1

OBSTETRICS
PRE-PREGNANCY AND PREGNANCY COUNSELING
Unplanned Pregnancy
Case: Jenny is 32-years-old and has attended your surgery for
routine checks for the past 3 years. She was last seen 6 months
ago for pap smear which was normal. At the time of the last
consultation, the BP was 130/70 and breast examination was
normal. CVS and respiratory examination were normal. Jenny is
married and has 2 sons, 10 and 8.
Patient Profile
Name: Jenny Smith
DOB: 10/04/74
No allergy
Occupation: Nursing home receptionist
Family history: Nil
Medication: Nil
PMHx: antidepressant given for 2 months at the age
of 20 years old; contraception: partner has vasectomy
2004
Task
a
b
c
History
-

History
Physical examination (BMI 24, PT +, urine dipstick
negative, BP
Discuss essential issues with patient and
management
Abdominal pain? SORTSARA? Reflux symptoms?
N/V? change in bowel movements or urine? Vaginal
discharge?
Symptoms of depression? Symptoms of STD
(nocturia, pain, weight loss, unexplained fever)

Physical examination
General appearance
Vital signs
ENT:
Chest and lungs
Cardiac
Abdomen
PV
Urine dipstick and BSL
Management
Offering appropriate treatment for nausea
Medications, rest and fluids
Explore patients attititude towards the situation
Ensure support is available
Offer support
Followup management
Plans for blood test and STD screening in the future
Home Delivery
Case: Your next patient in GP practice is a 24-year-old lady who
would like to discuss option of home delivery.
Task
a.
b.
c.

Relevant history (LMP 3months ago, confirmed by

home PT)
Examination findings
Investigation and Management

History
-

I understand that youre here because you wanted to

discuss about home delivery. Are you pregnant at this
stage? When was your LMP? How did you confirm
pregnancy? How were your periods before? Did you
see any doctor until now? Did you take any folic acid?
Do you have any history of hypertension, epilepsy,
diabetes or asthma? Any past history of admissions?
Do you know about your blood group? Were you ever
infected with Rubella? Is this is a planned pregnancy?
SADMA? Social history? Do you have enough
support? Financial problems? Do you have other
kids? How far do you live from the hospital? FHx?

Physical Examination
General appearance
Vital signs
Neck and breast
Chest and Lungs
Abdomen
Pelvic
Urine dipstick, BSL and urine PT
Management
I appreciate your concern. Before we discuss options
about home delivery, I would recommend for you to
have regular antenatal care which is very important for
you and your baby. As part of the routine, we will start
with blood tests: FBE, Iron studies, blood group and
Rh, TORCH, HIV, hepatitis B, syphilis, Pap smear if
due, urine MCS, and BSL. At 18 weeks we will
organize an ultrasound to check the placenta and
presence of abnormalities of fetus. Around 26-28
weeks we will organize a sweet drink test for diabetes
mellitus and at 36 weeks we will do a swab to detect a
bug in the vagina. I would like to review you monthly
up to 28 weeks then every 2 weeks from 28 weeks up
to 36 weeks then weekly until delivery.
You would like to have a home delivery. It is a good
idea because you will have your family members and
would be more comfortable for you. Usually, there is a
20-30% more chance of problems encountered during
the first pregnancy and labor. During pregnancy, there
might be an increased risk of having increased blood
pressure, diabetes, antepartum bleeding, decreased
fetal movements of the baby, and chance of twin
pregnancy. All these things are potentially risky and
can carry bad outcomes. That is the reason we are
doing antenatal care to pick them up early and
minimize the risk. Even with normal antenatal course,
there are some unpredictable complications at the
time of labor such as fetal distress,
intrapartum/postpartum hemorrhage, obstructed labor,
cord prolapse, shoulder dystocia, meconium
aspiration, and such complications need urgent
hospital setting with all medical staff and appropriate
equipments present. If you dont like hospitals, there
are birth centers or family birthing suites or units which
are small and home-like, but they have midwife and
specialist if required. I would recommend you to have
a safe delivery at the hospital, but at the end, it is your
choice. If you still want to go for home delivery, I would
advise you to stay near the hospital especially towards
the end of pregnancy. You must have ambulance
cover in case it is required and there should be
enough support at home. We will do regular antenatal
care and if there are problems during the course of
your pregnancy, then it is not recommended.
Reading materials. Review.

Pregnancy Counselling Regarding Timing Of Admission

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Case: G1P0 female at 24 weeks AOG asking when to go to
hospital for delivery

Arrange for followup with MW and may arrange for

specialist consultation if requested

Pre-pregnancy counseling regarding a patient with epilepsy

Tasks:
a.
b.
c.

Focused history
Answer patients questions
Counsel accordingly

Focused History:
Congratulate patient as it is her first pregnancy
Informed consent
How is the pregnancy? Any problems?
Any previous miscarriages (if yes: details on why,
when, AOG)
Is this a planned pregnancy?
Regular antenatal checkups?
Workups: blood tests? USD? results?
PMHx: infections (esp TORCH), DM, HPN
BLOOD GROUP
Location: how far do you live from the hospital? In
emergency cases, can anyone drive you to the
hospital? Do you have relatives? Who do you live with
at home?
P/SHx: smoker? Alcoholic beverage drinker?
Recreational drug use?
Any medications being taken? Allergies?
Last pap smear?
Gardasil vaccination
Counselling:
Timing of delivery varies among women. Generally, at
40 weeks, women experience backache, tummy pain,
and passage of mixture of water and blood from
vagina
Labor pains result from strong uterine contractions
similar to period pain and are usually intermittent,
initially after 20-45 minutes over a period of several
hours grows stronger and lasts longer time to go to
the hospital and MW will measure the time for the pain
Sometimes towards the end of pregnancy there are
UC that give a feeling of false pain and it is important
to recognize the pattern of labor pain
If you develop serious symptoms (bleeding, passing of
blood clots, reduced fetal movements, or trauma)
report to the hospital ASAP
Sometimes PIH can occur during 2nd and 3rd trimester.
Sx are headache, visual problems, swelling check
BP urgently and treat rising BP to prevent any
complications
Duration of labor is not predictable because it
depends on several factors:
o Size of the baby
o Position of the baby
o Age of the female
o Size of maternal pelvis
o Any form of comorbid illness
o Usually: <12 hours for multiparous and 1618 hours for primipara
Reassurance of support and pain relief throughout
duration of labor by the MW, MDs and nurses
Advise on regular antenatal checkups
o Monthly up to 28 weeks
o Fortnightly from 28-36 weeks
o Weekly >36 weeks until delivery
o Check BSL (OGTT) at 28 weeks AOG,
vaginal swab to check for GBS at 34 weeks)
important to predict a spontaneous and
normal labor
Give reading materials and write a script for vitamins

Case: 26-year-old female presented in your GP whos known to

be epileptic and is treated by sodium valproate. Over the last 2
years, she had not fits and now in your GP clinic, asking for an
advice for her chances and preparation to be pregnant.
Task
a.

Counsel patient (include risks)

History:
When were you diagnosed? When was the last fit?
Description of fit (tongue bite, loss of consciousness,
wetting of clothes, pre-warning signs-aura), any
known triggers (alcohol, excessive effort, drugs?)
when was the last assessment by her neurologist?
Any known complications? Any hospital admission? All
current and previous medications used and if any
complications? Any previous investigations (CT/EEG
and drug serum level)
Menstrual history: date of 1st period (menarche)?
Regularity of period? Description of cycle/period (no.
of days of cycle? Days of period) any painful period?
Any heavy bleeding or clots?
Sexual history: are you sexually active? In a stable
relationship? Any contraception used? Any known
previous STIs?
Antenatal history: details of any previous
pregnancies? Any previous miscarriages?
PMHx: any other associated systemic illnesses? DM?
Hypertension?
Social hx: family hx? SMADMA? Previous pap smear?
Gardasil vaccination (14-26)? Blood group?
Counselling tips:
Remember to be positive!
Tell criteria to be eligible for pregnancy
o For DM: HbA1c <7 for last 3 months
o Epilepsy: free of fit for 2 years
o SLE: no active disease for the last 6 months
o DVT/PE: thrombophilia screen negative
Mention fetomaternal risks associated with pregnancy!
The management should be by multi-disciplinary
approach.
Are you alone? Would you like someone to be with
us?
Counselling
Although the outcome is successful for more than
90% of epileptic women to be pregnant, there is
increased risk of fetomaternal risks during pregnancy.
For the mother, there is increased risk of vaginal
bleeding especially at the 3rd trimester, relapse of
seizures more towards 3rd trimester and during labor.
In 3rd trimester, level of absorption of medications is
reduced hence, there are higher chances of relapse
and bleeding.
For the baby, there is a risk of cleft lip, NTD, PTL, low
birth weight
But, you fit the criteria to be pregnant having no fits for
the last 2 years.
The management should be by multi-disciplinary
approach. I will refer you to a neurologist for review
and an obstetrician. I will also arrange for referral to a
high risk pregnancy clinic in a tertiary hospital to look
after you. The neurologist will review your medication
as I dont think sodium valproate is the best
medication for you during pregnancy. I believe

carbamazepine is less risky. Meanwhile, I will refer

you to an obstetrician to make sure everything is
alright and he will follow you up during pregnancy as
well.
All antenatal checkup tests will be done before
pregnancy.
We will start you with 5mg of folic acid from 1st visit
attempting pregnancy (3 months before pregnancy up
to 1st trimester).
Vitamin K to prevent bleeding especially 26th week
onwards
Post-delivery mother should nurse baby on the floor
surrounded by cushions. Breastfeeding is okay. Baby
will not be epileptic. Familial tendency doesnt
increase.
Review of anti-epileptic medications will be done by
neurologist after delivery.
High-risk pregnancy: combined 1st trimester screen
(blood plus usg looking for nuchal translucency and
nasal bone); if not high risk: 18-21 and 28-34 weeks
All should deliver in tertiary hospital and shall have
planned labor when they have completed 37 weeks.

Pre-pegnancy DVT Counseling

Case: Your next patient is a 28-year-old woman. Her last
pregnancy was 18 months ago which was complicated by DVT
and postpartum pulmonary embolism. She has come to see you
for pre-pregnancy counseling. She has stopped warfarin 12
months ago. There are no abnormalities on PE. She is not
overweight.
Task
a.
b.
History
-

Take relevant history (NSVD, episiotomy scar and

baby was normal; did not breastfeed; DVT happened
postpartum and treated with warfarin x 6 mos)
Management

Critical issues: failure to do thrombophilia screen; failure to

advise LMWH during pregnancy; and failure to advise about
warfarin use in pregnancy
Pre-Pregnancy Counseling of Obese Women
Case: You are a GP and a 30-year-old female came in because
she has been trying to conceive for the last 12 months. She
wants your advice on that matter. Height 1.5m, BMI 40, BP
Normal, BSL Normal
Task
a.
b.
c.

History
-

Management
- Since you had a previous history of clotting during
your first pregnancy, you have a high risk of having
another one. Pregnancy itself is a hypercoagulable
state because of the physiological and hormonal
changes. Your pregnancy will be monitored by a
physican and obstetrician and GP.
- Before you get pregnant I would like to do some tests
to exclude a group of disorders that can predispose to
clotting. This is known as thrombophilia screening.
There are 7 things in this screening: Protein C & S,
factor V Leiden, antithrombin III, anticardiolipin,
antiphospholipid antibodies and anti-lupus
anticoagulant
- Rubella vaccination if not yet immunized
- Start taking folic acid 0.5mg OD 3 months before
pregnancy and up to first trimester of pregnancy
- During pregnancy, you would be managed by a team.

History not more than 3 minutes (periods irregular, 5-6

weeks pain, stable partners, pap smear 1 year ago,
junk food, no exercise)
Counsel regarding
Advise Accordingly

Infertility
>12 mos: investigation
>24 months: infertile

How was the previous pregnancy? When did the DVT

happen and how was it treated? Have you had any
clotting episodes other than that? Do you have any
calf pains? Shortness of breath? Recent long
immobilization? Any other bleeding problems (in the
family)?
Contraception? Periods? Are they longer? Do you
bleed heavily during your periods? Blood group?
Rubella status (vaccinate and avoid pregnancy for 3
mos)?
FHx of bleeding disorders?
SADMA?

We will start you on LMWH on the 14th week of

gestation as a prophylactic measure until 6 weeks
post delivery.
Its advised to wear elastic compression stockings
during the day and avoid immobilization
Labor will be in a controlled manner at 38-39 weeks.
On the planned date, we will withhold the morning
dose of heparin. After labor, warfarin would be given
for 6 weeks (safe in breastfeeding) and we will monitor
INR everyday to begin with (INR 2-3).
If thrombophilia screen is positive: lifelong warfarin

I can see that you have been trying to conceive. Is

there anything in particular that concerns you? Do you
think you might be pregnant now? N/V/mood
changes? Irritability? Breast tenderness?
May I ask if you and your partner are aware of optimal
time for sexual activities? What contraceptives were
you using before? How are your periods? Regular?
Cycle? Any abdominal pain? Bleeding heavy?
Obstetric history: ever been pregnant? Miscarriages
before?
I understand you are in a stable relationship. Any
history of STI in yourself or your partner? PMHx or
Surgical conditions especially gynecologic surgery?
Thyroid problems? PCOS?
FHx: infertility? Gyne problems? Recurrent
miscarriages? Any pregnancy-related problems (CPD,
difficult delivery)
Have you noticed any recent changes to weight? Hair
growth, acne? How is your appetite? Water work?
Bowel habits? How is your sleep?
SADM (pills, steroid, anti-psychotic) A?
I can see from your notes that your BMI is a bit high.
Has it always been like this or is this a new change?
Anybody in family overweight?
Have you ever had BP, BSL, lipid level checked?
What was the result? Have you have ever had joint
problem? How do you feel about your weight? How
does your weight affect your life?

Diagnosis
First of all, it is very good that you have come for
some advice before falling pregnant. Apparently,
everything seems normal except your weight. The BMI
is an indicator of your healthy weight. The normal is
between 18-24. If >35 it is morbid obesity that puts the
patient at a very high risk of developing obesity-

related problems (heart disease, hypertension, stroke,

joint problems, DM, stress or depression).
I can see that you are already worried about your
weight. The obesity affects out health generally as
well as related to pregnancy especially. Obese
females have higher chance of developing menstrual
irregularities, problems with ovulation that can
sometimes lead to infertility. According to a study,
around 40% of obese females have problems
conceiving. Hence, it is very important for you to start
losing weight now.
o Set a goal: 5-10% of BW in 6-12 mos
o Make dietary changes refer to dietitian
o Increase energy expenditure by exercising
regularly. I will give you some written
material regarding exercise
o Please keep a diary of your diet and weight
o Come for regular followup
I want you to be aware of certain obesity-related
complications during your pregnancy, during labor and
afterwards.
During pregnancy, you are at risk of developing:
o GDM
o Pegnancy-induced hypertension
o Sleep apnea
o Problems with babys growth and
development (IUGR is common).
We will check your BSL at 26 weeks and regularly at
each visit. You will have regular ultrasound to check
growth of baby. Your antenatal visits will be more
frequent than other females. At 28-34 weeks, we will
send you to specialist for anesthetic assessment
because rate of CS is higher in obese females. We
want to be prepared for that.
During labor obese females have higher risk of
developing:
o Shoulder dystocia
o Non-progress of labor
o Obstructive labor
o CS and its complication
o More difficult to monitor HR and activity (fat
obstructs signals)
o Pain relief might be more difficult (more
adipose, more unequal distribution)
What we will do is a planned delivery in a controlled
environment under close monitoring by the specialist
obstetrician. A normal vaginal delivery is encouraged
as much as possible, however, they will be prepared
for CS
After labor, there is a higher risk for you to develop:
o Wound infection
o Clotting problems
o Postnatal depression (more common)
We will give you some meds to prevent clotting. You
will be encouraged to breastfeed child that helps you
to lose weight and to develop good bond with baby.
Come back after delivery and get wound checked.
Please be aware that elective CS is preferred because
it is hard to do emergency cesarean sections since it
is difficult to move patient. It is more difficult to give
epidural anesthesia to predict effects of medication.
Please bring your partner next time to discuss further
complications.
Reading material
Review

Pre-pregnancy counseling of SLE

Case: You are a GP and your next patient is a 24-year-old
patient who is a diagnosed case of SLE for 5 years. She wants
to become pregnant and is seeking your advice.

Task
a.
b.

Counsel the patient (steroids but no longer taking it

because she is symptom-free)
Answer her questions

SLE in Pregnancy
- Does not seem to cause exacerbations of SLE
- Can adversely affect pregnancy according to disease
severity
- Complications:
o Increased incidence of spontaneous
abortions and stillbirth related to lupus
anticoagulant and anticardiolipin antibodies
o Preeclampsia
o Prematurity
o IUGR
o Perital mortality
- Neonatal lupus syndrome: blood disorders and
cardiac abnormalities in neonate
- Increased maternal morbidity kidney complications
and pre-eclampsia
- Management
o Preconception counseling symptom free
for 6 months
o Refer for review of drugs
o Corticosteroids
o Low-dose aspirin
o Tests: lupus antibodies, APTI, FBE, RFTs,
ultrasound
o LMWH
o Timed delivery
Questions:
- Can I become pregnant like other females?
- What are the risks for my baby?
- How will my SLE be affected by pregnancy?
- Do I need some special medications during
pregnancy?
History
-

When was it diagnosed? What symptoms did you

have? What treatment was given? For how long? Did
you have any side effects from these medications?
How many relapses have you had during the past 5
years? Have you had regular checkups with
specialist? When was your last checkup? When was
the last blood test done? At the moment do you have
any symptoms like skin rash, joint pain, problems with
waterworks? Are you on any medications at the
moment? Which one and what dose (prednisolone
5mg)?
When was your LMP? How are your cycles? Are they
regular? How many days of bleeding? How many
days apart? Are you on any contraception at the
moment? Is this your first pregnancy? Any
miscarriages before? Hows your general health? Any
other medical conditions? Any FHx or SLE or
recurrent miscarriages? When was your last pap
smear? What is your blood group? SADMA?

Counseling
- As you already know, SLE is an auto-immune disease
which means that the bodys defense mechanism
becomes active against its own tissues. There is
usually inflammation of different tissues of the body
especially the skin, kidneys, and joints. The exact
cause is still not known but certain genes and viruses
have been implicated as stimulants. It is very common
in females of childbearing age (20-45).

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contraception are using? Any history of STI in yourself
or partner? Any other medical or surgical conditions?
-

SLE unfortunately cannot be cured, but it can be very

well controlled with medications to prevent flare-ups.
The good news is that majority of females with SLE
are able to have kids. It is important that they should
be symptom-free for at least 6 months before
conception.
There are certain risks associated with SLE:
o 40% have exacerbations/flare-ups however
10% have remissions
o Maternal risks: 20% develop pre-eclampsia,
2nd or 3rd (25%) miscarriages,
o Fetal risks: IUGR, prematurity (50%)
o Lupus-like syndrome at time of delivery (5%)
rash and abnormalities of blood cell
counts. This lupus like syndrome is not SLE.
This is a temporary response in the baby
because of transplacental transmission of
antiphospholipid antibodies from the mom to
the baby. It usually resolves within the 1st 4
weeks;
o congenital heart blocks: quite rare; only 2%
of pregnancies are complicated by this
SLE: small-vessel vasculitis which also deposits in the
placenta and small clots within the placenta IUGR,
prematurity, death
We will consider this pregnancy to be a high-risk
pregnancy. You will be managed by the specialist
throughout the pregnancy. They will decide upon the
best medications for you during pregnancy. Usually,
steroids are safe but dose of steroids will be
managed. Sometimes, azathioprine may be used. All
other cytotoxic drugs as we know are contraindicated.
We will do some blood tests and ultrasounds before
pregnancy and continue close monitoring throughout
your pregnancy. To prevent the risk of clotting
problems or thrombophilia, the specialist might start
you on ASA or LMWH that you will need to continue
after delivery (especially if anticardiolipin is positive).
The mode of delivery and timing will be best decided
by the specialist according to the babys condition. If
they have any problems with his growth, they might
intervene earlier.
I am going to write some blood tests for you: FBE,
UEC, Blood group, rubella antibody status,
anticardiolipin antibody, complete thrombophilia
screen.
Refer to obstetrician.
Reading material
SLE association of Australia

RH-isoimmunization Counseling
Case: You are a GP and a 25-year-old female comes to your
clinic. She had a miscarriage 2 years ago and she wants to
become pregnant again.
Task
a.
b.
History
-

History
Relevant management
When did you have it? What was the gestational age
of the pregnancy? Why was it terminated? What
method was used? Where was the termination done?
Any complications afterwards? Any blood transfusions
or further procedures were required? Have you been
pregnant again since then? How are your periods?
Are the cycles regular? Any bleeding in between? I
understand youre in a relationship, what

Any surgical/PM conditions? SADMA? What is your

blood group? What is your partners blood group?
Was the previous pregnancy with the same partner as
now? Did you receive any anti-D injections at that
time? Any history of rubella infection before? Were
you tested for rubella? When was your last pap
smear? What was the result? Are you vaccinated with
gardasil?
Management
- From the history the only problem that I noticed is that
you have a blood group that might carry some
problems for you and your baby in the future. Let me
explain to you about blood groups. Usually in our
blood, there are blood cells that carry oxygen to the
body. These cells carry proteins in the surface which
are named as A, B, O, AB as well as another factor
known as Rhesus factor (+ or -). The blood type is
determined depending upon the presence or absence
of these proteins. Around 85% of the population is
positive for rhesus factor. The rest are negative. This
is important if your partner is carrying it in his blood.
There is a 50% chance that your baby will be Rh+.
Sometimes, the babys blood cells cross the placenta
either during pregnancy, miscarriage, with trauma, or
even without any cause. In that case, the mothers
immune system produces antibodies against the
babys cells. This phenomenon is known as
isoimmunization. If the mother does not receive any
anti-D injections and she becomes pregnant again,
there is a very high chance that these circulating
antibodies reach the baby causing: hydrops fetalis,
hemolytic disease of the newborn, neonatal hemolytic
anemia. This results from breakdown of the babys
blood cells. The end result of the blood cell
metabolism is bilirubin which can be checked within
the amniotic fluid to check the degree of hemolysis. At
the moment, what we can do is to do regular antenatal
tests including your blood group and your partners
blood group.
- You need to start taking folic acid 0.5mg OD from now
onward. Once you become pregnant, at around 20
weeks of gestation, we will do a test that is called
amniocentesis to check the level of bilirubin. If
required, we will give you Rhogam or anti-D
immunoglobulin, an injection to neutralize the
antibodies. We will also test your blood for the level of
antibodies to Rh group and titer. If titer goes beyond
1:8, we will do amniocentesis earlier, further followup
testing and anti-D injections.
o Kleihauer test: determine how much
Rhogam is required. Tries to find out how
many fetal RBCs are present within the
mothers blood.
o Coombs test/antiglobulin test: done to check
the level of antibody in mothers blood.
Direct (checks the antibodies that
are bound to RBC)
Indirect (check the circulating free
antibodies)
- Recommendations: For all RH (-) whose pregnancy
progresses to 28 and 34 weeks and postpartum within
72 hours will be given 625 Rhogam injections
irrespective of antibody titers.
- If bilirubin too elevated: exchange transfusion
- Refer to obstetrician for possible assessment.
- Reading materials regarding isoimmunization.
- Review

6
-

RH ISOIMMUNIZATION INDICATIONS
All Rh(-) and unsensitized who requires or with:
INDICATIONS
Abortion or requires D&C (give within 72 hours to 910 days)
CVS/amniocentesis
Threatened abortion
Antepartum hemorrhage
Abdominal trauma
External podalic version
Bleeding during pregnancy
@ 1st trimester single
@ 1st trimester multiple
@2nd/3rd trimester
@ Postpartum
Pregnant women at 28 weeks
34 weeks
Rh (+) baby (give within 72 hours of delivery)

DOSE
250 IU IM
250 IU IM
<20 weeks: 250 IU
IM
>20 weeks: 625 IU
IM
250 IU IM
625 IU IM
625 IU IM
625 IU IM
625 IU IM
625 IU IM
625 IU IM

MISCARRIAGE AND ABORTION

Recurrent Miscarriages
Case: You are a GP and a young 26-year-old lady presents to
you in your GP clinic. She has had 3 miscarriages before. She
thinks she is pregnant again because she has not had her
periods for the last 6 weeks. She has a family history of alpha
thalassemia.
Task
a.

Counsel the patient

History (miscarriages x 3 episodes around 8-10 weeks, had

curettage once, irregular period 4-5weeks, Blood group B+)
Case 2: You are a GP and a young 28-year-old lady presents to
you in your GP clinic. She has had 3 miscarriages before at
around 8-10 weeks and has had D&C done. You did some
laboratory tests and she has come to collect the results.
Investigation: FBE, TORCH, chromosomal analysis, APAS,
TFTs, PRL, LFTs, Hepatitis B&C, Urine microscopy and culture,
FBS, HIV and STDs, thrombophilia, USD of uterus.
Causes:
- Immune-mediated: APAS, SLE, HLA incompatibility
between partners, thrombophilias, SLE
- Uterine abnormalities: cervical incompetence (2nd
trimester), gynecological surgeries, birth defects
(septate uterus)
- Infections: TORCH and STDs, Hepatitis B&C
- Endocrine: DM and thyroid
- Maternal age not a cause but risk factor; females
who become pregnant after 40 years has 50% chance
of miscarriage within the 1st trimester

I can see from the notes that you have a history of

recurrent or repeated miscarriages. At the moment,
you think that you might be pregnant. Have you done
a test to check for pregnancy? Do you have any
symptoms like morning sickness, breast tenderness,
or irritability? I understand your LMP was 6 weeks
ago, any bleeding since then? Tummy pain or
discharge from down below?

was your last pregnancy? How did you miscarry? Any

trauma? Did you have a D&C during any of the
pregnancies? Did they do an autopsy on the products
of conception? During the last 3 pregnancies, did you
suffer from any infections? Fever? Did you have the
antenatal blood tests done?
How is your general health? Any history of diabetes,
thyroid problems, immune-related diseases like SLE?
History of gynecological surgery? Blood group? Last
pap smear? Were you on any contraceptives before
this pregnancy?
SADMA?

Investigations
- We need to do a pregnancy test on you to confirm if
you are pregnant. If it positive, I will refer you to the
high-risk pregnancy clinic. If negative, I will refer you
to a specialist clinic called recurrent miscarriage clinic
where they will do some tests on you to find out the
possible cause of the miscarriages. They might ask
your partner to come in for a checkup as well.
- I would ask the examiner for the results of the blood
tests including FBE, Blood group, Ultrasound to check
any defects of the uterus, ovaries, and fallopian tubes.
I would like to run a complete thrombophilia screening
(Protein C, S, antithrombin III, anticardiolipin antibody,
factor V leiden most common deficiency, blood
homocystein levels), TORCH, Thyroid function tests,
BSL, urea and electrolytes. At the clinic they will order
HLA and karyotyping for both partners.
- If PT (+): I will refer you to the high-risk clinic where
you will be seen by the specialist obstetrician.
Recurrent miscarriages affect 1% of all couples.
Sometimes, even with extensive investigations, no
cause can be found. You still have a very high chance
of a normal pregnancy. After the 1st miscarriages,
chances of successful pregnancy is 80%, 2nd (75%),
3rd (70%). I will ask the psychologist, midwife, and
obstetrician to support you all this time whether or not
you are pregnant.
- One of my friend got cervical stitch, should I have it
too? It is usually done in cervical incompetence where
the miscarriage occurs in the 2nd trimester. We can do
ultrasound earlier this time.
- Referral letter
- Written material
Threatened Abortion
Case: You are a GP and a 28-year-old female comes to you with
vaginal bleeding after 8 weeks of amenorrhea.
Task
a.
b.

Definition
- >3 consecutive pregnancies lost by a female
History
-

How are your cycles? How many days of bleeding?

How many days apart? Please tell me more about
your previous pregnancies? Have you had any kids up
to now with this partner or previous partners? When

c.
d.

History (2pads, clots, regular periods, B+)

Physical examination (moderate bleeding, clot, os is
closed, uterus is normal and not enlarged, (+) CMT)
Investigation
Management

Case: You are a GP in a suburban GP practice. Your next

patient is a 24-year-old Mrs. Jones with heavy PV bleeding for
the last 24 hours. She is 7 weeks pregnant by date and she is
concerned and seeks your care.
Task
a.

Focused history

7
b.
c.
d.

Physical examination
Investigation
Diagnosis, management, and differential diagnosis

Differential Diagnosis
Ectopic Pregnancy: PV bleeding + b-hCG(+)+ os
closed + empty uterus
Threatened miscarriage: PV bleeding + b-hCG (+) +
os closed + intrauterine pregnancy
Incomplete abortion + b-hCG(+) + os open +
intrauterine pregnancy + POC on examination

Incomplete Abortion
Case: You are an HMO in ED and a 39-years-old female comes
in complaining of vaginal bleeding and abdominal pain. LMP
was 8 weeks ago.
Task
a.

History
-

Is my patient hemodynamically stable?

Please tell me more about the bleeding? When did it
start? How many pads did you use up to now? Did
you pass any clots? Do you have any associated
pain? Have you felt N/V/breast tenderness? Do you
feel dizzy at the moment? Any fever or discharge from
down below? Possibility you might be pregnant right
now? When was your LMP? Are you periods regular?
How many days of bleeding? How many days apart?
Have you ever had spotting in between? I understand
you are sexually active and in a relationship, what
method of contraception do you use? Are you
planning to fall pregnant? Have you ever been
pregnant before? Any miscarriages? When was your
last pap smear? What was the result? What is your
blood group? Any past medical or surgical condition
especially any bleeding disorders, thyroid problems,
gynecological conditions. FHx of bleeding disorders.
Have you or your partner ever been diagnosed with an
STI? Any problems with waterworks like burning,
frequency? How are your bowel habits? SADMA?

Physical examination
General appearance
Vital signs (postural drop)
Abdominal examination: distention, tenderness
especially on the RIF and LIF. Any visceromegaly,
bowel sounds
Pelvic examination: amount of bleeding, color of
blood, clots, discharge or signs of trauma? Sterile
speculum, check os whether open or close; POC; any
mass or lesion over the cervix; bimanual examination
checking for size, shape and position of uterus;
adnexal tenderness or mass; cervical excitation;
Urine dipstick, BSL, pregnancy test
Diagnosis and Management
If pregnancy test positive: most likely your condition is
called threatened abortion/miscarriage. Your
pregnancy test is positive, but because of your
bleeding, we need to admit you to the hospital to do
some tests which include FBE, U&E, blood group,
USD of the pelvis to look for the presence of a fetal
sac within the uterus and to check for cardiac activity.
Depending upon the results, the OB might advise you
to take rest. Sometimes, because of the attachment of
the placenta to the womb, some bleeding can happen.
In majority of cases (90-95%), this bleeding is quite
harmless. It will stop on its own within a few days.
Your pregnancy will continue without any problems,
but you need to avoid stress, anxiety, and rigorous
physical activity for the rest of your pregnancy. We do
not need to give you any medications as it has not
shown to alter the outcome in any way. If the bleeding
continues, we will repeat serial ultrasound to check for
fetal viability, but you will need to stay in the hospital
until the bleeding stops.

If pregnancy test negative: Most likely, this is a

delayed period. Sometimes, due to stress and with the
use of the pill, your periods can become irregular. If it
continues for the next 2 or 3 cycles, you will need to
see the specialist gynecologist. She might decide to
start you on regular OCPs to regulate the cycle.

b.

c.
History
-

History (lower tummy, comes and go, started 12 hours

ago; 4-5 pads/day; periods every 28-30 days, no easy
bruisability or bleeding disorders)
Physical examination (distress, pale and in pain; BP
80/50, os open with POC, PR:80 vasovagal shock;
size of uterus is 8 weeks, mobile, no adnexal
masses/tenderness; no CMT)
Diagnosis and management
Is my patient hemodynamically unstable?
When did the bleeding start? What is the color of the
bleeding? How many pads did you used since then?
Were they fully soaked? Did you pass any clots or
pieces of tissue? Did you bubbles or grape-like
tissues? Do you have any dizziness, SOB or fever? Is
it the first time?
Where is the pain? Is it there all the time or does it
come and go? Does it go anywhere? How severe is
the pain from 1-10? Anything that makes the pain
better or worse? Any trauma or intercourse before the
bleeding?
Are your periods regular? When was your LMP? How
many days of bleeding? How many days apart? Do
you have heavy periods?
Are you sexually active? Are you in a stable
relationship? Any contraception used? Have you or
your partner ever been diagnosed with STDs? Any
chance you could be pregnant? Do you know your
blood group? Have you ever been pregnant before?
Any miscarriages? Do you have N/V/ or breast
tenderness recently? When was your last pap smear?
Hows your general health? Do you have any FHx of
bleeding/clotting problems or miscarriages?

Physical Examination
- General appearance
- Vital signs
- Abdomen
- Pelvic remove POC immediately!!!
- Urine dipstick
Diagnosis and Management
- Admit the patient
- Start IV fluids and take blood for grouping and
crossmatching
- Give oxytocin or ergometrine or (Syntometrin) to stop
bleeding
- Refer to OB&Gyne registrar for curettage
- From history and examination, I am sorry to say that
this is a miscarriage. Most of the miscarriages occur
without any obvious reason. Let me reassure you that
it is not your fault. You did not do anything wrong. So
please do not feel any sense of guilt. Most likely in the
first 14 weeks, the reason of miscarriage is due to
chromosomal abnormalities. I have admitted you,
informed the registrar, and sent all the bloods for
necessary investigations. They will probably take you

8
to the theater and do a procedure called curettage.
They will empty whatever is left in the uterus to
prevent any complications. We will wait for your blood
group report to come and if it is negative, we will give
you an injection called anti-D.

Can I still get pregnant? Yes, you can still get pregnant
but it is advisable to wait for at least one normal period
before you get pregnant again.
I know it is a very hard time for you. Do you want me
to call anyone for you? Do you have enough support?
Being 38 years old puts you at a higher risk of your
child having Down syndrome. So in your next
pregnancy, it is advisable for you to consider doing
Down Syndrome screening.

Critical error:
- Not considering anti-D
- Not taking out POC immediately
- Doing unnecessary investigations like beta-hCG and
USD
EXTRAUTERINE AND ECTOPIC GESTATION
Ectopic Pregnancy
Case: A 23 years old female has recently been discharged from
the hospital after a procedure where the right Fallopian tube was
removed because of an ectopic pregnancy. The left ovary on the
ultrasound showed the presence of corpus luteum. The patient
wants to know why it happened to her.
Task
a.

Talk to the patient and explain about ectopic

pregnancy and its causes.

From the notes, I can see that you have recently

undergone a procedure to remove a right ectopic
pregnancy. How are you feeling at the moment? How
are you coping with the loss of this pregnancy?
I understand why you want to know why it happened
to you. Do you know what ectopic pregnancy means?
Usually, the egg from the mom and the sperm from
the dad meet within the tubes to form the fetus. This
fetus then travels and becomes attached to the wall of
the womb. Due to certain reasons, sometimes, the
fetus implants within the tubes. It is then called an
ectopic or extra-uterine pregnancy. The size of the
tube does not allow the fetus to grow therefore it may
rupture and leads to a lot of bleeding and other
complications. For you fortunately, such complications
were prevented and the tube was removed. Please
don't worry. You still have a chance of normal
pregnancy. The risk factors for ectopic pregnancies
are: previous history of PID and STI (increases risk
7x), previous surgeries of gynecologic nature
especially around the tubes, history of endometriosis,
IUCD use, use of emergency contraception (causes
retrograde contraction of the Tubes), embryonal
defects, previous history of ectopic pregnancy in the
opposite tube.
In most of the cases (97%), ectopic pregnancies are
found within the tubes. Sometimes, they can be found
in the ovary, peritoneal cavity, and on top of the uterus
For your next pregnancy, the chances of conception
are around 50%. Please remember that even one tube
can catch the eggs from the opposite ovary. You need
to wait for at least 3-6 months before trying to
conceive. Give yourself some rest and have a healthy
balanced diet. You can use OCPs but please avoid
IUCDs, Emergency pill and POPs.

When you miss your next period, please come and

see me ASAP. We will do some tests including serial
beta-hcg done starting day 5 of conception. We would
like to record the quantitative increase in beta-hcg

which usually rises every 48 hours. If it doesn't, then

we will do USG, progesterone (low) and CA-125 (rises
during impending rupture)
The gold standard for diagnosis remains to be
laparoscopy.
If we find that the next one is ectopic as well,
depending upon the fetal viability and damage to the
tube, the specialist obstetrician might decide to inject
MTX within the gestational sac that will help in
resorption of the fetus protecting the tube.
If you develop tummy pain, vaginal bleeding, episodes
of fainting or dizziness, or back pain (interscapular
area), please come to the hospital right away because
these are symptoms of early ectopic pregnancy.
The best option would be IVF if your opposite tube is
removed. Please be optimistic. You still have a very
high chance of having a normal pregnancy.
General risk for ectopic pregnancy: 1%; chance of
recurrence: 10-20%

ANTEPARTUM AND OTHER COMPLICATIONS IN

PREGNANCY
Antenatal Care:
Do beta-hCg (quantitative or qualitative)
Down Syndrome risk:
o @37: 1:200
o @40: 1:100
o @45: 1:50
Screening for down syndrome: HR: 1:200 or higher
o 1st tri: 80% predicted
10-12 weeks: PAP-A and betahCg;
12-13 weeks: USG (nuchal
translucency aneuploidy)
o 2nd tri: 60-70% predicted
QUAD screen @14-20 weeks:
AFP, b-Hcg, estriol, inhibin A
(ACEI)
May do dating usg during first visit
Amniocentesis (0.5%)/CVS (1%): risk of miscarriage
Blood group
o If (-): repeat blood at 28 weeks; then give
anti-D; repeat blood antibody screen at 34
weeks (2nd injection of anti-D) prevent
spontaneous transplacental hemorrhage
2nd tri: 12-15% fetal RBCs can be
found in maternal blood resulting
in isoimmunization
3rd tri: 20-30%
o Give anti-D after delivery
FBE: consider anemia (r/o hemoglobinopathy)
o Check the partner and check for trait
Screen for infections: Rubella, HIV, Hepatitis,
hepatitis B&C, syphilis
o If HbsAg (+) check partner for hepatitis b
antibody; talk about safe sexual practice
o For hepatits b&c refer to infectious
specialist
MSU for micro&culture: asymptomatic bacteriuria (or
in 6-8%) (+) if >100,000 col/ml; tx because
increased likelihood of getting severe UTI (e.g.
pyelonephritis)
Vitamin D levels: N: 70u; severe <20u

9
-

18-22 weeks: morphology scan to check for structural

abnormalities
28 weeks: check for anemia (FBE) physiologic
anemia and GCT

History
-

Average gestation: 40 weeks + 2 weeks; >42-43

weeks perinatal mortality doubles;
o Concern at 41-42 weeks: do fetal well-being
USD measuring umbilical artery flow (SD
ratio: difference between peak systolic flow
and end-diastolic flow), AFI and CTG

Antenatal checkup
Case: Your next patient in your GP practice is a 24-year-old
female who is 8 weeks pregnant. You saw her last week as a
part of her regular antenatal checks and ordered some blood
tests. Today she is here to know about the blood results. Her
health and pregnancy have been good so far. She is so excited
about having a healthy baby by the end of her pregnancy. Her
results are as follows:
FBE: Hgb 120, WBC 8000, Plt 170,000
UEC: Na 145, K 4.4, Cl 130
LFTs: normal
BSL: 4.3
Blood group: A-; Antibody screening test (-)
IgG (+) for Rubella and Varicella
Urine: MCS show GBS positive
HBV and HCV: negative
Task
a.

Explain result and advise on management

Management
Congratulate on her pregnancy
Give anti-D at 28, 34 weeks and 72 hours after
delivery if child is Rh (+) and if there are bleeding
episodes
If antibody screening test positive: measure the titers
using ELISA (1:8 or 1:16 or 1:32 then check bilirubin
by doing
o Amniocentesis: check bilirubin;
o Umbilical cord sampling: Hct (25%)
o MCA ultrasound: check velocity of blood
flow -- if there is hemolysis heart pumps
faster then velocity increases; less invasive
Urine MCS: positive for GBS (asymptomatic
bacteriuria) -- treat with antibiotics because of risk of
developing pyelonephritis
(Cefalexin/Augmentin/amoxicillin)
- Repeat culture after 1 week
- General advise for UTI
- Check partners blood group
- Advise on antenatal checkup
- Dietary advice, smoking and alcohol
- Down syndrome screening if older patient
First Antenatal Check Up
Case: Mrs. Hasim a migrant from Sudan presents to your GP
clinic for her fist antenatal visit.
Task
a.
b.

Take History
Your management in pregnancy

She is a professional boxer for 10 years. Can I do exercises?

Can I eat sushi? How about weight gain?

