Data Interpretation Obstetrics and Gynaecology

Jawaad Saleem Malik

Station 1: Hysterosalpingogram (Station 2.24 OSCE book v.3)

What type of investigation is this? Hysterosalpingogram When is it best to perform this investigation? Between days 5-12 of 28 day menstrual cycle. After menstruation and before ovulation as menstruation can effect contrast dye and x-rays can cause miscarriage. What type of dye is used? Contrast medium (Iodine) What does this investigation show? Bilateral tubal blockage What is the treatment of the condition? IVF Treatment

Other possible questions on HSG. How is the investigation performed? Similar to smear, use a speculum, clean cervix then insert a 7fg catheter through the cervix inflate the balloon to hold catheter in place then insert contrast medium (Iodine) and take x-rays. What is the scan used for? Investigation of infertility- Tubal blockage/uterine anomalies When is it best to do a HSG? Between days 5 -12 How long does the investigation last? 15-20 minutes What is alternative to hysterosalpingogram? Hysterosalpingo-contrast sonography use of ultrasound instead of X-rays. Laparoscopy and dye What are the risks of this procedure? Tubal spasm (pelvic pain) Anaphylaxis reaction to contrast dye Reactivation of pelvic infection What is the cause for infertility? Bilateral hydrosalpinges from PID (esp. Chylamidia Trachomatis) Uterine abnormalities (Bicornuate uterus/Unicornuae uterus) Bilateral Tubal blockage Endometriosis Fibroids What is the treatment? Bilateral hydrosalpinges from PID = IVF/Tubal surgery Uterine abnormalities = Surgery/ Utriculoplasty Tubal blockage = Tubal surgery/IVF

Station 2: IUGR

ASYMMETRICAL IUGR
What is the cause of ASYMMETRICAL IUGR? Pre-eclampsia Idiopathic Renal/cardiac disease Multiple pregnancies What is the treatment for ASYMMETRICAL IUGR? Emergency Caesarian section within 12 days.

SYMMETRICAL IUGR
What are the causes of SYMMETRICAL IUGR? Chromosomal abnormalitiesTrisomy 13 (Pataus syndrome)/ Trisomy 18 (Edwards syndrome) TORCH Infections Maternal smoking/alcohol/opiate use Sickel cell disease What is treatment of SYMMETRICAL IUGR? NONE/Monitor and increase nutrition of fetus

Station 3: Cardiotocography
Cardiotocography measures Fetal Heart Rate. Interpret in following order: Baseline rate (110-160bpm) Baseline variability (>5 bpm) Acceleration Decelerations -Early deceleration -Late decelerations -Variable decelerations.

The CTG trace generally shows two lines. The upper line is a record of the fetal heart rate in beats per minute. The lower line is a recording of uterine contractions. Baseline Rate | Baseline Variation | Accelerations | Decelerations Baseline Rate:- 110-160 bpm This is a section of CTG showing a typical normal baseline rate

FHR

Uterine contraction A steep sustained decline in baseline rate is indicative of fetal distress and if the cause cannot be reversed the fetus should be delivered.

Bradycardia:- <110 bpm BRADYCARDIA INDICATES FETAL DISTRESS This is a section of CTG showing a bradycardia

Tachycardia:- >160 bpm. Tachycardias can be indicative of fever or fetal infection and occasionally fetal distress (with other abnormalities). An epidural may also induce a tachycardia in the fetus. This is a section of CTG showing a tachycardia.

| Baseline Rate | Baseline Variation | Accelerations | Decelerations Baseline variations:- >5 bpm Prolonged reduced variability (<5 bpm) may be indicative of FETAL DISTRESS, MATERNAL OPIATES/FETAL SLEEP. This is a section of CTG showing decreased baseline variability.

| Baseline Rate | Baseline Variation | Accelerations | Decelerations Accelerations:- Acceleration >15 bpm for >15 seconds Accelerations are a good sign as they show fetal responsiveness and the integrity of the mechanisms controlling the heart (5)(6). This section of CTG shows a typical acceleration in response to stimulus (7).

| Baseline Rate | Baseline Variation | Accelerations | Decelerations Decelerations:- Deceleration <15 bpm >15 seconds Three types of deceleration: Early deceleration Late deceleration Variable deceleration

Early decelerations occur at the same time as uterine contractions and are usually due to fetal head compression. They are normally perfectly benign. Late decelerations persist after the contraction has finished and suggest fetal distress. Variable decelerations vary in timings and shape with respect to each other and may be indicative of hypoxia or cord compression. The following CTGs show examples of early, late and variable decelerations.

Management Confirm FETAL DISTRESS (Hypoxia) using Fetal blood scalp sampling (FBS). pH <7.20 = Fetal Distress (Hypoxia) If pH < 7.20 then deliver by caesarean section.

