Kindly sponsored by 27042012 Amrita banerjee amp OLA MARKIEWICZ Plan for the morning 91030 Lecture demonstration station 10301100 Break 1100 1230 Mock PACES stations x4 ID: 931269
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Slide1
PACES RevisionObstetrics and Gynaecology
Kindly sponsored by:
27/04/2012
Amrita
banerjee
& OLA MARKIEWICZ
Slide2Plan for the morning9-10.30 - Lecture + demonstration station10.30-11.00 - Break11.00
-12.30 - Mock PACES stations (x4)12.30-13.00 – Lunch
Slide3Outline of TalkObs & Gynae
HistoryExaminationClinical SkillsInvestigationsManagementRed FlagsEthics and LawCommon PACES StationsDemonstration StationTips and Advice Further Resources
Slide4HISTORY
Slide5The HistoryThe main part of all PACES stations!! Do not compromise on
this.PCHPCGynae historyObstetric HistoryPMHDHFH SHSystems review
Slide6The Gynaecological History
PeriodsDysmenorrhoeaOligomenorrhoeaAmenorrhoeaMenorrhagiaMittelschmerzDischargeSmellColourConsistency
Slide7The Gynaecological History
Think about sex:ContraceptionHPV vaccineHave sex:DyspareuniaPost-coital bleedingAfter sex catch:STI’sHPV – smears!Babies
Slide8The Gynaecological History
Boys RegularProtection – pregnancy and STI’sGUM clinic visitsPeer pressureLegal
Slide9The Gynaecological History
Obstetric History – don’t forget TOPs!Consequences of childbirthSphincter dysfunctionRectal/vaginal prolapse
Slide10The Gynaecological History
MenopauseSymptomsHRTPost menopausal bleeding!Vaginal atrophy Sex lifeQuality of life
Slide11Obstetric HistoryPC
HPCCurrent PregnancyWas this a planned pregnancy? EDD - scan or dates (LMP, Menstrual cycle)ComplicationsInvestigations so farGravidity – number of times a woman has been pregnant, regardless of outcomeParity = (any live or still birth after 24 weeks)Specific Symptoms...Nausea / Vomiting - if severe known as hyperemesis gravidarumUrinary frequency – pressure on the bladder causes this – rule out UTITirednessFetal Movements - usually felt at around 18-20 weeks gestation, earlier in multipsIdeas, Concerns & Expectations…
Slide12Obstetric HistoryDetails of each pregnancy:Date / Year
Place of birthGestationMode of deliveryBaby – sex, weight, current healthProblems during antenatal, labour & postnatalSame Partner? Consanguinity?Miscarriages & TerminationsPrevious difficulty conceiving/ assisted conceptionPlans for future pregnancies
Slide13Obstetric History Maternal: DEATH P
Diabetespre-EclampsiaAnaemiaThrombusHypertensionPainBleedingInfectionFetalMovementsScans/testsHospital admissions
For each pregnancy, including the current one if pregnant, ask about complications:
Slide14Obstetric History Cont.Past Gynaecological History
Contraceptive use?Last Cervical Smear – was the result normal? Any gynae surgery: - Loop excision of transitional zone (LETZ) -↑ risk of cervical incompetence- Previous myomectomy - ↑ risk of uterine rupture / placenta accreta /adhesionsGynae investigations & treatment for: - Infertility- Ectopic – ↑ risk of future ectopics- PID - chlamydia is most common cause – ↑ risk of ectopic
Slide15The rest of the historyPast Medical History and Past Surgical History
Drug HistoryPregnancy medication - folates, iron, anti-emetics, antacidsTeratogenic drugs – avoid at all costs - ACEi, Retinoids, Sodium Valproate, MethotrexateOTC Drugs - make sure to ask patient about these, to ensure nothing unsafeALLERGIESFamily HistoryMedical conditions - gestational diabetesInherited genetic conditions – CFPregnancy Loss - recurrent miscarriages in mother & sisters Pre-eclampsia - in mother or sister? – increased riskSocial historySmoking, Alcohol, Drug useLiving Situation, Relationship StatusOccupation Systems review
Slide16Other Important QuestionsHow do her symptoms affect her life
What support does she have at home – do not assume she is married!Is there anything else that you are worrying about?Is there anything else that you’d like to ask me?
Slide17EXAMINATION
Slide18The Physical ExaminationExaminationAbdomen:Gravid
Non-pregnantPelvic examinationSpeculumSwabsSmearTo complete my examinationBlood pressurePregnancy test
Slide19The Pelvic ExaminationBrief abdominal examinationInspect vulvaInspect cervix using Cusco’s speculum
Take smears and swabs if requiredWithdraw speculumBimanual examinationCervixUterusAdnexaeInspect fingers for blood or discharge
Slide20What is this?
