Obstetrics and Gynecology NOTES

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OBSTETRICS PRE-PREGNANCY AND PREGNANCY COUNSELING Unplanned Pregnancy Case: Jenny is 32-years-old and has attended your surgery for routine checks for the past 3 years. She was last seen 6 months ago for pap smear which was normal. At the time of the last consultation, the BP was 130/70 and breast examination was normal. CVS and respiratory examination were normal. Jenny is married and has 2 sons, 10 and 8. Patient Profile Name: Jenny Smith DOB: 10/04/74 No allergy Occupation: Nursing home receptionist Family history: Nil Medication: Nil PMHx: antidepressant given for 2 months at the age of 20 years old; contraception: partner has vasectomy 2004 Task a b c History -

History Physical examination (BMI 24, PT +, urine dipstick negative, BP Discuss essential issues with patient and management Abdominal pain? SORTSARA? Reflux symptoms? N/V? change in bowel movements or urine? Vaginal discharge? Symptoms of depression? Symptoms of STD (nocturia, pain, weight loss, unexplained fever)

Physical examination General appearance Vital signs ENT: Chest and lungs Cardiac Abdomen PV Urine dipstick and BSL Management Offering appropriate treatment for nausea Medications, rest and fluids Explore patient’s attititude towards the situation Ensure support is available Offer support Followup management Plans for blood test and STD screening in the future Home Delivery Case: Your next patient in GP practice is a 24-year-old lady who would like to discuss option of home delivery. Task a. b. c.

Relevant history (LMP 3months ago, confirmed by home PT) Examination findings Investigation and Management

History -

I understand that you’re here because you wanted to discuss about home delivery. Are you pregnant at this stage? When was your LMP? How did you confirm pregnancy? How were your periods before? Did you see any doctor until now? Did you take any folic acid? Do you have any history of hypertension, epilepsy, diabetes or asthma? Any past history of admissions? Do you know about your blood group? Were you ever infected with Rubella? Is this is a planned pregnancy? SADMA? Social history? Do you have enough support? Financial problems? Do you have other kids? How far do you live from the hospital? FHx?

Physical Examination General appearance Vital signs Neck and breast Chest and Lungs Abdomen Pelvic Urine dipstick, BSL and urine PT Management I appreciate your concern. Before we discuss options about home delivery, I would recommend for you to have regular antenatal care which is very important for you and your baby. As part of the routine, we will start with blood tests: FBE, Iron studies, blood group and Rh, TORCH, HIV, hepatitis B, syphilis, Pap smear if due, urine MCS, and BSL. At 18 weeks we will organize an ultrasound to check the placenta and presence of abnormalities of fetus. Around 26-28 weeks we will organize a sweet drink test for diabetes mellitus and at 36 weeks we will do a swab to detect a bug in the vagina. I would like to review you monthly up to 28 weeks then every 2 weeks from 28 weeks up to 36 weeks then weekly until delivery. You would like to have a home delivery. It is a good idea because you will have your family members and would be more comfortable for you. Usually, there is a 20-30% more chance of problems encountered during the first pregnancy and labor. During pregnancy, there might be an increased risk of having increased blood pressure, diabetes, antepartum bleeding, decreased fetal movements of the baby, and chance of twin pregnancy. All these things are potentially risky and can carry bad outcomes. That is the reason we are doing antenatal care to pick them up early and minimize the risk. Even with normal antenatal course, there are some unpredictable complications at the time of labor such as fetal distress, intrapartum/postpartum hemorrhage, obstructed labor, cord prolapse, shoulder dystocia, meconium aspiration, and such complications need urgent hospital setting with all medical staff and appropriate equipments present. If you don’t like hospitals, there are birth centers or family birthing suites or units which are small and home-like, but they have midwife and specialist if required. I would recommend you to have a safe delivery at the hospital, but at the end, it is your choice. If you still want to go for home delivery, I would advise you to stay near the hospital especially towards the end of pregnancy. You must have ambulance cover in case it is required and there should be enough support at home. We will do regular antenatal care and if there are problems during the course of your pregnancy, then it is not recommended. Reading materials. Review.

Pregnancy Counselling Regarding Timing Of Admission

2 Case: G1P0 female at 24 weeks AOG asking when to go to hospital for delivery

Arrange for followup with MW and may arrange for specialist consultation if requested

Pre-pregnancy counseling regarding a patient with epilepsy Tasks: a. b. c.

Focused history Answer patient’s questions Counsel accordingly

Focused History: Congratulate patient as it is her first pregnancy Informed consent How is the pregnancy? Any problems? Any previous miscarriages (if yes: details on why, when, AOG) Is this a planned pregnancy? Regular antenatal checkups? Workups: blood tests? USD? – results? PMHx: infections (esp TORCH), DM, HPN BLOOD GROUP Location: how far do you live from the hospital? In emergency cases, can anyone drive you to the hospital? Do you have relatives? Who do you live with at home? P/SHx: smoker? Alcoholic beverage drinker? Recreational drug use? Any medications being taken? Allergies? Last pap smear? Gardasil vaccination Counselling: Timing of delivery varies among women. Generally, at 40 weeks, women experience backache, tummy pain, and passage of mixture of water and blood from vagina Labor pains result from strong uterine contractions similar to period pain and are usually intermittent, initially after 20-45 minutes  over a period of several hours grows stronger and lasts longer  time to go to the hospital and MW will measure the time for the pain Sometimes towards the end of pregnancy there are UC that give a feeling of false pain and it is important to recognize the pattern of labor pain If you develop serious symptoms (bleeding, passing of blood clots, reduced fetal movements, or trauma)  report to the hospital ASAP Sometimes PIH can occur during 2nd and 3rd trimester. Sx are headache, visual problems, swelling  check BP urgently and treat rising BP to prevent any complications Duration of labor is not predictable because it depends on several factors: o Size of the baby o Position of the baby o Age of the female o Size of maternal pelvis o Any form of comorbid illness o Usually: 36 weeks until delivery o Check BSL (OGTT) at 28 weeks AOG, vaginal swab to check for GBS at 34 weeks) – important to predict a spontaneous and normal labor Give reading materials and write a script for vitamins

Case: 26-year-old female presented in your GP who’s known to be epileptic and is treated by sodium valproate. Over the last 2 years, she had not fits and now in your GP clinic, asking for an advice for her chances and preparation to be pregnant. Task a.

Counsel patient (include risks)

History: When were you diagnosed? When was the last fit? Description of fit (tongue bite, loss of consciousness, wetting of clothes, pre-warning signs-aura), any known triggers (alcohol, excessive effort, drugs?) when was the last assessment by her neurologist? Any known complications? Any hospital admission? All current and previous medications used and if any complications? Any previous investigations (CT/EEG and drug serum level) Menstrual history: date of 1st period (menarche)? Regularity of period? Description of cycle/period (no. of days of cycle? Days of period) any painful period? Any heavy bleeding or clots? Sexual history: are you sexually active? In a stable relationship? Any contraception used? Any known previous STIs? Antenatal history: details of any previous pregnancies? Any previous miscarriages? PMHx: any other associated systemic illnesses? DM? Hypertension? Social hx: family hx? SMADMA? Previous pap smear? Gardasil vaccination (14-26)? Blood group? Counselling tips: Remember to be positive! Tell criteria to be eligible for pregnancy o For DM: HbA1c 12 mos: investigation >24 months: infertile

How was the previous pregnancy? When did the DVT happen and how was it treated? Have you had any clotting episodes other than that? Do you have any calf pains? Shortness of breath? Recent long immobilization? Any other bleeding problems (in the family)? Contraception? Periods? Are they longer? Do you bleed heavily during your periods? Blood group? Rubella status (vaccinate and avoid pregnancy for 3 mos)? FHx of bleeding disorders? SADMA?

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We will start you on LMWH on the 14th week of gestation as a prophylactic measure until 6 weeks post delivery. It’s advised to wear elastic compression stockings during the day and avoid immobilization Labor will be in a controlled manner at 38-39 weeks. On the planned date, we will withhold the morning dose of heparin. After labor, warfarin would be given for 6 weeks (safe in breastfeeding) and we will monitor INR everyday to begin with (INR 2-3). If thrombophilia screen is positive: lifelong warfarin

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I can see that you have been trying to conceive. Is there anything in particular that concerns you? Do you think you might be pregnant now? N/V/mood changes? Irritability? Breast tenderness? May I ask if you and your partner are aware of optimal time for sexual activities? What contraceptives were you using before? How are your periods? Regular? Cycle? Any abdominal pain? Bleeding heavy? Obstetric history: ever been pregnant? Miscarriages before? I understand you are in a stable relationship. Any history of STI in yourself or your partner? PMHx or Surgical conditions especially gynecologic surgery? Thyroid problems? PCOS? FHx: infertility? Gyne problems? Recurrent miscarriages? Any pregnancy-related problems (CPD, difficult delivery) Have you noticed any recent changes to weight? Hair growth, acne? How is your appetite? Water work? Bowel habits? How is your sleep? SADM (pills, steroid, anti-psychotic) A? I can see from your notes that your BMI is a bit high. Has it always been like this or is this a new change? Anybody in family overweight? Have you ever had BP, BSL, lipid level checked? What was the result? Have you have ever had joint problem? How do you feel about your weight? How does your weight affect your life?

Diagnosis First of all, it is very good that you have come for some advice before falling pregnant. Apparently, everything seems normal except your weight. The BMI is an indicator of your healthy weight. The normal is between 18-24. If >35 it is morbid obesity that puts the patient at a very high risk of developing obesity-

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related problems (heart disease, hypertension, stroke, joint problems, DM, stress or depression). I can see that you are already worried about your weight. The obesity affects out health generally as well as related to pregnancy especially. Obese females have higher chance of developing menstrual irregularities, problems with ovulation that can sometimes lead to infertility. According to a study, around 40% of obese females have problems conceiving. Hence, it is very important for you to start losing weight now. o Set a goal: 5-10% of BW in 6-12 mos o Make dietary changes – refer to dietitian o Increase energy expenditure by exercising regularly. I will give you some written material regarding exercise o Please keep a diary of your diet and weight o Come for regular followup I want you to be aware of certain obesity-related complications during your pregnancy, during labor and afterwards. During pregnancy, you are at risk of developing: o GDM o Pegnancy-induced hypertension o Sleep apnea o Problems with baby’s growth and development (IUGR is common). We will check your BSL at 26 weeks and regularly at each visit. You will have regular ultrasound to check growth of baby. Your antenatal visits will be more frequent than other females. At 28-34 weeks, we will send you to specialist for anesthetic assessment because rate of CS is higher in obese females. We want to be prepared for that. During labor obese females have higher risk of developing: o Shoulder dystocia o Non-progress of labor o Obstructive labor o CS and its complication o More difficult to monitor HR and activity (fat obstructs signals) o Pain relief might be more difficult (more adipose, more unequal distribution) What we will do is a planned delivery in a controlled environment under close monitoring by the specialist obstetrician. A normal vaginal delivery is encouraged as much as possible, however, they will be prepared for CS After labor, there is a higher risk for you to develop: o Wound infection o Clotting problems o Postnatal depression (more common) We will give you some meds to prevent clotting. You will be encouraged to breastfeed child that helps you to lose weight and to develop good bond with baby. Come back after delivery and get wound checked. Please be aware that elective CS is preferred because it is hard to do emergency cesarean sections since it is difficult to move patient. It is more difficult to give epidural anesthesia to predict effects of medication. Please bring your partner next time to discuss further complications. Reading material Review

Pre-pregnancy counseling of SLE Case: You are a GP and your next patient is a 24-year-old patient who is a diagnosed case of SLE for 5 years. She wants to become pregnant and is seeking your advice.

Task a. b.

Counsel the patient (steroids but no longer taking it because she is symptom-free) Answer her questions

SLE in Pregnancy - Does not seem to cause exacerbations of SLE - Can adversely affect pregnancy according to disease severity - Complications: o Increased incidence of spontaneous abortions and stillbirth  related to lupus anticoagulant and anticardiolipin antibodies o Preeclampsia o Prematurity o IUGR o Perital mortality - Neonatal lupus syndrome: blood disorders and cardiac abnormalities in neonate - Increased maternal morbidity – kidney complications and pre-eclampsia - Management o Preconception counseling  symptom free for 6 months o Refer for review of drugs o Corticosteroids o Low-dose aspirin o Tests: lupus antibodies, APTI, FBE, RFTs, ultrasound o LMWH o Timed delivery Questions: - Can I become pregnant like other females? - What are the risks for my baby? - How will my SLE be affected by pregnancy? - Do I need some special medications during pregnancy? History -

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When was it diagnosed? What symptoms did you have? What treatment was given? For how long? Did you have any side effects from these medications? How many relapses have you had during the past 5 years? Have you had regular checkups with specialist? When was your last checkup? When was the last blood test done? At the moment do you have any symptoms like skin rash, joint pain, problems with waterworks? Are you on any medications at the moment? Which one and what dose (prednisolone 5mg)? When was your LMP? How are your cycles? Are they regular? How many days of bleeding? How many days apart? Are you on any contraception at the moment? Is this your first pregnancy? Any miscarriages before? How’s your general health? Any other medical conditions? Any FHx or SLE or recurrent miscarriages? When was your last pap smear? What is your blood group? SADMA?

Counseling - As you already know, SLE is an auto-immune disease which means that the body’s defense mechanism becomes active against its own tissues. There is usually inflammation of different tissues of the body especially the skin, kidneys, and joints. The exact cause is still not known but certain genes and viruses have been implicated as stimulants. It is very common in females of childbearing age (20-45).

5 contraception are using? Any history of STI in yourself or partner? Any other medical or surgical conditions? -

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SLE unfortunately cannot be cured, but it can be very well controlled with medications to prevent flare-ups. The good news is that majority of females with SLE are able to have kids. It is important that they should be symptom-free for at least 6 months before conception. There are certain risks associated with SLE: o 40% have exacerbations/flare-ups however 10% have remissions o Maternal risks: 20% develop pre-eclampsia, 2nd or 3rd (25%) miscarriages, o Fetal risks: IUGR, prematurity (50%) o Lupus-like syndrome at time of delivery (5%)  rash and abnormalities of blood cell counts. This lupus like syndrome is not SLE. This is a temporary response in the baby because of transplacental transmission of antiphospholipid antibodies from the mom to the baby. It usually resolves within the 1st 4 weeks; o congenital heart blocks: quite rare; only 2% of pregnancies are complicated by this SLE: small-vessel vasculitis which also deposits in the placenta and small clots within the placenta  IUGR, prematurity, death We will consider this pregnancy to be a high-risk pregnancy. You will be managed by the specialist throughout the pregnancy. They will decide upon the best medications for you during pregnancy. Usually, steroids are safe but dose of steroids will be managed. Sometimes, azathioprine may be used. All other cytotoxic drugs as we know are contraindicated. We will do some blood tests and ultrasounds before pregnancy and continue close monitoring throughout your pregnancy. To prevent the risk of clotting problems or thrombophilia, the specialist might start you on ASA or LMWH that you will need to continue after delivery (especially if anticardiolipin is positive). The mode of delivery and timing will be best decided by the specialist according to the baby’s condition. If they have any problems with his growth, they might intervene earlier. I am going to write some blood tests for you: FBE, UEC, Blood group, rubella antibody status, anticardiolipin antibody, complete thrombophilia screen. Refer to obstetrician. Reading material SLE association of Australia

RH-isoimmunization Counseling Case: You are a GP and a 25-year-old female comes to your clinic. She had a miscarriage 2 years ago and she wants to become pregnant again. Task a. b. History -

History Relevant management When did you have it? What was the gestational age of the pregnancy? Why was it terminated? What method was used? Where was the termination done? Any complications afterwards? Any blood transfusions or further procedures were required? Have you been pregnant again since then? How are your periods? Are the cycles regular? Any bleeding in between? I understand you’re in a relationship, what

Any surgical/PM conditions? SADMA? What is your blood group? What is your partner’s blood group? Was the previous pregnancy with the same partner as now? Did you receive any anti-D injections at that time? Any history of rubella infection before? Were you tested for rubella? When was your last pap smear? What was the result? Are you vaccinated with gardasil? Management - From the history the only problem that I noticed is that you have a blood group that might carry some problems for you and your baby in the future. Let me explain to you about blood groups. Usually in our blood, there are blood cells that carry oxygen to the body. These cells carry proteins in the surface which are named as A, B, O, AB as well as another factor known as Rhesus factor (+ or -). The blood type is determined depending upon the presence or absence of these proteins. Around 85% of the population is positive for rhesus factor. The rest are negative. This is important if your partner is carrying it in his blood. There is a 50% chance that your baby will be Rh+. Sometimes, the baby’s blood cells cross the placenta either during pregnancy, miscarriage, with trauma, or even without any cause. In that case, the mother’s immune system produces antibodies against the baby’s cells. This phenomenon is known as isoimmunization. If the mother does not receive any anti-D injections and she becomes pregnant again, there is a very high chance that these circulating antibodies reach the baby causing: hydrops fetalis, hemolytic disease of the newborn, neonatal hemolytic anemia. This results from breakdown of the baby’s blood cells. The end result of the blood cell metabolism is bilirubin which can be checked within the amniotic fluid to check the degree of hemolysis. At the moment, what we can do is to do regular antenatal tests including your blood group and your partner’s blood group. - You need to start taking folic acid 0.5mg OD from now onward. Once you become pregnant, at around 20 weeks of gestation, we will do a test that is called amniocentesis to check the level of bilirubin. If required, we will give you Rhogam or anti-D immunoglobulin, an injection to neutralize the antibodies. We will also test your blood for the level of antibodies to Rh group and titer. If titer goes beyond 1:8, we will do amniocentesis earlier, further followup testing and anti-D injections. o Kleihauer test: determine how much Rhogam is required. Tries to find out how many fetal RBCs are present within the mother’s blood. o Coombs test/antiglobulin test: done to check the level of antibody in mother’s blood.  Direct (checks the antibodies that are bound to RBC)  Indirect (check the circulating free antibodies) - Recommendations: For all RH (-) whose pregnancy progresses to 28 and 34 weeks and postpartum within 72 hours will be given 625 Rhogam injections irrespective of antibody titers. - If bilirubin too elevated: exchange transfusion - Refer to obstetrician for possible assessment. - Reading materials regarding isoimmunization. - Review

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RH ISOIMMUNIZATION INDICATIONS All Rh(-) and unsensitized who requires or with: INDICATIONS Abortion or requires D&C (give within 72 hours to 910 days) CVS/amniocentesis Threatened abortion Antepartum hemorrhage Abdominal trauma External podalic version Bleeding during pregnancy @ 1st trimester single @ 1st trimester multiple @2nd/3rd trimester @ Postpartum Pregnant women at 28 weeks 34 weeks Rh (+) baby (give within 72 hours of delivery)

DOSE 250 IU IM 250 IU IM 20 weeks: 625 IU IM 250 IU IM 625 IU IM 625 IU IM 625 IU IM 625 IU IM 625 IU IM 625 IU IM

MISCARRIAGE AND ABORTION Recurrent Miscarriages Case: You are a GP and a young 26-year-old lady presents to you in your GP clinic. She has had 3 miscarriages before. She thinks she is pregnant again because she has not had her periods for the last 6 weeks. She has a family history of alpha thalassemia. Task a.

