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MDC REVISION

OBSTETRICS & GYNECOLOGY

1. A 21-year old, previously healthy, primiparous (A woman who has given birth once
before) patient spontaneously delivered a 3500gm baby four days ago. A right medio-
lateral episiotomy was performed under local anesthesia. Two days ago, she developed
a temperature of 390C and oral ampicillin was started. The patient now appears ill and
dehydrated. She has a persisting fever and increasing episiotomy wound pain. The
perineum is erythematous, extremely tender and oedematous. In the past 36 hours the
oedema has extended to the right medial thigh and lower abdominal wall. Her
temperature is 39.40C; pulse is 130/min, respiration 35/min, and blood pressure
100/60mmHg. Haematocrit is 48%, leukocyte count is 32,000/mm3. Serum calcium
level is low and findings on urinalysis are normal.
a. What is your diagnosis?
 Puerperal Sepsis secondary to Episiotomy wound infection.

b. How will you treat this patient?


1) Admit
2) Administer Analgesics.
 e.g. IM Pethidine 100mg 6-8 hourly
3) Intravenous Fluids
4) Parenteral Antibiotics ( Usually 3 antibiotics are used)
• Cefuroxime- 1500mg 8 hourly for 24 hours then 750 mg 8 hourly
• Gentamicin – 1 G 6 hourly for 24 hours then 500mg 6 hourly
• Metronidazole – 500mg 8 hourly.

2. A 26 year old nulliparous ( A woman who has never given birth / A woman who has
never completed a pregnancy beyond 20 weeks / A woman in her first pregnancy and
who has therefore not yet given birth) woman who has had amenorrhea( for six
weeks now has vaginal spotting( Blood is brown or pink) and cramping lower
abdominal pain.
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a. Discuss the diagnosis, the differential diagnosis and the management.
Diagnosis: Ectopic Pregnancy

A woman presenting with Amenorrhea + Abdominal Pain+ Bleeding, I will think


Ectopic Pregnancy until proven otherwise.

DDX:
 Adnexal Torsion
 Spontaneous Abortion
 Pelvic Inflammatory Disease (PID)
 Molar pregnancy
 Endometriosis
 Ruptured Ovarian Cyst
 Hemorrhagic Corpus Luteum
 Appendicitis
 Diverticulitis
 Urinary calculi

Management:

Investigation:

 Abdomino-pelvic ultrasound
 Urine pregnancy test
 Serum beta-HCG

Treatment:

1. Airway Breathing and Circulation including IV fluids


2. Blood transfusion if patient is hemodynamically unstable
3. A patient with ruptured Ectopic – Need immediate surgery
4. Patients with non-ruptured Ectopic – Are admitted. Definitive treatment may be
done operatively or with methotrexate
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5. Stable patients with low suspicion and inconclusive testing may be discharge
home with follow-up in 48 hours to check a beta-hCG level.

3. A 30 year old G3P2+0 undergoes a spontaneous vaginal delivery of a healthy 3.3kg


boy. After 10 minutes without spontaneous placental delivery, traction is applied to
the umbilical cord. Placental tissue is expelled with the cord, but vaginal bleeding
follows immediately. The placenta is clearly not complete.
a. What is the most likely diagnosis?
 Primary Post-Partum Hemorrhage secondary to retained placenta.

b. How would you manage this case?


 Treatment goals
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 Arrest the bleeding
 Restore the volume

1. ABC
2. Supplemental oxygen
3. Take blood for grouping and cross-matching
4. 2 large bore IV for fluid resuscitation
5. Insert Foley catheter
6. Manual exploration of uterine cavity for retained placental fragments
7. Manual removal of placenta with anesthesia support
8. Prophylactic antibiotics

4. A 31 year old G4P1+2 who is approximately 34 weeks pregnant complains of bright red
vaginal bleeding and some cramps for the last hour.
a. What are the possible diagnoses?
 Abruptio placenta
 Placenta previa
 Vasa previa
 Uterine rupture
 Other causes:
 Marginal
 Heavy show
 Cervicitis
 Ca Cervix
 Vulva varicosities
 Vaginal thrush

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b. What can be learned from a sonographic examination of this pregnancy?

Ultrasound findings may show a retroperitoneal clot suggestive of Abruptio


placenta.

It may also show an abnormally positioned placenta (Low uterine segment


placental implantation) which is diagnostic of placenta previa.
 Placenta covers the cervical os – Total Previa
 Placenta extends to the margin of the os – Marginal Previa
 Placenta is in the close proximity to the os – Low-lying Previa

5. A 16 year old girl is brought by her mother for evaluation because she had never
menstruated.
a. What is the normal sequence in secondary sexual maturation?
1. Thelarche (Breast Dev.) – 9 to 10 years
2. Adrenarche (Pubic and Axillary hair) – 10 to 11 years
3. Maximum Growth spurt – 11 to 12 years
4. Menarche (Onset of first menses) – 12 to 13 years

b. What are the causes of delayed menarche?


1. Anatomic cause:
 Vaginal agenesis/septum
 Imperforate Hymen
 Müllerian Agenesis
2. Hormonal
 Complete Androgen insensitivity
 Gonadal Dysgenesis (Turner syndrome)
 Hypothalamic-pituitary insufficiency
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6. A couple in their thirties presents for evaluation for infertility. The woman is nulligravid
and has regular menses. The husband has no child. They have unprotected sexual
intercourse for 18 months. Neither has a history of sexually transmitted disease or
major illness.

a. What are the possible causes of their infertility?


