hyperplasia within a few hours. She gests nauseated and sometimes vomits
o Cancer (uterus, cervix, vagina) and sometimes she feels a nagging ache at the top of her thighs
47
when she gets the abdominal pain. Paracetamol does not - Medication
relieve the pain. Yesterday her mom gave her strong analgesia o ASA or PCM
with codeine (endone) which relieved the pain but she slept for o Prostaglandin inhibitors (Mefenamic acid)
the remainder of the day. Mary’s menarche was at 13 years of o NSAIDS (Naproxen or ibuprofen) Æ start 1
age. Her cycles were irregular for the first 6 months but now are day before the period then continue for the
regular every 28 days lasting about 7 days. She is otherwise next couple of days
well. Her mother suggested Mary to see you because she is o Thiamine 100mg
concerned that the severity of pain might indicate that there is o Low-dose OCP
something serious with Mary. - Initially during first 1 or 2 years of period, you don’t
produce eggs and therefore you don’t experience
Task pain. However, when eggs become produced,
a. History (menses started yesterday, 1 pad/day, every chemicals (prostaglandin) are released which increase
28 days, sexually active and uses condoms, not on the contraction of the uterus (womb) producing pain.
OCPs)
b. Physical examination Secondary dysmenorrhea: menstrual pain for which an organic
c. Investigation cause can be found; begins after menarche, after years of pain-
d. Diagnosis and management free menses; >30 years of age; begins 3-4 days before menses
and becomes more severe during menstruation. May have
- Ensure CONFIDENTIALITY at all times!!!!!! intermenstrual pain, dyspareunia, etc.
- Consent: - Causes:
o legal age: 18 y.o o PID
o sexual activity: 16 y.o. o Endometriosis
o mature minor: >12 y.o. o IUCD
- Scale PAIN! o Submucous myoma
- Sexual history: are you sexually active? How long o Intrauterine polyp
have you been active? Are you in a stable o Pelvic adhesions
relationship? How long? How many sexual partners
have you had? Do you practice safe sex? Investigations
- SADMA? - FBE
- Other bleeding problems - MSU
- Pregnancy test
Dysmenorrhea Differential diagnosis: - USD
- Hysteroscopy, D&C, HSSG
Primary dysmenorrhea
- Menstrual pain associated with ovular cycles without Mittelschmerz
any pathologic findings; usually commences within 1-2
years after menarche and becomes more severe with Case: You are an HMO in ED and a 14-year-old girl comes
time up to about 20 years. complaining of severe lower abdominal pain.
- 50% of women and up to 95% of adolescents
- Features: Task
o Low midline abdominal pain a. History (severe right lower quadrant pain, 7/10, for 2
o Pain radiates to back or thighs hours, 3rd time for 2 months relieved by panadeine
o Varies from a dull dragging to a severe forte, 2nd episode went to hospital, workup done was
cramping pain normal, can’t remember what doctor said, and
o Maximum pain at beginning of the period discharged after being pain-free, periods regular 28-
o May commence up to 12 hours before the 30 days, not sexually active, FHx of DM and MI; LMP
menses appear 2weeks
o Usually lasts 24 hours but may persist for 2- b. Physical examination (BMI 17, mild tenderness of
3 days deep palpation on RIF, hymen intact)
o May be associated with nausea and c. Investigation if relevant
vomiting, headache, syncope or flushing d. Diagnosis and management
o No abnormal findings on examination
- Investigations: Features
o MSU - Rupture of Graafian follicle Æ small amount of blood
- Risk factors: mixed with follicular fluid released into pouch of
o Obesity Douglas Æ peritonism
o Smoking - Features: onset of pain in mid-cycle, deep pain in one
o Early age at menarche or other iliac foosa (RIF>LIF), often described as
o Longer periods “horse-kick pain”; tends to move centrally; heavy
o Alcohol feeling in pelvis; relieved by sitting or supporting lower
o Lack of exercise abdomen; lasts for fe minutes to hours
o Anxiety, stress, depression - Patient otherwise well
- Management: - Sometimes can mimic acute appendicitis
o Lifestyle modification - Management
o Avoid smoking/alcohol o Explain and reassurance
o Relaxation techniques (yoga) o Simple analgesics
o Avoid exposure to extreme cold o Hot water bottle
o Place a water bottle over the painful area
48
Differential Diagnosis - Usually pain appears suddenly in the middle of the
- Ectopic pregnancy cycle and subsides within hours. It is not harmful and
- PID doesn’t signify presence of disease.
- Ruptured ovarian cyst - You need to have rest. Drink plenty of fluids. Take
- Ovarian torsion panadol or ibuprofen or Panadeine or Panadeine
- Mittelschmerz forte. You can use local heat applications or warm
- UTI baths.
- Acute appendicitis - If pain is severe and doesn’t respond to simple
painkillers, your doctor might consider OCP to block
History ovulation.
- Is my patient hemodynamically stable? I understand
you came to the ED because of abdominal pain. PREMENSTRUAL SYNDROME
When did it start? Can you show me with one finger
where is the pain? Has it always been there or did it Premenstrual Syndrome (PMS)
start somewhere else? Can you describe the type of
pain? Does the pain travel anywhere else? Can you Case: Nancy aged 32 years visit your surgery and tell you that
recall any precipitating factors? How bad is the pain she frequently feels irritable, tearful and bloated before her
on a scale of 1-10? Does anything make it better or periods every month. This has been going on for last couple of
worse? Is it the first episode? What happened last years. Her menses are regular lasting for about one week and
time? Do you remember any investigation result and symptoms completely resolve within 1-2 days of onset. Her
what doctor said? Are there associated symptoms like menses occur every month and she considers they are not
fever, nausea or vomiting? How’s your waterworks? painful and are not heavy. She has no bleeding in between her
Any stinging or burning sensation? Has the color of menses or after intercourse. She is a school teacher and lives
urine changed? How are your bowel movements? with her husband at home. She had two children aged four and
When was the last time you opened your bowels? six years of age.
