Obstetrics
Pre-pregnancy 1. 2. 3. 4. . #. (. *.
Antenatal counselling DM - T1counselling Epilepsy counselling Down syndrome counselling D!T " PE counselling $%P &P' )eart di disease +raves, di disease
Pregnancy Aortion n/ectiou n/ect iouss
Delivery diseas dis eases es
0)erpes-oster
uella cic5en po6 )! +&78
soimmuniaiton +DM +estational tropolast disease Acute pyelonepritis Pulmonary prolem in pregnancy Ectopic pregnancy $varian cyst torsion Anemia Placenta previa Placenta aruption 9TDs Twin pregnancy )yperemesis gravidarum Anormal presentation 7ort lady 7:E in pregnancy Polyydramnios ;+ Decreased /etal movement
PP$M Preterm laor Estimated date o/ con/inement )ome delivery counselling Pain relie/ during laor Elective induction o/ laor !&A% Postdate Prolon Pro long g 1st stage o/ laor Meconium aspiration &lood tran trans/usio s/usion n in
Post Partum Primary postnatal emorrage 7econdary postnatal emorrage Puerperal in/ection
Gynecology
Amenorrea Dysmenorrea Menorragia Metrorragia Mittelscmer Acute = pain !aginal discarge Trus PD Tricomoniasis Atropic vaginitis
P%$7 ;rine retention =iroid menorragia ? retetntion +enital erpes n/ertility %ontraception
&artolinitis 7e6ual assault > ;rinary incontinence urine +enital ulcer Pap smear Prolapse Adominal mass 0gyn8 )T Mental retardation Pruritus vulva Postpartum contraception Postmenopausal leeding 7teriliation
)oneymoon cystitis
Antenatal counseling Case 1: 02@@ Adelaide April 2@@# &risane =eruary AM% andoo5 P#28 Pre-pregnancy counselling previous D!T. A young lady ad er /irst ay 2 years ago and se ad pregnancy complicated wit D!T and PE 9ow se comes to see you ecause se wants to ecome pregnant again. Ta5e Ta5e /urter relevant )6 ant outline M6.
Gynecology
Amenorrea Dysmenorrea Menorragia Metrorragia Mittelscmer Acute = pain !aginal discarge Trus PD Tricomoniasis Atropic vaginitis
P%$7 ;rine retention =iroid menorragia ? retetntion +enital erpes n/ertility %ontraception
&artolinitis 7e6ual assault > ;rinary incontinence urine +enital ulcer Pap smear Prolapse Adominal mass 0gyn8 )T Mental retardation Pruritus vulva Postpartum contraception Postmenopausal leeding 7teriliation
)oneymoon cystitis
Antenatal counseling Case 1: 02@@ Adelaide April 2@@# &risane =eruary AM% andoo5 P#28 Pre-pregnancy counselling previous D!T. A young lady ad er /irst ay 2 years ago and se ad pregnancy complicated wit D!T and PE 9ow se comes to see you ecause se wants to ecome pregnant again. Ta5e Ta5e /urter relevant )6 ant outline M6. BsC ill get anoter D!T and PE Do need to anticoagulant t6 during ne6t pregnancy / so wat s tere any ris5 /rom anticoagulant t6 during pregnancy to my ay or me %ase @13 Case 2: 02@@ 7ydney April 028-F4 April 028-F4 2@@# Melourne =eruary 2@@* &risane diaetic Qs: %an conceive at sould do at will appen to me during te pregnancy i/ DM is not controlled well at will appen appen to my ay i/ DM is not controlled controlled well 7ould 5eep ta5ing nsulin ould need a %7 E6aminer BC at 5inds o/ lood test are you going to order en are you going to re/er er to endocrinologist e/ore pregnant or a/ter %ase @14 Case 3: 02@@ Pert $ctoer 2@@( Melourne 9ovemer -F18 BK1 -F18 A lady comes to see you 0+P8 mid 2@Gs se su//ers /rom epilepsy and is on penytoin 0in Mel se is on valproate8. 7e as een seiure /ree /or te last 2 years .7e is 5een to get pregnant and would li5e to discuss tis wit you. you. Tas5C Tas5C +ive er pre-pregnancy counselling. Epilepsy
02@@* Adelaide April-F3H April -F3H 02 028H 8H 8 Case 4: 02@@* Iou Iou are in a general practice. Iour Iour ne6t patient is a 3@yr old woman wo gave irt to a cild wit Down,s syndrome 1* monts ago. 9ow se is planning to get pregnant again. 7e went to a geneticist and e e6plained to er tat er cance o/ aving again a cild wit Down,s syndrome is 1 in 1@@. 7e is Fuite con/used aout tat and wants to discuss wit you.
Tas5C Tal5 to te woman and answer er Fuestions. Down,s Case5C 7:E in pregnancy
Abdominal trauma in pregnancy
BK4
B2
Case 5: 02@@ &risane Marc 2@@# Pert $ctoer 2@@# &risane $ctoer 2@@* +old %oast Marc-F4 2@@* 7ydney May-F#8 ED setting. Iou are wor5ing in ED at a tertiary ospital. Te amulance o//icers ring in a 3@w5 pregnant woman wo was involved in a M!A. 7e was sitting in te /ront seat wit seatelt wile er usand was driving. 7e is conscious and ale to sit at up and tal5 to you. 7e rings er antenatal note wit er. )er antenatal cec5 up as een normal so /ar including 1*w5 scan. )er &+ is $ negative. Tas5C ta5e relevant )J as5 E6 /inding /rom te e6aminer and M6 C! collar" bld group and #old" $#
Abortion Case 1: AM% /eedac5C %ncomplete abortion 02@@4 7ydney Marc 2@@ 7ydney April 2@@# Adelaide April 2@@( Melourne $ctoer AM% andoo5 P(18 A young lady presents wit vaginal leeding 1 day a/ter * wee5s o/ amenorrea very eavy 01 pad per our8 /eels diy. Period was regular e/ore. Tas5C Ta5e relevant istory As5 /indings o/ e6amination Management. 0during P! e6 a P$% was /ound in te cervi6 os8 BC ill it recur %ase 1@ Case 1a: 02@@* Melourne $ctoer retest AM%%ase 1@ >p(18 3Kyr lady wit adominal pain and P! leeding. )er :MP were *w5 ago. Tere was a PM)6 o/ miscarriage 1yr ago. Tas5C Ta5e relevant 6 as5 /or e6 /indings 0P! /indingsC no P$% was /ound only os open8 discuss te m6 plan and answer pt,s Bs. BC %an it recur %an still ave a ay 9eed to cover ne6t pregnancy $emo&e 'OC (rom Os" $#" )*G" +,C" -istological e!am o( curetting" .e!t preg screening
Case 2: AM% /eedac5C /aginal bleeding 0treatened aortion8 02@@ Adelaide April"$ctoer 2@@ Pert $ctoer 2@@* &risane =eruary AM% andoo5 P42@8 A 2# year old lady comes to see you in your +P setting wit vaginal leeding a/ter * wee5s o/ amenorrea.