Mrs Hasim, Do you need interpreter? I understand you

have come to see me regarding pregnancy. Is it your
first pregnancy (Yes)? Was it planned (Yes)?
Congratulations!
When was your LMP (8 weeks ago)?

Period questions: Do you have regular cycles? How

long is the cycle? How long is the bleeding time? Any
spotting in between? Do you have excessive pain or
bleeding during the period? How did you confirm your
pregnancy (I did pregnancy test at home)? Good on
you!
Pregnancy symptoms: Do you feel tired, nausea?
Have you vomited? Breast tenderness? Tummy pain?
Hows your water work? Do you have regular bowel
function? Do you have unusual vaginal discharge or
bleeding?
What type of contraception did you use before you got
pregnant? Have you been diagnosed with STD?
When was your last PAP smear (If no for last 2years
do it now!)? Do you know your blood group? Have you
had Rubella in the past or have you receive vaccine
for it?
Any serious illnesses or surgeries in the past? (Heart,
HTN, DM, anemia.) Is your husband generally
healthy? Are you on any medication? Are you taking
folic acid? Are you allergic to anything? Smoking,
Alcohol and drugs? How many cups of coffee do you
drink per day? What do you do for a living? When did
you migrate to Australia? Do you have any family
members or close friends here? Has anyone in the
family had twin pregnancies? Has anyone in the family
had pregnancy complicated by DM, HTN, birth
defects?

Management
- We need to order some routine lab tests to identify
any issue which needs to be addressed for the best
outcome of your pregnancy.
o FBE exclude anemia. Hb. Iron deficiency
Supplement.
o Blood group and RBC antibodies. If you are
Rh-you need anti-D immunoglobin
prophylactically to prevent problem in future
pregnancy. Repeat antibody test in
26weeks.
o Rubella status if you are not immunized to
rubella, I recommend you receive rubella
vaccination after delivery. (Contraindication
during the pregnancy)
o We will also do syphilis, Hepatitis B and C
and HIV screening.
o Vitamin D level.
o Midstream urine to check urinary tract
infection. Sometimes it can be
asymptomatic but need to be treated in
pregnancy. 30% of asymptomatic UTI can
become symptomatic.
o Theres another test which we offer in every
women in Australia. Its a Downs syndrome
screening test. Would you like to do it?
1st trimester: Pappa, beta HCG,
Ultrasound
2nd trimester quad. Test(1518weeks): beta HCG, AFP,
oestradiol, inhibin A
o You also need 18-20weeks mid pregnancy
ultrasound to make sure baby develops

10

o
o

properly and to look for position of the

placenta.
At 28weeks we screen for Gestational
Diabetics: sweet drink test/glucose
challenge test.
At 36 weeks you will need to be advised to
do a low vaginal swab to check for a
bacterial infection called GBS. If found you
will be given antibiotics prophylactically
during delivery.

You need to take folic acid 0.5mg for the 1st 3 months
of pregnancy because it decreases the occurrence of
neural tube defects.
Moderate exercise is good for you because it
improves cardiovascular and muscle strength. Best
exercises are low impact aerobics, swimming, walking
and yoga. No contact sport because of risk of trauma.
Weight gain should be around 11-16kg during
pregnancy. But it all depends on your pre-pregnancy
state. Your diet is important, it should be well
balanced. Food rich in protein, dairy food, starch food
(potatoes) and plenty of fruits and vegetables. Best
avoid a lot of sugary, salty and fatty food. Food
delicacies: uncooked meat, egg, soft cheese, shell fish
and raw fish should be avoided as they are potential
sources of Listeria and Salmonella.
No smoking, alcohol and drugs.
What about my sexual life? Sexual life is acceptable
and normal during pregnancy just follow your normal
desire.
Can I see a dentist? See your dentist in case any
dental care is required and it can be carried out in the
first half of the pregnancy.

Do you have enough support? I understand you live

80km away, how long does it take to go to the nearest
hospital by car? Can anyone drive you to the hospital
in case of emergency? Do you have any friend or
relatives who live near the hospital where you could
relocate a few days before the due date? Is there
anyone at home who will look after your first baby
when you are in the hospital?

Case: your next patient in GP practice is a 24-weeks pregnant

lady who has just moved into your town. She has come to see
you as her first GP. She lives 80km from the main hospital

Counseling
The first pregnancy is usually longer as compared to
succeeding ones. However, there are some warning
signs: if you have any contractions,any passage of
mucus or water, vagina bleeding, any reduction in fetal
movements, any sort of tummy pain, headache, blurry
vision, cloudy urine, or other warning signs, you have
to come to the hospital straight away.
The plan for your pregnancy is to come every month
until your28th week, then every fortnightly from 28-36
weeks and weekly after 36 weeks and until delivery. At
28 weeks, we will arrange a sweet drink test and
around 34-46 weeks, we will do the vaginal swab to
detect the bug called GBS.
If there are no warning signs as discussed before, it is
advisable to either relocate close to the hospital if you
have friends or relatives or get admitted to the hospital
a week or so before the due date.
Will I have a long labor this time as well? With regards
to your delivery, the exact duration of your labor is not
easy to predict as it depends on several factors at the
time of delivery such as medical conditions, size of the
baby, size of the pelvis, presentation of the baby, and
strength of the contractions. But usually, the duration
of labor in 2nd pregnancy is shorter compared to the
1st.
Right now everything sounds good. I will see you in
one month time and give you a few reading materials.

Task

Down Syndrome Screening

Timing of Admission to Hospital

a.
b.
c.
History
-

Relevant history (folic acid, regular checkup, normal

USD and blood tests; history of prolonged labor
because of poor contractions; instrumental delivery)
Advise when she immediately needs to attend the
hospital or midwife
Answer her question
Congratulations on your pregnancy. I can see that
youre concerned about when you should go to the
hospital for delivery. I understand that you live 80km
away from the hospital. Before I address your
concern, is it okay if I ask you some questions?
How is your pregnancy going so far? Was it a planned
pregnancy? Are you attending regular antenatal care?
How were the blood test results? Anything significant?
Do you know your blood group? What about the 18 th
week USD? Is it a single baby? Is the placenta in the
normal position? Any tummy pains or trauma so far?
Any discharge or bleeding so far? Any leakage of fluid
down below? Any headache, BOV, N/V? Any urgency,
frequency or smelly urine? Did you take folic acid? Is
your baby kicking well? Any previous pregnancy or
miscarriage? How was it? Was it term or preterm? Do
you know the reason for the prolonged labor? How
was the baby after delivery? Any complications? What
was the BW? Any previous medical or surgical issues
like BP, DM? Any problem with your periods? Are you
on any medications? SAD

Case: A young woman at 10 weeks gestational age comes to

see you in your GP practice. She is concerned about having a
baby with Down syndrome as recently, her sister had a baby
with Down syndrome.
Task
a.

Counsel patient

Is this a planned pregnancy? Congratulations.

I understand from the notes that you are here to
discuss about Down syndrome screening. I appreciate
your initiative to do that. I understand your anxiety. I
will give you all the information regarding the tests
which can be done and how effective they are.
How is your pregnancy going so far? Are you getting
your antenatal care? Are you done with your blood
tests? Any concerns or issues?
Down syndrome is one of the common genetic
abnormality with trisomy 21. There are some
indications in doing Down syndrome screening in
pregnant women:
o Increased maternal age (>30)
o Previous down syndrome baby
o History of down syndrome in the family
We have screening tests and confirmatory tests. In the
first trimester, there is a triple test a blood test which is
done at 9-13 weeks AOG. We check free beta-hCG
Pregnancy Associated Placental Protein-A. We

11
combine it with Ultrasound and it is done at 11-13
weeks AOG. Here we check for fetal nuchal
translucency. Screening tests can also be offered in
the 2nd trimester between 15 and 17 weeks. These
tests are not 100% confirmatory. In high-risk
pregnancies, we can offer diagnostic tests: CVS or
amniocentesis.

o
o

Baby: Macrosomia, Multifetal gestation,

Malpresentation (breech, face, brow,
transverse lie)
Labor: Power, Passage, Passenger

Eligibility: 1 previous LSTCS and NO contraindication

Induction of labor:
Risk of uterine rupture especially if induction of labor
with prostaglandin E2, oxytocin + amniotomy and
misoprostol is used
o Classic (5%)
o LSTCS (0.5%)

CVS
done ideally at 9-11 (11-12 at clinical book)
weeks
o results within 24 hours
o more accurate
o 1% risk of abortion
Amniocentesis
o Done ideally at around 14-15
o Longer (up to 3 weeks) and less accurate
o 0.5% risk of abortion
3 regimens:
o PAPPA and free hCG at 9-13 weeks
o Nuchal thickness at 11-13 weeks (combined
tests raises detection rate from 70 to 90%)
o If calculated to be more than 1/200-250
woman is offered CVS if gestation between
11 and 14 weeks or amniocentesis if at 1516 weeks
o Combined test: AFP, unconjugated estriol
and beta-hCG + Inhibin A at 15-20 weeks
increases detection rate from 65 to 7580% if inhibin A included
If previous pregnancy was down syndrome, the risk of
having Down syndrome in the next pregnancy
increases by 1%.
o

Vaginal Birth After Cesarean Section (VBAC)

Case: You are a GP and a 28-years-old lady with previous
cesarean section 2 years ago is in your GP clinic. She is now 7
weeks pregnant and she wants to have vaginal birth.
Task
a.
b.
c.

History (CS due to fetal distress, pap smear x 1 year

ago with
Ask examiner for previous medical/surgical notes of
the LSTCS (obstructed 2nd stage of labor hence
underwent CS, Apgar 6,8 BW 3kg, no CPD)
Discuss possibility of vaginal birth to patient

Predictors of successful VBAC (55-85%):

Non-recurring indication of CS (e.g. malpresentation)
PIH
Previous vaginal birth
Institutions in which success rates is high
Onset of labor is spontaneous
Contraindication
Previous classic cesarean section birth
Some uterine surgery (hysterotomy, deep
myomectomy, corneal resection and metroplasty)
Previous uterine rupture or dehiscence
Maternal or fetal reason for elective CS in current
pregnancy
o Mother: PIH, Diabetes, Antepartum
hemorrhage (previa/abruptio)

History
-

Mechanical cervical ripening device may be used

safely
1/5 of patients end up having cesarean section
Congratulations. Is it a planned pregnancy?
What about first pregnancy? Was it your first? Was it a
planned pregnancy? Did you have regular antenatal
checkups? Complications of pregnancy (DM,
hypertension, bleeding)? Why was the CS performed?
Was it an emergency? Do you know the type of
cesarean section? Complications of surgery
(infections, bleeding, DVT)? CPD (height of partner
and patient)? How was the baby at birth? Any
resuscitation needed?
History of previous uterine surgeries or rupture?
Are you taking folic acid?
How is your general health? Any medical condition
you have at this moment? Why do you want to have
vaginal birth?

Findings from Examiner

Reason for cesarean section
Classical or Low-segment cesarean section
Age of gestation
Complications: anesthetic, infection, hemorrhage,
damage to the adjacent organs like bladder, large
intestine etc, DVT
Baby: weight, apgar score, resuscitation done
Management
At this stage we are not sure about the outcome of the
pregnancy as it depends on its progress. However, in
majority of cases and in your case, successful vaginal
birth can be achieved safely. The success rate ranges
from 55-85%. I will do antenatal screening tests and
will monitor you during your antenatal visits to look for
certain conditions which can pose a risk during vaginal
delivery or which can be an indication for cesarean
section. If any of these are present, you will be
managed as a high-risk pregnancy.
I will arrange an appointment with an obstetrician at
26 weeks for discussion about possible mode of
delivery and at 36 weeks for definite decision
regarding vaginal birth. The specialist will explain the
risks and benefits of the mode of delivery to you and
the final choice will be made according to your wishes
and advice of the obstetrician. If vaginal birth is
decided, it will take place in a well-equipped hospital
under supervision of an experienced obstetrician
because vaginal delivery can progress to cesarean
section in 1/5 of the cases.
Folic acid prescription
Reading material
Review

12
Ovarian Cyst in Pregnancy
Case: You are HMO in ED. 25yo female 8weeks pregnant c/o
pain in the right lower abdominal pain.
Task

FBE, Serum beta HCG. U/S of pelvis and abdomen

looking at evidence of intrauterine pregnancy, rule out
ectopic pregnancy, ovarian cyst, fluid in the pouch of
Douglas.
Tumor markers: CA125, LDH

Diagnosis and Management

a.
b.

Take history
Ask for Physical Findings (All vitals stable. Healthy
looking. Abdominal examination: Tender in the right
iliac fossa. No organomegaly. Per speculum: no
discharge, no bleeding, no poc, os is closes.)

c.

Ask for one relevant investigation findings ((U/S:

Intrauterine pregnancy, Cyst in the right ovary 5cm in
size, no fluid in the pouch of Douglas)
Talk about relevant management

d.

Differential Diagnosis
UTI
Ectopic pregnancy

History
-

Is my patient haemodynamically stable?

Pain questions: How bad? 5-6/10 dull kind of pain not
radiated. Where? Go anywhere else? Does anything
make it better or worse? When did it develop? Is this
the first time? Any associated symptoms eg fever, N/V,
bleeding from down below, discharge from down
below?
Problems with water work: burning or frequency?
Bowel habits: history of constipation?
I understand from notes you are 8 weeks pregnant.
When was it confirmed? At the moment do you have
symptoms like morning sickness, irritability, breast
tenderness? Is this a planned pregnancy? Is this the
1st pregnancy? Any miscarriages before? History of
ectopic pregnancy? LMP? Are they regular? When
was the last PAP? Result?
Hows your general health? PMHx: appendectomy.
Have you or your partner ever dx with STD. History of
pelvic infection or gynecological procedure done for
yourself?
SADMA? Blood group? Which contraception were you
on before the pregnancy? Gardasil?

Physical Examination
-

General Appearance: pallor jaundice dehydration

Vitals: ask all vitals. If suspect appendicitis ask for
Pulse and BP.
Abdomen: Any visible distension, mass, scars?
Palpate any tenderness especially McBurneys point.
Pelvic examination:
o Inspection: Any discharge, bleeding?
o Sterile speculum: discharge, bleeding, POC,
OS
o Bimanual: Any tenderness, adnexal mass,
position and size of the uterus

From history and physical examination, most likely

your pain is coming from a cyst within the ovary.
Ovarian cyst is usually a benign condition where a
fluid filled sac is found near the surface of the ovary.
Its quite common in female of reproductive age group
the exact cause is unclear. However, the hormonal

changes during pregnancy can sometimes be

responsible. Rarely certain types of nasty growth may
develop within that cyst however the chances are very
low at your age. The management depends upon the
size of the cyst, your symptoms, and the opinions of
the obstetrician
According to JM
o If its a simple cyst <5cm reassess the
patient clinically and with a U/S in about 6
weeks time.
o If its a simple cyst >5cm recommend a u/s
guided aspiration.
o Complex cysts irrespectively to size,
excision laparoscopically
o Any symptoms or U/S evidence of torsion of
cyst: laparotomy and removal of cyst
For your case, because your cyst is still around 5cm
and your symptoms are controllable (pain killers
given). Ill ask obstetrician to come to see you. Most
likely they will advice careful monitoring to lookout for
any symptoms of torsion which are: severe pain all
over the tummy, recurring pain, symptoms of shock
(fainting, low BP). The risk of torsion is around 1015%. At the moment once your pain settles down we
will send you home. However, you need to report back
to us if any symptoms develop most likely you will
need to undergo surgery in that case. Usually
laparoscopic surgery doesnt affect early pregnancies.
However, slight increase risk of miscarriages. But we
will give you certain hormones to help maintain the
pregnancy (progesterone). Do the Surgery after
15weeks with progesterone therapy. I want you to be
aware of some other complication of ovarian cyst:
Infection: fever, and increasing pain, Cyst might
rupture, twist on its axis compromising the blood
supply to the ovary. However, around 80-95% of
ovarian cyst that presents to us resolves
spontaneously.
Review: in 6 weeks for U/S.

Alcohol Excess in Pregnancy

Case: Your next patient is a 10 weeks old pregnant lady who
came in for antenatal checkup. She is alcoholic beverage
drinker and a smoker for the last 10 years.
Task

Investigation:
U/S: Ovarian Mass
Ask the examiner for Doppler U/S: To see the blood
flow to the ovary(torsion), To determine the nature of
the cyst: homogenous mass(simple cyst) or a complex
cyst (malignant in nature).

a.
b.
c.

History (planned pregnancy; first pregnancy; not a

binge drinker; drinks with partner; cannot go without
alcohol for one day
Advise management
Focus on issues

13
History
-

Can you tell me a bit more about it? Is it a planned

pregnancy? Is it your first pregnancy?
I would like to ask you a few more questions
especially with your smoking and drinking habits. Is it
alright with you?
For how long have you been drinking? How much do
you drink per week? What type of alcohol do you
drink? Do you drink a lot on the weekends? Do you
drink alone, with partner or with friends? Are you
aware of the safe level of drinking? How long can you
go without alcohol? Do you need it to steady your
nerves? Does it help you go to sleep? Do you take a
drink in the morning when you wake up? Any
symptoms of agitation, sweating, nausea, or shakes if
you dont drink?

Hows your family life? Any problem at work or with

family relations? Any financial issues?
CAGE? Have you ever tried to cut down? Ever been
annoyed? Do you feel guilty? Do you drink when you
wake up in the morning? Do you know about its
effects in pregnancy?
How many cigarettes do you smoke per day and for
how long? What is your pattern of smoking during the
day? How soon do you have your first cigarette when
you wake up? Do you find it difficult to smoke in nonsmoking areas? Have you tried to quit smoking in the
past? Does your partner smoke?
Any medical condition such as liver, gastrointestinal,
heart? Any history of mental illness or depression?
DM? Hypertension?
Are you on any medications? do you take folic acid?
Have you used illicit drugs?

Counseling
I would like to talk about the effects of smoking and
alcohol in pregnancy and I would also like to do
investigations that we do during the first antenatal
checkup.
The effects of alcohol: In pregnancy, alcohol can pass
through the placenta to the baby and is broken down
more slowly than in adults leading to fetal alcohol
spectrum disorders. On one extreme is fetal alcohol
syndrome which is main cause of mental retardation in
babies. The other effects include vision and hearing
problems, learning, emotional and behavioral
problems, speech or language delays, low BW, and
birth defects including heart, face, eyes and other
organs of the body.
In pregnancy, there is increased risk of miscarriage
and premature birth. After the birth of the baby,
breastmilk production can also decrease.
Unfortunately, smoking exposes the baby to some
dangerous chemicals like nicotine, tar, and CO which
decrease the amount of oxygen for the baby which
can affect his/her development. It can also damage
babys lungs and can give rise to birth defects like cleft
lip and palate, low BW, and once baby is born, there is
increased risk of chest infection like asthma,
pneumonia, and ear infections.
In pregnancy, smoking is a risk factor for placental
abruption and stillbirth. Also, there is an increased
chance of SIDS if parents are smoking and drinking.
I know you are quite worried about hearing all this, but
the good news is that all of these can be avoided if
you stop smoking and drinking alcohol. The ideal
situation is if you stop smoking and alcohol altogether
if possible for you. The sooner you quit the better it is
for you and your baby. There is no known safe level of

alcohol use in pregnancy. (Limit to 1 SD per week but

any reduction is important).
Suggestions on how to quit: It is important to
understand the effects of alcohol and smoking and
admit it as a problem for you and your baby. Strong
motivation is the key to success. After making a
decision, establish clear and realistic goals and I will
help you implement them to stop alcohol and smoking
altogether. Choose a quit date for both alcohol and
smoking to stop.
I can arrange a family meeting to talk to your partner
and advise him to stay away from alcohol and
smoking. Avoid situation where you usually drink
alcohol like party and bars. Ask family and friends to
help you quit. Let your family members, friends, and
coworkers know that youre trying to stop drinking and
smoking.

You can experience withdrawal symptoms like

headache, shaking, sweating, N/V, anxiety, tummy
pain, diarrhea, problem with sleeping, high and low
BP, craving for alcohol and smoking. When you
experience these symptoms, please immediately
contact me so appropriate treatment could be given.
Lifestyle modification: Deal with stress in a healthy
way like exercise, sports, meditation and yoga.
I will refer you to alcohol anonymous. It is an
organization composed of groups of people having
problems with alcohol and who desire to stop it. I will
also refer you to support groups quitline for smoking
and give you some reading materials. Im available for
you for ongoing management and support for followups.
RWH:
o Sometimes it is not possible to stop
altogether.
o Avoid dehydration by drinking plenty of
water
o Vitamin D, iron and calcium
supplementation
o Folic acid for the first 3 months
o Nicotine replacement therapy shouldnt be
used in pregnancy but may refer to
specialist for advice
o Medications for withdrawal: Acamprosate
(champix) or naltrexone for 6-9 months;

Pregnancy with IUCD

Case: A-26-year old female comes to your GP clinic complaining
that her period is late. She has copper IUCD inserted.
Task
a.
b.
c.

Take focused history

Ask for physical examination (size of uterus is 7
weeks, no adnexal mass)
Advice the management

Case 2: Same Scenario You can see the thread of the IUCD
History:
- Hi. I know you are here to see me because you are
concerned about your period. When was your LMP?
Was it normal or light? Do you have regular cycles?
How long is the cycle? How long is the bleeding time?
Any spotting in between? Do you have excessive pain
or bleeding during the period? When did doctor insert
the contraceptive device? Did your period change
after the insertion? When was the last time you
checked strings or thread?
- Pregnancy questions: Do you feel nausea, vomiting,

14

breast tenderness? Increase urinary frequency? Any

abdominal pain? Have you notice usually vaginal
discharge? Did you do pregnancy test? Have you ever
been pregnant? Are you in a stable relationship? Have
you ever been diagnosed with STD or PID? When
was your last PAP smear? Do you know your blood
group?
Are you generally healthy? Any pelvic Surgery, Csection done before? Medication? Allergies? What
would be your intention if you are pregnant?

Physical Examination:
- General Appearance
- Vital Signs
- Palpate abdomen: Distension, Tenderness, Masses

Pelvic examination:
o Inspection
o Speculum: Appearance of cervix, OS, The
presence of the string
o Check vaginal discharge
o Check if thread is present!
o Per Vagina: Size of the uterus (7weeks)
Consistency (soft) Adnexal masses and
tenderness.
Urine dip stick and Urine pregnancy test (+)

Diagnosis and Management

- Jacky your pregnancy test is positive. And I can see a
string which means contraceptive device is in place.
How do you feel about it?
- Unfortunately every contraceptive method has a
failure rate. Effectiveness of IUCD is greater than 98%
but theres still a chance for being ineffective. You
dont need to make a decision now. You can go home
and discuss it with your partner. I will organize a pelvic
ultrasound for you to identify the exact position of
pregnancy and position of the device. If you decide to
continue with pregnancy the device should be
removed.
- Is it safe? The procedure doesnt increase the
miscarriage rate above that in population. (Every
pregnancy carries 15-20% risk of miscarriage.)
However if it is left inside it will increase the risk of
miscarriage to up to 25% and increase risk of
ascending infection. If you decide not to continue with
the pregnancy, I will refer you to a specialist for
termination and the device will be removed during the
procedure.
Case 2: NO thread
- Jacky, your pregnancy is positive and I cant see
strings of device. Two options are possible. Either
uterus expels the device (because device is a foreign
body) or string loss and you are pregnant with device
still in place. To find out I need to organize pelvic
ultrasound. How do you feel about pregnancy?
- What if device is still inside? We wouldnt be able to
remove it if it still has strings but an attempt to remove
it will be made. But without strings its impossible to
remove the device safely without harming pregnancy.
However pregnancy can be continued but theres high
risk of miscarriage and ascending infection. If
pregnancy will be successful device will be delivered
with the placenta and membrane. If you decide not to
continue with pregnancy I will refer you to a specialist
for termination.
Hyperemesis Gravidarum

Case: 38 year-old woman who came in with a 2-week history of

nausea and vomiting. She is 8 weeks pregnant and her
pregnancy is consistent with GA. She has no previous illness.
Task
a.
b.
c.

History
Investigations (1 only) -- MSU
Diagnosis and management

Differential diagnosis:
- Multifetal pregnancy?
- Hydatidiform mole (complete/incomplete)
- UTI
- Infectious Gastroenteritis
- Brain tumor/Addison disease

History:
- IS MY PATIENT HEMODYNAMICALLY STABLE?
- Congratulations on your pregnancy.
- How many episodes of vomiting did you have per
day? Is it getting worse? Is it in the morning or
throughout the day? What is the content? Do you
have fever? Diarrhea? How is your appetite? Are you
still drinking eating or drinking? How is your
waterworks? Any pain or burning sensation? Any
increased frequency? Any change in color of urine?
Any loin pain? Did you eat outside?
- Pregnancy: is this a planned pregnancy? How did you
confirm your pregnancy? Any family history of twins?
Is the pregnancy natural or assisted? Any abdominal
cramps or vaginal bleeding?
- Periods? Pills? Partner? Pap smear? Blood group?
- SADMA?
Examination:
- General appearance: tired, signs of dehydration
(tongue, skin turgor, CRT?
- VS: BP (check for orthostatic hypotension); PR
(tachy), RR, T normal
- Chest, heart, abdomen normal
- No pelvic exam needed.
- Urine dipstick nitrites, ketones (+), leukocytes
o MSU: (+) for ketones! admit!!!
Investigations:
- MCU
- Ultrasound examination
- Test for electrolytes, urea, LFTs
Diagnosis and management:
- You have a condition called hyperemesis gravidarum.
It means excessive nausea and vomiting in
pregnancy. These are common symptoms during
initial pregnancy. However, 1 in 1000 women will have
excessive vomiting and require hospitalization.
- On examination, you are dehydrated and this was
confirmed in urine analysis, so we need to admit you. I
will organize an ambulance. In the hospital they will
secure 2 IV cannulas, take the blood for FBE, U/E/,
RFTs and LFTs because dehydration can affect the
liver and kidney. We need to do MCS to rule out UTI
and USD to confirm intrauterine pregnancy, rule out
multiple pregnancy and molar pregnancy.
- They will also give medications to stop the vomiting
(metoclopramide mexalon, stemetil) and start IV
fluids and vitamin B6 (pyridoxine).
- We dont know the exact mechanism behind it.
However, it is usually due increased level of b-hCG

15

which is one of the pregnancy hormones. Once the

body has become used to the new environment, the
nausea and vomiting settles and this usually happens
by 14 weeks.
You are a 38-year-old mother and that puts you at a
very high risk of having a baby with Down syndrome.
So I would like to offer you screening for Down
syndrome (during your 10th week blood plus USD).

Critical Errors:
- Failure to recognize need for hospitalization
- Failure to do ultrasound and urine examination
Generalized Edema in Pregnancy
Case: A 35-years-old primigravida who is 32-weeks-GA is in
your clinic complaining of increased swelling in the body for the
last few days.

Management
From history and examination, most likely you have a
condition called generalized edema of pregnancy. It
typically involves the lower extremities but
occasionally it can cause swelling of the face and
hands. There are a few reasons such as hormoneinduced sodium retention, increase of blood volume
by 50% during pregnancy, and enlarged uterus may
compress the veins (IVC) when youre lying down
obstructing blood flow and causing the edema.

Task
a.

b.

c.

History (both legs and face; decreased when lying and

on left lateral position; no headache, visual problems,
tummy ache, had regular antenatal checkups, one
pregnancy, normal placenta, folic acid, sweet drink
test normal, no contraceptive, 1st pregnancy, last pap
smear was one year ago and normal, no general
medical health condition, no HTN; social support is ok
and no financial issues; no problem with waterworks
or BM? No fever?
Physical examination (generally well, mild generalized
pitting edema of the especially both legs, BMI is 27,
PR 80, T37.6, BP 120/80, RR: 12, neck for thyroid
swelling, no LAD, FH 32cm, lie longitudinal, cephalic,
FHR 120, pitting edema, urine dipstick proteinuria
negative, BSL normal)
Diagnosis and management

Pregnancy/planned pregnancy
Antenatal checkup/infections/medications
18 weeks ULD placental, baby, anomalies, liquor
volume, fibroid
Sweet drink test
Hemoglobin
Pre-eclampsia
Heart disease, HTN, DM, heart (CCF), liver, kidney,
severe hypothyroidism
History
-

Is this a planned pregnancy? Congratulations? Is this

your first pregnancy? Where exactly is the edema
(swelling)? Did it come suddenly or gradually? Any
pain in your legs? Anything increasing or decreasing
it? How is your pregnancy going so far? Have you had
regular antenatal checkups? Any infections? What
was the result of your midgestation USD (baby,
placenta, anomalies, liquor volume, fibroids)? What
was the result of your sweet drink test? What about
your BP? Have you checked it recently?
Hows your general health? did you have history of
high blood pressure or diabetes? Do you have any
recent headaches, visual disturbance, tummy pain,
SOB, chest pain, or racing of heart? Do you have
problems with your waterworks or bowel motions? Is
your baby kicking? Do you have a kick chart? Any
history of heart problem, liver, kidney or thyroid
problems? Any previous DVT, surgeries or previous
hospitalization? Are you on medications such as
steroids? SADMA? FHx of DM or HTN?

Physical examination
General appearance: pallor, dehydration, jaundice

Vital signs
Cardiovascular examination and JVP
Lungs
Abdomen: FH, lie, presentation, FHT, tenderness
Neurological examination: Reflex
Peripheries: redness, warmth, tenderness in any
areas
Urine dipstick and BSL

It can be reduced by intermittently lying on the left

side, elevating the lower extremities intermittently,
wearing elastic compression stockings, and
decreased salt intake in diet. It usually resolves after
birth of the baby as the uterus returns to prepregnancy size and the hormones return to normal.
At this stage there is no need for investigations but if
there are changes in your symptoms or if patient is
concerned: Do investigations FBE for Hb, infection,
platelet, U&E, LFTs, TFTs, RFTs,
Red flags: headache, blurring of vision, tummy pain,
increased blood pressure, feeling unwell, baby not
kicking
Reading materials. Review.

Stillbirth
Case: You are a GP and a 26-year-old lady comes to you 6
weeks after the delivery of a baby. The delivery was a stillbirth at
around 22 weeks of gestation. The patient is still very upset
about her babys death and she wants to know if this will happen
again.
Task
a.

a.
b.

Take history (had fever x 3-4 days continuously at 20

weeks, and started bleeding/discharge from down
below; ruptured BOW; did tests and baby was already
dead; )
Physical examination
Counsel accordingly

Approach to Patient Who has had Stillbirth

Emotional support must be ensured by offering
appropriate resources or referral
Take detailed history focusing on obstetric, medical
and family history and conditions surrounding previous
stillbirth
Discuss anomaly screening with patient
Discuss uterine artery Doppler studies at around 2224 week
Discuss dating USD in 1st trimester
Discuss lifestyle advice (smoking, alcohol, weight loss,
diet)
Discuss Serial USD for fetal growth monitoring (28
weeks onward)
Discuss fetal movement surveillance
Consider timing of birth
History
-

I am really sorry about the loss of your child. It is quite

understandable that you feel upset about this. Would

16

you like someone (a partner or a friend) to attend this

discussion? How are you feeling at the moment?
I understand that you pregnancy was at around 22
weeks, did you have regular checkups until that time?
Did you have blood tests, and USD? What was the
result? Can you please tell me what exactly
happened? Did you have any symptoms like fever,
rash, vaginal discharge, bleeding? Any problems like
headache, visual changes, or high blood pressure
during the pregnancy? Any tummy pain? Were you
feeling the babys movement at that time? What
happened afterwards? Where did the delivery occur?
Did the pain start by itself or was it induced? When the
baby was born, did they notice any abnormal
features? Did they do an autopsy of the child? Was it
your first pregnancy? Did you ever suffer from a

gynecological problem before that? Did you have any

gynecological surgeries done? Any D&C done? Have
you had regular pap smears? When was the last one?
What was the result? Are you having bleeding now
after the delivery? SADMA? Blood group? Gardasil?
Any FHx of birth defects or stillborn babies?

Intrauterine Fetal Death (IUFD)

Case: You are an HMO in the ED and a 34-weeks pregnant lady
comes in with abdominal pain.
Task
a.

Physical examination
General appearance and BMI
Vital signs
Thyroid enlargement
Chest and heart
Abdomen: size of uterus (involuted), tenderness,
organomegaly
Pelvic exam: discharge, bleeding, speculum
Urine dipstick and BSL
Causes of Stillbirth
Unknown
Infections (TORCH)
Cervical incompetence
Fetal growth restriction (IUGR)
PIH
Placental insufficiency
Thrombophilia defects in mother
FHx
Abruptio placenta
Chronic diseases in mom
Counseling
Most probably, from the history and examination, the
most likely cause of the stillbirth that you had was an
infection that you developed at around 22 weeks.
There are other causes as well like problems with
placenta, poor growth of the baby, and certain
coagulation defects. It is important to find out the
exact cause before your next pregnancy. However,
sometimes, there is no cause that can be found. We
need to do some tests now after consultation with the
specialist gynecologist which includes FBE, cervical
smear and culture to rule out hidden infections, ANA
testing, VDRL, FBS to rule out diabetes, thrombophilia
screening, and USD to rule out any structural defects
of the uterus. Later on, the specialist might decide to
do a hysterogram. This is an xray of the womb that
helps to find out any defects of the shape of the uterus
as well as any growths within the uterus. For your next
pregnancy, we will manage you in the high risk
pregnancy clinic. You will have an early dating
ultrasound at around 8-10 weeks. From then on, you
will have serial ultrasound after every 2 weeks to
monitor the babys growth. They will discuss with you
regarding screening for Down syndrome and neural

tube defects. Your pregnancy will be monitored very

closely and around 12-14 weeks, the OB will assess
you for possible cervical incompetence. We will make
sure that there is nothing that puts your next
pregnancy at risk. However, you need to make certain
lifestyle changes like maintaining your weight within
normal limits, quit smoking, stop drinking, avoiding
recreational drugs, healthy diet, and exercise.
The delivery will be in a controlled environment at
around 38 weeks in the presence of a specialist
obstetrician where we will prepare for the possibility of
emergency CS.
The specialist/midwife will educate you regarding kick
charting for fetal movement and you need to inform us
if you develop any symptoms like fever, vaginal
discharge, bleeding, rash, or reduced fetal movement.

b.

c.

History (dull, 2/10, similar to menstrual pain, started 2

days ago, no N/V, relieved by paracetamol, no fever,
no burning sensation, first pregnancy, blood group A+,
normal pap smear)
Physical examination (anxious, normal BP and HR,
FHR is absent with handheld doppler, no discharge,
water leakage, bleeding, urine dipstick negative, BSL
5.5 mmol/L)
Management

Differential Diagnosis
- Placental abruption
- Preterm labor
- Pre-eclampsia
- Urinary tract infection
- Red degeneration of fibroid
- Appendicitis
History
-

I understand you have come to the hospital because

you have abdominal pain. When did it start? Can you
describe the pain? Does it come and go? Does the
pain travel anywhere? Can you recall any precipitating
factor such as trauma, exercise or sexual intercourse?
Do you have a fever, headache or blurred vision? Do
you have N/V or back pain? Any burning sensation
when passing urine? Have you noticed unusual
vaginal discharge? Have you had any vaginal
bleeding or water leakage? Do you feel the babys
movements? When was the last time you felt the baby
kick? Is this your first pregnancy? Have you had
regular ANCU? Any problems with your blood tests,
midpregnancy USD, sweet drink test or blood
pressure? Do you know your blood group? SADMA?
Did anyone come with you today?

Physical Examination
- General appearance and edema
- Vital signs
- Abdomen: uterus, fundal height, lie, presentation,
engagement, palpate uterus if tender or hard/tense,
FHT
- Pelvic examination: discharge, bleeding, water
leakage, cervical os, swabs (endocervical and high
vaginal)
- Urine dipstick and BSL

17

Management
- Im sorry to tell you but I cant hear the babys heart.
Most likely, your baby has died. I can see youre very
distressed, do you know what we can do for you now
or do you need some time?
- First of all, we need to confirm this with an USD. We
will also look for signs of placental abruption which is
one of the possible causes for your presentation.
- Why did it happen? We will try to find a cause.
However, in majority of cases the death is
unexplained. For now, I want to order some blood
tests for you. FBE, HbA1c, urine MCS, swabs, LFTs,
U&E, TORCH infection screening, TFTs, ANA and
lupus anticoagulant

Counseling
- Im not sure how this news will sound to you but the
report says it is a twin pregnancy. Dont worry. We will
take care of you. We will do a multi-disciplinary team
approach which involves me as your GP, a specialist
obstetrician, and pediatrician for your babies.
- History: how is your pregnancy going so far? Any
abdominal pain, bleeding, or discharge? Any
excessive N/V? any headache, blurring vision, burning
in urine or leg swelling? Do you know what your blood
group is? Did you take folic acid during the early
pregnancy? Is it an assisted or natural pregnancy?
Any PMHx? Any FHx of twins, DM, or hypertension?
SADMA?
- We have two kinds of twins: dizygotic coming from 2
eggs and monozygotic which comes from one egg. In
your case, it is a dizygotic pregnancy with 2 sacs and
placenta. Twin pregnancies run in families or might be

Medical problems are unlikely at least in the first 3

weeks after fetal death has been diagnosed and
usually, labor will start during this time. You may
choose to await spontaneous labor or to have labor
induced. Either way you can have a family member or
friend during the delivery and we will give you
adequate painkillers to reduce the pain of childbirth. If
you choose to await spontaneous onset of labor, you
will need frequent blood checks. If labor wouldnt start
within 3 weeks, you will need to have labor induction.
If your choice is immediate treatment, we can prepare
the cervix by using prostaglandin. If you or your
partner wish to bring clothes, see or hold the baby, it is
possible. We strongly recommend an autopsy which
helps us to find a cause in up to 25% of cases. If
youre against autopsy, we can take a small sample of
skin usually in the (axilla region) for chromosomal
study. Placenta will also be examined under the
microscopy and routine cord blood test.
To suppress lactation after delivery, you need to wear
tight bra and use simple painkillers and ice packs in
case of engorgement.
We have a bereavement consultant and a social
worker who can help you with funeral arrangements.
Technically, you can get pregnant when your periods
are back. However, it is important to be physically and
emotionally ready for the future pregnancy.

MULTIFETAL PREGNANCY
-

Multifetal Gestation/Pregnancy

due to fertility medications. Is it risky? Yes. A twin

pregnancy is usually slightly high risk than the normal
pregnancy. There are risks to both mom and the
babies. The maternal complications are exaggeration
of signs and symptoms of pregnancy, preeclampsia,
premature labor, gestational DM, malpresentation,
antepartum hemorrhage, increased incidence of CS.
Fetal complications include PTL, IUGR, twin-twin
transfusion (more in monozygotic), malformations.
Do not worry. You are in safe hands. We will do our
best to manage you and prevent the complications. I
will refer you to the high risk clinic. The specialist there
will follow you up. You will need more frequent visits
(every 2 weeks until 28th week, weekly until delivery).
You may need multiple ultrasounds starting from 28
weeks (every 2-3 weeks). Babies will be monitored by
CTG from 34 weeks (2x a week). Aim to deliver the
babies at 38 weeks.
Increased supplements (iron/folic acid), nutrition
requirements and rest
Can I go for vaginal delivery? It is very early to
comment at this stage, but it will depend on the
presentation of the first baby and your general health.
If the first baby is cephalic, vaginal delivery is
possible. 70% (cephalic). If there are any
complications, then specialist might consider doing
cesarean section.
We will also do active management of first stage of
labor because of high chance of postpartum
hemorrhage due to overdistention of uterus.
Referral/Review/Reading materials (support groups)
Red flags: bleeding, abdominal pain, water leakage,
headache, blurry vision, urinary symptoms

Case: A 28-year-old primi who is 18 weeks pregnant comes to

your GP clinic to collect her ultrasound report that shows twin
pregnancy with 2 placentas and 2 amniotic sacs.

ANTEPARTUM HEMORRHAGE

Task

Placenta Previa
a.
b.
c.

Tell patient about diagnosis and findings

Focused history
Advise on management

Complications
- Maternal: anemia, symptoms of pregnancy (morning
sickness, varicose veins), preeclampsia x3,
antepartum and postpartum hemorrhage,
malpresentation, cord prolapse, CS
- Fetal: increased risk abnormalities, preterm delivery
(PPROM), IUGR in one of the fetus, twin-twin
transfusion, perinatal mortality x 5; prematurity,
malformations x 2-4

Case: You are an HMO in a hospital OBs-and-Gyne unit and

your next patient is a 26-year-old 28 weeks pregnant who came
in due to PV bleeding for 1 hour. She has been following up
regularly and there were no remarkable findings up to now.
Task
a.
b.
c.
d.

Relevant history (x 1 hour)

Physical examination (pale and stressed, BP:
Investigation
Management

Risk Factors
Smoking

18
History
-

Previous placenta previa

Previous cesarean section
Multiparity
Advanced maternal age

o
o

Is my patient hemodynamically stable?

