Mr. M HUSSAIN,MRCOG.

 What is it about?
 Logic sequence of events.
 Have a general frame.
 Write: resist temptation to be carried away.
 R/V.
 Key words:
 Instructions:discuss,evaluate,compare and
contrast.
 Scenario: why this scenario?
 Why some data are given in the
scenario:teenage,nulliparous,70 years
old,Afrocaribean etc.
 Do not read in-between the lines.
 Introduction: ectopic pregnancy remains one
of the important cause of maternal mortality
and morbidity.S/HE looks OK.
 The body of the answer: this is where you get
the marks.
 Conclusion: Still ectopic pregnancy remains a
challenge to diagnose. Careful approach to
the problem is very important:Yup S/He
deserves to pass.
 Instruction: critically appraise.
 Key words: methods of diagnosis. So the
following points are
relevant:History,examination and
investigations.
 50% accuracy.
 Ectopic pregnancy is suspected 10 times
more often than it occurs.
 Risk factors present in 25-50% of patients.
 Bleeding: miscarriage.
 Pain: surgical causes.
 Gold standard.
 Invasive.
 4% false negative & 5% false positive.
 Alone misses 25%.
 Acceptable, better image, no need for a full
bladder, diagnose ectopic pregnancy one
week earlier than TAS.
 Coloured and pulsed Doppler increase
sensitivity.
 Eliza: detect bhcg in urine 14 days post-
conception. Detection limit is 25-
50iu/L.Sensitivity is 98-100%.
 Immunometric radioassay:5-9 days
postconception,limits is less than 5
iu/L.Sensitivity is 100%.
 Abnormal doubling time: ectopic or
spontaneous miscarriage. However,13% of
ectopics will have normal doubling time and
15% of normal pregnancies will have
abnormal doubling time.
 A titre of 1000-1500 iu/L will be associated
with the presence of intrauterine pregnancy
on TVS(6000-6500 on TAS).Sensitivity is 99%
and specificity is 95-100%..Difficulties with
multiple or heterotopic pregnancies.
 More than 25ng/ml can exclude an ectopic
with 97% sensitivity.
 Culdocentesis:limited use with high false
positive rate.
 D&C:limited use.
 Future:oesradiol,AFP,Relaxin,Placental
proteins.
 Karyotyping:3-5% abnormality.
 TVS:uterine anomalies,PCO.
 APL:lupus anticoagulant and anticardiolipin.
 Thorombophila screen:APCR,Proteins
C,S,factorXIII & antithrombin III deficiency.
 BV.
 TFT,RFT,LFT.
 Laporoscopy,hysteroscopy.
 G.T.T & TORCH,Human Leucocyte antigen.
 Justify your management of an asymptomatic
17 years old primigravid at 27 weeks
gestation with confirmed proteinuria(2+) and
hypertension(150/100).
 Risk of fulminate pre-eclampsia.
 Risk of preterm delivery.
 Efficacy of potential treatments.
 Risk/benefit analysis of timing and route of
delivery.
 FBC,COAG,RFT,LFT.
 24 Hour urine protein,PCR.
 CTG,SCAN.
 Steroids.
 Antihypertensive.
 Timing and route of delivery.
 Justify your management of confirmed
spontaneous rupture of the membranes at
30 weeks gestation in a previously normal
pregnancy.
 Risks of preterm delivery.
 Risk of prolonged rupture of membranes.
 Efficacy of optimal treatment or lack of it.
 Risk/benefit analysis of timing and route of
delivery.
 Mother:FBC,CRP,HVS &TPR.
 Baby:CTG,SCAN.
 Tocolysis:why and for how long?
 Use of steroids: should they be repeated.
 Use of antibiotics, are they necessary?
 Timing of delivery and route.
 No marks given for talking about how to
diagnose SROM.
 A fit 60 years old patient, taking a cyclical
HRT,experiences some irregular vaginal
bleeding. Clinical examination excludes
obvious gynaecological pathology and a
recent cervical smear result is negative.
Consider the option for investigation and how
you would explain them to the patient.
 Endometrial sampling methods.
 Endometrial cancer?
 Re-assurance.
 The following options are suggested:
 A. outpatient sampling(Pippelle,vabra
etc):simple, tolerated by 80%,predictive value
similar to D&C. but blind procedure.
 B.Hysteroscopy(inpatient or outpatient):more
pain than sampling but direct
view.Time,anaesthesia etc.
 C. D&C:Blind,potential problems?
 The following should be mentioned with
reasons for and against:
 Scan:E.T less than 5 mm,no need for
sampling.
 Cytology of endometrial aspirate if no
obvious tissue obtained.
 The advantages and disadvantagesof each
method that are explained to the patient
should be fully and critically discussed in the
answer.
 Critically Appraise the Value of Antenatal HIV
testing.