Counsel the patient

History (miscarriages x 3 episodes around 8-10 weeks, had curettage once, irregular period 4-5weeks, Blood group B+) Case 2: You are a GP and a young 28-year-old lady presents to you in your GP clinic. She has had 3 miscarriages before at around 8-10 weeks and has had D&C done. You did some laboratory tests and she has come to collect the results. Investigation: FBE, TORCH, chromosomal analysis, APAS, TFTs, PRL, LFTs, Hepatitis B&C, Urine microscopy and culture, FBS, HIV and STDs, thrombophilia, USD of uterus. Causes: - Immune-mediated: APAS, SLE, HLA incompatibility between partners, thrombophilias, SLE - Uterine abnormalities: cervical incompetence (2nd trimester), gynecological surgeries, birth defects (septate uterus) - Infections: TORCH and STDs, Hepatitis B&C - Endocrine: DM and thyroid - Maternal age not a cause but risk factor; females who become pregnant after 40 years has 50% chance of miscarriage within the 1st trimester

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I can see from the notes that you have a history of recurrent or repeated miscarriages. At the moment, you think that you might be pregnant. Have you done a test to check for pregnancy? Do you have any symptoms like morning sickness, breast tenderness, or irritability? I understand your LMP was 6 weeks ago, any bleeding since then? Tummy pain or discharge from down below?

was your last pregnancy? How did you miscarry? Any trauma? Did you have a D&C during any of the pregnancies? Did they do an autopsy on the products of conception? During the last 3 pregnancies, did you suffer from any infections? Fever? Did you have the antenatal blood tests done? How is your general health? Any history of diabetes, thyroid problems, immune-related diseases like SLE? History of gynecological surgery? Blood group? Last pap smear? Were you on any contraceptives before this pregnancy? SADMA?

Investigations - We need to do a pregnancy test on you to confirm if you are pregnant. If it positive, I will refer you to the high-risk pregnancy clinic. If negative, I will refer you to a specialist clinic called recurrent miscarriage clinic where they will do some tests on you to find out the possible cause of the miscarriages. They might ask your partner to come in for a checkup as well. - I would ask the examiner for the results of the blood tests including FBE, Blood group, Ultrasound to check any defects of the uterus, ovaries, and fallopian tubes. I would like to run a complete thrombophilia screening (Protein C, S, antithrombin III, anticardiolipin antibody, factor V leiden – most common deficiency, blood homocystein levels), TORCH, Thyroid function tests, BSL, urea and electrolytes. At the clinic they will order HLA and karyotyping for both partners. - If PT (+): I will refer you to the high-risk clinic where you will be seen by the specialist obstetrician. Recurrent miscarriages affect 1% of all couples. Sometimes, even with extensive investigations, no cause can be found. You still have a very high chance of a normal pregnancy. After the 1st miscarriages, chances of successful pregnancy is 80%, 2nd (75%), 3rd (70%). I will ask the psychologist, midwife, and obstetrician to support you all this time whether or not you are pregnant. - One of my friend got cervical stitch, should I have it too? It is usually done in cervical incompetence where the miscarriage occurs in the 2nd trimester. We can do ultrasound earlier this time. - Referral letter - Written material Threatened Abortion Case: You are a GP and a 28-year-old female comes to you with vaginal bleeding after 8 weeks of amenorrhea. Task a. b.

Definition - >3 consecutive pregnancies lost by a female History -

How are your cycles? How many days of bleeding? How many days apart? Please tell me more about your previous pregnancies? Have you had any kids up to now with this partner or previous partners? When

c. d.

History (2pads, clots, regular periods, B+) Physical examination (moderate bleeding, clot, os is closed, uterus is normal and not enlarged, (+) CMT) Investigation Management

Case: You are a GP in a suburban GP practice. Your next patient is a 24-year-old Mrs. Jones with heavy PV bleeding for the last 24 hours. She is 7 weeks pregnant by date and she is concerned and seeks your care. Task a.

Focused history

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Physical examination Investigation Diagnosis, management, and differential diagnosis

Differential Diagnosis Ectopic Pregnancy: PV bleeding + b-hCG(+)+ os closed + empty uterus Threatened miscarriage: PV bleeding + b-hCG (+) + os closed + intrauterine pregnancy Incomplete abortion + b-hCG(+) + os open + intrauterine pregnancy + POC on examination

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Incomplete Abortion Case: You are an HMO in ED and a 39-years-old female comes in complaining of vaginal bleeding and abdominal pain. LMP was 8 weeks ago. Task a.

History -

Is my patient hemodynamically stable? Please tell me more about the bleeding? When did it start? How many pads did you use up to now? Did you pass any clots? Do you have any associated pain? Have you felt N/V/breast tenderness? Do you feel dizzy at the moment? Any fever or discharge from down below? Possibility you might be pregnant right now? When was your LMP? Are you periods regular? How many days of bleeding? How many days apart? Have you ever had spotting in between? I understand you are sexually active and in a relationship, what method of contraception do you use? Are you planning to fall pregnant? Have you ever been pregnant before? Any miscarriages? When was your last pap smear? What was the result? What is your blood group? Any past medical or surgical condition especially any bleeding disorders, thyroid problems, gynecological conditions. FHx of bleeding disorders. Have you or your partner ever been diagnosed with an STI? Any problems with waterworks like burning, frequency? How are your bowel habits? SADMA?

Physical examination General appearance Vital signs (postural drop) Abdominal examination: distention, tenderness especially on the RIF and LIF. Any visceromegaly, bowel sounds Pelvic examination: amount of bleeding, color of blood, clots, discharge or signs of trauma? Sterile speculum, check os whether open or close; POC; any mass or lesion over the cervix; bimanual examination checking for size, shape and position of uterus; adnexal tenderness or mass; cervical excitation; Urine dipstick, BSL, pregnancy test Diagnosis and Management If pregnancy test positive: most likely your condition is called threatened abortion/miscarriage. Your pregnancy test is positive, but because of your bleeding, we need to admit you to the hospital to do some tests which include FBE, U&E, blood group, USD of the pelvis to look for the presence of a fetal sac within the uterus and to check for cardiac activity. Depending upon the results, the OB might advise you to take rest. Sometimes, because of the attachment of the placenta to the womb, some bleeding can happen. In majority of cases (90-95%), this bleeding is quite harmless. It will stop on its own within a few days. Your pregnancy will continue without any problems, but you need to avoid stress, anxiety, and rigorous physical activity for the rest of your pregnancy. We do not need to give you any medications as it has not shown to alter the outcome in any way. If the bleeding continues, we will repeat serial ultrasound to check for fetal viability, but you will need to stay in the hospital until the bleeding stops.

If pregnancy test negative: Most likely, this is a delayed period. Sometimes, due to stress and with the use of the pill, your periods can become irregular. If it continues for the next 2 or 3 cycles, you will need to see the specialist gynecologist. She might decide to start you on regular OCPs to regulate the cycle.

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History (lower tummy, comes and go, started 12 hours ago; 4-5 pads/day; periods every 28-30 days, no easy bruisability or bleeding disorders) Physical examination (distress, pale and in pain; BP 80/50, os open with POC, PR:80  vasovagal shock; size of uterus is 8 weeks, mobile, no adnexal masses/tenderness; no CMT) Diagnosis and management Is my patient hemodynamically unstable? When did the bleeding start? What is the color of the bleeding? How many pads did you used since then? Were they fully soaked? Did you pass any clots or pieces of tissue? Did you bubbles or grape-like tissues? Do you have any dizziness, SOB or fever? Is it the first time? Where is the pain? Is it there all the time or does it come and go? Does it go anywhere? How severe is the pain from 1-10? Anything that makes the pain better or worse? Any trauma or intercourse before the bleeding? Are your periods regular? When was your LMP? How many days of bleeding? How many days apart? Do you have heavy periods? Are you sexually active? Are you in a stable relationship? Any contraception used? Have you or your partner ever been diagnosed with STDs? Any chance you could be pregnant? Do you know your blood group? Have you ever been pregnant before? Any miscarriages? Do you have N/V/ or breast tenderness recently? When was your last pap smear? How’s your general health? Do you have any FHx of bleeding/clotting problems or miscarriages?

Physical Examination - General appearance - Vital signs - Abdomen - Pelvic  remove POC immediately!!! - Urine dipstick Diagnosis and Management - Admit the patient - Start IV fluids and take blood for grouping and crossmatching - Give oxytocin or ergometrine or (Syntometrin) to stop bleeding - Refer to OB&Gyne registrar for curettage - From history and examination, I am sorry to say that this is a miscarriage. Most of the miscarriages occur without any obvious reason. Let me reassure you that it is not your fault. You did not do anything wrong. So please do not feel any sense of guilt. Most likely in the first 14 weeks, the reason of miscarriage is due to chromosomal abnormalities. I have admitted you, informed the registrar, and sent all the bloods for necessary investigations. They will probably take you

8 to the theater and do a procedure called curettage. They will empty whatever is left in the uterus to prevent any complications. We will wait for your blood group report to come and if it is negative, we will give you an injection called anti-D.

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Can I still get pregnant? Yes, you can still get pregnant but it is advisable to wait for at least one normal period before you get pregnant again. I know it is a very hard time for you. Do you want me to call anyone for you? Do you have enough support? Being 38 years old puts you at a higher risk of your child having Down syndrome. So in your next pregnancy, it is advisable for you to consider doing Down Syndrome screening.

Critical error: - Not considering anti-D - Not taking out POC immediately - Doing unnecessary investigations like beta-hCG and USD EXTRAUTERINE AND ECTOPIC GESTATION Ectopic Pregnancy Case: A 23 years old female has recently been discharged from the hospital after a procedure where the right Fallopian tube was removed because of an ectopic pregnancy. The left ovary on the ultrasound showed the presence of corpus luteum. The patient wants to know why it happened to her. Task a.

Talk to the patient and explain about ectopic pregnancy and its causes.

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From the notes, I can see that you have recently undergone a procedure to remove a right ectopic pregnancy. How are you feeling at the moment? How are you coping with the loss of this pregnancy? I understand why you want to know why it happened to you. Do you know what ectopic pregnancy means? Usually, the egg from the mom and the sperm from the dad meet within the tubes to form the fetus. This fetus then travels and becomes attached to the wall of the womb. Due to certain reasons, sometimes, the fetus implants within the tubes. It is then called an ectopic or extra-uterine pregnancy. The size of the tube does not allow the fetus to grow therefore it may rupture and leads to a lot of bleeding and other complications. For you fortunately, such complications were prevented and the tube was removed. Please don't worry. You still have a chance of normal pregnancy. The risk factors for ectopic pregnancies are: previous history of PID and STI (increases risk 7x), previous surgeries of gynecologic nature especially around the tubes, history of endometriosis, IUCD use, use of emergency contraception (causes retrograde contraction of the Tubes), embryonal defects, previous history of ectopic pregnancy in the opposite tube. In most of the cases (97%), ectopic pregnancies are found within the tubes. Sometimes, they can be found in the ovary, peritoneal cavity, and on top of the uterus For your next pregnancy, the chances of conception are around 50%. Please remember that even one tube can catch the eggs from the opposite ovary. You need to wait for at least 3-6 months before trying to conceive. Give yourself some rest and have a healthy balanced diet. You can use OCPs but please avoid IUCDs, Emergency pill and POPs.

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When you miss your next period, please come and see me ASAP. We will do some tests including serial beta-hcg done starting day 5 of conception. We would like to record the quantitative increase in beta-hcg

which usually rises every 48 hours. If it doesn't, then we will do USG, progesterone (low) and CA-125 (rises during impending rupture) The gold standard for diagnosis remains to be laparoscopy. If we find that the next one is ectopic as well, depending upon the fetal viability and damage to the tube, the specialist obstetrician might decide to inject MTX within the gestational sac that will help in resorption of the fetus protecting the tube. If you develop tummy pain, vaginal bleeding, episodes of fainting or dizziness, or back pain (interscapular area), please come to the hospital right away because these are symptoms of early ectopic pregnancy. The best option would be IVF if your opposite tube is removed. Please be optimistic. You still have a very high chance of having a normal pregnancy. General risk for ectopic pregnancy: 1%; chance of recurrence: 10-20%

ANTEPARTUM AND OTHER COMPLICATIONS IN PREGNANCY Antenatal Care: Do beta-hCg (quantitative or qualitative) Down Syndrome risk: o @37: 1:200 o @40: 1:100 o @45: 1:50 Screening for down syndrome: HR: 1:200 or higher o 1st tri: 80% predicted  10-12 weeks: PAP-A and betahCg;  12-13 weeks: USG (nuchal translucency  aneuploidy) o 2nd tri: 60-70% predicted  QUAD screen @14-20 weeks: AFP, b-Hcg, estriol, inhibin A (ACEI) May do dating usg during first visit Amniocentesis (0.5%)/CVS (1%): risk of miscarriage Blood group o If (-): repeat blood at 28 weeks; then give anti-D; repeat blood antibody screen at 34 weeks (2nd injection of anti-D)  prevent spontaneous transplacental hemorrhage  2nd tri: 12-15% fetal RBCs can be found in maternal blood resulting in isoimmunization  3rd tri: 20-30% o Give anti-D after delivery FBE: consider anemia (r/o hemoglobinopathy) o Check the partner and check for trait Screen for infections: Rubella, HIV, Hepatitis, hepatitis B&C, syphilis o If HbsAg (+) check partner for hepatitis b antibody; talk about safe sexual practice o For hepatits b&c  refer to infectious specialist MSU for micro&culture: asymptomatic bacteriuria (or in 6-8%) (+) if >100,000 col/ml; tx because increased likelihood of getting severe UTI (e.g. pyelonephritis) Vitamin D levels: N: 70u; severe 42-43 weeks perinatal mortality doubles; o Concern at 41-42 weeks: do fetal well-being USD measuring umbilical artery flow (SD ratio: difference between peak systolic flow and end-diastolic flow), AFI and CTG

Antenatal checkup Case: Your next patient in your GP practice is a 24-year-old female who is 8 weeks pregnant. You saw her last week as a part of her regular antenatal checks and ordered some blood tests. Today she is here to know about the blood results. Her health and pregnancy have been good so far. She is so excited about having a healthy baby by the end of her pregnancy. Her results are as follows: FBE: Hgb 120, WBC 8000, Plt 170,000 UEC: Na 145, K 4.4, Cl 130 LFTs: normal BSL: 4.3 Blood group: A-; Antibody screening test (-) IgG (+) for Rubella and Varicella Urine: MCS show GBS positive HBV and HCV: negative Task a.

Explain result and advise on management

Management Congratulate on her pregnancy Give anti-D at 28, 34 weeks and 72 hours after delivery if child is Rh (+) and if there are bleeding episodes If antibody screening test positive: measure the titers using ELISA (1:8 or 1:16 or 1:32 then check bilirubin by doing o Amniocentesis: check bilirubin; o Umbilical cord sampling: Hct (25%) o MCA ultrasound: check velocity of blood flow -- if there is hemolysis heart pumps faster then velocity increases; less invasive Urine MCS: positive for GBS (asymptomatic bacteriuria) -- treat with antibiotics because of risk of developing pyelonephritis (Cefalexin/Augmentin/amoxicillin) - Repeat culture after 1 week - General advise for UTI - Check partner’s blood group - Advise on antenatal checkup - Dietary advice, smoking and alcohol - Down syndrome screening  if older patient First Antenatal Check Up Case: Mrs. Hasim a migrant from Sudan presents to your GP clinic for her fist antenatal visit. Task a. b.

