OBS & GYNE

OSCE’S
Done by: Yazan Alawneh
SOUL BATCH
5 t h Year OSCE’S
History – Case of bleeding
at 7 week of gestation
 Take relevant Hx

 Physical Examination
Consultation – Gestational
DM
 What is the diagnostic criteria with numbers?

 Name the maternal & fetal complications?

Maternal Fetal
- ↑ risk of hypertension - Macrosomia (>4kg)
- ↑ risk of c –section, instrumental - increase C-section,
deliveries instrumental deliveries, birth
- ↑ risk (40-60%) of developing DMII trauma (brachial plexus
within 20-15 y (hence woman injuries, clavicular fractures)
should be screened annually) - ↑ in neonatal hypoglycemia
(24%), hyperbilirubinemia,
polycythemia
- ↑ risk of DMII, obesity in life
 What are the risk factors for Gestational DM?
- Age >25y
- BMI > 25
- previous GDM
- FHx of DM in 1st degree relative
- previous macrosomic baby (≥ 4Kg)
- polyhydramnios
- large for date baby in current pregnancy
- previous un explained stillbirth

 Name the physical examination findings?

IHSAN BATCH
5 t h Year OSCE’S
History – Suprapubic pain

 Take relevant Hx
 History – 48 years old
complaining of Urine
incontinence
 Take relevant Hx

 How would you examine her

 What investigations will you order

 History – Pre-clampsia
 Take relevant Hx

 What investigations will you order:

- Urine analysis (proteinuria, pliguria)
- CBC (low platelets, RBCs hemolysis)
- Liver enzymes (elevated)

 How would you Manage the pt:

- Delivery of the fetus even if preterm: If fetus <24
w then terminate pregnancy, >32w GA there is no
cause not to deliver the fetus!
- Anti-hypertensive therapy
- MgSO4 for prevention and control of convulsions
- Fluid Mx
 Consultation – Antenatal
Care Visit
 Discussion
 Consultation – Pregnant
lady comes with labor
pain (for NVD)
 What would you do to her “follow up”,
 What investigations/physical examination will you
do?)
 Consultation –
Contraception
 Discussion
IHSAN BATCH
6 t h Year OSCE’S
 Consultation – IUCD
Insertion
 Take Pt profile, LMP, G/P, Contraindications, Risk
assessment, Fertility Plan

 When to follow up after insertion?

- 4-6 weeks

 Give DDx for missing thread & Mx:

- Expulsion, PID, Perforation, Ectopic pregnancy,
Bleeding pattern, Pain, Lost Thread, Pregnancy
 Consultation – Twins (a
pregnant lady with twins
(dichorionic, diamniotic)
came to the clinic
 What are the risk factors for twin pregnancy?

 What are the complications on the mother and

the fetus?
- Answer is in the next slide
 Twin Complications:
Maternal Fetal
• Miscarriage • Prematurity (MC!)
• PTL • PROM
• PET • Congenital anomalies
• GD • Umbilical cord:
• Abruption velamentous, prolapse, vasa
• Anemia previa
• UTI • Discordance – unequal
• Anomalies weights
• Polyhydramnios • TTTS (all MC carry risk)
• Malpresentation • Antepartum death of 1 twin
• CS • IUGR
• PPH • unequal placenta surface
• genetic syndrome
• Cerebral palsy risk
 Consultation – A pt. is
scheduled for a
laparoscopic
hysterectomy, how to
take consent from her
(what would be written on
the consent paper?)
 Patient name, National Number

 Doctor name, Hospital Name

 Date of the consent, Date of the surgery

 Diagnosis, indication for the surgery

 Explain the procedure

 Explain the complications of the procedure:

- Intra-op: Injury to other organs: ureters, bladder,
rectum, bowel and blood vessels
- Post-op: Thrombosis, adhesions, post-op blood
transfusion, reopening, wound infection

 Take the patient signature

 Physical Examination –
Mrs. Suzan G3 P2, EDD
1/12/2019, presented with
gush of fluid (PROM)
 What will you do for physical examination?
- Vitals, General Exam
- Abdominal Exam, Leopold’s maneuver (detailed)
- Speculum exam
- Bishops score (detailed)
- Investigations to confirm (only the main, US & FHR
are not counted)
 Patient vitals are all normal, on bishops score
(cervix anterior, soft, station (+3), length 1 cm,
dilation 5 cm), calculate the score and is it a
favorable cervix?
- the score is 12 and yes she is favorable of having
a normal vaginal delivery (>8)

 What will you do for her?