1. Failure of ovulation
2. Pelvic factors
 Tubal disease
 Pelvic adhesions
 Endometrioses
3. Cervical factors
 Sperm-cervical mucus plug penetration
4. Male factors
 Oligospermia
 Azoospermia
5. Rare causes:
 Immunological factors
 Hypothyroidism
 Subclinical genital infections.
6. Impossible to diagnose (unexplained infertility)

b. What diagnostic tests are necessary for evaluating them?


Woman
1. Laboratory test
 FBC
 Urine analysis
 Fasting blood sugar
 Cervical cytology (Pap smear)

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2. Documentation of ovulation
 Basal body temp.
 Midluteal phase serum progesterone
 Endometrial biopsy
 Diagnostic D and C.
3. Postcoital test
4. Hysterosalpingogram
5. Immunological tests
6. Bacteriological test
7. Serum thyroid stimulating hormone and prolactin levels

Man

1. Routine
 FBC
 Sickling status
 Syphilis serology
 BUE
 LFT’S
2. Seminal analysis
3. Endocrine test
 Serum gonadotropins – LH and FSH tires
 Serum testosterone
 Serum Prolactin

7. A 25 year old hypertensive pregnant woman starts bleeding per vagina at 30 weeks.
a. List 4 differential diagnoses.
1. Abruptio placenta
2. Placenta previa
3. Rupture of a vasa previa
4. Uterine rupture
b. What is the most likely diagnosis?
 Abruptio Placenta

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c. List six complications associated with (b)
Maternal
1. Hypovolemic shock
2. Acute renal failure
3. DIC
4. PPH – from DIC or from Couvelaire uterus
5. Maternal mortality
6. Fetal Maternal Hemorrhage

Fetal

1. IUGR
2. Congenital malformations
3. Abnormal neonatal hematology- Anemia and transient coagulopathies
4. Perinatal mortality (Fetal still birth and early neonatal death).

8. A woman becomes unconscious five minutes after normal delivery:


a. List ten possible causes
1. PPH
2. Eclampsia
3. Any cause of Shock
4. Anemia
5. AMI
6. Hypoglycemia/ Hyperglycemia
7. Pulmonary Embolism
8. Encephalopathy – Stroke, Epilepsy, Electrolyte imbalance
9. DIC
10.Infection – Meningitis, Encephalitis
11. Amniotic fluid embolism
12. Drugs- Sedatives, Narcotics
13.Infection
14.Arrhythmia
15.Asphyxia
b. How would you manage any two of these causes?
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Eclampsia

1. ABC
2. Prevent aspiration
3. Administer oxygen by face mask or intra-nasally
4. Prevent fits from recurring – Give MgSO4.
5. Reduce blood pressure – Hydralazine , Labetalol
6. Maintenance fluid therapy is continued with crystalloids
7. Continuous urinary catheter drainage to monitor urine output
8. Monitor level of consciousness using the GCS.

PPH

Same as Above

9. A 29 year old woman has just missed her period and she experienced bleeding per
vagina
a. List five causes.
1. Implantation bleeding
2. Abortion- Spontaneous or induced.
3. Ectopic pregnancy
4. Molar pregnancy
5. Local cervical lesions E.g. Ca cervix, Chronic cervicitis and cervical erosion

b. How would you mange any of these causes?

ABORTION –

Threatened Abortion
1. Reassure the patient
2. Bed rest at home or hospital
3. To abstain from sexual intercourse.
4. To report back if bleeding or pain increases
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Inevitable Abortion

1. Resuscitate with IV fluids and blood as necessary


2. Nil by mouth
3. Analgesics to relieve severe pain.
4. Allow to abort. Give oxytocic’s
5. Evacuation of uterus
6. Allow home on Haematinics when stable

Incomplete Abortion

1. Resuscitate as necessary- IV fluids, blood transfusions etc.


2. Oxytocics
3. Evacuation of retained products of conception under general anesthesia or
MVA.
4. Rh(D) Negative women to have Anti D Rh Immune Globulin within 72 hours
5. Counselling and psychological support.
6. Report back to hospital when there is lower abdominal pains, bleeding, fever
and malodorous vaginal discharge.
7. Discharge on Haematinics as soon as patient is fit to go home
8. Review in 2 weeks.

Complete Abortion

1. Haematinics

Septic Abortion:

1. Involve a senior doctor early


2. Investigate appropriately:
 FBC, Sickling, Platelet count
 Clotting screen
 Blood culture and sensitivity
 Urine culture and sensitivity
 Endo-cervical swab for culture and sensitivity
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 BUE
 Abdominal X-ray
 Chest x-ray
 Abdomino-pelvic ultrasound
3. Allow to abort or oxytocin drip if fetus still in-situ
4. Adequate resuscitation.
5. Antibiotics( triple regime)
 IV Cefuroxime 750-1500mg 6-8 hourly for 24-72 hours
 IV Gentamicin 80mg 8 hourly × 5 days
 IV Metronidazole(Flagyl) 500mg 8 hourly × 24-72 hours
6. Evacuation of retained products of conception (ERPC) within 6 hours of
initiation of antibiotic therapy.
7. Analgesics
 IM Pethidine 100mg 4-6 hourly with IM Promethazine 25 mg 8-12
hourly.
8. Tetanus prophylaxis
9. If uterus is found to be perforated get senior help early.