Take History Your management in pregnancy

She is a professional boxer for 10 years. “Can I do exercises?” “Can I eat sushi?” “How about weight gain?”

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Mrs Hasim, Do you need interpreter? I understand you have come to see me regarding pregnancy. Is it your first pregnancy (Yes)? Was it planned (Yes)? Congratulations! When was your LMP (8 weeks ago)?

Period questions: Do you have regular cycles? How long is the cycle? How long is the bleeding time? Any spotting in between? Do you have excessive pain or bleeding during the period? How did you confirm your pregnancy (I did pregnancy test at home)? Good on you! Pregnancy symptoms: Do you feel tired, nausea? Have you vomited? Breast tenderness? Tummy pain? How’s your water work? Do you have regular bowel function? Do you have unusual vaginal discharge or bleeding? What type of contraception did you use before you got pregnant? Have you been diagnosed with STD? When was your last PAP smear (If no for last 2years do it now!)? Do you know your blood group? Have you had Rubella in the past or have you receive vaccine for it? Any serious illnesses or surgeries in the past? (Heart, HTN, DM, anemia.) Is your husband generally healthy? Are you on any medication? Are you taking folic acid? Are you allergic to anything? Smoking, Alcohol and drugs? How many cups of coffee do you drink per day? What do you do for a living? When did you migrate to Australia? Do you have any family members or close friends here? Has anyone in the family had twin pregnancies? Has anyone in the family had pregnancy complicated by DM, HTN, birth defects?

Management - We need to order some routine lab tests to identify any issue which needs to be addressed for the best outcome of your pregnancy. o FBE exclude anemia. Hb. Iron deficiency Supplement. o Blood group and RBC antibodies. If you are Rh-you need anti-D immunoglobin prophylactically to prevent problem in future pregnancy. Repeat antibody test in 26weeks. o Rubella status if you are not immunized to rubella, I recommend you receive rubella vaccination after delivery. (Contraindication during the pregnancy) o We will also do syphilis, Hepatitis B and C and HIV screening. o Vitamin D level. o Midstream urine to check urinary tract infection. Sometimes it can be asymptomatic but need to be treated in pregnancy. 30% of asymptomatic UTI can become symptomatic. o There’s another test which we offer in every women in Australia. It’s a Down’s syndrome screening test. Would you like to do it?  1st trimester: Pappa, beta HCG, Ultrasound  2nd trimester quad. Test(1518weeks): beta HCG, AFP, oestradiol, inhibin A o You also need 18-20weeks mid pregnancy ultrasound to make sure baby develops

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properly and to look for position of the placenta. At 28weeks we screen for Gestational Diabetics: sweet drink test/glucose challenge test. At 36 weeks you will need to be advised to do a low vaginal swab to check for a bacterial infection called GBS. If found you will be given antibiotics prophylactically during delivery.

You need to take folic acid 0.5mg for the 1st 3 months of pregnancy because it decreases the occurrence of neural tube defects. Moderate exercise is good for you because it improves cardiovascular and muscle strength. Best exercises are low impact aerobics, swimming, walking and yoga. No contact sport because of risk of trauma. Weight gain should be around 11-16kg during pregnancy. But it all depends on your pre-pregnancy state. Your diet is important, it should be well balanced. Food rich in protein, dairy food, starch food (potatoes) and plenty of fruits and vegetables. Best avoid a lot of sugary, salty and fatty food. Food delicacies: uncooked meat, egg, soft cheese, shell fish and raw fish should be avoided as they are potential sources of Listeria and Salmonella. No smoking, alcohol and drugs. What about my sexual life? Sexual life is acceptable and normal during pregnancy just follow your normal desire. Can I see a dentist? See your dentist in case any dental care is required and it can be carried out in the first half of the pregnancy.

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Do you have enough support? I understand you live 80km away, how long does it take to go to the nearest hospital by car? Can anyone drive you to the hospital in case of emergency? Do you have any friend or relatives who live near the hospital where you could relocate a few days before the due date? Is there anyone at home who will look after your first baby when you are in the hospital?

Case: your next patient in GP practice is a 24-weeks pregnant lady who has just moved into your town. She has come to see you as her first GP. She lives 80km from the main hospital

Counseling The first pregnancy is usually longer as compared to succeeding ones. However, there are some warning signs: if you have any contractions,any passage of mucus or water, vagina bleeding, any reduction in fetal movements, any sort of tummy pain, headache, blurry vision, cloudy urine, or other warning signs, you have to come to the hospital straight away. The plan for your pregnancy is to come every month until your28th week, then every fortnightly from 28-36 weeks and weekly after 36 weeks and until delivery. At 28 weeks, we will arrange a sweet drink test and around 34-46 weeks, we will do the vaginal swab to detect the bug called GBS. If there are no warning signs as discussed before, it is advisable to either relocate close to the hospital if you have friends or relatives or get admitted to the hospital a week or so before the due date. Will I have a long labor this time as well? With regards to your delivery, the exact duration of your labor is not easy to predict as it depends on several factors at the time of delivery such as medical conditions, size of the baby, size of the pelvis, presentation of the baby, and strength of the contractions. But usually, the duration of labor in 2nd pregnancy is shorter compared to the 1st. Right now everything sounds good. I will see you in one month time and give you a few reading materials.

Task

Down Syndrome Screening

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Timing of Admission to Hospital

a. b. c. History -

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Relevant history (folic acid, regular checkup, normal USD and blood tests; history of prolonged labor because of poor contractions; instrumental delivery) Advise when she immediately needs to attend the hospital or midwife Answer her question Congratulations on your pregnancy. I can see that you’re concerned about when you should go to the hospital for delivery. I understand that you live 80km away from the hospital. Before I address your concern, is it okay if I ask you some questions? How is your pregnancy going so far? Was it a planned pregnancy? Are you attending regular antenatal care? How were the blood test results? Anything significant? Do you know your blood group? What about the 18 th week USD? Is it a single baby? Is the placenta in the normal position? Any tummy pains or trauma so far? Any discharge or bleeding so far? Any leakage of fluid down below? Any headache, BOV, N/V? Any urgency, frequency or smelly urine? Did you take folic acid? Is your baby kicking well? Any previous pregnancy or miscarriage? How was it? Was it term or preterm? Do you know the reason for the prolonged labor? How was the baby after delivery? Any complications? What was the BW? Any previous medical or surgical issues like BP, DM? Any problem with your periods? Are you on any medications? SAD

Case: A young woman at 10 weeks’ gestational age comes to see you in your GP practice. She is concerned about having a baby with Down syndrome as recently, her sister had a baby with Down syndrome. Task a.

Counsel patient

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Is this a planned pregnancy? Congratulations. I understand from the notes that you are here to discuss about Down syndrome screening. I appreciate your initiative to do that. I understand your anxiety. I will give you all the information regarding the tests which can be done and how effective they are. How is your pregnancy going so far? Are you getting your antenatal care? Are you done with your blood tests? Any concerns or issues? Down syndrome is one of the common genetic abnormality with trisomy 21. There are some indications in doing Down syndrome screening in pregnant women: o Increased maternal age (>30) o Previous down syndrome baby o History of down syndrome in the family We have screening tests and confirmatory tests. In the first trimester, there is a triple test a blood test which is done at 9-13 weeks AOG. We check free beta-hCG Pregnancy Associated Placental Protein-A. We

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11 combine it with Ultrasound and it is done at 11-13 weeks AOG. Here we check for fetal nuchal translucency. Screening tests can also be offered in the 2nd trimester between 15 and 17 weeks. These tests are not 100% confirmatory. In high-risk pregnancies, we can offer diagnostic tests: CVS or amniocentesis.

o o

Baby: Macrosomia, Multifetal gestation, Malpresentation (breech, face, brow, transverse lie) Labor: Power, Passage, Passenger

Eligibility: 1 previous LSTCS and NO contraindication Induction of labor: Risk of uterine rupture especially if induction of labor with prostaglandin E2, oxytocin + amniotomy and misoprostol is used o Classic (5%) o LSTCS (0.5%)

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CVS done ideally at 9-11 (11-12 at clinical book) weeks o results within 24 hours o more accurate o 1% risk of abortion Amniocentesis o Done ideally at around 14-15 o Longer (up to 3 weeks) and less accurate o 0.5% risk of abortion 3 regimens: o PAPPA and free hCG at 9-13 weeks o Nuchal thickness at 11-13 weeks (combined tests raises detection rate from 70 to 90%) o If calculated to be more than 1/200-250  woman is offered CVS if gestation between 11 and 14 weeks or amniocentesis if at 1516 weeks o Combined test: AFP, unconjugated estriol and beta-hCG + Inhibin A at 15-20 weeks  increases detection rate from 65 to 7580% if inhibin A included If previous pregnancy was down syndrome, the risk of having Down syndrome in the next pregnancy increases by 1%. o

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Vaginal Birth After Cesarean Section (VBAC) Case: You are a GP and a 28-years-old lady with previous cesarean section 2 years ago is in your GP clinic. She is now 7 weeks pregnant and she wants to have vaginal birth. Task a. b. c.

History (CS due to fetal distress, pap smear x 1 year ago with Ask examiner for previous medical/surgical notes of the LSTCS (obstructed 2nd stage of labor hence underwent CS, Apgar 6,8 BW 3kg, no CPD) Discuss possibility of vaginal birth to patient

Predictors of successful VBAC (55-85%): Non-recurring indication of CS (e.g. malpresentation) PIH Previous vaginal birth Institutions in which success rates is high Onset of labor is spontaneous Contraindication Previous classic cesarean section birth Some uterine surgery (hysterotomy, deep myomectomy, corneal resection and metroplasty) Previous uterine rupture or dehiscence Maternal or fetal reason for elective CS in current pregnancy o Mother: PIH, Diabetes, Antepartum hemorrhage (previa/abruptio)

History -

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Mechanical cervical ripening device may be used safely 1/5 of patients end up having cesarean section Congratulations. Is it a planned pregnancy? What about first pregnancy? Was it your first? Was it a planned pregnancy? Did you have regular antenatal checkups? Complications of pregnancy (DM, hypertension, bleeding)? Why was the CS performed? Was it an emergency? Do you know the type of cesarean section? Complications of surgery (infections, bleeding, DVT)? CPD (height of partner and patient)? How was the baby at birth? Any resuscitation needed? History of previous uterine surgeries or rupture? Are you taking folic acid? How is your general health? Any medical condition you have at this moment? Why do you want to have vaginal birth?

Findings from Examiner Reason for cesarean section Classical or Low-segment cesarean section Age of gestation Complications: anesthetic, infection, hemorrhage, damage to the adjacent organs like bladder, large intestine etc, DVT Baby: weight, apgar score, resuscitation done Management At this stage we are not sure about the outcome of the pregnancy as it depends on its progress. However, in majority of cases and in your case, successful vaginal birth can be achieved safely. The success rate ranges from 55-85%. I will do antenatal screening tests and will monitor you during your antenatal visits to look for certain conditions which can pose a risk during vaginal delivery or which can be an indication for cesarean section. If any of these are present, you will be managed as a high-risk pregnancy. I will arrange an appointment with an obstetrician at 26 weeks for discussion about possible mode of delivery and at 36 weeks for definite decision regarding vaginal birth. The specialist will explain the risks and benefits of the mode of delivery to you and the final choice will be made according to your wishes and advice of the obstetrician. If vaginal birth is decided, it will take place in a well-equipped hospital under supervision of an experienced obstetrician because vaginal delivery can progress to cesarean section in 1/5 of the cases. Folic acid prescription Reading material Review

12 Ovarian Cyst in Pregnancy Case: You are HMO in ED. 25yo female 8weeks pregnant c/o pain in the right lower abdominal pain. Task

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FBE, Serum beta HCG. U/S of pelvis and abdomen looking at evidence of intrauterine pregnancy, rule out ectopic pregnancy, ovarian cyst, fluid in the pouch of Douglas. Tumor markers: CA125, LDH

Diagnosis and Management a. b.

Take history Ask for Physical Findings (All vitals stable. Healthy looking. Abdominal examination: Tender in the right iliac fossa. No organomegaly. Per speculum: no discharge, no bleeding, no poc, os is closes.)

c.

Ask for one relevant investigation findings ((U/S: Intrauterine pregnancy, Cyst in the right ovary 5cm in size, no fluid in the pouch of Douglas) Talk about relevant management

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Differential Diagnosis UTI Ectopic pregnancy

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History -

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Is my patient haemodynamically stable? Pain questions: How bad? 5-6/10 dull kind of pain not radiated. Where? Go anywhere else? Does anything make it better or worse? When did it develop? Is this the first time? Any associated symptoms eg fever, N/V, bleeding from down below, discharge from down below? Problems with water work: burning or frequency? Bowel habits: history of constipation? I understand from notes you are 8 weeks pregnant. When was it confirmed? At the moment do you have symptoms like morning sickness, irritability, breast tenderness? Is this a planned pregnancy? Is this the 1st pregnancy? Any miscarriages before? History of ectopic pregnancy? LMP? Are they regular? When was the last PAP? Result? How’s your general health? PMHx: appendectomy. Have you or your partner ever dx with STD. History of pelvic infection or gynecological procedure done for yourself? SADMA? Blood group? Which contraception were you on before the pregnancy? Gardasil?

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Physical Examination -

General Appearance: pallor jaundice dehydration Vitals: ask all vitals. If suspect appendicitis ask for Pulse and BP. Abdomen: Any visible distension, mass, scars? Palpate any tenderness especially McBurney’s point. Pelvic examination: o Inspection: Any discharge, bleeding? o Sterile speculum: discharge, bleeding, POC, OS o Bimanual: Any tenderness, adnexal mass, position and size of the uterus

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From history and physical examination, most likely your pain is coming from a cyst within the ovary. Ovarian cyst is usually a benign condition where a fluid filled sac is found near the surface of the ovary. It’s quite common in female of reproductive age group the exact cause is unclear. However, the hormonal

changes during pregnancy can sometimes be responsible. Rarely certain types of nasty growth may develop within that cyst however the chances are very low at your age. The management depends upon the size of the cyst, your symptoms, and the opinions of the obstetrician According to JM o If it’s a simple cyst 5cm recommend a u/s guided aspiration. o Complex cysts irrespectively to size, excision laparoscopically o Any symptoms or U/S evidence of torsion of cyst: laparotomy and removal of cyst For your case, because your cyst is still around 5cm and your symptoms are controllable (pain killers given). I’ll ask obstetrician to come to see you. Most likely they will advice careful monitoring to lookout for any symptoms of torsion which are: severe pain all over the tummy, recurring pain, symptoms of shock (fainting, low BP). The risk of torsion is around 1015%. At the moment once your pain settles down we will send you home. However, you need to report back to us if any symptoms develop most likely you will need to undergo surgery in that case. Usually laparoscopic surgery doesn’t affect early pregnancies. However, slight increase risk of miscarriages. But we will give you certain hormones to help maintain the pregnancy (progesterone). Do the Surgery after 15weeks with progesterone therapy. I want you to be aware of some other complication of ovarian cyst: Infection: fever, and increasing pain, Cyst might rupture, twist on its axis compromising the blood supply to the ovary. However, around 80-95% of ovarian cyst that presents to us resolves spontaneously. Review: in 6 weeks for U/S.

Alcohol Excess in Pregnancy Case: Your next patient is a 10 weeks old pregnant lady who came in for antenatal checkup. She is alcoholic beverage drinker and a smoker for the last 10 years. Task

Investigation: U/S: Ovarian Mass Ask the examiner for Doppler U/S: To see the blood flow to the ovary(torsion), To determine the nature of the cyst: homogenous mass(simple cyst) or a complex cyst (malignant in nature).

a. b. c.

History (planned pregnancy; first pregnancy; not a binge drinker; drinks with partner; cannot go without alcohol for one day Advise management Focus on issues

13 History -

Can you tell me a bit more about it? Is it a planned pregnancy? Is it your first pregnancy? I would like to ask you a few more questions especially with your smoking and drinking habits. Is it alright with you? For how long have you been drinking? How much do you drink per week? What type of alcohol do you drink? Do you drink a lot on the weekends? Do you drink alone, with partner or with friends? Are you aware of the safe level of drinking? How long can you go without alcohol? Do you need it to steady your nerves? Does it help you go to sleep? Do you take a drink in the morning when you wake up? Any symptoms of agitation, sweating, nausea, or shakes if you don’t drink?

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How’s your family life? Any problem at work or with family relations? Any financial issues? CAGE? Have you ever tried to cut down? Ever been annoyed? Do you feel guilty? Do you drink when you wake up in the morning? Do you know about its effects in pregnancy? How many cigarettes do you smoke per day and for how long? What is your pattern of smoking during the day? How soon do you have your first cigarette when you wake up? Do you find it difficult to smoke in nonsmoking areas? Have you tried to quit smoking in the past? Does your partner smoke? Any medical condition such as liver, gastrointestinal, heart? Any history of mental illness or depression? DM? Hypertension? Are you on any medications? do you take folic acid? Have you used illicit drugs?

