GOSH Notebook - Lecture notes All PDF

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Table of contents Aims and Learning Objectives................................................................................................................... Knowledge....................................................................................................................................

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Table of contents Aims and Learning Objectives...................................................................................................................3 Knowledge............................................................................................................................................................3 Skills......................................................................................................................................................................3 Attitudes................................................................................................................................................................4 Pre-Requisite Knowledge.......................................................................................................................................4

Obstetrics Core Conditions........................................................................................................................5 General Definitions................................................................................................................................................5 Antenatal Care.......................................................................................................................................................6 Routine Antenatal Care...........................................................................................................................................6 Antenatal Problems...............................................................................................................................................13 High Risk Pregnancies............................................................................................................................................20 Pregnancy Loss...................................................................................................................................................... 31 Intrapartum Care.................................................................................................................................................33 Normal Labour......................................................................................................................................................33 Induction of Labour...............................................................................................................................................39 Abnormal Labour...................................................................................................................................................42 Obstetric Complications........................................................................................................................................47 Post-partum Care.................................................................................................................................................52

Gynaecology & Sexual Health Core Conditions........................................................................................58 General Gynaecology...........................................................................................................................................58 Basic Science.........................................................................................................................................................58 Menstrual Cycle..................................................................................................................................................... 59 Postmenopausal Bleeding.....................................................................................................................................64 Chronic Pelvic Pain................................................................................................................................................66 Early Pregnancy Problems...................................................................................................................................71 Benign Tumours.....................................................................................................................................................75 Specialist Gynaecology........................................................................................................................................77 Sub-fertility............................................................................................................................................................77 Urinary Incontinence.............................................................................................................................................79 Prolapse.................................................................................................................................................................80 Cancer................................................................................................................................................................... 81 Contraception........................................................................................................................................................86

Sexual Health Core Conditions................................................................................................................99 General Topics.....................................................................................................................................................99 Bacterial STIs.....................................................................................................................................................103 Chlamydia............................................................................................................................................................ 104 Gonorrhoea.........................................................................................................................................................105 Trichomonas........................................................................................................................................................ 106 Urethral Discharge.............................................................................................................................................106 Genital Infections and Dermatosis.....................................................................................................................108 Thrush................................................................................................................................................................. 108 Bacterial Vaginosis...............................................................................................................................................109 Genital Skin Conditions.......................................................................................................................................110 Viral STIs............................................................................................................................................................112 Herpes.................................................................................................................................................................112 Genital Warts......................................................................................................................................................112 Molluscum Contagiosum...................................................................................................................................113 Syphilis..............................................................................................................................................................114 HIV....................................................................................................................................................................115

Skills.....................................................................................................................................................119 Obstetric History.................................................................................................................................................119 Obstetric Examination.........................................................................................................................................121

Gynaecological History .......................................................................................................................................122 Sexual History......................................................................................................................................................124 Female Genital Examination ...............................................................................................................................126 Male Genital Examination ..................................................................................................................................128 Prescribing in Pregnancy & Breastfeeding...........................................................................................................129

OSCE.....................................................................................................................................................130 OSCE Stations....................................................................................................................................................130 COCP..................................................................................................................................................................131 Emergency Contraception..................................................................................................................................132 Gynaecological History......................................................................................................................................133 Obstetrics Exam.................................................................................................................................................135

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Aims and Learning Objectives                