Ectopic Pregnancy

Unruptured Ectopic

1. Medical treatment with Methotrexate


2. Conservative surgery- salpingostomy with removal of trophoblastic tissue.
3. Salpingectomy if tube cannot be saved, esp. if it is 3 cm diameter or more.

Ruptured Ectopic

1. Treat Shock with crystalloids, colloids and blood.


2. Prepare for laparotomy.
 Pass urethral catheter to monitor urine output
 Monitor BP, Pulse- ¼ hourly till theater is ready
 Fluid intake-output chart
3. Laparotomy
4. Salpingectomy is done.
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5. For sever shock with coma intubate early and institute artificial respiration if
possible.

Molar Pregnancy

1. This is best managed on a specialist unit


2. Investigations
 FBC and Sickling
 Chest x-rays
 Clotting profile
 Serum T4,T3 and FTI
 Blood grouping and cross-matching for possible transfusion.
3. Admit patient and stabilize for surgery. Transfuse when necessary
4. Arrange for suction curettage under general anesthesia (GA) theatre.
5. Do sharp curettage after the suction
6. Send specimen for histology
7. Repeat ultrasound scan to confirm empty uterus. Repeat curettage in 2 weeks
if uterus is not empty or when bleeding occurs.
8. Appropriate follow up regime to be decided by consultant in charge.
9. To have contraception for 1-2 years.
10. Advice early scan in the next pregnancy to exclude another molar pregnancy
or choriocarcinoma.

Exam version

1. Evacuate the uterus and follow with weekly β-hCG.


2. Treat malignant disease with chemotherapy – Methotrexate
3. Treat residual uterine disease with hysterectomy.

10. A 50 year old woman presents with abdominal distention Ascites.


a. List six likely causes and indicate how you would manage one of these causes.
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1. Uterine Fibroid
2. Large Ovarian cyst
3. Ovarian cancer
4. Tubo-ovarian abscess
5. Heart failure
6. Cirrhosis
7. Nephrotic syndrome
8. Intestinal Obstruction
9. Large bowl obstruction
10. Splenic rupture (Delayed)
11. Fecal impaction
12. Constrictive pericarditis
13. Hepatocellular carcinoma

Uterine Fibroids

1. Treatment modalities involved in myoma management are as follows: Expectant, Medical and
Surgical.
2. Management generally depends on: The severity of symptoms, The size of the fibroid, The age of the
patient and The reproductive wishes of the patient.
3. General Management:
 Correct Anemia with oral or occasionally parenteral iron.
 Cases of infection would have to be treated with the appropriate antibiotics
4. Expectant Management:
 See patient every 3-6 months to review the symptoms and size of the myoma.
 All those who have not completed their families are encouraged to do so before the myomas
begin to cause infertility.
 Postmenopausal women with myoma uteri who are on estrogen replacement therapy should
be seen regularly and progestogen given once in every 6 month to reduce the effects of
unopposed estrogen.
5. Medical Management:
 Danazol, GnRH analogues, Mifepristone, Progestogens

6. Surgical Management:
 Myomectomy and Hysterectomy.

Ovarian cancer

Surgery:
1. Surgical staging followed by TAH/BSO with omentectomy, peritoneal washings and biopsies, and pelvic
and para-aortic lymphadenectomy.
2. Benign neoplasms warrant tumor removal or unilateral oophorectomy.
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3. Postoperative chemotherapy: is routine except for women with early stage or low-grade ovarian
cancer.
4. Radiation therapy is effective for dysgerminomas

Hepatocellular carcinoma

1. INVESTIGATIONS
 LFTs
 Blood level of alpha-fetoprotein
 Abdominal ultrasound scan
 Chest X-ray
2. To relieve pain - Analgesics
3. To relieve discomfort from gross ascites - Paracentesis
4. To prevent or treat hepatic encephalopathy

Intestinal Obstruction:

1. Nil by mouth
2. Start intravenous fluids Normal saline or Ringers lactate.
3. Pass a nasogastric tube
4. Pass urethral catheter and monitor the urine output aiming at 30 - 50 ml/hr
5. Start patient on broad-spectrum antibiotics.
6. Surgical referral

Splenic rupture (Delayed)

1. Insert a Large bore IV access


2. Group and cross-match blood
3. Start intravenous fluids
4. Colloids ± then blood
5. Pass a nasogastric tube
6. Nil by mouth
7. Urethral catheter to monitor output
8. Analgesics
9. Surgical referral for splenectomy

Large bowl obstruction

Same as for intestinal obstruction

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11. A 17 year old patient has developed a fever of 390C, severe abdominal pains and
offensive vaginal discharge following an abortion.

a. What is unsafe abortion?


An unsafe abortion is a procedure for terminating an unwanted pregnancy either by
persons lacking the necessary skills or in an environment lacking the minimal
medical standards, or both.
b. How would you manage this patient?

Same for septic abortion above or Simplified below


1. Rapid resuscitation with intravenous fluids, blood, broad spectrum antibiotic
therapy
2. evacuation of the uterus usually within 12 hours of admission, or
3. Laparotomy or both;
4. Hysterectomy when appropriate, will minimize maternal morbidity and mortality

c. How would you diagnose renal failure in this patient?


SYMPTOMS
Nausea and Vomiting, Oliguria, Anuria, Nocturia, edema, Decreased appetite,
Change in moods, Flank pain, Fatigue

1. Reduced GFR
2. Raised Serum Creatinine
3. Urinalysis: Proteins
4. BUN/Cr
5. BUE ( Increase K+), uric acid
6. Urine culture
7. Kidney biopsy
8. ABG (metabolic acidosis)

d. How would you diagnose endotoxic shock?