- When was your LMP? How long is your cycle? How
long is the bleeding? When was your first period? Any Task
excessive pain or bleeding during the periods? Are a. History
you sexually active? b. Physical examination
- How’s your general health? Any surgeries in the past? c. Diagnosis and further advice
SADMA?
- Whom do you live with at home? Any problems at Predisposing factors:
home or in school? ‐ Mental illness
- FHx ‐ Alcoholism
‐ Sexual abuse
Physical Examination ‐ Family history
- General appearance ‐ Stress
- Vital signs and growth chart
- Abdomen: Precipitating factors
o Inspection ‐ Cessation of OCP
o Palpation: guarding, rigidity, rebound ‐ Tubal ligation
tenderness, tenderness at McBurney point, ‐ Hysterectomy
Rovsing sign, Psoas sign (pain on extension
of hip), obturator sign (pain on internal Sustaining factors
rotation of hip) ‐ Diet – containing caffeine, alcohol, sugar
o Auscultation ‐ Smoking
- Urine dipstick ‐ Stress
‐ Sedentary lifestyle
Investigation: Transbadominal USD + Doppler (helps exclude
torsion) Differential diagnosis
‐ Psychologic: Depression
Diagnosis and Management ‐ Thyroid disorders
- According to your history and PE, most likely you have ‐ PCOS
a condition called mitteschmerz syndrome. Have you ‐ Mastalgia
ever heard about it? The word means “middle pain” ‐ Menopause syndrome
because this pain is typically felt during the middle of
the menstrual cycle. This pain coincides with History
ovulation. It’s a very common condition. As many as 1 ‐ Rule out anxiety and depression question
in 5 women experience mittelschmerz pain. Some ‐ Home situation
every cycle, some intermittently. It is more common in ‐ Ask about psychologic symptoms: Insomnia,
young women under 30. There are a number of Moodiness, Irritability, Anxiety, Tension, Depression,
theories why women experience this pain. Confusion, Food cravings
o The ovaries have no opening. At ovulation, ‐ Physical symptoms: headache, dizziness, hot flushes,
the eggs break through the ovary wall and breast swelling and tenderness, abdominal
causes pain. bloatedness, constipation
o At time of ovulation, blood is released from
ruptured egg follicles and may cause Management: Diary/CBT/Lifestyle modification/Relaxation Æ
irritation of the abdominal lining. antidepressants
o There is also contraction of fallopian tubes
and some other contributory factors leading
to spasm and pain
49
‐ Diary: write her symptoms for at least 2-3 months
period.
‐ CBT o You must note the temperature on a chart to
‐ Lifestyle modification (exercise, diet) compare changes from day-to-day. Avoid
‐ Relaxation sexual contact from the first day of period up
‐ Medication to 72 hours after rise in temperature
o Nil or negative: evening primrose oil, gingko o 99% effective if done correctly and
biloba, progesterone, OCP, bromocriptine consistently;
o Weak: magnesium, calcium, vitamin E, vitex o Benefits: no side effects
angus o Limitations: tedious and should be
o Moderate: pyridoxine vitamin b6 (mild- motivated; unsuitable if woman has fever or
moderate), st. john’s wort, spironolactone other health condition; period of abstinence
o Strong (for PMDD): SSRI and clomipramine, of longer
GnRH agonists, danazol ‐ Calendar/Rhythm Method:
‐ PMDD: fluoxetine 20mg mane for 10-14 days before o Monitor 6 (at least 12) cycles and select the
anticipated onset of menstruation or sertraline 50 mg shortest and longest cycle.
daily o Shortest Cycle (– 21) and Longest cycle
(10)
Pre-menstrual Dysphoric Disorder 14-6 = 8 (Sperm viable for 6 days)
14+2 = 18 (Egg viable for 2 days)
PMDD Criteria: (A) Symptoms must occur during the week o Avoid sexual contact on the unsafe days.
before menses and remit a few days after onset of menses; five o 95% effective if used correctly
of the following symptoms must be present with at least one o Benefits: No side effects, no cost, and do
being 1-4 and should be symptom free for one week: not require any special device
‐ Depressed mood or dysphoria o Limitations: must monitor length of
‐ Anxiety or tension menstrual cycle for 6 months;
‐ Affective lability ‐ Billings Ovulation Method
‐ Irritability o Based on careful observation of the nature
‐ Decreased interest in usual activities of mucus so that ovulation can be
‐ Concentration difficulties recognized
‐ Marked lack of energy o Fertile mucus is wet, clear, stringy and
‐ Marked change in appetite, overeating or food increased in amount and feels lubricated
cravings due to estrogen
‐ Hypersomnia o Last day of this type of mucus is peak
‐ Feeling overwhelmed mucus day which is followed by abrupt
‐ Other physical symptoms change of thick mucus associated with
‐ B. Symptoms must interfere with work, school, usual secretion of progesterone
activities or relationship o Infertile phase: 4 days after peak mucus day
‐ C. Symptoms must not merely b an exacerbation of o Intercourse is avoided from the first
another disorder awareness of increased clearer wet mucus
‐ D. Criteria A, B and C must be confirmed by until 4 days after maximum mucus
prospective daily ratings for at least 2 cycles secretion.