Slide21The Obstetric ExaminationInspection “There is an abdominal mass consistent with pregnancy
”Linea nigraStriaeScarsFetal movementsMeasure symphysio-fundal heightPalpate – use ballottementAssess amniotic fluid volumeFetal liePresentationEngagement (fifths palpable)
Slide22Slide23The Obstetric Examination cont.Fetal heart soundsBP and urinalysis
Antenatal notes
Slide24CLINICAL SKILLS
Slide25Clinical SkillsBlood PressureUrine dipstickPregnancy test
Gynae:Vaginal swabsCervical smearsObstetrics:CTG
Slide26Blood PressureMake sure you know how to use a sphyngomanometer
Roughly determine systolic BP using the radial pulseStart 20mmHg above this and measure BPKorotkoff sounds
Slide27Urine DipUse glovesExpiry dateRemove a strip, then close the bottle
Dip the strip into the urine and wipe any excess urine on the side of the bottle
Compare the strip to the bottle label
Slide28Pregnancy testPerform in almost every woman of childbearing ageDetects β
hCGDipsticks vs pipette urineControl lineTest lineConfirm result with another member of staff
Slide29Vaginal Swabs
BugSwabOtherTreatmentCandida albicansHigh vaginal swabMycelial filaments on microscopyClotrimazole cream or oral fluconazole
Bacterial vaginosisHigh vaginal swabWhiff test positive, clue cells, alkaline pHMetronidazole or clindamycin cream
Trichomonas vaginalis
High vaginal swab
Motile flagellated protozoa on microscopy, alkaline pH
Metronidazole
Chlamydia trachomatis
Endocervical swab
Nucleic acid amplification tests (NAATs) eg. PCR
Doxycycline or azithromycin
Neisseria gonorrhoea
Endocervical swab
Gram negative diplococci
Ceftriaxone
Slide30Cervical screening programmeAim: identification of CIN and initiating early treatment before the development of cervical carcinoma
NOT a test for cancer!Age range: 25-49 every 3 years50-64 5 yearly60+ if not screened since 50 or recent abnormal resultsTechnique: Rotate brush in the external os to pick up loose cells over the TZ for liquid based cytology
Slide31Cervical screening programme
Counselling and explaining the process/results/follow up!DYSKARYOSIS: Cytology – smearCervical Intraepithelial neoplasia: Histology - biopsyManagementmild
CIN1Can spontaneously regress6 month follow up. If persists then colposcopymoderate
CIN2
Colposcopy
+ treatment
severe
CIN3
Immediate
colposcopy
+
treatment
Slide32Slide33CardiotocographyDR – Define RiskC – ContractionsBRA – Baseline Rate
– mean rate over 5 – 10 mins. Normal = 110 – 160 bpmV – Variability – should be >5 bpmA – Accelerations – rise in fetal heart rate by at least 15 bpm lasting at least 15 secs.D – Decelerations – fall in fetal heart rate by at least 15 bpm lasting at least 15 secsO – Overall
Slide34INVESTIGATIONS
Slide35InvestigationsGeneral tips:Importance of observations and bedside tests
Do not mention lists of investigations unless you are able to justify why you want themHit the jackpot early (but don’t show off)Think outside the box – pregnant women get non-pregnant diseases
Slide36InvestigationsGynae:Cervical smears
Interpret hormone levels: FSH, LH,TFT’sUrodynamicsUltrasound: endometrial thicknessSurgery: endometrial biopsy, laparoscopy, lap + dyeContraceptive methods: IUDHysteroscopy
Slide37InvestigationsObstetrics:Pregnancy test (in A+E)Glucose Tolerance Test
CardiotocographsPartogramPelvic USSScreening testsAmniocentesis/chorionic villus sampling
Slide38MANAGEMENT
Slide39ManagementWhat everyone does worst on!
Don’t forget:Resus +CONSERVATIVEMEDICALSURGICALAnd VERY importantly ASK FOR HELP!
Slide40RED FLAGS
Slide41Red Flags - Obstetrics
ConditionSymptomsPlacenta praevia Painless PV bleeding late in pregnancyPlacental abruption Painful PV bleeding late in pregnancy(Ruptured) ectopic pregnancy Early pregnancy, pelvic pain, PV bleeding +/- faintness, shoulder-tip painObstetric cholestasis Itchy hands and feet during pregnancyShoulder dystocia Delayed delivery after delivery of the headCord ProlapseUmbilical cord descends below the presenting part following rupture of membranesAmniotic fluid embolism Dyspnoea, hypotension, hypoxia, seizures, heart failure
Slide42Red Flags – Obstetrics cont.
ConditionSymptomsUterine rupture Acute, severe pain during labour or, if epidural, sudden maternal hypotension, cessation of contractions, fetal hypoxiaUterine inversion Post-partum haemorrhage, pain and profound shockPre-eclampsiaHypertension, proteinuria, oedemaEclampsiaPre-eclampsia with RUQ pain, headaches, tonic clonic seizures, blurred visionPESOB, chest pain, hypoxia, cardiac arrest DVTAcute leg pain, redness, swelling, heat, +/-SOBPrimary and Secondary PPHPrimary ≥ 500 ml of blood loss within 24 hours of delivery. Secondary - abnormal or excessive bleeding between 24 hours and 12 weeks postnatally.
