Published on February 19, 2014
Gynaecology & obstetrics clinical principles for final MBBS students LSCS What is the best management option for an occipito posterior in a Elderly primi with an adequate pelvis? LSCS Patient with a previous LSCS and an adequate pelvis ? LSCS Young primi with no other complications and a borderline pelvis (non engaged head)-Trial of labour while providing good contractions What is the best management option for a patient with a major degree placenta praevia who is admitted with mild bleeding at 37 weeks and the bleeding stops after admission - Immediate LSCS Moderate bleeding at 32 weeks and the bleeding stops after admission. o She is haemodyamicaly stable -Keep under observation in the ward till 37 weeks. o Profuse bleeding at 32 weeks? Immediate LSCS What is the best management option for a patient with abruptioplacenta who is admitted with Mild moderate or profuse bleeding from 32 weeks onwards with a live fetus who may or may not be in labour -Immediate LSCS Moderate bleeding with poor haemodynamic state or profuse bleeding with a dead fetusimmediate LSCS Moderate bleeding with good haemodynamic state with a dead fetus in labour- augment labour with syntocinon What is the management option for a patient with delayed second stage If criteria for instrumental delivery are satisfied ( no part of the head should be palpable abdominally, the presentation and the position should be suitable, the pelvis should be adequate ) an instrument is applied. Vacuum is contraindicated for face presentation, prematurity. Wrigleys forceps is preferred to vaccum for fetal distress because it is faster. Wrigle’s forceps are contraindicated for OP position Kielland's forceps are indicated only for op position and deep transverse arrest. LSCS is the only option if the presentation is breech. Further observation or syntocinon is contraindicated. Best management option for primary dysfunctional labour If no CPD, malpresentation or malposition,fetal distress do ARM and start syntocinon and continuous fetal monitoring(if available) and observe for for two hours. If above are present- do LSCS Secondary arrest- Always LSCS What is the best management for a patient with past LSCS Uncomplicated LSCS for a non recurrent indication, <35 years, Dr.Eranthi Samarakoon- Dept of Gyn & Obs. Faculty of Medicine, University of Peradeniya
No secondary subfertility, P1 alive and healthy, Present pregnancy singleton, Uncomplicated, No malpresentations or malpositions, Fetal weight < than 3. 5 kg, Pelvis adequate, Spontaneous onset of labour at 40 weeks →Do Trial of scar LSCS scars do not rupture before the onset of labour. Syntocinon is contraindicated for a scarred uterus. Therefore induction and augmentation is contraindicatd. USCS scars rupture in pregnancy. LSCS is done at 37 weeks. Earliest sign of scar dehiscence is fetal distress. LSCS is mandatory in 1. Brow 2. Mento posterior face 3. Shoulder presentation transverse lie. Hand prolapse 4. Previous USCS,Full thickness myomectomy scar.past LSCS with a T extension, repair of a ruptured uterus 5. Prolonged 1st stage due to secondary arrest 6. Prolonged 1st and 2nd stage in breech, 7. Footling breech, breech with extended neck 8. Placenta praevia 9. Prolonged 2nd stage if conditions for instrumental delivery are not satisfied Best management option for grade 1 and 2 heart disease Outpatient antenatal and cardiology care Normal delivery in a tertiary care unit Best management option for grade 3 and 4 heart disease Admit LSCS at 37 - 38 weeks after optimizing the cardiac condition Heart failure is most likely to occur soon after delivery Best contraceptive option is condoms LRT is done after the second delivery The best time for LRT is 6 weeks after delivery In impending eclampsia and eclampsia Emergency treatment is IV MgSO4 Best management option is immediate delivery after cross matching blood and estimating the coagulation profile, usually by LSCS Dr.Eranthi Samarakoon- Dept of Gyn & Obs. Faculty of Medicine, University of Peradeniya