Station 4: Karotyping DOWNS SYNDROME

What is the diagnosis? Trisomy 21- Downs syndrome What is the screening test? Triple test AFP (Alpha fetoprotein- produced by fetal liver) HCG (Human chorionic gonadotrophin- produced by placenta) E3 (Oestriol)

Downs syndrome: HCG AFP E3 (Unconjugated oestriol)

Spina Bifida: AFP = Neural tube defect = Spina Bifida When is triple testing done? 15-20 weeks. Ideally 16 weeks. What is the diagnostic test? Amniocentesis. What are the risks of amniocentesis? 1 % risk of miscarriage When is amniocentesis carried out? 15 weeks (15/40) What alternative can be used at an earlier gestation? Chorionic villus sampling When is chorionic villus sampling carried out? 11 weeks (11/40) What is the risk of Chorionic villus sampling? 2% risk of miscarriage

What increases the risk of trisomies? Increasing maternal age. What are the clinical features of Downs syndrome? Sandal gap Single palmar crease Mongolian facies Round face Flat occiput Epicanthic folds Brushfield spots in iris Protruding tongue

Sandal gap

Single Palmar crease (Simian crease)

What are the causes of Downs syndrome? 95% Trisomy 21 (Non-disjunction) 3% Translocation 2% Mosaicism What is a screening test? A screening test screens for congenital abnormalities it is available to all women and is used to determine which women are at high risk. It is non-invasive. Screening tests Nuchal translucency (11-14/40) This is the distance between the skin and the soft tissue covering the cervical spine. This is used to screen for trisomies. It is carried out between 11-14 weeks. Maternal blood sampling (15/40) AFP (Alpha fetoprotein) uE3 (Unconjugated Oestriol) HCG (Human chorionic gonadotrophin) Other serum markers PAPPA (Pregnancy associated plasma protein A) Inhibin A

Ultrasound scan (19/40) Used to screen for congential abnormalities. Preimplantation genetic diagnosis Uses to screen for mitochondrial genetic disorders that can be passed on by the mother such as Angelmans syndrome. What is a diagnostic test? A diagnostic test diagnoses a congenital abnormality. It is only available to women at high risk. It is invasive. Examples of diagnostic tests Chorionic villus sampling (11/40) Ultrasound scan (12/40) Amniocentestis (15/40) Fetal blood sampling (19/40) Fetal tissue sampling (22/40)

TURNERS SYNDROME

What is the karyotype? 45 XO

What is the diagnosis? Turners syndrome

Which gender is predominantly affected? Females What are the clinical features? Webbed neck Short stature Infertility Wide-spaced nipples Wide carrying angle (Cubitus vulgus) Neonatal lymphoedema

Neonatal lymphoedema

What is the most common heart defect? Coarctation of the aorta How can this condition be diagnosed antenatally? USS Cystic hygroma (11-14) Amniocentesis (15/40) Chorionic villus sampling (11/40)

What is the treatment for Turners syndrome? Hormone replacement therapy: GH replacement Oestrogen replacement

Station 5: Forceps

(1)

(2)

(3)

1. What are the three types of forceps? 1 = Wrigleys forceps (non-rotational, pelvic and cephalic curve) 2 = Neville-Barnes forceps (non-rotational, pelvic and cephalic curve) 3 = Kiellands forceps (rotational, cephalic curve) 2. What are the components of a forcep? Handle Lock (English/French lock) Shank Blades 3. Indications for forceps Delayed 2nd stage labour (>1hr) Maternal distress/maternal exhaustion Fetal distress/Breech delivery

4. Conditions required for forceps delivery? Informed consent Fully dilated cervix 0 station Ruptured membranes Contraction Empty bladder Pain relief (Pudendal block) Skilled operator

5. Complications of instrumental delivery Ventouse cephalohaematoma, perineal and uterine tears/haemorrhage Forceps- Facial nerve injury and bruising. What are the functions of forceps? Traction +/- rotation (OP/OT MALPOSITIONS) 6. What is asynclitism and which forceps should be used?

Asynclitism- fetal head enters pelvis tilted, therefore enters with parietal bones. Treated with rotational forceps (Kiellands forceps)

Station 6: Polycystic Ovarian syndrome (Stein Leventhal syndrome)

What are the clinical features of PCOS? Subfertility (anovulation) Obesity Hirsutism/Acne Oligomenorrhoea/amenorrhea Recurrent miscarriage ( LH) What investigations are used for PCOS? Ultrasound scan Ultrasound scan shows multiple cysts/follicles on ovary (necklace)

Biochemical SHBG (Sex hormone binding globulin) LH:FSH Ratio (3:1) between day 5 and 8 of cycle Insulin Testosterone/androgens Laporoscopy Large ovaries What are the complications of PCOS? 40-50% of women develop diabetes Cardiovascular disease Endometrial/Breast cancer are more common

What is the treatment of PCOS? OCP Treats amenorrhoea/oligomenorrhoea Diannete Acne Finasteride Hirsuitism Infertility Anti-oestrogens Metformin Gonadotrophins

Station 7: Premature menopause

Menopause = Last menstruation Average Menopause = 51 yrs Premature/Early menopause = <45 yrs Blood results Day 3 FSH/LH >25 IU/ml Day 3 Oestrodiol <75IU/ml Low oestrogen means that the ovaries are starting to fail. Therefore LH/FSH produced from the pituitary gland is increased as they are trying to stimulate the ovaries to produce more oestrogen. This is known as early/premature menopause if it occurs before 45 yrs of age. What are the early menopausal symptoms? Vasomotor Hot flushes Psychological Insomnia Lethargy Poor concentration Anxiety Reduced Libido What are the long term effects? Cardiovascular disease Osteoporosis Other changes Genital tract atrophy Vaginal atrophy Skin and breast atrophy Treatment HRT