OSCE

2020
OBSTETRICS & GYNACOLOGY

43 ‫دفعة المقلوبة‬
 Case 1

What is the presenting diameter of breech presentation ?

Bi -trochanteric diameter 9.5 cm
What are the types of breech?
Frank. Complete .footling

What is the incidence of breech presentation at term?

3%
Name 4 predisposing factors to breech presentation ?
Prematurity . congenital uterine anomaly . placenta previa . congenital anomaly of
fetus . cervical fibroid . down syndrome

What are the options of managing breech presentation at term ?

External cephalic version
Vaginal breech delivery
Elective cesarean section
How would you select the patient for breech vaginal delivery ?
Weight less than 3.5 kg
Flexed head
Frank breech
 Case 2
In which women would you consider Anti D?
Rhesus negative
Non sensitized

Name 4 indication for use of Anti D ?

Delivery . abortion . ectopic . antepartum haemorrhage . amniocentesis . external
cephalic version . abdominal trauma

When is the best time to give Anti D ?

Within 72 hr of the sensitizing event

• How does it work ?

Blocking antigen site in fetal blood cels to prevent it being identified by the others
immune system

• What is the dose of Anti D ?

500 iu after 20weeks
250 iu before 20 weeks
May increase according to kleuher test

• What are the features of fetal hydrops ?

Pericardial effusion . pleural effusion . fetal ascites . scalp eodema . polyhydramniase.
 Case 3
Name 4 risk factors for endometrial cancer ?
Age 50 years . low parity . high social class . polycystic ovaries . hypertension .
diabetes . unopposed esterogen

What is the commonest presentation of endometrial cancer ?

Abnormal vaginal bleeding

How can we exclude endometrial cancer in a women with post menopausal bleeding ?
Endometrial biopsy

Name 3 methods used for determining endometrial biopsy ?

Pepelli or vibrae biopsy
Dialatation and curettage
Hysteroscopy and biopsy

What is the commonest histological type of endometrial cancer ?

Adenocarcinoma

How will you mange a case of stage 1 endometrial cancer ?

Total abdominal hysterectomy and bilateral salpingo oophorectomy
 Case 4

Identify this instrument ?

Uterine curette or dilator

What procedure is it used for ?

Dilatation and curettage

What are the indications for D&C ?

Therapeutic : missed abortion
Diagnostic : abnormal uterine bleeding

Name 4 complications of D&C ?

Anesthesia complication
Infection
Perforation
Bleeding
Aschermann’s syndrome
Cervical incompetence

What is Aschermann’s syndrome ?

Intrauterine adhesions due to over-curettage
How does a patient with Aschermann’s syndrome present ?
Oligomenorrhea/ amenorrhea /infertility
How can we diagnose Aschermann’s syndrome ?
Hysteroscope / HSG
 Case 5

What is menopause ?
Cessation of menstruation

What is the average age of menopause ?

Early 50

What are the main symptoms of the menopause?

Hot flushes and night sweats
Name any 2 different routs of administration of HRT ?
Oral . patches , implant . local . nasal rout

What are the benefits of HRT?

Relief of post menopausal symptoms
Reduce risk of osteoporosis
Reduce risk of Alzahimer
Reduce risk of cancer colon
What are the risks of HRT ?
DVT . Breast cancer ,

Why is it important to give women with a uterus combined HRT( Estrogen and
progesterone rather than estrogen ?

Progesterone protects the uterus against endometrial cancer .

 Case 6
A para 2 is 4 days post normal vaginal delivery , she present feeling umwell her
temperature was 39 ‘c .. name 4 importance point you would like to focus on her
history to determine the cause ?
Cough . pain in swalling . headache . abdominal pain .. loin pain .. vaginal discharge …
braest tenderness

What points will you consider on examination ?

Examine mouth
Chest examination
Abdominal examination
Renal angel
Speculum examination
Examination of breast
The patient complains of lower abdominal pain and offensive vaginal discharge , on
examinations uterus was larger than expected and tender what are the possible causes ?
Endometritis
Retained product of conception

How can you differentiate between these two causes ?

Ultrasound

The result of ultrasound shows empty uterus . you suspect endometritis how will you
manage ?
Admission
Antipyretic
Analgesia
Broad spectrum antibiotic

What are the complications of puerperal pyrexia ?

Septicemia and death
 Case 7
How do you define anemia in pregnancy ?
Hemoglobin less than 10,5 g.dl

When do we usually test for anemia in pregnancy ?

Booking clinc and around 28 weeks

What is the commenst type of anemia in pregnancy ?

Iron deficiency anemia

How can you diagnosis iron deficiency anemia ?

Microcytic hypochromic
Decrease serum iron
Decrease serum feritin
Increase iron binding capacity

A G7P6 is diagnosed with iron deficiency anemia and a HB of 7 at 30 weeks gestation

how will you manage her ?
Oral iron therapy

What are the complications of iron therapy ?

Constipation . metallic taste . gastritis . dark color stool

Name 2 complications of blood transfusion ?

In- compatibility , transmission of infection , fluid overload
 Case 8
A pregnancy at 10 weeks gestation presented to the causality complaining of severe
abdominal pain and vaginal bleeding . what is your differential diagnosis ?
Ectopic pregnancy
Abortion

How will you differentiate between both conditions ?

History
Examination
Ultrasound

On examination the cervix was open. She had heavy vaginal bleeding and the uterus
was 10 weeks size , ultrasound showed a viable intrauterine pregnancy of 10 weeks
gestation what is your diagnosis?
Inveitable abortion

How will you mange her now ?

Admission
CBC. Blood group . cross match
Vital signs
Analgesia
Drug to enhance abortion

What drugs will you use ?