SYMPTOMS
1. Feeling faint
2. Palpitations

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3. Sweating
4. Restlessness
5. Clouding of consciousness
SIGNS
1. Pallor
2. Cold extremities
3. Tachycardia
4. Hypotension Systolic BP < 90 mmHg

e. How will you treat Renal Failure in this patient


1. Involve the renal unit or the physician on call early or refer to a physician’s unit
as early as possible.
2. Adequate infusion / transfusion is initially necessary
3. After adequate fluids have been given challenge kidneys with 200-250 ml of 20%
Mannitol IV or IV furosemide (Lasix) 100-200mg.
4. If renal failure is established then restrict fluids and institute renal failure regime:
Low potassium containing fluids, low potassium diet etc.
f. How will you diagnose septic shock?
1. Warm extremities due to peripheral vasodilation
2. Sustained lowering of the BP even when volume replacement is adequate. SBP<
90 mmHg or it may drop by > 40mmHg.
3. Sensorial impairment or coma.
4. Fever
5. Hyperventilation

Associated lab findings?

Early

hyperglycemia/glycosuria, respiratoryalkalosis, hemoconcentration, leukopenia.

Late—leukocytosis, acidosis, elevated, lactic acid

g. What organisms may be involved


Generally these are:
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1. Gram negative bacilli, most commonly E. coli and Bacteroides fragilis and
2. Gram positive cocci, particularly enterococcus and beta hemolytic streptococcus
3. Other organisms include clostridium perfringes and clostridium tetanus.

12. A 14 year old girl with an unknown interval of amenorrhea, a positive urinary
pregnancy test and a morning sickness presents for antenatal care. Her uterus is not
palpable on abdominal examination.

a. Provide three questions that are useful in determining the gestational age.
1. When was the last time you had your menses?
2. Can you tell me when you started feeling sick in the mornings: feeling nauseous
and any vomiting?
3. Can you tell me when you noticed any changes in your breast?

b. What can give rise to a false positive urinary pregnancy test?


1. Molar Pregnancy
2. Ectopic Pregnancy
3. Recent Miscarriage
4. Certain Medications (e.g. some fertility drugs) that contain hCG
5. Evaporation Lines
6. waiting too long to read the results
7. Choriocarcinoma
8. The test was expired.
9. Other Tumors: tumor in the ovaries, uterus or endometrium.
10.She is post-menopausal, or just got a really sensitive test.
c. What can give rise to a false negative urinary pregnancy test?
1. She tested too early and hCG levels were not yet sufficient.
2. She didn't test too early but hCG levels were still insufficient.
3. Her urine was too diluted.
4. The test was done incorrectly
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5. The test was expired.
6. The test results were read too long after testing.
7. misread the result
d. How would you treat morning sickness?
It is a normal occurring in early pregnancy. It may be a sign the placental is
developing well. Severe case may be a sign of hyperemesis gravidarum.
Non-pharmacological treatment:
1. Eat small meals
2. Drink fluids 30 minutes before or after meals, but not with meals.
3. Drink small amounts of fluids during the day to avoid dehydration
4. Ask someone to cook for you if the odour bothers you.
5. Don not lie down after eating.

Mild cases:

1. Promethazine oral
2. Metoclopramide oral.

e. What is hyperemesis gravidarum?


This refers to excessive vomiting during the early part of pregnancy. It is quite
common. Often, no cause for the vomiting is found; however, it may also be
associated with multiple pregnancy or molar pregnancy.

Hyperemesis gravidarum is a diagnosis of exclusion. It is important to rule out other


causes of vomiting such as medical problems (e.g. malaria, gastritis, peptic ulcer
disease, hepatitis, hypoglycemia etc.); surgical problems (acute appendicitis, bowel
obstruction, Cholecystitis etc.) and gynecological problems such as twisted ovarian
cyst.

CAUSE
 Pregnancy

SYMPTOMS
 Excessive vomiting throughout the day
 Inability to eat or drink due to fear of vomiting
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 Weight loss

SIGNS

 The patient appears miserable


 Dehydration (dry skin, dry tongue, sunken eyes in extreme cases)
 The pulse is rapid and thready in extreme cases
 The BP may be low (from hypovolaemia)
 Deep and fast (acidotic) breathing in extreme cases

13.A 30 year old primigravid is in labour after 40 weeks of gestation. The cervix is 9cm
dilated.

a. What stage of labour is this?


Active phase of the first stage of labour

b. What could be done if uterine contractions are inadequate?


1. Augmentation of labour with Oxytocin

c. What are the complications of the method you would use in (b) above?
1. Poor uterine action
2. Abnormal fetal Heart rate pattern
3. Hyperstimulation
4. Uterine rupture
5. water intoxication
6. postpartum hemorrhage
7. Painful contractions
8. Uterine atony
9. Uterine inversion
d. What analgesic would you give this patient?
1. Inhalational - Entonox if available
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2. Epidural – if available
3. IV Pethidine + Phenergan IV.

14.A 45 year old woman complains of post-coital bleeding. General examination and
abdominal examination appear normal. Speculum examination reveals a growth on
the cervix.
a. Give two differential diagnoses of the growth on the cervix
1. Polyps
2. Ca Cervix

b. How can you differentiate between the 2 diagnoses clinically?