When did the bleeding start? How many pads have
you used? How soaked were they? Any clots? Any
tummy pain? Headache? Dizziness? Sweating?
Palpitations (assess severity of bleeding)? History of
trauma? Any bleeding disorders (menstrual history/are
you bleeding from anywhere else)?
Pregnancy: how is your pregnancy going so far? Is it a
single pregnancy? Planned pregnancy? Significant
findings in 18 week ultrasound? How was your sweet
drink test? Is the baby kicking? Previous pregnancy?
How was placenta in previous pregnancy?
Pills? Partner?

Period: are they too heavy or normal? Pap? Are you

aware of your blood group?
Social history: how far are you staying from the
hospital and do you have enough support?
SADMA?

Physical examination
General appearance: pallor, dehydration and jaundice,
signs of trauma
Vitals: sitting and standing BP, RR, PR, T, oxygen
saturation
o If with postural hypotension: I would like to
insert 2 IV bore cannulas, take blood for
blood group and crossmatching and start IV
fluids
Abdomen: FH (whether it corresponds to gestational
age), lie, presentation, tenderness of uterus,
engagement/floating, FHR
Pelvic exam: NO Per Vagina Exam!!!
o Inspection: discharge, blood, clot, signs of
trauma
o Speculum: discharge, blood, cervical os (if
open or close);
Urine dipstick and BSL
Placenta Previa:
Total placenta previa (completely obstructs the
cervical os)
Partial Placenta previa (partially obstructing the
cervical os)
Marginal (just at the beginning of the os)
Low-lying placenta
Diagnosis and Management
Most likely, you have placenta previa. At this stage, I
would admit you, put 2 IV lines and take blood for
FBE, blood grouping and crossmatching, and
coagulation profile. I will call the OBS&Gyne Registrar
to come and have a look at you
We need to organize an urgent USG to see the
position of the placenta and the obs and gyne registrar
might also consider doing CTG to check the status of
baby.
Placenta previa is an obstetric complication that
occurs in the 2nd half of pregnancy. It can cause
serious complications in both mom and baby.
Complications are fetal malpresentation, postpartum
hemorrhage, rebleeding, IUGR, isoimmunization
Reassure
Further management:

Total or partial: send to tertiary hospital and

stay until delivery; most cases delivered via
CS
Marginal or low-lying and with minor
bleeding and bleeding has stopped: go
home but needs to stay close to hospital;
USG at 34 weeks; delivery: depends on
USG at 34 weeks and specialist will decide
on that; CS organized at 38 to 39 weeks

If with severe bleeding and with fetal

compromise immediate cesarean section
Refer, Review and Reading materials
Red flags: bleeding, baby not kicking, water breaks,
tummy pain
o

Mild Abruptio Placenta

Case: You are an HMO in ED and a young primigravida who is
30 weeks gestational age comes to see you because of vaginal
bleeding on examination, she is stable and vitals are normal.
Abdomen is not tense but slightly tender. FHT 140/min
Task
a.
b.
c.

Focused history
Explain condition to patient
Management

Features
Separation of the placenta from the uterus
Revealed: bleeding
Concealed: severe hypotension
Complications: IUFD, DIC (micro thrombi)
Types:
o Mild - blood loss <500ml; no fetal
compromise; USG to exclude retroplacental
clots; CTG; -- bed rest; ambulate slowly
once bleeding stops; if term then might do
labor induction by amniotomy
o Moderate - about 1/4 of placenta has been
detached; blood loss >1L; severe abdominal
tenderness; shock; fetal compromise;
Admission and stabilize patient; if fetus alive
then cesarean section
o Severe - more than 1500ml of blood, shock,
severe tenderness, fetus is almost always
dead; DIC and coagulopathies are common
Risk factors
o Multiparty
o Hypertension in pregnancy
o Smoking
o Cocaine abuse
o Trauma
Differential diagnosis
Placental abruptio
Premature labor
Red degeneration of fibroids
Trauma
Placenta Previa
History
-

Is my baby okay? I understand that you are stressed.

Before I answer your questions, I would like to ask you
a few details regarding your pregnancy. Are you still

19
bleeding? When did it start? What were you doing
when it started? How much is the blood loss? How
many pads did you use? Was it fully soaked? Did you
pass any clots? What was the color? Any gush of
water coming out with the blood? Any tummy pain? Do
you feel dizzy or palpitations? Do you have any
bleeding disorders in you or the family?
How's the pregnancy so far? Are you regular with your
antenatal checkups? Do you remember your midgestation USG? How was your sweet drink test?
Anything abnormal? Is your baby kicking? Is it
reduced? Do you know blood group? Any previous
pregnancies? Are you regular with your pap smears?
Smoker? Illicit drugs?

your case. It is a dangerous condition and can

seriously affect you and your baby.
I know you are feeling unwell. Your BP is low and your
pulse is fast. They are signs of hemorrhagic shock
due to blood loss. Most likely you lost at least 30% of
your blood volume and you are still bleeding. It is an
indication for blood transfusion to increase you and
your babys chance for survival. No doctor I still dont
want to be transfused.
Miriam, it is your right to refuse the treatment.
However, it is important for me to explain the possible
outcomes so that you can make an informed decision.
Right now, we are doing important preparation for
emergency cesarean section. Bleeding will stop after
we empty the uterus. However, the operation itself is
associated with blood loss (500ml) and may worsen
your condition if blood transfusion is not started. We
can replace fluids and use synthetic blood substitutes
(Haemaccel). They will reduce shock. However, if
blood loss exceeds 40% of blood volume, the biggest
problem is hypoxia or oxygen deprivation, which may
quickly lead to multiorgan failure/shutdown and death.

Diagnosis and management:

-

You have a condition called a mild placental abruption.

Draw diagram. I will need to organize some
investigations to confirm the diagnosis and make sure
the baby is alright. I will request for an USG to check
the degree of abruptio and request for CTG, full blood
examination, UEC, crossmatching, coagulation profile,
indirect coomb test and kleihauer test.
Is this hospital a tertiary hospital? I would like to admit
you. At this stage the bleeding has stopped but the
condition is risky. I will call the OB registrar to come
and have a look. Meanwhile I will secure IV lines and
collect blood for investigations. Because you are RHwe will give you anti-D injection. We will consider
injection of Betamethasone 2 injections 12 hours apart
to help with the maturity of your baby's lung.
What about the delivery? At this stage, we cannot say.
You are stable now. We have to wait for the results of
the ultrasound and CTG. However, if your baby
becomes distressed or the bleeding recurs, the
specialist might decide to do an emergency cesarean
section.
Reassure.
If in pain, IV pethidine.

Blood Transfusion Consent in APH

Book case 123:
Task
a.
b.
c.

Ascertain patients view on blood transfusion

Explain risks and benefits of treatment to patient and
baby
After six minutes, answer examiners question

Counseling
- Hello Miriam, I want to explain your condition and
possible ways of management. You are having
severe bleeding, and we call it antepartum
hemorrhage. An emergency USD confirms placental
previa. Placenta previa means the placenta is lying in
the way of the baby. This condition is a common
cause of bleeding in pregnancy. Thirty percent of all
APH is because of placenta previa. It usually presents
with causeless, painless and recurrent bleeding.
Sometimes, it can present with severe bleeding like in

Blood loss may also affect your babys condition in the

same way. Less blood will come to the baby and he
will experience hypoxia.
You are losing RBCs which have a very special
function to carry oxygen to all organs and tissues in
your body. The only way to restore that is by blood
transfusion.
No doctor I still dont want to be transfused. Miriam, I
understand and respect your wish. Can you please tell
me if you fully understand all possible consequences
which may arise without blood transfusion?
We will do our best to save you and your babys life
without blood transfusion.

Examiner: Summarize legal and ethical issue in this situation

- Every competent patient has the right to accept/refuse
treatment.
- In this case, there is the potential to damage the fetus.
In Australia, the fetus has no rights.
- Born babies can be transfused without parental
consent providing it is a life-saving procedure.
How would you manage this situation?
- I will continue monitoring mother and babys condition
until emergency cesarean section has been arranged.
- I need to continue fluid transfusion.
- I need to talk to senior doctor to help me.
- If husband is available, then can talk to husband.
Pregnancy with Road Traffic Accident
Case: You are an HMO in ED and a 23-year-old female comes
to you complaining of tummy pain. She is 32 weeks pregnant
and was in a car accident.
Task
b.
c.
d.
History
-

History
Physical examination (B-, stable VS pallor,
generalized tenderness, FH=GA, cephalic, FHS +, no
bleeding, or contractions)
Management
Is my patient hemodynamically stable?

20
-

I would like to talk to my patient preferably in a

resuscitation cubicle with all the necessary
resuscitation equipment.
How are you feeling at the moment? Let me reassure
you that you are in safe hands. If you want, I can call
someone to be with you.
I understand you have tummy pain? Where is it? How
bad is it? What is the type of pain? Does it come and
go or is it constant? Does it go anywhere else (back or
towards genitalia to r/o pelvic organ damage)? Do
you think it is getting worse?
Can I ask more about the accident? When did it
happen? How? Who was driving? Were you in the
passenger seat/backseat? How fast was it going?
Were you wearing seatbelt? Do you have bleeding, or
discharge from down below? Do you have headache,
N/V? Did you hurt your head? Is there a wound
anywhere on your body? Did you lose consciousness
at any time? Do you feel the baby kicking?
Previous obstetric history? What is your blood group?
Partners blood group? Did you receive any injection
of anti-D during pregnancy? Any past history of
bleeding disorders, clotting problems, illnesses?
SADMA?

Concealed Placental Abruption

Case: You are an HMO and a 25-year-old female who is 32
weeks pregnant came in due to sudden onset of severe
abdominal pain.
Task
a.

b.

c.

Physical Examination
Full primary survey of the patient
Ensure her airway, breathing, circulation are not
compromised
Inspect for any visible signs of trauma all over the
body? Bruises? Pallor? Dehydration?
Vital signs especially BP
Secondary survey looking for signs of trauma to the
bones, joints, vessels (pulses)
Abdomen: palpate any tenderness, guarding, rebound
and signs of ecchymosis, large bruise over lower
tummy, fundal height, lie, presentation, FHS, uterine
contractions
Pelvic exam: visible bleeding, discharge, signs of
trauma, nitrazine test (if pH >5 normal; >5-7 amniotic
fluid)
B/E preferable done by obstetrician at tertiary care
Urine dipstick and BSL
Heart and chest
Management
I would like to ask for review by specialist obstetrician
and I will arrange for blood tests such as FBE, U&E,
BSL, crossmatching, D-dimer, coagulation profile,
ABG, Kleihauer test to determine amount of
fetomaternal hemorrhage to decide the amount of
antiD, ECG and xray of pelvic girdle.
Risk of fetal deformities are minimized during the third
trimester and usual radiation exposure is very low
o Typical pelvic xray 0.10 mGyron
o CT scan 20-50 mGyron
o Proven risk - >50-100 mGyron
I would also like to do USD to assess for fetal viability,
size, gestational age, and position of baby, and any
evidence of intraperitoneal fluid or hemorrhage. Also, I
would like to hook you to continuous CTG for 24 hours
to look for any signs of fetal distress.
o Indications for CTG: bleeding, previous CTG
is abnormal, trauma
Most likely, the obstetrician will advise anti-D IM
dosage after the results of the Kleihauer test.
Criteria for admission
o FHR on CTG shows variable decelerations

Serious trauma after second trimester where

the patient requires fetal monitoring for 24
hours or more
o Abnormal obstetric findings like vaginal
bleeding
Keep admitted until all possible complications have
been ruled out such as fetal death, premature ROM
leading to PTL, abruptio placenta (can be delayed for
up to 48 hours), amniotic fluid embolism, and
chorioamnionitis
o

History (pain is 7/10, sharp pain, started 45 minutes

ago, bending over decreases the pain, baby kicking;
waterworks normal, ANC, USD, and sweet test
normal)
Physical examination (pale, anxious, sweating,
increased HR, normal BP, RR, O2, Temperature, FH
appropriate for age, tender all over, mainly around
umbilicus, guarding +, cephalic, FHS+; pelvic no
bleeding or discharge; os closed)
Diagnosis and management

Differential Diagnosis
Placental abruption
Placenta Previa
Acute red degeneration of fibroid
Preterm labor
Appendicitis
Bowel obstruction
Torsion
History
-

Is my patient hemodynamically stable? I would like to

take a history and I would like to ask for IV access.
Can you please tell me more about the pain? When
did it start? How bad is it on a scale of 1-10? Can you
point out where exactly is the pain? Does it go
anywhere else like towards the flanks or downwards
toward the pubic area? Did you hurt yourself in that
area? Do you think this pain is associated with
N/V/headache/dizziness? Any bleeding from down
below? Vaginal discharge? Leaking of water? Do you
think the pain is continuous or does it come and go?
Do you think this pain was related to sexual activity
(placenta previa)? Do you have any associated
problems with waterworks? Any history of constipation
or bowel-related problems? Is this your first
pregnancy? Any miscarriages before? Have you had
regular antenatal visits? Are you aware of the results
of your last USD? What was the position of the baby?
Placenta? Can you feel the baby kicking? How often
during the last 1 hour? How is you general health?
Any medical or surgical condition? Is this the first
episode of pain? Do you have any fever along with the
pain? What is your blood group? What is your
husbands blood group? Have you received any anti-D
injections up to now?
FHx of HPN, DM, bleeding disorders

Physical examination
General appearance
Vital signs: postural BP drop

21
-

Abdomen: FH, lie/presentation, FHR, tenderness on

palpation, guarding, rigidity, tenderness especially
over the RIF/LIF?
Pelvic: inspect for signs of bleeding, discharge,
leaking; insert sterile speculum for bleeding,
discharge, pooling of fluid, nitrazine test; os if it is
open or closed
Bimanual examination is preferably avoided until an
ultrasound has been obtained

Investigations
FBE, blood grouping, crossmatching and hold. I would
like to do a CTG to assess fetal distress, coagulation
profile, LFTs, RFTs. If she is RH (-) I would like to do
kleihauer test to check fetomaternal hemorrhage.
Also, I would organize an USD to check for fetal
viability, position of placenta, and if there is any
abruption of the placenta and amount of blood.
Management
Unfortunately, what you have is a serious condition
called placental abruption. Basically, a part of the
placenta starts detaching from the wall of the womb
for some reason. The exact cause is not known.
However, there are certain risk factors like trauma,
smoking, high blood pressure in the mom, diabetes,
previous history of placental abruption, high parity,
poor nutrition, and sometimes, it is unexplained.
This condition can be quite serious as there is a high
risk of PROM, PTL, fetal distress, maternal shock,
acute renal failure and sometimes, IUFD.

I need to admit and you need to be urgently seen by a

specialist obstetrician. We will start you on IV fluid and
monitor your urine output with the help of catheter. We
will send blood for crossmatching. If required, we
might need to transfuse you. We need to prepare for
possible premature delivery. I will inform the theater to
prepare for emergency cesarean section. We will give
you steroids to help with the maturation of babys
lungs.
Usually, with moderate to large placental abruption,
there is a need to deliver the baby ASAP. We will also
give you anti-D injections to prevent any
incompatibility of blood groups.
If the baby is non-viable, if you are stable, we will
induce and deliver the baby. But if not, emergency
cesarean section is performed.

(derealization)? Do you feel the baby kicking? Have

you noticed any leaking from down below? Any
swelling of your ankles? Have you had all regular
antenatal checkups? USD? Blood tests? Sweet test?
Are you generally healthy? Any medical or surgical
condition? Before this pregnancy, have you ever been
diagnosed with high blood pressure, kidney problems,
DM or any other conditions? FHx of similar condition?
SADMA? Blood group!
Physical Examination
General appearance
Vital signs
Evidence of pedal edema (pitting or non-pitting)
Funduscopy for bulging of the disc
Chest and heart
Abdomen (FH, lie/presentation, FHT, tenderness)
Reflexes
Urine dipstick and BSL
Management
I would like to put the patient on the left lateral position
and call for help. Check the airway. If there are
secretions wipe with clean cloth or suction. Put airway.
Give oxygen by mask if possible. IV access. I would
like to start her on magnesium IV LD 4gms over 15
minutes diluted with NSS and continue with 1 gram
divided over 24 hours. IV hydralazine (5-10mg bolus
given over 5-10 minutes then an infusion of 5mg/hr is

HYPERTENSIVE DISORDERS OF PREGNANCY

Pregnancy-Induced Hypertension/Pre-eclampsia

Case: You are a GP and a 30-weeks-pregnant primigravida

comes to your clinic. She is complaining of headache. Her BP
today is 170/110mmHg. It was the same on a previous
occasion.

Task
a.
b.
History
-

Relevant History
Manage the case
Is my patient hemodynamically stable? I would like to
know all the vital signs.
I would like to give the patient methyldopa now.
If she develops fits while talking rectal diazepam 5-10
mg
I would like to ask some history from the patient.
Please tell me if youre having symptoms like
headache, BOV, tummy pain, or bleeding from down
below? Any abnormal feelings that you have

maintained. Aim is to keep the BP between 140/90

and 160/100; add beta-blocker if with tachycardia)
after the patient has been seen by the specialist.
At GP clinic methyldopa or nifedipine spray to
lower BP
I would inform the obstetric team to organize for
immediate delivery.
I would like to monitor the patient by monitoring her:
urine output, continuous ECG, reflexes, vital signs.
Investigation: FBE, U&E, LFTs, coagulation profile,
blood grouping and crossmatching, USD, CTG,
thrombophilia screening
Aim of treatment: prevent development of fits
Aim of treatment if with fits: deliver the baby
I would like to call in obstetrician. If the pregnancy is
less than 34 weeks, we will give the patient steroids
Betamethasone (Celestone) 11.4mg IM 2 dose 12
hours apart, stabilize patient, and monitor all
symptoms. The patient remains at the hospital for
observation. If symptoms worsen, we deliver by CS.
If pregnancy is more than 34 completed weeks,
deliver by induction or cesarean section.
If platelets are going low give FFP
If patient develops symptoms of pulmonary edema
give high-flow oxygen and diuretics.
Complications: ARF, cardiac failure, cerebral
hemorrhages, DIC, IUD, HELLP syndrome,

Counseling of mom
What your daughter has had just now is a fit as a
consequence of a very high blood pressure. This
condition is known as PIH. This can happen because
of certain chemicals that are released by the placenta
that cause constriction of blood vessels and formation
of clots because of reduced supply to the brain
resulting to the fit. It is very important to control the
symptoms to prevent complications like liver failure,
heart failure, and kidney failure. That is why we are
sending her to the hospital right away. She will be
seen by a specialist OB. They will lower her BP with
medications, but the cure is to deliver the baby.

22
a.
b.
c.

CARDIOVASCULAR, RESPIRATORY, HEMATOLOGIC,

NEUROLOGIC, GASTROINTESTINAL CONDITIONS IN
PREGNANCY
Abdominal pain (Early Pregnancy) Uncomplicated Cystitis

History
-

Case: You are an HMO in the ED and your next patient is a 12week GA pregnant lady complaining of nausea and vomiting.
This is her first pregnancy. No complications so far.

Task

a.
b.

c.
History
-

History (N/V with dull, nonspecific lower abdominal

pain x 2 days; malaise; tolerate meals)
Physical examination (T:37.6, BP: 115/80; soft, tender
in lower abdomen but not peritonitic signs; os is blue,
closed, no secretions or bleeding; free adnexas;
fundus expected high according to gestational age;
nitrites ++++, leukocytes +++, no blood, protein and
sugar)
Diagnosis and Management
Was it a planned pregnancy? Congratulations. When
did it start? Are you able to tolerate meals? Do you
feel tired? Do you have abdominal pain? What type of
pain? Any discharges or bleeding? Fever? Pregnancy
checks? Did you have any tests done? Are you taking
folic acid? Did they mention your blood group?

PMHx: any history of UTI;

5Ps: previous miscarriages; twin pregnancies?

Physical examination:
- General appearance: pallor, dehydration
- Vital signs: stable except temperature 37.5
- ENT/CVS/Lungs
- Abdomen: tenderness of lower abdomen
- Pelvic:
o Inspection of genitalia: bleeding, discharge;
o Speculum: no bleeding or discharge; os is
close;
o Bimanual examination: adnexa are free;
uterus is expected high
- Urine dipstick and BSL
Diagnosis and Management
- You have a condition called UTI most likely what we
call cystitis. Do you know what it is? At this point, I am
happy to send you back home, but if the condition
persists and you cannot tolerate foods or drinks, fever,
chills and pain in the back, then go to the ED.
- I will need to send your urine for culture and sensitivity
and I am going to start you on amoxicillin 500 mg TID
or cephalexin 500 mg BID or nitrofurantoin 50mg QID.
If pyelonephritis: ceftriaxone IV 1g OD.
- I will review you in 3 days and we will either continue
your medication or change it according to the results
of your culture. I will prescribe paracetamol for the
abdominal pain and metoclopramide for vomiting.
Anemia in Pregnancy
Case: You are a GP and a 28-year-old G4P3 20 weeks
pregnant lady has come to see you to know the results of the
recent blood tests. The blood tests hemoglobin is low, MCV is
low, transferrin is high, ferritin is low.
Task

History
Physical examination
Diagnosis and Management
I understand that youre here for your blood results
and it was found that you have iron deficiency anemia.
This means that there is less oxygen delivered to the
tissues.
Do you feel tired? Is there any dizziness, palpitations
or SOB?
How is your pregnancy so far? Have you had regular
antenatal checkups? How are your blood tests and
ultrasound? How about your pregnancies? Have you
had blood loss? When was your last pregnancy?
What about your periods? Did you have abnormal
bleeding? What about your diet? Any bleeding
disorders? Are you on any special diet? Is the baby
kicking? Any other health problems?
Blood group?

Physical examination
General examination: pallor, bruising, lethargy,
Vital signs: postural drop
Lungs
Cardiac: murmur (systolic)
Abdomen: FH (check for IUGR), abdomen soft or
tense, FHT
Pelvic examination: bleeding, discharge
Urine dipstick and blood sugar

Diagnosis and Management

You have a condition called iron-deficiency anemia. It
is the most common cause of anemia in pregnancy. It
is often asymptomatic and detected on screening as in
your case. There is high demand of iron during
pregnancy and in your case, most likely the reason is
due to the inadequate gap.
There are some risks to you and your baby because
of this. Anemia can predispose you to infections,
excessive blood loss during pregnancy, and can affect
your heart. Because of this, there is reduced oxygen
supply to the baby which can lead to IUGR, fetal
distress and in severe cases, stillbirth.
We need to give you iron supplements. 200 mg 2x
daily. The hemoglobin level should increase by 1gm/L
per week. There are some side effects like nausea,
tummy pain, black stool, and constipation. We will
stop the medications 3 months after your hemoglobin
levels become normal. I would also advise you to eat
more iron-rich foods such as iron-fortified cereals,
legumes, nuts and nut butters, seeds, wholegrain
breads, green leafy vegetables, dried fruit, ironenriched breakfast cereals, milo and ovaltine and liver.
Eating a lot of vitamin C rich foods to increase
absorption of iron;
Parenteral iron indications: if close to delivery and if
cannot tolerate oral iron and Hgb <7g/L
Anemia: Hgb <110g/L in 1st trimester and <100g/L in
late second or third trimester. Iron requirements
increased to 1300mg/day.
Review after 2 weeks. Refer if not increasing.
Reading material.
Asthma in Pregnancy
Case: A 26-year-old female who is 20 weeks pregnant comes to
your GP clinic complaining of SOB.
Task

23
a.
b.

c.

History (had mild asthma and use ventolin PRN;

sudden, fever; with wet cough; greenish or yellow; exsmoker and partner is a smoker)
Physical examination (in distress; audbible wheeze,
BP 120/80; T:38, RR26, O2 93, HR 100; RR
increased; increased work of breathing, retractions,
increase vocal fremitus in right lung base; dullness on
right lung base and decreased air entry on right lung
base and diffuse wheezing; FH 20cm, FHT 140,
uterus soft and non-tender)
Diagnosis and management

Differential Diagnosis
Pulmonary embolism
Asthma exacerbation
Spontaneous Pneumothorax
Heart failure

asthma attack. Most likely you will be nebulized with

ventolin, ipratropium and IV steroids and treatment of
infection with IV antiobiotics.
Which antibiotic would you like to use? Benzypenicillin
or amoxicillin or erythromycin if with allergy
You will also be hydrated with IV fluid and have
oxygen.
You will have some tests: FBE, ESR/CRP, blood
cultures, and U&E, sputum for microscopy and
culture; CXR if indicated
How long will I stay in the hospital? You will probably
stay for a few days. We need to control your
pneumonia and asthma. If your temperature has
returned to normal for 48 hours and you are free of
asthma symptoms, you will be discharged and treated
as an outpatient.

Pregnancy plus Cardiac Murmur

History
-

I understand you have come to see me because of

SOB? When did it start? Did it happen suddenly or
gradually? Do you feel SOB at rest or only on
exertion? Does anything make it better or worse? Is it
the first episode? Do you have a fever, shivers? Do
you have a cough? Is it dry or wet? Whats the
sputum? Did you notice blood in the sputum? Do you
have chest pain or tightness? Is it worse with deep
inspiration? Do you feel your heart is racing? Do you
feel nauseous? Have you been vomiting? Do you
have abdominal pain? Have you felt the baby kick?

Any Vaginal discharge or bleeding? Waterworks and

bowel? Calf tenderness or swelling?
Is it your first pregnancy? Hows your pregnancy so
far? Any problems with blood tests? Any problems
with USD? Do you know your blood group?
Can you please tell me more about your asthma?
When were you diagnosed? How often do you get
attacks? Do you have symptoms between attacks?
Which medications are you on? Have you ever been
admitted to the hospital with severe asthma attack?
Have you ever been admitted to the ICU or ever been
intubated? Do you know any precipitating factors
(smoking, cold air, exercise, dust, pollen, infection)?
Other medical or surgical conditions in the past? Are
you on any medications? Allergies? Smoking?
What do you do for a living? Any recent history of
travel?
FHx of asthma

Physical examination
General appearance and peripheral cyanosis; signs of
respiratory distress
Vital signs
ENT
Chest:
o Inspection: use of accessory muscle; chest
expansion;
o Palpation: chest expansion; vocal fremitus
o Percussion: dullness or hyperresonance
o Auscultation: air entry;
o Peak-flow meter
Heart
Abdomen: FH, FHT, uterus is soft and nontender
Management
According to your history and PE, it is most likely an
acute asthma attack secondary to chest
infection/pneumonia. You need to be admitted in the
hospital. You will receive treatment to control the

Case: You are a GP and a 32-year-old 10- week (or 20-week)

pregnant lady came in due to shortness of breathing. She is a
primigravida.
Task
a.

History (1st pregnancy; noted SOB x 1 month ago with

occasional palpitations, no chest pain, especially with
walking, + history of RF 6-7 years old,

b.

Physical examination (vital is normal, no thyroid

enlargement, no carotid bruits, no rashes or jaundice,
chest normal, apex is normal, tapping, auscultation
low-pitch, rumbling diastolic murmur best heard with
bell on the left lateral position; soft, nontender, no
hepatosplenomegaly; ankle edema)
Diagnosis and management

c.
History
-

I know you have come to see me because you are

short of breath. When did it start? Did it happen
suddenly or gradually? Do you have SOB at rest or
only during physical activity? How far can you walk
(block)? Is it the first episode? Associated symptoms:
fever, cough, noisy breathing, chest pain or tightness?
Do you notice your heart is racing or beating
irregularly? Do you sleep flat? How many pillows do
you use when you go to sleep? Have you ever woken
up at night SOB? Have you noticed swelling of your
ankles? Hows your appetite? Do you feel tired? Do
you have N/V? Do you have abdominal pain? Hows
your waterworks? Any unusual vaginal discharge or
bleeding? History of travel?
I know its your first pregnancy, is it planned? Did you
see any doctors regarding your pregnancy? How did
you confirm pregnancy? Do you know your blood
group? When was your last pap smear?
PMHx: Are you generally healthy? Any serious
condition or surgeries in the past? Any heart or lung
disease? Can you remember what type of treatment
did you receive? Did you have regular follow-ups?
Medications? Allergy? Smoking? Alcohol? Do you
have enough support? FHx of heart or lung problems?

Physical Examination
- General appearance
- Vital signs: PR (regular)

24
-

CVS: peripheral/central cyanosis and pallor, JVP,

inspection and palpation of precordium, apex beat,
thrills, murmur
Lungs: evidence of pulmonary edema or pleural
effusion
Abdomen: hepatomegaly, tenderness
Legs: peripheral edema

Diagnosis and Management

- According to your history and PE, I suspect heart
valve disease which is called mitral stenosis. Your
heart has 4 chambers. Mitral valve separates the
upper and lower chambers on the left side of the
heart. Stenosis means the valve doesnt open fully
restricting blood flow. Most likely, its the complication
of rheumatic fever.
- I will refer you to the cardiologist for further
assessment. You need to have ECG and echo to
confirm the diagnosis and assess the severity and
heart function.
- Normal pregnancy is associated with significant
hemodynamic changes (increased blood volume) and
your heart will need to work harder and may worsen
your condition. That is why, for the best outcome of
your pregnancy, you will be managed in a high-risk
pregnancy clinic. You will be seen by an OB,
cardiologist, midwives and GP.
- During the pregnancy you will have more frequent
follow-ups and the cardiologist will make a decision
about treatment

NYHA (Heart Failure)

o I no symptoms but with signs of cardiac
damage
o II symptoms comes with ordinary physical
exertion; dyspnea, SOB, palpitations,
tiredness; usually treatment not required in
pregnancy; monitor for deterioration
o III asymptomatic at rest but symptomatic
with minimal physical exertion; treatment
required
o IV symptomatic at rest; admission to
hospital for treatment
Will I be able to deliver vaginally? Most women who
have heart disease have an easy spontaneous labor.
There is no indication for inducing labor. During labor,
you will need to be on your side or well-propped up to
avoid compression of the major vessels (aorta) which
may cause marked decrease in BP. If there is a delay
at the 2nd stage of labor, instruments (forceps/vacuum)
will be used. If there is a need for medication to
stimulate uterine contractions, oxytocin is the
preferable one. You will be closely monitored during
the delivery and after.
If heart failure needs to be treated, same drugs (betablocker, digoxin, diuretics) are given as for nonpregnant apart from ace inhibitors.
Do you have any questions?

The plasma glucose level was 9.2mmol/L (N<8mmol/L) after 1

hour.
Task
a.
b.
c.
d.
History
-

Case: Your next patient in GP practice is a 28-year-old woman

who is 28-weeks pregnant. She returns to you for the results of
the GCT with 75 grams of oral glucose load done 2 days ago.

Hows your pregnancy going so far? How was your

midpregnancy ultrasound? Is this your first
pregnancy? Have you ever been diagnosed with
diabetes before? Recurrent thrush/candidiasis?
Polyuria, polyphagia? Any other previous illnesses or
surgeries? Any FHx of diabetes? Blood group? Are
you regular with pap smear? Weight before pregnancy
and weigh now?
Do you think your tummy is more distended than what
you expect it to be? Any previous pregnancies or
miscarriages? Do you have headache, frothy urine, or
blurred vision? SADMA? Social history?

Physical examination
- General appearance: edema, BMI
- Vital signs
- Chest and heart
- Abdomen: FH, lie or presentation, floating/engaged,
FHT
- Pelvic examination: discharge, spotting/blood, os,

Diagnosis and management

- I would like to organize some confirmatory tests
because the GCT we did 2 days ago is one of the
screening tests so I would like to do the oral glucose
tolerance test. In that test, you have to fast and well
give you oral glucose and measure the blood sugar
levels at 1 and 2 hours. In addition, I would also
organize FBE, HbA1c, urine MCS, USD and CTG.
-

ENDOCRINE DISORDERS OF PREGNANCY

Gestational Diabetes

Further history (FHx of DM, regular PNCU, no

symptoms of DM)
Explain the results
Examination (FH, FHT +, cephalic)
Diagnosis and outline management

From the history and examination, you have a

condition called gestational diabetes. This means that
during the pregnancy your blood sugar has increased
too much. Gestational diabetes is the result of the
hormone called Human placental lactogen (HPL)
produced by the placenta, progesterone, beta-hCG,
and cortisol. All these substances/hormones have
anti-insulin effects.
Gestational diabetes increases the mothers risk and
puts the baby at risk as well. Mothers glucose crosses
the placenta, but insulin cannot and fetal pancreas
gets activated and starts secreting additional insulin
and because of that babys can become macrosomic
(large babies), hence we will do frequent USD. The
baby may also develop jaundice and there is
increased chance of premature delivery, which leads
to prematurity and hyaline membrane disease. There
is also a risk of neonatal hypoglycemia because of
increased insulin, as well IUGR and IUFD.
Do not worry. You are in safe hands, but with good
monitoring done by the MDT these risks can be
minimized dramatically. I need to refer you to a
diabetic physician/endocrinologist, obstetrician,
dietitian and diabetic educator. Our main aim is to

25

maintain the BSL to <7mmol/L by dietary

modifications. You need to measure you BSL at least
3x a day. If the BSL is not controlled with the diet we
will start with insulin. I would advise you to maintain a
diary of your BSL. You might also need to be reviewed
by ophthalmologist and kidney specialist. We will
monitor you by doing the HbA1c and urine protein
(microalbuminuria).
From 32 weeks of pregnancy, we will start doing CTG
to monitor the baby. If your sugar is well controlled, we
will do it once a week but if not, we will do 2x a week.
If euglycemia is achieved, the specialist may give you
a trial of labor/normal delivery. They will also organize
USD in the 3rd trimester to assess the growth of the
baby and we do a planned delivery at term (38
weeks). Depending on how your glucose levels are,
you might need intermittent insulin injections during
labor. If baby is big or any other complications
happen, the specialist might consider doing cesarean
section.
Dont worry. We just have to control your blood sugar
level.
Will I remain diabetic? Usually, the diabetes
will not patient
Pregnant
resolve after delivery. However, there is an increased
chance of recurrence in succeeding pregnancies and
30% risk of developing DM later in life. Hence, we
need to organize a followup GTT 6-8 weeks after
delivery and to be checked 2 yearly (every 5 years in
clinical book).
Red flags: uterine contractions, leaking of water, etc.

IgG +, IgM -

(b-hCg -) Vaccination and avoid pregnancy till the ne

IgG -, IgM -

Mild illness: symptomatic control; she can b

IgG -, IgM +

Vaccination
Immunoglobulin
Termination

INFECTIONS IN PREGNANCY
Rubella exposure in pregnancy
Case: 28-year-old schoolteacher presented in your GP clinic
concerned she was exposed to an 8-year-old student who was
confirmed to have Rubella infection. She is not sure if she is
pregnant or not. LMP was 10 weeks ago.
Task:
a.
b.
c.

Talk to the patient

Discuss her concerns
Answer her concerns

Immunized; safe to be pregnant

Rubella
No
No
Yes if IgM (+)

Varicella
No
Yes
Never

Complete damage of baby (>45%) if mother exposed

during the 1st trimester
Further damage can result to deafness and cataract
Offer termination of pregnancy
NO vaccination in pregnancy
Can cause abortion, miscarriage, stillbirth, IUGR, fetal
infection
Congenital rubella:
o Cataract, deafness, developemental delay,
irritability, mental retardation, microcephaly,
neurologic (meningoencephalitis)
o Heart: patent ductus arteriosus, tricuspid
stenosis

Chickenpox in pregnancy
History:
I know that you are concerned about being exposed to
Case: 25-year-old G3 female who is currently 10 weeks
a child with rubella and being pregnant. How long
pregnant. She is worried because her son has chickenpox.
have you been exposed to this child? Have you had
any fever? Rash? Body ache? Did you have any
Task:
previous vaccination against rubella or any chance
a. Counsel the patient
youve been infected with rubella before? When was
your LMP? How frequent were
your periods?
Immunized;
safeDid
toyou
continue pregnancy
Congratulate on pregnancy
IgG +, IgM check PT? Do you have signs of pregnancy? N/V?
I understand from the notes that your son is having
morning sickness? Tender breasts? Are you in a stage
chickenpox. How is he? Is he feeling better? When
of having a planned pregnancy?
exactly did he have the rash? Who diagnosed the
Do you have any other systemic illnesses? Are you
chickenpox? Is the rash becoming dry by now? Have
Pregnant patient
(b-hCg
+)
using
folic acid?
Meds?
Pap smear?
group?pregnancy and repeat
Avoid
further
contact;
can Blood
continue
2-3 weeks
youtest
had in
chickenpox
before? At the moment are you
SADMA? IgG -, IgM suffering from fever, rash or any other symptoms?

Were you vaccinated against chickenpox. Have you

had regular antenatal checkups up till now? Did you
have the
tests? USD?malformations.
Results?
1st 8-10 weeks of gestation and this condition is called congenital rubella syndrome with
lotsblood
of congenital
Offer patient r
Do I have any examination findings?
Management

IgG -, IgM +

26
-

How much do you know about chickenpox?

Chickenpox is a viral infection caused by varicella
zoster virus. It is a very common infection especially in
school-going kids. From statistics, we know that 80%
of pregnant females are found to be immune or
protected either as a result of exposure in childhood or
from immunization. This immunity is lifelong. If you
have had it before, the risk is minimal for you.
I will arrange some blood tests if you have antibodies
in your blood. There are two types of antibodies that
we check: IgG (if + that means you are immune and
can continue with pregnancy without any problems);
IgM (if + it indicates that you have been recently
exposed to this infection, but let me reassure you that
the risk to the baby within the first trimester is only
0.4% and later on goes up to 2%.
The period of highest risk both for the baby and for
you is 1 week before and after delivery. Especially for
the mother with an active chickenpox infection, there
is a 10% chance of developing certain complications
e,g. encephalitis, pneumonia and hepatitis which can
be fatal.
If baby is infected, he/she might be born with a
condition called congenital varicella syndrome
where he might have a rash, similar to the chickenpox
rash, limb defects, IUGR, microcephaly, cataracts,
micropthalmia, MR (due to cortical atrophy), muscle
and bone defects
If IgM+ give Immunoglobulins that can prevent and
reduce severity of disease for mother. It is usually
given via IM injections preferably within 4 days of
exposure because efficacy is highest. If you develop
sx, we will give acyclovir that reduces the severity and
duration of chickenpox.

Please dont worry too much because the risk of

infection and complications is low. I will write the order
for you. Please come back tomorrow for review.
If IgM is positive then you have to proceed to the
hospital for review by an obstetrician.

Critical Errors:
Failure to advise mother that it can be serious for the
baby
If you tell neonatal sepsis can be handled easily
Offering antibiotics now
Recurrent Herpes in Pregnancy
Case: You are a GP and 28-year-old primigravida who is 20
weeks GA comes in complaining of pain and ulcers over the
vulva over the last 2 days.
Task
a.
b.
c.

History
-

GBS In Pregnancy
Case: Mrs. Mary Jones had her last antenatal visit at 37th week
and vaginal swab for GBS was done which is positive. She is
concerned to hear and wants to know the risks for the baby and
herself.
Task:
a.
b.
-

Explain nature of disease and its appropriate

management
Answer patients questions
Congratulate pregnancy
From the notes I understand that you are here to
discuss your results. Your vaginal swab shows the
presence of bacteria called GBS. This is a bug. Before
we go ahead, I would like to ask some question. Is it
alright?
Ask for burning sensation in urine, smelly, increased
frequency, lower burning pains, change in color of
urine
How is your pregnancy going so far? Any concerns?
Are you allergic to any medications?
GBS are normal vaginal bacteria in healthy women
and is found in 18-27% of pregnant women. It will
cause no harm to you, but we are concerned that if
present during labor, it can harm your baby. 40-50% of
babies are colonized but only 1% develops neonatal

sepsis. Although only 1% gets it, it is a serious

infection and carries serious mortality for the infected
baby.
There are some risk factors which can exaggerate the
risk of infecting your baby:
o Preterm delivery
o Prolonged rupture of membrane
o Maternal fever >38C during labor
o Previous GBS infection
Reassurance dont worry, its good we have picked
up at this stage and we will do our best
We will give IV antibiotics (Penicillin 3G initially as LD
then 1.5 gms or erythromycin q4) during labor which is
started at least 4 hours before delivery
Baby will be assessed by pediatrician. If completely
healthy, and no risk factors, no antibiotics will be
given.
Give reading material and red flags arrange for review
after 1 week

History
Physical examination
Management at present and during labor

Are you in a lot of pain? Would you like some

painkillers? When did it start? How bad is it from 110? What kind of pain? Burning? Stabbing? Shooting?
Is this the first time? Do you have any problems with
your waterworks? Have you noticed any fever,
headache, any lumps and bumps in the body
especially in the groin area? Any vaginal discharge?
What about the ulcers? Did they come with the pain or
afterwards?
I understand youre 20 weeks pregnant. How is it so
far? Have you had regular antenatal checkup? Have
you had all the blood tests? Can you feel the baby
kicking? Any bleeding or spotting down below? Any
tummy pain?
Are you in a stable relationship? May I ask how many
partners have you had previously? Have you or any of
your partners every suffered from an STI? What
contraceptives were you using before this pregnancy?
How is your general health? When was your last
episode of genital ulcers? Did you have fever and
lumps in the body at the time? What treatment was
given by your doctor? Did it help? Any problems?
SADMA?