Tas5C Ta5e )6 esults o/ e6amination and nvestigations and management plan. 0P! /indingC sligt leeding no clot no tissue pass os close no tissue at os adne6a clear cervical e6citation test negative uterine enlargement to *w5 pregnancy8 %ase @(K Case 2a: 02@@4 &risane $ctoer 2@@# Melourne 0need to consider non-pregnancy causes8 %ase @*2 & cg > neg > late period > ormonal test & cg > pos > level ;7+ Case 3: 02@@ &risane $ctoer 2@@* Adelaide AprilH pd/ 8 BK5 2* year old lady wit a istory o/ tree consecutive miscarriages etween *-1@w5. 7e comes to cec5 some test results today wic you ave done /or er last wee5. Tas5C As5 te e6aminer te test results you only get wat you as5 /or Tell patient wat you will do er and give your provisional diagnosis and manage te patient. BC Do need any medication to prevent miscarriage BC $ne o/ my /riends is also aving te same prolem ut te doctor applied some stitc to er cervi6. Do need to ave any stitc applied ecurrent Case 3a: 02@@( 7ydney August-2-028-F2@H 2( 8 B5 A young lady ad tree miscarriages earlier and tin5s tat se is si6 wee5 amenorrea and now se is ere to meet you in +P setting. 0#"K Eac*8 Tas5C %ounsel te pt 0during 6 ta5ing tis lady is a !ietnamese immigrant. 7o talassemia is a possile cause. Arrange emogloin electroporesis8 ecurrent 2
G+0
BK4
Case: 02@@4 =eruary Melourne 2@@# April Adelaide 2@@( April Melourne 2@@* =eruary &risane AM% andoo5 P4K#8 0+P setting8 A 34 years old lady wit 2* wee5s pregnancy came /or antenatal cec5up se ad a /asting level o/ lood sugar at (. and prandial level was K.. Tas5C )6 PE /rom e6aminer and tal5 to te patient aout your Management plan. %ase @K( ).$ > DM MDT :i/estyle modi/ication =inger pric5 ld sugar test > 3-4 times " day ;sg > 32 w5 /or macrosomia %T+ > wee5ly " twice wee5ly i/ on insulin" Macrosomia" Poly starting /rom 32 w5s
Deliver e/ore term %7 may e needed Monitor ctg in laour is5 > 3@L type 2 @L - recurrence $+TT every yrs
CaseC 34yr 2*"4@ came /or A9 cec5 up > &7l > K. 1r post ( g glucose 0no /asting8 Tas5 C )"$ P"E M6 +%T > 9o /asting 1r a/ter ( g o/ glucose 7creening test only Anl * $+TT > /asting N . Ten give (g o/ glucose 2rs a/ter N*
Gestational trop#oblast disease Case: 02@@# 7ydney 7eptemer8 B4" BK5"BK1 2 yr /emale * wee5s amenorrea. D6. Molar pregnancy ydati/orm. Tas5C Ta5e 6 counsel te pt. BsC at,s te management ill tis appen again )ow long do need to stay in ospital tropolast disease
%n(ectious diseases during pregnancy /iral in(ections /aricellaoster Paed %ase Case 1: 02@@# Melourne 9ovemer 2@@* Melourne August-F148 A woman wit 1@w5s preg comes to see you ecause er yo niece ad rases on te ac5 0picture providedC listers on te upper ody8. 7e as 2 cildren aged Kmo and #yo. Tas5C Provide D6 /rom a given pictureH Advise moter aout pregnancy and M6 aout two cildren. BC %an you give vaccine to young 5ids at Kmo BC )ow aout m6 in pregnancy !aricella oster Case 2: 02@@4 &risane May 2@@4 Melourne May 2@@# &risane $ctoer8 B1 Pt 2@ w5 pregnancy as noticed yesterday tat er # yr cild developed cic5enpo6. 7e is enFuiring er ris5s o/ e6posure to cic5enpo6. Tas5C Ta5e relevant istory and answer pt,s Bs. !ricella oster
en e6actly ur son develop ras g + 0-8 give !Og
g M0'8 > give acyclovir i/ moter 7"- serious (ds e/ore delivery
$ubella German measles %aseC 02@@ Melourne August 2@@* +old %oast Marc-B8 An 3@yr lady came to see you ecause o/ e6posure to * years old oy wit ruella. 7e also tin5s se could e pregnant. TA7C Tal5 to te patient and management BsC )ow will 5now weter ave contacted te ruella / were pregnant and got ruella wat would appen to me and my ay E6aminer BsC )ow will you /ollow up at will you see on ;"7 uella BK2
BK3 Genital #erpes %aseC 02@@4 Melourne May 2@@4 Melourne 9ovemer retest 2@@ Melourne May018-F*8 A 2@ year old /emale 24 wee5 pregnant come to you se /ound two ulcers in er vulva. Tas5C Tal5 to te patient and answer te Fuestions. BsC at do ave ill it a//ect my ay s tat get /rom my partner or will pass to my partner Am allowed to ave se6 wile ave tat prolem )ow will deliver my ay +enital erpes +enital erpes-pain
*abs (rom &esicle" *6+ screening" $! t#e partner" A&oid se! until complete resolution" 7*C* i( lesions present at t#e time o( labour
-%/ in(ection B1 %aseC 02@@ &risane Marc-B11 12t8 A 2# year old prostitute lady is an ! drug user as come to you a/ter missing er period. Pregnancy test was positive. 7e is now 1@w5 pregnant. :ast wee5 one o/ your colleagues did te tests and today se as come to you /or te results o/ te tests. Tas5C As5 /or te test reports /rom te e6aminerH Tal5 to te patient aout test result and /urter management. )!