Misopristol , syntocinon , ergometrin

After the patient delivered the sac she still has bleeding , ultrasound showed retained
products of conceptions . what is the diagnosis ?
Incomplete abortion

What is the next step in her management

Evacuation of retained products of conception
 Case 9
Following a normal vaginal delivery a P2 had a sudden gush of sever bleeding
immediately after clamping the cord . what would be your first immediate action ?
Call for help

What are the first initial steps in the management of this patient ?
Vital signs , pulse 120 and very week , BP 90l50
Insert at least 2 large canules
Deliver the placenta

As you star to deliver the placenta the cord snaps with the placenta still inside ? the
patient is still bleeding heavily . what would be the next step in her management ?
Send blood for CBC and cross match at least 4 units of blood
Start intravenous fluid
Embty the urinary bladder
Give ergometrin
Remove of placenta under anesthesia urgently

After removing the placenta the bleeding continues. What could be the cause and how
will you mange now ?
Uterine atony
Drugs to stimulate uterine contraction
Name two drugs that can be used ?
Syntocinon . ergometrin . prostaglandin F2 alpha . misopristol

If the placenta is difficult to remove . what would you suspect ?

Placenta accrete

How would you manage a case of placenta acreta that bleeds heavily ?
Hysterectomy
 Case 10

Identify the abnormality in this picture ?

Placenta previa

What is the grade of this placenta previa ?

Grade VI or placenta centralis

How will you manage such a case if presented at 32 weeks gestation with no
symptoms ?
Admission to hospital
Prepare blood at least 4 units
Check and correct hemoglobin

How and when you deliver this patient ?

After 37 weeks by cesarean section

Mention 2 important points we should include when counseling this patient ?

Risk of bleeding
Risk of hysterectomy
Name 2 complications that can occure during her cesarean section ?
Complications of anesthesia , bleeding . injury to bladder or bowel . placenta accreta
During her cesarean the placenta was found to be accerta and she started bleeding what
is the next appropriate action ?
Hysterectomy

Who should perform her cesarean ?

The most senior /the consultant
 Case 11

What is this instrument ?

Penard stethoscope
What is the normal fetal heart rate ?
110-150 bpm
How frequent should fetal heart be auscultated in labour ?
15-30 minutesin the first stage
Every 5 minutes in the second stage
When would be the best time in labour to listen to the fetal heart ?
At the end of contractions
Name 4 situation in which continuous monitoring with CTG is necessary in labour ?
Prolonged pregnancy . induction of labour . augmentation of labour . antepartum
haemorrhage . pre-eclampsia . diabetes . IUGR . muconium . abnormal fetal heart
Name the criteria of a normal CTG in labour ?
Normal base line heart rate
Good variability {5-10 bpm}
Presence of accelerations
No decelerations or early decelerations
Define early decelerations ?
Decelerations that start with contraction reach their peak with end of contraction and
end with the contraction
If CTG is abnormal in labour how can we confirm fetal distress ?
Fetal scalp PH
 Case 12
A couple with history of primary infertility for 3 years . the results of the seminal
analysis are as follows
Show the students the results
What are the abnormalities seen ?
Reduce count
Reduced of mobility
Increase in abnormal form

What is the lower limit for the normal values ?

Count >20 million
Motility >25 %
Normal form > 30 %

Name 2 causes for this result ?

1 mark for any causes

How will you manage this case ?

IVF
 Case 13
A G3P2 presents at 9 weeks gestation with mild vaginal bleeding and lower abdominal
pain she gave history of trying to induce abortion at home she looks sick and unwell
what important points will you consider in her examination ?
Vital signs { P= 120 . BP = 80/40 . T= 40 c . breathing shallow 20 bpm }
Abdominal examination ( tenderness in lower abdominal )
Vaginal examination ( products of conception felt in the cervix )

What are the clinical diagnosis ?

Septic abortion and septic shock
Explain the initial steps in managing this patient ?
Call for help
Maintain airway and breathing
Insert 2 large canula
Intravenous fluids
CBC. Coagulation profile
Renal function test . LFT
Input – output chart
Broad spectrum antibiotic

When should evacuation be carried out ?

At least 6 hours following the start of antibiotics

What are the complicationition of this condition ?

Renal failure . septicemia . death
 Case 14
What are the types of abnormal vaginal bleeding ?
Menorrhagia . IMP . PCB . postmenopausal bleeding
Define menorrhagia ?
Menstrual bleeding >80 ml per cycle

Name 4 causes of menorrhagia ?

DUB. Fibroid. Adenomyosis . endometriosis. PID . hypothyroidism. Bleeding
disorders. Ca.cervix . ca.endometrium. polys

Which contraceptive is associated with menorrhagia ?

The copper coil

What is dysfunctional uterine bleeding ?

Abnormal bleeding with no organic cause

Name 4 different options for management of dysfunctional uterine bleeding ?

Mefanemic acid . trenaxemic acid .COC. long term progesterone . mirena. Danazol.
GnTRH analogues . endometrial ablation and resection. Hysterectomy

How can we exclude endometrial cancer as a cause of menorrhagia ?

D&C or hysteroscopy or outpatient biopsy
 Case 15

What type of breech is shown in this picture ?

Frank breech
What are the options in managing breech presentation?
Trial of labor
External cephalic version
Elective cesarean section

Name 2 contraindications to a trial of breech delivery ?

Fetal weight more than 3.5 kg
Deflexed head
Footling

How to prepare a patient for external cephalic version ?

Fasting
Close to operating theater
CTG before the procedure
May consider tocolytics

Name 2 contraindications for ECV ?

What are the risks involves when delivering a footling breech vaginaly ?
Cord prolapsed
Entrapment of the after coming head in un dilated cervix
 Case 16

This baby has just been delivered , what is the abnormality ?

Macrosomia

What is the normal birth weight ?

2.5 – 4 kg

Name 2 risk factors for macrosomia ?