 What is the progress of cervical dilation?

- She’s multipara: 1.2 cm/hour

 How would you monitor the FHR?

- Every 5 minutes or after every other contraction
 Mnemonic: Alphabetical order:
The modified Bishop score
A–X
replaced cervical effacement
B–X
with cervical length in cm, and its
C – Cervical consistency
score is calculated as follows:
C – Cervical length
Score 0: cervical length >4 cm
C – Cervix position
Score 1: cervical length 3-4 cm
D – Dilation
Score 2: cervical length 1-2 cm
E – Effacement (not used)
Score 3: cervical length <1 cm
F – Fetal station
HEALING BATCH
5 t h Year OSCE’S
 History – 29 year old
female G2 P1 presented
with vaginal discharge of
4 hour duration
 Take relevant Hx

 Give 2 DDx

 What investigations you would like to do

 History – 21 year old
presented with
abdominal pain and
vaginal bleeding
 Take relevant Hx

 Give 2 DDx

 What investigations you would like to do

 History – Patient
presented with acute
abdomen
 Take relevant Hx

 Name DDx

 What tests you would like to do

 History – Patient with
recurrent pregnancy
losses and she is now 10
week gestation
 Take a focused history

 What are the investigations you want to order

 What is the management and at what

gestational age will you do it
 History – 1st Antenatal
Care Visit (P2)

 Take relevant Obstetric Hx

 Consultation – PPH
 Causes
Tone • Antepartum: • Intrapartum:
70-90% - previous PPH - Prolonged labor >12
- placenta previa hr
- maternal obesity - Prolonged 3rd labor
- baby >4kg stage
- multiple pregnancy - Sepsis
- IOL
Thrombin • Antepartum: • Intrapartum:
- PET - Placental abruption
- Sepsis - Sepsis
- Anticoagulants
- Inherited bleeding
Trauma - Uterine/cervical/vaginal injury (instrumental, CS)
Tissue - Retained products (placenta, membranes)
 Risk factors

 Management:
- Call for help, check ABCs, vitals, 2 large bore IV
lines for IV fluids, send laps and prepare cross
match, insert catheter
- Medications: Uterotonics (oxytocin)
- Manual uterine massage
- Removal of retained placental tissue (if present)
- Packing the uterus (ballooning)
- Trying off bleeding vessels
- B-lynch suture
- Internal iliac artery ligation
- Hysterectomy
- Arterial Embolization
HEALING BATCH
6 t h Year OSCE’S
History – Abdominal pain
with vaginal spotting

 The Dx was Ectopic Pregnancy

 History – Preterm labor
(PTL)

 Take a relevant history

 History – Patient with 3rd
trimester bleeding

 Take a relevant history

 Consultation – Pregnant
lady at 8 week gestation
with vaginal bleeding
 What are the DDx?
- Miscarriage, Ectopic pregnancy, molar
pregnancy

 What investigations you want to order?

- Beta-HCG
- Pelvic examination
- Ultrasound
 The US showed a fetus with no heart sound, what
is the diagnosis?
- Missed Miscarriage

 How would you Mx the patient?

- The management is divided into 3 categories:
1) Expectant: since in most cases it will progress to
complete miscarriage
2) Medical: Misoprostol
3) Surgical: D/C
PULSE BATCH
5 t h / 6 t h Year OSCE’S
 History – 69 year old
female patient came to
your clinic complaining of
heavy vaginal bleeding
 Take a focused history

 Give a DDx

 What are the risk factors for endometrial cancer?

 History – 48 year old
female complaining of
urine leakage

 Take a focused history

 what will you find on physical examination

 Mention 2 investigations to be done

History – 26 year old female
after 1 week of vaginal
delivery complaining of
fever and offensive vaginal
discharge
 Take a focused history
 what will you find on physical examination
 Mention the investigations to be done
 What is your Dx?
 History – Infertility
 Take a focused history

 What is the criteria for PCOS?