Bacterial in(ections Group B streptococcus %aseC 02@@4 Adelaide 7eptemer 2@@ 7ydney Marc 2@@# 7ydney Marc 2@@( Adelaide 7eptemer -F14 2@@( Melourne $ctoerH AM% andoo5 P4218 A pregnant woman 3@"4@ primigravida was /ound to ave a 0'8 swa on antenatal cec5 up wic se regularly attends since te start o/ er pregnancy. 7o /ar se,s doing /ine e6cept /or tis. +P setting. 0$ter investigations were all normalH PE > normal8 Tas5sC E6plain to te patient wat a 0'8 swa means Management BC at is +&7 )ow did get it at is te m6 y can,t ta5e te antiiotics now s my ay sa/e at are te ris5s to my ay %ase @*1
1@-1L - carry organism @L - colonied 1L - in/ected Main principle- prevent te ay getting in/ected +&7 can,t eradicated /rom vg
%soimmuniation Case: 02@@ 7ydney 7eptemer 1@ t BK3 A 21 year-old lady visited you at your +P clinic 4 wee5s ago as se got pregnant 014"4@8. Iou e6amined er and did routine lood test /or /irst A9%. 4 wee5s later se comes ac5 /or te result. Iou /ound tat se as >ve lood type oters are normal. 9ow se is 1*"4@ and te pregnancy as een well so /ar. Tas5C Ta5e relevant istory /rom te patient E6plain te lood test to te patient E6aminer BsC at is te medication you will give at is te test,s name at will you do a/ter delivering te ay D H enel
)6% in pregnancy Case: 02@@ Melourne August8 B3 A young woman comes to see you wit vomiting and adominal pain wit a 1@w5 gestation. TA7C =urter istory ta5ing and management. 0#!C pregnancy con/irmed vague ado ac5 pain and vomiting /or 4 days increase urine /reFuency. 9o P! discarge. 9o past )6 o/ 7TD or PD or molar pregnancy planned pregnancy. '89C 3*.4 degree &P 12@"*@ ;terus as date no discarge no loodH :oin painH ;rine dipstic5 /ound &% &% nitrate and 5etone. Iou can order nvestigation ut tey all not availale now.8 pyelonepritis 6C ! Amo6ycillin %e/tra6ione %e/ota6ime M7; every 2-3 w5s until end o/ pregnancy
'ulmonary problem during pregnancy Case: 02@@# 7ydney May-F1@ 2@@( &risane $ctoer -F28 BK4 A 2# year-old primigravida 2@ wee5 +A came to ED complains o/ increased sortness o/ reat and weee in recent 1 wee5. 7e ad astma e/ore and er symptoms were relieved y pu//er. )owever te symptoms o/ weee and 7$& are getting worse in recent 3 days and er sleep was distured at nigt. Tas5C 1. Ta5e relevant istory
2. As5 pysical /indings /rom te e6aminer 3. Manage te patient 0tis pt is allergic to penicillin"cepalosporin and was treated wit do6ycycline e/ore.8 BC %ould receive same antiiotic as e/ore Pneumonia during pregnancy Ait#romycin ollo up o( ast#ma a(ter controlling in(ection
Anemia during pregnancy Case: 02@@# 7ydney 7eptemer AM% andoo5 P338 3yr multigravida /emale is pregnant. During routine cec5up se was /ound to e DA. Tas5C ta5e relevant 6 m6. 0During 6 ta5ing se is a vegetarian.8 %ase @(1 9eed to tal5 aout screen test /or Down. B9" iron studies" i( iron studies ; nl ; need to do -b electrop#oresis Gi&e e supplement a(ter taing bld (or %/" arn *<9 o( e $epeat -b" reticulocytes in 2852 a(ter gi&en iron<
9ctopic pregnancy Case 1: 02@@4 Adelaide 7eptemer 2@@ Pert $ctoer 2@@( Melourne 9ovemer retestB48 2#yr /emale presents wit vaginal leeding a/ter *w5 amenorrea. +eneral ealt is /ine. Tas5C )6 E6 6 D6 ? M6. Melourne Ectopic pregnancy
Case 2: 02@@* Marc 7ydney 2@@* Marc +old %oast-est recall 8 B5 Pt ad an operation 2w5 ago due to EP. &lood was /ound in adominal cavity ot ovaries and tue were normal. %+ was 1@@;. : /allopian tue was removed y laparoscopy. Tas5C Tal5 to te pt and answer er Bs. BsC at is te cause y tey removed te tue Any oter t6 %an it appen again )ow to prevent %an e pregnant again Do need != at sould do /or te ne6t pregnancy )ow early can you con/irm tis
/ unsuccess/ul in 12mts - != Ectopic pregnancy 2
O&arian cyst torsion Case: 02@@4 Melourne April 2@@ Melourne 9ovemer -F11 2@@* 7ydney August 23 rd B128 2@@K &risane =eurary 0+P setting8 A 2 y"o PD student was *w5 o/ pregnancy. 7e complained rigt lower intermittent adominal pain /or a wee5. Tas5C /ocused )6 P"E and 6 /rom e6aminer M6 BC ill te ostetrician remove te cyst $upture cyst %onservative - Q 4cm nternal leeding Minimal pain :aproscopic surgery > comple6 large cysts e6t ge
'lacenta pre&ia Case 1: 02@@( +old %oast
Case 2: 02@@4 7ydney
'lacental abruption Case 1: 02@@ Melourne =eruary 2@@* Adelaide April-B38 Iou are in te ED. Iour ne6t patient is a 2 yr old primigravida wo is 3@ w5s pregnant. )er lood group is A >ve. 7e is complaining o/ leeding since te last 1 our and te leeding is rigt red. 7e is also aving adominal pain. Iou e6amined er and er vital signs are normal. $n adominal e6amination te adomen is not tense ut a little it tender and te /etal eart sounds are normal. !aginal e6amination is not done. Tas5C ta5e istory /rom te patient tell er aout te investigations tat se needs and /urter management. Placental aruption