Physical examination
General appearance
Vital signs
Abdomen: Fundal height, tenderness, rash in the
abdomen, blisters/ulcers (dermatomal distribution), lie
of baby and fetal heart sounds
Pelvic:

27
Inspection: redness, discharge, ulcers
(unilateral syphilis or bilateral herpes;
weeping/wet herpes; pus or discharge
superimposed bacterial infection), vesicles,
warts
o Groin for tenderness and evidence of
lymphadenopathy
Urine dipstick and BSL
o

ASHM (Australasian sexual health medicine) and RCOG

Differential Diagnosis for Genital Ulcer Disease
Herpes until proven otherwise
Syphilis single, painless, wet ulcer
Allergy/scabies/vulvar (squamous cell carcinoma)
Varicella painful vesicles ulcer with dermatomal
radiation
Donovanosis not common in Australia;
Calymmatobacterium granulomatis)
Trauma
Lymphogranuloma venereum Chlamydia
Chancroid (Haemophilus ducreyi) painful
Investigation
FBE, MSU (if indicated), swabs from ulcer to send for
PCR, antibody testing in the blood specific for herpes,
oral swabs
Offer full STD screening, and preferably the partner as
well
Management
Most likely you are having recurrent genital herpes. As
you know, it is a viral infection that is usually acquired
by sexual contact. This virus stays within the body
lifelong even after treatment of the first attack. It lives
within the nerve root. Whenever there is a period of
stress, like for example, a febrile illness, pregnancy,
and in females, during periods, this virus becomes

activated and causes symptoms (e.g. pain, blisters,

ulcers, fever, swollen glands, and vaginal discharge).
Unfortunately, this virus cannot be eliminated from the
body, but treatment reduces the severity of symptoms,
duration of illness, and prevents spread of infection.
When you had the first infection, you were given oral
antivirals. This time, we will give you a cream
containing acyclovir that you can apply locally. I will
also write for you some topical lignocaine gel to
reduce the pain. You can use warm salt water baths to
relieve the pain. It is important to avoid sexual contact
until the ulcers heal completely.
Wash your hands immediately after touching or
scratching the area. Take oral analgesics as well.
During pregnancy, herpes infection can come again. If
it happens within 6 weeks before EDD, we will give
you oral antivirals. We will refer you to the specialist
obstetrician who might offer you cesarean section
because there is a risk that with normal vaginal
delivery, 5% of babies might get the infection and
develop neonatal herpes. Neonatal herpes can be a
serious infection for the baby. The baby might be born
prematurely, develop herpes of the eye, meningitis,
and rarely, can be fatal within 1st 7 days. Some
specialists recommend using continuous acyclovir
starting from 36 weeks until delivery.
If insistent on NSVD:
o Avoid fetal scalp pH monitoring, artificial
rupture of membranes and other invasive
procedures.
o Acyclovir will be started as soon as labor is
established

o Treat baby with acyclovir after delivery

If with 1st infection of herpes: risk to the baby is 50%.

DISEASES OF PLACENTA AND MEMBRANES

Molar Pregnancy Counseling
Case: You are a GP and a 30-year-old female comes to
complaining of tummy pain, vaginal bleeding and passing grapelike material with the bleeding. The ultrasound was done that
has confirmed molar pregnancy.
Features:
- Bleeding + passage of grape-like debris
- May be exagerrage symptoms of pregnancy
(hyperemesis)
- Uterus large for dates
Investigations:
- FBC, blood group and cross-match, beta-hcG,
ultrasound (pelvic: snow-storm appearance), CXR
- Suction curette with oxytocin drip
- Hysterectomy if patient has completed family planning
- Register in trophoblastic registry
Followup
- CXR
- Weekly serum beta-hcG until zero (8-12 weeks) then
monthly for 12months
- Avoid pregnancy for 12 months after hcG levels are
normal
- OCP is appropriate
Task
a.

Counsel patient regarding current and future

management

Is my patient hemodynamically stable? How do you

feel at the moment? Do you feel dizzy or do you feel
like lying down. I can see from the notes that youve
had some bleeding and tummy pain and that youve
noticed some grape-like material passing out from the
vagina. From the investigation, you have a condition
called molar pregnancy. This condition can be a
serious problem. Unfortunately, there is no fetal tissue
that we can see. I understand that it might be
shocking for you. Is it alright for me to continue?
Molar pregnancy occurs when the fetus is not able to
form completely. As you know, in a normal pregnancy,
the sperm and the egg fuse to form the fetus. This
fetus carries equal genetic material from mother and
father. Sometimes, the egg is empty or it is fertilized
by 2 sperms at the same time. The resulting tissue
lacks maternal genes, therefore only the placenta is
formed. This placenta grows and invades/erodes the
lining of the womb which causes bleeding. The
placenta is also responsible for the production of a
hormone called beta-hcg that gives the usual
symptoms of pregnancy such as nausea, vomiting,
and breast tenderness. In a molar pregnancy, the
placenta is abnormal and grows massively and it
contains fluid-filled sacs or cysts. The grape-like
material that you have noticed is the same sac.
Rarely, the placenta starts to grow and invade the
uterus. It travels within the circulation sometimes
reaching the lungs, brain, bones. We then label it as
invasive mole or choriocarcinoma that can carry
serious consequences for you.

28
-

At the moment, I need to send you to the hospital

urgently. They will admit you and call the obstetrician.
This pregnancy needs to be removed either by
dilatation and evacuation or by suction curettage. It
will be done under general anesthesia so you will not
feel any pain.
After the procedure, they might decide to give you a
form of chemotherapy (Methotrexate) as some cells
from the mole can reach the circulation. We will need
to do serial hcg monitoring every week until it touches
normal level and stays normal for the next 3 samples,
do monitoring hCg monthly x6 months then annually.
We will also do serial USD every 2 weeks.
If it remains elevated or persistently highly, we will
need to check for the spread of the disease by doing
CT scans of the chest and abdomen. If anything is
detected, you will be referred to the cancer specialist.
Once the treatment is completed, you need to avoid
pregnancy for 1 year because the pregnancy
hormones can induce recurrence of the cancer.
OCP: Yes.
Regarding your next pregnancy, there is still a very
high chance that you might have a normal pregnancy,
but the recurrence rate is higher (1:80 compared to
1:15,000 for general population).
I will refer you to the counselor because you need a
lot of emotional support at this time. It is normal to be
upset after losing a pregnancy.

Case: Your next patient in a small country town is a 26-year-old

Mrs. Jones who is 30-weeks-pregnant. She has recently moved
to this area. Her antenatal care up to now has been taken cared
of by one of your colleage. Midgestation USD is normal. 4
weeks ago her fundal height was 26cm, but today, it is 40cm.
She feels a bit tired and uncomfortable with a large tummy and
wants you to take over her antenatal care. She recently traveled
overseas.
Task
a.
b.
c.
d.
Causes
History
-

Oligohydramnios
Case: Your next patient in your GP practice is a 28-year-old
primi who works as a nurse in the Renal transplant unit. You
have looked after her pregnancy so far, and all appeared normal
up to her last visit 4 weeks ago. When she was 30 weeks AOG
she had a SFH of 28cm. Today her SFH is 29 cm and there
appears to be less amount of liquor.

Task:
a.
b.
c.

Further relevant history

Relevant Physical examination findings and
investigation
Diagnosis and subsequent management plan

Problem list
a. Recognize and managem oligohydramnios
b. Management plan and appropriate investigations
c. Relieve patient concern regarding baby safety
Differential diagnosis:
Maternal factors:
Wrong dates
Constitutional: small mother (hx, weight, parity, ethnic
group)
Medical: HTN, DM, Immunological (SLE)
Socioeconomic: nutritional factors anemia
Medication usage steroids, warfarin, anti-epileptic
Previous pregnancy with IUGR; FHx: IUGR
Tobacco and substance misuse
Fetal factors:
Genetic: chromosomal fetal defects
Multiple pregnancy (each child IUGR)
Fetal infections (TORCH)
Placental insufficiency placenta previa, abruption,
immunological
Polyhydramnios

Brief history (traveled to NZ, no fever or jaundice,

single baby, 18 weeks USD, B+)
Physical Examination (FHT normal, FH 40, cephalic,
head freely mobile, FHT, no tenderness, cervix closed)
Investigations
Diagnosis and management
Wrong dating
Multifetal gestation
GDM
Chorioangioma
Fetal abnormalities (NTD, UGI atresia)
TORCH (CMV and toxoplasmosis)
Fibroids
Congratulations on your pregnancy. Is it planned?
How was it confirmed? Are you regular with your
antenatal checkup? Did you visit your GP before
leaving? Did you receive appropriate vaccinations
before leaving? Did you have any problems there or
on flights? How was your midpregnancy USD?
Placenta? Single baby? How were your blood tests?
Any FHx of congenital anomalies? How is your baby?
Is he kicking well? Did you maintain a kick chart? Is
this distended tummy giving you any problems like
SOB or day-day lifestyle? Any fever or signs of
infection in the last 3 months.

Do you have any tummy pain? Is your tummy tender?

Any bleeding or discharge per vagina? How are your
periods? Are they regular? Heavy or normal? Are you
regular with your pap smear? Do you know what your
blood group is? Any other symptom symptoms like
headache, blurring of vision, polyuria or polyphagia?
Any chance of exposure to cats or dogs? Any past
history of uterine fibroids? Did you eat raw meat
recently?
SADMA?

Physical examination
- General appearance
- Vital signs
- Chest and heart
- Abdomen: FH (40cm), lie and presentation, head if
engaged or mobile, FHT/FHR
- Pelvic exam: inspection and speculum
- Signs of edema
Management
- I have noticed that your pregnancy is larger than the
date. There are a number of causes for it. It could be
wrong date, multiple pregnancy but it is not your case.
It could also be diabetes or abnormalities in the baby
or certain infections. It may also be due to uterine
fibroids. At this stage, I would refer you to the
obstetrician and organize blood tests such as FBE,
blood group, TORCH, BSL, urine microscopy and
culture, ultrasound, biophysical profile (AFI >25cm is
diagnostic of polyhydramnios).

29
-

We will also need to do CTG and GTT (even with

normal GCT).
Can it be risky? Dont worry, we have picked it up
early. You will be seen by the specialist. Having said
that, there are some complications like premature
labor, premature rupture of membrane,
malpresentation, placental abruption, cord prolapse,
pregnancy-induced hypertension, and postpartum
hemorrhage. That is why we will monitor you and your
baby very closely.
How will they treat it? If the polyhydramnios is mild
and asymptomatic, we just do observation. However, if
it is moderate to severe, and you get SOB, you cannot
sit or lie down comfortably, and you are <35 weeks,
the specialist might do amnioreduction up to 500 ml. if
the pregnancy is >35, the specialist might do induction
of labor by artificial rupture of membrane. At this
stage, the specialist might consider giving
indomethacin to reduce urine production.
Prophylactic steroid decided by specialist.
Red flags: bleeding, discharge, blurring of vision,
SOB, tummy pain, kindly go to the ED of the nearest
hospital immediately.
Reading material. Review,

VARIATIONS IN DURATION OF PREGNANCY (PRETERM

AND POSTDATISM)
Preterm Labor
Case: Sarah is a 27 year old female and presents to a district
hospital where you work as HMO in ED. She is 32 weeks
pregnant and noticed some pain in the lower abdomen since
yesterday. She didn't break her water and the baby is kicking
well.

Contraindications for tocolytics: Chorioamnionitis,

cervix >5cm, IUFD, abruptio placenta

Preterm Labor
Case: Linda aged 34 years presents to a country hospital where
you are working as year 1 HMO. Linda is 33 weeks pregnant
and since this morning she had noticed few contractions and
cramps in the lower abdomen. There is no vaginal discharge
and baby is moving well. Up till now, pregnancy has progressed
well and all investigations have been normal
Task
a.
b.
c.

History (started contractions a few hours ago,

occurring every 5 minutes)
Physical examination (3cm open, 50% effaced)
Probable diagnosis and management

Features
- Gestational period is less than 36 completed weeks
- Uterine contractions preferably recorded on tocograph
occur every 5-10 minutes, last for at least 30 seconds
and persist for at least 60 minutes
- Cervix is more than 2.5cm dilated and more than 5075% effaced
- Contraindications to tocolytics: APH, effacement
>75%, cervical dilatation >5cm
Physical Examination
- General appearance
- Vital signs
- Abdomen: FH, presentation, lie, contractions,
engagement
- Pelvic examination: inspection and speculum
examination; No IE done
Diagnosis and Management
Investigations
o Cervical swab looking for pathogens

Task
a.
b.

c.

History (spasms that are getting worse, all over, 8/10,

no bleeding, good antenatal checkups, pap smear a
year ago)
Physical examination (distressed and in pain, FH
consistent with GA, cephalic presentation, FHT (+),
nontender on palpation, pelvic examination: no
discharge, bleeding, bulging of BOW, normal cervix,
3cm dilated, 70% effacement)
Advise on management

Preterm labor:
Gestational age <36 weeks, UC q5-10mins x 30 secs
in 60 mins, cervix >2.5cm dilated and 75% effaced
Physical examination
Abdomen: lie, presentation, FH, head is engaged or
floating
Pelvic:
o Inspection: discharge, bleeding
o Speculum: discharge, bleeding, cervical os,
effacement, nitrazine test
o IE: consistency, position, station
Management
CTG, fibronectin and nitrazine test
Start tocolytics (nifedipine or salbutamol) -- nifedipine
10mg orally q20 then 20 q4
Betamethasone 11.4mg IV 24 hours apart
Refer to metropolitan hospital.

Nitrazine test or amnisure

Fetal fibronectin (may be FP if had sexual
intercourse within 24 hours, bimanual
examination done)
o Ultrasound (Abdomen):
o FBE: signs of infections
o ESR/CRP
o Urine MCS
Management
o Pain-relief Panadeine, Pethidine IM 25100mg, diazepam
o Tocolytic
o Betamethasone 11._ mg 2 doses 24 hours
apart
Refer to tertiary hospital
o
o

Premature Rupture of Membranes

Case: 32 weeks GA pregnant female presented complaining of
passage of fluid 2 hours ago. She is 24 years old. She has cone
biopsy done for abnormal pap smear and cervical suture is in
place. You are a GP in a rural area.
Task
a.
b.
c.

Relevant history
Examination findings
Management

Focused history:

30
-

How much (how many pads? Is it soaked)? What is

the color (is it clear? associated mucus? Blood?
Greenish material? How long? Is there any tummy
pain? Contractions? Any other associated waterwork
problems (e.g. increased frequency of urination?), any
vaginal secretions? Fever? Hot flushes? Dizziness?
Vomiting? Heart-racing? Do you still feel the baby
kicking?
Pregnancy: is this the first pregnancy? Previous
antenatal checkup? Any abnormalities on usd ? What
is your blood group? Previous deliveries and previous
gynecological problems?
Pap smear: what was the cause detected. For the
cone biopsy, when and where did you have this done?
PMHx: hypertension? DM? meds? SADMA?
How far do you live from here? Who can care for you
if we decide to transfer you to a tertiary hospital?

Physical examination:
General appearance: pallor, anxious, BMI
Vital signs: temperature, BP (postural drop), pulse, RR
Urine dipstick
Rapidly Id like to check chest and heart
Focus on the abdomen: general look abdomen. Id like
to start with superficial palpation (tenderness means
chorioamnionitis), feel fetal parts, check fetal position,
gestational age, fetal heart sounds
With the consent of the page, Id like to go for pelvic
examination and ask consent for swabs. Id like to
inspect for fluids. Can I have a description of the fluid?
Is it clear? Does it smell? Blood/mucus or other
discharge. With complete aseptic condition, Id like to
perform speculum examination (fluid at fornices). Id
like to collect cervovaginal swabs for MCS and collect
low vaginal and anorectal swabs for GBS. Id like to
confirm the diagnosis of PRM by nitrozine/lithmus test.
Remove cervical suture and send for MCS!
Investigations and Management
Id like to arrange some investigations as soon as
possible: FBE, U/E, LFTs, CRP, CTG, USG, and refer
patient to hospital.

Give her erythromycin 250 mg QD for 7 days and

betamethasone 2 injections 24 hours apart.
If there is no evidence of infection or no
contraindication for tocolysis: nifedipine/salbutamol
Organize admission at local hospital and tertiary
hospital by nets (neonatal emergency transfer
service).

History
-

Task
a.
b.

c.

History
Physical examination (FH 39, head just, engaged, lie
is longitudinal, FHT normal, speculum: no discharge,
bleeding or show; closed, long, posterior, no bulging of
membranes)
Management

Definition:
RWH: >41 weeks + 6 days
LJ: 40 + 2 completed weeks
Risks:
-

Placental insufficiency
Meconium aspiration
Fetal asphyxia

Is this a planned pregnancy? Congratulations! How is

the pregnancy so far? Can you tell me how your
pregnancy was confirmed? Have you had regular
antenatal visits? All blood tests? What were the
results? Any problems? Did you have the sweet drink
test? Was it alright? When was your last ultrasound?
What was the result? Is it a single baby? Weight?
Placenta? What was the expected date of delivery on
that ultrasound?
Hows your general health? Any past history of
diabetes, high blood pressure? Currently do you have
any symptoms of headache, blurred vision, or swelling
of the legs? Any bleeding or discharge from down
below? Any tummy pain? backache? Is the baby
kicking alright? Have you counted how many times in
how many hours? Do you have kick chart with you (10
in 12 hours)?
FHx of postdated deliveries? Big babies?
Have you had any gynecological surgeries or
procedures (adhesions)? What is your blood group?
When was your last pap smear? Have you been
vaccinated against gardasil? SADMA?
Do you have enough support at home? Any
problems? How far do you live from the hospital? Is
there anyone who can drive you in case of an
emergency?

Physical examination
General appearance
Vital signs: BMI and height

Postdated Pregnancy
Case: You are a GP and a 41-weeks primigravida comes to your
clinic because she is worried when she will deliver.

Difficult deliveries (problems with molding)

Increased risk of operative deliveries
Increased risk of labor induction
Dystocia
4x increased risk of stillbirths
3x increased risk of neonatal death
10x increased risk of neonatal seizures (within 1st 48
hours of life)

Chest and heart

Abdomen: FH, lie of the baby, presenting part,
engagement, FHT, tenderness over the abdomen,
contractions
Pelvic examination:
o Inspection and speculum: discharge,
bleeding, presence of show,
nitrazine/lithmus test to detect amniotic fluid
in the vagina,
o Bimanual: position, size, and effacement of
cervix
Urine dipstick and BSL

Management
It seems like your pregnancy is advancing towards
postdatism. 5-10% of normal pregnancies can go
beyond 42 weeks something we call as postdated
pregnancy. You are still within the normal range so
please dont worry. However, I want you to be aware
of certain risks associated with postdated pregnancy,
for example, placental insufficiency, meconium
aspiration, fetal distress, difficult delivery with higher
risk of undergoing cesarean section.
What we need to do is monitor you very closely to
prevent postdated pregnancy. Starting from now, we
will do CTGs 2x a week to assess fetal distress. We
will also do ultrasound once a week to check the
babys growth (BPS). We will also check the AFI. Also,

31

I will recommend a Doppler study of the umbilical cord

to check the flow of blood to the baby.
At the end of all these tests, you will need to see the
specialist obstetrician. They might give you options
which include elective induction of labor with the help
of prostaglandin tablets that are inserted within the
vagina to initiate contractions. The second option
would be to continue the pregnancy but with regular
CTGs, USD and Doppler studies. The third option is
elective CS that carries minimal risk in safe hands.
The decision is yours. Please bring your partner for
the next consultation so we can discuss it together.
Meanwhile please look out for signs of labor which
includes bleeding, discharge, leaking of fluid,
continuous/intermittent back or tummy pain.

ABNORMAL PRESENTATIONS
Breech Presentation
Case: You are a GP and a 25 year-old primagravida with breech
presentation at 32 weeks GA came in for consultation.
Task
a.
b.

c.

History
Physical Examination (lower pole of the uterus is a
soft, smooth and with a rounded mass that bounces
between the fingers, position of heart sound is above
the umbilicus)
Diagnosis and management

Causes of Breech
Maternal
o
o
o
o
o
o
Fetal
o
o

o
o
o
History
-

Polyhydramnios
Uterine abnormalities (bicornuate, septate)
Placental abnormalities (previa)
Multiparity
Contracted maternal pelvis
SOLs (fibroids)
Prematurity
Fetal anomalies (neurological,
hydrocephalus, anencephaly)

Diagnosis and Management

Your babys position is breech. Normally, the babys
head is down and the bottom is up. In your case, the
babys butt/bottom is presenting down.
There are three kinds of breech
o Frank: hips flexed and knees extended
o Complete: hips and knees flexed
o Single or Double Footling: one of both legs
are completely extended.
First of all we need to do USD to confirm the diagnosis
and exclude the causes of breech and to make sure
that the baby is fine. In most of the cases of breech
near term or at the time of delivery, baby takes the
normal cephalic presentation. If not, with your
consent, the specialist obstetrician will try to turn your
baby in the normal position by gently pressing the
tummy. Do not worry. It is a painless procedure and it
is done in a tertiary hospital.
There are some complications which can be possible:
o Failure baby can come back to breech
presentation
o Premature labor
o Bleeding
o Fetal distress if umbilical cord goes to the
neck (0.5%)
Contraindications of ECV
o Oligohydramnios
o Antepartum hemorrhage (placenta previa)
o Multiple pregnancy
o Uterine structural abnormality
o Fetal abnormalities
What about the delivery? If the breech is complete or
frank, the specialist can offer a trial vaginal delivery
but there are some risk to vaginal delivery which
includes fetal distress because of cord prolapse, hip or
shoulder dislocation, fracture of humerus, femur or
clavicle and asphyxia. If these develop during the trial

Multiple pregnancy
Fetal death
Short umbilical cord

Is it a planned pregnancy? Congratulations on your

pregnancy. How is the pregnancy so far? Are you
regular with your antenatal checkups? How were your
tests? Ultrasound? Was it a single baby? What was
the position of the placenta? Amniotic fluid? Sweet
drink test? Blood group? Have you taken folic acid?
Is the baby kicking normally? Are you maintaining a
kick chart? Do you have any headache, dizziness,
BOV or leg swelling? Do you go to washroom quite
often? Do you drink a lot of water? Does your tummy
feel more distended than usual? Any vaginal bleeding,
discharge, tummy pain?
How are your periods before? Were they very heavy?
Were the cycles regular? Were you ever been
diagnosed with fibroids or any other abnormality?

Physical examination
General appearance
Vital signs especially BP
Abdominal: FH, bell shaped, lower pole of uterus is
occupied by a soft, smooth rounded mass that

bounces between the fingers, FHS usually loudest

above the umbilicus, tenderness, FHT
Pelvic exam/Speculum: discharge, os
Leg edema
Urine dipstick and BSL

of labor the specialist will do cesarean delivery. If

footling, then do Cesarean delivery. We can reduce
the risk of complications by 50% if we choose elective
cesarean section at 39th week. If you do decide to go
on a trial with vaginal delivery, we will still do our best
to monitor you and your baby by doing regular CTG
and USD. It will be done in a tertiary hospital in the
care of an experienced obstetrician.
Is it a serious condition? Not really, but it makes
NSVD difficult but not impossible. However, you are
still at 32 weeks and there is a high chance that your
baby will still change its presentation
Reading material. Referral.
Red Flags: bleeding, tummy pain, blurring of vision

Transverse lie in Multigravida

Case: You are an HMO working at a district hospital and a 38weeks multigravida who lives 80 km from the tertiary hospital
was found that the baby had a transverse lie.
Task
a.
b.

Relevant history
Physical Examination (FH does not correspond to
gestational, uterus is ovoid, fundus is empty and head
lies in one of the flanks, no tenderness, FHT normal)

32
c.

Management

Case 2: Julia aged 35 years presents to your surgery for routine

antenatal checkup as advised by you last week. She is 38
weeks pregnant and till now her pregnancy has been
progressing well. On routine questioning she tells you that today
she had uncomfortable feeling in her flanks and tense feeling
but no other associated symptoms. She had normal USD at 18
weeks and other blood tests performed during pregnancy. This
is Julias 2nd pregnancy. She had one abortion when she was 32
years old. Julia lives with her partner in an apartment close to
your surgery. She stopped smoking when she became pregnant
but is still having a glass of wine here and there.
Differential Diagnosis
Labor
Placental abruption
UTI/Pyelonephritis
Task
a.
b.

c.

Focused history (tense on both sides, no radiation,

baby kicking well)
Examination and investigation findings from examiner
(FH 36cm, transverse lie, FHT+, no tenderness, no
discharge and os is closed on pelvic exam; urine
dipstick +1, BSL 4.6mmol/L)
Probable diagnosis and management advise

Risk factors
Multiparity
Lax uterus most common cause
Previous cesarean section
Polyhydramnios
Placenta previa
Uterine malformation
Small pelvis
History
-

I found out from the notes that your babys position is

different from the expected. Can I ask a few more
questions? How is your pregnancy so far? Any
abdominal pain/contractions or water leakage?
Any vaginal bleeding? Do you feel the baby is

kicking? Are you maintaining a kick chart? Did you

have regular antenatal checkups? How were the blood
tests? What about the midpregnancy USD? Do you
remember what the doctor said about the baby and
placenta (Single baby and position of placenta)?
Sweet drink test? Did you have a low vaginal swab
done (GBS)? Do you know your blood group? Do you
feel your tummy is more distended than it should be?
Did you have any infection during pregnancy?
How many children did you have? What type of
delivery (2 normal and 1 CS)? Were they big babies?
Complications?
How is your general health? Ever been diagnosed
with fibroids or any uterine problems? FHx of
malpresentations? SADMA?

Physical Examination
General appearance
Vital signs
Chest and Lungs
Abdomen: FH, FHT, broad transverse uterus with a
firm ballotable round head in one iliac fossa and a
softer mass in the other, assess AFI (very subjective
abdomen tense and hard to palpate fetal parts)
Pelvic: Inspection and Speculum: discharge, blood,
cervical os, nitrazine test, NO PV

Management
Your baby has a transverse lie which is different from
the normal or expected position during term. It is
uncommon. It occurs in 0.5 to 1% of women. There
are several reasons for that: placenta previa (placenta
lying in the way of the baby and prevents the baby
from turning to normal position). We will need to do an
ultrasound to rule out this condition and
polyhydramnios (or increased amniotic fluid in the
baby) which is also another cause of this abnormal
position. The commonest reason is a relatively large
and lax uterus
after previous pregnancies. For now I
Doppler
will organize an ultrasound and CTG for you and
arrange for an obstetric assessment.
(-) are
FHTtwo options
(+) FHT
There
to manage yourCTG
pregnancy.
Whichever you choose, you will need to stay here until
delivery (Do we have a cesarean section unit in this
hospital? If not, then transfer to tertiary hospital
because labor may commence soon).
Why do I have to this stay in this hospital? The reason
for that is if labor starts and the baby has transverse
lie, it can quickly progress to obstructed labor which
can lead to uterine rupture. Another risk is cord
prolapse (cord can slip into vagina) after membranes
rupture and it is a life-threatening condition for the
baby.
If you agree, after ultrasound, an obstetrician can
rotate the baby to normal position. We call this
external cephalic version. If it is successful and your
cervix is favorable, OB will rupture the membrane and
you will go to normal vaginal delivery. External
cephalic version is quite a safe procedure. However,
approximately 0.5% requires immediate cesarean
section due to fetal distress or vaginal bleeding
(abruption). Your second option is elective cesarean
delivery. Regardless of your decision, we are here to
help you.
Let me reassure you that you and your baby will be
closely monitored by the specialist. I will call the
ambulance for transfer.

Normal

Hypoxia
If patient not at term:
Gentle cephalic version maybe attempted at 36-38
weeks if patient consents. If successful, may induce
labor and go to vaginal delivery.
Advise to report to hospital immediately when labor
starts or if social conditions are unfavorable
IUFD
Elective cesarean section

LABOUR AND DELIVERY

Reduced Fetal Movements
No fetal movement
Case: You next patient in a country clinic is a 38 weeks
gestational age lady with no fetal movements in the past 12
hours.
Task
a.
b.
c.

History
Physical examination
Diagnosis and management

33
Case: You are a GP and a 34-weeks pregnant female comes to
you asking for early induction of labor at around 37 weeks
because she wants her husband to attend the delivery and hes
going on a business trip in about 4 weeks time.
Task
a.

History
-

I understand you have come to see me because you

havent felt your babys movement for the past 12
hours. Is it the first time? Have you noticed that your
baby is moving less in the last few days? Is it your first
pregnancy? Did you have regular antenatal
checkups? How was your USD? Lab tests? Sweet
drink test? Did you have a low vaginal swab? How
was your BP throughout pregnancy? Do you know
your blood group? Did you have any infections or
febrile episodes? Do you have a fever? Headache or
abdominal pain? Hows your waterworks? Have you
noticed any unusual vaginal discharge or bleeding?
General medical health? SADMA?
Where do you live and who you do you live with? Do
you have any family members or close friends with
you today?

Physical examination
General appearance
Vital signs
Abdomen:
o FH: 20-36 weeks = 32 +2, 36-40 = +3cm,
>40 weeks = 4cm,
o uterus (soft, tender, contractions)
o Speculum: nitrazine
o Per vagina: check the cervix (4cm, posterior,
closed, station -3)

Diagnosis
I can hear your babys heart sound and it is within
normal range. There are two possible explanations for
your presentation. The babys activity could be
different throughout the day and absence of babys
movement could be due to rest or sleep. However, we
need to exclude the other possible cause which is
fetal distress due to hypoxia or lack of oxygen to the
fetus which makes your baby quiet. For this reason, I
need to send you to the hospital where CTG will be
performed. Its a simple and safe procedure. Two
sensors will be placed on your abdomen to record
babys heart rate, uterine contractions and fetal
movements. You will also be assessed by an
obstetrician. If the CTG pattern is normal, you might
have an ultrasound to assess the amount of amniotic
fluid around the baby. If everything is fine, you might
go home after that and the doctor will explain a kick
chart for you. If the CTG pattern is suspicious, the
doctor will most likely discuss induction of labor with
you. If the CTG is abnormal, you might need to have
an urgent cesarean section. You made a right decision
to come and see me today.
Elective Induction of Labor

Counsel patient and answer her questions

Indications for Induction of Labor

Maternal
o Postdated pregnancy
o PROM
o IUGR/Oligohydramnios
o Maternal Diabetes
o Pulmonary Embolism (shunting of oxygen)
Fetal
o Fetal abnormalities
o Placental insufficiency
o IUGR
Contraindications
Fetal distress
Placenta Previa
Malpresentation
CPD
Previous CS
Risk of Induction of labor
Fetal Distress
Postpartum hemorrhage
High risk of operative delivery
Uterine rupture
Counseling
Congratulations. Please tell me why you want to have
an early induction. Is there any way that your husband
can delay his trip?
How is your pregnancy so far? Any bleeding,
discharge, tummy pain, headache, visual problems,
swelling? Did you have regular antenatal checks? Did
you have all the blood tests especially the sweet test?
When was your last USD? What was the result? Do
you feel the baby kicking? Is this your first pregnancy?

Any miscarriages? Do you have any history of medical

conditions like diabetes, or high blood pressure? Any
surgical conditions for example gynecological
surgeries like cervical biopsies? How are you feeling
at the moment? Are you sleeping well? Appetite?
Bowel habits? Waterworks? Blood group? SADMA?
FHx of operative/difficult deliveries or fetal
abnormalities? Do you know your height and weight?
Do you have any family or friends to support you in
your husbands absence? How far do you live from the
hospital? Is there anyone who can drive you in case of
emergency?
As you know, elective induction of labor is a big
decision by itself. As a medical health practitioner,
there are certain indications where induction is
necessary. This includes pregnancy extending beyond
42 weeks, chronic kidney or liver disease in the mom,
very small baby, and problems with placenta. There
also some contraindications which will make it
impossible for us to induce labor like if the baby is too
big to pass through mothers pelvis, or if the baby
develops any kind of stress because of insufficient
oxygen supply. Sometimes, we avoid induction in
those who have had a previous surgical procedure to
the tummy.

34
-

There are some risks associated with elective

induction which includes high chance of bleeding from
the womb, risk of rupture of the womb, and because
the baby is delivered before term, he might suffer from
consequences of prematurity. You need to know that
not all inductions end up having NSVD. Sometimes,
we need to use instrumental deliveries such as
forceps or vacuum, or ultimately cesarean section to
deliver the baby.
Induction of labor is usually done in the hospital where
cesarean section facilities are available. You will be
seen by the obstetrician and they will assess the
babys position and size. If there are no
contraindications, they might go through it. Please
understand that we prefer to leave the baby inside the
womb until Mother Nature decides for delivery. It is
important for the babys growth and maturity. If you
wish, I can arrange a meeting with the obstetrician. It
would be preferable if you could bring your partner to
the meeting. If you like I can give you a certificate for
you husband which he can use to delay his trip.
Reading material. Review. Referral.
In the end, the decision is up to you. You can decide
with your partner after you discuss with the
obstetrician.

Pain Relief During Labor

Case: You are a GP and a 30-weeks pregnant primigravida
came to you asking about pain relief in labor.

NO2 and oxygen in a 50:50. This procedure

is very safe for both mom and the baby.
IM Pethidine injections gives pain relief
for at least 2-3 hours. Effect comes rapidly
within 15 minutes. It is commonly used but it
does have side effects (e.g. acidity and
reflux symptoms, drowsiness, and
respiratory depression in the baby) we
will adjust the dose according to side effects
Epidural analgesia gives complete pain
relief in around 95% of patients; usually
given by anesthetist into lower back
protecting the spine. Sometimes, patientcontrolled epidural analgesia is given. There
are some side effects like headache,
dizziness, and shivering. Rarely, leakage of
spinal fluid (dural tap). It has been noticed
that the use of epidural analgesia during the
2nd stage of labor leads to higher risk of
operative delivery for the patient
IV pethidine analgesia reserved for
patients after cesarean section

High Mobile Head At Term

Case: You are a GP and a 40 weeks primigravida is referred to
you by a nurse because the babys head is still 5cm above the
pubic bone.
Task

Task
a.

Counsel accordingly

Congratulations! How is your pregnancy so far? I

understand from the notes that you want to know
about pain relief. Do you know why there is labor
pain? Actually, there is contraction of the uterus,
dilatation of the cervix, and distention of pelvic tissues
as well as pressure in certain organs.
There are many methods of pain relief including nonpharmacological and pharmacological methods.
Regarding non-pharmacological methods:

Adjusting the position brings comfort to the

mom (e.g. kneeling down or standing
upright)
o Hot or cold bags applied to the tummy, back
and perineum
o Relaxation or breathing techniques with or
without a massage to encourage the mother
to tolerate the pain and reduce the anxiety.
o Transcutaneous electrode nerve stimulation
(TENS) we place 2 electrodes parallel to
your backbone. It is helpful by interrupting
the transmission of pain to the nerves. The
frequency of the current can be modified
accordingly.
o Hydrotherapy departments within the
hospital hot showers to feel better
o Hypnotherapy
o Injection of sterile water in lower back
Pharmacological
o Inhalation of nitrous oxide gas which gives
pain relief for 20-30 secs. Patient can
administer the gas by herself through a
mask during a contraction. The machine is
called entonox which contains a mixture of

a.
b.
c.

History
Physical examination
Discuss possible causes and management

Differential Diagnosis
- Passage:
o CPD depends on age, nutritional status,
type of pelvis; more common in
underdeveloped countries; risks involve
obstructed labor, shoulder dystocia,
increased risk of CS in primigravida, higher
maternal morbidity and mortality, difficulty
with subsequent pregnancies
o Fibroids/Ovarian tumors
o Placenta Previa

History
-

Passenger:
o Malposition especially occipitoposterior
position
o Fetal macrosomia (>95% percentile)
o Coil abnormalties (short coil/cord coil)
How are you doing at the moment? I understand you
are 40 weeks pregnant. Any problems like bleeding,
discharge, or leaking of fluid? Tummy pain?
contractions? Headaches or visual problems? Have
you noticed swelling anywhere in the body? How has
your pregnancy been so far? Have you had regular
antenatal checks, blood tests, and ultrasound? When
was your last USG? What was the result? Do you
remember the babys weight from the USG? What
about the placenta? Was it normally located? How
about the amount of fluid around the baby? Did you
have a sweet test (16-28)? What was the result? Is
this your first pregnancy? Any previous miscarriages?
If not previous pregnancy: what was previous weight?
Any complications? Mode of delivery?

35
-

Any medical or surgical history? How is your general

health? Do you know your weight or BMI? May I ask
how tall you are? Have you ever been diagnosed with
any problems like fibroids or growth within the
ovaries?
SADMA? Gardasil? Blood group? Trauma to pelvic
bones? FHx of difficult deliveries?

Physical examination
- General appearance
- Vital signs: BMI
- Abdomen: FH, lie, presentation, FHT, engagement
(>36 weeks/floating), amount of liquor
- Pelvic exam:
o Inspection: bleeding, discharge, show,
leaking of fluid
o Speculum: cervical os, discharge, bleeding,
bulging of membranes, nitrazine test
(leakage of amniotic fluid)
o Bimanual examination: tenderness, position
of cervix, length, mass
Investigations
- Ultrasound: look for fetal wellbeing, AFI, additional
masses or abnormalities
Management
- From history and examination, it seems like there is
nothing that might be preventing the babys head from
engaging within the pelvic bone. It could be a normal
phenomenon where the head may go down within the
next few days. You will then have the signs of labor
which are abdominal contractions, leakage of water, +
small amounts of bleeding
- What I want you to do is:
o Keep a daily kick chart for the babys
movements (at least 10 in 12 hours)
o I will write a request for ultrasound with
Doppler
o Come for CTGs 2x/week until 42 weeks
if during the 42nd week, condition remains
the same, the specialist might decide to
admit you for possible induction of labor with
the help of artificial rupture of membranes
and the use of a vaginal gel (prostacyclin).

During your visit with the specialist, she might decide

to do a pelvic examination to assess for possible CPD
where the mothers pelvis is not suitable for the babys
head to engage into. It is done with the help of a
bimanual examination. Sometimes, the specialist
might do an Xray or a CT scan in doubtful cases. It
also depends on the mothers height. If during
pelvimetry the specialist thinks that your pelvis is
insufficient for NSVD, they may offer you a trial of
labor, possibly followed by cesarean section.
Pelvimetry: AP <13, Oblique < 12, and tranverse
diameter <11 contracted pelvis
Referral and review

Prolonged First Stage of Labour

Case: A 25-year-old primigravida has been admitted for labour 4
hours ago. At that time vaginal examination showed cervix was
effaced 4cm dilated. 4 hours later cervix is 5 cm dilated
Task

a.
b.
c.

History
Physical examination
Management

Features: Expected speed

- Latent phase: 6hours up to 4cm
- Active phase: 1cm per hour. Up to 6 hours.
- In this case now the expected speed: At least 3
contraction in 10 mins lasting 30-90sec
History
-

Hello Margaret. How are you? How long have you

been having contractions (8 hours ago)? How often do
they come (had 2 contractions in 10 min)? How long
do they last (30seconds)? Are they painful? 0-10? Did
you have something for the pain? Did it work? We can
adjust your pain relief in a few minutes. Have you
notice water leakage or bleeding (No)?
Just a few questions regarding your pregnancy: Did
you have regular check-ups? Any problems with your
blood test? Mid pregnancy ultrasound? Sweet drink
test (big baby)? GBS swab? Result? Do you know
your blood group?
What is your and your partners height (big husband
and small wife)? Are you generally healthy? PMHx:
DM? Surgeries? Pelvis bone fracture? Ever been
diagnosed with ovarian cyst or fibroid (occlude the
pelvis)?
If multi: How big was the baby? What was before?

Physical Examination:
- General Appearance: Is it just a delayed of 1st stage
labour or obstructive labour
- Vitals: tachycardia in obstructive labour
- Abdomen: palpate the uterus and assess frequency
and length of contractions, lie and presentation. How
much of fetal head palpable per abdomen (5 fingers
palpable head above the pelvic brim. 0 fingers means
the head is already in the pelvis)? FHR?
- Pelvic: Per Vaginal examination: effacement dilated?
How much? Is membranes intact or not (NO)? The
position of the head: Try to find the fontanelle: Anterior
Fontanelle: diamond shape. Occipital bone: posterior
fontanelle. Occipital anterior/ occipital
posterior/transverse position/oblique. Stations: relation
to Ischial spine -5 to +5. Moulding and caput? Overlap
of the suture line.

o
o

If mild moulding not concerned

If severe moulding think of obstructive
labour.