Polyps:
 Speculum examination reveals smooth, red or purple, fingerlike projections
from the cervical canal

Ca cervix

 Speculum examination may reveal an endophytic/ulcerative growth or


exophytic, cauliflower or fungating growth.

c. How do you arrive at the definitive diagnosis?

Cervical biopsy

Cervical biopsy in polys reveals: Mildly atypical cells and sings of infection.
Cervical biopsy in Ca cervix : Most common diagnosis is squamous cell
carcinoma. May also reveal Adenocarcinoma or both.

d. How would you treat the patient?

If biopsy confirms Polyps:

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1. Polyps can be removed be gentle twisting or by tying a surgical string around
the base and cutting it off. Removal of the polyp’s base is done by
electrocautery or with a laser.
2. Because many polyps are infected, an antibiotic may be given after the
removal even if there are no or few signs of infection.
3. Although most cervical polyps are benign, the removed tissue should be sent
to pathology.
4. Regrowth of polyps is uncommon.

If biopsy confirms Ca cervix:

1. Metastasis workup: Once a tissue diagnosis of invasive carcinoma is made, a


metastatic workup should be done that includes pelvic examination, chest x-
ray, intravenous pyelogram, cystoscopy, and sigmoidoscopy.
2. Imaging studies for staging: Invasive cervical cancer is the only genecological
cancer that is staged clinically. CT or MRI scans cannot be used for clinical
staging.
3. Surgical treatment based on the stage of cancer:
 Stage Ia1: Total simple hysterectomy
 Stage Ia2: Modified radical hysterectomy
 Stage Ib: Radical hysterectomy
4. Follow –up
 All patients with invasive cervical cancer should be followed up with Pap
smears every 3 months for 2 years after treatment and then every 6
months for the subsequent 3 years
 Local recurrence: treat with radiation therapy.
 Distant metastasis: consider for chemotherapy treatment.

15. A 30 year old student has been sexually assaulted and she requests an emergency
contraception.
a. Name any two emergency contraception methods
1. Emergency contraceptive pills
 Ethinyl oestradiol
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 Norgestrel
 Levonorgestrel
2. Danazol
3. Progestogen-only-contraceptive pill
4. Postcoital IUCD insertion
5. Mifepristone (RU 486)
b. What are the benefits?
1. Very effective in prevention of pregnancy when used early
2.

c. What are the risks?


1. There is still a chance of pregnancy.
2. ECP changes the amount, duration, and timing of the next menstrual period
3. Ectopic (tubal) pregnancy may be a possible result
4. Does not provide protection from sexually transmitted diseases
5. Nausea, vomiting, abdominal pain, fatigue, headache etc.
6. Serious risk include: heart attack, blood clots, and strokes.

d. How would she prevent an acute pelvic inflammatory disease?


1. Prophylactic antibiotics
 Ceftriaxone + Metronidazole + Doxycycline.
16. A 25 yr old hypertensive pregnant woman bleeding per vagina at 30 week. 10 causes.
Diagnose
Causes:
1. Placenta previa
2. Abruptio placentae
3. Vasa previa
4. Cervical polyps
5. Cervical carcinoma
6. Cervical ectropion
7. cervicitis
8. Vaginal thrush
9. Vulval varicosities
10.Uterine rupture
11. Heavy show
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12.Blood dyscrasias(rare) :
• Idiopathic thrombocytopenia.
• Von Willebrand’s disease.
• Leukaemia.
• Hodgkin’s disease.
• Antiphospholipid syndrome.
13.Trauma
14.Idiopathic
15. IUCD
16. Coagulopathy – Blood clotting disorders
17.Urinary or anal bleeding may be reported as vaginal bleeding in error. They need
exclusion

Diagnose: Placenta Abruptio

17. Excessive bleeding after delivery. 10 causes?


1. Uterine atony
2. Retained products of conception
3. Uterine inversion
4. Uterine cavity infection
5. Uterine rupture
6. Trauma
7. Coagulopathy
8. High parity
9. Precipitous labour
10. Rapid or prolonged labour

University of Ghana Final Exams

1. A) Define the various degrees of Anemia in pregnancy?


b) List 6 risk factors predisposing to anemia in pregnancy?
1. Nutritional
 Iron deficiency (commonest)
 Folic acid deficiency (rare)
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2. Bleeding during pregnancy
3. Acute infections such as malaria and pyelonephritis
4. Hemolysis such as from Sickle cell disease and red cell G6PD defect
5. AIDS
6. Aplastic state (rare)
c) Briefly outline your management of a 39 year old grandmultipara (Para 8) with
iron deficiency anemia (Hb 5.4gm/dl) at 38 weeks gestation.

1. Take blood for FBC, Grouping and cross match for transfusion
2. IM furosemide
3. Blood transfusion: best to give packed RBCs
4. Iron therapy
5. Tab folic acid
6. Replenish iron stores

2. A) What is induction of labour

A planned initiation of labour or

Induction of labour is the artificial initiation of cervical dilation and effacement


leading to progressive uterine contractions.