o Most effective method if done correctly;
CONCEPTION CONTROL failure rate is 1-2/100 women-years
o Failure: women are only able to detect 3-
Natural methods of contraception 4days of wetness prior to the peak moisture
day and still have sex 4-6 days prior to
Case: A 19-year-old females comes to your GP clinic to consult ovulation when sperm survival is still
about contraception as she is now going to start sexual relations possible
with her boyfriend. She is not interested in barrier methods or ‐ Coitus interruptus: male withdrawal before ejaculation;
hormonal contraceptives and wants to know about natural least effective
contraception. ‐ NOT EFFECTIVE AGAINST SEXUALLY
TRANSMITTED INFECTIONS
Task
a. Focused history : 5Ps (gardasil vaccination) and Counseling about OCP
general health
b. Explain methods Case: 14-year-old girl who seems to be mature for her age
came to you for contraceptive advice. She is your regular
Natural: They require regular periods and high motivation. patient, is generally healthy. She has been with her 15-year-old
These methods will help determine when to avoid intercourse boyfriend 6 months now, and wants to discuss the OCP with
during your cycle, meaning your safe and unsafe periods. you.
‐ Bibasal temperature: relies on measurement of your
body temperature Task:
o Check temperature every morning before a. take a further history required
getting out of bed or any activities. b. ask for relevant findings
Temperature rises slightly during ovulation. c. discuss OCP with the patient
o 0.2-0.5C increase in temperature indicates
ovulation Æ avoid sexual contact for up to
72 hours after the change in temperature
50
Problem list: - It also depends on the type of progesterone.
a. confidentiality and consent - At this stage, I would recommend for you to continue
b. social/ethical aspect (boyfriend’s age) for 4-6 months and if it does not stop after that, then
c. 14-year-old minor – Gillick’s test we might consider changing your OCP dose to a
d. Discuss OCP – r/o contraindications; usage higher estrogen-containing pill or different
instructions and adverse effect progesterone.
- Review and Reading materials.
HEADS (psych history) - Red flags: severe bleeding, nausea/vomting, etc…
Home situation
Education/employment Indications for high-dose estrogen OCPs
Activity/alcohol - Uncontrolled menorraghia
Depression/drugs - Taking other enzyme inducing (p450) drugs such as
Suicidality/smoking anti-epileptics
- Low dose pill failure
Management
- Partner's age: >2 years age difference is not On OCP wants to change to HRT
acceptable;
- Gillick's test: if you are able to show me that you're A 45-year-old lady came to your GP clinic and she is on OCP.
able to understand what you are saying, and at the She wants to change to HRT because she has heard about it
end of the conversion you are able to understand what from her friends.
I said, then I can give you the script. (how are you
going to use the OCP? What will you do if you missed *48-year-old px with irregular periods and husband had
the pill?) vasectomy;
- Will not protect against STIs.
- Advise on 7 days row. Use other contraceptive *53-year-old with amenorrhea for last 2 days (years)/with history
methods for the first 7 days. If you missed the pill or of breast cancer.
have had any nausea, vomiting, diarrhea then use
barrier method Task
- Reading materials a. History
- Review again for 3 months b. Management
c. Answer her questions
Breakthrough Bleeding with OCPs
History:
Case: Your next patient in GP practice is a 22-year-old female ‐ 5Ps:
who started using Microgynon 30 because she wants to start ‐ Vasomotor symptoms: hot flushes? Night sweats?
sexual relationship with her partner in the near future. She has Palpitations? Lightheadedness/dizziness? Migraine?
had some per vagina spotting over the last 4 weeks and is ‐ Urogenital: dyspareunia? UTI? Vaginal dryness?
concerned. Decline in libido? Bladder dysfunction (dysuria)?
Stress incontinence/prolapse?
Task: ‐ Psychogenic: irritability, depression, anxiety/tension,
a. History (spotting x 2-3 for 4 weeks) fearfulness, loss of concentration, tearfulness, loss of
b. Diagnosis concentration, poor short term memory, unloved
c. Management feelings, mood changes, loss of self-confidence
‐ Frequent headaches? Migraine? FHx: CVS, cancers,
History osteoporosis? Breast lumps? History of heart
- Could you talk more about it? Do you take the pills at disease? Hypertension? Unusual bleeding? Pills? Any
a regular time? Have you skipped or missed a pill? weight gain? Nausea/vomiting?
Smoking? STDs? Are you taking any other ‐ SADMA: smoking? Medications: steroids?
medications (anti-epileptics/antibiotics)? Recent ‐ FHx: Premature menopause
diarrhea or vomiting?
- Any chance you could be pregnant? Partner? Pap ‐ Contraindications of HRT:
smear? o Estrogen-dependent tumor (endometrial,
breast cancer)
Factors for breakthrough bleeding: o Recurrent thromboembolism
- Not taking pills at the same time (decreases efficacy) o Acute IHD (absolute)/history of CHD
- Missed pill (relative)
- Smoking o Uncontrolled hypertension
- Medications o Active liver disease
- AGE o Pregnancy
o Undiagnosed vaginal bleeding
Management o Otosclerosis? Intermittent porphyria
- What you have is a case of breakthrough bleeding
which occurs in between periods. It could be a light Investigations: FBE, LFTs, BSL, Lipid profile, U/C/E, TFTs,
spotting in your case or a heavy bleeding. It is a Estrogen/FSH/LH
common side effect of OCPs.
- There are several reasons why breakthrough bleeding Management:
can happen: if not taking pills at the same time (15 ‐ From the history, you are not a candidate for HRT.
minutes), should not skip pills, smoking, medication or However, I would like to request for some medications
STDs, or AGE. For some women, the low-dose pill to check if you’re already reaching menopause. HRT
does not contain enough estrogen to maintain the is not a contraceptive method. Both HRT and OCPs
stability of the endometrium (lining of the uterus) do not prevent STIs.
which causes breakthrough bleeding.