Management
- Margaret I know you have been in labour for the past
8 hours. Unfortunately your last 4 hours are not very
efficient. You are at active phase of 1st stage labour.
Cervix should dilate more rapidly. Expected rate is
1cm per hour. The most likely cause for failure for
cervix to dilate is inefficient uterine contractions.
- What could be done? In this case management is
artificial rupture of the membranes. With your consent
we will break your water. (Empty the uterus easy for
uterine to contract). +/- Oxytocin or 1- 2hours of
observation.
- We will monitor progress of labour closely.
Contractions will be assessed every 15-20min. Rate of
oxytocin infusion will be slowly increased and

36
adjusted. You will be on continuous CTG monitoring
once oxytocin is given. If in 4 hours the cervix fails to
dilate by >4cm we will consider C-section. Abnormal
CTG pattern or signs of obstruction will also be an
indication for C-section. Otherwise normal vaginal
delivery is possible once contractions are efficient. I
will also organize pain relief for you.

Case: You are in ED in a district hospital where facilities for Csection and new born resuscitation are available. Your next
patient Mrs. Brown, is a 32-year-old G2P2L1 10days postdated.
She presents with a history of leaking water which is green in
colour. The pregnancy was uneventful, except for 36 weeks
group B streptococcus positive.

Case (Condition 125): Your patient is a 25yo primigravida who is

in early labour at 41 weeks of gestation. She is in the local
district hospital where you are attending as a general
practitioner. The hospital has good facilities but a consultant
obstetrician is not available. Pelvic examination 30 minutes ago
showed the cervix was 3cm dilated, well effaced, and well
applied to the presenting part. The cephalic presentation was
position left occiptotransverse (LOT), at zero station, with no
caput or moulding evident. The membranes were still intact and
allowed to remain so. Spontaneous rupture of the membranes
then occurred and revealed profuse, thick meconium-stained
liquor. The pregnancy had been uneventful to date, and blood
pressure and urine testing have been normal in labour. The fetal
heart rate, as defined using auscultation, has been between 130
and 140/min.

Task

Task

Meconium Stained Liquor

a.
b.
c.
History
-

Take history
Physical examination (Per abdomen: cephalic
position, engaged , FHS: normal OS dilated 2 cm, and
well effaced; CTG: normal)
Management
I understand its your second pregnancy. Could you
tell me more about it? Any pain? Any bloody
discharge? Is the baby kicking as usual? From your
notes your 36 weeks bug test was positive. The doctor
must have informed you. We will take care of that. Are
you allergic to any med? Whats your blood group? If
the previous pregnancy was normal?

Physical Examination:
- General Appearance
- Vital signs
- Chest and heart
- Abdomen: Size of the uterus, Lie of the fetus
(longitudinal or transvers), presentation, head if mobile
or engaged. FHS
- Pelvic: Inspection for discharge, blood; per speculum:
any discharge? Dilated? Effacement? Membrane
ruptured? Cord prolapse?
Diagnosis and Management
- Mrs Brown you are postdated by 10 days, and you
have rupture of membranes. We have to admit you.
We will do an ultrasound and CTG (continuous). Baby
looks fine now, if these two tests are good labor will be
induced. You will be taken cared of by the OB

registrar. We will monitor the progress of the labour

and baby with CTG. If it progresses normally, we will
allow you to have normal labour, but if not or if the
baby isnt well we will have to intervene, and use
instruments to facilitate labour or you might need an
emergency C-section if the baby goes into distress.
Meconium stained liquor is quite common in postdated
pregnancy. Baby passes stool in the amniotic fluid and
it turns green. If CTG is normal we dont need to worry
about the meconium. A pediatrician will be present
during the labour. They will suction the nose and
mouth and remove the meconium. Then they will
cover the baby, check the APGAR score. If the baby is
in distress they might consider giving your baby a
stomach wash.
For the GBS infection: From the onset of labour IV
benzyl penicillin, 1.2g first dose at admission and then
600mg 4-6hourly.

a.
b.
c.
History
-

Take any further relevant history you require.

Ask the examiner about relevant findings likely to be
evident on general and obstetric examination
Advise the patient of the diagnosis and subsequent
management during and after delivery.
When your water break? Was it green in color? How
long have you been in labor/When did the contraction
start? How often is your contraction? How long does it
last? Do you feel movements of the baby? Is your due
date a week ago? Is that correct? I know your
pregnancy has been uneventful, any problems with
blood tests, midpregnancy USD, or GBS swab? Do
you know your blood group? I know youre a bit
overdue, have you had an USD and CTG last week?
Are you generally healthy?

Physical Examination
- General appearance
- Vital signs every 2 hours
- Abdomen: FH, fetal lie and presentation, uterine
contractions,
- Pelvic examination: cervix, effacement, dilatation,
presence of membranes, presence of cord loop,
station, position of fetal head, signs of caput/moulding
Diagnosis and Management
- The baby has passed meconium which is the babys
first stool. That is why your water looks green. It is
common and often normal in post-term labor.
However, it can also be an indirect sign of fetal

distress due to lack of oxygen. That is why we need to

monitor your baby closely. I will organize
cardiotocograph for you. CTG is a safe, non-invasive
method commonly used during pregnancy and labor.
We will place 2 sensors in your abdomen to record
babys movements, heart rate and uterine
contractions. CTG will help us to assess your babys
wellbeing.
If CTG is normal and progression of labor is good, you
will still be able to have vaginal delivery. If CTG shows
small abnormalities, we will perform fetal scalp blood
sampling to assess acidosis. If present, we will need
to perform emergency CS because this is a sign of
fetal distress.
If your baby shows signs of distress in the 2nd stage of
labor (after full cervical dilatation). A pediatrician will
be present at your delivery. After birth, we will use

37

suction to clear the babys mouth and nose to prevent

particles of meconium to descend to the lungs.
o If CTG abnormal oxygen to mom, stop
oxytocin, left lateral position check
monitor if still abnormal fetal scalp
blood sampling to check pH (<7.2) and
lactate (>4.2) emergency cesarean
section
If hospital doesnt have facilities for emergency CS,
then transfer patient to tertiary hospital.

POSTPARTUM
Postpartum Hemorrhage due to Endometritis
Case: A 30-year-old lady comes to GP clinic had her second
baby 10 days ago. Now she comes of complaining increase
bleeding per vagina
Task
a.

b.

c.
d.
e.

History (6pads fully soaked with clots. Slight lower

abdominal pain. Full term vaginal delivery no
complications. No fibroids. Skin delicate and easily
bruised. No breast tenderness, no swelling or legs or
discoloration.)
Physical Examination findings (GA: Well. A bit pale,
V/S: BP: low but within normal range. Tachycardia,
Neck is normal., Abdominal examination: No rigidity
but mild tenderness in the lower abdomen, Uterus 14
weeks in size, Pelvic examination: No laceration, no
hematoma, Per speculum: Bleeding (+), OS: 2cm,
Bimanual examination: No cervical excitation, 2
fingers above the public symphysis)
Investigations
Diagnosis and Differential Diagnosis
Management

Differential Diagnosis
Retained placenta
Bleeding disorder
Endometritis
DIC
Trauma
History:
Is my patient is hemodynamically stable? If no:
DRABC
Bleeding questions: When did it start? How much?
How many pads are you changing? Are they
completely soaked? Are there clots? Any smell? Is it
bright red or dark bleeding? Any bleeding from
anywhere else in the body? (DIC) Do you have any

fever? N/V? tummy pain? Any dizziness? SOB? Chest

pain? Any vaginal discharge? How about your water
work? Dysuria? Frequency? Hows the baby? How are
you coping?
Pregnancy Questions: Was the pregnancy normal?
Any complications during pregnancy? Is this your first
baby? Was it a normal full term vaginal delivery? How
long was the labour? Was it a normal or complicated
labour? Any PROM? Did you have episiotomy? Were
there any instrumental or other assistant method used
during delivery? Was the 3rd stage of labour complete?
Was the placenta completely removed? Was there
any complication after delivery? Were you discharged
from the hospital early? Any bleeding or clotting
problem? Were you on any medications? Do you have
any chronic condition? SADMA?

Physical Examination
GA: any signs of dehydration?
V/S: BP: 115/65 Temp: febrile RR:20 sat: normal
Breast examination
Heart and lung
Abdomen: Not distended, no signs of peritonitis, bowel
sound heard. Slight tenderness in the suprapubic
area. Renal angle tenderness (-)
Pelvic examination:
o Inspection: Any laceration, Any hematoma,
Any episiotomy cut infected bleeding any
discharge.
o Speculum (OBD): OS, Bleeding, Discharge,
laceration? Trauma to the vaginal wall? Any
blood discharge or tissue coming out from
the OS
o Bimanual Examination (TAC): Tenderness,
Adnexal, Cervical excitation, Uterine size:
after delivery: 20weeks
1day: 16weeks
10days: 10 weeks or less
2weeks: inside the pelvis
Calf pain/tenderness?
Urine dip stick: blood +++
Diagnosis and Management
Based on physical examination and history the most
probable diagnosis is Endometritis. Do you know what
it is? The inner lining of the uterus is infected. But you
can also have retained POC or some bleeding
problems. Id like to do some investigations to rule out
other conditions: FBC,CRP, ESR, Blood group and
hold, If the temperature is about 38.5 we do blood
culture, urine micro/cult and sensitivity, coagulation
profile, LFTs, U/S, Swabs(high vaginal swabs, wound
swabs, Endo cervical swab)
If its mild Endometritis: Outpatient treatment: Panadol
or oral Amoxycillin plus Metronidazole.
This patient is allergic to penicillin: use Cephalexin or
Erythromycin.
If moderate or severe (Temp: 39, Dehydrated, Toxic
and tachycardia): hospitalize and IV antibiotics:
cephalosporins and Metronidazole 5~7days
Review: in 2 weeks time
Red Flags: Increase temperature, chills and rigors,
and increase in abdominal pain
Retained POC: Antibiotics for 24 hours and D&C
Mastitis: Flucoloxacillin. Continue breast feeding with
complete empty. Compresses(hot and cold) Follow up
in 2 days.

Postpartum Pyrexia
Case: You are a GP and a 29-year-old female had a normal
vaginal delivery 3 weeks ago. She had a baby boy who is
healthy and doing well. Patient is complaining of fever and
shivering.
Task
a.
b.

History (fever since 2 days ago, decreased appetite,

breastfeeding, NSVD, abdominal pain (+),
PE: pulse: 106, T: 38.6; mild tenderness over lower
umbilicus, uterus involuted, no mass or tenderness;
dipstick and BSL N; pelvic: no clots, discharge,
episiotomy scar healing, no mass and tenderness;
fissured nipple, cracked and inflamed

38
c.

Management

Mnemonic: After Uni, Every Woman Should Marry

Atelectasis (0-1)
UTI (1-2)
Endometritis (2-3)
Wound infection (3-5)
Septic thrombophlebitis (5-7)
Mastitis (7-21)

Breast abscess: can happen anytime

Organism:
- Staphylococcus aureus (from babys mouth or over
skin)
- E. coli
- Candida
History
-

Congratulations on your pregnancy and delivery. How

is your baby doing? Please tell me more about this
fever? Since when? Chills? Severity? Is it continuous
or come and goes? Medicine? Did it help?
Associated symptoms: cough? SOB? Chest pain?
How are your waterworks? N/V? tummy pain?
Discharge from down below? How was the delivery
(Normal or CS)? Did you have an episiotomy? Does
the wound hurt?
Any leg pain? Redness over calf? Temperature?
Swelling?
Are you breastfeeding the child? Tenderness/pain
over the breasts? Redness over skin? Bleeding
around nipples? Is it painful while feeding?
PMHx: DM? Hypertension?
SADMA?

Physical examination
- General: Dehydration? Pallor? Jaundice?
- Vitals
- Chest: auscultation for air entry or added sounds
- Heart: visible localized swelling
- Breast: redness? Fissure? Cracked nipples? Palpate
for tenderness, engorgement of breast, change in
temperature over that area, local lymph nodes that are
enlarged
- Abdomen: tenderness especially suprapubic, size of
uterus, loin tenderness (pyelonephritis)
- Pelvic: lochia, discharge, odor, color; episiotomy:
redness, edema, tenderness over wound; discharge
swab for culture and sensitivity
- Leg: swelling, redness and tenderness
- Urine dipstick and BSL

Mastitis

Case 2: You are a GP and a 29-year-old woman came in

because of fever. She had cesarean section 3 weeks ago and
was recovering well until 2 days ago when she becomes shivery
and cold.
Case 3: A 25-year-old lady 4 days postpartum forceps delivery
used, Temp 39, Redness and tenderness in right breast:
Task
a. History
b. Physical examination (flushed, T: 39, PR: 90,
Bp:125/75, axillary lymphadenopathy on the right,
obvious erythema of the right breast, tenderness on
the RUOQ, well-healed CS wound,. BSL 6.6, urine
dipstick normal; pelvic examination: normal discharge,
no tenderness )
c. Diagnosis and management
Causes of Pyrexia
- Genital
o Endometritis
o NSVD: infected episiotomy scar; infected
laceration
o CS: wound infection
- Non-genital
o UTI
o Mastitis
o DVT
History
-

Investigations
- FBE, CRP
- Urine MCS
- Swabs if appropriate
- USG: retained POC
- USG of breasts if in doubt of abscess; mastitis: clinical
diagnosis
Management
- Postpartum pyrexia where patients develop fever
within 6 weeks of giving birth is due to a number of
reasons including infection of womb, UTI, or breast
infections. On exam, I could see that your left breast is
red and tender. Most likely you have mastitis. It is very

common during initial breastfeeding period.

Sometimes, because of poor feeding technique, the
baby suckles on the nipple only. The nipple cracks
and bleeds and bugs from the babys mouth or moms
skin enter the breast tissue and cause infection. At the
moment, I would give some antibiotics (flucloxacillin or
cephalexin for the next 7-10 days). I would give some
analgesics (PCT). It is important to keep the breast
drained by feeding or manual evacuation/expression.
For soothing effects, refrigerated cabbage leaf. While
feeding, try to massage the breasts towards the nipple
to help evacuation. There are ointments available to
help with cracked nipples. I will give you reading
materials regarding proper feeding techniques. You
need to rest and have ample fluids. We will perform
USG of the breast and repeat 3 days later to see if
abscess has developed.
Red flags: If the redness/pain does not go away, if you
feel a swelling on the breast, fever persists, please
come back or if very ill or high spikes of fever
admit for IV antibiotics
Endometritis: admit! Rehydrate (aminoglycoside +
clindamycin + metronidazole)

Congratulations on the birth of your baby. Is it your

first baby? Is everything going well at home?

I understand you have come to see me because

youre feeling unwell. Did you measure your
temperature? Is it up and down or constantly high?
Hows your appetite? Do you have N/V? Do you feel
tired? Do you have loin or back pain? Hows your
waterworks? Do you have burning sensation when
passing urine? Has the color of your urine change?
Do you have abdominal pain? How is the wound
looking? Any discharge or redness? Do you notice any
unusual vaginal discharge or bleeding? Tummy pain?
Do you have cough, runny nose, earache or sore
throat? Are you breastfeeding? Any problems with

39

breastfeeding? Do you have breast pain? Have you

noticed any changes in the color of breast skin? Any
lumps or swelling? Any swelling under the armpits?
Do you have calf pain or swelling? Did you have a
planned or emergency CS? Were you discharge from
the hospital as expected?
Are you generally healthy? Medications? allergies?

Physical examination
- General appearance
- Vital signs
- Lymphadenopathy: neck and axilla
Breast:
o Erythema, swelling, cracked nipples?
o Palpation: tenderness and lump (site, size,
shape, surface, border, mobility, tenderness,
fluctuation), temperature
- Abdomen: scar, palpable uterus (no longer palpable
by 2 weeks); renal angle tenderness
Pelvic: abnormal discharge; PV: size of uterus,
tenderness (bulky and tender if endometritis), adnexal
masses and tenderness
- Calf tenderness
- Urine dipstick

Postpartum Issues:
Fever
Depression
Psychosis
Mastalgia
Dyspareunia
Contraception
History
-

Congratulations! How does it feel to be a mother?

How is the baby? Does the nurse visit you?
Was it a planned pregnancy? How was the antenatal
care? Anything significant? How was the delivery?
Long labor? Any complications? Are there any pain
down below, discharge? Are you breastfeeding or
bottlefeeding? Any breast pain or sore nipples? Any
masses or lumps in the breast?
Is there any social support available to you?
Pap smear? Pills? Periods?
Partner: Are you sexually active now? Any problems
with intercourse? Was there any bleeding after
intercourse? STIs? Did you get your periods back?
What contraception were you using before? Have you
started taking any contraception?
General health?

Diagnosis and Management

Vital Signs
- You have a condition called lactational mastitis. Do
General appearance
you know what it means? It is a common condition.
Vital signs
About 20% of breastfeeding women in Australia will
face similar problems.
- Mastitis is an inflammation of the breast which is
Breast examination
commonly associated with bacterial infection
Pelvic examination:
(staphylococcus). Commonly, breastfeeding is
o Inspection: discharge, lochia
challenging and can cause cracked nipples, which is a
o Speculum: check for dryness of vagina,
painful condition that leads to milk stasis. It also
episiotomy scar
creates an access for bacteria which live on the skin
to enter the breast tissue and cause inflammation. I
Postpartum dyspareunia
will order some blood tests (FBE, CRP and blood
culture).
- You need to continue breastfeeding. Do you need the
HISTORY
help of a breastfeeding specialist? You need to keep
the affected breast well drained. You can have a hot
shower or put a face towel before breastfeeding. Cool
the breast after breastfeeding. Massage any breast
Pre-existing
Acquired
lump gently towards the nipple while feeding. Empty
the breast completely after breastfeeding (manual or
pump).
Refer to psycho-sexual therapist
- I will give you antibiotics (Flucloxacillin x 5
Non-organic
Organic
days/Cephalexin/Clindamycin) and painkillers.
- If your condition does not improve in 24-48 hours or if
you have any concerns, please come back to see me.
Vaginal dryness
Episiotomy Scar Issues
We might need to do breast USD to rule out breast
abscess. Otherwise, I will see you in 2-3 days to
discuss results of your test.
Initial: continue with breast feeding. If no response in
12-14 hours treat with Flucoloxacillin 500 QID
OB referral
Lubricant
If allergic: Cephalexin oral 500

Postpartum Checkup
Case: Your next patient in GP practice is a 22-year-old lady for
checkup after her first baby was born 6 weeks. Her pregnancy
was uneventful and the baby was delivered normally.
Task
a.
b.
c.

Relevant history (dyspareunia)

Physical examination
Diagnosis and management

Diagnosis and Management

On examination, we found that you have a dry vagina.
It can happen normally after childbirth. At this moment
you are breastfeeding that is why a hormone called
prolactin is high which inhibits estrogen, the lack of
which leads to a dry vagina and painful intercourse. It
should be fine within a few months. In the meantime,
you can use lubricants. If it becomes persistent, I
might need to refer you to the obstetrician.

40
-

In terms of contraception, breastfeeding can be an

effective form of contraception but you have to fulfill
several criteria: exclusive breastfeeding in infant, child
<6months, you have not had your periods yet. Failure
rate is 1-2%. There are other methods of
contraception which are safe in lactation. Minipills or
progesterone only pills. It is better to start after 3-6
weeks and their efficacy is better. Another option is
depo-provera. It is injected intramuscularly and needs
7 days before becoming effective. The efficacy is 98%.
Another option is implanon and it is better to start 3
weeks after delivery and can be used up to 3 years.
The last one is IUCD. These are devices inserted into
the uterus 6 weeks after vaginal delivery and 12
weeks after cesarean section. IUCDs are effectively
immediate, last for 10-12 years. Efficacy is 99%.
Higher chances of PID and ectopic pregnancy.
Condoms.
It is your choice.
Reading material.
Review.

Primary Postpartum Hemorrhage

Case: Your next patient is a 25-year-old primi who had a normal
vaginal delivery 20 minutes ago in one of the country district
hospital. You are an HMO on call. Pregnancy was normal. Labor
went for 14 hours and now the midwife calls you because the
patient has lost 1.5L of blood. She asks you to come and help
her.
Task
a.
b.
c.
Types
-

Ask the midwife appropriate questions (BP 85/5-, pale,

blood clotting, uterine lax, no lacerations)
Advise her on what to do until you arrive
Complete the management when you reach the
hospital
Primary: blood loss per vagina of more than 500ml in
the first 24 hour after delivery
Atonic uterus (insufficient contraction
shortening and kinking of the uterine blood
vessels and prevent further blood loss)
o Retained placental fragments prevent
placental site retraction
o Laceration of genital tract
o Uterine rupture
Secondary: bleeding of more than 500 ml after 24
hours
o Retained products of conception (placenta)
o Birth trauma
o Uterine infections (endometritis)
o

History
-

there are retained products? Is the blood clotting? Is

the patient bleeding from anywhere else (No)?
On arrival:
- Check vitals, IV lines and catheter
- Start syntometrin (Oxytocin + Ergometrine)
o Ergometrin contraindication: heart disease
and hypertension
- Massage uterine fundus
- Check placenta
- Do speculum examination to check for lacerations
- Call registrar
Management
I have called the registrar and they will take you to the
theater to examine the uterus under anesthesia to
check for any retained placental fragments. They can
do bimanual compression of the uterus. If it doesnt
work, they will give you intrauterine prostaglandins to
promote contraction. If unsuccessful, they will go for
internal iliac artery ligation.
- If all measures fail, the last resort would be
hysterectomy. However, we will do our best to prevent
this as this is only your first pregnancy.
Secondary Postpartum Hemorrhage
Case: You are an HMO in ED and your next patient is a 35-yearold woman. She delivered her baby 5 days ago and she is
complaining of vaginal bleeding.
Task
a.
b.
c.
History
-

What are the vitals (85/50, 130)? Is she

hemodynamically stable? Can you please secure IV
lines, take blood for grouping and crossmatching, and
start IV fluids. Is she on a urinary catheter? If not, can
you please insert a catheter?

Is she conscious (Yes)? Is she having SOB (yes)?

Can you please give her oxygen. What was the mode
of delivery (instrumental delivery with forceps)? Was it
a single baby or multiple? Any genital tear? Was
episiotomy done? What is the weight of the baby and
how is the condition? Is the uterus lax or contracted
(lax)? Have you checked the placenta? Do you think

History (started 10 hours ago, soaked 7-8 pads,

NSVD, BS 3.2 kg, epistiotomy +, pain in stomach +,
NSVD, full term, not a difficult labor)
Physical examination (pale, SOB, increased HR,
fever, tachypneic, postural drop, + tender uterus, +
bleeding, scar okay, no laceration)
Management

Is my patient hemodynamically stable? When did it

start? How many pads have you used since then? Is
the pad fully soaked? Have you passed any clots or
tissues? Are you bleeding from anywhere else like
nose, gums, urine? Do you have SOB, palpitations or
dizziness? Do you think you have fever? Any other
vaginal discharge? Any tummy pains? How was the
delivery? Was the baby term? Was it a long or difficult
labor? Did they use forceps? Did they give you a cut
during delivery? What was the weight and size of the
baby? Have you established breastfeeding? Any
problems with breastfeeding? Any problems with
waterworks? Are you aware of your blood group and
your babys blood group? Any pain in your legs?
Any other significant past medical history? do you
have any FHx of bleeding problems?

Physical Examination
- General appearance
- Vital signs
- Abdomen: distention, uterus, masses, organomegaly

41
-

Pelvic: episiotomy wound, check site of bleeding

whether from wound, cervix or uterus, discharge;
lacerations, od open; uterus; adnexal masses
Urine dipstick and BSL

Diagnosis and Management

- From the history and examination, you are suffering
from a condition called secondary postpartum
hemorrhage which is bleeding after 24 hours of labor.
There could be a number of reasons for that but most
likely, in your case, it is because of a small piece of
placenta which has been retained in your womb.
- At this stage, I will admit you, secure IV lines take
blood for FBE, coagulation profile, grouping and
crossmatching and start IV fluids. I will take some
swabs from your vaginal area for any infections.
- I will call the OB registrar and arrange an USD. If the
ultrasound confirms retained placenta, the specialist
will do curettage. I will also start you on antibiotics
because the uterus might have been infected
(ampicillin + gentamycin + metronidazole).

Primary amenorrhea(Constitutional Delay/Familial)

Case: Your next patient is an 18-year-old girl with primary
amenorrhea. All secondary sexual signs have been present for
the past 3 years. She has not spoken about this to anyone, but
is now in a relationship.
Task
a.
b.
c.

Focused history
Examination
Diagnosis and management

Differential Diagnosis:
- Imperforate hymen
- Genital malformations/Mullerian duct agenesis
- Excessive exercise
- Eating disorders
- Pituitary tumors/Hyperprolactinemia
- Hypothalamic disorder (stress)
- Turner syndrome
- Gonadal dysgenesis (ovaries)
- Thyroid disorders
History
-

Ensure confidentiality
HPI: how about your growth spurt (recently 2-3
years)? Do you think your breasts have developed?
Axillary and pubic hair? How is your height when you
compare it to your friends? Are you on a special diet?
Do you do excessive exercise? Do you take laxatives
or induce vomiting? Do you consider yourself
overweight? How do you feel when you look at
yourself in the mirror? Any change in your weight? Do
you have any weather preferences? Any lump in your
neck or change in your voice? How about your bowel
motion? Have you noticed any milk secretions from
your breast? Any problems with vision or headache?
Do you experience cyclical abdominal pain every
month? Any breast tenderness or early morning
sickness?
Partner, Pills, Pregnancy, Pap
Social: how are things at home? Hows the uni? Any
stressors (boyfriend, home)?
FHx: do you know when your mom had her periods?
Do you have a sister? When did she have her
periods?
SADMA
Are you stressed or worried about this?

Examination
- General appearance: normal for age; BMI - normal;
hirsutism
o Puberty: 8-13 (F), 9-14 (M)
- VS: BP;
- ENT: thyroid swelling
- Breast: breast development; axillary hair
- Chest and heart: normal
- Abdomen: suprapubic mass (imperforate hymen)
- Pelvic exam: inspect external genitalia (tanner staging
pubic hair development); speculum: hymen
- Urine dipstick, PT and BSL

GYNECOLOGY
DISORDERS OF MENSTRUATION

Investigations:
- FSH, LH, prolactin, estradiol
- Chromosome analysis
- Pelvic ultrasound

42
Management
- You have a condition called primary amenorrhea. It is
defined as failure to start menstruation by 16 years of
age. In your case, it is most likely physiological or
constitutional or familial as your mom also had
delayed periods, but there could be other causes as
well. So I would like to organize some investigations:
FBE, USD (abdominal), and hormonal studies, TFTs.
- Reassure. But if persistent, I can refer you to a
specialist gynecologist who may consider hormone
challenge test.
- Review after reports are back.
Amenorrhea
Case: 24-year-old female with a 1 year history of amenorrhea.
Task:
a.
b.
c.
d.
e.

Focused history
Physical examination
Investigations
Management
Differential diagnosis

Secondary Amenorrhea
Natural: pregnancy/lactation/menopause
Metabolic: unstable DM, renal failure, hepatic
failure, thyroid disorders
Hypothalamic: eating disorders (anorexia),
emotional stress, excessive exercise (competitive
sports), drugs (GnRh
agonist/danazol/contraceptives)
Pituitary: tumors, micro and macro-adenoma,
pituitary infarction (Sheehan syndrome)
Ovaries: POF, PCOS
Uterus: asherman syndrome
History:
Can you please tell me when was your last menstrual
period? Did your period stop suddenly or gradually?
Period: Menarche? Were they regular? How long is
the cycle? How long is the bleeding time? Did you
have excessive bleeding or pain during periods?
Spotting in between periods?
Partner: are you sexually active? Are you in a stable
relationship?
Pills: do you use any form of contraception? Which
type?
Pap smear? Offer if >2 years. Was it normal?
Pregnancy: Have you ever been pregnant?
Are you on a special diet? Have you been stressed for
the past year? Do you exercise regularly? And how
often?
Do you suffer from headaches? Visual disturbance?
Have you noticed milky discharge from your nipple?
Can you tolerate cold weather? Any change in weight
in the past year? Do you suffer from constipation?
Hot flushes? Dryness of vagina? Is intercourse
painful?
Do you notice any excessive hair growth? Acne?
Deepening of the voice?
Are you generally healthy? Any gynecological
procedures in the past? SADMA?
FHx: POF, thyroid disorders
Physical examination
General appearance: BMI, hirsutism, acne
VS

ENT: visual fields; palpate thyroid; do breast

examination including nipple discharge
Abdomen:
Pelvic exam:

inspection and speculum: atrophic vaginitis

size of uterus; palpate adnexa for masses
and tenderness
DO pregnancy test: I understand that the likelihood of
my patient being pregnant is low but pregnancy must
always be included.
o
o

Investigations:
FBE, U&E, LFTs
FSH, LH, estradiol, prolactin, TSH
Pelvic USD
BSL
Bone density scan
CT/MRI if suspecting pituitary tumors
Management:
Kathy according to you history and PE, you most likely
have secondary amenorrhea due to excessive
exercise? We will still run investigations to exclude
other causes like problems with the thyroid gland,
ovaries, and pituitary glands.
Decrease amount of exercise to moderate and your
periods will come back to normal
Other options include OCP or HRT to prevent
osteoporosis thinning of your bones
Increase calcium in diet or we can consider ca/vit D
supplementation
Asherman syndrome after miscarriage
Case: 30-year-old lady who had a miscarriage 5 months ago
and has come to see you because she hasnt had a period yet.
OTHER: after manual removal of placenta
Task
a. History
b. Manage case
History:
I understand that you have come to see me due to
absence of your period since 5 months.
Did you experience any spotting? Sorry to ask but at
which age of pregnancy did you miscarriage? Did you
have curettage? Any problems after miscarriage
(fever? Bleeding? Discharge?)
5Ps
Ho w many pregnancies have you had? Could you be
pregnant? Any gynecological procedures done in the
past?
Ask differential diagnosis questions
Management:
Sophie first we would do PT to exclude pregnancy. We
also would check your hormones, FSH, LH, estradiol,
prolactin, TSH to exclude different causes
We will do pelvic usd. According to your history you
most likely have secondary amenorrhea due to
asherman syndrome. It is the formation of adhesion or
scar tissues inside the uterus. It is a well-recognized
complication of curettage.
The ability of the inner lining of the uterus to recover is
reduced during the pregnancy. Together with surgical
procedure, it contributes to scarring inside the uterus.
There is a treatment for this condition. I will refer you
to a gynecologist. Most likely the doctor will perform
hysteroscopy. Under anesthesia,a small flexible optic
tube is placed thru the cervix into the uterine cavity. It
helps to see intrauterine adhesions and cut them.

Sometimes its not possible to see inside the uterus

immediately, so contrast and xray study might be used

43

to find the uterine cavity and define all the scar

tissues.
After procedure, gynecologist will prescribe estrogen
to increase the repair of the inner lining.
As any surgical procedure, hysteroscopy carries some
risks. Complications are uncommon but it includes
anesthesia risk, infection, bleeding. Rarely,
perforation.
It is effective treatment and most likely you can get
pregnant again. Success depends on the extent of the
disease and how difficult is the treatment.

Secondary Amenorrhea (Premature Ovarian Failure)

Case: 30-year-old presenting because she hasnt had a period
for about 1 year.

Secondary Amenorrhea secondary to Polycystic Ovarian

Syndrome
Case: A 21-years-old lady has come to see you in your GP
clinic. She hasnt had a period for a few months.
Task
a.

Task:
a.
b.
c.
d.

History
Physical examination
Investigations
Diagnosis
Management

History: same as 1st 2 cases. Ask for differentials!!

PMHx: autoimmune disease (SLE, DM, RA etc..)
Chemoradiotherapy or previous surgery
Drugs (especially cytotoxic)
FHx: 10% of POF run in family
Physical examination:
General appearance: hirsutism, acne, BMI
Vitals
Visual fields, Thyroid, breast
Abdomen
Pelvic: Inspection atrophic changes
Bimanual examination size of uterus, adnexal
masses and tenderness
Pregnancy test
Investigations:
FSH (high), LH, estradiol, prolactin, TSH
Pelvic USD (thin endometrium, few follicles growing)
BSL
Bone density scan
Management:
According to your history and PE, you have secondary
amenorrhea most likely due to premature ovarian
failure. POF is a condition in which ovaries stop
functioning normally in women who are younger than
40. In women with POF, the ovaries stop releasing
eggs or release them only intermittently, and stop
producing the hormones estrogen, progesterone and
testosterone or produce them only intermittently.
In the vast majority of cases, POF has no known
cause. Some cases of the condition can be explained
by genetic abnormalities (Turner or fragile x
syndrome), exposure to toxins and autoimmune
disorder.
Thats why I would like to refer you to a gynecologist
for further assessment and management.
You also need to know that POF often interferes with
a womans ability to get pregnant. Even so, between 1
and 10% of women with the condition are able to
conceive normally as there is a chance of intermittent
improvement of ovarian function.
However, if infertility is a problem, there is also
effective an treatment for that, IVF with donor eggs.

One of the main goals for POF is replacement of

estrogen that the ovaries stopped producing. OCP or

HRT are usually used. These hormonal pills will

reduce your symptoms, prevent osteoporosis and
possibly, cardiovascular disease. Most experts agree
that young women with POF should use hormonal
therapy at least until they turn 50.
HRT if patient wants to get pregnant because of
lower levels of hormones

b.
c.
d.

History (sexually active, stable partner, not on OCP,

amenorrhea x 6 months; menarche at 16, teacher, not
so stressed; no headache, weakness, n/v, s/p
appendectomy, goes to gym 2x a week, no weather
preference,
Physical examination (BMI 27, increased hair on chin
and upper lip)
Investigations
Management

Features:
- Roterdam criteria (2/3)
o Anovulatory cycles (prolonged >40 days and
irregular)
o Clinical or biochemical of androgen excess
o PCO on USD (>12): necklace appearance
- Increased LH increased androgen
(androstenedione) converted to testosterone
- Decreased FSH increased insulin secretion
History
-

I understand you came to see me because you are

worried about your periods? When was your LMP?
Did your periods stop suddenly or gradually?
Periods: When was your first period? How many days
of bleeding? How many days apart? Any bleeding in
between?
Stable relationship? Sexually active?
Are you on any contraceptives? When was your last
pap smear? Was it normal?
Have you ever been pregnant? Are you trying to
conceive at the moment?
Are you on a special diet? Have you been stressed
recently? Do you exercise regularly? Have you
suffered from headaches or any visual disturbance?
Have you noticed milky discharge from your nipples?
Can you tolerate cold weather? Any recent change in
your weight? Any recent change in your weight? Do
you suffer from constipation? Do you have hot
flushes? Is intercourse painful? Have you noticed
excessive hair growth, acne, thinning of your hair or
deepening of your voice?
Are you generally healthy? Have you ever had any
surgeries or gynecological procedures? SADMA?
FHx

Physical Examination
- General appearance, hirsutism, acne and BMI
- Vital signs
- Visual field, thryoid and breast exam
- Abdomen
- Pelvic exam: size of uterus, adnexal masses and
tenderness
- Urine dipstick and urine PT

Investigations

44
-

LH: FSH ratio = 3:1; estradiol, testosterone,

androstenedione, prolactin, TFTs, FBS, pelvic USD

Management
- According to history and PE, you most likely have
secondary amenorrhea due to Polycystic ovarian
syndrome. We will run investigations to confirm it and
exclude other causes.
- PCOS is a condition that causes irregular menstrual
cycles because monthly ovulation is not occurring and
levels of androgens or male hormones are elevated. It
is a very common condition. About 5-10% of women
are diagnosed with PCOS. The cause of PCOS is not
completely understood. Its believed that abnormal
levels of the pituitary hormone LH and high level of
androgen interfere with normal function of the ovary.
- Classic PCOS symptoms include absent or irregular
periods, abnormal hair growth, scalp hair loss, acne,
weight gain, and difficulty becoming pregnant.
Although PCOS is not completely reversible, there are
a number of treatments that can reduce symptoms.
- What is your main concern? Periods and Hirsutism
o Lifestyle modification like healthy diet and
regular exercise often help to normalize
menstrual function.
o We can also use oral contraceptives for 6
months plus hair treatment like laser therapy
or electrolysis
o If its not effective I will prescribe OCP plus
anti-androgen (spironolactone or
cyproterone acetate) Yasmin and Diane
- Pregnancy
o Lifestyle modification and try to have regular
sexual life for 6 months. If you cannot
conceive, I will refer to gynecologist for
specific treatment.
o Metformin (improves insulin resistance and
weight loss):
o Clomiphene citrate 50-70%
o FSH injection
o Surgery: drilling
o IVF
- Are there any complications of PCOS?
o Type II Diabetes
o Endometrial Hyperplasia and Cancer
o Sleep apnea
o Metabolic syndrome
o Depression
- Review once labs are in. Reading material.
Pubertal Menorrhagia (Metrostaxis)
Case: Your next patient in GP practice is a 12-year-old who is
having heavy periods for the last 10 days
Task
a. History (vaginal bleeding 5-6 pads/day, soaked with
big clots; 1st period)
b. Physical examination (distressed, pale, tenderness in
lower abdomen; postural hypotension; tachycardia)
c. Diagnosis and management
History
-

Is my patient hemodynamically stable?

When did the bleeding start? How many pads per
day? Are they soaked? Is it getting worse or better?
What is the color of the blood? Any clots? Is it smelly?
Is she bleeding from anywhere else? Is this her first
period? Does she bruise easily from minor trauma?
Any dizziness, SOB, fainting or palpitations? Is there
any tummy pain? Any possibility of trauma or foreign

body down below? Do you know if your daughter is

sexually active? Any chance she could be pregnant?
Any bleeding disorder running in the family? How
about the development of breast and pubic hair? Is
she on any kind of medications? Do you know her
blood group? SADMA? Is her immunization up to
date? Have you considered vaccination against HPV?
Physical Examination
General appearance: distressed, pallor, dehydration,
jaundice
Vital signs: postural hypotension, tachycardia, RR,
Temperature and oxygen saturation normal
Neck swelling (Thyroid) and LAD
Tanner Staging
Signs of skin bruising
Chest and heart
Abdomen: organomegaly, tenderness
Pelvic exam: inspection for blood clots, signs of
trauma, sexual abuse; development of genitalia;
Diagnosis and Management
Your daughter has a condition called pubertal
menorrhagia which is not uncommon. Because Jane
is not stable, and her BP is falling, I would like to
organize an ambulance, and start IV lines. They will
take blood for investigations: FBE, coagulation profile,
PT, APTT, vWF screen (factor VIII assay, vWF
antigen, ristocetin cofactorm PFA-100), urine
Chlamydia, PCOS screen, 17-OH-P, platelet-function
assay, iron studies, pregnancy test, TFTs, blood group
and crossmatching.
At the hospital she will be seen by a specialist and
they will start her on IV premarin for sometime plus
tranexamic acid to control the bleeding. Depending on
the results, they might do blood transfusion. Once she
is stabilized, they would put her in
uninterrupted/continuous OCPs plus iron tablets until
her hemoglobin is normal for at least 3 months.
Reassure.
If patient is hemodynamically stable: give oral
estrogen, do workup, continuous and iron tablets.
Abnormal/Dysfunctional Uterine Bleeding
Case: 43/F comes in with painless heavy periods for the last
four months. She is mother to 3 kids. Previously, some
investigations have been done including FBE, hormonal profile,
pap smear, diagnostic d&c and an endometrial biopsy. All results
are normal except for her hemoglobin which is 70.
Task: No further history taking allowed.
a. Talk to the patient regarding diagnosis and future
management
Differential Diagnosis:
a. Fibroids
b. Endometrial cancers
c. DUB
d. Bleeding disorders
e. Hypothyroidism
f. Cystic hyperplasia
g. PREGNANCY
h. Drugs anticoagulants, estrogen-containing
preparations, anti-psychotics
i. IUCD
j. Trauma
k. PID (Chronic)
l. AVM

45

History:
HPI: Since when? Are your periods regular? How
many days do you bleed for? How many pads do you
in a day? Are they soaked? Any clots? Any associated
discharge with the bleeding? When was your last
period? Any spotting or bleeding in between your
periods? Any pain during periods? What was your age
at menarche? Do you have symptoms like n/v
headache, irritability, swelling of your body before
periods? Are you sexually active? Stable relationship?
May I ask do you have any problems related to
intercourse, e.g. pain/bleeding? What contraception
do you use? What type and since when? Have you
used IUCD? Have you ever been diagnosed with STIs
or other pelvic infections?
I understand you have 3 kids, age of last child? Mode
of delivery?
Have you ever suffered from a bleeding disorder, DM,
thyroid? Any previous gynecologic sx? Have you lost
weight recently or change in appetite? Any night
sweats or prolonged fever?
SADMA? Pap-smear?
FHx: bleeding, thyroid
Physical examination:
General appearance: pallor, jaundice, dehydration,
BMI
VS: BP (postural)
Skin: bruises or purpura
Stigmata of hyperandrogenism: acne, hirsutism,
central obesity, pigmentation, change of voice, malepattern baldness
Palpate thyroid for enlargement and LN
Auscultate chest/heart
Palpate abdomen and check for tenderness especially
the R/L iliac fossa; palpable mass;
With patients consent, I would like to ask for the
pelvic exam. On inspection, I would like to quantify
bleeding (soaked pads), any clots or associated
discharge? With a sterile speculum I would like to look
at the cervix for any signs of trauma, ulcerations,
lesions, and polyp. Take swabs of vagina and culture
to check for infections. Do bimanual examination
looking for any signs of cervical excitation, size and
shape of uterus, and any pelvic mass I can feel.
Investigations:
FBE, U,C/E, coagulation profile, blood grouping, LFTs,
TFTs, iron studies, complete hormonal assay including
serum b-hcg, pap smear, TVS (fibroids and check
thickness of endometrium).
Hysteroscopy w/ or w/o endometrial sampling
visualization of uterus
CT/MRI may needed
Management
Most likely from your history and PE, you have a
condition called DUB where you have bleeding without
an apparent cause in spite of complete investigations.
It is a very common condition, the cause of which is
usually not known. It is suggested that disturbances of
the normal brain axis leads to hormonal changes.
Sometimes there is a problem within the vasculature
of the endometrium, which is the lining of your womb,
(there is reduced vasoconstriction of endometrial
vessels and increased prostaglandin E1 and
prostacyclin)
It is a diagnosis of exclusion. The therapy is a stepladder therapy. We start with medical intervention,
reserving the surgical intervention for resistant cases.

