PACES Revision

Obstetrics and
Gynaecology
27/04/2012
AMRITA BANERJEE & OLA MARKIEWICZ

Kindly sponsored by:

 Plan for the morning

 9-10.30 - Lecture + demonstration station

 10.30-11.00 - Break
 11.00-12.30 - Mock PACES stations (x4)
 12.30-13.00 – Lunch
 Outline of Talk

 Obs & Gynae

 History
 Examination
 Clinical Skills
 Investigations
 Management
 Red Flags
 Ethics and Law
 Common PACES Stations
 Demonstration Station
 Tips and Advice
 Further Resources
HISTORY
 The History

 The main part of all PACES stations!! Do not compromise on

this.

 PC
 HPC
 Gynae history
 Obstetric History
 PMH
 DH
 FH
 SH
 Systems review
The Gynaecological History

Periods
• Dysmenorrhoea
• Oligomenorrhoea
• Amenorrhoea
• Menorrhagia
• Mittelschmerz

Discharge
• Smell
• Colour
• Consistency
 The Gynaecological History

Think about sex:

• Contraception
• HPV vaccine

Have sex:
• Dyspareunia
• Post-coital bleeding

After sex catch:

• STI’s
• HPV – smears!
• Babies
The Gynaecological History

Boys
• Regular
• Protection – pregnancy and STI’s
• GUM clinic visits
• Peer pressure
• Legal
The Gynaecological History

Obstetric History – don’t forget TOPs!

Consequences of childbirth
• Sphincter dysfunction
• Rectal/vaginal prolapse
The Gynaecological History

Menopause
• Symptoms
• HRT
• Post menopausal bleeding!
• Vaginal atrophy
• Sex life
• Quality of life
 Obstetric History

PC
HPC

Current Pregnancy
 Was this a planned pregnancy?
 EDD - scan or dates (LMP, Menstrual cycle)
 Complications
 Investigations so far

Gravidity – number of times a woman has been pregnant, regardless of outcome

Parity = (any live or still birth after 24 weeks)

Specific Symptoms...
 Nausea / Vomiting - if severe known as hyperemesis gravidarum
 Urinary frequency – pressure on the bladder causes this – rule out UTI
 Tiredness
 Fetal Movements - usually felt at around 18-20 weeks gestation, earlier in multips

Ideas, Concerns & Expectations…

 Obstetric History

Details of each pregnancy:

 Date / Year
 Place of birth
 Gestation
 Mode of delivery
 Baby – sex, weight, current health
 Problems during antenatal, labour & postnatal
 Same Partner? Consanguinity?

Miscarriages & Terminations

Previous difficulty conceiving/ assisted conception
Plans for future pregnancies
 Obstetric History

 For each pregnancy, including the current one if

pregnant, ask about complications:

 Maternal: DEATH P  Fetal

 Diabetes
 Movements
 pre-Eclampsia
 Anaemia  Scans/tests
 Thrombus  Hospital admissions
 Hypertension
 Pain

 Bleeding
 Infection
 Obstetric History Cont.

Past Gynaecological History

 Contraceptive use?

 Last Cervical Smear – was the result normal?

 Any gynae surgery:

- Loop excision of transitional zone (LETZ) -↑ risk of cervical
incompetence
- Previous myomectomy - ↑ risk of uterine rupture /
placenta accreta /adhesions

 Gynae investigations & treatment for:

- Infertility
- Ectopic – ↑ risk of future ectopics
- PID - chlamydia is most common cause – ↑ risk of ectopic
 The rest of the history

Past Medical History and Past Surgical History

Drug History
 Pregnancy medication - folates, iron, anti-emetics, antacids
 Teratogenic drugs – avoid at all costs - ACEi, Retinoids, Sodium Valproate, Methotrexate
 OTC Drugs - make sure to ask patient about these, to ensure nothing unsafe
 ALLERGIES

Family History
 Medical conditions - gestational diabetes
 Inherited genetic conditions – CF
 Pregnancy Loss - recurrent miscarriages in mother & sisters
 Pre-eclampsia - in mother or sister? – increased risk

Social history
 Smoking, Alcohol, Drug use
 Living Situation, Relationship Status
 Occupation

Systems review
 Other Important Questions

 How do her symptoms affect her life

 What support does she have at home – do not

assume she is married!