If the fetus is dead delivery may be delayed in the absence of abruption if the eclampsia improves In Post partum haemorrhage The best way to determine the cause is to estimate the consistency of the uterus by abdominal palpation If the uterus is hard _ traumatic If the uterus is soft- atonic The best way to treat traumatic haemorrhage is to explore the genital tract for tears and suture in the labour room in any hospital The best way to treat atonic haemorrhage is to give IV oxytocics if the placenta is completely expelled Vaginal delivery is allowed in a breech presentation In a fertile young patient(< than 35 years ) who is greate than 5' in hght Without any obstetric complications (PIH. Diabetes e. t.c.) Estimated fetal weight <than 3.5 kg Breech well engaged at term Pelvis adequate on clinical pelvic assessment In the absence of an extended neck Who goes into spontaneous onset of labour by 40 weeks In the absence of footling breech Induction of labour is contraindicated. Syntocinon is contraindicated for induction and augmentation GYNAECOLOGY CLINICAL PRINCIPLES Ureteric damage and uretero vaginal fistula cannot occur after vaginal hysterectomy. Leaking of urine with the catheter in situ- injury to the ureter (or due to a large injury to the bladder) Leaking of urine soon after removing the catheter - injury to the bladder Leaking of urine a few days after removing the catheter= retention with overflow Contraceptives What is the best method of contraception for a nulliparous woman OCP condoms may be used if OCP is contraindicated or is unwilling to use OCP IUCD insertion is difficult and can cause PID DMPA and implants cause prolonged amenorrhoea What is the best method of contraception for a multiparous woman Any of the above methods tan be used IUCD is the best method for those above 35 years as hormonal methods are best avoided LRT Dr.Eranthi Samarakoon- Dept of Gyn & Obs. Faculty of Medicine, University of Peradeniya
For women over 30 years who have 3 or more children Post partum by mini laparotomy -+ Interval by laparoscopy or mini laparotomy Menstrual disturbances What is the best method of treatment for abnormal vaginal bleeding For an Adolescent OCP or norethisterone( 5 mg bd) for at least one cycle, preferably for 3 cycles after performing USS and full blood count For women in the reproductive age Do a speculum and vaginal examination, Pap smear, TVS and a full blood count Treat the cause If no cause is found give OCP or norethisterone for 1-3 cycles If age is > than 35 years give norethisterone D & C is; required only in the presence of RPOC, endometrial or cervical polyps or thick endometrium For a woman in the 40- 50 age group Do a speculum and vaginal examination, Pap smear, TVS and a full blood count. D & C or hysteroscopy is required in the presence of endometrial polyp, thick endometrial, prolonged bleeding or suspicion of malignancy Treat any cause If no cause is found and malignancy is excluded give norethisterone for 1-3 cycles as a therapeutic trial If recurrence occurs do TAH Adenomyosis Dysmenorrhea, dyspareunia, menorrhagia Only sign- smoothly enlarged uterus <16wks in size Mx-TAH Endometriosis What is the best treatment option for endometriosis In an infertile patient without severe symptoms or large cysts - Keep under observation In a patient with symptoms, ovarian cysts > than 5 cms and extensive endometriosis Cystectomy and medical treatment In a patient with symptoms no cysts and extensive endometiosis -Medical treatment Medical treatment for endometriosis GnRh analogues 3.75 mg IM once a month for 3 months DMPA 150 mg IM once a month for 3 - 6 m Danazol 400 -800 mg daily for 3 - 6 months OCP continuosly for 6 months Fibroids The best method of treatment for large (> 14 weeks ) or symptomatic fibroids In a woman who has completed her family-Abdominal hysterectomy Dr.Eranthi Samarakoon- Dept of Gyn & Obs. Faculty of Medicine, University of Peradeniya