51
‐ Menopause is a natural phenomenon. One of the Physical examination
things I am concerned about menopause is ‐ General appearance and BMI
osteoporosis and heart disease. It is advisable to ‐ Vital signs
change lifestyle: maintain healthy weight, adequate ‐ Dysmorphic features of cushing syndrome, PCOS
relaxation and exercise, do pelvic floor exercises ‐ Palpate thyroid
regularly, reduced smoking, caffeine, alcohol intake, ‐ Auscultate chest and heart
increased exposure to sunlight. ‐ Abdomen to palpate renal or suprarenal mass and
‐ Some other methods of contraception: barrier, IUCD, listen to bruit
implanon, injectables, etc… during next consultation ‐ Pelvic exam:
o Inspection: discharge, bleeding
Additional information: o Bimanaual exam: position and size of
‐ Ways to know: organize LH and FSH (30-40) Æ most uterus, tenderness, cervical excitation
likely menopausal; if FSH and LH are that high Æ ‐ Urine dipstick, pregnancy test and BSL
stop OCP and get symptoms Æ HRT; require regular
follow up. Management
‐ 45 Æ too early; but requires support; usually high ‐ From the history and examination, the most important
dose HRT given; finding is that of a high blood pressure. Have you ever
had your blood pressure checked before? Usually, at
OCP-Induced Hypertension your age, having a high blood pressure can be due to
a number of causes. Most likely, it can be related to
Case: You are a GP and a 26-year-old female comes to your the use of the pill as the headaches that you have
clinic asking about the chances of becoming pregnant within the started along with the use of the pill. I still need to rule
next 6 months out other causes of hypertension such as smoking,
any problems with the blood supply to the kidneys,
Case Before: Patient coming to you who is a heavy smoker and certain growths in the adrenal gland related to the
has hypertension. She is on OCP. kidney, cardiac problems, and the like. I would do
some investigations like FBE, U&E, Urine MCS, ECG,
Task uric acid level, lipid profile, LFTs, TFTs, blood group,
a. History (regular 2-3 days, 28 days, on the pill, pap rubella antibody, infection screening.
smear n, no previous pregnancies/miscarriages, non- ‐ We still need to check your BP during the next visit.
smoker, social drinker, mom with DM) However, I want you to please stop using the pill.
b. Physical examination: BP 155/95, Around 2% of females, especially those who have
c. Diagnosis and management family history of high BP, those who are overweight,
>35 years old, and smokers can develop high blood
History pressure due to OCPs. Some women get high BP
‐ I can see from the notes you wish to become pregnant from the progesterone component of the pill. Usually,
in the near future. Congratulations on your decision. this rise in blood pressure is only seen with the
‐ Please tell me more about your periods? Are they systolic component. The good news is that it is
regular? How many days of bleeding? How many completely reversible. However, you need to stop
days apart? Are your periods heavy? Are they painful? smoking and adopt a healthy lifestyle to reduce this
Any spotting in between? risk to minimum. Meanwhile, you may use another
‐ I understand you’re sexually active, since when? What form of contraception, probably condoms. Becoming
form of contraception do you use? What type of pill pregnant at this stage might further complicate your
are you on? Since when? Have you had any side condition, so my advice is once the results are back
effects from the pill (nausea, weight gain, and your BP is normalized, you can plan for the
intermenstrual spotting)? Have you or your partner pregnancy. I would like to see you in one week’s time
ever been diagnosed with a STI? At the moment, do with the results of the tests. Please come back if you
you suffer from any vaginal discharge? Any bleeding develop further headaches, visual problems, fainting
or itchiness down below? Have you ever had pelvic or dizziness.
infections before? Have you had any
pregnancy/miscarriages/gynecological surgeries Post-pill amenorrhea??
before?
‐ When was your last pap smear? What was the result? Case: Your next patient in GP practice is a 30-year-old woman.
Have you had gardasil? She did not have periods for the last 2 months. She is on
‐ PMHx: diabetes, hypertension, kidney disease, MIcrogynon 30.
infections, liver? History of clotting problems in you or
your family? Task
‐ SADMA? a. History (on the pill, periods stopped GRADUALLY,
‐ How’s your appetite/sleep? Any recent history of b. Physical examination
fever, cough, diarrhea, tummy pain? How do you c. Diagnosis
consider your weight to be? Do you know your blood d. Management
group?
‐ Any FHx of fertility problems? Pregnancy related Secondary Amenorrhea
problems? Diabetes? High blood pressure? ‐ Pregnancy (breast tenderness, spotting, early morning
‐ Headache: how frequent, since when? Have you N/V)
noticed any association with particular food or time of ‐ PCOS (weight gain, acne, hirsutism, irregular periods)
day? What do you take to relieve pain? Any ‐ Hypthyroidism (weather preference, puffy face,
associated N/V/abnormal sensations/visual edema, mood)
disturbance? ‐ Eating disorder/exercise induced
‐ Hyperprolactinemia (breast discharge, medications,
headache, nausea and vomiting
52
‐ Asherman syndrome (gynecological procedures/D&C) History
‐ Stress - Can you please tell me, what is your main concern?
‐ Premature ovarian symptoms Do you think your daughter has started her periods?
‐ Post-Pill Amenorrhea Did you notice any breast development? Since when?
Have you noticed any hair growths in the armpits over
History the pubic area? Since when? I understand she is on
‐ I understand you have not had your menses for the phenytoin/carbamazepine? Any side effects? Who
last 2 months. Any chance you might be pregnant? takes care of her medications? Since when did she
What’s your LMP? Do you have symptoms like breast last see her neurologist.
pain, N/V, spotting? - Please tell me more about her mental retardation.