Maternal diabetes . maternal obesity . previous history
Why does diabetes lead to macrosomia ?
Maternal hyperglycemia leads to fetal hyperinsulinaemia
Insulin is an anabolic hormone that leads to macrosomia

What are the complications of macrosomia ?

On the mother : tears and lacerations / PPH/ future incontinence l instrumental delivry
Increase risk of cesarean section
On the fetus : shoulder dystocia . trauma

Name 4 other complications associated with fetus of a diabetic mother ?

Hypoglycemia . hypomagnicemia. Hypocalcemia . hyper billirobinemia . polycythemia
. respirato distress syndrome .
 Case 17

What is in the picture ?

Hysterosalpingogram

Name 2 indications for its use ?

Infertility
Recurrent abortion
Suspected uterine anomaly

What is the advantage of hysterosalpingogram when compared to laparoscopy in

infertility investigation ?
Requires no anesthesia
Show the inner structure of the uterus

What is the advantage of laparoscopy when compared to hysterosalpingogram in

infertility investigation ?
Diagnosis adhesions
Diagnosis endometriosis
Has therapeutic value

If both methods show bilateral tubal block . what would be the options of management?
Tubal surgery . IVF
Name 2 complications of IVF ?
Multiple pregnancy , ovarian hyperstimulation . failure
 Case 18

What is the object ?

Mirena coil

What is the mirena coil ?

Intrauterine system that releases progesterone

What is it used for ?

Contraception
Treatment of menorrhagia

How does the mirena coil act as contraceptive ?

Thickening of cervical mucus secretions to prevent penetration of sperms

Name one side effect of mirena ?

Irregular bleeding for first 3-6 months
Progesterone side effects

What is the advantage of mirena over copper coil in contraception ?

Reduce menstrual loss
Reduces infection

What is the disadvantage of mirena when compared to the copper coil?

Expensive
 Case 19
What are the methods used for intrapartum fetal monitoring ?
Intermittent auscultation of fetal heart
Continuous monitoring with CTG

What points do we consider when reading a CTG ?

Uterine contraction
Baseline fetal heart rate
Variability
Accelerations
Decelerations

What are the types of decelerations that occur during labour ?

Early . late and variable

What is the difference between early and late ?

Early decelerations:
start with the beginning of contraction peak with the peak of contractions and end with
the end of contractions
late decelerations : start after the beginning of contractions . peak after the peak of
contractions and end after the contractions

how do we confirm fetal distress in case of abnormal CTG in labour ?

fetal scalp ph

what is the normal fetal scalp pH?

>7.25
 Case 20

What abnormal clinical sign is seen in this picture ?

Edema
This patient is a 24 year old PG at 33 weeks gestation . her pregnancy was
uncomplicated so far what would be your main concern ?
Pre- eclampsia

How can you confirm the diagnosis ?

Measure her blood pressure … result Bp = 150/100
Urine albumen ….. result = +++

How would you manage this patient now ?

Admission to hospital
Observation of blood pressure
24 hour urine collection
Ultrasound scan
Dexamethasone

What investigation are important in her case ?

CBC. LFT. RFT. Coagulation screen

Her platelet levels were low and LFT were high . What complication has developed ?
HELLP syndrome

What is the most appropriate management in this case ?

Termination of pregnancy
 Case 21

What is the pathology in this picture ?

Vesicular mole

What is the molar pregnancy ?

Abnormal conception or abnormal proliferation of trophoblastic tissue

What are the types of benign trophoblastic disease and how are they formed ?
Complete mole :
One or two sperms fertilizing an ovum with no nucleus
Partial mole : two sperms fertilizing an ovum

What is the genetic difference between both types ?

Complete =46 xx or 46 xy
Partial = 69 chromosome

Name 2 presenting symptoms of this disease ?

Accidently diagnosis during follow up
Bleeding
Passage of vesicles

How can you manage a complete mole at 12 weeks gestation ?

Suction and curettage

Name 4 complications that may occur as a result of this procedure ?

Complications of anesthesia
Bleeding
Perforation
Infection
Incompetent cervix
Ashermann” s
How do we follow up this patient ?
By BHCG

Case 22
Name 4 symptoms of endometriosis ?
Pelvic pain . dysmenorrhea . dyspareunia . menorrhagia . infertility

How is it diagnosis ?
Laproscopy

Name 2 common site of endometriosis ?

Uterosacral ligament , ovary .

What are the medical options used in the treatment of endometriosis ?

Psudopregnancy :
Oral contraceptive , long term progesterone
Psudomenopause : danazol . gonadotrophine releasing hormone analogue

How do we manage a case of endometriosis and infertility?

Surgical management
Invitro fertilization

How will you manage a case of chocolate cyst ?

Laparotomy / laparoscopy and cystectomy .
 Case 23

What is the abnormality in this picture ?

Anencephaly

How can this be diagnosed antenataly ?

By ultrasound scan

What maternal blood may be elevated in this condition ?

Alpha fetoprotein

Name 2 women who have increase risk of having a baby with anencephaly ?
Diabetic . drugs e.g anti epileptic or previous history

What is the prognosis of this fetus ?

Incompatible with life
How can we prevent this abnormality ?
Folic acid 5 mg daily
From 3 months before conception until 3 months after

What other abnormalities would be associated with anecephaly ?

Spina bifida
Polyhydramnious
 Case 24

Identify the instrument ?

Cuco’s speculum

Name 2 indications for its use ?

Vaginal discharge
Abnormal vaginal bleeding
Inserting IUCD
Cervical smear
Colposcopy
Uterine prolapsed

What are the causes of vaginal discharge in women ?

Physiological
Infection
Foreign body

Name 2 methods used to diagnose bacterial vaginosis ?

Inclusion bodies
Fish test
Increase ph

How is bacterial vaginosis treated ?

Metronidazole

Name 2 organisms causing bacterial vaginosis ?

