PACES Revision Obstetrics and Gynaecology 27/04/2012 AMRITA BANERJEE & OLA MARKIEWICZ Kindly sponsored by: Plan for the morning 9-10.30 - Lecture + demonstration station 10.30-11.00 - Break 11.00-12.30 - Mock PACES stations (x4) 12.30-13.00 – Lunch Outline of Talk Obs & Gynae History Examination Clinical Skills Investigations Management Red Flags Ethics and Law Common PACES Stations Demonstration Station Tips and Advice Further Resources HISTORY The History The main part of all PACES stations!! Do not compromise on this. PC HPC Gynae history Obstetric History PMH DH FH SH Systems review The Gynaecological History Periods • Dysmenorrhoea • Oligomenorrhoea • Amenorrhoea • Menorrhagia • Mittelschmerz Discharge • Smell • Colour • Consistency The Gynaecological History Think about sex: • Contraception • HPV vaccine Have sex: • Dyspareunia • Post-coital bleeding After sex catch: • STI’s • HPV – smears! • Babies The Gynaecological History Boys • Regular • Protection – pregnancy and STI’s • GUM clinic visits • Peer pressure • Legal The Gynaecological History Obstetric History – don’t forget TOPs! Consequences of childbirth • Sphincter dysfunction • Rectal/vaginal prolapse The Gynaecological History Menopause • Symptoms • HRT • Post menopausal bleeding! • Vaginal atrophy • Sex life • Quality of life Obstetric History PC HPC Current Pregnancy Was this a planned pregnancy? EDD - scan or dates (LMP, Menstrual cycle) Complications Investigations so far Gravidity – number of times a woman has been pregnant, regardless of outcome Parity = (any live or still birth after 24 weeks) Specific Symptoms... Nausea / Vomiting - if severe known as hyperemesis gravidarum Urinary frequency – pressure on the bladder causes this – rule out UTI Tiredness Fetal Movements - usually felt at around 18-20 weeks gestation, earlier in multips Ideas, Concerns & Expectations… Obstetric History Details of each pregnancy: Date / Year Place of birth Gestation Mode of delivery Baby – sex, weight, current health Problems during antenatal, labour & postnatal Same Partner? Consanguinity? Miscarriages & Terminations Previous difficulty conceiving/ assisted conception Plans for future pregnancies Obstetric History For each pregnancy, including the current one if pregnant, ask about complications: Maternal: DEATH P Diabetes pre-Eclampsia Anaemia Thrombus Hypertension Pain Bleeding Infection Fetal Movements Scans/tests Hospital admissions Obstetric History Cont. Past Gynaecological History Contraceptive use? Last Cervical Smear – was the result normal? Any gynae surgery: - Loop excision of transitional zone (LETZ) -↑ risk of cervical incompetence - Previous myomectomy - ↑ risk of uterine rupture / placenta accreta /adhesions Gynae investigations & treatment for: - Infertility - Ectopic – ↑ risk of future ectopics - PID - chlamydia is most common cause – ↑ risk of ectopic The rest of the history Past Medical History and Past Surgical History Drug History Pregnancy medication - folates, iron, anti-emetics, antacids Teratogenic drugs – avoid at all costs - ACEi, Retinoids, Sodium Valproate, Methotrexate OTC Drugs - make sure to ask patient about these, to ensure nothing unsafe ALLERGIES Family History Medical conditions - gestational diabetes Inherited genetic conditions – CF Pregnancy Loss - recurrent miscarriages in mother & sisters Pre-eclampsia - in mother or sister? – increased risk Social history Smoking, Alcohol, Drug use Living Situation, Relationship Status Occupation Systems review Other Important Questions How do her symptoms affect her life What support does she have at home – do not assume she is married! Is there anything else that you are worrying about? Is there anything else that you’d like to ask me? EXAMINATION The Physical Examination Examination Abdomen: Gravid Non-pregnant Pelvic examination Speculum Swabs Smear To complete my examination Blood pressure Pregnancy test The Pelvic Examination Brief abdominal examination Inspect vulva Inspect cervix using Cusco’s speculum Take smears and swabs if required Withdraw speculum Bimanual examination Cervix Uterus Adnexae Inspect fingers for blood or discharge What is this? The Obstetric Examination Inspection “There is an abdominal mass consistent with pregnancy” Linea nigra Striae Scars Fetal movements Measure symphysio-fundal height Palpate – use ballottement Assess amniotic fluid volume Fetal lie Presentation Engagement (fifths palpable) The Obstetric Examination cont. Fetal heart sounds BP and urinalysis Antenatal notes CLINICAL SKILLS Clinical