‐ Pills: any problems with that? Do you think you might Was she born this way? How would you describe her
have missed your pill anytime? Are you taking it mental age to be? Is she able to do daily life activities
regularly? Did you have any diarrhea or vomiting? Are like eating, dressing, and going to the toilet? Does she
you on any other medications? need partial or complete supervision? Who takes care
‐ Review of systems: hirsutism of her most of the time? Do you experience any
‐ Partner? Pap? Gardasil vaccination? difficulties while taking care of your daughter? How is
‐ Any previous pregnancies? her school performance? Any problems at school? Is it
‐ Any Family history of premature ovarian failure or a special school? Do you think she might already be
cancers? sexually active? Have you discussed anything with her
‐ SADMA? PMHX like Periods? Contraception? Previous medical or
surgical illnesses? Any concerns about her growth?
Physical Examination Do you have enough support at home, from family
‐ General appearance friends and partner? Financial problem?
‐ Vital signs and BMI
‐ Visible hirsutism, acne, puffy face or edema Counseling
‐ Vision: visual fields, funduscopy, visual acuity - I understand from the history that your daughter has
‐ Neck: thyroid enlargement not had her periods up till now. However, some
‐ Breast examination: nipple discharge degree of breast development has occurred so we
‐ Abdomen: masses, tenderness might expect that she will start menstruating soon. It is
‐ Pelvic exam: very good that you have come at this time to discuss
o Inspection: discharge, atrophic vagina contraception. However, no form of contraception is
o Speculum: cervical os, bleeding required until periods start. Usually, we recommend
o Bimanual: size of uterus, adnexal masses, oral contraceptives that might be most suitable for her.
CMT Because she is on antiepileptic medications, we might
‐ Urine dipstick, BSL, Pregnancy Test need to give her a pill with high dose of estrogen.
Please understand that the pill prevents pregnancy
Diagnosis and management only and not STDs. If you find that giving a pill
‐ There is no abnormality on physical examination. everyday is inconvenient, we can give her injections of
According to your history, the most likely cause of not depo-provera every 3 months. However, with
having the periods is endometrial atrophy secondary prolonged use, it will produce side effects including
to the pill. reduced density of bones as well as problems with
‐ However, we need to rule out pregnancy. The only periods. There are other options as well like implanon
possible reason is one of the hormones and IUCDs. However, the management is better
(progesterone) in the pill is causing thinning of the suitable for females who can look after themselves.
lining of the womb. - Can we remove her womb instead? The oral pill is the
‐ DIAGRAM best option for your child because you are already
‐ Do not worry. It is a reversible condition. At this stage, giving her some medications and you just need to add
we will stop the Microgynon 30 and you can use other one more. Regarding permanent sterilization, it is
forms of contraception at this time or I can shift you to usually not allowed for girls under the age of 18 years
Microgynon 50 or we can use the triphasic pills. Most without approval from the court. Please understand
likely your periods will return. In case you don’t or that being mentally disabled does not deprive your
you’re really concerned, I can refer you to the daughter from the right to be treated just like other
gynecologist for further investigation. people. We, as doctors, only prescribe something if it
‐ Reading material. Referral. Review. is in the best interest of your daughter. I understand
you are concerned; however, I am sure you would be
Request for sterilization for a disabled person/Contraceptive equally worried if your daughter suffered from any of
advise for disabled the complications of this surgery which includes
complications with anesthesia, bleeding, infections,
Case: You are a GP and a mother of 13-year-old child comes to and long-term effects on her bone growth and
you. She is intellectually disabled and epileptic. She is on hormonal imbalances.
carbamazepine. She wants your advice because the child goes - I gave the consent appendicectomy. Why can’t I do it
to school for both boys and girls. She is worried about now? Appendectomy is a medical emergency where
contraception and the risk of pregnancy. the decision is taken on medical grounds. If you like,
you can contact the family court or the guardianship
Task board. They have the legal authority to allow this kind
a. Relevant history of procedure.
b. Address mother’s concerns
53
Depo-Provera Counseling History
‐ Why do you want to change? Who suggested
Case: A 25-years-old female is in your GP clinic and who wants implanon? Any side effects of OCP? Any chance you
to have depo-provera. are pregnant now? Did you have previous STIs? Pap
smear
Task ‐ Previous pregnancies/miscarriages? How are your
a. Advise about depo-provera cycles? When was your LMP? Any medical conditions
and FHx of hypertension, diabetes?
Counseling ‐ SADMA?
- It is the only injectable IM contraceptive available in
Australia and it has progesterone in it. The dose is Counseling
150mg by deep IM injection in the first 5 days of ‐ The implanon, as you know, is a small device that
menstrual cycle and same dose is given every 12 goes below the skin in the non-dominant upper arm
weeks. under local anesthesia. It contains a certain hormone
- Do you have any migraine? Stroke? Cancer? Any (etonogestrel) that will cause 2 things: inhibits
undiagnosed vaginal bleeding? Hypertension? Heart ovulation and increases the viscosity of the cervical
disease? Diabetes? Lipids? Liver disease? mucus. It is a very safe contraceptive method. The
- 5Ps: periods, pap smear, do you want to be pregnant failure rate is <1% and it lasts for 3 years.
in the next 12 months? ‐ Upon removal, most women will ovulate during the
- When the woman has depo-provera in the body her first month. The procedure needs to be done by a
own hormone production is switched off. Because of trained personnel.