Chalmydia +gonrrohea
 Case 25
History
Enquires about the name of the patient and uses it when speaking to her
Enquires about age and parity
Establishes the main complain and duration
Asks about length and frequency of periods
Tries to quantify the amount of bleeding clots {. flooding . number of pads }
Asks about inter-menstrual bleeding and post coital bleeding
Asks about dysmenorrhea and other abdominal pain
Asks if her symptoms effect her life
Asks about any previous treatment for her condition
Asks about obstetric history
Use of contraception and last smear
Enquires about medical diseases

Examination
Ask the candidate . what important points he / she would like to consider in the
examination?
Pallor result = very pallor
Abdominal examination= a firm irregular mass is palpable up to umbilicus
Speculum examination= normal

What is the most likely diagnosis ?

Uterine fibroid

What investigations would the candidate like to perform for this patient ?
CBC
Result :HB= 6g/dl
Ultrasound show 3 large fibroids

What is the best option for managing this patient ?

Correct hemoglobin
Myomectomy
 Case 26
What are the types of abnormal vaginal bleeding ?
Menorrhagia . IMB . PCB . postmenopausal bleeding

Define menorrhagia ?
Menstural bleeding > 80 ml per cycle

Name 4 cause of menorrhagia ?

DUB . fibroid . adenomyosis . endometriosis . PID. Hypothyroidism . bleeding
disorders . ca cervix . endometrium polyp

Which contraceptive is associated with menorrhagia ?

Copper coil

What is dysfunctional uterine bleeding ?

Abnormal bleeding with no organic cause

Name 4 different options for management of dysfunctional uterine bleeding ?

Nefanemic acid . trenaxemic acid . COC. Long term progesterone . mirena . danazol .
endometrial ablation and resection . hysterectomy

How can we exclude endometrial cancer as a cause of menorrhagia ?

Hysteroscopy or outpatient biopsy
 Case 27
History
Enquires about the name of the patient
Uses name when speaking to her
Enquires about age
Establishes parity
Establishes NVD 2 weeks ago
Establishes history of fever and rigor last night
Asks about common cold or tonsils
Aska about cough . sputum . chest pain
Asks about breast pain
Asks about urinary symptoms
Lochia smell and color
Asks about abdominal pain
Enquires about medical diseases
Is fluent and professional

examination
what important points he/ she would like to consider in the examination ?
pulse and temperature { p = 120 bpm . temp = 39.5 c }
examination of the breast
redness and tenderness in the right breast
test for fluctuation { no fluctuation }

what is your diagnosis ?

acute purpural mastitis

how will you manage this patient ?

admission
analgesia
antipyretic
anti staph antibiotic

can she breast feed her baby ?

yes

name 2 other problems that can occur in breast feeding mothers ?

breast engorgement . cracked nipples . breast abscess
 Case 28
History
Asks about name and uses it when talking to the patient
Ask about age and parity
Establishes the main complain of vaginal discharge
Asks about color and smell of discharge
Ask about the duration of complain
Associated lower abdominal pain
Ask about dyspareunia
Ask about the periods { regularity. Duration. Frequency }
Aska about obstetric history
Asks about contraception
Asks about previous problems in the past

What is your next step in her management ?

Check vital signs .. normal
Speculum examination and HVS

You suspect bacterial vaginosis how will you confirm ?

Fishy smell with KOH
Clue cells on microscopy
Increase vaginal ph

How will you treat bacteria vaginosis ?

Metronidazole
After the course of metropodazol she starts com[laining of a whitish discharge with
severe itching

What could be the problem and how will you treat her ?
Candidiasis
Clotrimazole
 Case 29
History
Enquires about her name and uses it when speaking with her
Establishes age and pairty
Establishes main complain of urinary incontinence and duration
Ask about leaking when coughing and laughing
Asks about leaking with urgency
Asks about leaking at night
Asks about urinary symptoms
Enquires about chronic cough . constipation
Enquires about obstetric history
Restrictions in her social activities

Examination
What important points he/ she would like to consider in the examination ?
General tract examination for prolapsed ….. no prolapsed
Demonstrating incontinence with cough

What is the most likely cause of her incontinence ?

Stress incontinence

What risk factors does she have for developing this condition ?
Multiparity

How will we manage this case ?

Weight reduction
Physiotherapy ( pelvic floor exercise )

If physiotherapy fails how can we help her ?

Surgery

Name one surgical procedure that used in the management of stress incontinence ?
Burch colposuspension . TVT
 Case 30
Enquires about the name of the patient and uses it when speaking to her
Enquires about age and establishes that the patient is single
Establishes the main complain and duration
Ask about menarche and enquires about cycles
Ask directly about hirsuitism
Asks about galactorrhea
Ask about headache , and visual problems
Asks about medical history and drugs
Asks about any previous treatment for her condition
Tries to establish if the patient has had any underlying stress or sudden loss od weight
and severe exercise

What examination would you like to perform ?

BMI result 24
Hair distribution no sign of hirsuitism

What investigation will you perform for this patient ?

Prolactin level result = 24
Imaging of pituitary fossa ( x-ray . CT scan or MRI ) result = normal
Perimetry

What is the most likely diagnosis ?

Pituitary microadenoma
How will you manage this patient ?
Bromocriptine or cabergoline
What is the main complication of this drug ?
Hypotension
How would you manage her if she had a large tumor causing symptoms ?
Surgery

Case 31
History
Enquires about the name of the patient and uses it when speaking to her
Establishes that her daughter complains of amenorrhea
Enquires about the age of the daughter
Asks about axillary and pubic hair
Asks about breast formation
Asks about chronic illness and drugs
Asks about galactorrhea
Asks about cyclic pain
Asks about any previous treatment for her condition
Tries to establish if the patient has any underlying stress
Asks about sudden loss of weight and sever exercise

Examination
What important points he / she would like to consider in the examination ?
BMI = 25
Axillary and pubic hair distribution = present
Breasts = well formed
Examination of external genitalia = finding bulging of hymen
What is the her problem ?
Primary amenorrhea

What investigations would the candidate to perform ?