Skills Blood Pressure Urine dipstick Pregnancy test Gynae: Vaginal swabs Cervical smears Obstetrics: • CTG Blood Pressure Make sure you know how to use a sphyngomanometer Roughly determine systolic BP using the radial pulse Start 20mmHg above this and measure BP Korotkoff sounds Urine Dip Use gloves Expiry date Remove a strip, then close the bottle Dip the strip into the urine and wipe any excess urine on the side of the bottle Compare the strip to the bottle label Pregnancy test Perform in almost every woman of childbearing age Detects βhCG Dipsticks vs pipette urine Control line Test line Confirm result with another member of staff Vaginal Swabs Bug Swab Other Treatment Candida albicans High vaginal swab Mycelial filaments on microscopy Clotrimazole cream or oral fluconazole Bacterial vaginosis High vaginal swab Whiff test positive, clue cells, alkaline pH Metronidazole or clindamycin cream Trichomonas vaginalis High vaginal swab Motile flagellated protozoa Metronidazole on microscopy, alkaline pH Chlamydia trachomatis Endocervical swab Nucleic acid amplification tests (NAATs) eg. PCR Doxycycline or azithromycin Neisseria gonorrhoea Endocervical swab Gram negative diplococci Ceftriaxone Cervical screening programme Aim: identification of CIN and initiating early treatment before the development of cervical carcinoma NOT a test for cancer! Age range: 25-49 every 3 years 50-64 5 yearly 60+ if not screened since 50 or recent abnormal results Technique: Rotate brush in the external os to pick up loose cells over the TZ for liquid based cytology Cervical screening programme DYSKARYOSIS: Cytology – smear Cervical Intraepithelial neoplasia: Histology - biopsy Management Can spontaneously regress 6 month follow up. If persists then colposcopy mild CIN1 moderate CIN2 Colposcopy + treatment CIN3 Immediate colposcopy + treatment severe Counselling and explaining the process/results/follow up! Cardiotocography DR – Define Risk C – Contractions BRA – Baseline Rate – mean rate over 5 – 10 mins. Normal = 110 – 160 bpm V – Variability – should be >5 bpm A – Accelerations – rise in fetal heart rate by at least 15 bpm lasting at least 15 secs. D – Decelerations – fall in fetal heart rate by at least 15 bpm lasting at least 15 secs O – Overall INVESTIGATIONS Investigations General tips: Importance of observations and bedside tests Do not mention lists of investigations unless you are able to justify why you want them Hit the jackpot early (but don’t show off) Think outside the box – pregnant women get non- pregnant diseases Investigations Gynae: Cervical smears Interpret hormone levels: FSH, LH,TFT’s Urodynamics Ultrasound: endometrial thickness Surgery: endometrial biopsy, laparoscopy, lap + dye Contraceptive methods: IUD Hysteroscopy Investigations Obstetrics: Pregnancy test (in A+E) Glucose Tolerance Test Cardiotocographs Partogram Pelvic USS Screening tests Amniocentesis/chorionic villus sampling MANAGEMENT Management What everyone does worst on! Don’t forget: Resus + CONSERVATIVE MEDICAL SURGICAL And VERY importantly ASK FOR HELP! RED FLAGS Red Flags - Obstetrics Condition Symptoms Placenta praevia Painless PV bleeding late in pregnancy Placental abruption Painful PV bleeding late in pregnancy (Ruptured) ectopic pregnancy Early pregnancy, pelvic pain, PV bleeding +/- faintness, shoulder-tip pain Obstetric cholestasis Itchy hands and feet during pregnancy Shoulder dystocia Delayed delivery after delivery of the head Cord Prolapse Umbilical cord descends below the presenting part following rupture of membranes Amniotic fluid embolism Dyspnoea, hypotension, hypoxia, seizures, heart failure Red Flags – Obstetrics cont. Condition Symptoms Uterine rupture Acute, severe pain during labour or, if epidural, sudden maternal hypotension, cessation of contractions, fetal hypoxia Uterine inversion Post-partum haemorrhage, pain and profound shock Pre-eclampsia Hypertension, proteinuria, oedema Eclampsia Pre-eclampsia with RUQ pain, headaches, tonic clonic seizures, blurred vision PE SOB, chest pain, hypoxia, cardiac arrest DVT Acute leg pain, redness, swelling, heat, +/-SOB Primary and Secondary PPH Primary ≥ 500 ml of blood loss within 24 hours of delivery. Secondary - abnormal or excessive bleeding between 24 hours and 12 weeks postnatally. Red Flags - Gynaecology Condition Symptoms Ovarian cyst torsion/accident Severe pelvic pain associated with hypovolaemic shock Endometrial carcinoma Abnormal uterine bleeding, especially PMB Ovarian carcinoma Non-specific symptoms of abdominal