Therapy:
o Medical (controls up to 70% of cases):
Mefenamic acid (500mg TID) 4 days before
next period tranexamic acid (1g OD on
D1 of menses) OCP Danazol (antiestrogen) GnRh agonist (zoladex and
synarel)
o Surgical: D&C (high recurrence)
endometrial ablation (laser/cautery)
uterine artery ligation/embolization
hysterectomy
Give iron supplements: ferrous sulfate 325mg TID
Prognosis is good with medical therapy. Up to 70%
success rate.

Dysfunctional Uterine Bleeding

Case: Reena, aged 41 years presents to your clinic. She tells
you that she had heavy periods for the last few months and
describes them as a nightmare. Previously she had regular
periods but for sometime, they have becomes excessively
heavy. She feels tired and has to put herself to bed every month
for at least one day. She works as an accountant in a busy
company and has to take a few offs every month due to which
her boss is not happy and she is at risk of losing her job. She
lives at home with her partner and two children.
Task
a.
b.
c.

Further history
Physical examination
Differential diagnosis and management

Differential diagnosis
- Fibroids
- Contraceptives (depo-provera)
- Endometriosis
- IUD
- Bleeding disorders and warfarin
- Miscarriage and ectopic pregnancy
- Endometrial cancer
- Thyroid disorders
History:
- 5Ps. Signs and symptoms of thyroid disorders,
bleeding disorders, weight loss
Physical examination
- General appearance
- Vital signs
- Chest and Lung
- Abdomen: masses
- Pelvic examination
- DO PREGNANCY TEST!
Investigations
- FBE, TFTs, LFTS, UEC
- Abdominal and vaginal ultrasound
- D&C
- Endometrial sampling
- D&C
- Hysteroscopy
Treatment
- Aim is to reduce the amount of blood loss
- Give hormone replacement (progesterone), antiprostaglandin medication (NSAID) or blood clotting
and reduce bleeding (tranexamic acid)
- Options: OCP, progesterone tablets, progesterone
releasing IUD, tranexamic acid (most effective
therapy; reduce bleeding by 50% 4x a day for 4 days)
- Keep a menstrual diary
- Rest as much as possible

46

Take iron supplements

Eat well-balanced diet
Avoid aspirin

Postcoital Bleeding (Cervical Cancer)

Case: You are a GP and a 40-year-old female comes to you
complaining of vaginal bleeding after intercourse for the last 7
days. She is a mother of 4 kids. Her husband passed away 2
years ago and she has a new partner recently.
3 cases about cervical cancer:
Task
a.
b.

c.

Relevant history (2 pads/day x 2days; no clots; last

pap smear x 14 years ago)
Physical examination findings: abdomen: non-tender
mass palpable and uterus enlarged to 12 weeks;
inspection: (+) bright red blood on speculum, os
closed and (+) mass probably originating from the
cervix; speculum: small ulcer on the cervix
Management

Presentation: postcoital bleeding in a female smoker who does

not have regular pap smears
Differential Diagnosis
- Atrophic vaginitis
- Cervical ectropion
- Cervical polyp
- Cervical cancer
- Endometrial cancer
- Bleeding disorder
History
-

Is my patient hemodynamically stable?

Please tell me more about the bleeding? Was it
related to intercourse the first time you had bleeding?
How many pads are you using for the bleeding at the
moment? Any clots? Any discharge apart from the
bleeding? Any itchiness? Any problems passing
water? Any bleeding from anywhere else in the body
(nose, gums)? When was your LMP? Any possibility
you might be pregnant at the moment?
Contraception?
At the moment do you have any dizziness, N/V,
lightheadedness? How are your cycles? Are they
regular? Any bleeding in between cycles?
I understand you have 4 kids. When was your last
delivery? Any complications during any of the
pregnancies or deliveries?
How is your general health? Any history of high blood
pressure, DM, bleeding disorders, thyroid problems?
When was your last Pap smear? What was the result?
May I ask why you didnt have any pap smears?
SADMA?
FHx: gynecological cancers, bleeding
Do you have any weight loss? night sweats?
Tiredness? Any pain anywhere in the body? Any
lumps you have noticed?

Physical examination
- General appearance
- Vital signs: postural BP
- Abdomen: obvious abdominal distention, tenderness
on palpation, mass (can I find out if it is uterine or
ovarian in origin) is it tender? Mobile? Percussion
note? Any other viscera that is enlarged? Ausculate
bowel sounds?
- Lymph nodes especially inguinal lymph nodes
- Heart and lungs

Pelvic examination
o Inspection: discharge, bleeding, clots
o Pelvic examination: evidence of ectropion
(seen as very red patch over cervix which
bleeds upon touching), cervical os
o Bimanual examination: palpate mass,
tenderness, whether os is open or close,
cervical excitation, adnexal mass that I can
feel?
Urine dipstick and pregnancy test

Diagnosis and Management

- From the history and examination, my concern is a
mass we have noticed to be arising from the pelvis.
Unfortunately, it seems like this mass is probably a
nasty growth of the cervix.
- Do you understand what Im saying? Do you want me
to call someone for you? Are you alright to continue?
- The first step would be to confirm the diagnosis with
the help of a procedure called colposcopy and biopsy.
It will be done by the specialist gynecologist. We will
also do some blood tests before the biopsy including
FBE, LFTs, UEC, TFTs, MSU for MCS. Once the
diagnosis is confirmed, they will do CT scans of the
chest, abdomen and pelvis to find out at which stage
the disease is at. Depending upon the staging, the
treatment options are cone biopsy (reserved for stage
1), total hysterectomy, chemotherapy and
radiotherapy.
- Staging
o I confined to cervix
o II involves the uterus but not the lower 3 rd
of vagina
o III extends to the pelvic walls including the
lower 1/3 of vagina
o IV distant metastasis
- Refer to gynecologist for further management
- Please dont worry. There is still a lot of hope for you.
- Support groups. Counselor.
- Review
- Reading material.
- If pregnant:
o <20 weeks: offer termination
o >20 weeks: may still offer termination but
usually induction of labor done after 35
weeks gestation
Postmenopausal bleeding
Case: Your next patient in your GP practice is a 52-year-old lady
who complains of bleeding PV. She initially noticed brownish
staining of her underpants a week ago and came to get a
checkup.
Investigations ordered:
bHcG normal
FBE Hb 12m/L, wbc 8500
Abdominal USG
o Normal uterus, tubes and ovaries
o Endometrium 12 mm thick (4-8mm)
Problem list:
Hemodynamic stability
History to r/o differential diagnosis
o Hormones estrogen content of HRT
o Vaginal /uterine atrophy
o Uterine cervical polyps
o Endometrial hyperplasia
o Cancer (uterus, cervix, vagina)

47

Risk factors:
Nulliparity
Early menarche, late menopause
Unopposed estrogen therapy (OCP/HRT)
DM
Obesity
Task:
a.
b.
c.

Take a further history required

Ask the examiner relevant examination findings
Discuss further management plan with the patient

when she gets the abdominal pain. Paracetamol does not

relieve the pain. Yesterday her mom gave her strong analgesia
with codeine (endone) which relieved the pain but she slept for
the remainder of the day. Marys menarche was at 13 years of
age. Her cycles were irregular for the first 6 months but now are
regular every 28 days lasting about 7 days. She is otherwise
well. Her mother suggested Mary to see you because she is
concerned that the severity of pain might indicate that there is
something serious with Mary.
Task
a.

Physical examination
General appearance: BMI,
Vitals: BP, RR, PR, Temperature
Abdomen: scars, masses, striae, masses,
organomegaly, FHT, lateral grip, pelvic grip, FHT
Gynecological exam:
o informed consent
o inspection: discharge, ulcers, lesions, warts,
scratch, atrophic changes; speculum
cervix, atrophic changes; do PAP and
endometrial sampling where possible
Atrophic vaginitis dx usually done using speculum examination
seen as thin, friable vaginal wall which may bleed to touch.
Typically, history will be a 10-year-postmenopausal lady
complaining of a yellowish-brown vaginal discharge or just
mucus. (+) dyspareunia; tx: topical estrogen cream initially and
systemic estrogen/progesterone (if uterus intact)
Cervical polyps diagnosis usually made in speculum
examination seen as red protrusion from the cervical os; tx:
attempt removal by grasping it with sponge forceps and twisting
the pedicle
Endometrial polyp usually identified on hysteroscopy where
the polyp is directly visualized; typical history of a 50-year-old
female with bleeding PV; estrogen dependent (incidence
decreases after menopause. History of tamoxifen use; tx:
removal during hysteroscopy and send to pathology
Endometrial hyperplasia diagnosed on hysteroscopy; TVS is
more accurate. Two types: simple (proliferative endometrium)
or complex (proliferative endometrium with atypical changes and
if left untreated will progress to cancer in 2 years); tx: high-dose
progesterone with frequent reassessment; definitive tx:
hysterectomy with oophorectomy
Endometrial CA 5th most common cancer in women in
Australia. Px complains of vaginal bleeding or irregular
postmenopausal bleeding; (+) hx of anovulatory cycles or
abnormal endometrial cells on pap; tx: surgical removal (Total
hysterectomy bilateral salpingo-oophorectomy bilateral
pelvic and para-aortic LAD peritoneal cytology) and staging
during surgery; good prognosis if diagnosis is made early;
consider RT for deeply invasive tumor
DYSMENORRHEA AND ABDOMINAL PAIN
Dysmenorrhea
Case: Mary is 14 years old presents to your GP clinic while her
mother is outside in the waiting room. You know her for 6 years.
She complained of severe central lower abdominal pain with her
periods for the past few menstrual cycles. The pain gradually
begins on day one of her menses and becomes very severe
within a few hours. She gests nauseated and sometimes vomits
and sometimes she feels a nagging ache at the top of her thighs

b.
c.
d.
-

History (menses started yesterday, 1 pad/day, every

28 days, sexually active and uses condoms, not on
OCPs)
Physical examination
Investigation
Diagnosis and management
Ensure CONFIDENTIALITY at all times!!!!!!
Consent:
o legal age: 18 y.o
o sexual activity: 16 y.o.
o mature minor: >12 y.o.
Scale PAIN!
Sexual history: are you sexually active? How long
have you been active? Are you in a stable
relationship? How long? How many sexual partners
have you had? Do you practice safe sex?
SADMA?
Other bleeding problems

Dysmenorrhea Differential diagnosis:

Primary dysmenorrhea
Menstrual pain associated with ovular cycles without
any pathologic findings; usually commences within 1-2
years after menarche and becomes more severe with
time up to about 20 years.
50% of women and up to 95% of adolescents
Features:
o Low midline abdominal pain
o Pain radiates to back or thighs
o Varies from a dull dragging to a severe
cramping pain
o Maximum pain at beginning of the period
o May commence up to 12 hours before the
menses appear
o Usually lasts 24 hours but may persist for 23 days
o May be associated with nausea and
vomiting, headache, syncope or flushing
o No abnormal findings on examination
Investigations:
o MSU
Risk factors:
o Obesity
o Smoking
o Early age at menarche
o Longer periods
o Alcohol
o Lack of exercise
o Anxiety, stress, depression
Management:
o Lifestyle modification
o Avoid smoking/alcohol
o Relaxation techniques (yoga)
o Avoid exposure to extreme cold
o Place a water bottle over the painful area

48

Medication
o ASA or PCM
o Prostaglandin inhibitors (Mefenamic acid)
o NSAIDS (Naproxen or ibuprofen) start 1
day before the period then continue for the
next couple of days
o Thiamine 100mg
o Low-dose OCP
Initially during first 1 or 2 years of period, you dont
produce eggs and therefore you dont experience
pain. However, when eggs become produced,
chemicals (prostaglandin) are released which increase
the contraction of the uterus (womb) producing pain.

Secondary dysmenorrhea: menstrual pain for which an organic

cause can be found; begins after menarche, after years of painfree menses; >30 years of age; begins 3-4 days before menses
and becomes more severe during menstruation. May have
intermenstrual pain, dyspareunia, etc.
Causes:
o PID
o Endometriosis
o IUCD
o Submucous myoma
o Intrauterine polyp
o Pelvic adhesions
Investigations
FBE
MSU
Pregnancy test
USD
Hysteroscopy, D&C, HSSG
Mittelschmerz
Case: You are an HMO in ED and a 14-year-old girl comes
complaining of severe lower abdominal pain.
Task
a.

b.
c.
d.

History (severe right lower quadrant pain, 7/10, for 2

hours, 3rd time for 2 months relieved by panadeine
forte, 2nd episode went to hospital, workup done was
normal, cant remember what doctor said, and
discharged after being pain-free, periods regular 2830 days, not sexually active, FHx of DM and MI; LMP
2weeks
Physical examination (BMI 17, mild tenderness of
deep palpation on RIF, hymen intact)
Investigation if relevant
Diagnosis and management

Features
Rupture of Graafian follicle small amount of blood
mixed with follicular fluid released into pouch of
Douglas peritonism
Features: onset of pain in mid-cycle, deep pain in one
or other iliac foosa (RIF>LIF), often described as
horse-kick pain; tends to move centrally; heavy
feeling in pelvis; relieved by sitting or supporting lower
abdomen; lasts for fe minutes to hours
Patient otherwise well
Sometimes can mimic acute appendicitis
Management
o Explain and reassurance
o Simple analgesics
o Hot water bottle

Differential Diagnosis
Ectopic pregnancy
PID
Ruptured ovarian cyst
Ovarian torsion
Mittelschmerz
UTI
Acute appendicitis
History
-

Is my patient hemodynamically stable? I understand

you came to the ED because of abdominal pain.
When did it start? Can you show me with one finger
where is the pain? Has it always been there or did it
start somewhere else? Can you describe the type of
pain? Does the pain travel anywhere else? Can you
recall any precipitating factors? How bad is the pain
on a scale of 1-10? Does anything make it better or
worse? Is it the first episode? What happened last
time? Do you remember any investigation result and
what doctor said? Are there associated symptoms like
fever, nausea or vomiting? Hows your waterworks?
Any stinging or burning sensation? Has the color of
urine changed? How are your bowel movements?
When was the last time you opened your bowels?
When was your LMP? How long is your cycle? How
long is the bleeding? When was your first period? Any
excessive pain or bleeding during the periods? Are
you sexually active?
Hows your general health? Any surgeries in the past?
SADMA?
Whom do you live with at home? Any problems at
home or in school?
FHx

Physical Examination
General appearance
Vital signs and growth chart
Abdomen:
o Inspection
o Palpation: guarding, rigidity, rebound
tenderness, tenderness at McBurney point,
Rovsing sign, Psoas sign (pain on extension
of hip), obturator sign (pain on internal
rotation of hip)
o Auscultation
Urine dipstick
Investigation: Transbadominal USD + Doppler (helps exclude
torsion)
Diagnosis and Management
According to your history and PE, most likely you have
a condition called mitteschmerz syndrome. Have you
ever heard about it? The word means middle pain
because this pain is typically felt during the middle of
the menstrual cycle. This pain coincides with
ovulation. Its a very common condition. As many as 1
in 5 women experience mittelschmerz pain. Some
every cycle, some intermittently. It is more common in
young women under 30. There are a number of
theories why women experience this pain.
o The ovaries have no opening. At ovulation,
the eggs break through the ovary wall and
causes pain.

49
o
o

At time of ovulation, blood is released from

ruptured egg follicles and may cause
irritation of the abdominal lining.
There is also contraction of fallopian tubes
and some other contributory factors leading
to spasm and pain

Management: Diary/CBT/Lifestyle modification/Relaxation

antidepressants

Usually pain appears suddenly in the middle of the

cycle and subsides within hours. It is not harmful and
doesnt signify presence of disease.
You need to have rest. Drink plenty of fluids. Take
panadol or ibuprofen or Panadeine or Panadeine
forte. You can use local heat applications or warm
baths.
If pain is severe and doesnt respond to simple
painkillers, your doctor might consider OCP to block
ovulation.

PREMENSTRUAL SYNDROME
Premenstrual Syndrome (PMS)
Case: Nancy aged 32 years visit your surgery and tell you that
she frequently feels irritable, tearful and bloated before her
periods every month. This has been going on for last couple of
years. Her menses are regular lasting for about one week and
symptoms completely resolve within 1-2 days of onset. Her
menses occur every month and she considers they are not
painful and are not heavy. She has no bleeding in between her
menses or after intercourse. She is a school teacher and lives
with her husband at home. She had two children aged four and
six years of age.
Task
a.
b.
c.

History
Physical examination
Diagnosis and further advice

Predisposing factors:
- Mental illness
- Alcoholism
- Sexual abuse
- Family history
- Stress
Precipitating factors
- Cessation of OCP
- Tubal ligation
- Hysterectomy
Sustaining factors
- Diet containing caffeine, alcohol, sugar
- Smoking
- Stress
- Sedentary lifestyle
Differential diagnosis
- Psychologic: Depression
- Thyroid disorders
- PCOS
- Mastalgia
- Menopause syndrome
History
-

Physical symptoms: headache, dizziness, hot flushes,

breast swelling and tenderness, abdominal
bloatedness, constipation

Diary: write her symptoms for at least 2-3 months

period.
CBT
Lifestyle modification (exercise, diet)
Relaxation
Medication
o Nil or negative: evening primrose oil, gingko
biloba, progesterone, OCP, bromocriptine
o Weak: magnesium, calcium, vitamin E, vitex
angus
o Moderate: pyridoxine vitamin b6 (mildmoderate), st. johns wort, spironolactone
o Strong (for PMDD): SSRI and clomipramine,
GnRH agonists, danazol
PMDD: fluoxetine 20mg mane for 10-14 days before
anticipated onset of menstruation or sertraline 50 mg
daily

Pre-menstrual Dysphoric Disorder

PMDD Criteria: (A) Symptoms must occur during the week
before menses and remit a few days after onset of menses; five
of the following symptoms must be present with at least one
being 1-4 and should be symptom free for one week:
- Depressed mood or dysphoria
- Anxiety or tension
- Affective lability
- Irritability
- Decreased interest in usual activities
- Concentration difficulties
- Marked lack of energy
- Marked change in appetite, overeating or food
cravings
- Hypersomnia
- Feeling overwhelmed
- Other physical symptoms
- B. Symptoms must interfere with work, school, usual
activities or relationship
- C. Symptoms must not merely b an exacerbation of
another disorder
- D. Criteria A, B and C must be confirmed by
prospective daily ratings for at least 2 cycles
CONCEPTION CONTROL
Natural methods of contraception
Case: A 19-year-old females comes to your GP clinic to consult
about contraception as she is now going to start sexual relations
with her boyfriend. She is not interested in barrier methods or
hormonal contraceptives and wants to know about natural
contraception.
Task

Rule out anxiety and depression question

Home situation
Ask about psychologic symptoms: Insomnia,
Moodiness, Irritability, Anxiety, Tension, Depression,
Confusion, Food cravings

a.
b.

Focused history : 5Ps (gardasil vaccination) and

general health
Explain methods

Natural: They require regular periods and high motivation.

These methods will help determine when to avoid intercourse
during your cycle, meaning your safe and unsafe periods.

50
-

Bibasal temperature: relies on measurement of your

body temperature
o Check temperature every morning before
getting out of bed or any activities.
Temperature rises slightly during ovulation.
o 0.2-0.5C increase in temperature indicates
ovulation avoid sexual contact for up to
72 hours after the change in temperature

boyfriend 6 months now, and wants to discuss the OCP with

you.

You must note the temperature on a chart to

compare changes from day-to-day. Avoid
sexual contact from the first day of period up
to 72 hours after rise in temperature
o 99% effective if done correctly and
consistently;
o Benefits: no side effects
o Limitations: tedious and should be
motivated; unsuitable if woman has fever or
other health condition; period of abstinence
of longer
Calendar/Rhythm Method:
o Monitor 6 (at least 12) cycles and select the
shortest and longest cycle.
o Shortest Cycle ( 21) and Longest cycle
(10)
14-6 = 8 (Sperm viable for 6 days)
14+2 = 18 (Egg viable for 2 days)
o Avoid sexual contact on the unsafe days.
o 95% effective if used correctly
o Benefits: No side effects, no cost, and do
not require any special device
o Limitations: must monitor length of
menstrual cycle for 6 months;
Billings Ovulation Method
o Based on careful observation of the nature
of mucus so that ovulation can be
recognized
o Fertile mucus is wet, clear, stringy and
increased in amount and feels lubricated
due to estrogen
o Last day of this type of mucus is peak
mucus day which is followed by abrupt
change of thick mucus associated with
secretion of progesterone
o Infertile phase: 4 days after peak mucus day
o Intercourse is avoided from the first
awareness of increased clearer wet mucus
until 4 days after maximum mucus
secretion.
o Most effective method if done correctly;
failure rate is 1-2/100 women-years
o Failure: women are only able to detect 34days of wetness prior to the peak moisture
day and still have sex 4-6 days prior to
ovulation when sperm survival is still
possible
Coitus interruptus: male withdrawal before ejaculation;
least effective
NOT EFFECTIVE AGAINST SEXUALLY
TRANSMITTED INFECTIONS

Problem list:
a. confidentiality and consent
b. social/ethical aspect (boyfriends age)
c. 14-year-old minor Gillicks test
d. Discuss OCP r/o contraindications; usage
instructions and adverse effect

Counseling about OCP

Case: 14-year-old girl who seems to be mature for her age
came to you for contraceptive advice. She is your regular
patient, is generally healthy. She has been with her 15-year-old

Task:
a.
b.
c.

take a further history required

ask for relevant findings
discuss OCP with the patient

HEADS (psych history)

Home situation
Education/employment
Activity/alcohol
Depression/drugs
Suicidality/smoking
Management
Partner's age: >2 years age difference is not
acceptable;
Gillick's test: if you are able to show me that you're
able to understand what you are saying, and at the
end of the conversion you are able to understand what
I said, then I can give you the script. (how are you
going to use the OCP? What will you do if you missed
the pill?)
Will not protect against STIs.
Advise on 7 days row. Use other contraceptive
methods for the first 7 days. If you missed the pill or
have had any nausea, vomiting, diarrhea then use
barrier method
Reading materials
Review again for 3 months
Breakthrough Bleeding with OCPs
Case: Your next patient in GP practice is a 22-year-old female
who started using Microgynon 30 because she wants to start
sexual relationship with her partner in the near future. She has
had some per vagina spotting over the last 4 weeks and is
concerned.
Task:
a.
b.
c.
History
-

History (spotting x 2-3 for 4 weeks)

Diagnosis
Management
Could you talk more about it? Do you take the pills at
a regular time? Have you skipped or missed a pill?
Smoking? STDs? Are you taking any other
medications (anti-epileptics/antibiotics)? Recent
diarrhea or vomiting?
Any chance you could be pregnant? Partner? Pap
smear?

Factors for breakthrough bleeding:

Not taking pills at the same time (decreases efficacy)
Missed pill
Smoking
Medications
AGE

51

Management
What you have is a case of breakthrough bleeding
which occurs in between periods. It could be a light
spotting in your case or a heavy bleeding. It is a
common side effect of OCPs.
There are several reasons why breakthrough bleeding
can happen: if not taking pills at the same time (15
minutes), should not skip pills, smoking, medication or
STDs, or AGE. For some women, the low-dose pill
does not contain enough estrogen to maintain the
stability of the endometrium (lining of the uterus)
which causes breakthrough bleeding.

On OCP wants to change to HRT

A 45-year-old lady came to your GP clinic and she is on OCP.
She wants to change to HRT because she has heard about it
from her friends.
*48-year-old px with irregular periods and husband had
vasectomy;
*53-year-old with amenorrhea for last 2 days (years)/with history
of breast cancer.
Task
History
Management
Answer her questions

History:
- 5Ps:
- Vasomotor symptoms: hot flushes? Night sweats?
Palpitations? Lightheadedness/dizziness? Migraine?
- Urogenital: dyspareunia? UTI? Vaginal dryness?
Decline in libido? Bladder dysfunction (dysuria)?
Stress incontinence/prolapse?
- Psychogenic: irritability, depression, anxiety/tension,
fearfulness, loss of concentration, tearfulness, loss of
concentration, poor short term memory, unloved
feelings, mood changes, loss of self-confidence
- Frequent headaches? Migraine? FHx: CVS, cancers,
osteoporosis? Breast lumps? History of heart
disease? Hypertension? Unusual bleeding? Pills? Any
weight gain? Nausea/vomiting?
- SADMA: smoking? Medications: steroids?
- FHx: Premature menopause
-

Contraindications of HRT:
o Estrogen-dependent tumor (endometrial,
breast cancer)
o Recurrent thromboembolism
o Acute IHD (absolute)/history of CHD
(relative)
o Uncontrolled hypertension

Active liver disease

Pregnancy
Undiagnosed vaginal bleeding
Otosclerosis? Intermittent porphyria

Investigations: FBE, LFTs, BSL, Lipid profile, U/C/E, TFTs,

Estrogen/FSH/LH
Management:
- From the history, you are not a candidate for HRT.
However, I would like to request for some medications
to check if youre already reaching menopause. HRT
is not a contraceptive method. Both HRT and OCPs
do not prevent STIs.

It also depends on the type of progesterone.

At this stage, I would recommend for you to continue
for 4-6 months and if it does not stop after that, then
we might consider changing your OCP dose to a
higher estrogen-containing pill or different
progesterone.
Review and Reading materials.
Red flags: severe bleeding, nausea/vomting, etc

Indications for high-dose estrogen OCPs

Uncontrolled menorraghia
Taking other enzyme inducing (p450) drugs such as
anti-epileptics
Low dose pill failure

a.
b.
c.

o
o
o
o

Menopause is a natural phenomenon. One of the

things I am concerned about menopause is
osteoporosis and heart disease. It is advisable to
change lifestyle: maintain healthy weight, adequate
relaxation and exercise, do pelvic floor exercises
regularly, reduced smoking, caffeine, alcohol intake,
increased exposure to sunlight.
Some other methods of contraception: barrier, IUCD,
implanon, injectables, etc during next consultation

Additional information:
- Ways to know: organize LH and FSH (30-40) most
likely menopausal; if FSH and LH are that high
stop OCP and get symptoms HRT; require regular
follow up.
- 45 too early; but requires support; usually high
dose HRT given;
OCP-Induced Hypertension
Case: You are a GP and a 26-year-old female comes to your
clinic asking about the chances of becoming pregnant within the
next 6 months
Case Before: Patient coming to you who is a heavy smoker and
has hypertension. She is on OCP.
Task
a.
b.
c.
History
-

History (regular 2-3 days, 28 days, on the pill, pap

smear n, no previous pregnancies/miscarriages, nonsmoker, social drinker, mom with DM)
Physical examination: BP 155/95,
Diagnosis and management
I can see from the notes you wish to become pregnant
in the near future. Congratulations on your decision.
Please tell me more about your periods? Are they
regular? How many days of bleeding? How many
days apart? Are your periods heavy? Are they painful?
Any spotting in between?
I understand youre sexually active, since when? What
form of contraception do you use? What type of pill
are you on? Since when? Have you had any side
effects from the pill (nausea, weight gain,
intermenstrual spotting)? Have you or your partner
ever been diagnosed with a STI? At the moment, do
you suffer from any vaginal discharge? Any bleeding
or itchiness down below? Have you ever had pelvic
infections before? Have you had any
pregnancy/miscarriages/gynecological surgeries
before?
When was your last pap smear? What was the result?
Have you had gardasil?

52
-

PMHx: diabetes, hypertension, kidney disease,

infections, liver? History of clotting problems in you or
your family?
SADMA?
Hows your appetite/sleep? Any recent history of fever,
cough, diarrhea, tummy pain? How do you consider
your weight to be? Do you know your blood group?
Any FHx of fertility problems? Pregnancy related
problems? Diabetes? High blood pressure?
Headache: how frequent, since when? Have you
noticed any association with particular food or time of
day? What do you take to relieve pain? Any
associated N/V/abnormal sensations/visual
disturbance?

Physical examination
- General appearance and BMI
- Vital signs
- Dysmorphic features of cushing syndrome, PCOS
- Palpate thyroid
- Auscultate chest and heart
- Abdomen to palpate renal or suprarenal mass and
listen to bruit
- Pelvic exam:
o Inspection: discharge, bleeding
o Bimanaual exam: position and size of
uterus, tenderness, cervical excitation
- Urine dipstick, pregnancy test and BSL
Management
- From the history and examination, the most important
finding is that of a high blood pressure. Have you ever
had your blood pressure checked before? Usually, at
your age, having a high blood pressure can be due to
a number of causes. Most likely, it can be related to
the use of the pill as the headaches that you have
started along with the use of the pill. I still need to rule
out other causes of hypertension such as smoking,
any problems with the blood supply to the kidneys,
certain growths in the adrenal gland related to the
kidney, cardiac problems, and the like. I would do
some investigations like FBE, U&E, Urine MCS, ECG,
uric acid level, lipid profile, LFTs, TFTs, blood group,
rubella antibody, infection screening.
- We still need to check your BP during the next visit.
However, I want you to please stop using the pill.
Around 2% of females, especially those who have
family history of high BP, those who are overweight,
>35 years old, and smokers can develop high blood
pressure due to OCPs. Some women get high BP
from the progesterone component of the pill. Usually,
this rise in blood pressure is only seen with the
systolic component. The good news is that it is
completely reversible. However, you need to stop
smoking and adopt a healthy lifestyle to reduce this
risk to minimum. Meanwhile, you may use another
form of contraception, probably condoms. Becoming
pregnant at this stage might further complicate your
condition, so my advice is once the results are back
and your BP is normalized, you can plan for the
pregnancy. I would like to see you in one weeks time
with the results of the tests. Please come back if you
develop further headaches, visual problems, fainting
or dizziness.
Post-pill amenorrhea??
Case: Your next patient in GP practice is a 30-year-old woman.
She did not have periods for the last 2 months. She is on
MIcrogynon 30.

Task
a.
b.
c.
d.

History (on the pill, periods stopped GRADUALLY,

Physical examination
Diagnosis
Management

Secondary Amenorrhea
- Pregnancy (breast tenderness, spotting, early morning
N/V)
- PCOS (weight gain, acne, hirsutism, irregular periods)
- Hypthyroidism (weather preference, puffy face,
edema, mood)
- Eating disorder/exercise induced
- Hyperprolactinemia (breast discharge, medications,
headache, nausea and vomiting

History
-

Asherman syndrome (gynecological procedures/D&C)

Stress
Premature ovarian symptoms
Post-Pill Amenorrhea
I understand you have not had your menses for the
last 2 months. Any chance you might be pregnant?
Whats your LMP? Do you have symptoms like breast
pain, N/V, spotting?
Pills: any problems with that? Do you think you might
have missed your pill anytime? Are you taking it
regularly? Did you have any diarrhea or vomiting? Are
you on any other medications?
Review of systems: hirsutism
Partner? Pap? Gardasil vaccination?
Any previous pregnancies?
Any Family history of premature ovarian failure or
cancers?
SADMA? PMHX

Physical Examination
- General appearance
- Vital signs and BMI
- Visible hirsutism, acne, puffy face or edema
- Vision: visual fields, funduscopy, visual acuity
- Neck: thyroid enlargement
- Breast examination: nipple discharge
- Abdomen: masses, tenderness
- Pelvic exam:
o Inspection: discharge, atrophic vagina
o Speculum: cervical os, bleeding
o Bimanual: size of uterus, adnexal masses,
CMT
- Urine dipstick, BSL, Pregnancy Test
Diagnosis and management
- There is no abnormality on physical examination.
According to your history, the most likely cause of not
having the periods is endometrial atrophy secondary
to the pill.
- However, we need to rule out pregnancy. The only
possible reason is one of the hormones
(progesterone) in the pill is causing thinning of the
lining of the womb.
- DIAGRAM
- Do not worry. It is a reversible condition. At this stage,
we will stop the Microgynon 30 and you can use other
forms of contraception at this time or I can shift you to
Microgynon 50 or we can use the triphasic pills. Most
likely your periods will return. In case you dont or
youre really concerned, I can refer you to the
gynecologist for further investigation.
- Reading material. Referral. Review.

53

Request for sterilization for a disabled person/Contraceptive

advise for disabled
Case: You are a GP and a mother of 13-year-old child comes to
you. She is intellectually disabled and epileptic. She is on
carbamazepine. She wants your advice because the child goes
to school for both boys and girls. She is worried about
contraception and the risk of pregnancy.

Task
a.
b.

History
-

equally worried if your daughter suffered from any of

the complications of this surgery which includes
complications with anesthesia, bleeding, infections,
and long-term effects on her bone growth and
hormonal imbalances.
I gave the consent appendicectomy. Why cant I do it
now? Appendectomy is a medical emergency where
the decision is taken on medical grounds. If you like,
you can contact the family court or the guardianship
board. They have the legal authority to allow this kind
of procedure.

Relevant history
Address mothers concerns

Depo-Provera Counseling
Can you please tell me, what is your main concern?
Do you think your daughter has started her periods?
Did you notice any breast development? Since when?
Have you noticed any hair growths in the armpits over
the pubic area? Since when? I understand she is on
phenytoin/carbamazepine? Any side effects? Who
takes care of her medications? Since when did she
last see her neurologist.
Please tell me more about her mental retardation.
Was she born this way? How would you describe her
mental age to be? Is she able to do daily life activities
like eating, dressing, and going to the toilet? Does she
need partial or complete supervision? Who takes care
of her most of the time? Do you experience any
difficulties while taking care of your daughter? How is
her school performance? Any problems at school? Is it
a special school? Do you think she might already be
sexually active? Have you discussed anything with her
like Periods? Contraception? Previous medical or
surgical illnesses? Any concerns about her growth?
Do you have enough support at home, from family
friends and partner? Financial problem?

Counseling
I understand from the history that your daughter has
not had her periods up till now. However, some degree
of breast development has occurred so we might
expect that she will start menstruating soon. It is very
good that you have come at this time to discuss
contraception. However, no form of contraception is
required until periods start. Usually, we recommend
oral contraceptives that might be most suitable for her.
Because she is on antiepileptic medications, we might
need to give her a pill with high dose of estrogen.
Please understand that the pill prevents pregnancy
only and not STDs. If you find that giving a pill
everyday is inconvenient, we can give her injections of
depo-provera every 3 months. However, with
prolonged use, it will produce side effects including
reduced density of bones as well as problems with
periods. There are other options as well like implanon
and IUCDs. However, the management is better
suitable for females who can look after themselves.
Can we remove her womb instead? The oral pill is the
best option for your child because you are already
giving her some medications and you just need to add
one more. Regarding permanent sterilization, it is
usually not allowed for girls under the age of 18 years
without approval from the court. Please understand
that being mentally disabled does not deprive your
daughter from the right to be treated just like other
people. We, as doctors, only prescribe something if it
is in the best interest of your daughter. I understand
you are concerned; however, I am sure you would be

Case: A 25-years-old female is in your GP clinic and who wants

to have depo-provera.
Task
a.

Advise about depo-provera

Counseling
It is the only injectable IM contraceptive available in
Australia and it has progesterone in it. The dose is
150mg by deep IM injection in the first 5 days of
menstrual cycle and same dose is given every 12
weeks.
Do you have any migraine? Stroke? Cancer? Any
undiagnosed vaginal bleeding? Hypertension? Heart
disease? Diabetes? Lipids? Liver disease?
5Ps: periods, pap smear, do you want to be pregnant
in the next 12 months?
When the woman has depo-provera in the body her
own hormone production is switched off. Because of
this the ovaries will not release eggs thus pregnancy
is prevented. It is a highly effective method of
contraception more effective than the combined pill
and failure rate is 1%.
The advantages of depo-provera are: It is highly
effective and therefore has low failure rate. It can
relieve pre-menstrual tension and period pain. It is
also likely to cause some reduction in risk of ovarian
and endometrial cancer, and endometriosis. As it is
given every 12 weeks, no other effort or remembering
is required.
The disadvantage is that you have to take injection
every 3 months. Once the injection is given, the
hormone cannot be removed and if you want to stop
depo-provera you have to wait for the hormone to
wear off. In some women, it can take 6-12 months for
periods to return. There is a concern about the risk of
thinning of bones if woman is using depo-provera for a
long period of time.
Side effects may include reduced periods due to low
level of hormones. After 2-3 injections, most women
will have no periods at all because there is no lining
building up to shed. Some have intermenstrual
bleeding which is usually light and irregular or have
heavy bleeding which can be controlled by hormone
treatment. A small amount of weight gain can occur.
There can be headache, abdominal discomfort and
mood changes. Women who have increased
incidence of depression can have reduced interest in
sex.
Contraindications
o Bleeding disorders or taking anticoagulant
medication

54
Undiagnosed vaginal bleeding
History of some forms of cancer
Serious medical conditions
Already pregnant or those who want to
become pregnant within 12 months
Not recommended for greater than 2 years.
o
o
o
o

Implanon Counseling
Case: Your next patient is a 19-year-old female previously on
OCP and now requests implanon.
Task
a.
b.

History
-

Relevant history (friend mentioned; no problems

except missed pill)
Advice patient and answer questions

Why do you want to change? Who suggested

implanon? Any side effects of OCP? Any chance you
are pregnant now? Did you have previous STIs? Pap
smear
Previous pregnancies/miscarriages? How are your
cycles? When was your LMP? Any medical conditions
and FHx of hypertension, diabetes?
SADMA?

Counseling
- The implanon, as you know, is a small device that
goes below the skin in the non-dominant upper arm
under local anesthesia. It contains a certain hormone
(etonogestrel) that will cause 2 things: inhibits
ovulation and increases the viscosity of the cervical
mucus. It is a very safe contraceptive method. The
failure rate is <1% and it lasts for 3 years.
- Upon removal, most women will ovulate during the
first month. The procedure needs to be done by a
trained personnel.
- Advantages: convenience, rapid reversibility, available
at low cost through the PBS systems, suitable for
women with CI to estrogen
- Absolute contraindications: pregnancy, undiagnosed
vaginal bleeding, active thromboembolic disease,
present or history of severe liver disease,
progestogen-dependent tumors, breast cancer,
hypersensitivity to components of implanon
- Relative contraindications: long-term use of liver
enzyme inducing drugs, past or family Hx of
thromboembolic disease, obesity (>100kg efficacy
is less), women for whom regular periods are
important
- Side effect: Menstrual disturbance is the most
common reason for removal
o bleeding approximating normal (35%),
infrequent bleeding (26%), amenorrhea
(21%), frequent or prolonged bleeding
(18%)
o breast tenderness, fluid retention, weight
gain, skin disorders (improve), mood change
- Effective immediately if inserted during day 1-5 of the
patients menstrual cycle; if not, then important to
ascertain the patient is not pregnant and alternative
contraception should be used for 7 days after
insertion.
Emergency Contraception after Rape
Case: You are a GP and 18-year-old Samantha came to your
clinic asking for emergency contraception and advice.

Task
a.
b.

Explain methods of emergency contraception

Manage the case

Case: Rosie aged 24 years presents to the ED of the local

hospital where you are working as an intern. She tells you that
she was sexually assaulted by a person to whom she met in a
pub. She is very distressed and teary. On further questioning
she discloses that she doesnt know this person and had never
met him before. He offered her a lift home and then stopped the
car in a lonely place and assaulted her. Rosie is an overseas
university student and lives in a shared accommodation and had
no other medical or any surgical problems.
Task
a.
b.
c.

Further relevant history

Physical examination
Management advice

I understand from the notes that you are here for

emergency contraception which is available OTC. Is
there some special reason to see me today?
I am sorry to hear that, but dont worry there is a lot of
support and you are not alone at this moment of crisis.
Confidentiality statement.
Would you like to take any legal action? (No doctor.
This man is known to my family and I dont want to
make a fuss about it.) I respect your decision but I
would like to get samples and keep it in the hospital
just in case you will change your mind later.
Were you injured anywhere else?
Menstrual history: When was your LMP (3 weeks
ago)? How are your periods? Are they regular? What
is the cycle? Bleeding? How many days apart?
Sexual history: Do you know if the man suffered from
any STIs (No)/Did you see any discharge on his
private part? Are you sexually active? Are you in a
stable relationship? Are you using any form of
contraception? Have you or your partner ever been
diagnosed with STIs? Pap smear
Any history of clotting, hypertension, migraine,
undiagnosed vaginal bleeding, breast cancer?