Ultrasound shows hematocolpus

What does this mean ?

Blood in vagina

What is the most likely diagnosis ?

Imperforate hymen

What is the treatment for this condition?

Incision
 Case 32
Enquires about the name of the patient and uses it when speaking to her
Enquires about age and parity
Establishes the main complain and duration
Establishes nature and radiation of the pain
Tries to determine severity effect of daily life . use of analgesia
Establishes the relation of the pain to the days of bleeding
Establishes menstrual history
History of vaginal discharge
History of dyspareunia
Asks about use of contraception
Bowel and urinary symptoms
Is systematic and fluent

Examination
What important points he / she would like to consider in the examination ?
Abdominal examination for mass and tenderness result= no tenderness
Pelvic examination for tenderness and discharge
Result = tenderness in uterosacral ligament

What is the most likely diagnosis ?

Endometriosis
How will you confirm the diagnosis ?
Laparoscopy
How would you manage this patient and why ?
Combined oral contraception . because she wants to avoid pregnancy
If she tries for a pregnancy and develops infertility . what are the options of
management ?
Laparoscopy
IVF

Case 33
A 32 years old primigravida is presented to the antenatal clinic for routine follow . 32
weeks she has no complain on examination her blood pressure was 160/100 her urine
albumin is +++ what is her most likely diagnosis ?
Preeclampsia
At what level is protein urea considered significant in pregnancy ?
>300 mg / 24 hour
On examination her fundal height corresponding to 28 weeks gestation what would be
the most likely cause in her case ?
IUGR / oligohydramnios
How will you manage this patient now ?
Hospital admission
Observation of BP
Maternal assessment ( investigation )
Fetal assessment ultrasound
Dexamethasone
Consider aldomate
What other investigations would you like to perform on this patient and why ?
CBC for platelets
LFT for liver failure
Uric acid . prognostic
RFT for renal failure
Coagulation screen for DIC
Show the candidate the result of the investigation and ask them about the diagnosis
Help syndrome
How will you mange this patient now ?
Termination of pregnancy

Case 34
A G2 P1 presents at booking clinic at 8 weeks gestation . she is known diabetic on
insulin how can you determine long term blood sugar control ?
Glycosylated hemoglobin ( HBA1c)

Show the student the result of the hbA1 what would this indicate ?
She needs control of blood sugar

How will you control her blood sugar ?

She will require serial blood sugar and adjust insulin according to the result

How is serial blood sugar performed ?

Blood sugar measured at fasting 2 hour after lunch 2 hours after dinner . midnight

Show the student the results of serial blood sugar what action is required ?
Increase in dose of insulin

Increasing dose of insulin may lead to hypoglycemia what are the symptoms of
hypoglycemia ?
Sweating . palpitation . dizziness

What fetal complication may occur as a result of this high level of blood sugar in early
pregnancy ?
Congenital anomaly
Miscarriage
 Case 35
After delivery of the fetal head in G7p6 with diabetes . the shoulders failed to follow
what is your first immediate action ?
Call for help
Senior obstetrician
Senior midwife
Pediatrician

List the steps used in management of shoulder dystocia ?

Episiotomy
Hyperflexion of hip + knees
Suprapubic pressure
Internal rotation
Removal of posterior arm

If these basic maneuvers fail name 2 other maneuvers that can help ?
Fracture clavicle . symphysial separation . zavanelie . repeat maneuvers with mother on
all fours

How long do we have to deliver the fetus in good condition ?

5 minutes
What complications can occur ?
Maternal: laceration . perineal tears. postpartum hemorrhage
Fetal : erb’s palsy , fracture humures , fracture clavicle . cerebral palsy . deaths

How can we reduce the risk of post partum haemorrhage in this patient ?
Active management of the third stage
 Case 36
A G3P2 with 2 pervious cesarean section , she had no problems antenatally and is
admitted at 38 weeks gestation for elective cesarean section
Why does she need an elective cesarean section ?
She has high risk of rupture uterus
Why is 38 weeks best time for a cesarean section ?
<38 risk of RDS
>38 risk of spontaneous labor
Her cesarean is tomorrow morning how will you prepare her for a cesarean sections ?
Consent
CBC
Blood group and cross match
Fasting from midnight
Ranitidine
This is the result of her CBC what is the abnormality ?
Microcytic hypochromic anemia
How will you manage this patient now ?
Blood transfusion
Name 2 complications of blood transfusion ?
Hypersensitivity reaction . transmission of viral infections
On the day of the operative she had a urinary catheter inserted why is this necessary
before cesarean section ?
To avoid injury to the bladder
How can we reduce her risk of having DVT ?
Early mobilization
Good hydration
Elastic stocking
Prophylactic heparin
 Case 37
What are the criteria of PCO ?
Oligomenorrhea / Amenorrhea
Biochemical and clinical sings of hyperandrogenism
Polycystic ovary on USS

How can you define polycystic ovary on US ?

10-12 small follicle . 2-8 mm in diameter

How can the pt be presented ?

Amenorrhea / oligomenorrhea
Hairsuitism
Infertility

What are the option of management for a pt with PCO complaining of infertility ?
Wt reduction
Metformin
Ovulation induction
Laparoscopic ovarian drilling
IVF

What are the long – term complications ?