Counseling I would like to talk about the effects of smoking and alcohol in pregnancy and I would also like to do investigations that we do during the first antenatal checkup. The effects of alcohol: In pregnancy, alcohol can pass through the placenta to the baby and is broken down more slowly than in adults leading to fetal alcohol spectrum disorders. On one extreme is fetal alcohol syndrome which is main cause of mental retardation in babies. The other effects include vision and hearing problems, learning, emotional and behavioral problems, speech or language delays, low BW, and birth defects including heart, face, eyes and other organs of the body. In pregnancy, there is increased risk of miscarriage and premature birth. After the birth of the baby, breastmilk production can also decrease. Unfortunately, smoking exposes the baby to some dangerous chemicals like nicotine, tar, and CO which decrease the amount of oxygen for the baby which can affect his/her development. It can also damage baby’s lungs and can give rise to birth defects like cleft lip and palate, low BW, and once baby is born, there is increased risk of chest infection like asthma, pneumonia, and ear infections. In pregnancy, smoking is a risk factor for placental abruption and stillbirth. Also, there is an increased chance of SIDS if parents are smoking and drinking. I know you are quite worried about hearing all this, but the good news is that all of these can be avoided if you stop smoking and drinking alcohol. The ideal situation is if you stop smoking and alcohol altogether if possible for you. The sooner you quit the better it is for you and your baby. There is no known safe level of

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alcohol use in pregnancy. (Limit to 1 SD per week but any reduction is important). Suggestions on how to quit: It is important to understand the effects of alcohol and smoking and admit it as a problem for you and your baby. Strong motivation is the key to success. After making a decision, establish clear and realistic goals and I will help you implement them to stop alcohol and smoking altogether. Choose a quit date for both alcohol and smoking to stop. I can arrange a family meeting to talk to your partner and advise him to stay away from alcohol and smoking. Avoid situation where you usually drink alcohol like party and bars. Ask family and friends to help you quit. Let your family members, friends, and coworkers know that you’re trying to stop drinking and smoking.

You can experience withdrawal symptoms like headache, shaking, sweating, N/V, anxiety, tummy pain, diarrhea, problem with sleeping, high and low BP, craving for alcohol and smoking. When you experience these symptoms, please immediately contact me so appropriate treatment could be given. Lifestyle modification: Deal with stress in a healthy way like exercise, sports, meditation and yoga. I will refer you to alcohol anonymous. It is an organization composed of groups of people having problems with alcohol and who desire to stop it. I will also refer you to support groups – quitline for smoking and give you some reading materials. I’m available for you for ongoing management and support for followups. RWH: o Sometimes it is not possible to stop altogether. o Avoid dehydration by drinking plenty of water o Vitamin D, iron and calcium supplementation o Folic acid for the first 3 months o Nicotine replacement therapy shouldn’t be used in pregnancy but may refer to specialist for advice o Medications for withdrawal: Acamprosate (champix) or naltrexone for 6-9 months;

Pregnancy with IUCD Case: A-26-year old female comes to your GP clinic complaining that her period is late. She has copper IUCD inserted. Task a. b. c.

Take focused history Ask for physical examination (size of uterus is 7 weeks, no adnexal mass) Advice the management

Case 2: Same Scenario You can see the thread of the IUCD History: - Hi. I know you are here to see me because you are concerned about your period. When was your LMP? Was it normal or light? Do you have regular cycles? How long is the cycle? How long is the bleeding time? Any spotting in between? Do you have excessive pain or bleeding during the period? When did doctor insert the contraceptive device? Did your period change after the insertion? When was the last time you checked strings or thread? - Pregnancy questions: Do you feel nausea, vomiting,

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breast tenderness? Increase urinary frequency? Any abdominal pain? Have you notice usually vaginal discharge? Did you do pregnancy test? Have you ever been pregnant? Are you in a stable relationship? Have you ever been diagnosed with STD or PID? When was your last PAP smear? Do you know your blood group? Are you generally healthy? Any pelvic Surgery, Csection done before? Medication? Allergies? What would be your intention if you are pregnant?

Physical Examination: - General Appearance - Vital Signs - Palpate abdomen: Distension, Tenderness, Masses

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Pelvic examination: o Inspection o Speculum: Appearance of cervix, OS, The presence of the string o Check vaginal discharge o Check if thread is present! o Per Vagina: Size of the uterus (7weeks) Consistency (soft) Adnexal masses and tenderness. Urine dip stick and Urine pregnancy test (+)

Diagnosis and Management - Jacky your pregnancy test is positive. And I can see a string which means contraceptive device is in place. How do you feel about it? - Unfortunately every contraceptive method has a failure rate. Effectiveness of IUCD is greater than 98% but there’s still a chance for being ineffective. You don’t need to make a decision now. You can go home and discuss it with your partner. I will organize a pelvic ultrasound for you to identify the exact position of pregnancy and position of the device. If you decide to continue with pregnancy the device should be removed. - Is it safe? The procedure doesn’t increase the miscarriage rate above that in population. (Every pregnancy carries 15-20% risk of miscarriage.) However if it is left inside it will increase the risk of miscarriage to up to 25% and increase risk of ascending infection. If you decide not to continue with the pregnancy, I will refer you to a specialist for termination and the device will be removed during the procedure. Case 2: NO thread - Jacky, your pregnancy is positive and I can’t see strings of device. Two options are possible. Either uterus expels the device (because device is a foreign body) or string loss and you are pregnant with device still in place. To find out I need to organize pelvic ultrasound. How do you feel about pregnancy? - What if device is still inside? We wouldn’t be able to remove it if it still has strings but an attempt to remove it will be made. But without strings it’s impossible to remove the device safely without harming pregnancy. However pregnancy can be continued but there’s high risk of miscarriage and ascending infection. If pregnancy will be successful device will be delivered with the placenta and membrane. If you decide not to continue with pregnancy I will refer you to a specialist for termination. Hyperemesis Gravidarum

Case: 38 year-old woman who came in with a 2-week history of nausea and vomiting. She is 8 weeks pregnant and her pregnancy is consistent with GA. She has no previous illness. Task a. b. c.

History Investigations (1 only) -- MSU Diagnosis and management

Differential diagnosis: - Multifetal pregnancy? - Hydatidiform mole (complete/incomplete) - UTI - Infectious Gastroenteritis - Brain tumor/Addison disease

History: - IS MY PATIENT HEMODYNAMICALLY STABLE? - Congratulations on your pregnancy. - How many episodes of vomiting did you have per day? Is it getting worse? Is it in the morning or throughout the day? What is the content? Do you have fever? Diarrhea? How is your appetite? Are you still drinking eating or drinking? How is your waterworks? Any pain or burning sensation? Any increased frequency? Any change in color of urine? Any loin pain? Did you eat outside? - Pregnancy: is this a planned pregnancy? How did you confirm your pregnancy? Any family history of twins? Is the pregnancy natural or assisted? Any abdominal cramps or vaginal bleeding? - Periods? Pills? Partner? Pap smear? Blood group? - SADMA? Examination: - General appearance: tired, signs of dehydration (tongue, skin turgor, CRT? - VS: BP (check for orthostatic hypotension); PR (tachy), RR, T – normal - Chest, heart, abdomen – normal - No pelvic exam needed. - Urine dipstick – nitrites, ketones (+), leukocytes o MSU: (+) for ketones! – admit!!! Investigations: - MCU - Ultrasound examination - Test for electrolytes, urea, LFTs Diagnosis and management: - You have a condition called hyperemesis gravidarum. It means excessive nausea and vomiting in pregnancy. These are common symptoms during initial pregnancy. However, 1 in 1000 women will have excessive vomiting and require hospitalization. - On examination, you are dehydrated and this was confirmed in urine analysis, so we need to admit you. I will organize an ambulance. In the hospital they will secure 2 IV cannulas, take the blood for FBE, U/E/, RFTs and LFTs because dehydration can affect the liver and kidney. We need to do MCS to rule out UTI and USD to confirm intrauterine pregnancy, rule out multiple pregnancy and molar pregnancy. - They will also give medications to stop the vomiting (metoclopramide – mexalon, stemetil) and start IV fluids and vitamin B6 (pyridoxine). - We don’t know the exact mechanism behind it. However, it is usually due increased level of b-hCG

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which is one of the pregnancy hormones. Once the body has become used to the new environment, the nausea and vomiting settles and this usually happens by 14 weeks. You are a 38-year-old mother and that puts you at a very high risk of having a baby with Down syndrome. So I would like to offer you screening for Down syndrome (during your 10th week – blood plus USD).

Critical Errors: - Failure to recognize need for hospitalization - Failure to do ultrasound and urine examination Generalized Edema in Pregnancy Case: A 35-years-old primigravida who is 32-weeks-GA is in your clinic complaining of increased swelling in the body for the last few days.

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Management From history and examination, most likely you have a condition called generalized edema of pregnancy. It typically involves the lower extremities but occasionally it can cause swelling of the face and hands. There are a few reasons such as hormoneinduced sodium retention, increase of blood volume by 50% during pregnancy, and enlarged uterus may compress the veins (IVC) when you’re lying down obstructing blood flow and causing the edema.

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Task a.

b.

c.

History (both legs and face; decreased when lying and on left lateral position; no headache, visual problems, tummy ache, had regular antenatal checkups, one pregnancy, normal placenta, folic acid, sweet drink test normal, no contraceptive, 1st pregnancy, last pap smear was one year ago and normal, no general medical health condition, no HTN; social support is ok and no financial issues; no problem with waterworks or BM? No fever? Physical examination (generally well, mild generalized pitting edema of the especially both legs, BMI is 27, PR 80, T37.6, BP 120/80, RR: 12, neck for thyroid swelling, no LAD, FH 32cm, lie longitudinal, cephalic, FHR 120, pitting edema, urine dipstick proteinuria negative, BSL normal) Diagnosis and management

Pregnancy/planned pregnancy Antenatal checkup/infections/medications 18 weeks ULD – placental, baby, anomalies, liquor volume, fibroid Sweet drink test Hemoglobin Pre-eclampsia Heart disease, HTN, DM, heart (CCF), liver, kidney, severe hypothyroidism History -

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Is this a planned pregnancy? Congratulations? Is this your first pregnancy? Where exactly is the edema (swelling)? Did it come suddenly or gradually? Any pain in your legs? Anything increasing or decreasing it? How is your pregnancy going so far? Have you had regular antenatal checkups? Any infections? What was the result of your midgestation USD (baby, placenta, anomalies, liquor volume, fibroids)? What was the result of your sweet drink test? What about your BP? Have you checked it recently? How’s your general health? did you have history of high blood pressure or diabetes? Do you have any recent headaches, visual disturbance, tummy pain, SOB, chest pain, or racing of heart? Do you have problems with your waterworks or bowel motions? Is your baby kicking? Do you have a kick chart? Any history of heart problem, liver, kidney or thyroid problems? Any previous DVT, surgeries or previous hospitalization? Are you on medications such as steroids? SADMA? FHx of DM or HTN?

Physical examination General appearance: pallor, dehydration, jaundice

Vital signs Cardiovascular examination and JVP Lungs Abdomen: FH, lie, presentation, FHT, tenderness Neurological examination: Reflex Peripheries: redness, warmth, tenderness in any areas Urine dipstick and BSL

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It can be reduced by intermittently lying on the left side, elevating the lower extremities intermittently, wearing elastic compression stockings, and decreased salt intake in diet. It usually resolves after birth of the baby as the uterus returns to prepregnancy size and the hormones return to normal. At this stage there is no need for investigations but if there are changes in your symptoms or if patient is concerned: Do investigations  FBE for Hb, infection, platelet, U&E, LFTs, TFTs, RFTs, Red flags: headache, blurring of vision, tummy pain, increased blood pressure, feeling unwell, baby not kicking Reading materials. Review.

Stillbirth Case: You are a GP and a 26-year-old lady comes to you 6 weeks after the delivery of a baby. The delivery was a stillbirth at around 22 weeks of gestation. The patient is still very upset about her baby’s death and she wants to know if this will happen again. Task a.

a. b.

Take history (had fever x 3-4 days continuously at 20 weeks, and started bleeding/discharge from down below; ruptured BOW; did tests and baby was already dead; ) Physical examination Counsel accordingly

Approach to Patient Who has had Stillbirth Emotional support must be ensured by offering appropriate resources or referral Take detailed history focusing on obstetric, medical and family history and conditions surrounding previous stillbirth Discuss anomaly screening with patient Discuss uterine artery Doppler studies at around 2224 week Discuss dating USD in 1st trimester Discuss lifestyle advice (smoking, alcohol, weight loss, diet) Discuss Serial USD for fetal growth monitoring (28 weeks onward) Discuss fetal movement surveillance Consider timing of birth History -

I am really sorry about the loss of your child. It is quite understandable that you feel upset about this. Would

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you like someone (a partner or a friend) to attend this discussion? How are you feeling at the moment? I understand that you pregnancy was at around 22 weeks, did you have regular checkups until that time? Did you have blood tests, and USD? What was the result? Can you please tell me what exactly happened? Did you have any symptoms like fever, rash, vaginal discharge, bleeding? Any problems like headache, visual changes, or high blood pressure during the pregnancy? Any tummy pain? Were you feeling the baby’s movement at that time? What happened afterwards? Where did the delivery occur? Did the pain start by itself or was it induced? When the baby was born, did they notice any abnormal features? Did they do an autopsy of the child? Was it your first pregnancy? Did you ever suffer from a

gynecological problem before that? Did you have any gynecological surgeries done? Any D&C done? Have you had regular pap smears? When was the last one? What was the result? Are you having bleeding now after the delivery? SADMA? Blood group? Gardasil? Any FHx of birth defects or stillborn babies?

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Intrauterine Fetal Death (IUFD) Case: You are an HMO in the ED and a 34-weeks pregnant lady comes in with abdominal pain. Task a.

Physical examination General appearance and BMI Vital signs Thyroid enlargement Chest and heart Abdomen: size of uterus (involuted), tenderness, organomegaly Pelvic exam: discharge, bleeding, speculum Urine dipstick and BSL Causes of Stillbirth Unknown Infections (TORCH) Cervical incompetence Fetal growth restriction (IUGR) PIH Placental insufficiency Thrombophilia defects in mother FHx Abruptio placenta Chronic diseases in mom Counseling Most probably, from the history and examination, the most likely cause of the stillbirth that you had was an infection that you developed at around 22 weeks. There are other causes as well like problems with placenta, poor growth of the baby, and certain coagulation defects. It is important to find out the exact cause before your next pregnancy. However, sometimes, there is no cause that can be found. We need to do some tests now after consultation with the specialist gynecologist which includes FBE, cervical smear and culture to rule out hidden infections, ANA testing, VDRL, FBS to rule out diabetes, thrombophilia screening, and USD to rule out any structural defects of the uterus. Later on, the specialist might decide to do a hysterogram. This is an xray of the womb that helps to find out any defects of the shape of the uterus as well as any growths within the uterus. For your next pregnancy, we will manage you in the high risk pregnancy clinic. You will have an early dating ultrasound at around 8-10 weeks. From then on, you will have serial ultrasound after every 2 weeks to monitor the baby’s growth. They will discuss with you regarding screening for Down syndrome and neural

tube defects. Your pregnancy will be monitored very closely and around 12-14 weeks, the OB will assess you for possible cervical incompetence. We will make sure that there is nothing that puts your next pregnancy at risk. However, you need to make certain lifestyle changes like maintaining your weight within normal limits, quit smoking, stop drinking, avoiding recreational drugs, healthy diet, and exercise. The delivery will be in a controlled environment at around 38 weeks in the presence of a specialist obstetrician where we will prepare for the possibility of emergency CS. The specialist/midwife will educate you regarding kick charting for fetal movement and you need to inform us if you develop any symptoms like fever, vaginal discharge, bleeding, rash, or reduced fetal movement.

b.

c.

History (dull, 2/10, similar to menstrual pain, started 2 days ago, no N/V, relieved by paracetamol, no fever, no burning sensation, first pregnancy, blood group A+, normal pap smear) Physical examination (anxious, normal BP and HR, FHR is absent with handheld doppler, no discharge, water leakage, bleeding, urine dipstick negative, BSL 5.5 mmol/L) Management

Differential Diagnosis - Placental abruption - Preterm labor - Pre-eclampsia - Urinary tract infection - Red degeneration of fibroid - Appendicitis History -

I understand you have come to the hospital because you have abdominal pain. When did it start? Can you describe the pain? Does it come and go? Does the pain travel anywhere? Can you recall any precipitating factor such as trauma, exercise or sexual intercourse? Do you have a fever, headache or blurred vision? Do you have N/V or back pain? Any burning sensation when passing urine? Have you noticed unusual vaginal discharge? Have you had any vaginal bleeding or water leakage? Do you feel the baby’s movements? When was the last time you felt the baby kick? Is this your first pregnancy? Have you had regular ANCU? Any problems with your blood tests, midpregnancy USD, sweet drink test or blood pressure? Do you know your blood group? SADMA? Did anyone come with you today?