Examination
General appearance
Vitals
Pelvic examination with consent
o Inspection: sign of injury, vaginal secretions,
consent to take low and high vaginal swabs
for STD screening
Chest, heart, abdomen to check signs of assault
Urine dipstick
Management
We need to take blood samples for HIV, syphilis,
Hepatitis B&C, HSV and take urine sample for PCR
and Chlamydia
I would give you antibiotic coverage: Azithromycin 1g
SD
I would like to refer you to a psychologist or counselor
for support (rape crisis team).
Lets talk about emergency contraception. The first
method is levonorgestrel (Postinor). This is a POP. 2
pills (0.75mg each) 12 hours apart or 1 pill (1.5mg)
given up to 5 days but most efficient if taken within 72
hours. Efficacy is 85%.
The next method is combined pills or Yuzpe method
75% efficacy ([50mcg estrogen and 250 mcg
progesterone] 2 tablets now then 2 tablets 12 hours
apart) or copper IUDs with a failure rate of <1% if
used within 72 hours.
There are chances of getting pregnant even after
taking the emergency pills. Therefore, I would like to

55

review you after 2-3 weeks to do pregnancy test

especially if you miss you period.
Most common side effect is nausea and vomiting. If
she develops it, she needs to take the drug again.
Reading material

Tubal ligation
Case: 32-year-old lady comes to you in your GP practice. She
has 3 kids and would like to go ahead with tubal ligation.
Task:
a.
b.

Vasectomy
Case: A couple comes to your GP clinic. They have completed
their family and want to discuss with you about vasectomy.
Task
a.

Counsel the patient regarding ligation

Answer patients questions

Counseling
- REVEAL THE CONCERN: why have you decided
that?
- Are you in a stable relationship? Have you completed
your family? Hows your general medical health? Any
medical/surgical problems in the past.
WARNING: I would like to inform you that reversal
can be done, but has a very low successful rate, and
tubal ligation is considered a permanent form of
sterilization
- COUNSELING: I will tell you what the method is
about, advantages and disadvantages, and other
alternative methods. Tubal ligation can be done by 2
methods done by specialist under general anesthesia.
The first method is either the specialist can cut the
tubes and tie them together so that the sperm and ova
do not meet, or can put clips. Success rate is more
with the first method, whereas with the second
method, there are chances that clips may dislodge.
Failure rate is 1:300 which means one in every 300
women who gets the procedure gets pregnant.
Disadvantages of tubal ligation: a. reversal rate is low,
and reversal is not covered by medicare, b.
anesthesia risk/complication, c. ectopic pregnancy, d.
will not protect from STIs.
- How long in hospital; 1-2 days.
- ALTERNATIVES: I would like to give you some
information about the other methods you can use such
as IUDs, implants, depo-provera where compliance is
not a major issue. For men, there is also a procedure
called vasectomy. The advantages are: a. simple, b.
done under local anesthesia, c. less complications, d.
lower failure rate
- QUESTIONS:
o Will it affect my sexual life? No. It makes it
better because youre not scared about
pregnancy.
o When can I resume sexual life? Once
effects of operation is over.
o Is there any effect on my periods? Not really,
but there are some studies which have
shown that if more of the fallopian tube is
cut, it leads to heavier bleeding. Not yet
proven.
o Will I gain weight? No.
o What if I need kids later? The cut tubes may
be rejoined by microsurgery, but there is no
guarantee of reversal of fertility. Pregnancy
rate after reversal varies from 30-80% and
that depends on the technique. The simple
clip method gives better chance of reversal.
Regardless, it is considered a permanent
method and shouldnt be entered lightly.

CLOSURE: I would recommend you to go home and

discuss what we have talked about today and if you
have decided, I will give you a referral letter.

b.
c.
d.
e.

Relevant history (family complete, and wife doesnt

want to take OCPs
because of side effects)
Explain the procedure
Complications
Follow up

Relevant history
How much do you know about vasectomy? Did you
make this decision after discussing with your wife?
What is your age? Are you married? How many
children do you have? What are the ages of your
children?
How is your general health? Any previous medical
conditions (DM, breathing disorder, hypertension??
Previous operations especially in your private parts?
SADMA?
Any problems or issues with your personal life?
If person is unmarried, <35 years of age, says he
doesnt have a children, emotional crisis or spouse is
not involved be very careful
Procedure
I would like to explain the procedure to you, its
complications, how effective it is and important issues
regarding reversibility.
It is the most common method of sterilization in men.
It is a simple operation that can be done under local or
general anesthesia. It usually takes about 30 minutes.
Two small cuts are made on each side of the back of
the scrotum or one cut is made in the middle. The
tube that carries the sperm (vas deferens) which lies
just below the skin is picked up and cut. About 1 cm of
it is removed. The ends are tied off and burned with a
hot needle. This blocks the flow of sperm so when you
ejaculate, the semen will be free of sperms.
What happens to the sperm? They are still produced
in the testicles and lie around the blocked tubes for
around 3 weeks. After that, they become nonfunctional and absorbed.
How effective is it? 1 in 500 vasectomies fail because
the tubes somehow manage to rejoin.
Complications: bruising, hematoma, bleeding,
infection but usually settles very quickly. You will
be given pain killers. The sperm granulomas, which
are brought about by blockage of the semen usually
clear up by themselves.
It can take about 15-20 ejaculations to clear all the
sperms from the tubes above the cut. About 2-3
months after the operation, you will have 2 separate
sperm counts to make sure semen has no sperm.
Until that time, it is important to use some form of
contraception.
When to start sexual activity? Normal sexual activity
can be started 4-8 days after vasectomy.
Can it be reversed? Consider it to be permanent and
irreversible procedure. The cut tubes can be rejoined
by microsurgery but there is no guarantee of regaining
fertility. Only 40% chance that it can lead to
pregnancy.

56
-

Written permission of the wife is preferable. Discuss

other methods briefly.
Is it going to affect my sexual function? NO. It will
make no difference. Rather, it can be improved
because the worry of conception is removed. Before
you go for the procedure you can take your time to
reconsider it and avoid strenuous activity for 4-7 days
after the procedure.
There is no known association with prostate or
testicular cancer. Vasectomy doesnt help to prevent
STIs.

procedures? Have you ever used any method of

contraception? What was it? Any problems because of
that? Any history of diabetes, thyroid or increased
blood pressure? Any FHx of infertility from your side or
your partners side? Any issues with your married life?
How often do you have intercourse? Are you aware of
your fertile/infertile days? Any stress? Are you a happy
couple? Do you have problems with your waterworks
or bowel? Do you exercise a lot? SADMA?
Management
- I could not find anything positive in the history other
than the frequency of your intercourse which could be
the cause of not having a baby. Do you know which
days you are fertile? If your cycles are regular we can

INFERTILITY
Primary Infertility
Case: Your next patient in GP practice is a young couple who
comes to you because they have been trying to conceive for the
last 15 months. They are happily married for 3 years and have
not sought any medical attention before.

Task
a.

b.
Causes
-

History (26 year old, no medical problems, most of the

time in overseas, sexual contact 1x/week, menarche
13 years old, on pills, STDs, surgeries or
gynecological problem)
Counsel patient about management
Male factor
Ovulatory (PCOS, HPA, POF)
Tubal (PID, tubal damage, pelvic adhesion)
Maternal age (rate of fertility declines >30)
Endometriosis
Coital problems (frequency, erection, problems,
psychological factors)
Cervical (mucus) or uterine factors (adhesions, polyps
or myomas)
Unexplained

Investigation
- Hormones: FSH, LH, midluteal progesterone, TFTs,
estrogen,
- TVS for structural abnormalities
- HSSG
History
-

Confidentiality
Have you ever been pregnant before? Any history of
miscarriages? Pregnancy from any previous
relationships? How long have you been trying to
conceive? Does your husband have kids from
previous relationship?
Periods: menarche, regular, how many bleeding, how
many days apart? How is the flow? Do you pass
clots? Any bleeding in between period? When was
your LMP? Do you get any severe pain when you
have your periods? Any pain on intercourse? Have
you noticed any abnormal hair growth on your body?
Have you gained weight recently? Have you noticed
any milky discharge from the breast? Any problem
with your vision? Have you ever been diagnosed or
screened for STIs? Any history of pelvic infections?
Any history of previous surgeries or gynecological

calculate it, or check your temperature, or observe the

consistency of mucus (time of maximum vaginal
wetness corresponds to day of ovulation) to know the
time of ovulation. At this time, it is recommended you
have more frequent intercourse or at least 3x a week.
Still, I would like to organize some investigations to
rule out the other causes of infertility. I would advise
for your partner to have semen analysis. For you, we
will start with FBE, TFTs, hormonal assay like
midluteal phase progesterone, FSH, LH, prolactin,
estrogen, sperm antibody screen, TVS, and if
required, the specialist might consider doing
hysterosalpingography (HSSG) or hysteroscopy. I
would refer you to the gynecologist/infertility clinic for
further evaluation and management.
Do not worry. I understand that it is a very difficult time
for you but I am here to help. Even if we find
something, a lot of options can be done for you: ICSI,
IVF, surrogacy, or adoption.
Reading material. Referral. Review.

ENDOMETRIOSIS AND ADENOMYOSIS

Endometriosis
Case: A 30 years old lady comes to your GP clinic complaining
of dysmenorrhea for the last 3 months. She tried using OCP but
was not relieved.
Task
a.
b.
c.

History
Physical examination
Investigations and management

Differential diagnosis
- Endometriosis
- Chronic PID
- Adhesions (previous surgery)
- Fibroids (submucous myoma)
- Uterine polyps
- Ovarian masses
- IUCD
- PCOS
Location
-

Ovaries: 60%
Uterosacral ligaments: 60%
Pouch of Douglas: 28%
Causes adhesions and fibrosis and during
menstruation would cause bleeding as well due to
hormonal stimulation;

57
History
-

Symptoms: dysmenorrhea, dyschezia, dyrsuria,

dyspareunia, infertility

as well. Now, on examination, everything is normal except there

is mild erythema of vulva and vagina. Urine dipstick is clear.
Task

Can you tell me more about the pain? (dull tummy

pain before menstruation and more severe during
menses for 6 mos; tried ocp prescribed by gp but not
relieved severity 4/5; may radiate to thigh/back)
SORTSARA? Mass in tummy? Previous history of
PID? Previous surgery? Fever? Vaginal discharge?
5Ps; any painful intercourse, or defecation? Urine? Do
you have any kids (no but been trying to conceive);
Pap smear? Any unprotected intercourse? Any
previous STD? Past history of pelvic surgery? HOW
IS THE PAIN AFFECTINGYOUR LIFE? SADMA? FHx

Examination
- Anxious; vital signs normal; focused examination on
abdomen: no visible/palpable mass or tenderness in
abdomen; inspection and speculum normal;
uterosacral nodularities and tenderness on bimanual
examination; may have fixed retroverted tender uterus
- Pelvic examination:
o inspection: discharge, bleeding, redness,
lacerations, mass, ulcers,
o speculum: Vagina and cervix: cervical
motion tenderness (PID/ectopic pregnancy);
cervical os (miscarriage)
o bimanual examination: site, size, shape,
consistency, mobility, and adnexal
masses/tenderness
Investigation and management:
- Most likely you have a condition called endometriosis.
Did you ever hear it before?
- Explain retrograde menstruation and draw diagram.
The tissue lining your womb is deposited in unusual
locations by backing up of menstrual flow into
Fallopian tube, ovaries, abdominal cavity or other
organs of the body. These abnormally located tissues
form nodules and adhesions that respond to your
hormones during periods causing pain.
- Start with painkillers
- Refer to OB gyne for usd but gold standard is
laparoscopy. It is a tube with camera for direct
visualization of your tummy to see these nodules to
make a definite diagnosis
- Treatment Options
o Medical: stop hormone production
(progesterone oral/IM); GnRh agonist x 6
months; danazol - treatment of choice
according to JM;
o Surgical: laparoscopy -- definitive
investigation and laser surgery performed
when needed; laparotomy;
- Pregnancy: helpful because it creates a state of
menopause
- Support groups
- Family meeting and refer to counselor
- Reading materials; review;
INFECTIONS OF THE GENITAL TRACT
Vulvovaginitis
Case: A father came with her 4-year-old daughter who has had
a 2nd episode of painful urination over the last year. During the
first episode, the daughter had some yellow vaginal discharge

a.
b.

History
Diagnosis and management

Differential Diagnosis
Vulvovaginitis
Foreign body
Child abuse
Allergy
Infestation of pinworm
Type I diabetes Mellitus
UTI

History
-

Describe the discharge? Is it thick or thin? Is it foulsmelling? What about the amount? Any fever?
Frequency of urination? Any change in color of urine?
Is it a smelly urine? Is she toilet-trained? Any change
in toilet training (bed wetting)? Is she drinking more
water than usual? Who looks after her? Does she go
to childcare/kindergarten? Do you think she might
have put something in her private area? Any abnormal
behavior like sexual plays or playing with the
genitalia? Is it possible that she is left unattended or
unsupervised? Does she scratch her bottom at night?
Have you changed her soap recently? Does she take
a bubble bath? Does she go for swimming?
BINDS
FHx of asthma or allergies

Examination:
General appearance
Vital signs and BMI
Abdomen: distention, mass, scratch marks, sign of
abuse
Genital inspection: redness, discharge, scratch marks
Urine dipstick and BSL
Management
Your child has an inflammation of the private part
called vulvovaginitis. It is a common condition in this
age group (2-8 years). In this age, there is lack of
estrogen so the mucosa (lining) of the vagina is thin
and irritable. When the child scratches, it becomes
infected easily. It usually resolves by itself. I would
also like to do urine microscopy and culture and take a
swab of the discharge.
There are risk factors: FHx of eczema, bubblebaths or
salt baths, nappies, irritating soaps, wet swimsuits,
sand from the sandpit, and overweight
It is not a serious condition. Avoid bubblebaths, use
cotton underwears and loose clothing, general vulval
hygiene, wipe bottom from front to back to avoid
infection, warm shallow bath with a cup of vinegar,
advise zinc cream or castor oil to relieve redness
When to refer: if foreign body is suspected and if
general measures fail and condition is persistent
Complications: vulvar adhesions, UTI
Reading material
Review
Trichomonas Vaginitis
Case: You are a GP and young female came in with greenish
vaginal discharge.

58

Task:
a.
b.
c.

Focused History
Physical Examination
Management

Vaginal discharges:
Whitish, curd-like candida albicans
Grayish bacterial vaginosis
Brownish atrophic vaginitis
Greenish trichomoniasis
Focused History:
When did the discharge start? Continuous?
Describe the consistency (sticky or watery), color and
smell
How many pads do you use per day? Are they
soaked?

Associated features: fever, bleeding, tummy pain,

itching?
Relation to periods?
LMP? How many days? How many days apart?
Bleeding inter-menstrually?
Are you sexually active? Are you in a stable
relationship?
Is your partner suffering from any STI?
Method of contraception? Number of previous sexual
partners?
History of previous STIs?
How are your waterworks? Burning? Frequency on
urination?
Have you been pregnant before? Any chance you are
pregnant now?
PMHx: DM, HPN, previous gynecological
surgery/procedure
Recent use of cream or pessaries (consider allergic
rxn)
Latest pap smear?
Meds taken? Steroids?
Vaccination (gardasil)
Smoke/drink/recreational drug use

Physical Examination:
General appearance: pallor, jaundice, dehydration,
BMI
VS: temperature, PR, RR, BP (postural drop)
Ausculation of chest/heart
Abdominal examination: tenderness (posterior fornix
of the vagina), organ enlargements, mass, bowel
sounds
Inspection of pelvic area bleeding, discharge (color,
quantity, and smell), scratch marks, warts
Bimanual palpation adnexal mass, cervical
excitation, check size/position of uterus and cervix
Sterile speculum examination check where the
discharge is coming from and position/condition of the
cervix; take a swab and send for culture and wet
mount
Get urine dipstick/finger BSL/PT
Management
Most likely from the history and PE, what you have is
a vaginal infection called trichomonas vaginitis
Caused by a parasite called T. vaginalis, usually
transmitted thru sexual contact
Most common STI worldwide
Common in females of child-bearing age
Possible to carry organism without signs and
symptoms
Gives symptoms like itching, burning of urine, watery
greenish discharge with fishy smell

Infections in male are asymptomatic

Diagnosis is by visualizing the organism within the
vaginal secretion under the microscope
Treatment:
o Metronidazole 2g SD (+ antiemetic due to
SE of N/V, metallic taste) or 400 mg BD x 5
days
o Alternative for pregnant women:
Clotrimazole
Important to prevent complications: UTI, PID,
Recurrent trichomoniasis infertility
Higher chances of developing other STIs especially
HIV important to test for other STIs (consent)
Practice good genital hygiene wash vaginal area
before and after intercourse
Do not share towels
Remember to shower after swimming
Practice safe sex with condoms
Advise to bring partner for consultation and treatment

Vaginal Discharge
Itchy
Dyspareunia
Discharge

Trichomonas vaginalis
+
+
fishy frothy and green

Candida vagin
+
+
curdy

Vaginal Swab
Other investigation

Organism

Hyphae

In pregnancy

Very dangerous
Cause: preterm labour,
premature rupture of
membrane
Tinidazole
Pregnancy:
Metronidazole
+

safe

Treatment

Treat partner
Mucopurulent
Investigation
In pregnancy

Treatment
Treat partner

Gonorrhea
+
1st void urine PCR or
endocervical swab
PROM
Pneumonia
Ophthalmia
Ceftriazone +
Azithromycin
+

Local Clotrimox
(pessary)
Chlamydia
+
same
same

Azithromycin 1 dose
1 g stat
+

Recurrent Moniliasis/Candidiasis
Case: You are a 25-year-old lady complaining of recurrent white
vaginal discharge. She was diagnosed with monilial infection
and was given treatment for that. She has now come to you for
further advice.
Task
a.

b.
c.

History (on-and-off for the last 3 months, given vaginal

tablets by GP without relief, on OCP, not pregnant, no
history of long-term use of steroids or antibiotics, or
obesity)
Examination (+ whitish curd-like discharge with vulvar
erythema)
Diagnosis and management

Differential Diagnosis
Candidiasis
Trichomonas vaginalis
Foreign body

59
Risks
-

History
-

Atrophic vaginosis
Cervical ectropion
Malignancy

Long-term OCP
Diabetes
Pregnancy

(1tsp bicarbonate in 1 L water). Bathe genital area

gently 2-3x a day for symptomatic relief. Thoroughly
cleanse vagina including recesses between rugae and
fornices, and also the folds around vulva. Avoid
wearing pantyhose, tight jeans, or using tampons.
Avoid having intercourse or oral sex during infected
period. Do not use vaginal douches, powders or
deodorants or take bubble baths.

Long-term use of steroids and antibiotics

Obesity
Wearing tight clothing
I understand that you have recurrent white vaginal
discharge. When did this episode start? What is the
color of the discharge? Any blood stains? Is it smelly?
Is it itchy? Is it sore down below? How many attacks?
How was it diagnosed? Did you take anything for that?
Which treatment were you on? Is the discharge
related to your period or intercourse? Any tummy
pains?
Are you sexually active? Are you in a stable
relationship? Have you or your partner ever been
diagnosed with STDs? What contraception are you
using? Do you have any problems with the OCPs?
Does your partner have any symptoms?
Periods: LMP? Are they regular? How many days of
bleeding? how many days apart?
Pregnancy: Any chance you can be pregnant now?
Any previous pregnancies?
Pap: Are you regular with your pap?
Any possibility of using local perfumes or local creams
down below? Some people use sexual toys, do you
happen to use them?
PMHx: Any medical history of long-term use of steroid,
diabetes or any long-term antibiotics?
What is your profession? Do you wear tight jeans?
FHx: diabetes, cancers?
SADMA?

Physical Examination
General appearance and BMI
Vital signs
Chest and heart
Abdomen: masses or RIF/LIF tenderness
Pelvic examination: nature of discharge, color, smell,
thick, blood stain, vulvar erythema; per speculum
cervix is healthy with discharge; per vagina
examination for any CMT, adnexal masses
Urine dipstick, BSL, pregnancy test (optional)
Diagnosis and Management
From the history and examination you have a
condition called recurrent moniliasis or candidiasis. It
is a fungal infection caused by Candida albicans. It is
a common condition and there are some risk factors
leading to repeated attacks. The risk factors are longterm use of OCPs, DM, pregnancy, obesity, long-term
use of steroids, antibiotics and wearing tight clothings.
At this stage, I would like to check the BSL, FBE and
do swab. I would advise you to stop OCPs and I can
book another appointment to discuss the alternative
methods of contraception. Until then, I would advise
you to use condoms. It is not STD but it is best to
abstain from intercourse until the condition resolves.
I will shift you to oral antifungals with fluconazole
50mg or Itraconazole 100 mg OD for up to 2 weeks
(up to 6 months depending on the severity) or vaginal
Nystatin if not comfortable with oral formulation. For

remission or long-term prophylaxis we can give

weekly fluconazole for a few months.
Before taking any antibiotics, advise GP that you are
undergoing treatment.
Wear loose undergarments. Keep the area dry and
thoroughly dry after bathing. Dont use any creams or
perfumes in the vagina/vulva. Advise vaginal douche

Pelvic Inflammatory Disease

Case: You are an HMO in the Emergency Department and a 24year-old female comes in due to pain in the RIF for 1 day.
Task
a.
b.

c.
d.
e.

History (getting worse, not related to change in

position, feverish, vaginal discharge, smoking 10
cigarettes per day, LMP 2 weeks ago)
Physical examination (in pain, pale, feverish (39), BP
110/70, PR 104, tenderness at RIF, yellowish
discharge on undergarments and vagina, cervical
excitation and adnexal tenderness on right side, no
mass and uterine size normal)
Investigation
Provisional and Differential diagnosis
Management

Differential Diagnosis
- Pelvic inflammatory disease
- Ectopic Pregnancy
- Acute appendicitis
- Ruptured ovarian cyst
- Torsion of ovary
History
-

Is my patient hemodynamically stable? I would like to

interview the patient in the resuscitation table. Where
is the pain? How severe is the pain? Character?
Associated symptoms like discharge, bleeding,
waterworks, N/V/ fever? When was the last time you
opened your bowel? History of constipation or
diarrhea? Is this the first episode of pain? Have you
had surgeries done previously?
When was your LMP? Are your cycles regular? Do
you get pain or spotting in between your periods? Any
complaints of excessive pain on day 1?
Are you sexually active? Are you in a stable
relationship? What contraception do you use? How
many sexual partners have you had previously? Have
you or your partners ever been diagnosed with an
STI? Have you ever been pregnant before? Any
possibility you might be pregnant now? Have you had
gardasil vaccinations? Pap smear?
How is your general health? SADMA?

Physical Examination
- General appearance
- Vital signs and orthostatic hypotension
- Abdominal: distention, tenderness, guarding, rigidity,
Rovsing, mass, bowel sounds, hernial orifices

60
-

Genital: discharge (color, quantity, smell), bleeding,

signs of itching, trauma; sterile speculum looking for
discharge, bleeding, condition of the cervix like
redness; bimanual for size and position of uterus,
cervical excitation, adnexal mass and tenderness
Urine dipstick, pregnancy test, and BSL

Investigations
- FBE, urine for MCS, U&E, USD of abomen (fluid in the
adnexa or in sac or normal), complete STD screening
(urine PCR for Chlamydia and Herpes, Pap smear,
high vaginal swab for wet film preparation for
Trichomonas, endocervical swab for Chlamydia and
Gonorrhea, syphilis with VDRL and RPR, Hepatitis B
serology, HIV, throat swab or anorectal swab if
indicated, urethral swab if indicated)
Diagnosis and Management
- My most likely diagnosis is PID. It is the infection of
pelvic organs caused by bugs that are usually
acquired through sexual contact. The most common
ones are Chlamydia and Gonorrhea. These infections
are very common in young sexually active females.
The usual symptoms are high-grade fever, severe
tummy pain, and tenderness of the cervix.
- It is important to treat this infection carefully because
there are a number of complications both short- and
long-term.
- Short-term complications are abscess formation and
peritonitis
- Long-term complications include a 10% chance of
damage and obstruction of the fallopian tube after first
episode of PID and 30% after second episode, and
75% after 3rd episode, infertility, ectopic pregnancy,
chronic pelvic pain and infection.
- That is why, we need to admit you and start you on IV
antibiotics most likely ceftriaxone IV 250 mg SD along
with Azithromycin 1gm oral and later one switch to oral
medications that you will need to continue for the next
2 weeks (doxycycline + metronidazole).
- Please avoid sexual activity until you are completely
free of symptoms. Practice safe sex. If not already
done, get yourself vaccinated with gardasil. We might
need to trace the contacts if required. Do not worry.
With IV antibiotics, the recurrence is quite low, but you
need to be careful and practice safe sex in the future.

How long have you been suffering from this? Do you

currently have ulcers? Have you ever had them
checked? Did you notice any precipitating symptoms
like periods, stress, pregnancy? At the moment, are
you having any pain? Any vaginal discharge? Fever?
Body aches? Body pain? Urinary symptoms? Are you
sexually active? Do you have a steady partner? Have
you had unprotected sexual intercourse? Any history
of sexually transmitted disease? Have you ever been
screened for STI? Does your partner have similar
symptoms? Are you regular with your pap smear? Did
you get the gardasil vaccination?

Period: menarche, LMP, regular?

Pills? Do you use condoms?
Have you ever been pregnant?
PMHx or FHx? Social history? SADMA?

Physical examination
- General appearance
- Vital signs and BMI
- Rashes or ulcers anywhere else in the body
- Pelvic:
o Inspection: ulcers, bleeding, painful,
discharge,
o Swab
- Abdomen/chest/heart
- Urine dipstick and BSL

Case: your next patient in GP practice is a 30-year-old lady

complaining of recurrent vulvar ulcers.

Diagnosis and management

- Most likely your ulcers are caused by a virus called
herpes simplex virus. This virus stays in one of the
nerve roots of your body and under certain conditions
such as menstruation, pregnancy, or low immunity, it
reoccurs and forms ulcers.
- Usually the first attack is most severe. This is a
sexually transmitted disease and I am afraid that you
have acquired the virus from unprotected sex. At this
stage, I would like to organize some investigations. I
would like to take a swab and send it for culture and
sensitivity and I would also like to screen you for other
STIs. I will give you some strong pain killer and local
gels (lignocaine) to apply.
- Acyclovir within 72 hours of onset of rash.
- Rest. Warm salt baths. Do not scratch ulcers because
you can spread it in other parts of the body. Please
wash your hands if you scratch them. Wear loose
clothings and clean cotton underwear all the time.
Avoid tight jeans.
- Sexual abstinence until the active lesions clear and
please practice safe sex (condoms + washing of
genitals before and after intercourse).
- I would also like to recommend for your partner to
come and see me or his GP to organize STD
screening as well.
- Reading material. Review.

Task

STI Screening

Recurrent Ulcers (Herpes)

a.

b.
c.
History
-

History (4x in that last year, went to dr gave

medications and occur again, painful, discharge
yellowish no fever, 6/10, sexually active and affects
sexual activity, pap smear normal)
Physical examination (irritated and distressed, vitals
normal, no mouth ulcers, pelvic: ulcers few 3-4,
discharge +, not offensive, vulvar region, tenderness)
Diagnosis and management

Case: Suzie aged 20 years presents to your surgery for the first
time. She has recently started working at a local brothel and her
employer has told her she needs to have a 3-monthly health
checkup and get a certificate. Suzie lives independently in a
shared accommodation and had no other medical or surgical
problems.
Task

To help you today, I need to ask you some questions

and some of them might be sensitive, is it alright with
you?

a.
b.
c.

Further history
Examination
Management advise

61
Further history
Since when? What type of sexual practices do you
do? Are customers practicing safe sex? Any vaginal
discharge? Are you on any contraception (OCP)?
Have you had any STIs? Did you have your pap
smear? Have you had gardasil vaccination?
Management
STI Screening: Chlamydia, gonorrhea, syphilis, HIV,
HBV, HCV (if with history of IV drug abuse); hepatitis A
(MSM)
Doctor is it legal? If the place is licensed, then it is
legal.

Management:
From history and PE, you have retained tampon which
got infected which I already removed. Since you dont
have signs of infection such as fever, no need for
antibiotics at this stage.
I would like to give you advice to prevent further
recurrence

What are the risks? There are more risk of sexually

transmitted infection, physical or sexual abuse,
pregnancy, drug and alcohol abuse
I will give you a medical clearance once we have the
results.
Offer gardasil vaccination

Case: 35/F presenting with offensive vaginal discharge.

History
Physical examination
Diagnosis
Management

DIFFERENTIAL DIAGNOSIS
Bacterial vaginosis
Trichomonas infection
Foreign body (tampon/condom)
Cervicitis
Cervical ectropion
Neoplasm
Atrophic vaginitis
History
I understand from your notes that you have offensive
vaginal discharge. I might need to ask some sensitive
questions. Is that okay?
When? Describe the discharge. Color? consistency?
Continuous/on-and-off? Related to coitus or menstrual
cycle? Itchy or painful down below? Pain in your
tummy? Fever?
Has it happened before?
Periods: regular? Amount? Duration? Painful?
Menarche? LMP? Do you use tampons or pads? Have
you recently lost/missed a tampon
Partner: are you sexually active? Do you have a
stable partner? Does your partner have symptoms?
Have you or your partner been diagnosed with STIs in
the past?
Pills: what contraceptives do you use? Any history of
unprotected sex?
Pregnancy: how many? Ask for details if required
Pap smear: when? Any abnormal results?
General history: water works and bowel movement?
PMHx/FHx/SADMA
Examination
General appearance: pallor, BMI,
Vitals: BP, Temperature, RR, PR, O2 saturation
Quick chest/heart
Abdomen: masses/tenderness
Focused pelvic exam: ask for informed consent
o Ask about discharge color, amount,
consistency, smell, blood, redness, scratch
marks

Personal hygiene
Change tampons 3-4x a day
Use external pads at night
Red flags: fever, muscle aches, pains,
dizziness,
Advise to review after 3 days to see if there is any
infection
Give reading material
If with fever or signs of TSS: Call ambulance and
admit. Start IV fluids and IV antiobiotics (flucloxacillin x
5-7 days) and should not use tampons in the future at
all.
If with fever only: clean with povidone iodine 3x/day
for 2 days and oral flucloxacillin; send blood and urine
for culture; vaginal and cervical swab for culture
o
o
o
o

Retained Tampon

Task:
a.
b.
c.
d.

Bimanual examination: uterine size, shape,

tenderness, adnexal masses, mass in fornix
(can I remove the mass) cervical motion
tenderness (+ in ectopic pregnancy, PID,
endometriosis)

Bartholin Abscess
Case: You are a GP and a 35-year-old lady comes in with a
lump in the vulva which she finds uncomfortable.
Task
a.

b.

c.
History
-

History (very painful lump, (+) yellowish to reddish

discharge, cant sit or walk comfortably, periods
regular, sexually active, in stable relationship x 1 year,
on pills)
Physical examination (irritable, BMI 28, VS normal,
vulva: left labia majora, pea size, no redness but with
discharge, no ulcer, tender, hot to touch; urine
dipstick, BSL, normal)
Diagnosis and management
When did you notice the lump? Does it come and go
or is it there all the time? Is it increasing in size? Any
discharge? What is the color? Is it painful? How is it
affecting your life? Have you noticed any lump in any
part of your body? Any rash or vesicle in your private
part? Is it the first time? Do you feel feverish? Any
problem with your waterworks? Bowel habits?
5Ps
Any past medical or surgical history? Are you on any
medications? SADMA?

Physical examination
- General appearance and BMI
- Vital signs
- Chest and heart
- Abdomen
- Pelvic:
o Inspection: site, size, shape, discharge and
if smelly, color
o Palpation: temperature, tenderness,
consistency, fluctuant
o Speculum examination
o Bimanual examination
- Lymph nodes

62
-

Urine dipstick and BSL

Urinary Tract Infection/Prescription Writing

Diagnosis and Management

- You have a condition called bartholin abscess. Theres
a gland called bartholin gland located on each side of
your vaginal opening and there is a collection of pus in
the small duct. Because it is blocked, the secretions
and pus are trapped causing a painful swelling. It
usually appears within 2-3 days and causes severe
pain on walking and sitting. It is usually caused by a
bug E. coli, Streptococcus, Staphylococcus.

Can it be STD doctor? It is unlikely, but it can also be

caused by gonorrhea. Therefore, with your
permission, I would like to ask you to undergo STD
screening and swab the discharge.
I would advise you to have Hot Sitz bath 4x a day,
give you pain relief, and refer you to a gynecologist
ASAP to drain the pus. This procedure is called
marsupialization where a cut is done at the center, roll
it and stitch it outside that leads to a permanent
opening. I would also give you Azithromycin and
Ceftriaxone.
I would advise you to wear loose clothing, maintain
good personal hygiene, and practice safe sex.
Can it happen again doctor? Yes, there is a 10%
chance of recurrence but prognosis is good and
recovery is excellent.
Reading material. Referral. Red flags.

Case: You are a GP and your next patient is a 23-year-old

female who complains of lower abdominal pain.
Task:
a.
b.
c.
d.

History
-

Cystitis
Case: You are a GP and a 24-year-old female Melissa comes in
complaining of pain on micturition with frequency, urgency, and
lower abdominal discomfort for 2 days. She is married, a nonsmoker, and has had appendectomy 10 years ago.
Task
a.
b.
c.
d.

History (terminal dysuria, no fever/N/V)

Physical Examination (mild suprapubic tenderness,
urine dipstick: ++++ RBC, ++ leukocytes)
Investigation
Management

Differential Diagnosis
Cystitis
PID
STDs
History
-

Pain questions: SORTSARA?

5Ps especially Periods (LMP) and sexual history
FHx of kidney problems
Allergies? Previous history of UTIs

Physical Examination
General appearance
Vital signs
Abdomen: tenderness, masses, CVA tenderness
Urine dipstick, urine PT
Management
Lifestyle modification
o Drink ample fluids
o Voiding post-intercourse
o Cranberry juice
o Hygiene: wipe from front to back
Medications: trimethoprim/amoxicillin/cefalexin
Review after 3 days to check for sensitivity to drug

History: dull constant, not related to menses; LMP: 6

weeks
Physical examination: suprapubic tenderness;
Diagnosis
Management and write script

Can you tell me where exactly is the pain? How bad is

it on a scale of 1-10 (4)? Does it go anywhere? Can
you describe the character? Is it a dull ache or sharp
pain? Any aggravating or relieving factors like
movement? Any associated nausea, vomiting, fever or
vaginal discharge? Bleeding or spotting? Any history
of constipation or change in bowel habits? How are
your waterworks? Any burning or frequent passing of
urine? Have you noticed any blood in the urine? Is this
the first time to have it? When did you have it? What
were the symptoms? What test? What treatment was
given? Any problems? When was the last episode of
UTI?
Partner/Pills: Are you sexually active? Are you in a
stable relationship? How many partners have you had
previously? Do you always practice safe sex by the
use of condoms? Any history of STIs? What method of
contraception do you use?
Period: When was your LMP? Are they regular? How
is the cycle like? Any chance that you might be
pregnant?
SADMA? PMHx

Examination
- General appearance: pallor, jaundice, dehydration
- Vital signs
- Chest/heart
- Abdomen: distention? Tenderness on palpation
especially in the RIF/LIF. Any mass palpable? Organ
enlargement? Bowel sounds? Hernia?
- Pelvic exam: Inspection (bleeding, discharge, scratch
marks, ulcers); speculum (bleeding, discharge,
position of cervix); bimanual (size and shape of
uterus, cervical excitation, adnexal mass/tenderness)
- Urine dipstick (leukocytes and nitrates), pregnancy
test and BSL
Management
- As previously you had another attack of UTI, do you
know what it is? At the moment, I am sending a
sample of your urine for culture and microscopy. You
need to drink ample fluids especially cranberry juice.
After passing water and stools, please wipe from front
for you.name
Name to
of back.
patientI will write some antibiotics
Doctors
Trimethoprim or Cephalexin (500mg 2x a day for 5
days or amoxicillin + clavulanic acid
(500mg/125mg
DOB/age
Address
2x a day for 5 days (especially if pregnant)
Address
Telephone number
Prescriber no.
PBS/Private

Tab Trimethoprim
300 mg x daily for 3 days

63
-

Caffeine
Constipation
Chronic cough
Multiparity
Menopause

History

What do you mean by losing urine? Is it small or

large? Do you lose urine when you laugh, cough,
exercising or just normal? Do you lose a lot of urine
when you try to reach the toilet? Any feeling of
masses down below?
Any burning in urination? Frequency? Frothy urine?
Change in color of urine? Polyuria? Polydypsia or
polyphagia?

UTEROVAGINAL PROLAPSE AND INCONTINENCE

Urinary (Stress) Incontinence
Case: A 50-year-old woman who had 3 kids aged 29, 25 and 22
came to your GP clinic complaining of leakage of urine.
Task
History
Appropriate investigations
Diagnosis and management
Causes of incontinence (DIAPPEERSS)
D elirium
I infection of UT
A -trophic urethritis
P harmacological (diuretics)
P sychological (acute distress)
E ndocrine (hypercalcemia)
E nvironmental (unfamiliar surrounding)
R estricted mobility
S tool impaction
S hincter damage or weakness
Drugs Causing Incontinence
Antihypertensives/vasodilators - (ACEI, prazosin,
labetalol, phenoxybenzamine)
Bladder relaxants (anticholinergics, TCAs)
Bladder stimulants (cholinergic, caffeine)
Sedatives (antidepressants, antihistamines,
antipsychotics, hypnotics, tranquilizers)
Others: alcohol, loop diuretics, lithium
Incontinence:
Stress: small amounts of urine; involuntary during
coughing, straining, laughing, etc; due to weakening of
muscles in the pelvis increasing intra-abdominal
pressure results in leakage of urine
Urge: large amounts of urine; want to go to bathroom
but cannot control; problem with detrussor or nerves
Investigations
MSU!!!
Urodynamic studies (measure pressure in the bladder
and urethra)
o Urge incontinence: pressure in bladder
increases very fast reducing bladder
capacity;
o Stress incontinence: intravesical pressure
does not increase when urine fills; bladder
capacity is normal
Risk factors:
UTI
Obesity
Smoking

Was it difficult labor? Assisted labor? Assisted

delivery? Symptoms of menopause? Hot flushes?
Dyspareunia? Mood swings? Pap smear? Partner?
Stable relationship? Any previous history of STDs?
Have you started with mammography?
Any medical history? Chronic cough or constipation?
Joint problems?
SADMA? BMI?

Examination
General appearance: BMI, dehydration, pallor,
jaundice
Vitals
Chest/heart: chronic infections
Abdomen
Pelvic examination: rule out prolapse (cystocele)
Ask examiner for any demonstrable stress
incontinence (ask patient to cough and check for
leakage of urine)
BSL and Dipstick
Diagnosis and Management
You most likely have a condition called stress
incontinence. When the urethra is no longer in the
pelvis, there is an increase in intra-abdominal
pressure, which affects both bladder and urethra
increasing the bladder pressure more than the urethral
pressure, resulting to involuntary loss of urine.
I completely understand that it is a very frustrating
condition for you, but let me assure you that we can
manage it.
Stress incontinence is highly associated with UTI so I
would like to order urine microscopy and culture (ask
examiner for results).
I would advise you to maintain a bladder diary. Avoid
too much physical stress, lifestyle modification (weight
reduction, smoking cessation, decrease caffeine
intake), avoid constipation and coughing
Start pelvic floor exercises (contract pelvic muscles as
if your lifting your pelvis or holding urine 40-50x daily
at 3 months)
Refer to gynecologist regarding vaginal pessaries.
They may consider giving you HRT and urodynamic
studies but will be decided upon by the specialist.
Surgery will only be indicated if conservative
measures fail. Bladder neck suspension, suburethral
rings, and local injection of collagen.
For urge incontinence: bladder training and anticholinergic medications (oxybutynin, propantheline,
imipramine, tolterodine) refer to physiotherapist
Review and Reading Material
Stress incontinence: MSU for urine and culture
Postmenopausal bleeding: Transvaginal
Ultrasound

64

Post-hysterectomy Prolapse
Case: You are a GP and a 52-year-old female comes to your
clinic complaining of something coming out from her vagina
especially after straining

Task
a.
b.
c.
History
-

History
Physical examination
Management
Please tell me more about your problem? Since when
have you noticed this lump? Is it present all the time or
does it come and go? Any changes with change in
position like prolonged standing or lying down? Do

you have associated tummy pain or heavy/dragging

kind of sensation in the lower tummy? Any urinary
complaints like frequency, burning or leaking of urine?
Any loin pain? Any history of prolonged cough,
constipation, asthma or respiratory problems? Do you
have any problems emptying the bowels? Any
complaints of discharge or bleeding from down below?
Any fever? Itching? When was your LMP? Any
problems during or after menopause?
When did you have the hysterectomy? Why did you
have it? Any complications afterwards? Was it done at
a tertiary care center? After the surgery, did you do
pelvic floor exercises? Any other surgeries that I
should be aware of? Did you take any HRT
afterwards?
May I know are you sexually active at the moment?
Any complaints of pain or discomfort during sex? How
many kids have you had? Any history of big babies?
Difficult or instrumental deliveries?
SADMA?
Have you recently noticed weight loss? Change in
appetite? Night sweats? Lumps and bumps in the
body? Pap smear? Mammogram?