DM . HTN . endometrial cancer . coronary heart disases
 Case 38
Primigravida 30 weeks of gestation on examination her vital sings were normal
abdominal examination a fundal height of 36 weeks
Name 4 causes of large for date ?
Wrong date
Multiple pregnancy
Macrosomia
Polyhydramnios
Fibroid
How can you differentiate between these cause ?
By US and conformation of her date
How would you confirm the date ?
Ask her the LNMP and the regularity of her cycle
If she has early pregnancy U/S
Her U/S showed polyhydramnios name 2 causes of polyhydramnios ?
Diabetes
Congenital abnormality = fetal GI tract obstruction
Idiopathic
Her U/S showed no congenital abnormality how can you exclude diabetes ?
GTT
The examiner will show you a result of GTT you will have to interrupt the result
Name 2 complication their lady may suffer
Preterm labor. PROM
Malpresentation
Maternal discomfort due to abdominal distension
 Case 39
20 yrs . primigravida . 30 weeks of gestation . complains of lower abdominal pain , for
2 days
History
Personal data
Main complain :site . onset . duration . nature . radiation .
Dysuria . frequency . nocturia . urgency
Contraction ( frequency of abdominal cramps ) reugularity
Leakage . mucus with blood
Associated . fever , vomiting, fatigue

What examination will you perform?

General examination : vital sings ( temp, pulse )
Provided that temp 38.5 c . pulse 110 bpm . BP 120/80
Renal angle tendrnesse = +ve
Abdominal examination : provided that the abdomen is soft lax . no contraction

From hx and examination what is your diagnosis ?

Upper UTI ( pyelonephritis )

How would you confirm your diagnosis ?

Mid – steam clean catch urine analysis
Culture and sensitivity
Significant bacteriuria
Pus cells +
RBC +
Turbid in color
How would you manage ?
Admission
IV fluids
IV antibiotics
Analgesia and antipyretic

You started Augmentin . 2 days later you received the result of C/S . this strain is
resistant to Augmentin but sensitive to cephalosporine what is your next step ?
( provided that the pt. clinically improved on Augmentin )
ANSWER : continue Augmentin as the pt. improved
( if the pt. didn’t improve change to cephalosporine
 Case 40

A known case of pre-eclampsia . admitted to hospital . in 36 weeks of gestation

developed tonic clonic convulsion
What is your immediate action ?
Call for help
What are the intial steps of management of this patient ?
Airway . breathing. Circulation
Start mg so4 or diazepam
Start antihypertensive drug ( if needed)
Send for investigation

Her blood pressure was 180/120 . what anti-hypertension would you use?
Hydralazine ------- direct vasodilators
Labetalol --------- alpha and beta blocker

What further management would the patient need?

Admit to ICU
Control blood preesure
Maintain Mg so4 for 24 hrs
Catheter ( input &output chart )
Close observation for R.R . pulse . reflexes
Terminate pregnancy

What mode would you chose to terminate pregnancy ?

Induction of labor if cervix is favorable and no other indication for C/S
 Case 41

Identify this instrument

Obstetric forceps

What are the indication ?

Fetal distress
Maternal distress
To shorten 2nd stage of labour in case of medical disease
Prolonged 2nd stage of labour

Name 3 criteria of which should be fulfilled before forceps use ?

Cervix is fully dialted
Membranous are rupture
Engaged head
Empty bladder and rection
Appropriate persecution
Name 4 postions in which forceps can be used ?
Occipito anterior
Occipito posterior
Mentoanterior
After coming head of breech
During C/S

What are complications of forceps ?

Maternal : PPH / traumatic lesion / bone injury
Fetal : fetal skull fracture
Intracranial injury
Intracranial hge
Facial nerve palsy
 Case 42
Mrs .karima 23 years old G4P2+1 abortion.32 weeks gestation presented with lower
abdominal pain . colicky in nature . not progerrsive on & of f since 2 day . not
associated with vaginal bleeding no watery vaginal discharge . not aggravated or
received by any factors history of previous preterm labour
History
Name . age . parity
Main complain and analysis
Vaginal discharge
Urinary symptoms
Vomiting and diarrhea
Antenatal care
History of preterm
History of miscarriage

What examination would you perform ?

General examination : temp for infection provided that 36.5
Abdominal examination : provided that abdominal examination showed no
tendrenessand 3 contraction / 10 min each contraction last for 40 sec , cervix was 5 cm .
well effaced
Palpate uterine contraction
Vaginal examination

What your diagnosis ?

Preterm labour

How are you going to manage ?

Admission contiouns CTG
Inform neonatology deparment
Allow spontous labour
What is the most serias complication for the baby ?
Neonatal respiratory distress syndrome
Case of jaundice
36 years old, G1P0 at 34 weeks gestation with twin pregnancy presented to delivery
unit with 4 weeks history of nausea, vomiting, and epigastric pain. Her skin and eyes
slightly changed yellowish, her prenatal course until now has been uneventful. BP is
normal, prenatal lab studies are within normal ranges. Her past medical and surgical
history are unremarkable. On examination: scleral ictrus, slight right hypochondrial
pain.
- What is the normal liver physiology in pregnancy?

Liver size and blood flow remain the same, metabolic, synthetic and excretory
function are affected by increased estrogen and progesterone in pregnancy.

- What are the changes of LFT in pregnancy?

Transaminases: initially unchanged, drop by 25% in 3rd trimester

GGT: unchanged
ALP : 2-4 folds increase
Cholesterol: 2 folds increase
Triglycerides: 2-3 folds increase
Increase in alpha and beta globulins

- What is the effect of hyperbilirubinemia on the fetus?

Elevated levels of maternal unconjugated bilirubin do not have an effect on
neurodevelopment of offspring

- What is the main cause of jaundice in pregnancy?

Viral hepatitis
 Provided that the lab findings in this case are as follows:
Transaminases are moderately elevated, PT & PTT are prolonged, fibrinogen is
decreased, glucose level is decreased, platelets are mildly decreased, bilirubin level is
increased

- What is the diagnosis?

Acute fatty liver in pregnancy

- What are the clinical features observed in acute fatty liver of pregnancy?
The incidence is 1:1000, more in 3rd trimester, associated with maternal obesity and
male fetus, associated with multiple pregnancy, has considerable overlap with HELLP
syndrome.
Presented with nausea, vomiting, abdominal pain, signs and symptoms of liver failure
and hepatic encephalopathy, DIC, HTN, proteinuria in 50% of cases, polydipsia,
psudodiabetes.
Rarely after delivery.