 Is there anything else that you are worrying about?

 Is there anything else that you’d like to ask me?

EXAMINATION
 The Physical Examination

 Examination
 Abdomen:
 Gravid
 Non-pregnant

 Pelvic examination
 Speculum
 Swabs
 Smear

 To complete my examination
 Blood pressure
 Pregnancy test
 The Pelvic Examination

 Brief abdominal examination

 Inspect vulva
 Inspect cervix using Cusco’s speculum
 Take smears and swabs if required
 Withdraw speculum
 Bimanual examination
 Cervix

 Uterus

 Adnexae

 Inspect fingers for blood or discharge

What is this?
 The Obstetric Examination

 Inspection “There is an abdominal mass consistent

with pregnancy”
 Linea nigra
 Striae
 Scars
 Fetal movements
 Measure symphysio-fundal height
 Palpate – use ballottement
 Assess amniotic fluid volume
 Fetal lie
 Presentation
 Engagement (fifths palpable)
 The Obstetric Examination cont.

 Fetal heart sounds

 BP and urinalysis
 Antenatal notes
CLINICAL SKILLS
 Clinical Skills

 Blood Pressure
 Urine dipstick
 Pregnancy test

Gynae:
 Vaginal swabs
 Cervical smears

Obstetrics:
• CTG
 Blood Pressure

 Make sure you know how to use a sphyngomanometer

 Roughly determine systolic BP using the radial pulse
 Start 20mmHg above this and measure BP
 Korotkoff sounds
 Urine Dip

 Use gloves
 Expiry date
 Remove a strip, then close the bottle
 Dip the strip into the urine and wipe any excess
urine on the side of the bottle
 Compare the strip to the bottle
label
 Pregnancy test

 Perform in almost every woman of

childbearing age
 Detects βhCG
 Dipsticks vs pipette urine
 Control line
 Test line
 Confirm result with another member
of staff
 Vaginal Swabs

Bug Swab Other Treatment

Candida High vaginal Mycelial filaments on Clotrimazole cream

albicans swab microscopy or oral fluconazole

Bacterial High vaginal Whiff test positive, clue Metronidazole or

vaginosis swab cells, alkaline pH clindamycin cream

Trichomonas High vaginal Motile flagellated protozoa Metronidazole

vaginalis swab on microscopy, alkaline pH

Chlamydia Endocervical Nucleic acid amplification Doxycycline or

trachomatis swab tests (NAATs) eg. PCR azithromycin

Neisseria Endocervical Gram negative diplococci Ceftriaxone

gonorrhoea swab
 Cervical screening programme

 Aim: identification of CIN and initiating early

treatment before the development of cervical
carcinoma
NOT a test for cancer!
 Age range:
 25-49 every 3 years
 50-64 5 yearly
 60+ if not screened since 50 or recent abnormal results
 Technique: Rotate brush in the external os to pick
up loose cells over the TZ for liquid based cytology
 Cervical screening programme

Cervical
DYSKARYOSIS: Intraepithelial Management
Cytology – smear neoplasia:
Histology - biopsy
Can spontaneously
regress
mild CIN1 6 month follow up. If
persists then colposcopy

moderate CIN2 Colposcopy + treatment

Immediate colposcopy +
severe CIN3 treatment

Counselling and explaining the process/results/follow up!