Physical examination
- General appearance
- Vital signs
- Chest and Lungs
- Abdomen: for tenderness
- Pelvic exam
o inspection: Obvious lump, discharge, ulcer,
redness, discharge
o Sterile speculum examination asking the
patient to strain looking for any visible lump
while straining; sims left lateral position
(knee-chest position) gradually withdraw
while asking a patient to strain
lump/bulge in the vagina (best way to detect
cystocele and rectocele)
- Urine dipstick and BSL
Diagnosis and Management
- Most likely what you have is prolapse of the vaginal
wall after hysterectomy. Once the uterus is removed,
the upper part of the vagina loses its anatomical
support. Usually, during hysterectomy, the surgeon will
secure the upper part of vagina with the help of
ligaments attached to the backbone and pelvic wall.
Some of these ligaments become loose because of: a.
loss of estrogen b. prolonged straining/coughing c.
putting on weight.
- This phenomenon is quite common after
hysterectomy. Up to 30% of patients might develop
this. It can affect the urinary system leading to

frequent recurrent UTIs. It can also affect the wall of

the bowel causing constipation. Sexual functioning
may be affected and might cause pain and discomfort
during intercourse.
The treatment will be tailored according to your
wishes, but you will need to see a specialist
gynecologist. The first option is conservative
management which includes pessaries along with
pelvic floor exercises. Usually, this suitable for old,
females who are not fit for surgeries. The second
option is the surgical approach. It is called vaginal wall
suspension surgery (sacrocolpopexy). The surgeon
will attach the upper part of the vagina to the strong
tissues within the pelvis usually to the lower backbone
or sacrum. There are 2 options regarding the
approach: laparoscopic or keyhole surgery OR
abdominal approach best decided by the surgeon.

The recurrence rate after the surgery is very low

therefore the surgery is mostly curative.
Review. Reading material.
Pelvic floor exercise (kegel): done to strengthen the
muscles of the pelvic floor. The exercise can be done
either sitting or lying down. The patient needs to
empty the bladder before exercise. Contract the pelvic
muscles, hold contraction for at least 5 seconds,
release it slowly and repeat 3-4x and gradually build
up duration for up to 10 seconds. She must not
contract the abdominal, thigh or buttock muscles.
Exercises must be repeated 3x a day as many times
as possible. Results are usually apparent within 8-10
weeks. Safe to be done during pregnancy

Uterine Prolapse
Case: An a 80-year-old lady comes to your GP clinic
complaining of mass protruding down below and rash around
the private area for several months.
Task
a.
b.
c.
History
-

Relevant history
Physical examination (BMI 29, maculopapular rash
around introitus and inside of thigh, urine dipstick +
sugar, BSL 11.3mmol/L
Diagnosis and management
I read from your notes that you have something
bulging from your private area. Since when? Can you
tell how it happened? Is it increasing? Do you feel any
abdominal discomfort? What is the effect of this
bulging on your life? Is this swelling affecting your
waterworks? Do you leak urine while you strain,
cough, etc? Do you have a strong urge to void on the
way to the toilet or do you leak a large amount of urine
on the way to the toilet? Any discharge down below?
Constipation? Waterworks?
Rash? Since when? Is it itchy? Can you describe the
rash for me?
Period: When was your last period? Any irregular
bleeding after that? Hot flushes? Mood swings?
Breast pain? Irritable?
Pregnancy: how many pregnancies? Were they big
babies? Did you have any difficult labor or prolonged
labor?
Partner: are you sexually active? Do you have a
stable partner? Do you have painful intercourse?
Have you or your partner ever been diagnosed with
STDs?
Pap smear: When was your last pap smear? Result?
Mammography?
Past medical history: chronic cough, diabetes, asthma

65
-

FHx: Osteoporosis, MI
SADMA

Physical Examination
General appearance
Vital signs
Abdomen
Pelvic examination:
o Inspection for morphology of the rash
(maculopapular rash around the introitus
and groin area), scratch marks, discharge,
obvious bulge
o Speculum: wall of vagina, rash, discharge,
blood, ask patient to cough (cervix comes
up to the introitus), leakage of urine, cervix
o PV: adnexal masses, CMT,

PR: differentiate between cystocele and rectocele

BSL and Urine dipstick

Diagnosis and Management

You have a condition called uterovaginal prolapse with
stress incontinence and candidiasis,
Menopause resulting to lack of estrogen, difficult labor,
big babies and constipation leads to the laxity of the
pelvic floor ligaments. It is a common condition among
females in your age group.
At this stage, I would like to refer you to the
gynecologist. I would advise you to start with pelvic
floor exercises (contract pelvic floor muscles as if
trying to hold urine).
The specialist might insert a pessary which is a device
inserted into the vagina to support the uterus. They
need to be changed every 3-6 months. They also
advise topical estrogen to improve the discomfort.
Will it affect intercourse? Pessaries will not interfere
with your sexual performance.
If conservative measures do not work, the specialist
might consider doing surgery to fix the ligaments.
How long will I be in the hospital? Usually 3-5 days.
You can go home once youre feeling well and once
you have started urinating without problems.
Postop advice: For the first two weeks, restrict your
activities. Rest. Avoid heavy lifting. Avoid sports and
swimming. For 1st 6 weeks abstain from sexual
intercourse.
Driving: It is not advisable to drive for the first 2
weeks.
Complications: Pain, bleeding, injury to nearby
structures, anesthesia complications
For the candida, I will prescribe you antifungals. It
might be related to high blood sugar. I will give you
referral to physician to investigate further
Lifestyle modification: normal BMI, stop smoking,
high-fiber diet
Referral to specialist obstetrician. Reading material.
Review.
Advise OGTT.
Prolapse:
I: cervix remains within vagina
II: cervix comes up to introitus
III: most of uterus lie outside vagina
Uterine Prolapse
Case: A 58-year-old lady comes in your GP clinic complaining of
lump from the vagina.

Task
a.
b.
c.
History
-

History
Physical examination
Explain management
I understand you have come because you are worried
about a lump that is coming out from your vagina.
When did you first notice it? Does it come and go or is
it present all the time? Did you notice that it appears
when youre straining? Do you have a dragging
sensation or heaviness in the tummy? Any unusual
vaginal discharge or bleeding?
Do you have chronic cough? Hows your waterworks?
Have you noticed increased frequency or feeling that
your bladder is emptying incompletely? Do you have
urine leakage during coughing, straining or laughing?
Do you have regular bowel movements?

When was your LMP (menopause risk factor)? Any

spotting or bleeding after that? Are you sexually
active? Does this problem cause difficulty or pain with
intercourse? When was your last pap smear? Was it
normal? How many pregnancies have you had? How
many children do you have? Do you remember the
birth weight (>4kg)? Did you have NSVD? Did you
have instrumental delivery?
Are you generally healthy? Surgeries? Medications?
Smoking? What are you doing for a living?

Physical examination
General appearance
Vital signs and BMI
Abdomen: masses and tenderness
Pelvic:
o Inspection: evidence of prolapse and
atrophic changes; can you please strain or
cough (for 2nd degree prolapse)?
o Speculum (left lateral position): using sims
speculum prolapse, check for cystocele or
rectocele, degree of prolapse, atrophic
changes, discharge, appearance of cervix,
o Bimanual examination: any pelvic masses
palpable, size of uterus, and adnexa; ask
patient to squeeze to fingers to assess of
pelvic muscle strength
Urine dipstick and BSL
Degree of prolapse
I cervix protrudes/sits into lower 1/3 of vagina
II cervix protrudes on straining outside of vagina
III cervix/uterus lies outside of the vagina
Diagnosis and Management
You have a condition called uterine prolapse. Have
you ever heard about it? The uterus, bladder and
bowel are supported by a tight hammock of muscles
slung between the tail and pubic bone. These muscles
are known as pelvic floor muscles. Ligaments also
anchor uterus in place. If these tissues are weakened
or damaged, the uterus can slip down into the vagina.
We call it uterine prolapse.
Common causes of uterine prolapse include vaginal
childbirth especially if baby was large or delivered
quickly or if there was a prolonged pushing phase or
instrumental delivery. Another group of risk factors is
being overweight, having chronic cough, constipation,
and heavy lifting which are factors that increase intra-

66

abdominal pressure. The last predisposing factor is a

low level of estrogen after menopause.
I will refer you to a gynecologist for further
assessment and to discuss treatment options.
Treatment depends on age, degree of prolapse, and
patient preference.
Meanwhile, I will arrange a meeting with a
physiotherapist who will teach you pelvic floor
exercises (effective for 1st and 2nd degree). I also
recommend for you to have lifestyle modification. Try
to keep your weight within the ideal range, have a
balanced diet, regular exercise, and smoking
cessation.
The most effective treatment is surgery which is
vaginal hysterectomy. Sometimes before surgery or if
woman is not fit for surgery, or if woman does not
want surgery, a vaginal pessary can be used which is
a donut-shaped device inserted into the vagina and
positioned to prop the cervix and uterus. It should be
changed every 6 months. Side effects include irritating
discharge and increased risk of ulceration as well.
Local estrogen can be used to decrease the side
effect.

Needle vaginal drainage by USD

for simple larger cyst
Laparoscopy: complex cysts, large
cysts, or external bleeding

Ovarian torsion
o Mainly from dermoid cysts
o Symptoms: severe cramping lower
abdominal pain, diffuse, pain may radiate to

o
o
o

flank, back or thigh; repeated vomiting,

exquisite pelvic tenderness, patient looks ill
Signs: smooth, rounded mobile mass
palpable in abdomen; may be tenderness
and guarding over the mass
Investigation: USD + color Doppler
Management: Laparotomy

Differential Diagnosis
- Ectopic Pregnancy
- Ruptured ovarian cyst/torsion
- PID

BENIGN TUMORS
-

Ovarian Torsion/Ruptured Ovarian Cyst

Case: Julia aged 35 years presents to ED of local hospital
where you are working as year 1 RMO. She had severe right
sided abdominal pain for the last 1-2 hours associated with
nausea and vomiting. She had similar pain a few months ago
but lasted only for a few minutes and was relived with panadol
and neurofen. She had no other significant medical or surgical
problems. She had known allergies and is not on any regular
medications. Julia works as a business consultant in a local firm
and lives with her partner. She smokes about 10 cigarettes per
day and is a social drinker.

History
-

Task
a.

b.

c.

Further history (10/10 in severity, tried panadol and

neurofen but did not work; RLQ, no fever, no rash, no
problems with bowel motions or waterworks; periods
are regular, LMP 3 weeks ago)
Physical examination (uncomfortable but fully
conscious and oriented, PR 84, BP: 100/70, T and RR
normal; no LAD, no lumps and bumps, chest and
heart normal; inspection normal; no distention; palpate
tender at RIF but no rebound or guarding/rigidity, no
palpable mass; no organomegaly; pelvic examination:
normal; PR normal; urine PT negative, urine dipstick;
FBE normal U&E normal; USD pending)
Diagnosis and management

Features
- Ovarian Cysts:
o Common in women under 50 years of age
o Best defined by TVS
o Symptoms: pain, pressure symptoms,
menstrual irregularities
- Ruptured ovarian cyst:
o 15-25 years
o Symptoms: Sudden onset of pain in one or
other iliac fossa; No systemic signs; Pain
usually settles within a few hours
o Signs: tenderness and guarding in iliac
fossa, PR: tenderness in rectovaginal pouch
o Investigation: USD + color Doppler
o Management
Explanation and reassurance
Conservative: simple cyst <4cm,
internal hemorrhage, minimal pain

Acute appendicitis
Acute mesenteric ischemia
Renal colic
Since when? SORTSARA? Associated features like
fever? Nausea? Vomiting? Any discharge from below?
Any problems with waterworks or bowel movements?
5Ps:
o Period: LMP? How many days of bleeding?
How many days apart? Any bleeding in
between? Any chance you might be
pregnant?
o Pills
o Partner: stable relationship? Ever been
diagnosed with STIs? Partner?
o Pap smear
o Pregnancy
PMHx: Surgery or any medical illnesses?
FHx:

Physical Examination
- General appearance
- Vital signs
- Abdomen and inguinal orifice
- PR
- Pelvic examination
- Urine dipstick, urine PT, BSL
Diagnosis and management
- Refer to OB registrar
- Start IV line and take bloods
Uterine Fibroid
Case: A 35-year-old female comes to your GP clinic complaining
of heavy menstrual flow for several months. she has 2 children 6
and 8 years. She still wants to have a baby in the future. Her
FBE showed low hemoglobin.
Task
a.

b.

History (x6 months, change pads every 3 hours, 4-5

pads/day, 9-10 days, feel pressure and fullness in
lower tummy and sometimes has difficulty passing
urine, urinary frequency)
Physical examination (Specific findings will be given
only when asked) uterus 12 weeks size and irregular

67
c.
d.
History
-

Investigation
Management
Are you bleeding now? Since when did you have the
heavy periods? How many times do you have to
change a pad in a day? Are the pads fully soaked? Do
you pass any clots as well? What is the duration of
your periods? Do you feel dizzy, palpitations, fainting?
Any pain during your periods? Do you have bleeding
between periods? Do you have any bleeding
disorders? LMP? Any chance you could be pregnant?
Are you sexually active? Are you in a stable
relationship? Are you on any contraceptive? Have you
or your partner ever been diagnosed with STDs?
Previous pregnancies? Pap smear?
Any problem with your waterworks? Do you have any
burning while urinating?
FHx of bleeding disorders or gynecological
tumors/cancers?
-

Physical Examination
- General appearance
- Vital signs
- Abdomen: Visible masses, organomegaly, tenderness
- Pelvic Exam: discharge, bleeding, cervical os
close/open, enlarged irregular uterus about the size of
12 weeks GA. No palpable adnexal masses. CMT
negative.
- Urine dipstick, BSL, urine PT
Diagnosis and Management
- From the history and examination, the most likely
cause of your heavy periods is uterine fibroid or
myoma. However, I need to do some investigations to
confirm the diagnosis. The investigations are betahcg, iron studies, coagulation profile, urine MCS, and
TVS. On TVS, there is a large 10 cm hypoechogenic
region in the fundus of the uterus.
- A fibroid is a benign tumor which is formed inside the
uterus. It is very common in the reproductive age
group. Let me reassure you that it is not a cancer. The
exact cause is unknown, but it is suspected that the
sex hormones, estrogen and progesterone, play a
significant role. That is the reason why fibroids rarely
grow in pre-pubescent girls and postmenopausal
women. Pre-existing fibroids stop growing and even
shrink once a woman passes menopause. Fibroids
often cause no problems but occasionally, it can be
associated with:
o Anemia - because of excessive menstrual
blood loss and cause fatigue, pallor and
breathlessness
o Urinary problems - because large fibroids
can bulge the uterus against the bladder
causing a sensation of fullness or discomfort
and the need to urinate often
o Infertility - presence of fibroids can interfere
with the implantation of fertilized egg in a
number of ways making successful
implantation difficult
o Miscarriage and premature delivery can
reduce blood flow to placenta or may
compete for space with the developing baby
- I will need to refer you to the gynecologist for further
assessment and management. Treatment depends on
the location, size, and number of fibroids. If fibroids

are small and not causing symptoms, we may just

observe. For the large fibroids, we can use drugs to
shrink prior to surgery and these drugs are danazol
(GnRh agonist) or medroxyprogesterone. The surgical
options are uterine artery embolization. It is done
under local anesthesia. A fine tube is passed via an
artery in the arm of leg into the main artery supplying
the fibroids. Fine particles like sand are then injected
into the artery to block its blood supply. The fibroids
slowly die and symptoms should settle over a few
months. The whole process is monitored by xray.
Another option is hysteroscopic myomectomy. The
gynecologist can pass a tube via the cervix and
remove the fibroid. They can also choose to do
laparoscopic myomectomy which is a key-hole
surgery through abdomen. Very less likely, they will go
for open surgeries especially if the fibroids are very
big. The last option is hysterectomy. This is done
especially if the woman has completed her family. The
one disadvantage of having open surgery is that
cesarean section is more likely done in succeeding
pregnancies because of the weakening of the
abdominal and myometrial wall.
Iron therapy.
Reading material. Referral.

Acute Urinary Retention secondary to Fibroids

Case: A 45-year-old woman comes to you in your GP clinic
complaining of difficulty to pass urine.
Task
a.
b.

c.
Causes
History
-

History (3children, NSVD, pap smear >2 years

normal, USD GB normal, + discomfort during sexual
intercourse, regular bowel movement)
Physical examination (BMI 25, vital signs normal, soft,
no distention or masses, no discharge or bleeding,
bimanual normal, pelvic mass which is hard to
distinguish if it arises from uterus or adnexa, urine
dipstick and BSL)
Management
Pelvic Mass (Fibroids or ovaries)
Pregnancy
Herpes simplex
Prolapse
Neurologic problems
Renal stones
Constipation (elderly)
Medications (antidepressants/antipsychotics)
Males: Prostate enlargement
I understand you came to see me because you cant
pass urine? For how long? Are you comfortable
enough for me to ask you a few questions or you want
me to address this problem first?
Is it the first time? Can you recall any precipitating
factors like trauma to the back or pelvis? Have you
noticed change in urination or frequency before? Do
you have any bowel problems? Do you have difficulty
or discomfort when you try to urinate? Did you have
leakage of urine while laughing, coughing or
sneezing? Have you noticed any rash in your private
area? Have you noticed any unusual vaginal
discharge? Have you noticed any lump coming out of
your vagina?
When was your LMP? Is it regular? Any excessive
pain or bleeding? Have they always been heavy or is
it something new? Are you in a stable relationship?

68

Have you ever been diagnosed with STD? Do you

have pain or discomfort during sexual intercourse?
What type of contraception do you use? How many
pregnancies have you had? How many children do
you have? Type of delivery? BW? When was your last
pap smear? Was it normal?
Are you generally healthy? Ever been diagnosed with
renal stone? Any medications? Allergies?

Physical examination
- General appearance
- Vital signs and BMI
- Abdomen: palpate distended bladder (smooth, firm,
oval dull suprapubic mass)
- Pelvic exam
o Inspection: any evidence of prolapse
o Speculum in left lateral position with sims
speculum
Bimanual examination: size of uterus,
contour, consistency, adnexal mass
Urinary catheter and take urinary sample for
microscopy and culture. After emptying bladder, can I
palpate any abdominal masses?
Urine dipstick and PT
o

Diagnosis and Management

- You have an acute retention of urine and on PE, I
found a pelvic mass which can arise from the uterus
or the ovaries. You need to have a pelvic USD to
establish the diagnosis. I need to refer you the
hospital where you will be assessed by the
gynecologist.
- The gynecologist will arrange further investigations
including FBE, U&E, CA-125, and TVS/TAS.
- If this problem is due to fibroid which is a benign tumor
of the uterus, the treatment will depend on site, size
and desire for pregnancy. You have an acute
presentation and most likely it will require surgery,
laparoscopic or open.
- If it is benign ovarian cyst or tumor, cystectomy can be
performed. However, in women above 40, bilateral
salpingo-oophorectomy plus total hysterectomy is
preferred. A gynecologist will discuss diagnosis and
all available options.
- A catheter should stay in the bladder until a cause for
your presentation has been identified and treated.
BREAST
Cyclical Mastalgia
Case: A 40-year-old woman comes to see you in your GP
practice. She complains of cyclic pain in both breasts. On
examination, there are some lumps in her breasts on the upper
outer quadrant. She was not able to tolerate OCPs because of
vomiting and her mother was diagnosed with breast cancer
when she was 60 and was treated with radical mastectomy.
Task
a.
b.
c.

History
Diagnosis
Management

Risk factors:
- Caffeine intake
- Inappropriate brassieres
- Obesity
History

Let me acknowledge your pain and your concern

about the breast lumps. I know youre worried about
your moms condition, but before we go ahead I would
like to ask you some questions.
Some of the questions might be sensitive, is that
okay?
When did you start having pain in your breast?
Severity (1-10), site (both breasts/single)? radiation?
Aggravating factor (periods)? Associated factors? How
is it affecting your life? Any previous history of similar
problems? Any previous breast problems in general?
Nipple discharge? Changes in breast? Swelling and
erythema? Any lumps and bumps in the body?
Back/bone pains? Any cough or other chest
symptoms? Headache, N/V, or visual changes?
Do you drink too much coffee? Do you have bra
problems?
5Ps: pregnancy: any chance you could be pregnant at
the moment? Partner, pills, periods (regular?
Bleeding? Clots duration of cycle? Menarche); pap
smear: any abnormal pap so far?
FHx: other cancers? PMHx

Management
- With respect to your worries about the cancer, let me
reassure you that the pain and lump sensation is due
to a benign condition called cyclical mastalgia. Most
likely, it is because of hormonal changes during
menstruation. It usually starts a couple of days before
menstruation and relieved during the commencement
of menstruation, but let me reassure you that it is not
cancer. It is very common in women aged 30-40 years
- Advise weight reduction
- Reduce caffeine intake (not >1-2 cups/day) and low
fat
- Stop smoking
- Wear good quality comfortable brassiere
- Prescribe analgesics
- If not responsive, then add mefenamic acid, vitamin
b1 and b6. evening primrose oil danazol
- Because of your concern about your moms condition,
which increases your risk of having a breast cancer
(1:14 to 1:10), I will refer you to a specialist who will
order further investigations like mammography (every
2 years from now) and annual examination by GP and
monthly self-breast examination.
- Exercise (aerobic upper exercises)
- See his sister
- Cause: Estrogen
Nipple discharge (Intraductal Papilloma)
Case: Marion aged 51 years presents to your GP clinic in a busy
afternoon and tells you that she is quite worried about her nipple
discharge. The discharge is from right nipple describing it as
pinkish. The discharge is spontaneous and she had also noticed
discoloration on her nightie. It happened last night and also last
week. It is of small amount, leaving a stain about the size of 20
cent piece on her clothing. She never had any breast problems
before and is very concerned. Marion is a mother of 3 who she
bottlefed. She had paternal grandmother who had mastectomy
although she doesnt know any more details. She had attended
a breast screen clinic about six months ago and was all OK. She
is still menstruating but her cycles have become quite irregular
and scanty over the last year.

69
Task
a.
b.
c.

Further history
Physical examination
Differential diagnosis and management advise
DISCHARGE

Blood
Green
Yellow

White

Straw-color
Serous

FSH/LH increase and estradiol decrease

Symptoms:
o Bleeding: oligmenorrhea/menorrhagia
o Hot flushes: heat centered on the face and
spreads to neck and chest; accompanied by
vasodilation and sweating; episodes last 2-4
minutes happening several times a day;
should be fine after 70 years
o Sleep disturbance
o Vaginal dryness (estrogen deficiency which
can lead to vaginal atrophy and
dyspareunia; pale vagina; pH which is
usually <4.5 in reproductive years increases
to 6-7 and hence more prone to infections)
o Sexual dysfunction: low libido and
decreased vaginal lubrication; elasticity of
wall decreases and vagina may become
shorter; continuing sexual activity may
prevent changes
o Incontinence
o Breast pain and tenderness in early
menopause
o Skin changes
o Osteoporosis
o Cardiovascular problems
o Dementia
o Anxiety, tearfulness, blues, loss of
concentration are NOT menopausal
symptoms

Management
o Education
o Investigations
o Healthy lifestyle (diet, exercise, pelvic floor
exercise)
o Consider HRT
Relieve flushes and vaginal
symptoms
Induce feeling of wellbeing
Prevent osteoporosis
Improve skin
Efficacy regarding
cardioprotection is controversial
Itchy, bitchy, sweaty, sleepy, bloated, forgetful and
psycho

DIAGNOSIS
Intraductal papilloma
Cancer
Duct ectasia
Mammary dysplasia
Mammary duct ectasia
Abscess
Carcinoma
Lactation cyst
Hyperprolactinemia
Drugs: chlorpromazine
Fibroadenoma
Carcinoma

Abnormal:
- Color of discharge (serous, blood)
- Spontaneous discharge
- Discharge coming from nipple
Differential Diagnosis
- Ductal papilloma
- Infiltrating ductal carcinoma
- Medications (metoclopramide, SSRIs, OCP, cocaine)

Paget disease of nipple

Breast eczema

Features
- Benign hyperplastic lesions within large mammary
ducts and not premalignant
- Present with nipple bleeding or blood-stained
discharge and must be differentiated from infiltrating
carcinoma
- Involved duct and affected breast segment should be
excised ductectomy
Triple Test for Lumps
- History and physical examination
- Imaging (USD or mammography)
- Biopsy (Fine needle or core biopsy)
MENOPAUSE
Menopause Investigations
Case: Your next patient is a 54-year-old female who had her last
period 18 months ago. Now, she has mood swings, sweating,
and dyspareunia. She also has FHx of osteoporosis. She has 3
children and her mother has osteoporosis.

History
-

Task
a.
b.
c.
d.

History
Physical Examination: dry vagina
Investigation
Management

Features
- Cessation of menses for >12 mos.
- Pre-menopausal 5 years before the onset of last
menstrual period
- Perimenopause the time when menses become
irregular (2 years before)
- Postmenopause women who have not experienced
menstrual bleeding from a minimum of 12 months and
up to 5 years after menopause

Ask menopausal symptoms: problems with bleeding?

Hot flushes? Sleep disturbance? Dyspareunia?
Sexual dysfunction? Incontinence? Breast pain and
tenderness? Skin changes? Osteoporosis (bone pain,
backaches)? CV problems? Signs of dementia?
Differentiate mood swing from depression? Any
change in weight or appetite?
5Ps: pills, pregnancy, partner (history of STD), Pap
smear, mammography? Periods (postmenopausal
bleeding)?
How is it affecting your life?
Contraindications for HRT: ever been diagnosed with
stroke, TIA, migraine, hypertension, thyroid disease,
clots in legs or lungs, undiagnosed vaginal bleeding,
liver disease, personal or FHx of breast or endometrial
cancer?
SADMA?

Investigations
- FBE with iron studies
- Urinalysis

70
-

U&E, Ca and Vitamin D levels

LFts, TFTs, Lipid profile
Pap smear
Mammography (all women before or after 3 months on
HRT)
Hormone levels: FSH, LH, estradiol, progesterone,
testosterone, PRL,
Coagulation profile
TVS to check for endometrial thickness
DEXA scan
Diagnostic hysteroscopy and endometrial biopsy (if
with undiagnosed vaginal bleeding or increased
thickness)
Urodynamic studies for incontinence

Management
- I have organized the investigations for you. At this
stage, since you have dry vagina, I will give you
estrogen creams. I would advise to have a healthy
lifestyle including exercises 30 minutes a day 5 days a
week, healthy diet with lots of calcium, pelvic floor
exercises, smoking cessation, advise on safe levels of
drinking
- Use evening primrose oil for breast tenderness
- For social issues: handle accordingly
- I would like to refer you to a gynecologist who may
consider starting you on HRT and I would like to
review you once all the investigations are back and we
may need to change some of the management
depending on the results.

Speculum: discharge, vaginal wall for pallor,

dryness, thin, atrophic, rectocele or
cystocele or prolapse, pap smear
o PV: cervical motion tenderness, adnexal
masses
Urine dipstick and BSL
o

Diagnosis and Management

You have a condition called atrophic vaginitis. It is a
common condition in postmenopausal women
because at this age, there is lack of estrogen and the
vaginal wall starts to have atrophic changes because
of that.
For this I will give you local estrogen creams.
Also, we need to further assess the womb lining. I will
refer you to a gynecologist and arrange an ultrasound
to rule out any nasty changes in your womb.
Lifestyle modification. More calcium.
Reading material.
Review.
Lichen Sclerosus et atrophicus
You are a GP and a 68-year-old female came to your GP
practice complaining of itching of the vulva for 1 year.
Task
a.
b.
c.

History: chronic itching x 1 year with pain/discomfort

Diagnosis based on picture given
Investigations and manage the case

Biopsy: chronic Inflammatory changes dermatoses -- lichen

sclerosis
r/o MALIGNANCY!
Atrophic Vaginitis
Case: You are a GP and a 60-year-old female comes in
complaining of vaginal discharge.
Task
a.
b.
c.
History
-

History (vaginal discharge x 5 days, brownish,

menopause 5-6 years ago, no HRT)
Physical examination (thin and dry; pale, discharge)
Diagnosis and management
When did you notice it? Whats the color? How much?
Is it smelly? Is it itchy? Does your partner have similar
complaints?
Periods: menarche, LMP, menopause? Are you
sexually active? Are you in a stable relationship? Do
you have problems with sex? Have you or your
partner ever been diagnosed with STIs?
Pregnancies? Pap smear? When was the last one?
Mammography?
4B and 2Ps in a postmenopausal woman:
o Bladder, bowel, breast, bone
o Prolapse and Postmenopausal symptoms
(mood swings, hot flushes, irritability,
dyspareunia, bleeding)
FHx: cancers
How is your general health? SADMA

Physical Examination
General examination
Vital signs and BMI
Breast examination for lumps
Pelvic examination
o Inspection: discharge, color, amount, smell,
scratch marks, visible prolapse,

History
-

Please tell me more about the problem? Is it present

all the time or does it come and go? Does it wake you
up at night? Any bleeding? Discharge? Any problem
with passing water like burning sensation, frequency
of urination, any problems with the stream (scarring
due to LS may cause problems with urination?
Previous infections or surgeries down there? Skin
allergies? Have you ever been diagnosed with DM?
Or prolonged steroid use? When was your LMP? Did
you have symptoms of menopause like flushing,
palpitations, irritability, dry vagina? HRT use? For how
long? Any problems with that? Did you have any
bleeding or spotting since then? When was your last
pap smear? Are you sexually active? Stable
relationship? Any problems during intercourse? Did
you have a mammogram recently? How many
children do you have? All NSVD? Complications?
Change in weight? Appetite? Lumps around body? Do
you feel tired most of the time? Any FHx of
gynecological cancers or similar conditions? Any
PMHx or surgical conditions? SADMA?
Picture: white shiny plaques on both vulva with lacelike patterns w/ or w/o bleeding; may bleed when
scratched

Investigations
- BSL, pap smear, swab if with discharge
- Multiple punch biopsy of lesion
Differential diagnosis
- lichen sclerosis
- candidiasis
- atrophic vaginitis
- vulvar Cancer

71
-

psoriasis
diabetes
paget disease
leukoplakia
vulvovaginitis
trauma
Eczema

Management
- You have a condition called lichen sclerosis (genital
pruritus + genital soreness+ white wrinkled plaques). It
is a chronic inflammatory skin condition. The exact
cause is unknown, but there is a genetic pattern and it
is linked to certain immune-mediated conditions, e.g.
Autoimmune thyroid disease, vitiligo, psoriasis,
pernicious anemia, alopecia
- Please don't worry. This is not an infection and this is
not cancer. It is not contagious. It usually presents as
itching, vulvar pain, bleeding with scratching,
sometimes blister formation.
- It is important to treat the condition to prevent
scarring. 5% of these patients may develop cancers
within the scar.
- Is it because of my menopause? (up to now there has
been no association proven between lack of estrogen
and appearance of the condition)
- Treatment with steroids (clobetasol propionate) -apply 2x a day for x 1 month, then once every night x
1 month then 2x weekly x 3 months then once weekly
until asymptomatic then PRN
- Inform about risk of steroid therapy: thinning of skin,
redness, fungal infections

95% of patients improve with this treatment. Maintain

good genital hygiene. Avoid using any other creams in
that area. Try to avoid scratching. If required, you may
use emollient to keep the area moist
If not relieved, may use retinoids, tacrolimus, UV
therapy
Refer to gynecologist for treatment and followup

LSIL with HPV

Task
a.
b.

Explain result to patient

Management accordingly

Guidelines for Pap Smear Results for Asymptomatic Females

Results
Action
Negative
Repeat x 2 years
LSIL
Repeat in 1 year
HSIL
Colposcopy and biopsy
Unsatisfactory
Repeat in 6-12 weeks
Glandular cells
Colposcopy and biopsy

LSIL
o Mild dyskariosis/dysplasia or HPV infection
o Repeat in 12 mos
If normal repeat in 12 mos. if
normal then every 2 years

HSIL

Moderate to severe dyskariosis

Do Colposcopy and biopsy
If colposcopy shows intracellular
(LSIL) lesions ablation (laser,
cryotherapy, diathermy or surgical
excision)
If colposcopy is positive for
invasive lesion do cone biopsy
o NO cone biopsy in pregnancy
Complications: bleeding, cervical
incompetence, cervical stenosis
May affect further pregnancy:
premature labor or premature
rupture of membranes
o In pregnancy:
If LSIL wait and can do ablation
after pregnancy
If HSIL:
<20 weeks: offer
termination and
aggressive cancer
treatment
>20 weeks: up to
mother to decide
>35 weeks: continue
pregnancy and do
cesarean section and
aggressive cancer
treatment
Any active problems with cervix/abnormal pap smear
in pregnancy is a contraindication to vaginal delivery

HPV

ABNORMAL PAP SMEAR

Case: You are a GP and 24-year-old female came to find out the
result of her pap smear. This showed low-grade intraepithelial
squamous lesion and HPV infection.

If (+) LSIL colposcopy and

biopsy
If colposcopy shows LSIL
ablation (laser, cryotherapy,
diathermy or surgical excision)

Around 200 types

40 are found within anogenital area
Spread by sexual contact and skin-to-skin contact
Type 6 and 11: low-risk HPV responsible for 90%
of genital warts; not related in any way to cancers
Types 16 and 18: high-risk HPV responsible for
70% of cervical cancers all over the world
Causes microabrasions within cervical epithelium
Are extremely common within the first 10 years of
sexual life but majority are transient
Body is able to get rid of the virus on its own but might
take up to 12 months to clear the infection
Also known as common cold of sexual activity

Counseling
- I have the results of the test with me. May I ask a few
relevant questions?
- When did you have your last pap smear? What was
the result? I understand you are sexually active, are
you in a stable relationship at the moment? How many
partners have you had previously? Did you always
practice safe sex with the use of condoms? Have you
or your partner ever been diagnosed with a STI
(warts)? At the moment, do you have any symptoms,
vaginal discharge, bleeding, or itching? Any pain
during intercourse? Any chance you might be
pregnant now? Have you ever been pregnant before?
Any miscarriages? When was your LMP? Cycles
regular?

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-

How is your general health? SADMA? Do you have a

family history of gynecological cancers or breast
cancer?

Counseling
- As you know, pap smear is a screening test for early
asymptomatic cervical cancer. We usually detect for
the presence of abnormal cells in the cervix. At the
moment, your results showed that there are some
cells that look different from normal. We call it LSIL.
Basically it means that there are minor changes within
the lining of the cervix, which could be because of the
presence of a coexisting infection with HPV. This virus
induces temporary changes in the lining of the cervix.
What is important is that LSIL has a very low but
definite risk of transforming into cancer. We need to
repeat the test within 12 months time. There are two
possibilities: If pap smear is normal, we will repeat it
again in 1 year time and if still normal then go back to
2-yearly regime. The other possibility is persistent
LSIL or HSIL. If this happens, I will have to refer you
to a specialist for colposcopy and biopsy. It is a
process where we introduce a small tube with a
camera into the cervix to look at the lining. If there is a
suspicious lesion, then a piece of tissue will be taken
out. If not, acetic acid will be applied and a suspicious
area will turn white and a sample will be taken.
- Regarding HPV infection, the body will be able to clear
off the infection in majority of cases. It is very difficult
to find out how and when you got this infection
because it can happen even in stable relationships. It
is important for you to be vaccinated with gardasil to
protect you from the other 3 subtypes of HPV. If you
like, we can check you for other STDs.

Management
Offer HPV vaccination
Repeat after 1 year (or 6 months if age >30 and pap
smear >2 years ago)
Counsel against risk factors and safe sex
Abnormal Pap smear with Actinomyces
Case: You are a GP and a 38-year-old female comes in with pap
smear showing abnormal cells + Actinomyces. She has IUCD
for 5 years.
Task
a.
b.
c.
History
-

We are planning to have a baby, can I fall pregnant?

There is a 10% that the baby might acquire the
infection during labor only. It usually goes into the
babys throat (respiratory papillomatosis) causing
warts. The baby may or may not be able to get rid of
the infection on its own, but we can give certain
medications to help him. It is important to practice safe
sex from now onwards.
Review. Reading material.

History (periods regular, IUCD checks monthly,

2children, NSVD, STI -, DM + Grandmother,
Physical examination (can see string of pap smear
BSL 5.5)
Diagnosis and Management
I know you have come to see me because you want to
discuss your pap smear result.
Prior to our discussion, can I ask a few symptoms?
How are you feeling? Have you noticed any low
abdominal pain or discomfort? Any unusual discharge
or bleeding?
Periods:
Are you in a stable relationship? Have you ever been
diagnosed with STD or PID? Is it your first IUCD?
What type of IUCD do you have? Have you ever been
pregnant? How many children have you had? Have
you ever had an abnormal pap smear in the past
(No)? When was it? What was it? What was done for
that? When was your last pap smear apart from this
one? Hows your general health? SADMA?
FHx

Physical examination
- General appearance
- Vital signs
- Abdomen: tenderness and masses
- Pelvic: inspection/speculum: appearance of cervix,
any abnormal discharge, thread of IUCD? PV: size of
uterus, adnexal masses/tenderness, cervical
excitation/CMT
- Urine dipstick and BSL

Pap Smear (CIN I)

Case: Katharin aged 25 years presents to your surgery for result
of her Pap smear which you did last week. The result shows
changes consistent with CIN 1. Her last Pap test was two years
ago and that was normal. She is otherwise well and had no
previous medical or any surgical problems. Katharine lives by
herself and works in a local bar. She smokes on average 10-15
cigarettes per day and drink socially.
Task
a.
b.
c.
History
-

Explain result of pap smear

Further relevant history
Management
Multiple partners? Smoker? What age of coitarche?
Practicing safe sex? Promiscuity? What is your work?
Low socioeconomic status? FHx of cancers?

Diagnosis and Management

- Your pap smear result showed abnormal cells and
actinomyces. Actinomyces is a gram positive bacteria
and is relatively common to find smears positive for

Actinomyces in women who use IUCDs. I want to refer

you to a gynecologist for further assessment and
management. Usually, with symptomatic Actinomyces,
IUCD should be removed, threads cut, and IUCD sent
for microscopy and culture. If it is positive, prolonged
antibiotic treatment with penicillin for 6 weeks is done.
After treatment, pap smear should be repeated in 6-12
weeks because it might be due to the coexisting
infection with the bug.
Gardasil Vaccine

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Case: You are a GP and your next patient is a 45-year-old Mr.

Walker wants to know about Gardasil vaccination. His 15 year
old daughter will receive vaccine in school and he is worried that
it will encourage early sexual life.
Task

a.

Respond to patient inquiry

Hello Mr. Walker. I understand you have come to see

me to discuss Gardasil vaccine. How much do you
know about this vaccine? Have you ever heard about
HPV infection?
Gardasil vaccine was designed to prevent HPV
infection and it doesnt promote early sexual life.
Gardasil is effective against 4 types of HPV. There are
40 types of HPV that affect the genital tract. This
vaccine is against types 16 and 18 causative agents in
70-80% of all cervical cancer and types 6 and 11,
which are associated with 90% of genital warts. HPV
infection is transmitted by sexual intercourse. That is
why this vaccine is given to young girls (9-26) since
most of them hasnt started sexual life and havent
been infected and thus will benefit the most. However,
even sexually active girls can benefit from gardasil
vaccine. Majority of them will not yet be infected, or
may be infected by 1 or 2 types and get protection
against others.
Gardasil vaccine is part of the school immunization
program. It is free and given within 6 months. It is
administrated by intramuscular injection usually in the
shoulder. The only absolute contraindication to HPV

vaccination is severe allergic reaction (anaphylaxis)

following a previous dose of the vaccine.
Gardasil contains virus-like particles which are noninfectious and do not have any cancer-causing
potential. This vaccine is generally safe and welltolerated.
Possible side effects: Injection site pain, swelling, and
redness.

Gardasil vaccine does not protect against other STDs.

It doesnt encourage girls to start sexual life earlier.
The main purpose of the HP V vaccine is to protect
them against cervical cancer and genital warts.
However, it doesnt give 100% protection. All girls
need to be screened for cervical pathology using pap
smear from the age of 18 or 2 years after they
become sexually active (whichever comes later).
Can be given to boys but not included in the
immunization program.
Pregnant women? No, but you can give them after
labor even while breastfeeding.
It is no longer beneficial after the age of 27.