Physical Examination - General appearance and edema - Vital signs - Abdomen: uterus, fundal height, lie, presentation, engagement, palpate uterus if tender or hard/tense, FHT - Pelvic examination: discharge, bleeding, water leakage, cervical os, swabs (endocervical and high vaginal) - Urine dipstick and BSL

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Management - I’m sorry to tell you but I can’t hear the baby’s heart. Most likely, your baby has died. I can see you’re very distressed, do you know what we can do for you now or do you need some time? - First of all, we need to confirm this with an USD. We will also look for signs of placental abruption which is one of the possible causes for your presentation. - Why did it happen? We will try to find a cause. However, in majority of cases the death is unexplained. For now, I want to order some blood tests for you. FBE, HbA1c, urine MCS, swabs, LFTs, U&E, TORCH infection screening, TFTs, ANA and lupus anticoagulant

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Counseling - I’m not sure how this news will sound to you but the report says it is a twin pregnancy. Don’t worry. We will take care of you. We will do a multi-disciplinary team approach which involves me as your GP, a specialist obstetrician, and pediatrician for your babies. - History: how is your pregnancy going so far? Any abdominal pain, bleeding, or discharge? Any excessive N/V? any headache, blurring vision, burning in urine or leg swelling? Do you know what your blood group is? Did you take folic acid during the early pregnancy? Is it an assisted or natural pregnancy? Any PMHx? Any FHx of twins, DM, or hypertension? SADMA? - We have two kinds of twins: dizygotic coming from 2 eggs and monozygotic which comes from one egg. In your case, it is a dizygotic pregnancy with 2 sacs and placenta. Twin pregnancies run in families or might be

Medical problems are unlikely at least in the first 3 weeks after fetal death has been diagnosed and usually, labor will start during this time. You may choose to await spontaneous labor or to have labor induced. Either way you can have a family member or friend during the delivery and we will give you adequate painkillers to reduce the pain of childbirth. If you choose to await spontaneous onset of labor, you will need frequent blood checks. If labor wouldn’t start within 3 weeks, you will need to have labor induction. If your choice is immediate treatment, we can prepare the cervix by using prostaglandin. If you or your partner wish to bring clothes, see or hold the baby, it is possible. We strongly recommend an autopsy which helps us to find a cause in up to 25% of cases. If you’re against autopsy, we can take a small sample of skin usually in the (axilla region) for chromosomal study. Placenta will also be examined under the microscopy and routine cord blood test. To suppress lactation after delivery, you need to wear tight bra and use simple painkillers and ice packs in case of engorgement. We have a bereavement consultant and a social worker who can help you with funeral arrangements. Technically, you can get pregnant when your periods are back. However, it is important to be physically and emotionally ready for the future pregnancy.

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MULTIFETAL PREGNANCY -

Multifetal Gestation/Pregnancy

due to fertility medications. Is it risky? Yes. A twin pregnancy is usually slightly high risk than the normal pregnancy. There are risks to both mom and the babies. The maternal complications are exaggeration of signs and symptoms of pregnancy, preeclampsia, premature labor, gestational DM, malpresentation, antepartum hemorrhage, increased incidence of CS. Fetal complications include PTL, IUGR, twin-twin transfusion (more in monozygotic), malformations. Do not worry. You are in safe hands. We will do our best to manage you and prevent the complications. I will refer you to the high risk clinic. The specialist there will follow you up. You will need more frequent visits (every 2 weeks until 28th week, weekly until delivery). You may need multiple ultrasounds starting from 28 weeks (every 2-3 weeks). Babies will be monitored by CTG from 34 weeks (2x a week). Aim to deliver the babies at 38 weeks. Increased supplements (iron/folic acid), nutrition requirements and rest Can I go for vaginal delivery? It is very early to comment at this stage, but it will depend on the presentation of the first baby and your general health. If the first baby is cephalic, vaginal delivery is possible. 70% (cephalic). If there are any complications, then specialist might consider doing cesarean section. We will also do active management of first stage of labor because of high chance of postpartum hemorrhage due to overdistention of uterus. Referral/Review/Reading materials (support groups) Red flags: bleeding, abdominal pain, water leakage, headache, blurry vision, urinary symptoms

Case: A 28-year-old primi who is 18 weeks pregnant comes to your GP clinic to collect her ultrasound report that shows twin pregnancy with 2 placentas and 2 amniotic sacs.

ANTEPARTUM HEMORRHAGE

Task

Placenta Previa a. b. c.

Tell patient about diagnosis and findings Focused history Advise on management

Complications - Maternal: anemia, symptoms of pregnancy (morning sickness, varicose veins), preeclampsia x3, antepartum and postpartum hemorrhage, malpresentation, cord prolapse, CS - Fetal: increased risk abnormalities, preterm delivery (PPROM), IUGR in one of the fetus, twin-twin transfusion, perinatal mortality x 5; prematurity, malformations x 2-4

Case: You are an HMO in a hospital OBs-and-Gyne unit and your next patient is a 26-year-old 28 weeks pregnant who came in due to PV bleeding for 1 hour. She has been following up regularly and there were no remarkable findings up to now. Task a. b. c. d.

Relevant history (x 1 hour) Physical examination (pale and stressed, BP: Investigation Management

Risk Factors Smoking

18 History -

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Previous placenta previa Previous cesarean section Multiparity Advanced maternal age

o o

Is my patient hemodynamically stable? When did the bleeding start? How many pads have you used? How soaked were they? Any clots? Any tummy pain? Headache? Dizziness? Sweating? Palpitations (assess severity of bleeding)? History of trauma? Any bleeding disorders (menstrual history/are you bleeding from anywhere else)? Pregnancy: how is your pregnancy going so far? Is it a single pregnancy? Planned pregnancy? Significant findings in 18 week ultrasound? How was your sweet drink test? Is the baby kicking? Previous pregnancy? How was placenta in previous pregnancy? Pills? Partner?

Period: are they too heavy or normal? Pap? Are you aware of your blood group? Social history: how far are you staying from the hospital and do you have enough support? SADMA?

Physical examination General appearance: pallor, dehydration and jaundice, signs of trauma Vitals: sitting and standing BP, RR, PR, T, oxygen saturation o If with postural hypotension: I would like to insert 2 IV bore cannulas, take blood for blood group and crossmatching and start IV fluids Abdomen: FH (whether it corresponds to gestational age), lie, presentation, tenderness of uterus, engagement/floating, FHR Pelvic exam: NO Per Vagina Exam!!! o Inspection: discharge, blood, clot, signs of trauma o Speculum: discharge, blood, cervical os (if open or close); Urine dipstick and BSL Placenta Previa: Total placenta previa (completely obstructs the cervical os) Partial Placenta previa (partially obstructing the cervical os) Marginal (just at the beginning of the os) Low-lying placenta Diagnosis and Management Most likely, you have placenta previa. At this stage, I would admit you, put 2 IV lines and take blood for FBE, blood grouping and crossmatching, and coagulation profile. I will call the OBS&Gyne Registrar to come and have a look at you We need to organize an urgent USG to see the position of the placenta and the obs and gyne registrar might also consider doing CTG to check the status of baby. Placenta previa is an obstetric complication that occurs in the 2nd half of pregnancy. It can cause serious complications in both mom and baby. Complications are fetal malpresentation, postpartum hemorrhage, rebleeding, IUGR, isoimmunization Reassure Further management:

Total or partial: send to tertiary hospital and stay until delivery; most cases delivered via CS Marginal or low-lying and with minor bleeding and bleeding has stopped: go home but needs to stay close to hospital; USG at 34 weeks; delivery: depends on USG at 34 weeks and specialist will decide on that; CS organized at 38 to 39 weeks

If with severe bleeding and with fetal compromise  immediate cesarean section Refer, Review and Reading materials Red flags: bleeding, baby not kicking, water breaks, tummy pain o

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Mild Abruptio Placenta Case: You are an HMO in ED and a young primigravida who is 30 weeks gestational age comes to see you because of vaginal bleeding on examination, she is stable and vitals are normal. Abdomen is not tense but slightly tender. FHT 140/min Task a. b. c.

Focused history Explain condition to patient Management

Features Separation of the placenta from the uterus Revealed: bleeding Concealed: severe hypotension Complications: IUFD, DIC (micro thrombi) Types: o Mild - blood loss 1L; severe abdominal tenderness; shock; fetal compromise; Admission and stabilize patient; if fetus alive then cesarean section o Severe - more than 1500ml of blood, shock, severe tenderness, fetus is almost always dead; DIC and coagulopathies are common Risk factors o Multiparty o Hypertension in pregnancy o Smoking o Cocaine abuse o Trauma Differential diagnosis Placental abruptio Premature labor Red degeneration of fibroids Trauma Placenta Previa History -

Is my baby okay? I understand that you are stressed. Before I answer your questions, I would like to ask you a few details regarding your pregnancy. Are you still

19 bleeding? When did it start? What were you doing when it started? How much is the blood loss? How many pads did you use? Was it fully soaked? Did you pass any clots? What was the color? Any gush of water coming out with the blood? Any tummy pain? Do you feel dizzy or palpitations? Do you have any bleeding disorders in you or the family? How's the pregnancy so far? Are you regular with your antenatal checkups? Do you remember your midgestation USG? How was your sweet drink test? Anything abnormal? Is your baby kicking? Is it reduced? Do you know blood group? Any previous pregnancies? Are you regular with your pap smears? Smoker? Illicit drugs?

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your case. It is a dangerous condition and can seriously affect you and your baby. I know you are feeling unwell. Your BP is low and your pulse is fast. They are signs of hemorrhagic shock due to blood loss. Most likely you lost at least 30% of your blood volume and you are still bleeding. It is an indication for blood transfusion to increase you and your baby’s chance for survival. No doctor I still don’t want to be transfused. Miriam, it is your right to refuse the treatment. However, it is important for me to explain the possible outcomes so that you can make an informed decision. Right now, we are doing important preparation for emergency cesarean section. Bleeding will stop after we empty the uterus. However, the operation itself is associated with blood loss (500ml) and may worsen your condition if blood transfusion is not started. We can replace fluids and use synthetic blood substitutes (Haemaccel). They will reduce shock. However, if blood loss exceeds 40% of blood volume, the biggest problem is hypoxia or oxygen deprivation, which may quickly lead to multiorgan failure/shutdown and death.

Diagnosis and management: -

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You have a condition called a mild placental abruption. Draw diagram. I will need to organize some investigations to confirm the diagnosis and make sure the baby is alright. I will request for an USG to check the degree of abruptio and request for CTG, full blood examination, UEC, crossmatching, coagulation profile, indirect coomb test and kleihauer test. Is this hospital a tertiary hospital? I would like to admit you. At this stage the bleeding has stopped but the condition is risky. I will call the OB registrar to come and have a look. Meanwhile I will secure IV lines and collect blood for investigations. Because you are RHwe will give you anti-D injection. We will consider injection of Betamethasone 2 injections 12 hours apart to help with the maturity of your baby's lung. What about the delivery? At this stage, we cannot say. You are stable now. We have to wait for the results of the ultrasound and CTG. However, if your baby becomes distressed or the bleeding recurs, the specialist might decide to do an emergency cesarean section. Reassure. If in pain, IV pethidine.

Blood Transfusion Consent in APH Book case 123: Task a. b. c.

Ascertain patient’s view on blood transfusion Explain risks and benefits of treatment to patient and baby After six minutes, answer examiner’s question

Counseling - Hello Miriam, I want to explain your condition and possible ways of management. You are having severe bleeding, and we call it antepartum hemorrhage. An emergency USD confirms placental previa. Placenta previa means the placenta is lying in the way of the baby. This condition is a common cause of bleeding in pregnancy. Thirty percent of all APH is because of placenta previa. It usually presents with causeless, painless and recurrent bleeding. Sometimes, it can present with severe bleeding like in

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Blood loss may also affect your baby’s condition in the same way. Less blood will come to the baby and he will experience hypoxia. You are losing RBCs which have a very special function to carry oxygen to all organs and tissues in your body. The only way to restore that is by blood transfusion. No doctor I still don’t want to be transfused. Miriam, I understand and respect your wish. Can you please tell me if you fully understand all possible consequences which may arise without blood transfusion? We will do our best to save you and your baby’s life without blood transfusion.

Examiner: Summarize legal and ethical issue in this situation - Every competent patient has the right to accept/refuse treatment. - In this case, there is the potential to damage the fetus. In Australia, the fetus has no rights. - Born babies can be transfused without parental consent providing it is a life-saving procedure. How would you manage this situation? - I will continue monitoring mother and baby’s condition until emergency cesarean section has been arranged. - I need to continue fluid transfusion. - I need to talk to senior doctor to help me. - If husband is available, then can talk to husband. Pregnancy with Road Traffic Accident Case: You are an HMO in ED and a 23-year-old female comes to you complaining of tummy pain. She is 32 weeks pregnant and was in a car accident. Task b. c. d. History -

History Physical examination (B-, stable VS pallor, generalized tenderness, FH=GA, cephalic, FHS +, no bleeding, or contractions) Management Is my patient hemodynamically stable?

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I would like to talk to my patient preferably in a resuscitation cubicle with all the necessary resuscitation equipment. How are you feeling at the moment? Let me reassure you that you are in safe hands. If you want, I can call someone to be with you. I understand you have tummy pain? Where is it? How bad is it? What is the type of pain? Does it come and go or is it constant? Does it go anywhere else (back or towards genitalia – to r/o pelvic organ damage)? Do you think it is getting worse? Can I ask more about the accident? When did it happen? How? Who was driving? Were you in the passenger seat/backseat? How fast was it going? Were you wearing seatbelt? Do you have bleeding, or discharge from down below? Do you have headache, N/V? Did you hurt your head? Is there a wound anywhere on your body? Did you lose consciousness at any time? Do you feel the baby kicking? Previous obstetric history? What is your blood group? Partner’s blood group? Did you receive any injection of anti-D during pregnancy? Any past history of bleeding disorders, clotting problems, illnesses? SADMA?

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Concealed Placental Abruption Case: You are an HMO and a 25-year-old female who is 32 weeks pregnant came in due to sudden onset of severe abdominal pain. Task a.

b.

c.

Physical Examination Full primary survey of the patient Ensure her airway, breathing, circulation are not compromised Inspect for any visible signs of trauma all over the body? Bruises? Pallor? Dehydration? Vital signs especially BP Secondary survey looking for signs of trauma to the bones, joints, vessels (pulses) Abdomen: palpate any tenderness, guarding, rebound and signs of ecchymosis, large bruise over lower tummy, fundal height, lie, presentation, FHS, uterine contractions Pelvic exam: visible bleeding, discharge, signs of trauma, nitrazine test (if pH >5 normal; >5-7 amniotic fluid) B/E  preferable done by obstetrician at tertiary care Urine dipstick and BSL Heart and chest Management I would like to ask for review by specialist obstetrician and I will arrange for blood tests such as FBE, U&E, BSL, crossmatching, D-dimer, coagulation profile, ABG, Kleihauer test to determine amount of fetomaternal hemorrhage to decide the amount of antiD, ECG and xray of pelvic girdle. Risk of fetal deformities are minimized during the third trimester and usual radiation exposure is very low o Typical pelvic xray – 0.10 mGyron o CT scan – 20-50 mGyron o Proven risk - >50-100 mGyron I would also like to do USD to assess for fetal viability, size, gestational age, and position of baby, and any evidence of intraperitoneal fluid or hemorrhage. Also, I would like to hook you to continuous CTG for 24 hours to look for any signs of fetal distress. o Indications for CTG: bleeding, previous CTG is abnormal, trauma Most likely, the obstetrician will advise anti-D IM dosage after the results of the Kleihauer test. Criteria for admission o FHR on CTG shows variable decelerations

Serious trauma after second trimester where the patient requires fetal monitoring for 24 hours or more o Abnormal obstetric findings like vaginal bleeding Keep admitted until all possible complications have been ruled out such as fetal death, premature ROM leading to PTL, abruptio placenta (can be delayed for up to 48 hours), amniotic fluid embolism, and chorioamnionitis o

History (pain is 7/10, sharp pain, started 45 minutes ago, bending over decreases the pain, baby kicking; waterworks normal, ANC, USD, and sweet test normal) Physical examination (pale, anxious, sweating, increased HR, normal BP, RR, O2, Temperature, FH appropriate for age, tender all over, mainly around umbilicus, guarding +, cephalic, FHS+; pelvic no bleeding or discharge; os closed) Diagnosis and management

Differential Diagnosis Placental abruption Placenta Previa Acute red degeneration of fibroid Preterm labor Appendicitis Bowel obstruction Torsion History -

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Is my patient hemodynamically stable? I would like to take a history and I would like to ask for IV access. Can you please tell me more about the pain? When did it start? How bad is it on a scale of 1-10? Can you point out where exactly is the pain? Does it go anywhere else like towards the flanks or downwards toward the pubic area? Did you hurt yourself in that area? Do you think this pain is associated with N/V/headache/dizziness? Any bleeding from down below? Vaginal discharge? Leaking of water? Do you think the pain is continuous or does it come and go? Do you think this pain was related to sexual activity (placenta previa)? Do you have any associated problems with waterworks? Any history of constipation or bowel-related problems? Is this your first pregnancy? Any miscarriages before? Have you had regular antenatal visits? Are you aware of the results of your last USD? What was the position of the baby? Placenta? Can you feel the baby kicking? How often during the last 1 hour? How is you general health? Any medical or surgical condition? Is this the first episode of pain? Do you have any fever along with the pain? What is your blood group? What is your husband’s blood group? Have you received any anti-D injections up to now? FHx of HPN, DM, bleeding disorders

Physical examination General appearance Vital signs: postural BP drop

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Abdomen: FH, lie/presentation, FHR, tenderness on palpation, guarding, rigidity, tenderness especially over the RIF/LIF? Pelvic: inspect for signs of bleeding, discharge, leaking; insert sterile speculum for bleeding, discharge, pooling of fluid, nitrazine test; os if it is open or closed Bimanual examination is preferably avoided until an ultrasound has been obtained

Investigations FBE, blood grouping, crossmatching and hold. I would like to do a CTG to assess fetal distress, coagulation profile, LFTs, RFTs. If she is RH (-) I would like to do kleihauer test to check fetomaternal hemorrhage. Also, I would organize an USD to check for fetal viability, position of placenta, and if there is any abruption of the placenta and amount of blood. Management Unfortunately, what you have is a serious condition called placental abruption. Basically, a part of the placenta starts detaching from the wall of the womb for some reason. The exact cause is not known. However, there are certain risk factors like trauma, smoking, high blood pressure in the mom, diabetes, previous history of placental abruption, high parity, poor nutrition, and sometimes, it is unexplained. This condition can be quite serious as there is a high risk of PROM, PTL, fetal distress, maternal shock, acute renal failure and sometimes, IUFD.