In a infertile nulliparous woman or in a woman who has not completed the family o o o For a submucous fibroid < than 5 cms- Myomectomy by hysterescopy For a single interstitial fibroid - uterine artery embolisation (no scar→can go for NVD. If no surgery, no tubal damage.) For others-myomectomy GnRh analogues are used to reduce the size of fibroids before myomectomy Small (<12 wks size) or asymptomatic fibroids do not require treatment Ovarian tumours The best method of treatment for benign ovarian tumours In a young woman who has not completed the family For simple unilocular thin walled cysts < than 5 cms - no treatment is required For simple unilocular thin walled cysts 5 cms — 7cms no immediate treatment is required, Yearly follow up with USS Larger cysts require cystectomy by laparoscopy or laparotomy Cysts with solid areas or very large cysts require laparotomy Aspiration is not recommended because of high rate of recurrence Twisted ovarian cyst→ cystectomy can’t In a post menopausal woman For simple unilocular thin walled cysts < than 5 cms - no treatment is required if Ca 125 is not elevated Larger cysts require oophorectomy by laparotomy What is the best method of treatment for ovarian cysts where malignancy is suspected In a young woman who has not completed the family Unilateral salpingo- oophorectomy and histology in stage la tumours and in germ cell tumours. In all others TAH and BSO and infracolic omentectomy In a older woman who has completed the family TAH and BSO and infracolic omentectomy Adjuvant chemotherapy from stage 1c onwards Solid tumor – 1.dermoid 2.malignancy Cervical carcinoma The best treatment option for cervical carcinoma Stage 1a - < than 3 and 7 cms LLETZ Other stage 1 disease surgery or radiotherapy Disease beyond the cervix- radiotherpy Dr.Eranthi Samarakoon- Dept of Gyn & Obs. Faculty of Medicine, University of Peradeniya
Chemotherapy is used to reduce bulk before surgery & post operatively with radiotherapy Endometrial carcinoma What is the best treatment option for endometrial carcinoma TAH and BSO in stage 1 disease. Lymphadenectomy is not done as 50% drain to the para aortic nodes which are sampled. Dissection of pelvic nodes and para aortic node sampling is done if cervical spread is detected before surgery Post operative radiotherapy is given only if nodes are involved and in recurrent disease Amenorrhoea What is the most likely cause of amenorrhea In a patient without secondary sexual characteristics Hypothalamic pituitary ( FSH and LH will be low or prolactin will be high ) or ovarian cause ( FSH and LH will be high ) In a patient without secondary sexual characteristics and short stature Turner's Syndrome Treatment - oestrogen for 6 months followed by oestrogen and progesterone for life time. Fertility cannot be restored In a patient with secondary sexual characteristics Normal hypothalamic pituitary ovarian function with outflow tract abnormality (Rx by re constructing the tract. If uterus is present and communication is restored fertility can be restored) Testicular feminization(Rx excision of the gonads after puberty) In a patient who is virilised If xx and serum 17alpha hydroxyl progesterone levels are high- congenital adrenal hyperplasia o Rx- with large dose of corticosteroids/ cosmetic syrgey If xy - androgen insensitivity True haemoaphrodite- not virilized at birth. If so CAH. Cryptomenorrhea- USS Infections What is the best method of detecting Chlamydia - DNA testing by PCR of material from the endo cervix ( others-ELISA test on cervical swabs, DFA on cervical smears) Gonorrhoea - demonstrating gram negative intra cellular diplococcic in gram stained smears from endo cervix urethra and rectum ( culture in blood agar in 7% CO2 with antibiotics) Bacterial vaginosis - by demonstrating clue cells and a large number of gram positive and gram negative cocci and less gram positive lacto bacilli in a gram stained vaginal smear (others-refer book) Trichomonasis - microscopy of saline mixed vaginal smear and culture in Fineberg Whittington medium Candida- direct and gram stained smears of vaginal discharge ( culture inFineberg Whittington medium) Dr.Eranthi Samarakoon- Dept of Gyn & Obs. Faculty of Medicine, University of Peradeniya
Pelvic inflammatory disease - laparoscopy Herpes simplex- electoron microscopy of material from ulcers (culture in a tissue mono layer, antibody testing to type the virus) Syphilis – serological tests FTA, VDRL ( dark field microscopy for primary syphilis) Dr.Eranthi Samarakoon- Dept of Gyn & Obs. Faculty of Medicine, University of Peradeniya
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