- ESHRE/ASRM (2 of the following + R/O other causes):
1) Oligo and/or anovulation
2) Hyperandrogenism (clinical) and/or
hyperandrogenemia (biochemical)
3) PCO on U/S (≥12 follicles per ovary, 2-9mm and/or
ovary volume (>10ml))
 What are the tests you would order for her?
- TSH
- Fasting Blood Sugar (FBS) and lipid profile
- Prolactin (PRL): ↑ in 40% 2ry chronic estrogen
- Free Androgen Index
- FSH and Estradiol (to exclude POF / FSH >25 + E2
<30)

 Mention 4 treatment options for PCOS?

1) Weight loss
2) Metformin
3) Climiphene
4) Letrozole aromatase inhibitor
5) FSH/LH Injections
6) Laparoscopic Ovarian Drilling (LOD)
7) IVF
 History – 18 hours
postpartum patient

 Take a focused history

 What will you do on physical examination

 What advices will you give her on discharge?

History – 69 year old female
comes with post
menopausal bleeding of 2
days duration

 Take a proper history

 History – Post Vaginal
Delivery
 Take a focused history:
- Blood group, RH
- Any complaints
- GA at time of delivery
- Was labor spontaneous or induced?
- Type of vaginal delivery (Instrumental or not)
- Fetal outcome
- Post-partum complications
- Urinate well
- Breast feeding
- Hx of episiotomy
 Perform a relevant physical examination:
- General condition, Vital signs
- Breast examination
- Abdominal examination for tenderness and
contractions
- Local inspection of pads or underwear for
bleeding
- Examine for episiotomy

 Give her advices on her discharge:

- Breast feeding
- Early post-natal visit for the mother and infant
- Family planning
- Care for episiotomy
 History – 29 year old
female G1 P0 came to
your clinic for a regular
visit, her pregnancy was
uneventful, she is now 37
weeks of gestation
 Take relevant Obstetric Hx

 Ask about fetal movements, fluid leakage,

bleeding

 Perform leopolds examination

 if Symphysial fundal heigh (SFH) was 32 what do

you call it?

 Mention DDx
History – Huda is a 43 year
old G3 P2+1 presents to
the emergency
department complaining
of SOB and dizziness, she
also complained of HMB
for the past 6 months
 Her abdominal exam and
pelvic exam were not
significant, her TA/TV US was
normal, these are her labs:
HB: 7.9
MCV: 66
Platelets: 170,000/mm3
WBC: 7500/mm3
 What is your Dx?
- Iron deficiency anemia secondary to her HMB

 Mention 4 medical treatments you can offer?

- COCP, IUS, GnRH Analogue, NSAIDs

 What investigations would you order?

- Endometrial sampling and Hysteroscopy

 Mention surgical Mx you can offer to Huda?

- Hysterectomy
- Endometrial Ablation
- Uterine artery embolization
 Consultation – Nawal is a
32 year old lady G2 P2
she had a vaginal
delivery 6 hours ago
 Mention 4 criteria for normal vaginal delivery?
 In a brief history what would you like to ask Nawal?
 On abdominal exam the uterus was found to be
2cm above the umbilicus, mention possible causes:
- Uterine atony, retained products of conception,
full bladder, fibroids, ovarian mass
Consultation – 28 year old
female patient G1 P1 is at
your post-natal ward, 18
hours after her vaginal
delivery
 How would you assess her before discharge?

 What advices will you give her?

 Consultation – 33 year old
patient presents to you with
RLQ pain after inserting an
IUCD a few weeks ago, she
also had appendectomy a
while ago
 Give a DDx
 How would you approach her?
 What will you order for her?
Consultation – 35 year old
female in the labor ward
she is at 39 week of
gestation with spontaneous
contractions

 How will you asses the case?

 How will you monitor her during the labor?
Consultation – Patient in the
st
1 day post-TAH due to
large fibroids?
 What do you want to ask her?

 What are the non-pharmacological things that can

be done to decrease the DVT risk?
- Early mobilization
- Good hydration
- Leg exercise
 If her temperature is 38.4 what are the DDx?
- Atelectasis, UTI

 After 1 week she comes back with fever & discharge

from the wound, how will you manage her?
- Admission (very important)
- Take swab & Culture
- Clean the wound and dressing
- Give Antibiotics
Physical Examination – 20
year old pregnant patient
G1 P0 comes for her
normal antenatal visit
 Do a proper abdominal examination for her
GOOD LUCK!
‫دعواتكم‬