 Cardiotocography

 DR – Define Risk
 C – Contractions
 BRA – Baseline Rate – mean rate over 5 – 10
mins. Normal = 110 – 160 bpm
 V – Variability – should be >5 bpm
 A – Accelerations – rise in fetal heart rate by at
least 15 bpm lasting at least 15 secs.
 D – Decelerations – fall in fetal heart rate by at
least 15 bpm lasting at least 15 secs
 O – Overall
INVESTIGATIONS
 Investigations

General tips:

 Importance of observations and bedside tests

 Do not mention lists of investigations unless you are able

to justify why you want them

 Hit the jackpot early (but don’t show off)

 Think outside the box – pregnant women get non-

pregnant diseases
 Investigations

Gynae:
 Cervical smears
 Interpret hormone levels: FSH, LH,TFT’s
 Urodynamics
 Ultrasound: endometrial thickness
 Surgery: endometrial biopsy, laparoscopy, lap + dye
 Contraceptive methods: IUD
 Hysteroscopy
 Investigations

 Obstetrics:
 Pregnancy test (in A+E)
 Glucose Tolerance Test

 Cardiotocographs
 Partogram
 Pelvic USS
 Screening tests
 Amniocentesis/chorionic villus sampling
MANAGEMENT
 Management

What everyone does worst on!

Don’t forget:
 Resus +
CONSERVATIVE
MEDICAL
SURGICAL

And VERY importantly

ASK FOR HELP!

RED FLAGS
 Red Flags - Obstetrics
Condition
Placenta praevia
Placental abruption
(Ruptured) ectopic pregnancy
Obstetric cholestasis
Shoulder dystocia
Cord Prolapse
Amniotic fluid embolism
Symptoms
Painless PV bleeding late in pregnancy
Painful PV bleeding late in pregnancy
Early pregnancy, pelvic pain, PV
bleeding +/- faintness, shoulder-tip pain
Itchy hands and feet during pregnancy
Delayed delivery after delivery of the
head
Umbilical cord descends below the
presenting part following rupture of
membranes
Dyspnoea, hypotension, hypoxia,
seizures, heart failure
 Red Flags – Obstetrics cont.

Condition Symptoms

Uterine rupture Acute, severe pain during labour or, if epidural,

sudden maternal hypotension, cessation of
contractions, fetal hypoxia
Uterine inversion Post-partum haemorrhage, pain and profound
shock
Pre-eclampsia Hypertension, proteinuria, oedema

Eclampsia Pre-eclampsia with RUQ pain, headaches, tonic

clonic seizures, blurred vision
PE SOB, chest pain, hypoxia, cardiac arrest

DVT Acute leg pain, redness, swelling, heat, +/-SOB

Primary and Secondary PPH Primary ≥ 500 ml of blood loss within 24 hours
of delivery.
Secondary - abnormal or excessive bleeding
between 24 hours and 12 weeks postnatally.
 Red Flags - Gynaecology
Condition
Ovarian cyst torsion/accident
Endometrial carcinoma
Ovarian carcinoma
Cervical carcinoma
PID
Symptoms
Severe pelvic pain associated with
hypovolaemic shock
Abnormal uterine bleeding, especially
PMB
Non-specific symptoms of abdominal
distension, pain, abnormal bleeding,
weight loss
IMB, PCB, PMB, offensive vaginal
discharge
PV discharge, pelvic pain, fever,
abnormal bleeding
COUNSELLING
 Counselling

 Shared decision making

 MDT
 Empathy
 Active listening
 Use of silence
 Avoid jargon
 Ideas, concerns, expectations
 Counselling cont.

 Congenital abnormalities e.g. Downs, Turners

syndrome
 Cervical smear results
 Ectopic pregnancy
 Miscarriage
 Contraception
LAW AND ETHICS
 Law and Ethics

 Everyone ignores but is very important!

 Most sued specialty

 Extremely sensitive issues: cultural, religious, personal

Important principles:
 Gillick competence
 The Abortion Act
 The Mental Capacity Act
 Law and Ethics

 Everyone ignores but is very important!