B) List 4 indications for induction of labour

1. Maternal disease:
 Existing before pregnancy, e.g. diabetes.
 Occurring in pregnancy, e.g. pre-eclampsia.
 heart disease, and history of fast labors
2. Fetal disease, e.g. Rh disease.
3. Fetuses at risk from reduced placental perfusion, being SGA.
4. Post-maturity (or more strictly post-dates),
5. Fetal death or abnormality.
6. Poor past obstetric history.
7. A pregnancy resulting from infertility treatment.
8. Recurrent unexplained APH.
9. At the woman’s, or her partner’s, wish (to be avoided).
10. Prolonged pregnancy, Rh incompatibility, fetal abnormality, chorioamnionitis,
premature rupture of membranes, placental insufficiency, suspected intrauterine
growth restriction.
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c) Outline the procedures involved in induction of labour

1. Examine vaginally to determine Bishops score and a membrane sweep


performed.
2. Give prostaglandin, this will start labour on its own
3. If not, 4 hours later, repeat the PG and wait 4hours.
4. If no action after 4 hours, rupture membranes
5. Administer oxytocin if uterine contractions do not follow closely or if labour
becomes prolonged and abnormal.

d) List 4 complications of induction of labour


1. Uterine hyperstimulation may lead to fetal distress and so to a Caesarean
section.
2. Prolonged rupture of the membranes may increase the risk of intrauterine
infection.
3. Prolonged labour may lead to a Caesarean section.
4. Women whose labours are induced have a higher incidence of Caesarean
section.
3. A) Define puerperal pyrexia?
 Oral temperature of 38oC on 2 or more occasions during the first 10 days of
the puerperium excluding the first day.
b) List six causes of puerperal pyrexia?
1. Malaria
2. Puerperal sepsis
3. Breast problems – mastitis, abscess
4. UTI
5. DVT
6. Chest infection
7. Others: Tonsilitis, Typhoid fever, Acute appendicitis etc.

C) Describe the presentation and management of puerperal sepsis?


Presentation:
1. General malaise
2. Fever
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3. Lower abdominal pain
4. Offensive lochia
5. Tachycardia
6. Lower abdominal tenderness with varying degrees of rebound tenderness and
guarding depending on the degree of infection
7. Visible infection of episiotomy wound, perineal or vaginal tears
8. Uterine sub- involution
9. Speculum examination reveals dilated cervical os and discharge.

Management

Same as for septic abortion

1. Admit
2. Administer oral antipyretic/analgesics
3. Fluid intake: Encourage fluid intake to avoid dehydration
4. Oral broad spectrum antibiotics
5. Change antibiotics according to sensitivity results
6. May need evacuation of retained products of conception from uterus.

4. A 30 year old woman known to be carrying an intrauterine pregnancy of 14 weeks


gestation reports with a day’s history of vaginal bleeding:

A) What in the history and clinical examination findings will lead you to make a
diagnosis of threatened abortion?
1. Vaginal bleeding
2. Early gestational age – 14 weeks.

An ultrasound scan indicates that the woman has a missed abortion.

B) List 3 investigations you will carry out as part of your management.


1. Dilation and curettage
2. Blood Rh status
3. Speculum examination
4. Ultrasound
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C) Outline how you will treat her missed abortion?

1. Scheduled suction D&C or


2. Conservative management awaiting a spontaneous completed abortion or
3. Induced contractions with misoprostol.

5. A) Define infertility
Inability of a couple to conceive within one year of unprotected sexual intercourse
b) How may the diagnosis of anovulation be made?

1. Basal body temperature


2. Urine LH levels
3. Mid-luteal phase serum progesterone(Day 21-23)
4. Endometrial biopsy
5. Serial pelvic ultrasound examinations may be used to follow follicular size and
rupture (ovulation) and it may confirm the diagnosis of polycystic ovarian syndrome.

C) List 3 medications that may be used to treat anovulation?


1. Clomiphene citrate
2. Bromocriptine
3. Human Menopausal Gonadotrophin (hMG)

D) List 2 complications that may be associated with the use of the above
mentioned medications.

1. Multiple pregnancies
2. Congenital anomalies. This is not increased above that of the general population.
3. The abortion and preterm delivery rates are increased. The abortion and neonatal
death rates are significantly increased.

6. Describe the pharmacological methods of pain relief in labour?


7. Diagnosis, management and complications of pregnancy induced hypertension.
8. A 35 year old nulliparous woman presents at the gynecology OPD with mas about
20cm in diameter arising from the pelvis. Describe your management?

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9. A 70 year old presents at the gynecology OPD with second degree uterovaginal
prolapse. Describe the factors that could have contributed to her having this
condition. Describe your management of this woman.
10.What do you understand by the term “malpresentation”?
List 4 factors that predispose to malpresentation.
Outline the conditions associated with malpresentation during labour and delivery.
11.Define preterm labour
List 4 factors associated with increased risk of preterm labour
Describe the problems that a baby born preterm may have
How may the diagnosis be made
12.What are the effects that malaria may have in pregnancy
What measures may be taken to prevent malaria in pregnancy.
13.What is unsafe abortion?
Outline your management of a 25 year old woman with septic incomplete abortion.
List 4 complications that may follow septic abortion
14.What is endometriosis
List 3 of the theories put forward to explain the pathogenesis of endometriosis
How may the diagnosis of endometriosis be made?

15.Outline the embryologic development of the uterus


List the congenital abnormalities that may occur in the development of uterus
16.List 5 leading causes of maternal mortality in Ghana.
Describe the prevention of one of the leading causes of maternal mortality.
17.Define puerperal pyrexia
List 8 causes of puerperal pyrexia
Outline the management of a woman who delivered 5 days ago with a temperature
of 39o and offensive lochia.
18.Briefly describe all the route of administration and their complications of hormonal
contraceptives.
19.Discuss the etiological factors, diagnosis and management of preterm spontaneous
rupture of the membrane.
20.Write and essay on vaginal examination in obstetrics.
21. Describe the aetiological factors of endometrial and cervical carcinoma
22.Describe the diagnosis and management of stage II carcinoma of the cervix.
23.What is meant by abnormal uterine bleeding
List 4 causes of abnormal uterine bleeding
Discuss the options available for the management of abnormal uterine bleeding.