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I need to admit and you need to be urgently seen by a specialist obstetrician. We will start you on IV fluid and monitor your urine output with the help of catheter. We will send blood for crossmatching. If required, we might need to transfuse you. We need to prepare for possible premature delivery. I will inform the theater to prepare for emergency cesarean section. We will give you steroids to help with the maturation of baby’s lungs. Usually, with moderate to large placental abruption, there is a need to deliver the baby ASAP. We will also give you anti-D injections to prevent any incompatibility of blood groups. If the baby is non-viable, if you are stable, we will induce and deliver the baby. But if not, emergency cesarean section is performed.

(derealization)? Do you feel the baby kicking? Have you noticed any leaking from down below? Any swelling of your ankles? Have you had all regular antenatal checkups? USD? Blood tests? Sweet test? Are you generally healthy? Any medical or surgical condition? Before this pregnancy, have you ever been diagnosed with high blood pressure, kidney problems, DM or any other conditions? FHx of similar condition? SADMA? Blood group! Physical Examination General appearance Vital signs Evidence of pedal edema (pitting or non-pitting) Funduscopy for bulging of the disc Chest and heart Abdomen (FH, lie/presentation, FHT, tenderness) Reflexes Urine dipstick and BSL Management I would like to put the patient on the left lateral position and call for help. Check the airway. If there are secretions wipe with clean cloth or suction. Put airway. Give oxygen by mask if possible. IV access. I would like to start her on magnesium IV LD 4gms over 15 minutes diluted with NSS and continue with 1 gram divided over 24 hours. IV hydralazine (5-10mg bolus given over 5-10 minutes then an infusion of 5mg/hr is

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HYPERTENSIVE DISORDERS OF PREGNANCY Pregnancy-Induced Hypertension/Pre-eclampsia

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Case: You are a GP and a 30-weeks-pregnant primigravida comes to your clinic. She is complaining of headache. Her BP today is 170/110mmHg. It was the same on a previous occasion.

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Task a. b. History -

Relevant History Manage the case Is my patient hemodynamically stable? I would like to know all the vital signs. I would like to give the patient methyldopa now. If she develops fits while talking rectal diazepam 5-10 mg I would like to ask some history from the patient. Please tell me if you’re having symptoms like headache, BOV, tummy pain, or bleeding from down below? Any abnormal feelings that you have

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maintained. Aim is to keep the BP between 140/90 and 160/100; add beta-blocker if with tachycardia) after the patient has been seen by the specialist. At GP clinic  methyldopa or nifedipine spray to lower BP I would inform the obstetric team to organize for immediate delivery. I would like to monitor the patient by monitoring her: urine output, continuous ECG, reflexes, vital signs. Investigation: FBE, U&E, LFTs, coagulation profile, blood grouping and crossmatching, USD, CTG, thrombophilia screening Aim of treatment: prevent development of fits Aim of treatment if with fits: deliver the baby I would like to call in obstetrician. If the pregnancy is less than 34 weeks, we will give the patient steroids Betamethasone (Celestone) 11.4mg IM 2 dose 12 hours apart, stabilize patient, and monitor all symptoms. The patient remains at the hospital for observation. If symptoms worsen, we deliver by CS. If pregnancy is more than 34 completed weeks, deliver by induction or cesarean section. If platelets are going low  give FFP If patient develops symptoms of pulmonary edema  give high-flow oxygen and diuretics. Complications: ARF, cardiac failure, cerebral hemorrhages, DIC, IUD, HELLP syndrome,

Counseling of mom What your daughter has had just now is a fit as a consequence of a very high blood pressure. This condition is known as PIH. This can happen because of certain chemicals that are released by the placenta that cause constriction of blood vessels and formation of clots because of reduced supply to the brain resulting to the fit. It is very important to control the symptoms to prevent complications like liver failure, heart failure, and kidney failure. That is why we are sending her to the hospital right away. She will be seen by a specialist OB. They will lower her BP with medications, but the cure is to deliver the baby.

22 a. b. c.

CARDIOVASCULAR, RESPIRATORY, HEMATOLOGIC, NEUROLOGIC, GASTROINTESTINAL CONDITIONS IN PREGNANCY Abdominal pain (Early Pregnancy)  Uncomplicated Cystitis

History -

Case: You are an HMO in the ED and your next patient is a 12week GA pregnant lady complaining of nausea and vomiting. This is her first pregnancy. No complications so far.

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Task

a. b.

c. History -

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History (N/V with dull, nonspecific lower abdominal pain x 2 days; malaise; tolerate meals) Physical examination (T:37.6, BP: 115/80; soft, tender in lower abdomen but not peritonitic signs; os is blue, closed, no secretions or bleeding; free adnexas; fundus expected high according to gestational age; nitrites ++++, leukocytes +++, no blood, protein and sugar) Diagnosis and Management Was it a planned pregnancy? Congratulations. When did it start? Are you able to tolerate meals? Do you feel tired? Do you have abdominal pain? What type of pain? Any discharges or bleeding? Fever? Pregnancy checks? Did you have any tests done? Are you taking folic acid? Did they mention your blood group?

PMHx: any history of UTI; 5Ps: previous miscarriages; twin pregnancies?

Physical examination: - General appearance: pallor, dehydration - Vital signs: stable except temperature 37.5 - ENT/CVS/Lungs - Abdomen: tenderness of lower abdomen - Pelvic: o Inspection of genitalia: bleeding, discharge; o Speculum: no bleeding or discharge; os is close; o Bimanual examination: adnexa are free; uterus is expected high - Urine dipstick and BSL Diagnosis and Management - You have a condition called UTI most likely what we call cystitis. Do you know what it is? At this point, I am happy to send you back home, but if the condition persists and you cannot tolerate foods or drinks, fever, chills and pain in the back, then go to the ED. - I will need to send your urine for culture and sensitivity and I am going to start you on amoxicillin 500 mg TID or cephalexin 500 mg BID or nitrofurantoin 50mg QID. If pyelonephritis: ceftriaxone IV 1g OD. - I will review you in 3 days and we will either continue your medication or change it according to the results of your culture. I will prescribe paracetamol for the abdominal pain and metoclopramide for vomiting. Anemia in Pregnancy Case: You are a GP and a 28-year-old G4P3 20 weeks’ pregnant lady has come to see you to know the results of the recent blood tests. The blood tests hemoglobin is low, MCV is low, transferrin is high, ferritin is low. Task

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History Physical examination Diagnosis and Management I understand that you’re here for your blood results and it was found that you have iron deficiency anemia. This means that there is less oxygen delivered to the tissues. Do you feel tired? Is there any dizziness, palpitations or SOB? How is your pregnancy so far? Have you had regular antenatal checkups? How are your blood tests and ultrasound? How about your pregnancies? Have you had blood loss? When was your last pregnancy? What about your periods? Did you have abnormal bleeding? What about your diet? Any bleeding disorders? Are you on any special diet? Is the baby kicking? Any other health problems? Blood group?

Physical examination General examination: pallor, bruising, lethargy, Vital signs: postural drop Lungs Cardiac: murmur (systolic) Abdomen: FH (check for IUGR), abdomen soft or tense, FHT Pelvic examination: bleeding, discharge Urine dipstick and blood sugar

Diagnosis and Management You have a condition called iron-deficiency anemia. It is the most common cause of anemia in pregnancy. It is often asymptomatic and detected on screening as in your case. There is high demand of iron during pregnancy and in your case, most likely the reason is due to the inadequate gap. There are some risks to you and your baby because of this. Anemia can predispose you to infections, excessive blood loss during pregnancy, and can affect your heart. Because of this, there is reduced oxygen supply to the baby which can lead to IUGR, fetal distress and in severe cases, stillbirth. We need to give you iron supplements. 200 mg 2x daily. The hemoglobin level should increase by 1gm/L per week. There are some side effects like nausea, tummy pain, black stool, and constipation. We will stop the medications 3 months after your hemoglobin levels become normal. I would also advise you to eat more iron-rich foods such as iron-fortified cereals, legumes, nuts and nut butters, seeds, wholegrain breads, green leafy vegetables, dried fruit, ironenriched breakfast cereals, milo and ovaltine and liver. Eating a lot of vitamin C rich foods to increase absorption of iron; Parenteral iron indications: if close to delivery and if cannot tolerate oral iron and Hgb 2 years age difference is not acceptable; Gillick's test: if you are able to show me that you're able to understand what you are saying, and at the end of the conversion you are able to understand what I said, then I can give you the script. (how are you going to use the OCP? What will you do if you missed the pill?) Will not protect against STIs. Advise on 7 days row. Use other contraceptive methods for the first 7 days. If you missed the pill or have had any nausea, vomiting, diarrhea then use barrier method Reading materials Review again for 3 months Breakthrough Bleeding with OCPs Case: Your next patient in GP practice is a 22-year-old female who started using Microgynon 30 because she wants to start sexual relationship with her partner in the near future. She has had some per vagina spotting over the last 4 weeks and is concerned. Task: a. b. c. History -

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History (spotting x 2-3 for 4 weeks) Diagnosis Management Could you talk more about it? Do you take the pills at a regular time? Have you skipped or missed a pill? Smoking? STDs? Are you taking any other medications (anti-epileptics/antibiotics)? Recent diarrhea or vomiting? Any chance you could be pregnant? Partner? Pap smear?

Factors for breakthrough bleeding: Not taking pills at the same time (decreases efficacy) Missed pill Smoking Medications AGE

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Management What you have is a case of breakthrough bleeding which occurs in between periods. It could be a light spotting in your case or a heavy bleeding. It is a common side effect of OCPs. There are several reasons why breakthrough bleeding can happen: if not taking pills at the same time (15 minutes), should not skip pills, smoking, medication or STDs, or AGE. For some women, the low-dose pill does not contain enough estrogen to maintain the stability of the endometrium (lining of the uterus) which causes breakthrough bleeding.

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On OCP wants to change to HRT A 45-year-old lady came to your GP clinic and she is on OCP. She wants to change to HRT because she has heard about it from her friends. *48-year-old px with irregular periods and husband had vasectomy; *53-year-old with amenorrhea for last 2 days (years)/with history of breast cancer. Task History Management Answer her questions

History: - 5Ps: - Vasomotor symptoms: hot flushes? Night sweats? Palpitations? Lightheadedness/dizziness? Migraine? - Urogenital: dyspareunia? UTI? Vaginal dryness? Decline in libido? Bladder dysfunction (dysuria)? Stress incontinence/prolapse? - Psychogenic: irritability, depression, anxiety/tension, fearfulness, loss of concentration, tearfulness, loss of concentration, poor short term memory, unloved feelings, mood changes, loss of self-confidence - Frequent headaches? Migraine? FHx: CVS, cancers, osteoporosis? Breast lumps? History of heart disease? Hypertension? Unusual bleeding? Pills? Any weight gain? Nausea/vomiting? - SADMA: smoking? Medications: steroids? - FHx: Premature menopause -

Contraindications of HRT: o Estrogen-dependent tumor (endometrial, breast cancer) o Recurrent thromboembolism o Acute IHD (absolute)/history of CHD (relative) o Uncontrolled hypertension

Active liver disease Pregnancy Undiagnosed vaginal bleeding Otosclerosis? Intermittent porphyria

Investigations: FBE, LFTs, BSL, Lipid profile, U/C/E, TFTs, Estrogen/FSH/LH Management: - From the history, you are not a candidate for HRT. However, I would like to request for some medications to check if you’re already reaching menopause. HRT is not a contraceptive method. Both HRT and OCPs do not prevent STIs.

It also depends on the type of progesterone. At this stage, I would recommend for you to continue for 4-6 months and if it does not stop after that, then we might consider changing your OCP dose to a higher estrogen-containing pill or different progesterone. Review and Reading materials. Red flags: severe bleeding, nausea/vomting, etc…

Indications for high-dose estrogen OCPs Uncontrolled menorraghia Taking other enzyme inducing (p450) drugs such as anti-epileptics Low dose pill failure

a. b. c.

o o o o

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Menopause is a natural phenomenon. One of the things I am concerned about menopause is osteoporosis and heart disease. It is advisable to change lifestyle: maintain healthy weight, adequate relaxation and exercise, do pelvic floor exercises regularly, reduced smoking, caffeine, alcohol intake, increased exposure to sunlight. Some other methods of contraception: barrier, IUCD, implanon, injectables, etc… during next consultation

Additional information: - Ways to know: organize LH and FSH (30-40)  most likely menopausal; if FSH and LH are that high  stop OCP and get symptoms  HRT; require regular follow up. - 45  too early; but requires support; usually high dose HRT given; OCP-Induced Hypertension Case: You are a GP and a 26-year-old female comes to your clinic asking about the chances of becoming pregnant within the next 6 months Case Before: Patient coming to you who is a heavy smoker and has hypertension. She is on OCP. Task a. b. c. History -

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History (regular 2-3 days, 28 days, on the pill, pap smear n, no previous pregnancies/miscarriages, nonsmoker, social drinker, mom with DM) Physical examination: BP 155/95, Diagnosis and management I can see from the notes you wish to become pregnant in the near future. Congratulations on your decision. Please tell me more about your periods? Are they regular? How many days of bleeding? How many days apart? Are your periods heavy? Are they painful? Any spotting in between? I understand you’re sexually active, since when? What form of contraception do you use? What type of pill are you on? Since when? Have you had any side effects from the pill (nausea, weight gain, intermenstrual spotting)? Have you or your partner ever been diagnosed with a STI? At the moment, do you suffer from any vaginal discharge? Any bleeding or itchiness down below? Have you ever had pelvic infections before? Have you had any pregnancy/miscarriages/gynecological surgeries before? When was your last pap smear? What was the result? Have you had gardasil?

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PMHx: diabetes, hypertension, kidney disease, infections, liver? History of clotting problems in you or your family? SADMA? How’s your appetite/sleep? Any recent history of fever, cough, diarrhea, tummy pain? How do you consider your weight to be? Do you know your blood group? Any FHx of fertility problems? Pregnancy related problems? Diabetes? High blood pressure? Headache: how frequent, since when? Have you noticed any association with particular food or time of day? What do you take to relieve pain? Any associated N/V/abnormal sensations/visual disturbance?

Physical examination - General appearance and BMI - Vital signs - Dysmorphic features of cushing syndrome, PCOS - Palpate thyroid - Auscultate chest and heart - Abdomen to palpate renal or suprarenal mass and listen to bruit - Pelvic exam: o Inspection: discharge, bleeding o Bimanaual exam: position and size of uterus, tenderness, cervical excitation - Urine dipstick, pregnancy test and BSL Management - From the history and examination, the most important finding is that of a high blood pressure. Have you ever had your blood pressure checked before? Usually, at your age, having a high blood pressure can be due to a number of causes. Most likely, it can be related to the use of the pill as the headaches that you have started along with the use of the pill. I still need to rule out other causes of hypertension such as smoking, any problems with the blood supply to the kidneys, certain growths in the adrenal gland related to the kidney, cardiac problems, and the like. I would do some investigations like FBE, U&E, Urine MCS, ECG, uric acid level, lipid profile, LFTs, TFTs, blood group, rubella antibody, infection screening. - We still need to check your BP during the next visit. However, I want you to please stop using the pill. Around 2% of females, especially those who have family history of high BP, those who are overweight, >35 years old, and smokers can develop high blood pressure due to OCPs. Some women get high BP from the progesterone component of the pill. Usually, this rise in blood pressure is only seen with the systolic component. The good news is that it is completely reversible. However, you need to stop smoking and adopt a healthy lifestyle to reduce this risk to minimum. Meanwhile, you may use another form of contraception, probably condoms. Becoming pregnant at this stage might further complicate your condition, so my advice is once the results are back and your BP is normalized, you can plan for the pregnancy. I would like to see you in one week’s time with the results of the tests. Please come back if you develop further headaches, visual problems, fainting or dizziness. Post-pill amenorrhea?? Case: Your next patient in GP practice is a 30-year-old woman. She did not have periods for the last 2 months. She is on MIcrogynon 30.

Task a. b. c. d.