Case 2: 02@@4 Melourne 9ovemer 2@@# Melourne 9ovemer -F#8 2 year old pregnant lady 32 wee5 presented to ED wit suddenly severe adominal pain. Tas5C relevant istory. +et PE and 6 /rom e6aminer and +ive your D6 and M6 te patient. 7till irt -- /etal deat in uterusC %ausesC T$%) DM Pre-eclampsia trauma anencepalic ydrops. Must as5 lood group talassamia 9e6t pregnancy put into ig ris5 clinic. =olic acid. Early ;"7
.eural tube de(ects Case: 0AM% andoo5 P#38 A 2yr primi wo as Rust ad an ;"7 per/ormed at 1*w5 o/ gestation wic as revealed an anencepalic /etus. A maternal serum screening was done at 1#w5 and tis ad sown elevated levels o/ A=P Tas5C ta5e /urter 6 advise te pt o/ te relevant o/ te d6 and suseFuent m6 in tis pregnancy advise te pt te care you would recommend in a suseFuent pregnancy. %ase @1 6ermination 'ost mortem e!am o( baby $is o( recurrence ; 25> *creening olic 8a
6in pregnancy Case: 02@@4 7ydney Marc-PD=-B18 A 2 yr primi already ad an ;"7 at 1* t w5 A$+. ;"7 sowed a two placentae two separate /etuses. )er ) was 13g"d:. Tas5C E6plain condition and your M6 no )6. BsC s tere any complications Pregnancy > twin
-yperemesis gra&idarum
B4
Case: 02@@4 7ydney May retest 2@@4 Pert April 2@@* 7ydney May AM% andoo5 P(18 3*yr wo as come to your +P clinic ecause o/ severe a"n"v /or last 2w5 in er 1 st pregnancy. 7e claims tat se as een unale to 5eep /oods or /luids down. )er :MP was *w5 ago and pelvic e6 y your colleague in +P 2w5 ago sowed te uterine sie was appropriate /or gestation and a pregnancy test was positive. 7e as no PM)6. Tas5C )6 E6 D6 M6 %ase 144
)
'oly#ydramnios
B4
Case: 02@@4 7ydney May 2@@ Adelaide $ctoer * 2@@( 7ydney Marc AM% andoo5 P(8 Pregnant primigravida > you last saw er 4"2 ago wen se was 2#"4@ and te =) N2*cm. 9ow se is presenting to you /or anoter cec5 up > ut no complaints. Te =) toug is 4@cm and a weigt gain o/ #5g during te 4w5 interval. Tas5C )istory ta5ing As5 te e6aminer aout e6 /indings and investigations Management %ase 11@ )*G" C6G" B7+ Gp" %n( screening" GC6
Oligo#ydramnios Case: 02@@4 7ydney May-B1@8 34 wee5 pregnant and everyting else is normal. Tas5C istory e6am investigation and management. ;"7 as sown decreased liFuor.
*79 in pregnancy
BK4
%aseC 2# yr old woman ).$ 7:E /or past yrs Prepregnancy counseling wondering i/ 7:E will inter/ere wit M6 o/ pregnancy. Tas5C %ounseling
%)G$ Case: 02@@4 7ydney May 2@@# Melourne April 2K t 2@@# 7ydney 7eptemer 2@@( 7ydney August 2@@* Melourne August AM% andoo5 P#(28 Iou,re +P. Iour patient was 2Kcm at 3@ wee5s now 4 wee5s later se,s 34 wee5s. =igures may ave een di//erent ut still decreased growt around 2*"34 wee5s TA7C ta5e /urter )6 as5 PE and 6 discuss results wit Pt. Case 133
%auses M$T)E smo5ing drugs. Previous ;+ ypertension DM leeding during
pregnancy in/ection. P:A%E9TAC aruption =ET;7C cromosome in/ection is5sC %7 Premature delivery 6C ;?E urinary protein ;ric "a lupus anticoagulant anticardiolipin antiody urine M%7 &7: $+TT in/ection screen ;"7 every 2-3 w5s %T+ twice wee5ly aminocentesis i/ ;7+ sows cong mal/ormation Doppler ;7g :7%7 > prior to estimated due date P6 > good i/ no in/ection and cong a9l not ypo6ic
+ecreased (etal mo&ement Case: 02@@4 7ydney
''$O0 Case 1: 07ydney 2@@
'reterm labor Case 1: 02@@# Melourne 9ovemer retest 2@@* Melourne May-B48 BK3 Iou are wor5ing in a country ospital wic is 3@@5m /rom te nearest neonatal intensive care unit. Iour ne6t patient is a 2#"4@ prim. 7e as adominal pain /or 3 ours. Tas5C )istory PE Manage te case
Case 2: 02@@* Pert $ctoer -B1@8 7ame as e/ore ut pt ad casual unprotective se6 2 days ago. Preterm laor enel
9stimated date o( con(inement
B1
Case: 02@@ Melourne May 2@@( Melourne August-+2； 028-F8 A young woman 24 wee5s o/ pregnancy Rust move /rom city to country side 0*@5m /rom city8. 7e came to your +P clinic ecause se wants to 5now wen se needs to go to te ospital. t,s er second pregnancy /irst o/ wic was reec pregnancy. Tas5C Ta5e istory Tal5 to woman and answer er Fuestions. Timing o/ delivery
-ome deli&ery counselling Case: 02@@4 &risane $ctoer 2@@( Melourne =eruary8 B2 A 2# year-old lady 12"4@ wee5s comes to you /or advice aout ome delivery. 7e was ealty previously. Te /irst antenatal visit was normal. 9ow se is attending 2nd antenatal visit. Tas5C /urter istory answer patient,s Fuestions no PE reFuired. )ome delivery #y are u concerning about #ome deli&ery All A. test s8b done , nl All medical , obs abnl s8b screened 6#ere s#ould be someone at #ome #o can send u to #osp< *uccess(ul #ome deli&ery ; D>
