Data Interpretation Obstetrics and GynaecologyJawaad Saleem Malik

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

What type of investigation is this?

Hysterosalpingogram

When is it best to perform this investigation?

Between days 5-12 of 28 day menstrual cycle.

After menstruation and before ovulation as menstruation can effect contrast dye and x-rays can cause miscarriage.

What type of dye is used?

Contrast medium (Iodine)

What does this investigation show?

Bilateral tubal blockage

What is the treatment of the condition?

IVF Treatment

Other possible questions on HSG.

How is the investigation performed?

Similar to smear, use a speculum, clean cervix then insert a 7fg catheter through the cervix inflate the balloon to hold catheter in place then insert contrast medium (Iodine) and take x-rays.

What is the scan used for?

Investigation of infertility- Tubal blockage/uterine anomalies

When is it best to do a HSG?

Between days 5 -12

How long does the investigation last? 15-20 minutes

What is alternative to hysterosalpingogram?

Hysterosalpingo-contrast sonography – use of ultrasound instead of X-rays.Laparoscopy and dye

What are the risks of this procedure?

Tubal spasm (pelvic pain)Anaphylaxis reaction to contrast dyeReactivation of pelvic infection

What is the cause for infertility?

Bilateral hydrosalpinges from PID (esp. Chylamidia Trachomatis)Uterine abnormalities (Bicornuate uterus/Unicornuae uterus)Bilateral Tubal blockageEndometriosisFibroids

What is the treatment?

Bilateral hydrosalpinges from PID = IVF/Tubal surgeryUterine abnormalities = Surgery/ UtriculoplastyTubal blockage = Tubal surgery/IVF

Station 2: IUGR

ASYMMETRICAL IUGR

What is the cause of ASYMMETRICAL IUGR?

Pre-eclampsiaIdiopathicRenal/cardiac diseaseMultiple pregnancies

What is the treatment for ASYMMETRICAL IUGR?

Emergency Caesarian section within 12 days.

SYMMETRICAL IUGR

What are the causes of SYMMETRICAL IUGR?

Chromosomal abnormalities- Trisomy 13 (Patau’s syndrome)/ Trisomy 18 (Edwards syndrome)TORCH InfectionsMaternal smoking/alcohol/opiate useSickel cell disease

What is treatment of SYMMETRICAL IUGR?

NONE/Monitor and increase nutrition of fetus

Station 3: Cardiotocography

Cardiotocography measures Fetal Heart Rate.

Interpret in following order:

Baseline rate (110-160bpm) Baseline variability (>5 bpm) Acceleration Decelerations

-Early deceleration-Late decelerations-Variable decelerations.

The CTG trace generally shows two lines. The upper line is a record of the fetal heart rate in beats per minute. The lower line is a recording of uterine contractions.

Baseline Rate | Baseline Variation | Accelerations | Decelerations

Baseline Rate:- 110-160 bpm

This is a section of CTG showing a typical normal baseline rate

FHR

Uterine contraction

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

Bradycardia:- <110 bpm

BRADYCARDIA INDICATES FETAL DISTRESS

This is a section of CTG showing a bradycardia

Tachycardia:- >160 bpm.

Tachycardias can be indicative of fever or fetal infection and occasionally fetal distress (with other abnormalities). An epidural may also induce a tachycardia in the fetus.

This is a section of CTG showing a tachycardia.

| Baseline Rate | Baseline Variation | Accelerations | Decelerations

Baseline variations:- >5 bpm

Prolonged reduced variability (<5 bpm) may be indicative of FETAL DISTRESS, MATERNAL OPIATES/FETAL SLEEP.

This is a section of CTG showing decreased baseline variability.

| Baseline Rate | Baseline Variation | Accelerations | Decelerations

Accelerations:- Acceleration >15 bpm for >15 seconds Accelerations are a good sign as they show fetal responsiveness and the integrity of the mechanisms controlling the heart (5) (6) .

This section of CTG shows a typical acceleration in response to stimulus (7).

| Baseline Rate | Baseline Variation | Accelerations | Decelerations

Decelerations:- Deceleration <15 bpm >15 seconds

Three types of deceleration:

Early deceleration Late deceleration Variable deceleration

Early decelerations occur at the same time as uterine contractions and are usually due to fetal head compression. They are normally perfectly benign.

Late decelerations persist after the contraction has finished and suggest fetal distress.

Variable decelerations vary in timings and shape with respect to each other and may be indicative of hypoxia or cord compression.

The following CTGs show examples of early, late and variable decelerations.

Management

Confirm FETAL DISTRESS (Hypoxia) using Fetal blood scalp sampling (FBS).pH <7.20 = Fetal Distress (Hypoxia)

If pH < 7.20 then deliver by caesarean section.

Station 4: Karotyping

DOWN’S SYNDROME

What is the diagnosis?

Trisomy 21- Down’s syndrome

What is the screening test?

Triple test-

AFP (Alpha fetoprotein- produced by fetal liver) HCG (Human chorionic gonadotrophin- produced by placenta) E3 (Oestriol)

Down’s syndrome:

↑HCG↓AFP↓E3 (Unconjugated oestriol)

Spina Bifida:

↑ AFP = Neural tube defect = Spina BifidaWhen is triple testing done?

15-20 weeks.Ideally 16 weeks.

What is the diagnostic test?

Amniocentesis.

What are the risks of amniocentesis?