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24.Describe the diagnosis and management of incomplete abortion in a woman after 3
months of pregnancy.
25.Describe the various ways in which a woman with uterine fibroids may present?
26.How may the diagnosis of labour be made
Define the 3 stages of labour
Describe the management of labour in singleton vertex presentation, from the
second stage onwards.
Describe the management of a 25 year old woman, 34 weeks pregnant who presents
with severe frontal headaches, epigastric pain, a blood pressure of 170/120 mmHg
and proteinuria of 3+.
27.Describe the management of a 28 year old woman who has premature rupture of
membrane at 32 weeks gestation.

28.What are uterine fibroids


Describe the symptoms and signs that may be associated with fibroids.
What are the complications that may occur with fibroids?
29.Define postpartum hemorrhage
List predisposing factors to postpartum hemorrhage
Describe the management of a woman, Para one, who starts bleeding after the
delivery of the placenta.
30.List the causes of pelvic peritonitis. Discuss the management of pelvic peritonitis in a
young woman.
31.Compare and contrast the android pelvis and the platypelloid pelvis.
32.List the indications for forceps delivery
Discuss the complications associated with this form of operative vaginal delivery
33.Define pelvic inflammatory disease
List the endogenous and exogenous pathologic organisms responsible for PID.
Discuss briefly the mode of spread of the infection and its therapy
34.Define dysfunctional uterine bleeding.
Discuss the differential diagnosis of this abnormal bleeding.
What investigations would you do.
35.Define the ideal contraceptive method.
Discuss the current contraception I use
36.Define obstructed labour
Enumerate the clinical features of obstructed labour
Discuss the management of obstructed labour in a 25 year old primigravida at 38
completed weeks of gestation.
37.Define abruptio placentae
How does it usually present
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Discuss the management of a 39 year old Gravida 6 para 5 with an abruptio placenta
at 30 weeks of gestation.
38.Define ectopic pregnancy
What types of ectopic pregnancy are known?
Discuss the management of an unruptured ectopic gestation in 20 year old para 0.

39.Define the main pathophysiological types of carcinoma of the cervix


Discuss the epidemioaetiological factors involved in the carcinoma of the cervix.
Discuss the mangagement of a 22 year old para 4 with stage IB carcinoma of the
cervix.
40.Describe the anatomy of the uterine cervix
Describe the changes in the cervix during pregnancy.
41.Define intrauterine contraceptive device
Discuss the mechanism of action and the contraindications to its use.
42.Describe the perineal body
What steps would you take to minimize injury to this structure during childbirth?
43.Define fetal surveillance
Describe in general terms tests used for antepartum fetal surveillance
List 5 patients who should receive antepartum fetal surveillance.
44.Define labour
Describe the active management of labour
What are the cardinal movements of the fetus during labour in breech presentation?
45.What is vulvovaginitis
Name 3 common causes of vaginitis
How is a definitive diagnosis made?
46.Define antepartum hemorrhage
Compare and contrast the management of placenta previa and abruptio in a 26 year
primigravida at 32 weeks gestation
47.Define pregnancy induced hypertension
What the features are of sever preeclapsia
A 35 year old primigravida who is a regular attendant at the antenatal clinic, is found
to have a blood pressure of 150/100 mmHg at 30 weeks of gestation. Discuss the
magement.
48.Why must adnexal masses be diagnosed and evaluated
List 6 differential diagnosis for adnexal masses
Discuss the characteristics of adnexal masses which would help to distinguish
malignant and benign masses
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49.What is meant by premalignant cervical disease
What are the risk factors for cervical carcinoma?
Discuss the management of cancer of the cervix, stage IIA in a 30 year old woman.
50.Describe the anatomy of the uterus
Discuss the anomalies that can occur during the development of the uterus.
51.List the indications for a vacuum extraction
Discuss the complications associated with this type of operative vaginal delivery.
52.What is lymphogranuloma venereum(LGV)
Discuss the cause the cause and management of LGV.
53.Define safe abortion
Discuss the complications of abortion.
54.Mastitis is a complication in the puerperium.
What are the organisms responsible for mastitis?
Discuss the management of mastitis in the puerperium.
55.Define gestational diabetes
What are the features of gestational diabetes?
Discuss the management of a 36 year old para 3, gravida 4 with a gestational
diabetes at 30 weeks of gestation.
56.Define menopause
How would you manage a 52 year old patient with postmenopausal bleeding?
57.List the malignant tumors of the ovary.
Discuss the aetiological factors and management of ovarian carcinoma.
58.Define oligohydramnios.
Discuss the causes and complications of oligohydramnios
59.Define fibromyomata.
Discuss the secondary changes that can occur in the fibromyomata
60.Discuss the side effects of systemic contraceptives.
61.Define preterm labour.
Discuss the causes and management of preterm labour.
62.Discuss the evaluation for recurrent pregnancy loss.
63.Describe the anatomy of the bony pelvis.
Outline how this affects the outcome of labour.