this the ovaries will not release eggs thus pregnancy ‐ Advantages: convenience, rapid reversibility, available
is prevented. It is a highly effective method of at low cost through the PBS systems, suitable for
contraception more effective than the combined pill women with CI to estrogen
and failure rate is 1%. ‐ Absolute contraindications: pregnancy, undiagnosed
- The advantages of depo-provera are: It is highly vaginal bleeding, active thromboembolic disease,
effective and therefore has low failure rate. It can present or history of severe liver disease,
relieve pre-menstrual tension and period pain. It is progestogen-dependent tumors, breast cancer,
also likely to cause some reduction in risk of ovarian hypersensitivity to components of implanon
and endometrial cancer, and endometriosis. As it is ‐ Relative contraindications: long-term use of liver
given every 12 weeks, no other effort or remembering enzyme inducing drugs, past or family Hx of
is required. thromboembolic disease, obesity (>100kg Æ efficacy
- The disadvantage is that you have to take injection is less), women for whom regular periods are
every 3 months. Once the injection is given, the important
hormone cannot be removed and if you want to stop ‐ Side effect: Menstrual disturbance is the most
depo-provera you have to wait for the hormone to common reason for removal
wear off. In some women, it can take 6-12 months for o bleeding approximating normal (35%),
periods to return. There is a concern about the risk of infrequent bleeding (26%), amenorrhea
thinning of bones if woman is using depo-provera for a (21%), frequent or prolonged bleeding
long period of time. (18%)
- Side effects may include reduced periods due to low o breast tenderness, fluid retention, weight
level of hormones. After 2-3 injections, most women gain, skin disorders (improve), mood change
will have no periods at all because there is no lining ‐ Effective immediately if inserted during day 1-5 of the
building up to shed. Some have intermenstrual patient’s menstrual cycle; if not, then important to
bleeding which is usually light and irregular or have ascertain the patient is not pregnant and alternative
heavy bleeding which can be controlled by hormone contraception should be used for 7 days after
treatment. A small amount of weight gain can occur. insertion.
There can be headache, abdominal discomfort and
mood changes. Women who have increased Emergency Contraception after Rape
incidence of depression can have reduced interest in
sex. Case: You are a GP and 18-year-old Samantha came to your
- Contraindications clinic asking for emergency contraception and advice.
o Bleeding disorders or taking anticoagulant
medication Task
o Undiagnosed vaginal bleeding a. Explain methods of emergency contraception
o History of some forms of cancer b. Manage the case
o Serious medical conditions
o Already pregnant or those who want to Case: Rosie aged 24 years presents to the ED of the local
become pregnant within 12 months hospital where you are working as an intern. She tells you that
- Not recommended for greater than 2 years. she was sexually assaulted by a person to whom she met in a
pub. She is very distressed and teary. On further questioning
Implanon Counseling she discloses that she doesn’t know this person and had never
met him before. He offered her a lift home and then stopped the
Case: Your next patient is a 19-year-old female previously on car in a lonely place and assaulted her. Rosie is an overseas
OCP and now requests implanon. university student and lives in a shared accommodation and had
no other medical or any surgical problems.
Task
a. Relevant history (friend mentioned; no problems Task
except missed pill) a. Further relevant history
b. Advice patient and answer questions b. Physical examination
c. Management advice
54
- I understand from the notes that you are here for Counseling
emergency contraception which is available OTC. Is ‐ REVEAL THE CONCERN: why have you decided
there some special reason to see me today? that?
- I am sorry to hear that, but don’t worry there is a lot of ‐ Are you in a stable relationship? Have you completed
support and you are not alone at this moment of crisis. your family? How’s your general medical health? Any
- Confidentiality statement. medical/surgical problems in the past.
- Would you like to take any legal action? (No doctor. ‐ WARNING: I would like to inform you that reversal
This man is known to my family and I don’t want to can be done, but has a very low successful rate, and
make a fuss about it.) I respect your decision but I tubal ligation is considered a permanent form of
would like to get samples and keep it in the hospital sterilization
just in case you will change your mind later. ‐ COUNSELING: I will tell you what the method is
- Were you injured anywhere else? about, advantages and disadvantages, and other
- Menstrual history: When was your LMP (3 weeks alternative methods. Tubal ligation can be done by 2
ago)? How are your periods? Are they regular? What methods done by specialist under general anesthesia.
is the cycle? Bleeding? How many days apart? The first method is either the specialist can cut the
- Sexual history: Do you know if the man suffered from tubes and tie them together so that the sperm and ova
any STIs (No)/Did you see any discharge on his do not meet, or can put clips. Success rate is more
private part? Are you sexually active? Are you in a with the first method, whereas with the second
stable relationship? Are you using any form of method, there are chances that clips may dislodge.
contraception? Have you or your partner ever been Failure rate is 1:300 which means one in every 300
diagnosed with STIs? Pap smear women who gets the procedure gets pregnant.
- Any history of clotting, hypertension, migraine, Disadvantages of tubal ligation: a. reversal rate is low,
undiagnosed vaginal bleeding, breast cancer? and reversal is not covered by medicare, b.
anesthesia risk/complication, c. ectopic pregnancy, d.
Examination will not protect from STIs.
- General appearance ‐ How long in hospital; 1-2 days.
- Vitals ‐ ALTERNATIVES: I would like to give you some
- Pelvic examination with consent information about the other methods you can use such
o Inspection: sign of injury, vaginal secretions, as IUDs, implants, depo-provera where compliance is
consent to take low and high vaginal swabs not a major issue. For men, there is also a procedure
for STD screening called vasectomy. The advantages are: a. simple, b.
- Chest, heart, abdomen to check signs of assault done under local anesthesia, c. less complications, d.