1 % risk of miscarriage

When is amniocentesis carried out?

15 weeks (15/40)

What alternative can be used at an earlier gestation?

Chorionic villus sampling

When is chorionic villus sampling carried out?

11 weeks (11/40)

What is the risk of Chorionic villus sampling?

2% risk of miscarriage

What increases the risk of trisomies?

Increasing maternal age.

What are the clinical features of Down’s syndrome?

Sandal gap Single palmar crease Mongolian facies Round face Flat occiput Epicanthic folds Brushfield spots in iris Protruding tongue

Sandal gap

Single Palmar crease (Simian crease)

What are the causes of Down’s syndrome?

95% Trisomy 21 (Non-disjunction)3% Translocation2% Mosaicism

What is a screening test?

A screening test screens for congenital abnormalities it is available to all women and is used to determine which women are at high risk. It is non-invasive.

Screening tests

Nuchal translucency (11-14/40)

This is the distance between the skin and the soft tissue covering the cervical spine.This is used to screen for trisomies.It is carried out between 11-14 weeks.

Maternal blood sampling (15/40)

AFP (Alpha fetoprotein)uE3 (Unconjugated Oestriol)HCG (Human chorionic gonadotrophin)

Other serum markers

PAPPA (Pregnancy associated plasma protein A)Inhibin A

Ultrasound scan (19/40)

Used to screen for congential abnormalities.

Preimplantation genetic diagnosis

Uses to screen for mitochondrial genetic disorders that can be passed on by the mother such as Angelman’s syndrome.

What is a diagnostic test?

A diagnostic test diagnoses a congenital abnormality. It is only available to women at high risk. It is invasive.

Examples of diagnostic tests

Chorionic villus sampling (11/40) Ultrasound scan (12/40) Amniocentestis (15/40) Fetal blood sampling (19/40) Fetal tissue sampling (22/40)

TURNER’S SYNDROME

What is the karyotype? 45 XO

What is the diagnosis?

Turner’s syndrome

Which gender is predominantly affected?

Females

What are the clinical features?

Webbed neck Short stature Infertility Wide-spaced nipples Wide carrying angle (Cubitus vulgus) Neonatal lymphoedema

Neonatal lymphoedema

What is the most common heart defect?

Coarctation of the aorta

How can this condition be diagnosed antenatally?

USS Cystic hygroma (11-14)

Amniocentesis (15/40)

Chorionic villus sampling (11/40)

What is the treatment for Turner’s syndrome?

Hormone replacement therapy:

GH replacement Oestrogen replacement

Station 5: Forceps

(1) (2) (3)

1. What are the three types of forceps?

1 = Wrigley’s forceps (non-rotational, pelvic and cephalic curve)

2 = Neville-Barnes forceps (non-rotational, pelvic and cephalic curve)

3 = Kielland’s forceps (rotational, cephalic curve)

2. What are the components of a forcep?

HandleLock (English/French lock)ShankBlades

3. Indications for forceps

Delayed 2nd stage labour (>1hr)Maternal distress/maternal exhaustionFetal distress/Breech delivery

4. Conditions required for forcep’s delivery?

Informed consentFully dilated cervix0 stationRuptured membranesContractionEmpty bladderPain relief (Pudendal block)Skilled operator

5. Complications of instrumental delivery

Ventouse – cephalohaematoma, perineal and uterine tears/haemorrhageForceps- Facial nerve injury and bruising.

What are the functions of forceps?

Traction +/- rotation (OP/OT MALPOSITIONS)

6. What is asynclitism and which forceps should be used?

Asynclitism- fetal head enters pelvis tilted, therefore enters with parietal bones.

Treated with rotational forceps (Kielland’s forceps)

Station 6: Polycystic Ovarian syndrome (Stein Leventhal syndrome)

What are the clinical features of PCOS?

Subfertility (anovulation)ObesityHirsutism/AcneOligomenorrhoea/amenorrheaRecurrent miscarriage (↑ LH)

What investigations are used for PCOS?

Ultrasound scan

Ultrasound scan shows multiple cysts/follicles on ovary (necklace)

Biochemical

↓SHBG (Sex hormone binding globulin)↑LH:FSH Ratio (3:1) – between day 5 and 8 of cycle↑Insulin ↑Testosterone/androgens

Laporoscopy

Large ovaries

What are the complications of PCOS?

40-50% of women develop diabetesCardiovascular diseaseEndometrial/Breast cancer are more common

What is the treatment of PCOS?

OCPTreats amenorrhoea/oligomenorrhoea

DianneteAcne

FinasterideHirsuitism

InfertilityAnti-oestrogensMetforminGonadotrophins

Station 7: Premature menopause

Menopause = Last menstruationAverage Menopause = 51 yrsPremature/Early menopause = <45 yrs

Blood results

Day 3 FSH/LH >25 IU/ml

Day 3 Oestrodiol <75IU/ml

Low oestrogen means that the ovaries are starting to fail.Therefore LH/FSH produced from the pituitary gland is increased as they are trying to stimulate the ovaries to produce more oestrogen. This is known as early/premature menopause if it occurs before 45 yrs of age.

What are the early menopausal symptoms?

VasomotorHot flushes

PsychologicalInsomniaLethargyPoor concentrationAnxietyReduced Libido

What are the long term effects?

Cardiovascular diseaseOsteoporosis

Other changesGenital tract atrophyVaginal atrophySkin and breast atrophy

Treatment

HRT