64.Describe the anatomy of the breast


List the hormones involved in its development.
65.What are vulva warts
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Describe the causes and management of the disease.
66.What are the benign tumors of the uterus?
67.Define the following
Oligomenorrhoea
Menorrhagia
Metrorrhagia
68.Outline the embryonic developemt of the uterus.
69.Write an essay on lower segment caesarean section under the following headings:
Indications
The operative procedure (main steps)
Complications (excluding anesthetic related ones)
Post-operative care in the uncomplicated case until discharge
70.Describe the complications associated with pregnancy, labour and delivery in twin
gestation.
71.What is augmentation of labour/
Briefly describe how augmentation of labour may be carried out in a 27 year old
primigravida (with a term pregnancy) at 5cm dilatation with intact membranes.
List 4 complications that may be associated with augmentation of labour
72.What are the clinical features of placenta previa?
A 30 year old primigravida at 35 weeks gestation has and ultrasound scan done
because of suspected fetal macrosomia. However the ultrasound scan shows
normally grown fetus but with the placenta partially covering the internal os. Outline
your subsequent management of this woman up to delivery.

73.A 29 year old woman G3P1+1 at 39 weeks gestation presents with complain of loss of
watery fluid per vagina. Describe how you would make a diagnosis of premature
rupture of membrane (PROM) in this woman.
List 4 complications that may be associate with PROM in the above-mentioned
woman.
Briefly outline your management of PROM in this 29 year old woman who is 39
weeks pregnant.
74.Primary postpartum hemorrhage (PPH) is the leading cause of maternal mortality in
Ghana.
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Define primary PPH
Define maternal mortality
Name 4 other direct causes of maternal mortality
Outline the 3 key steps during labour aimed at preventing atony primary PPH
75.A 35-year old grandmultipara is seen in the postnatal ward. She is due to be
discharge a day after spontaneous vaginal delivery.
List 4 main issues for counseling and health education of this woman.
Outline the key points to be covered in 2 of the issues you have mentioned.
76.A 20 year old G1P0 is admitted at 34 weeks with severe pre-eclampsia.
What are the criteria for making this diagnosis?
Mention 6 other symptoms /signs that may be found in this woman.
Outline the protocol you will use for administering magnesium sulphate in this
woman.
77.A 17 year old girl has not menstruated yet
What are the causes of this condition?
Name the five stages of pubertal development
Mention 6 physical findings that may contribute to the making of specific diagnosis of
this girl.
78.Name 3 long term reversible contraceptives
Outline the protocol for providing ONE of the contraceptives you have mentioned.
What follow up advice will you give?

79.A 40 year old G8P7 is admitted to the labour ward with ruptured uterus
Describe the clinical features you will expect?
What investigations would you undertake?
Describe your management of this case
What are some complications that may occur in this woman?
How could this condition have been prevented in this woman?
80.Describe the management of unstable lie using the following guidelines
Diagnosis and initial assessment
Causes
Approach to delivery
Complications
81.Write an essay on unsafe abortion using the following guidelines
Definition
Predisposing factors
Clinical features
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Investigations
Management
82.Write an essay on endometrial cancer under the following guideline:
Risk factors
Clinical presentation
Staging
Management
83.Describe the difference between the gynecoid pelvis and the android pelvis.
Describe the effects of these differences on child-bearing.
84.How would you induce labour in a primigravida woman whose pregnancy has
progressed satisfactorily to 42 weeks.
85.What is breech presentation?
Describe how the diagnosis is made.
Describe briefly how vaginal breech delivery is done.
86.What is ultrasound
Describe the use of ultrasound in modern gynecological practice.

87.What is gestational diabetes mellitus (GDM)


a) List 6 neonatal complications of GDM
b) Describe the antenatal management of a woman who has been newly c)
diagnosed as diabetic at 32 weeks gestation.
d) How would you deliver the woman described in (C) above?

88.What is sickle cell disease (SCD)


List 6 complications of SCD in pregnancy
Describe the antenatal management of a patient with SCD.
Describe the management of labour and delivery in a young woman with SCD.
89.List the risk factors of ovarian cancer?
Describe the methods available for the diagnosis of ovarian cancer.
How would you manage ovarian cancer in a 65 year old woman.
90.Describe the diagnosis and management of cancer of the cervix
How may the disease be prevented.
91.A 25 year old primigravida attends antenatal clinic at 18 weeks gestation. Her VDRL is
reported as “Reactive”. Describe your subsequent course of action.

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92.A 28 year old woman G3P2 is found at booking at 20 weeks gestation to be of blood
group AB rhesus Negative, antibodies negative. What measures may be take inview
of this report during pregnancy, labour and/or at delivery.
What do you understand by the term labour?
Describe the components of the partograph
How is progress of labour examined?
93.Briefly describe the non-contraceptive benefits of the use of the combined oral
contraceptive pill.
List 4 complications that may be associated with the use of the copper-T intrauterine
contraceptive device.
94.Outline the diagnosis and treatment of the following
Vulvo-vaginal candidiasis
Bacterial vaginosis
95.What is IUGR and how may its diagnosis be made
Give an account of the risk factors predisposing to IUGR
Briefly outline the complictions that may be associated with an infant born growth-
restricted.
96.A 22 year old woman in her first pregnancy has a CS for fetal distress with the
delivery of a still born baby. Describe the post-operative management until she is
discharged from hospital.
97.Briefly describe the functions of the placenta
List 4 abnormalities of the placenta
98.What is urinary incontinence
List 4 causes of urinary incontinence
Describe briefly the management of vesico-vaginal fistula(VVF)
99.Describe the changes that occur in the breast during pregnancy and lactation.
List 6 advantages of breast feeding.
100. Write an essay on the importance of antenatal care

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