- What are lab abnormalities seen in HELLP syndrome nd acute fatty liver?
Acute fatty liver: hypoglycemia, low platelets (moderate), slight elevation of
transaminases, increased bilirubin, increased WBCs, increased ammonia
HELLP: low platelets, increased bilirubin, elevated transaminases, hemolysis in
peripheral blood smear, increased LDH

- What are the complication of acute fatty liver of pregnancy?

Maternal: hepatic failure, encephalopathy, coagulopathy, death (10-15%)
Fetal: IUFD, perinatal mortality (15-65%), neonatal risk of hypoglycemia,
cardiopathy, neuromyopathy.

- Hoe to treat?
Maternal resuscitation and stabilization/ admit to ICU/ fetal monitoring/ parenteral
glucose/ packed RBCs, fresh frozen plasma, cryoprecipitate, platelets/ continuous
monitoring of glucose level/ monitoring fluid status and renal function/ Neomycin and
Lactulose/ urgent delivery
Define maternal mortality?

Death of women during pregnancy or within 42 days post-partum due to causes related
to pregnancy and its complications.
Name 4 causes of maternal mortality?

Hemorrhage, thromboembolism, hypertensive disorders, infection

What is the 1st cause of maternal mortality in developing countries?

Hemorrhage.

Case 43
35 years, at 32 weeks gestation, presented with swollen leg and you suspect DVT
Name 4 risk factors of DVT?

Age, thrombophilia, parity, operative delivery, previous DVT, family history of DVT.
How would you confirm your diagnosis?

By duplex Doppler US
How will you manage her?

Unfractionated heparin IV, 5000-10000 IU loading dose, 1000-2000 IU/hr

maintenance.
How would you monitor heparin?

APTT
Why should warfarin be avoided?

It causes congenital anomalies in 1st trimester, and bleeding tendency in newborn in

3rd trimester.
 Case 44
What are the methods of antenatal fetal monitoring?

Kick chart, CTG, biophysical profile, US, Doppler US

What are the components of biophysical profile?

CTG, gross body movement, amniotic fluid index, fetal tone, fetal breathing
movements
.
What are the advantages and disadvantages of kick chart?

Advantages: cheap, involvement of the mother.

Disadvantages: subjective.
Case 45

35 years para 4, 3 days post CS, complains of chest pain, dyspnea, cough and
hemoptysis
What examination you would perform?

General examination: vital signs ( pulse 120bpm, temp. 37.5 degrees)

Chest examination
What examinations would you like to do?

CBC, ABG, ECG, chest x-ray

What is your concern?

Pulmonary embolism

How can you confirm the diagnosis?

CT angiography
Ventilation perfusion scan
How will you manage?

Admit to ICU, oxygen supply, therapeutic heparin

 Case 46
49 years old, P3, complaining of inability to control urine
Points to ask about :
- Personal data
- Use the patient’s name.
- Ask about frequency, urgency, dysuria, nocturia
- If she pass urine when cough, laugh, lift heavy weight, or when exercise
- If she can’t make her way to toilet
- Chronic cough or constipation
- Feeling of sth coming down or back pain
- Obstetric history: difficult labour, instrumental delivery, perineal tear,
macrosomic baby
- The effect of the complaint on her life.
- Previous treatment
- Neurological disease
- HRT
- Past medical & surgical history

What examinations would you like to perform?

General examination: body weight
Abdominal examination: looking for abdominal masses
Chest examination
Vaginal examination: for prolapse
Neurological examination for lower limbs
What investigations would you like to do?
Urodynamic study, MSU to exclude UTI
What is the main treatment of detrusal instability?
Medical: anticholinergic drugs.
Bleeding in early pregnancy:
- Ask about age & parity.
- Establish the complaint and its duration (vaginal bleeding)
- Ask about last period and its regularity
- Ask directly about the possibility of pregnancy
- Ask about the amount and colour
- Ask about abdominal pain
- Ask about vomiting
- Ask about clots, or vesicles
- Past obs. History
- Contraceptive use
- Pelvic surgery
- History of ectopic or PID
- Use of IUCD
- Antenatal follow up and previous US

- What examination would you like to perform?

General examination: vital signs (BP 120/80 mmHg, pulse 84 bpm,

temp. 36.5 )
Signs of anemia
Abdominal examination (soft, lax, not tender, the uterus is larger than
expected)
Vaginal examination: closed cervix, not tender
- What investigations would you like to do?
Beta HCG ( more than 100000 IU/L)
US (snow storm appearance)
CBC
- What is the diagnosis?
Complete mole
- How will you manage?
Suction & curettage
- How will you follow up this patient?
Beta HCG monthly for 6 months
- What advice would you give her?
Avoid pregnancy, contraception use ( not hormonal)
 Case 47

Following rupture of membrane of a patient in the labour ward there was sudden fetal
bradycardia, vaginal examination confirmed cord prolapse, the cervix was 6 cm
- What is your immediate action?
Call for help
- Why is cord compression associated with fetal distress?
Due to cord compression, and vasospasm when the cord is exposed to
the room temp.
- Name 2 measures to relieve cord compression?
Elevate the presenting part with fingers to relieve pressure, knee-chest
position, filling the bladder with saline.
- What is the mode of delivery?
Emergency C/S
- Name 4 predisposing factors for cord prolapse?
Polyhydramnios, malpresentation, long cord, multiparity, prematurity,
twins.
- Name one situation that you will consider vaginal delivery?
The cervix is fully dilated, non-pulsating cord, anencephaly.
- Name 4 complication of emergency C/S?
Complication of anesthesia, injury of the bladder, injury of the
bowels, hemorrhage, increased risk of DVT post-operative.
 Case 48
Pregnant lady at 32 weeks of gestation complains of severe lower abdominal pain
On examination: pale, tense abdomen, BP 80/60 mmHg, pulse 120 bpm
- What is your diagnosis?
Abruption placenta
- How will you manage this case?
Call for help
ABC
Inset 2 large poor canula
Blood transfusion
Stabilize and deliver
- Her Hb level was 6 gm%, what is your next step?
Blood transfusion
- What are the complications?
Fetal: IUFD
Maternal: hypovolemic shock, multiorgan failure, DIC, PPH, death
- She received 5 units of blood, name 2 complication she may suffer?
Hypersensitivity reaction, transmission of infections, over load.