distension, pain, abnormal bleeding, weight loss Cervical carcinoma IMB, PCB, PMB, offensive vaginal discharge PID PV discharge, pelvic pain, fever, abnormal bleeding COUNSELLING Counselling Shared decision making MDT Empathy Active listening Use of silence Avoid jargon Ideas, concerns, expectations Counselling cont. Congenital abnormalities e.g. Downs, Turners syndrome Cervical smear results Ectopic pregnancy Miscarriage Contraception LAW AND ETHICS Law and Ethics Everyone ignores but is very important! Most sued specialty Extremely sensitive issues: cultural, religious, personal Important principles: Gillick competence The Abortion Act The Mental Capacity Act Law and Ethics Everyone ignores but is very important! Most sued specialty Extremely sensitive issues: cultural, religious, personal Important principles: Gillick competence The Abortion Act The Mental Capacity Act The Abortion Act Permits termination of pregnancy by a registered practitioner subject to certain conditions. Must be performed by registered medical practitioner in an NHS hospital or DoH approved location (e.g. British Pregnancy Advisory Service Clinics) An abortion may be approved for the following reasons: A The continuance of pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy was terminated. B The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman. C The continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman. D The continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing children of the family of the pregnant woman E There is a substantial risk that if the child were born it would suffer from physical or mental abnormalities as to be seriously handicapped, or in emergency, certified by the operating practitioners as immediately necessary F To save the life of a pregnant woman G To prevent grave permanent injury to the physical or mental health of the pregnant woman. The Human Fertlisation & Embryology Act 1990 Section 37 of the HFEA made changes to the 1967 abortion act: Time limit of abortion is 24 weeks under statutory grounds C and D Statutory grounds A, B and E are now without time limit Fraser Guidelines (Gilllick Competence) Those <16 may be prescribed contraception without parental consent if: They understand the doctor’s advice The young person cannot be persuaded to inform their parents that they are seeking contraceptive advice They are likely to begin or continue intercourse with or without contraceptive treatment Unless the young person receives contraceptive treatment their physical or mental health is likely to suffer The young person’s best interests require that the doctor gives advice and/or treatment without parental consent THE EXAM O&G PACES 6 stations in total O&G probably 2/6 stations Combined with other specialities and GP 15 mins/station 5th Year PACES 4 domains of marking: 1. Clinical skills 2. Formulation of clinical issues 3. Discussion of Management 4. Professionalism and Patient centred approach Practice Case Miss Sarah Jones, 25 years old 13/02/1988, has come to the antenatal clinic for her screening test results. Candidate Instructions: Please take a brief history and explain the results of her test: 6 mins Discuss further investigations and management options: 3 mins Discussion with examiner: 4 mins Past stations: Obstetrics 15 year old wanting TOP Missed miscarriage + speculum Pre-eclampsia VBAC counseling Recurrent miscarriages + antiphospholipid syndrome HIV and pregnancy (in multiple circuits) PE in pregnancy (confused a lot of people) Gestational diabetes Down’s syndrome screening Small for dates- young smoker Alcohol and pregnancy Multiple pregnancy Abnormal lie and ECV Counseling a patient with molar pregnancy PV discharge in pregnancy Contraceptive advice post-pregnancy Pre-term rupture of membranes Hyperemesis gravidarum Antenatal check Past stations: Gynaecology Abnormal bleeding Menopause Amenorrhoea and infertility Underage/pressured sex Sexually transmitted infections Urogynae – incontinence, self esteem Vaginal discharge Pelvic pain Subfertility Contraception Gynae oncology Ethics How to prepare Clerk and examine as many patients on the wards and in clinic as possible Preparing for the written exam will improve your performance in PACES Textbook eg. Impey - the summary pages at the end of each chapter and the end of the book are really helpful PACES groups EMQ: books, questions Use the RCOG Greentop/ NICE Guidelines Online bank of questions – intranet and PasTest Recommended Books Thanks for listening! Good luck!! Any questions?