'ain relie( during labor
BK5" 7oose 'aper
Case: 02@@4 7ydney August 2@@( 7ydney Marc8 2@"4@w5 pregnant woman came to +P. 7e is concerned aout pain in laor. Tas5C %ounseling te pt. Pain relie/ Pain relie/ in laor oyal omen e
9lecti&e induction o( labor Case: 02@@4 7ydney August 2@@( 7ydney Marc ( t retest8 BK1 34"4@w5 primi pregnant woman came to +P. 7e as5ed /or induction o/ laor at 3(w5 since er usand would go aroad in 4w5. Tas5C %ounseling te lady and your advice. Elective induction o/ laor
/BAC
BK4
Case: 02@@4 Melourne August 2@@# Melourne August 2@@( &risane =eruary 2@@( Adelaide 7eptemer8 A 2*y old /emale delivered a ealty ay y %7 1 years ago. Tat was te /irst ay. 9ow se is pregnant at 1# wee5s. 7e comes to your clinic ecause se is worried aout te deliveryH se wants te normal vaginal delivery. Tas5C Ta5e a istoryH /ind out te reason o/ te 1st %7. E6plain to er weter er ne6t delivery will e vaginally or %7 5DED> can deli&er &aginally< )terine rupture ; 12> )nder O,G care" special clinic %nduction o( labour ; not recommended" a&oid i( not really needed
'ostdate pregnancy Case: 02@@4 Melourne 9ovemer 2@@# Melourne 9ovemer 2@@* Melourne =eruary8 Ioung primigravida 41"4@w5 gestation came to +P. All antenatal visits were normal. +TT and +&7 done recently all normal. 7e worried aout te pregnancy. Tas5C Address er concerns M6. BsC )ow long sould wait /or Do need a %7 1< %nduction o( labour 2< ait one more ; do C6G tice ly" )*G (or biop#ysical pro(ile" +oppler studies" (etal ic count c#art 3< C<*
'rolong 1st stage o( labor Case 1: 02@@ 7ydney 7eptemer 23 rd8 1K years old lady primigravida started laor and present to &irt suite at 2am y dilated
cervi6 o/ 4cm ut poorly progressed and very pain/ul. 7e was given 32mg o/ Petidine. A/ter 4r still poor progress. D6 as $P. Tas5C M6 Case 2: 02@@# +old %oast
Abnormal presentation Case 1: 02@@ 7ydney
aandoned i/C 18 4rs no dilatation despite strong contractions.0or 2rs a/ter rupture memrane. 28 =etal distress 38 =ull dilatation not acieve witin 12rs.
0econium aspiration
B5
Case: 02@@4 7ydney May 2@@# Melourne April 2@@( &risane =eruary AM% andoo5 P##8 2yr primi 41"4@w5 in local ospital. Pelvic e6 sowed cervi6 3cm well e//aced and well applied to te presenting part. :$T @ no caput or moulding evident. 7$M revealed pro/use tic5 meconium-stained liFuor. =) 13@-14@"min. Tas5C )6 E6 M6. /aginal e!am to r8o cord prolapse Continuous C6G Adeuate aspiration o( mout# and nasop#aryn!
Blood trans(usion in He#o&a#Is itness
BK1
Case: 02@@ 7ydney Marc 2@@ 7ydney
-ypertensi&e disorder during pregnancy omen,s we Case 1: 02@@4 Melourne =eruary 2@@ &risane $ctoer BK5 24 year old lady wit 34 wee5 pregnancy come to see you /or antenatal routine cec5 up. Iou /ound out er &P 1@"1@@mm)g on two separated reading you did urine test wic is normal. )er &p was 1@@"(@ at 2@w5 gestation. 7e as no any symptoms. Tas5C Ta5e relevant istory As5 te e6aminer pysical /indings Do /urter investigation and Manage te patient. Case 2: 02@@( Melourne April8 0+P setting8 2y primigravida attends +P at 3#"4@ complains o/ generalied oedema and
lurred vision &P 1*@"12@ urinary protein '''. 7e is oterwise well. Tas5C )6 PE 6 M6. As5 previous )T9 and renal disease. Missing +? ) Case 3: 02@@ Melourne =eruary 2@@# &risane $ctoer 2@@( 7ydney Marc 2@@* Melourne August8 Iour are a resident in a country ospitalS . A woman in te laor ward as Rust ad a /it one our a/ter te delivery o/ er ay. Te seiure was controlled and now te moter is asleep. Te usand is wit er and wants an e6planation< BK1 Tas5C tal5 to usand aout te condition answer K5ois Fuestions. Buestions /rom te usandC at appened s tis epilepsy ill se ave any more /its at are you going to do now at aout a /uture pregnancy and ow to prevent it %an se reast /eed te ay Case 4: 02@@4 7ydney August retest 2@@# Melourne =eruary 2@@( Melourne 9ovemer AM% andoo5 P4K#8 34yr primi 3*"4@ came to your +P clinic /or regular cec5-up. 7e got convulsion in te waiting room. 9ow se is not /itting anymore. Tas5C Ta5e relevant 6 /rom er moter Tal5 to er moter aout er daugter regarding wat appened Discuss your M6. BC ill se e ypertensive in times wen se is not pregnant %ase @K# Case 5: 02@@4 Melourne April8 A 2#yr woman wit )T9 was on antiypertensive medication 0don,t 5now wic one could e A%E8. 7e wants to start er /amily and as5s aout er ris5 in pregnancy and &P control during pregnancy. Tas5C ta5e 6 e6 counseling.