- Urine dipstick lower failure rate
‐ QUESTIONS:
Management o Will it affect my sexual life? No. It makes it
- We need to take blood samples for HIV, syphilis, better because you’re not scared about
Hepatitis B&C, HSV and take urine sample for PCR pregnancy.
and Chlamydia o When can I resume sexual life? Once
- I would give you antibiotic coverage: Azithromycin 1g effects of operation is over.
SD o Is there any effect on my periods? Not
- I would like to refer you to a psychologist or counselor really, but there are some studies which
for support (rape crisis team). have shown that if more of the fallopian tube
- Let’s talk about emergency contraception. The first is cut, it leads to heavier bleeding. Not yet
method is levonorgestrel (Postinor). This is a POP. 2 proven.
pills (0.75mg each) Æ 12 hours apart or 1 pill (1.5mg) o Will I gain weight? No.
given up to 5 days but most efficient if taken within 72 o What if I need kids later? The cut tubes may
hours. Efficacy is 85%. be rejoined by microsurgery, but there is no
- The next method is combined pills or Yuzpe method guarantee of reversal of fertility. Pregnancy
75% efficacy ([50mcg estrogen and 250 mcg rate after reversal varies from 30-80% and
progesterone] 2 tablets now then 2 tablets 12 hours that depends on the technique. The simple
apart) or copper IUDs with a failure rate of <1% if clip method gives better chance of reversal.
used within 72 hours. Regardless, it is considered a permanent
- There are chances of getting pregnant even after method and shouldn’t be entered lightly.
taking the emergency pills. Therefore, I would like to ‐ CLOSURE: I would recommend you to go home and
review you after 2-3 weeks to do pregnancy test discuss what we have talked about today and if you
especially if you miss you period. have decided, I will give you a referral letter.
- Most common side effect is nausea and vomiting. If
she develops it, she needs to take the drug again.’ Vasectomy
- Reading material
Case: A couple comes to your GP clinic. They have completed
Tubal ligation their family and want to discuss with you about vasectomy.
History
What do you mean by losing urine? Is it small or
large? Do you lose urine when you laugh, cough,
Tab Trimethoprim exercising or just normal? Do you lose a lot of urine
when you try to reach the toilet? Any feeling of
300 mg x daily for 3 days masses down below?
- Any burning in urination? Frequency? Frothy urine?
Change in color of urine? Polyuria? Polydypsia or
polyphagia?
63
- Was it difficult labor? Assisted labor? Assisted you have associated tummy pain or heavy/dragging
delivery? Symptoms of menopause? Hot flushes? kind of sensation in the lower tummy? Any urinary
Dyspareunia? Mood swings? Pap smear? Partner? complaints like frequency, burning or leaking of urine?
Stable relationship? Any previous history of STDs? Any loin pain? Any history of prolonged cough,
Have you started with mammography? constipation, asthma or respiratory problems? Do you
- Any medical history? Chronic cough or constipation? have any problems emptying the bowels? Any
Joint problems? complaints of discharge or bleeding from down below?
- SADMA? BMI? Any fever? Itching? When was your LMP? Any
problems during or after menopause?
Examination ‐ When did you have the hysterectomy? Why did you
- General appearance: BMI, dehydration, pallor, have it? Any complications afterwards? Was it done at
jaundice a tertiary care center? After the surgery, did you do
- Vitals pelvic floor exercises? Any other surgeries that I
- Chest/heart: chronic infections should be aware of? Did you take any HRT
- Abdomen afterwards?
- Pelvic examination: rule out prolapse (cystocele) ‐ May I know are you sexually active at the moment?
- Ask examiner for any demonstrable stress Any complaints of pain or discomfort during sex? How
incontinence (ask patient to cough and check for many kids have you had? Any history of big babies?
leakage of urine) Difficult or instrumental deliveries?
- BSL and Dipstick ‐ SADMA?
‐ Have you recently noticed weight loss? Change in
Diagnosis and Management appetite? Night sweats? Lumps and bumps in the
- You most likely have a condition called stress body? Pap smear? Mammogram?
incontinence. When the urethra is no longer in the
pelvis, there is an increase in intra-abdominal Physical examination
pressure, which affects both bladder and urethra ‐ General appearance
increasing the bladder pressure more than the urethral ‐ Vital signs
pressure, resulting to involuntary loss of urine. ‐ Chest and Lungs
- I completely understand that it is a very frustrating ‐ Abdomen: for tenderness
condition for you, but let me assure you that we can ‐ Pelvic exam
manage it. o inspection: Obvious lump, discharge, ulcer,
- Stress incontinence is highly associated with UTI so I redness, discharge
would like to order urine microscopy and culture (ask o Sterile speculum examination asking the
examiner for results). patient to strain looking for any visible lump
- I would advise you to maintain a bladder diary. Avoid while straining; sims left lateral position
too much physical stress, lifestyle modification (weight (knee-chest position) Æ gradually withdraw
reduction, smoking cessation, decrease caffeine while asking a patient to strain Æ
intake), avoid constipation and coughing lump/bulge in the vagina (best way to detect
- Start pelvic floor exercises (contract pelvic muscles as cystocele and rectocele)
if your lifting your pelvis or holding urine 40-50x daily ‐ Urine dipstick and BSL
at 3 months)
- Refer to gynecologist regarding vaginal pessaries. Diagnosis and Management
They may consider giving you HRT and urodynamic ‐ Most likely what you have is prolapse of the vaginal
studies but will be decided upon by the specialist. wall after hysterectomy. Once the uterus is removed,
- Surgery will only be indicated if conservative the upper part of the vagina loses its anatomical
measures fail. Bladder neck suspension, suburethral support. Usually, during hysterectomy, the surgeon
rings, and local injection of collagen. will secure the upper part of vagina with the help of
- For urge incontinence: bladder training and anti- ligaments attached to the backbone and pelvic wall.
cholinergic medications (oxybutynin, propantheline, Some of these ligaments become loose because of: a.
imipramine, tolterodine)Æ refer to physiotherapist loss of estrogen b. prolonged straining/coughing c.