Have gained an understanding of the mechanisms governing sexual health and women’s health and reproduction. Be able to understand and discuss the clinical practice of Gynaecology, Obstetrics and Sexual Health. Have a holistic approach to women and the integral part their families and the community play in their health Have gained competence in assessing women through history and examination (both in obstetrics and gynaecology) Have gained competence in assessing patients attending a sexual health clinic. Have an understanding of the particular issues and sensitivities that affect health care in the areas of sexual health and reproduction. Be able to understand and discuss the clinical science basis of obstetrics and gynaecology. Be able to recognize the common syndromes of sexually transmitted infections (STI) and HIV likely to present in non-specialist settings. Gain an understanding of the principles of managing sexually transmitted infections (STI) including the importance of confidentiality and partner notification. Be able to take a clinical history and perform a physical examination in an obstetric or gynaecology patient. Be able to take an appropriate history from patients at risk of STI, including Sexual history and HIV risk history. Be able to discuss relevant differential diagnoses and develop management plans. Develop skills in communication and be aware of the sensitivities involved in practising clinical Gynaecology, Obstetrics and Sexual Health. Be aware of the relevance of clinical governance in Gynaecology, Obstetrics and Sexual Health. Be aware of the current ethical issues in Gynaecology, Obstetrics and Sexual Health. Be able to understand the physical, emotional and social impact of sexually transmitted infections on the individual and the general community.

Knowledge  An understanding of normal changes in development and function of the female genital tract in relation to women’s health  To understand the normal and abnormal antenatal course  To recognize the difference between the normal and abnormal processes of parturition  To understand the role of aftercare of the mother and infant following parturition  An understanding of the community services and facilities available to women,  To develop a better understanding of the various methods which are available for the delivery of child, antenatal and gynaecological health care  An understanding of the medical, legal and ethical dilemmas of caring for pregnant women  The nature and functioning of sexual health services provided to men and women  An understanding of the principles and methods of contraception and family planning

Skills  Development of an ability to relate to patients presenting for care in the sexual health and in obstetric and gynaecological settings  To develop the interpersonal and organisation skills required to take a competent history from such patients  Development of the necessary examination skills  An ability to evaluate a clinical problem after the history and examination, and thereby be able to deduce a reasonable differential diagnosis  An ability to describe the principles of further management including appropriate investigation, therapeutic options, and the importance of communication / counselling  To have the technical skills to undertake a cervical smearTo have the technical skills to take vaginal and cervical swabs 2

Attitudes  Regular attendance including a responsible approach to informing course staff if for any reason attendance is not possible  A professional approach relating to patients and their families  A professional attitude towards learning with active participation in teaching sessions, follow up reading, and preparation for set teachings  Appropriate self-directed work (both clinical and non-clinical)  A caring and holistic approach to patients and families, and sensitivity to their needs and feelings

Pre-Requisite Knowledge  Clinical skills and knowledge for history taking and clinical examination in adults up to Year 3 level  Knowledge of basic science that applies to O&G up to Year 3 level

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Obstetrics Core Conditions General Definitions Term Gravidity

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Parity

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Primigravid Nulliparous

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Multiparous

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1st Trimester 2nd Trimester 3rd Trimester

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Definition How many times a woman has been pregnant Includes o Miscarriage o Ectopic o Termination o Live birth o Still birth o Molar o CURRENT How many babies a woman has delivered at 24+ weeks gestations a = Alive or stillbirth b= losses before 24 weeks Pa+b First ever pregnancy G1P0 Has had no delivery of a baby >24 weeks gestation Has had one or more deliveries of babies >24 weeks Weeks 1-12 Weeks 13-27 Weeks 28-delivery

Antenatal Care Routine Antenatal Care 2/3rds maternal mortality due to a medical/mental health condition, not directly related to pregnancy

Community/Consultant Based Care WOMEN WITH ONE OR MORE OF THE FOLLOWING RISK FACTORS SHOULD BE REFERRED TO CONSULTANT LED CARE Maternal Factors  Maternal age 40+ at EDD  Maternal age 16 and under at booking  Grand multiparity  more than 6 deliveries at >24 weeks  Late booker (>24 weeks) if unknown/uncertain LMP  IVF with ICSI or donor egg  BMI >35 at booking or >30 with additional risk factors o VTE leading cause of direct maternal deaths  Women who decline blood or blood product  Tocophobia  pathological fear of childbirth Previous Obstetric History  Stillbirth  Neonatal death  Preterm delivery 1500ml  Traumatic delivery  Shoulder dystocia  3rd/4th degree tear  CS or other uterine scar  Retained placenta with PPH  Previous placenta accreta  Puerperal psychosis Gynaecological History  IUCD in situ  Uterine abnormalities  Pelvic mas  Endometrial resection  Cone biopsy or more than one LLETZ 5