'rimary postpartum #emorr#age Case: 02@@4 Melourne August 2@@ Adelaide April 2@@# &risane =eruary AM% andoo5 P#@(8 A 2yr primi ad a normal vaginal delivery y te midwi/e 2@min ago. Te pregnancy ad een normal. Te laor was o/ 14r duration. Te estimated lood loss at delivery was only aout 2@m:. )owever a /urter 1@@m: o/ rigt lood as een passed in te last 1min. Te midwi/e as Rust poned you to advise o/ tese /acts and to as5 you to come and elp. Tas5C As5 midwi/e appropriate Bs to de/ine te cause and care Advise midwi/e wat se sould do now Advise te e6aminer o/ te most proale cause o/ te emorrage and your m6. 6 O2 and %& (luid Bld Gp , m and #old t#e blood Coagulation study %nsert cat#eter< %/ 9rgometrine D<25 mg
Add *yntocinon i( bleeding continuous< C#ec placenta" laceration *ynto %n(usion 2D5D units8 l e!am under anaest#esia $'OC %ntramyometrial prostaglandin *urgery
*econdary postpartum #emorr#age Case: 02@@4 Pert April 2@@ Melourne 9ovemer retest 2@@# Melourne 7eptemer retest 2@@* Melourne =eruary 2@@* 7ydney Marc8 2*yr woman came to your +P 1@ days a/ter er delivery o/ er 2 nd ay. 7e as vaginal leeding canging pads every 2r and more severe witin te last 24r. During delivery te episiotomy was done. Tas5C )6 E6 M6
0/A during pregnancy 3# w5 o/ gestation M!A =ront seat wile er usand is driving 9ow ale to sit up and tal5 to you. Tas5C ).$ P.E /indings M6 B2
'uerperal in(ection
&1
Case: 02@@ Melourne May 0(8 2@@# Melourne August 2@@K &risane =euary8 A /emale %"$ T3K on te 4t day o/ er cild irt. 7e ad episiotomy and vaginal delivery. Tas5C Ta5e a istory 9o nvestigation is availale DD6 Management
Amenorr#ea 'rimaryF post pill" #yperprolactinaemia" primary o&rian (ailure" anore!ia ner&osa e!clude pregnancy in any 2 nd amenorr#ea Case 1: 02@@4 Melourne April 2@@4 Melourne 9ovemer 2@@ 7ydney Marc 2@@# BK4 7ydney Marc AM% andoo5 P14K8 An 1*yr came girl to your +P as se as never ad a menstrual period. Tas5C )6 E6 6 M6 0primary8 0ont#ly pain" breast " pubic #air" se! acti&e" (amilial" t#yroid" eating" stress" e!ercise" prolactin
)*G" -ormone test 2 amenorr#oea 1< 6#yroid 66 2< 'rolactin 'rolactin 3< 'CO* ; se! #r 4< 'reg ; ." /" breast enlargement" nipple discom(ort ; b#cg 5< *tress8 an!iety8 eating d8o8 e!ercise E< As#erman ; trans &g )*G Case 2a: 02@@4 Adelaide 7eptemer 2@@# Melourne April-c( AM% andoo5 P421-case @*@8 B3 3@yr woman on $%P no period /or 2 monts comes to you as +P. 9$ 6 result availale TA7C /urter )6 discuss condition wit pt. 0 post pill notes8
As5 7"- o/ preg do preg test 2 options > cease ocp and u,ll see ur period will return to nl 0cange to oter /orm o/ contraception8 or cange to ig estrogen containing pill )ormonal test > no need
Case 2b: 0 2@@( Melourne August-$+38
A 24yr woman as come to your +P ecause se asn,t ad periods /or 12mo. Tas5C )6 E6 D6 M6. B2 0yperprolactinemia8 %ncrease in prolactin #r due to grot# in t#e gld in t#e brain called pit gld +e!a scan" C6 scan Bromocriptine to reduce t#e le&el o( #r *pecialist ill decide (or surgery -$6 Case 2c: 02@@ Melourne 7eptemer-c(8 A 2(yr woman presented wit #mo o/ amenorrea. 7e is not on $%Ps. )er =7) and :) are ig. Tas5C )6 E6 6 D6 M6 0 premature ovarian /ailure8 As5 menopause symptoms. Case 2d: 02@@4 &risane May N 2@@4 Mel may 2@@( Adelaide Marc 31 st 2@@* Melourne August8 B3 A 1#yr girl allet dancer came to your +P. 7e as not ad period /or te last 2yr. t was per/ectly ealty e/ore. 6 doneC =7)":) normal E2 low. Tas5C )6 E6 M6. E6ercise induced amenorroea
Are u trying to lost wt Do u ever s5ip meals 0anore6ia nervosa > pt /or period 8
:evel o/ e6ercise s" reduced to 1@-2@L Tal5 to trainer Dietitian Endocrinologist > )T $steoporosis Case 2e: 02@@4 Pert April-%* Q 2@@* &risane =eruary-%8 2* year /emale wit a istory o/ 3 year amenorrea patient as5ed will e pregnant. Tas5C ta5e te istory as5 e6aminer test result management. 0pt &M is 14.4H anore6ia nervosa > pt /or pregnancy8 > counselling 1* year old allet dancer wit istory o/ amenorrea. Ta5e a relevant istory /or # mins and ten as5 te e6aminer /or relevant /indings on pysical e6amination. $utline you management /or tis patient wo already as er ormonal levels done :) increased =7) :$$E7TAD$: 4@ mmol"l 0low8.as a case o/ anore6ia nervosa wit rigorous e6ercise. telling wat would appen if se ad amenorrea /or a long time tey wanted to ear osteoporosis due to low oestrogen.