- Review and Reading Material putting on weight.
- Stress incontinence: MSU for urine and culture ‐ This phenomenon is quite common after
- Postmenopausal bleeding: Transvaginal hysterectomy. Up to 30% of patients might develop
Ultrasound this. It can affect the urinary system leading to
frequent recurrent UTIs. It can also affect the wall of
Post-hysterectomy Prolapse the bowel causing constipation. Sexual functioning
may be affected and might cause pain and discomfort
Case: You are a GP and a 52-year-old female comes to your during intercourse.
clinic complaining of something coming out from her vagina ‐ The treatment will be tailored according to your
especially after straining wishes, but you will need to see a specialist
gynecologist. The first option is conservative
Task management which includes pessaries along with
a. History pelvic floor exercises. Usually, this suitable for old,
b. Physical examination females who are not fit for surgeries. The second
c. Management option is the surgical approach. It is called vaginal wall
suspension surgery (sacrocolpopexy). The surgeon
History will attach the upper part of the vagina to the strong
‐ Please tell me more about your problem? Since when tissues within the pelvis usually to the lower backbone
have you noticed this lump? Is it present all the time or or sacrum. There are 2 options regarding the
does it come and go? Any changes with change in approach: laparoscopic or keyhole surgery OR
position like prolonged standing or lying down? Do abdominal approach best decided by the surgeon.
64
‐ The recurrence rate after the surgery is very low - PR: differentiate between cystocele and rectocele
therefore the surgery is mostly curative. - BSL and Urine dipstick
‐ Review. Reading material.
‐ Pelvic floor exercise (kegel): done to strengthen the Diagnosis and Management
muscles of the pelvic floor. The exercise can be done - You have a condition called uterovaginal prolapse with
either sitting or lying down. The patient needs to stress incontinence and candidiasis,
empty the bladder before exercise. Contract the pelvic - Menopause resulting to lack of estrogen, difficult
muscles, hold contraction for at least 5 seconds, labor, big babies and constipation leads to the laxity of
release it slowly and repeat 3-4x and gradually build the pelvic floor ligaments. It is a common condition
up duration for up to 10 seconds. She must not among females in your age group.
contract the abdominal, thigh or buttock muscles. - At this stage, I would like to refer you to the
Exercises must be repeated 3x a day as many times gynecologist. I would advise you to start with pelvic
as possible. Results are usually apparent within 8-10 floor exercises (contract pelvic floor muscles as if
weeks. Safe to be done during pregnancy trying to hold urine).
- The specialist might insert a pessary which is a device
Uterine Prolapse inserted into the vagina to support the uterus. They
need to be changed every 3-6 months. They also
Case: An a 80-year-old lady comes to your GP clinic advise topical estrogen to improve the discomfort.
complaining of mass protruding down below and rash around - Will it affect intercourse? Pessaries will not interfere
the private area for several months. with your sexual performance.
- If conservative measures do not work, the specialist
Task might consider doing surgery to fix the ligaments.
a. Relevant history - How long will I be in the hospital? Usually 3-5 days.
b. Physical examination (BMI 29, maculopapular rash You can go home once you’re feeling well and once
around introitus and inside of thigh, urine dipstick + you have started urinating without problems.
sugar, BSL 11.3mmol/L - Postop advice: For the first two weeks, restrict your
c. Diagnosis and management activities. Rest. Avoid heavy lifting. Avoid sports and
swimming. For 1st 6 weeks abstain from sexual
History intercourse.
- I read from your notes that you have something - Driving: It is not advisable to drive for the first 2
bulging from your private area. Since when? Can you weeks.
tell how it happened? Is it increasing? Do you feel any - Complications: Pain, bleeding, injury to nearby
abdominal discomfort? What is the effect of this structures, anesthesia complications
bulging on your life? Is this swelling affecting your - For the candida, I will prescribe you antifungals. It
waterworks? Do you leak urine while you strain, might be related to high blood sugar. I will give you
cough, etc? Do you have a strong urge to void on the referral to physician to investigate further
way to the toilet or do you leak a large amount of urine - Lifestyle modification: normal BMI, stop smoking,
on the way to the toilet? Any discharge down below? high-fiber diet
Constipation? Waterworks? - Referral to specialist obstetrician. Reading material.
- Rash? Since when? Is it itchy? Can you describe the Review.
rash for me? - Advise OGTT.
- Period: When was your last period? Any irregular
bleeding after that? Hot flushes? Mood swings? Prolapse:
Breast pain? Irritable? - I: cervix remains within vagina
- Pregnancy: how many pregnancies? Were they big - II: cervix comes up to introitus
babies? Did you have any difficult labor or prolonged - III: most of uterus lie outside vagina
labor?
- Partner: are you sexually active? Do you have a Uterine Prolapse
stable partner? Do you have painful intercourse?
Have you or your partner ever been diagnosed with Case: A 58-year-old lady comes in your GP clinic complaining of
STDs? lump from the vagina.
- Pap smear: When was your last pap smear? Result?
- Mammography? Task
- Past medical history: chronic cough, diabetes, asthma a. History
- FHx: Osteoporosis, MI b. Physical examination
- SADMA c. Explain management
Gardasil Vaccine
Task
a. Respond to patient inquiry