PACES Revision

Obstetrics and Gynaecology

2 7 / 0 4 /2 0 1 2
A M RI T A B A N E RJ E E & O L A M A R KI E W IC Z
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:
STIs
HPV smears!
Babies

The Gynaecological History

Boys
Regular
Protection pregnancy and STIs
GUM clinic visits
Peer pressure
Legal

The Gynaecological History

Obstetric History dont 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 youd like to ask me?

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!

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 dont show off)
Think outside the box pregnant women get non-pregnant

diseases

Investigations
Gynae:
Cervical smears
Interpret hormone levels: FSH, LH,TFTs
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!
Dont 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:

The continuance of pregnancy would involve risk to the life of the

pregnant woman greater than if the pregnancy was terminated.

The termination is necessary to prevent grave permanent injury

to the physical or mental health of the pregnant woman.

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.

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

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

To save the life of a pregnant woman

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 doctors 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 persons best interests require that the doctor
gives advice and/or treatment without parental consent

THE EXAM

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

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
Downs 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