Case 49
- What are the complications of twins pregnancy?
Maternal: increased risk of hyperemesis gravidarum, anemia, miscarriage, pre-
eclampsia, GDM, placenta previa, operative delivery, PPH
Fetal: increased risk og congenital anomalies, IUGR, preterm labour, IUFD
- How can you differentiate between monochorionic and dichorionic twins?
Lambda sign
- Name 2 specific complications of monochorionic twins?
Twin-twin transfusion syndrome, conjoined twins.
 Case 50
- To whom anti-D should be offered?
Nonsensitized Rh –ve women after any sensitizing event: post-partum, miscarriage,
antepartum hemorrhage, ECV, amniocentesis….
Within 72 hr
- How does it work?
Blocks the antigenic sites in fetal RBC to prevent the stimulation of maternal immune
system.
- What is the dose?
250 IU in pregnancies less than 20 weeks
500 IU in pregnancies more than 20 weeks
The dose may be increased based on Kleihaur test.
- What are the features of hydrops fetalis?
Ascites, pericardial effusion, pleural effusion, polyhydramnios, scalp edema.

Case 51
32 years old, P2, with 8 weeks amenorrhea, complaining of abdominal pain and
vaginal bleeding
- What are your DD?
Ectopic pregnancy, miscarriage, vesicular mole
- What investigation would you like to do to discriminate between them?
Beta HCG, U/S
-provided that beta HCG was 2000IU/L, U/S showed no intrauterine sac, what is your
diagnosis?
Ectopic pregnancy
- While the patient was talking to you she felt dizzy and fainted, how will you
manage?
Call for help, resuscitation, emergency laparotomy and salpingectomy.
- Name 4 risk factors of ectopic pregnancy?
Previous ectopic, PID, previous pelvic surgery, adhesions, IVF/ICSI.
 IUGR case
Kawther Juma is a 32 years old G2P1 presented to tha antenatal clinic at 32 weeks
gestation for follow up. She had booking visit early in her pregnancy but had no follow
up since then. She has no complaints in her pregnancy. On examination, her blood
pressure was 110/70 mmHg, abdominal examination showed fundal height of 28
weeks.
- What is your initial diagnosis?
Small for gestational age
- What are the differential diagnosis for small for date?
Wrong date/ small for GA/ IUGR/ oligohydramnios/ abnormal lie/
anencephaly/ IUFD/ pendulous abdomen/ presenting part deep in the
pelvis.
- How will you confirm that she is 32 weeks?
Check an early USS

We confirm her date and her US shows a cephalic fetus with normal
liquor.
The measurement of the fetus are corresponding wih 29 weeks.
- What measurements are usually taken by US at this stage of
pregnancy?
Biparital diameter, head circumference, abdominal circumference,
femoral length, amniotic fluid index, estimated fetal weight
- What is small for gestational age fetus?
Estimated weight of the fetus is below 10th percentile for its GA
(severe SGA is classified as EFW below the 3rd percentile)
- What are the causes of IUGR?
Maternal: chronic maternal disease DM, HTN, cardiac disease/
substance abuse/ smoking/ autoimmune disease APL/ thrombophilia/
uterine mal formation/ poor nutrition/ low socioeconomic status.
Placental: abnormal trophoblastic invasion pre-eclampsia, placenta
accrete/ infarction/ abruption/ placenta previa/ chorioangioma/
abnormal umbilical cord.
Fetal: genetic abnormalities/ congenital abnormalities e.g cardiac,
gastroschisi…/ congenital infection/ multiple pregnancy twin twin
transfusion syndrome
- How can you confirm the diagnosis?
 US: fetal weight < 10th centile
Serial growth scan every 2-3 weeks
Umbilical artery Doppler
Screening of fetal infection
Offer karyotyping in severe IUGR
- How will you manage this case?
History: weight gain in pregnancy, tobacco use, drugs, previous
history of low birth weight.
Examination: maternal BMI, blood pressure
Investigation: CMV and Rubella serology, antiphospholipid
antibodies
Fetal assessment: USS to detect fetal anomalies, evaluation of the
placenta, Doppler US, NST (nonstress test), biophysical profile, kick
chart
- What are the components of biophysical profile?
CTG, amniotic fluid index, fetal breathing movements, fetal gross
movements, fetal tone

Kawther had BPP of 10 and a normal Doppler, how would you

manage the reminder of pregnancy?
Reassure the mother about the test results, repeat BPP in 1 week and
Doppler after 2 weeks, close monitoring of both mother and fetus with
frequent regular follow ups, serial US for the fetus to determine
growth rate in the following weeks.

2 weeks later, Kawther was seen in the antenatal clinic and the fetus
showed no growth in the last two weeks, the US showed reduced
liquor, CTG was normal, she is now 34 weeks what is your
management plan?
Hx , examination to exclude PROM
Investigation: BPP, UA Doppler (abnormal), admission to hospital
(check nursery facility), dexamethasone, delivery
- What are the complication of IUGR?
Neonatal: hypothermia, hypoglycemia, RDS, hypocalcemia,
polycythemia, necrotizinf enterocolitis
Adulthood: type 2 DM, HTN, cerebrovascular disease