History (on the pill, periods stopped GRADUALLY, Physical examination Diagnosis Management

Secondary Amenorrhea - Pregnancy (breast tenderness, spotting, early morning N/V) - PCOS (weight gain, acne, hirsutism, irregular periods) - Hypthyroidism (weather preference, puffy face, edema, mood) - Eating disorder/exercise induced - Hyperprolactinemia (breast discharge, medications, headache, nausea and vomiting

History -

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Asherman syndrome (gynecological procedures/D&C) Stress Premature ovarian symptoms Post-Pill Amenorrhea I understand you have not had your menses for the last 2 months. Any chance you might be pregnant? What’s your LMP? Do you have symptoms like breast pain, N/V, spotting? Pills: any problems with that? Do you think you might have missed your pill anytime? Are you taking it regularly? Did you have any diarrhea or vomiting? Are you on any other medications? Review of systems: hirsutism Partner? Pap? Gardasil vaccination? Any previous pregnancies? Any Family history of premature ovarian failure or cancers? SADMA? PMHX

Physical Examination - General appearance - Vital signs and BMI - Visible hirsutism, acne, puffy face or edema - Vision: visual fields, funduscopy, visual acuity - Neck: thyroid enlargement - Breast examination: nipple discharge - Abdomen: masses, tenderness - Pelvic exam: o Inspection: discharge, atrophic vagina o Speculum: cervical os, bleeding o Bimanual: size of uterus, adnexal masses, CMT - Urine dipstick, BSL, Pregnancy Test Diagnosis and management - There is no abnormality on physical examination. According to your history, the most likely cause of not having the periods is endometrial atrophy secondary to the pill. - However, we need to rule out pregnancy. The only possible reason is one of the hormones (progesterone) in the pill is causing thinning of the lining of the womb. - DIAGRAM - Do not worry. It is a reversible condition. At this stage, we will stop the Microgynon 30 and you can use other forms of contraception at this time or I can shift you to Microgynon 50 or we can use the triphasic pills. Most likely your periods will return. In case you don’t or you’re really concerned, I can refer you to the gynecologist for further investigation. - Reading material. Referral. Review.

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Request for sterilization for a disabled person/Contraceptive advise for disabled Case: You are a GP and a mother of 13-year-old child comes to you. She is intellectually disabled and epileptic. She is on carbamazepine. She wants your advice because the child goes to school for both boys and girls. She is worried about contraception and the risk of pregnancy.

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Task a. b.

History -

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equally worried if your daughter suffered from any of the complications of this surgery which includes complications with anesthesia, bleeding, infections, and long-term effects on her bone growth and hormonal imbalances. I gave the consent appendicectomy. Why can’t I do it now? Appendectomy is a medical emergency where the decision is taken on medical grounds. If you like, you can contact the family court or the guardianship board. They have the legal authority to allow this kind of procedure.

Relevant history Address mother’s concerns

Depo-Provera Counseling Can you please tell me, what is your main concern? Do you think your daughter has started her periods? Did you notice any breast development? Since when? Have you noticed any hair growths in the armpits over the pubic area? Since when? I understand she is on phenytoin/carbamazepine? Any side effects? Who takes care of her medications? Since when did she last see her neurologist. Please tell me more about her mental retardation. Was she born this way? How would you describe her mental age to be? Is she able to do daily life activities like eating, dressing, and going to the toilet? Does she need partial or complete supervision? Who takes care of her most of the time? Do you experience any difficulties while taking care of your daughter? How is her school performance? Any problems at school? Is it a special school? Do you think she might already be sexually active? Have you discussed anything with her like Periods? Contraception? Previous medical or surgical illnesses? Any concerns about her growth? Do you have enough support at home, from family friends and partner? Financial problem?

Counseling I understand from the history that your daughter has not had her periods up till now. However, some degree of breast development has occurred so we might expect that she will start menstruating soon. It is very good that you have come at this time to discuss contraception. However, no form of contraception is required until periods start. Usually, we recommend oral contraceptives that might be most suitable for her. Because she is on antiepileptic medications, we might need to give her a pill with high dose of estrogen. Please understand that the pill prevents pregnancy only and not STDs. If you find that giving a pill everyday is inconvenient, we can give her injections of depo-provera every 3 months. However, with prolonged use, it will produce side effects including reduced density of bones as well as problems with periods. There are other options as well like implanon and IUCDs. However, the management is better suitable for females who can look after themselves. Can we remove her womb instead? The oral pill is the best option for your child because you are already giving her some medications and you just need to add one more. Regarding permanent sterilization, it is usually not allowed for girls under the age of 18 years without approval from the court. Please understand that being mentally disabled does not deprive your daughter from the right to be treated just like other people. We, as doctors, only prescribe something if it is in the best interest of your daughter. I understand you are concerned; however, I am sure you would be

Case: A 25-years-old female is in your GP clinic and who wants to have depo-provera. Task a.

Advise about depo-provera

Counseling It is the only injectable IM contraceptive available in Australia and it has progesterone in it. The dose is 150mg by deep IM injection in the first 5 days of menstrual cycle and same dose is given every 12 weeks. Do you have any migraine? Stroke? Cancer? Any undiagnosed vaginal bleeding? Hypertension? Heart disease? Diabetes? Lipids? Liver disease? 5Ps: periods, pap smear, do you want to be pregnant in the next 12 months? When the woman has depo-provera in the body her own hormone production is switched off. Because of this the ovaries will not release eggs thus pregnancy is prevented. It is a highly effective method of contraception more effective than the combined pill and failure rate is 1%. The advantages of depo-provera are: It is highly effective and therefore has low failure rate. It can relieve pre-menstrual tension and period pain. It is also likely to cause some reduction in risk of ovarian and endometrial cancer, and endometriosis. As it is given every 12 weeks, no other effort or remembering is required. The disadvantage is that you have to take injection every 3 months. Once the injection is given, the hormone cannot be removed and if you want to stop depo-provera you have to wait for the hormone to wear off. In some women, it can take 6-12 months for periods to return. There is a concern about the risk of thinning of bones if woman is using depo-provera for a long period of time. Side effects may include reduced periods due to low level of hormones. After 2-3 injections, most women will have no periods at all because there is no lining building up to shed. Some have intermenstrual bleeding which is usually light and irregular or have heavy bleeding which can be controlled by hormone treatment. A small amount of weight gain can occur. There can be headache, abdominal discomfort and mood changes. Women who have increased incidence of depression can have reduced interest in sex. Contraindications o Bleeding disorders or taking anticoagulant medication

54 Undiagnosed vaginal bleeding History of some forms of cancer Serious medical conditions Already pregnant or those who want to become pregnant within 12 months Not recommended for greater than 2 years. o o o o

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Implanon Counseling Case: Your next patient is a 19-year-old female previously on OCP and now requests implanon. Task a. b.

History -

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Relevant history (friend mentioned; no problems except missed pill) Advice patient and answer questions

Why do you want to change? Who suggested implanon? Any side effects of OCP? Any chance you are pregnant now? Did you have previous STIs? Pap smear Previous pregnancies/miscarriages? How are your cycles? When was your LMP? Any medical conditions and FHx of hypertension, diabetes? SADMA?

Counseling - The implanon, as you know, is a small device that goes below the skin in the non-dominant upper arm under local anesthesia. It contains a certain hormone (etonogestrel) that will cause 2 things: inhibits ovulation and increases the viscosity of the cervical mucus. It is a very safe contraceptive method. The failure rate is 100kg  efficacy is less), women for whom regular periods are important - Side effect: Menstrual disturbance is the most common reason for removal o bleeding approximating normal (35%), infrequent bleeding (26%), amenorrhea (21%), frequent or prolonged bleeding (18%) o breast tenderness, fluid retention, weight gain, skin disorders (improve), mood change - Effective immediately if inserted during day 1-5 of the patient’s menstrual cycle; if not, then important to ascertain the patient is not pregnant and alternative contraception should be used for 7 days after insertion. Emergency Contraception after Rape Case: You are a GP and 18-year-old Samantha came to your clinic asking for emergency contraception and advice.

Task a. b.

Explain methods of emergency contraception Manage the case

Case: Rosie aged 24 years presents to the ED of the local hospital where you are working as an intern. She tells you that she was sexually assaulted by a person to whom she met in a pub. She is very distressed and teary. On further questioning 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 car in a lonely place and assaulted her. Rosie is an overseas university student and lives in a shared accommodation and had no other medical or any surgical problems. Task a. b. c.

Further relevant history Physical examination Management advice

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I understand from the notes that you are here for emergency contraception which is available OTC. Is there some special reason to see me today? I am sorry to hear that, but don’t worry there is a lot of support and you are not alone at this moment of crisis. Confidentiality statement. Would you like to take any legal action? (No doctor. This man is known to my family and I don’t want to make a fuss about it.) I respect your decision but I would like to get samples and keep it in the hospital just in case you will change your mind later. Were you injured anywhere else? Menstrual history: When was your LMP (3 weeks ago)? How are your periods? Are they regular? What is the cycle? Bleeding? How many days apart? Sexual history: Do you know if the man suffered from any STIs (No)/Did you see any discharge on his private part? Are you sexually active? Are you in a stable relationship? Are you using any form of contraception? Have you or your partner ever been diagnosed with STIs? Pap smear Any history of clotting, hypertension, migraine, undiagnosed vaginal bleeding, breast cancer?

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Examination General appearance Vitals Pelvic examination with consent o Inspection: sign of injury, vaginal secretions, consent to take low and high vaginal swabs for STD screening Chest, heart, abdomen to check signs of assault Urine dipstick Management We need to take blood samples for HIV, syphilis, Hepatitis B&C, HSV and take urine sample for PCR and Chlamydia I would give you antibiotic coverage: Azithromycin 1g SD I would like to refer you to a psychologist or counselor for support (rape crisis team). Let’s talk about emergency contraception. The first method is levonorgestrel (Postinor). This is a POP. 2 pills (0.75mg each)  12 hours apart or 1 pill (1.5mg) given up to 5 days but most efficient if taken within 72 hours. Efficacy is 85%. The next method is combined pills or Yuzpe method 75% efficacy ([50mcg estrogen and 250 mcg progesterone] 2 tablets now then 2 tablets 12 hours apart) or copper IUDs with a failure rate of 4kg)? Did you have NSVD? Did you have instrumental delivery? Are you generally healthy? Surgeries? Medications? Smoking? What are you doing for a living?

Physical examination General appearance Vital signs and BMI Abdomen: masses and tenderness Pelvic: o Inspection: evidence of prolapse and atrophic changes; can you please strain or cough (for 2nd degree prolapse)? o Speculum (left lateral position): using sims speculum prolapse, check for cystocele or rectocele, degree of prolapse, atrophic changes, discharge, appearance of cervix, o Bimanual examination: any pelvic masses palpable, size of uterus, and adnexa; ask patient to squeeze to fingers to assess of pelvic muscle strength Urine dipstick and BSL Degree of prolapse I – cervix protrudes/sits into lower 1/3 of vagina II – cervix protrudes on straining outside of vagina III – cervix/uterus lies outside of the vagina Diagnosis and Management You have a condition called uterine prolapse. Have you ever heard about it? The uterus, bladder and bowel are supported by a tight hammock of muscles slung between the tail and pubic bone. These muscles are known as pelvic floor muscles. Ligaments also anchor uterus in place. If these tissues are weakened or damaged, the uterus can slip down into the vagina. We call it uterine prolapse. Common causes of uterine prolapse include vaginal childbirth especially if baby was large or delivered quickly or if there was a prolonged pushing phase or instrumental delivery. Another group of risk factors is being overweight, having chronic cough, constipation, and heavy lifting which are factors that increase intra-

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abdominal pressure. The last predisposing factor is a low level of estrogen after menopause. I will refer you to a gynecologist for further assessment and to discuss treatment options. Treatment depends on age, degree of prolapse, and patient preference. Meanwhile, I will arrange a meeting with a physiotherapist who will teach you pelvic floor exercises (effective for 1st and 2nd degree). I also recommend for you to have lifestyle modification. Try to keep your weight within the ideal range, have a balanced diet, regular exercise, and smoking cessation. The most effective treatment is surgery which is vaginal hysterectomy. Sometimes before surgery or if woman is not fit for surgery, or if woman does not want surgery, a vaginal pessary can be used which is a donut-shaped device inserted into the vagina and positioned to prop the cervix and uterus. It should be changed every 6 months. Side effects include irritating discharge and increased risk of ulceration as well. Local estrogen can be used to decrease the side effect.

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Needle vaginal drainage by USD for simple larger cyst Laparoscopy: complex cysts, large cysts, or external bleeding

Ovarian torsion o Mainly from dermoid cysts o Symptoms: severe cramping lower abdominal pain, diffuse, pain may radiate to

o o o

flank, back or thigh; repeated vomiting, exquisite pelvic tenderness, patient looks ill Signs: smooth, rounded mobile mass palpable in abdomen; may be tenderness and guarding over the mass Investigation: USD + color Doppler Management: Laparotomy

Differential Diagnosis - Ectopic Pregnancy - Ruptured ovarian cyst/torsion - PID

BENIGN TUMORS -

Ovarian Torsion/Ruptured Ovarian Cyst Case: Julia aged 35 years presents to ED of local hospital where you are working as year 1 RMO. She had severe right sided abdominal pain for the last 1-2 hours associated with nausea and vomiting. She had similar pain a few months ago but lasted only for a few minutes and was relived with panadol and neurofen. She had no other significant medical or surgical problems. She had known allergies and is not on any regular medications. Julia works as a business consultant in a local firm and lives with her partner. She smokes about 10 cigarettes per day and is a social drinker.

History -

Task a.

b.

c.

Further history (10/10 in severity, tried panadol and neurofen but did not work; RLQ, no fever, no rash, no problems with bowel motions or waterworks; periods are regular, LMP 3 weeks ago) Physical examination (uncomfortable but fully conscious and oriented, PR 84, BP: 100/70, T and RR normal; no LAD, no lumps and bumps, chest and heart normal; inspection normal; no distention; palpate tender at RIF but no rebound or guarding/rigidity, no palpable mass; no organomegaly; pelvic examination: normal; PR normal; urine PT negative, urine dipstick; FBE normal U&E normal; USD pending) Diagnosis and management

Features - Ovarian Cysts: o Common in women under 50 years of age o Best defined by TVS o Symptoms: pain, pressure symptoms, menstrual irregularities - Ruptured ovarian cyst: o 15-25 years o Symptoms: Sudden onset of pain in one or other iliac fossa; No systemic signs; Pain usually settles within a few hours o Signs: tenderness and guarding in iliac fossa, PR: tenderness in rectovaginal pouch o Investigation: USD + color Doppler o Management  Explanation and reassurance  Conservative: simple cyst 2 years normal, USD GB normal, + discomfort during sexual intercourse, regular bowel movement) Physical examination (BMI 25, vital signs normal, soft, no distention or masses, no discharge or bleeding, bimanual normal, pelvic mass which is hard to distinguish if it arises from uterus or adnexa, urine dipstick and BSL) Management Pelvic Mass (Fibroids or ovaries) Pregnancy Herpes simplex Prolapse Neurologic problems Renal stones Constipation (elderly) Medications (antidepressants/antipsychotics) Males: Prostate enlargement I understand you came to see me because you can’t pass urine? For how long? Are you comfortable enough for me to ask you a few questions or you want me to address this problem first? Is it the first time? Can you recall any precipitating factors like trauma to the back or pelvis? Have you noticed change in urination or frequency before? Do you have any bowel problems? Do you have difficulty or discomfort when you try to urinate? Did you have leakage of urine while laughing, coughing or sneezing? Have you noticed any rash in your private area? Have you noticed any unusual vaginal discharge? Have you noticed any lump coming out of your vagina? When was your LMP? Is it regular? Any excessive pain or bleeding? Have they always been heavy or is it something new? Are you in a stable relationship?

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Have you ever been diagnosed with STD? Do you have pain or discomfort during sexual intercourse? What type of contraception do you use? How many pregnancies have you had? How many children do you have? Type of delivery? BW? When was your last pap smear? Was it normal? Are you generally healthy? Ever been diagnosed with renal stone? Any medications? Allergies?

Physical examination - General appearance - Vital signs and BMI - Abdomen: palpate distended bladder (smooth, firm, oval dull suprapubic mass) - Pelvic exam o Inspection: any evidence of prolapse o Speculum in left lateral position with sims speculum Bimanual examination: size of uterus, contour, consistency, adnexal mass Urinary catheter and take urinary sample for microscopy and culture. After emptying bladder, can I palpate any abdominal masses? Urine dipstick and PT o

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Diagnosis and Management - You have an acute retention of urine and on PE, I found a pelvic mass which can arise from the uterus or the ovaries. You need to have a pelvic USD to establish the diagnosis. I need to refer you the hospital where you will be assessed by the gynecologist. - The gynecologist will arrange further investigations including FBE, U&E, CA-125, and TVS/TAS. - If this problem is due to fibroid which is a benign tumor of the uterus, the treatment will depend on site, size and desire for pregnancy. You have an acute presentation and most likely it will require surgery, laparoscopic or open. - If it is benign ovarian cyst or tumor, cystectomy can be performed. However, in women above 40, bilateral salpingo-oophorectomy plus total hysterectomy is preferred. A gynecologist will discuss diagnosis and all available options. - A catheter should stay in the bladder until a cause for your presentation has been identified and treated. BREAST Cyclical Mastalgia Case: A 40-year-old woman comes to see you in your GP practice. She complains of cyclic pain in both breasts. On examination, there are some lumps in her breasts on the upper outer quadrant. She was not able to tolerate OCPs because of vomiting and her mother was diagnosed with breast cancer when she was 60 and was treated with radical mastectomy. Task a. b. c.