Slide43Red Flags - Gynaecology
ConditionSymptomsOvarian cyst torsion/accidentSevere pelvic pain associated with hypovolaemic shockEndometrial carcinoma Abnormal uterine bleeding, especially PMBOvarian carcinoma Non-specific symptoms of abdominal distension, pain, abnormal bleeding, weight lossCervical carcinoma IMB, PCB, PMB, offensive vaginal dischargePID PV discharge, pelvic pain, fever, abnormal bleeding
Slide44COUNSELLING
Slide45CounsellingShared decision makingMDTEmpathyActive listening
Use of silenceAvoid jargonIdeas, concerns, expectations
Slide46Counselling cont.Congenital abnormalities e.g. Downs, Turners syndromeCervical smear results
Ectopic pregnancyMiscarriageContraception
Slide47LAW AND ETHICS
Slide48Law and EthicsEveryone ignores but is very important!Most sued specialtyExtremely sensitive issues: cultural, religious, personal
Important principles:Gillick competenceThe Abortion ActThe Mental Capacity Act
Slide49Law and EthicsEveryone ignores but is very important!Most sued specialtyExtremely sensitive issues: cultural, religious, personal
Important principles:Gillick competenceThe Abortion ActThe Mental Capacity Act
Slide50The Abortion Act Permits termination of pregnancy by a registered practitioner subject to certain conditions.Must be performed by registered medical practitioner in an NHS hospital or
DoH approved location (e.g. British Pregnancy Advisory Service Clinics)An abortion may be approved for the following reasons:
Slide51A
The continuance of pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy was terminated. BThe termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman. CThe continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman.DThe continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing children of the family of the pregnant womanEThere is a substantial risk that if the child were born it would suffer from physical or mental abnormalities as to be seriously handicapped, or in emergency, certified by the operating practitioners as immediately necessaryFTo save the life of a pregnant womanGTo prevent grave permanent injury to the physical or mental health of the pregnant woman.
Slide52The Human Fertlisation & Embryology Act 1990
Section 37 of the HFEA made changes to the 1967 abortion act:Time limit of abortion is 24 weeks under statutory grounds C and DStatutory grounds A, B and E are now without time limit
Slide53Fraser Guidelines (Gilllick Competence)Those <16 may be prescribed contraception without parental consent if:
They understand the doctor’s adviceThe young person cannot be persuaded to inform their parents that they are seeking contraceptive adviceThey are likely to begin or continue intercourse with or without contraceptive treatmentUnless the young person receives contraceptive treatment their physical or mental health is likely to sufferThe young person’s best interests require that the doctor gives advice and/or treatment without parental consent
Slide54THE EXAM
Slide55O&G PACES6 stations in totalO&G probably 2/6 stationsCombined with other specialities and GP15
mins/station
Slide565th Year PACES4 domains of marking:
1. Clinical skills2. Formulation of clinicalissues3. Discussion of Management4. Professionalism and Patient centred approach
Slide57Practice CaseMiss Sarah Jones, 25 years old 13/02/1988, has come to the antenatal clinic for her screening test results. Candidate Instructions:
Please take a brief history and explain the results of her test: 6 minsDiscuss further investigations and management options: 3 minsDiscussion with examiner: 4 mins
Slide58Past stations: Obstetrics15 year old wanting TOP
Missed miscarriage + speculumPre-eclampsiaVBAC counselingRecurrent miscarriages + antiphospholipid syndrome HIV and pregnancy (in multiple circuits) PE in pregnancy (confused a lot of people) Gestational diabetesDown’s syndrome screeningSmall for dates- young smokerAlcohol and pregnancyMultiple pregnancyAbnormal lie and ECVCounseling a patient with molar pregnancyPV discharge in pregnancyContraceptive advice post-pregnancyPre-term rupture of membranesHyperemesis gravidarumAntenatal check
Slide59Past stations: GynaecologyAbnormal bleedingMenopause
Amenorrhoea and infertilityUnderage/pressured sexSexually transmitted infectionsUrogynae – incontinence, self esteem Vaginal dischargePelvic painSubfertilityContraceptionGynae oncologyEthics
Slide60How to prepareClerk and examine as many patients on the wards and in clinic as possiblePreparing for the written exam will improve your performance in PACES
Textbook eg. Impey - the summary pages at the end of each chapter and the end of the book are really helpfulPACES groupsEMQ: books, questionsUse the RCOG Greentop/ NICE GuidelinesOnline bank of questions – intranet and PasTest
Slide61Recommended Books
Slide62Thanks for listening!
Good luck!!Any questions?