anore6ia nervosa -- )6 ta5ing
+ysmenorr#ea Case: 02@@4 Adelaide Marc 2@@# &risane
Past )"$ 7TD PD Myoma
0enorr#agia Case 1: 02@@ &risane Marc-F@2 2@@# Adelaide 7eptemer -F@# 2@@* 7ydney Marc-F1@" Marc retest8 A 12 yr girl as /irst time eavy vaginal leeding /or 1@ days. Moter comes to your +P clinic see5ing advicean. Tas5C Ta5e a /ocused )6 /rom moter As5 pysical e6amination /indings. E6plain te condition and /urter investigations Provide management plan and answer moter,s Fuestion 0etrosta!is BK2 2 se! c#aracteristics" preg" ot#er causes o( blding .o /g e!am< inspection (or blding" trauma
e supplement @ -r $! Case 2: 02@@ Melourne August-F1 2@@ Pert $ctoer 2@@( Melourne 7eptemer B4 retest-F@28 A 43yr woman comes to your +P a/ter you re/erred er to gynaecologist /or menorragia 0ysteroscopy pap smearC normal8. 9ow su//ering /rom menorragia again ) (@. Tas5C Discuss management wit patient. 0dys/unctional uterine leeding - @28 All %/ come bac .l and t#ey donIt s#o any underlying cause (or blding ; e usu +! +)B As *e! -8O" contracepti&e -8O 'lan to #a&e more c#ildren in t#e (uture 0ore %/ ; B9" e studies" 66" coagulation studies" )*G Case 3: 02@@( &risane $ctoer 8 A 3-year-old /emale presented wit eavy menstrual /low /or several monts. 7e as two cildren # ? * years old. 7e still wants to ave ay in te /uture. )er =&% sowed low ) level. Tas5C Ta5e istoryH pysical /indings /rom e6aminerH Arrange investigationsH Management 0/iroid8
0etrorr#agia 8 midcycle bleeding Case: 02@@4 Adelaide May 2@@( Melourne =eruary 028-B@28 B4 A 4( year-old woman presents wit vaginal leeding /or ( days. 7e as 4 cildren. )usand died /ive years ago. Tas5sC Ta5e relevant istory As5 P"E 0only given wat is as5ed8 Possile diagnosis Management Metrorragia" midcycle leeding Post coital lding Pap smear" ig !g swa" P% /or %lamydia" preg test Most li5ely - ectopion 1st time lding wit nl pap smear ? P.E > review ut as5 er to come ac5 i/ ld again 2nd time lding pap anl P.E anl > re/er to $?+ /or colposcopy 'ost menopausal blding - &lding itsel/ - =eatures o/ %A - %auses o/ lding - :MP" 7"- o/ menopause" )T - Partners - Pregnancies - Pap smear - =amily )"$ %A - 7ocial )"o
0ittelsc#mer 8 midcycle pain Case: 02@@ 7ydney Marc 2@@( Melourne April-F@#8 A young woman wit adominal pain came to +P. Te pelvic ;"7 was done and sowed a *2@mm cyst in ovary wit 1@ oter smaller ones. Te uterus and adne6a were normal. Tas5C )6 E6 6 D6"M6. Mittelscuner Q 4cm > oserve Pain" lding" d"c :MP %ange in owel motion ).$ 7TD" PD Does it occur on te same time o/ eac cycle Preg test
Acute $% pain Case 1: 02@@4 Melourne April 2@@4 7ydney August 2@@4 &risane $ctoer 2@@# Adelaide 7eptemer -F18 A 2yr woman comes to te A ? E department complaining o/ acute adominal pain on te rigt lower adomen. Iour tas5 is toC Ta5e a /ocused istory. As5 pysical e6amination /indings /rom e6aminer. $rder necessary investigations and tell e6aminer te most li5ely diagnosis and di//erential diagnosis and Answer patient,s Fuestions regarding management. 0$pen station no result availale8 ule out- appendicitis ectopic pregnancy acute PD ;T torsion ovarian cyst
Torsion o/ ovarian cyst Case 2: BK4 02@@ 7ydney
/aginal disc#arge Case 1: 02@@ 7ydney
Case 2: 02@@* Melourne May8 B2 A young /emale wit recurrent greenis# vaginal discarge. Iour colleague treated er wit anti/ungal and do6ycycline ut discarge is recurrent. Tas5C Ta5e a istory E6amine te patient Advise on plan o/ management. &act vaginosis Case 3: 02@@ 7ydney
Pain d"c" /ever" lower ad discom/ort" dyspareunia 6 > A 7was 6 partner 9oti/iale oter 7TD screening
JJJJJ+o pregnancy test be(ore prescribing ABJJJJJ'lease please please Case 4: 02@@4 Melourne =eruary-B# 2@@( &risane =eruary-B8 BK2 #@ yrs old lady came to +P clinic c"o o/ bronis# discarge P! and itcy vulval area. Tas5C =ocussed istory M6 Atropic !aginitis
-oneymoon cystitis Case: 02@@ 7ydney 7eptemer 1@-B1@ 2@@ Adelaide $ctoer 2@@( 7ydney Marc retest"August-F18 A lady in er 2@s as urning sensation wen passing urine and goes to te toilet more /reFuently. Tas5C Ta5e istory E6plain diagnose and management %ystitisH Dr enel
'CO*
B4
Case: 02@@# Melourne August-F12 2@@4 &risane $ctoer - F*8 A 21y /emale %"$ irregular periods 2 periods in te last years se is overweigt &M 31. Tas5C Ta5e a istory As5 e6aminer aout te PE $rder investigations 0 Tey given ;"7 result tere were 1#-24 cysts in te ovary8 E6plain te diagnosis to er Management 0se is concerned aout te /ertility and te period8. BsC y my periods are irregular %an ave cildren in te /uture want to ecome pregnant in 2yr are you going to give me anyting /or tat P%$7
)rine retention Case 1: 02@@4 Adelaide May-B# 2@@( +old %oast
DD6 > erpes myoma pregnancy ac5 prolems +enital erpes 0enel8
Genital ulcer Case: 02@@4 &risane May 2@@4 Melourne May 2@@# Melourne 9ovemer 2@@* &risane
%n(ertility Case 1: 02@@# &risane"+old %oast /emale Case 2: 0AM% andoo5 P31K8 A married couple ave een trying to conceive /or te last 12mo. E6 /or ot are normal. 6 /or sperm count sowing low and anormalities. Tas5C ta5e /urter 6 counseling te usand. %ase @#4
Contraception Case 1: 02@@4 7ydney tus tripasic pills Case 2: 02@@# 7ydney MayH syd2H syd38 B28 BK3 22yr woman is planning marriage and se started $%P a #w5 ago. 7e is not se6ually active. 7e came to your clinic /or P! spotting o/ 4w5" no period /or 2 mts. $terwise well non 9"! no /ever. 9o relevant PM)6 noted. Tas5H Advice and M6. Mid-cycle spotting Pregnancy test 2@L get rea5troug lding in 1 st 3-# mts
$%P induced amenorroea Case 3: 02@@# &risane =eruary-@4-B4 2@@( Melourne $ctoer 2K t8 2@yr old /emale student came to your +P. 7e ad se6ual intercourse last nigt toug partner wore a condom it ruptured and now se is a/raid weter se ecome pregnant. Tas5C Ta5e some /ocussed istory Advise on te 6 you do and m6 Emergency contraception N 6 as case @1@ B2 1 tab o( 5Dug postinor (olloed by anot#er tab 12#rs later Case 4: 02@@* Melourne 9ovemer -F38 A 14yr girl wants to start se6 wit er 1yr oy/riend and comes to +P to as5 /or $%Ps. Tas5C ta5e 6 e6 i6 m6 %ounseling 14y girl Case 5: 02@@ 7ydney April 2@@# Adelaide April 2@@* 7ydney May AM% andoo5 P#3(8 A parent reFuesting steriliation o/ er intellectually disaled daugter. BK2 %ase 122 Case E: 02@@ 7ydney
Tas5C Tal5 to te patient wy se wants to do steriliation e6plain te procedure o/ surgery and tell to te patient wat is advantage and disadvantage o/ tual legation. 6ubal legation Case : BK4 2#yr old lady came to discuss er possiility o/ pregC wile e6amination > &P was /ound to e ig. Tas5 C ).$ and m6 $%P induced ypertension *top OC'" c#ange to ot#er met#od o( contraception -6 is C% (or OC'
Bart#olinitis B3 Case: 02@@( 7ydney August-F8 A lady in er tirties ad recently noticed a lump in er vulva and it was enlarging and ecoming pain/ul tat se couldn,t wal5 com/ortaly. Tas5C elevant istory E6am /indings /rom e6aminer M6 &artolinitis N enel =&E E7 %P 7TD screening &road spectrum A& e/er
*e!ual assault Case: 02@@4 &risane $ctoer 2@@ Melourne 9ovemer AM% andoo5 PK8 A 2@yr university student came to ED ecause se was raped y a man tat se met at a disco. Te rape occurred #r ago. 7e as decided not to involve te police. 7e as ad no PM)6. Tas5C ta5e /urter 6 e6 i6 m6 %ase @1@
)rinary incontinence Case 1: 02@@# 7ydney retest 2@@* &risane
Case 2: 02@@( Melourne 9ovemer pd/-F13H pd/3-FK8 A #yr lady wit urinary incontinence came to your +P. 7e ad a pad everyday. 7e always ad a /eeling o/ going to te toilet urgently. $terwise lea5ing would e ta5en place. Tas5C M6
0te lady is aving urge to urinate and lea5ing. 9o lea5age in couging sneeing straining.8 BsC Do need surgery ;rge Case 3: 02@@ &risane $ctoer8 year old lady come to see you complaining urine lea5ing in te past /ive monts wen se as a coug or sneee. 7e as tree previous vagina delivery. Tas5 ta5e a detail istory do relevant investigation tests and manage tis patient.