PMHx  Alcohol/drug misuse  Anaesthetic problems  Cardiac disease  Cardiac murmur  Renal disease  Endocrine disorders o Diabetes  Psychiatric disorder o Requiring secondary care, admission, suicide attempt or on medication  Haematological disorders  Neurological disorders  Epilepsy  CF  Severe asthma  Other respiratory disorders  GI disease  HIB  HBV  HCV  Autoimmune disorders  Inflammatory arthritis  Malignancy  Any other long term illness  FGM  Relevant operations  Fractured pelvis FHx  VTE (1st degree relative)  Foetus at risk of inherited conditions Social Factors  Teenage pregnancy  Maternal age >40  High parity and low interpregnancy interval  Poor SES  Alcohol intake  Substance abuse

Present Obstetric History  Bleeding after 1st trimester  HTN o Eclampsia  Proteinuria  2+ UTIs  Persistent Haematuria  Gestational diabetes  Low Hb not responding to treatment  Deranged LFTs  Newly diagnosed STI  Red cell antibodies  Multiple pregnancy  Abnormal foetal growth  Abnormal amniotic fluid volume  Abnormal umbilical artery Doppler  Malpresentation after 36/40w  Foetal abnormality  Confirmed exposure to Zika virus  Developed new medical problem

Red flags for severe mental illness o Recent significant change in mental state or emergence of new symptoms, o New thoughts or acts of violent self-harm o New and persistent expressions of incompetency as a mother or estrangement from the infant. o Admission to a mother and baby unit should always be considered where a woman has any of the following:

Booking visit 10 weeks, most important appointment 6

Problems in this pregnancy  Multiple pregnancy  Small for gestational age  Placenta praevia (low lying placenta)  Gestational diabetes  Pre-eclampsia Problems during labour  Meconium stained liquor  Blood stained liquor  Worrying features on CTG  Need for oxytocin infusion  Lack of progress High Risk Pregnancy  Counselling  Special investigations  USS  Specialist clinics  Anaesthetic reviews  Close observation o o o o o o

rapidly changing mental state, suicidal ideation (particularly of a violent nature), pervasive guilt or hopelessness, significant estrangement from the infant, new or persistent beliefs of inadequacy as a mother, evidence of psychosis

What happens:  Pregnant patient is seen by midwife  Risk assessment  Midwife/GP-led care vs Consultant-led care Summary  Obstetrics History  BP, Urinalysis, BMI  Antenatal screening, explain and gain consent  Booking bloods  Appointment overview and access to services  Place of birth  Risk assessment  referrals to appropriate places  Lifestyle advice and health education Obstetric History  Age  >40 and 7 days) and/or heavy (>80ml) uterine bleeding o Occurring at regular intervals o Think about IUCD, fibroids, endometriosis, adenomysosis, PID, polyps, hypothyroidism, coagulation disorders o TVUS, endometrial biopsy, outpatient hysteroscopy o 1st test - FBC o Mirena coil is 1st line treatment o Mefenamic acid, Tranexamic acid, NSAIDs, COCP o Ablation/hysterectomy if finished family  Polymenorrhoea o An abnormally short interval between regular menses o 35 days o Commonly caused by PCOS  Amenorrhoea o Primary 67

 Failure to start menstruating – needs investigation in 16 year old, or 14 year old with no breast development  Do they have normal external secondary sexual characteristics? Are internal genitalia normal?  Examine and karyotype – Turner’s syndrome o Secondary  Periods stop for more than 6 months (not due to pregnancy)  Hypothalamic-pituitary-ovarian axis disorders are common – up to 44% competitive athletes have amenorrhoea  Hyperprolactinaemia  Ovarian causes  Uterine causes  Ovarian insufficiency/failure – may be due to chemotherapy, radiotherapy or surgery  Genetic disorders  ovarian folli...