History Diagnosis Management

Risk factors: - Caffeine intake - Inappropriate brassieres - Obesity History

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Let me acknowledge your pain and your concern about the breast lumps. I know you’re worried about your mom’s condition, but before we go ahead I would like to ask you some questions. Some of the questions might be sensitive, is that okay? When did you start having pain in your breast? Severity (1-10), site (both breasts/single)? radiation? Aggravating factor (periods)? Associated factors? How is it affecting your life? Any previous history of similar problems? Any previous breast problems in general? Nipple discharge? Changes in breast? Swelling and erythema? Any lumps and bumps in the body? Back/bone pains? Any cough or other chest symptoms? Headache, N/V, or visual changes? Do you drink too much coffee? Do you have bra problems? 5Ps: pregnancy: any chance you could be pregnant at the moment? Partner, pills, periods (regular? Bleeding? Clots duration of cycle? Menarche); pap smear: any abnormal pap so far? FHx: other cancers? PMHx

Management - With respect to your worries about the cancer, let me reassure you that the pain and lump sensation is due to a benign condition called cyclical mastalgia. Most likely, it is because of hormonal changes during menstruation. It usually starts a couple of days before menstruation and relieved during the commencement of menstruation, but let me reassure you that it is not cancer. It is very common in women aged 30-40 years - Advise weight reduction - Reduce caffeine intake (not >1-2 cups/day) and low fat - Stop smoking - Wear good quality comfortable brassiere - Prescribe analgesics - If not responsive, then add mefenamic acid, vitamin b1 and b6.  evening primrose oil  danazol - Because of your concern about your mom’s condition, which increases your risk of having a breast cancer (1:14 to 1:10), I will refer you to a specialist who will order further investigations like mammography (every 2 years from now) and annual examination by GP and monthly self-breast examination. - Exercise (aerobic upper exercises) - See his sister - Cause: Estrogen Nipple discharge (Intraductal Papilloma) Case: Marion aged 51 years presents to your GP clinic in a busy afternoon and tells you that she is quite worried about her nipple discharge. The discharge is from right nipple describing it as pinkish. The discharge is spontaneous and she had also noticed discoloration on her nightie. It happened last night and also last week. It is of small amount, leaving a stain about the size of 20 cent piece on her clothing. She never had any breast problems before and is very concerned. Marion is a mother of 3 who she bottlefed. She had paternal grandmother who had mastectomy although she doesn’t know any more details. She had attended a breast screen clinic about six months ago and was all OK. She is still menstruating but her cycles have become quite irregular and scanty over the last year.

69 Task a. b. c.

Further history Physical examination Differential diagnosis and management advise DISCHARGE

Blood Green Yellow

White

Straw-color Serous

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FSH/LH increase and estradiol decrease Symptoms: o Bleeding: oligmenorrhea/menorrhagia o Hot flushes: heat centered on the face and spreads to neck and chest; accompanied by vasodilation and sweating; episodes last 2-4 minutes happening several times a day; should be fine after 70 years o Sleep disturbance o Vaginal dryness (estrogen deficiency which can lead to vaginal atrophy and dyspareunia; pale vagina; pH which is usually 12 mos. - Pre-menopausal – 5 years before the onset of last menstrual period - Perimenopause – the time when menses become irregular (2 years before) - Postmenopause – women who have not experienced menstrual bleeding from a minimum of 12 months and up to 5 years after menopause

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Ask menopausal symptoms: problems with bleeding? Hot flushes? Sleep disturbance? Dyspareunia? Sexual dysfunction? Incontinence? Breast pain and tenderness? Skin changes? Osteoporosis (bone pain, backaches)? CV problems? Signs of dementia? Differentiate mood swing from depression? Any change in weight or appetite? 5Ps: pills, pregnancy, partner (history of STD), Pap smear, mammography? Periods (postmenopausal bleeding)? How is it affecting your life? Contraindications for HRT: ever been diagnosed with stroke, TIA, migraine, hypertension, thyroid disease, clots in legs or lungs, undiagnosed vaginal bleeding, liver disease, personal or FHx of breast or endometrial cancer? SADMA?

Investigations - FBE with iron studies - Urinalysis

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U&E, Ca and Vitamin D levels LFts, TFTs, Lipid profile Pap smear Mammography (all women before or after 3 months on HRT) Hormone levels: FSH, LH, estradiol, progesterone, testosterone, PRL, Coagulation profile TVS to check for endometrial thickness DEXA scan Diagnostic hysteroscopy and endometrial biopsy (if with undiagnosed vaginal bleeding or increased thickness) Urodynamic studies for incontinence

Management - I have organized the investigations for you. At this stage, since you have dry vagina, I will give you estrogen creams. I would advise to have a healthy lifestyle including exercises 30 minutes a day 5 days a week, healthy diet with lots of calcium, pelvic floor exercises, smoking cessation, advise on safe levels of drinking - Use evening primrose oil for breast tenderness - For social issues: handle accordingly - I would like to refer you to a gynecologist who may consider starting you on HRT and I would like to review you once all the investigations are back and we may need to change some of the management depending on the results.

Speculum: discharge, vaginal wall for pallor, dryness, thin, atrophic, rectocele or cystocele or prolapse, pap smear o PV: cervical motion tenderness, adnexal masses Urine dipstick and BSL o

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Diagnosis and Management You have a condition called atrophic vaginitis. It is a common condition in postmenopausal women because at this age, there is lack of estrogen and the vaginal wall starts to have atrophic changes because of that. For this I will give you local estrogen creams. Also, we need to further assess the womb lining. I will refer you to a gynecologist and arrange an ultrasound to rule out any nasty changes in your womb. Lifestyle modification. More calcium. Reading material. Review. Lichen Sclerosus et atrophicus You are a GP and a 68-year-old female came to your GP practice complaining of itching of the vulva for 1 year. Task a. b. c.

History: chronic itching x 1 year with pain/discomfort Diagnosis based on picture given Investigations and manage the case

Biopsy: chronic Inflammatory changes dermatoses -- lichen sclerosis r/o MALIGNANCY! Atrophic Vaginitis Case: You are a GP and a 60-year-old female comes in complaining of vaginal discharge. Task a. b. c. History -

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History (vaginal discharge x 5 days, brownish, menopause 5-6 years ago, no HRT) Physical examination (thin and dry; pale, discharge) Diagnosis and management When did you notice it? What’s the color? How much? Is it smelly? Is it itchy? Does your partner have similar complaints? Periods: menarche, LMP, menopause? Are you sexually active? Are you in a stable relationship? Do you have problems with sex? Have you or your partner ever been diagnosed with STIs? Pregnancies? Pap smear? When was the last one? Mammography? 4B and 2Ps in a postmenopausal woman: o Bladder, bowel, breast, bone o Prolapse and Postmenopausal symptoms (mood swings, hot flushes, irritability, dyspareunia, bleeding) FHx: cancers How is your general health? SADMA

Physical Examination General examination Vital signs and BMI Breast examination for lumps Pelvic examination o Inspection: discharge, color, amount, smell, scratch marks, visible prolapse,

History -

Please tell me more about the problem? Is it present all the time or does it come and go? Does it wake you up at night? Any bleeding? Discharge? Any problem with passing water like burning sensation, frequency of urination, any problems with the stream (scarring due to LS may cause problems with urination? Previous infections or surgeries down there? Skin allergies? Have you ever been diagnosed with DM? Or prolonged steroid use? When was your LMP? Did you have symptoms of menopause like flushing, palpitations, irritability, dry vagina? HRT use? For how long? Any problems with that? Did you have any bleeding or spotting since then? When was your last pap smear? Are you sexually active? Stable relationship? Any problems during intercourse? Did you have a mammogram recently? How many children do you have? All NSVD? Complications? Change in weight? Appetite? Lumps around body? Do you feel tired most of the time? Any FHx of gynecological cancers or similar conditions? Any PMHx or surgical conditions? SADMA? Picture: white shiny plaques on both vulva with lacelike patterns w/ or w/o bleeding; may bleed when scratched

Investigations - BSL, pap smear, swab if with discharge - Multiple punch biopsy of lesion Differential diagnosis - lichen sclerosis - candidiasis - atrophic vaginitis - vulvar Cancer

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psoriasis diabetes paget disease leukoplakia vulvovaginitis trauma Eczema

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Management - You have a condition called lichen sclerosis (genital pruritus + genital soreness+ white wrinkled plaques). It is a chronic inflammatory skin condition. The exact cause is unknown, but there is a genetic pattern and it is linked to certain immune-mediated conditions, e.g. Autoimmune thyroid disease, vitiligo, psoriasis, pernicious anemia, alopecia - Please don't worry. This is not an infection and this is not cancer. It is not contagious. It usually presents as itching, vulvar pain, bleeding with scratching, sometimes blister formation. - It is important to treat the condition to prevent scarring. 5% of these patients may develop cancers within the scar. - Is it because of my menopause? (up to now there has been no association proven between lack of estrogen and appearance of the condition) - Treatment with steroids (clobetasol propionate) -apply 2x a day for x 1 month, then once every night x 1 month then 2x weekly x 3 months then once weekly until asymptomatic then PRN - Inform about risk of steroid therapy: thinning of skin, redness, fungal infections

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95% of patients improve with this treatment. Maintain good genital hygiene. Avoid using any other creams in that area. Try to avoid scratching. If required, you may use emollient to keep the area moist If not relieved, may use retinoids, tacrolimus, UV therapy Refer to gynecologist for treatment and followup

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LSIL with HPV

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Task a. b.

Explain result to patient Management accordingly

Guidelines for Pap Smear Results for Asymptomatic Females Results Action Negative Repeat x 2 years LSIL Repeat in 1 year HSIL Colposcopy and biopsy Unsatisfactory Repeat in 6-12 weeks Glandular cells Colposcopy and biopsy 

LSIL o Mild dyskariosis/dysplasia or HPV infection o Repeat in 12 mos  If normal à repeat in 12 mos. à if normal then every 2 years

HSIL  

Moderate to severe dyskariosis Do Colposcopy and biopsy  If colposcopy shows intracellular (LSIL) lesions à ablation (laser, cryotherapy, diathermy or surgical excision)  If colposcopy is positive for invasive lesion à do cone biopsy o NO cone biopsy in pregnancy  Complications: bleeding, cervical incompetence, cervical stenosis  May affect further pregnancy: premature labor or premature rupture of membranes o In pregnancy:  If LSIL à wait and can do ablation after pregnancy  If HSIL:  20 weeks: up to mother to decide  >35 weeks: continue pregnancy and do cesarean section and aggressive cancer treatment Any active problems with cervix/abnormal pap smear in pregnancy is a contraindication to vaginal delivery

HPV

ABNORMAL PAP SMEAR

Case: You are a GP and 24-year-old female came to find out the result of her pap smear. This showed low-grade intraepithelial squamous lesion and HPV infection.

If (+) LSIL à colposcopy and biopsy If colposcopy shows LSIL à ablation (laser, cryotherapy, diathermy or surgical excision)

Around 200 types 40 are found within anogenital area Spread by sexual contact and skin-to-skin contact Type 6 and 11: low-risk HPV  responsible for 90% of genital warts; not related in any way to cancers Types 16 and 18: high-risk HPV  responsible for 70% of cervical cancers all over the world Causes microabrasions within cervical epithelium Are extremely common within the first 10 years of sexual life but majority are transient Body is able to get rid of the virus on its own but might take up to 12 months to clear the infection Also known as “common cold” of sexual activity

Counseling - I have the results of the test with me. May I ask a few relevant questions? - When did you have your last pap smear? What was the result? I understand you are sexually active, are you in a stable relationship at the moment? How many partners have you had previously? Did you always practice safe sex with the use of condoms? Have you or your partner ever been diagnosed with a STI (warts)? At the moment, do you have any symptoms, vaginal discharge, bleeding, or itching? Any pain during intercourse? Any chance you might be pregnant now? Have you ever been pregnant before? Any miscarriages? When was your LMP? Cycles regular?

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How is your general health? SADMA? Do you have a family history of gynecological cancers or breast cancer?

Counseling - As you know, pap smear is a screening test for early asymptomatic cervical cancer. We usually detect for the presence of abnormal cells in the cervix. At the moment, your results showed that there are some cells that look different from normal. We call it LSIL. Basically it means that there are minor changes within the lining of the cervix, which could be because of the presence of a coexisting infection with HPV. This virus induces temporary changes in the lining of the cervix. What is important is that LSIL has a very low but definite risk of transforming into cancer. We need to repeat the test within 12 months time. There are two possibilities: If pap smear is normal, we will repeat it again in 1 year time and if still normal then go back to 2-yearly regime. The other possibility is persistent LSIL or HSIL. If this happens, I will have to refer you to a specialist for colposcopy and biopsy. It is a process where we introduce a small tube with a camera into the cervix to look at the lining. If there is a suspicious lesion, then a piece of tissue will be taken out. If not, acetic acid will be applied and a suspicious area will turn white and a sample will be taken. - Regarding HPV infection, the body will be able to clear off the infection in majority of cases. It is very difficult to find out how and when you got this infection because it can happen even in stable relationships. It is important for you to be vaccinated with gardasil to protect you from the other 3 subtypes of HPV. If you like, we can check you for other STDs.

Management Offer HPV vaccination Repeat after 1 year (or 6 months if age >30 and pap smear >2 years ago) Counsel against risk factors and safe sex Abnormal Pap smear with Actinomyces Case: You are a GP and a 38-year-old female comes in with pap smear showing abnormal cells + Actinomyces. She has IUCD for 5 years. Task a. b. c. History -

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We are planning to have a baby, can I fall pregnant? There is a 10% that the baby might acquire the infection during labor only. It usually goes into the baby’s throat (respiratory papillomatosis) causing warts. The baby may or may not be able to get rid of the infection on its own, but we can give certain medications to help him. It is important to practice safe sex from now onwards. Review. Reading material.

History (periods regular, IUCD checks monthly, 2children, NSVD, STI -, DM + Grandmother, Physical examination (can see string of pap smear BSL 5.5) Diagnosis and Management I know you have come to see me because you want to discuss your pap smear result. Prior to our discussion, can I ask a few symptoms? How are you feeling? Have you noticed any low abdominal pain or discomfort? Any unusual discharge or bleeding? Periods: Are you in a stable relationship? Have you ever been diagnosed with STD or PID? Is it your first IUCD? What type of IUCD do you have? Have you ever been pregnant? How many children have you had? Have you ever had an abnormal pap smear in the past (No)? When was it? What was it? What was done for that? When was your last pap smear apart from this one? How’s your general health? SADMA? FHx

Physical examination - General appearance - Vital signs - Abdomen: tenderness and masses - Pelvic: inspection/speculum: appearance of cervix, any abnormal discharge, thread of IUCD? PV: size of uterus, adnexal masses/tenderness, cervical excitation/CMT - Urine dipstick and BSL

Pap Smear (CIN I) Case: Katharin aged 25 years presents to your surgery for result of her Pap smear which you did last week. The result shows changes consistent with CIN 1. Her last Pap test was two years ago and that was normal. She is otherwise well and had no previous medical or any surgical problems. Katharine lives by herself and works in a local bar. She smokes on average 10-15 cigarettes per day and drink socially. Task a. b. c. History -

Explain result of pap smear Further relevant history Management Multiple partners? Smoker? What age of coitarche? Practicing safe sex? Promiscuity? What is your work? Low socioeconomic status? FHx of cancers?

Diagnosis and Management - Your pap smear result showed abnormal cells and actinomyces. Actinomyces is a gram positive bacteria and is relatively common to find smears positive for

Actinomyces in women who use IUCDs. I want to refer you to a gynecologist for further assessment and management. Usually, with symptomatic Actinomyces, IUCD should be removed, threads cut, and IUCD sent for microscopy and culture. If it is positive, prolonged antibiotic treatment with penicillin for 6 weeks is done. After treatment, pap smear should be repeated in 6-12 weeks because it might be due to the coexisting infection with the bug. Gardasil Vaccine

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Case: You are a GP and your next patient is a 45-year-old Mr. Walker wants to know about Gardasil vaccination. His 15 year old daughter will receive vaccine in school and he is worried that it will encourage early sexual life. Task

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Respond to patient inquiry

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Hello Mr. Walker. I understand you have come to see me to discuss Gardasil vaccine. How much do you know about this vaccine? Have you ever heard about HPV infection? Gardasil vaccine was designed to prevent HPV infection and it doesn’t promote early sexual life. Gardasil is effective against 4 types of HPV. There are 40 types of HPV that affect the genital tract. This vaccine is against types 16 and 18 causative agents in 70-80% of all cervical cancer and types 6 and 11, which are associated with 90% of genital warts. HPV infection is transmitted by sexual intercourse. That is why this vaccine is given to young girls (9-26) since most of them hasn’t started sexual life and haven’t been infected and thus will benefit the most. However, even sexually active girls can benefit from gardasil vaccine. Majority of them will not yet be infected, or may be infected by 1 or 2 types and get protection against others. Gardasil vaccine is part of the school immunization program. It is free and given within 6 months. It is administrated by intramuscular injection usually in the shoulder. The only absolute contraindication to HPV

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vaccination is severe allergic reaction (anaphylaxis) following a previous dose of the vaccine. Gardasil contains virus-like particles which are noninfectious and do not have any cancer-causing potential. This vaccine is generally safe and welltolerated. Possible side effects: Injection site pain, swelling, and redness.

Gardasil vaccine does not protect against other STDs. It doesn’t encourage girls to start sexual life earlier. The main purpose of the HP V vaccine is to protect them against cervical cancer and genital warts. However, it doesn’t give 100% protection. All girls need to be screened for cervical pathology using pap smear from the age of 18 or 2 years after they become sexually active (whichever comes later). Can be given to boys but not included in the immunization program. Pregnant women? No, but you can give them after labor even while breastfeeding. It is no longer beneficial after the age of 27.