)/'
BK3
4yr old post menopausal woman %"$ lump in !g > getting worse as around te groin Tas5C ).$ P.E /indings M6 ;rine dipstic5 &7: 6 ras ;rodynamic studies e/ore re/erring to surgeon
+1 ? 2 > pessary and pelvic /loor
e6ercise +3 > surgery 0sortening o/ uterosacral lig" TA)" !)8
'ap smear Case 1: 02@@( Melourne August-+1 B 3 24 yr /emale as come to your +P clinic to discuss er Pap smear test results. Pap smear test sows low grade anormality and )P! was /ound. Tas5C Ta5e /urter istory E6plain results and your management to te patient Answer er Fuestions Pap smear To prevent Fuestion aout un/ait/ul partner said tat in most cases virus is transmitted y se6 intercourse ut it can appear spontaneously even in stale relationsip. t can lie silently /or years and woman may 5now noting aout itH wen virus is /ound it,s very di//icult to 5now wen and /rom wom person get tis in/ection. $epeat pap smear in 12mt#s ; i( it is still positi&e; re(er to OG (or colposcopy - %( negati&e ; repeat 12mt#s later " t#en i( negati&e" return to 2yrly screening -'/ in(ection ; LD> sel(limiting immune system get rid o( t#e in(ection O((er *6+ screening
Case 2: 02@@( 7ydney Marc ( > B# H 8 Ioung /emale pap smear result sows ca in situ and warts virus in/ection. Tas5C )6 %ounseling M6 %a in situ BK4 %olposcopy ' %one &6
'rolapse Case: 02@@ Melourne
Abdominal mass Gyn Case 1: 02@@( &risane $ctoer 8 A 3-year-old /emale presented wit eavy menstrual /low /or several monts. 7e as two cildren # ? * years old. 7e still wants to ave ay in te /uture. )er =&% sowed low ) level. Tas5C Ta5e istoryH As5 pysical /indings /rom e6aminer te speci/ic /indings will e given only wat you as5 /orH Arrange investigations you tin5 is necessary and Manage te patient. 0/iroid8 $!" iron tablet" Me/enamic acidF COC" re(er" Gn$- 8 0yomectomy Case 2: 02@@( Melourne =eruary 2@@* Adelaide 7eptemer -F48 BK4 24 year old /emale ad a pap smear done y one o/ your colleague 2 years ago. 7e as come ac5 to repeat te test. ile you are e6amining er you ave /ound an adominal mass e6tending 2cm aove te umilicus. Tas5C Ta5e relevant istory As5 /or e6amination /indings0 e will only tell you wat you as58 Proale diagnosis and management. 0/iroid8 $! ; re(er" Gn$- 8 0yomectomy
-$6 Case 1: 02@@( 7ydney May 028-F1#H 038-8 A 4 year old lady currently on $%P wants to 5now aout )T. Tas5-Ta5e istory tal5 aout )T M6 )T 9$ Case 2: 02@@ Adelaide $ctoer -F1#8 4-y.o lady post menopausal presenting %"$ ot /luses. ants to 5now i/ se can ta5e )T. 7e ad a reast cancer 3@ years ago and mastectomy.
Tas5C )istory ta5ing Advice i/ appropriate to ave )T. .O Case 3: 02@@ Melourne 9ovemer -F1@H good recallH PD=-F1H PD=2 8 A @ y"o lady is %"$ ot /lus and irregular periods /or 11 monts. 9o weigt loss or discarge. Two cildrenC 2@ and 22 y"o. All P"E is normal. Tas5C M6 0no /urter )6 and P"E8 )T3 Ies
'ruritus &ul&a Case: 02@@* Melourne =eruary 2@@* Melourne $ctoer >F28 #@ y. o lady presents wit 1yr 6 o/ vulvae itciness to +P clinic. Tas5C Ta5e relevant istory n pysical e6amination as5 e6aminer /or picture ten e6plain to e6aminer Diagnosis and management :icen 7clerosis 0enel8
'ostmenopausal bleeding Case: 02@@( Adelaide 7eptemer -F12H PD=8 B4 A 1yr lady as een leeding /or last 4 days li5e er period. Tas5C )6 ta5e PE /indings and results o/ investigations /rom e6aminer Tal5 to er M6. postmenopausal leeding
%ase2C 2@@( =e ris 2@@K Marc #@yr old woman %"$ yellowis rownis d"c Tas5 C )6 PE ! M6 Atropic vaginitis
BK2