 Concept???
 Vertical and horizontal transmission.

 Mode of delivery.
 Cost of the test.
 Screening should be accompanied by
counseling
 Positive results require careful management.
 Positive result may require checking HBV &
HCV.
 Universal screening may increase the cost,
but it reduces vertical transmission and hence
prolonged use of beds.
 Precautions by birth attendants to reduce the
risk of horizontal transmission.
 Antiviral treatment reduces the risk of vertical
transmission by more than 60%.
 No breast feeding reduces the risk by 50%.
 Plasma viral load less than 50 HIV RNA
copies/ml and on treatment, the patient can
have planned vaginal delivery. More than
50,then the patient will have planned
c.section.
 VBAC is acceptable if the viral load is less
than 50.
 SROM at or more than 34 weeks, delivery
should be expedited: less than 50 copies,
immediate IOL,more than 50,immediate
c.section.
 Less than 34 weeks:MDT,steroids,antiviral &
timing of delivery.
 Pediatrician to attend the delivery.
 How would you manage a 30 years old lady
who is troubled with recurrent vulvovaginal
candidiasis?

 Note: How would you manage a 30 years old

lady who is troubled with recurrent vaginal
discharge?
 Recurrent thrush can lead to immense long-term
physical and psychosexual problems.
 Great effort should be made to reach an accurate
diagnosis.
 A careful history should be taken to ascertain the
presence of any obvious predisposing
factors,e.g,D.M,antibiotics,immunosupressives,C
OCS,IUCD,bubble-bath,non-cotton underwear.
 Symptoms:itching,burning,soreness,dysuria,dysp
areunia. Symptoms are typically worse before
and better after menstruation.
 Typically, the vulva is red, dry and fissured. In
severe cases, the vulva may be edematous.
 White curd-like discharge may be adherent to
vagina and cervix.
 Normal PH,i.e,between 3.5 and 4.5.If the PH is
high, consider BV or trichomoniasis.
 Microscopy: add a drop of normal saline or 10%
KOH to the discharge to see the spores or
pseudo-hyphae.This is relatively insensitive
diagnostic test.
 Culture on Sabouraud’s medium: the presence of
more than 10 colonies ,supports the
diagnosis.However,a positive culture result does
not, in itself, prove that a woman’s symptoms are
due to thrush as at any one time,25% of young
healthy women are colonized by Candida.
 May be difficult to treat.
 Any predisposing factor should be
addressed,e.g,post-antibiotic thrush, give
prophylactic treatment.
 Avoid local irritants such as bubble- bath,
tightly fitted synthetic garments.
 Long course of anti-fungal maintenance
therapy(6 months).
 If the maintenance therapy failed, then
C.galabrata is the likely causative organism.
 Resistant yeasts can be treated with
intravaginal boric acid or topical flucytosine.
Lack of safety data means that these drugs
can not be used for maintenance therapy.
 DMPA has also been tried in cases of
refractory candidiasis.
 No value for treating the sexual partner.
 The patient should understand the nature of
the problem and participate in designing a
management plan sensitive to her needs and
circumstances.