 Most sued specialty

 Extremely sensitive issues: cultural, religious, personal

Important principles:
 Gillick competence
 The Abortion Act
 The Mental Capacity Act
 The Abortion Act

 Permits termination of pregnancy by a registered

practitioner subject to certain conditions.
 Must be performed by registered medical
practitioner in an NHS hospital or DoH approved
location (e.g. British Pregnancy Advisory Service
Clinics)
 An abortion may be approved for the following
reasons:
A The continuance of pregnancy would involve risk to the life of the
pregnant woman greater than if the pregnancy was terminated.
B The termination is necessary to prevent grave permanent injury
to the physical or mental health of the pregnant woman.
C The continuance of the pregnancy would involve risk, greater than if
the pregnancy were terminated, of injury to the physical or
mental health of the pregnant woman.
D The continuance of the pregnancy would involve risk, greater than if
the pregnancy were terminated, of injury to the physical or
mental health of any existing children of the family of the
pregnant woman
E There is a substantial risk that if the child were born it would
suffer from physical or mental abnormalities as to be
seriously handicapped, or in emergency, certified by the operating
practitioners as immediately necessary
F To save the life of a pregnant woman
G To prevent grave permanent injury to the physical or mental
health of the pregnant woman.
The Human Fertlisation & Embryology Act 1990

 Section 37 of the HFEA made changes to the 1967

abortion act:
 Time limit of abortion is 24 weeks under statutory
grounds C and D
 Statutory grounds A, B and E are now without time
limit
 Fraser Guidelines (Gilllick Competence)

Those <16 may be prescribed contraception without parental

consent if:

 They understand the doctor’s advice

 The young person cannot be persuaded to inform their
parents that they are seeking contraceptive advice
 They are likely to begin or continue intercourse with or
without contraceptive treatment
 Unless the young person receives contraceptive treatment
their physical or mental health is likely to suffer
 The young person’s best interests require that the doctor
gives advice and/or treatment without parental consent
THE EXAM
 O&G PACES

 6 stations in total
 O&G probably 2/6 stations
 Combined with other specialities and GP
 15 mins/station
 5th Year PACES

4 domains of marking:

1. Clinical skills
2. Formulation of clinical
issues
3. Discussion of Management
4. Professionalism and
Patient centred approach
 Practice Case

 Miss Sarah Jones, 25 years old 13/02/1988, has

come to the antenatal clinic for her screening test
results.

 Candidate Instructions:
 Please take a brief history and explain the results of
her test: 6 mins
 Discuss further investigations and management
options: 3 mins
 Discussion with examiner: 4 mins
 Past stations: Obstetrics

 15 year old wanting TOP

 Missed miscarriage + speculum
 Pre-eclampsia
 VBAC counseling
 Recurrent miscarriages + antiphospholipid syndrome
 HIV and pregnancy (in multiple circuits)
 PE in pregnancy (confused a lot of people)
 Gestational diabetes
 Down’s syndrome screening
 Small for dates- young smoker
 Alcohol and pregnancy
 Multiple pregnancy
 Abnormal lie and ECV
 Counseling a patient with molar pregnancy
 PV discharge in pregnancy
 Contraceptive advice post-pregnancy
 Pre-term rupture of membranes
 Hyperemesis gravidarum
 Antenatal check
 Past stations: Gynaecology

 Abnormal bleeding
 Menopause
 Amenorrhoea and infertility
 Underage/pressured sex
 Sexually transmitted infections
 Urogynae – incontinence, self esteem
 Vaginal discharge
 Pelvic pain
 Subfertility
 Contraception
 Gynae oncology
 Ethics
 How to prepare

 Clerk and examine as many patients on the wards

and in clinic as possible
 Preparing for the written exam will improve your
performance in PACES
 Textbook eg. Impey - the summary pages at the end of each
chapter and the end of the book are really helpful
 PACES groups
 EMQ: books, questions
 Use the RCOG Greentop/ NICE Guidelines
 Online bank of questions – intranet and PasTest
Recommended Books
Thanks for listening!

Good luck!!

Any questions?