PACES Revision
Obstetrics and
Gynaecology
27/04/2012
AMRITA BANERJEE & OLA MARKIEWICZ
Kindly sponsored by:
Plan for the morning
 9-10.30 - Lecture + demonstration station
 10.30-11.00 - Break
 11.00-12.30 - Mock PACES stations (x4)
 12.30-13.00 – Lunch
Outline of Talk
 Obs & Gynae
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History
Examination
Clinical Skills
Investigations
Management
Red Flags
 Ethics and Law
 Common PACES Stations
 Demonstration Station
 Tips and Advice
 Further Resources
HISTORY
The History
 The main part of all PACES stations!! Do not compromise on
this.
 PC
 HPC
 Gynae history
 Obstetric History
 PMH
 DH
 FH
 SH
 Systems review
The Gynaecological History
Periods
• Dysmenorrhoea
• Oligomenorrhoea
• Amenorrhoea
• Menorrhagia
• Mittelschmerz
Discharge
• Smell
• Colour
• Consistency
The Gynaecological History
Think about sex:
• Contraception
• HPV vaccine
Have sex:
• Dyspareunia
• Post-coital bleeding
After sex catch:
• STI’s
• HPV – smears!
• Babies
The Gynaecological History
Boys
• Regular
• Protection – pregnancy and STI’s
• GUM clinic visits
• Peer pressure
• Legal
The Gynaecological History
Obstetric History – don’t forget TOPs!
Consequences of childbirth
• Sphincter dysfunction
• Rectal/vaginal prolapse
The Gynaecological History
Menopause
• Symptoms
• HRT
• Post menopausal bleeding!
• Vaginal atrophy
• Sex life
• Quality of life
Obstetric History
PC
HPC
Current Pregnancy
 Was this a planned pregnancy?
 EDD - scan or dates (LMP, Menstrual cycle)
 Complications
 Investigations so far
Gravidity – number of times a woman has been pregnant, regardless of outcome
Parity = (any live or still birth after 24 weeks)
Specific Symptoms...
 Nausea / Vomiting - if severe known as hyperemesis gravidarum
 Urinary frequency – pressure on the bladder causes this – rule out UTI
 Tiredness
 Fetal Movements - usually felt at around 18-20 weeks gestation, earlier in multips
Ideas, Concerns & Expectations…
Obstetric History
Details of each pregnancy:
 Date / Year
 Place of birth
 Gestation
 Mode of delivery
 Baby – sex, weight, current health
 Problems during antenatal, labour & postnatal
 Same Partner? Consanguinity?
Miscarriages & Terminations
Previous difficulty conceiving/ assisted conception
Plans for future pregnancies
Obstetric History
 For each pregnancy, including the current one if
pregnant, ask about complications:
 Maternal: DEATH P
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Diabetes
pre-Eclampsia
Anaemia
Thrombus
Hypertension
Pain
Bleeding
Infection
 Fetal
 Movements
 Scans/tests
 Hospital admissions
Obstetric History Cont.
Past Gynaecological History
 Contraceptive use?
 Last Cervical Smear – was the result normal?
 Any gynae surgery:
- Loop excision of transitional zone (LETZ) -↑ risk of cervical
incompetence
- Previous myomectomy - ↑ risk of uterine rupture /
placenta accreta /adhesions
 Gynae investigations & treatment for:
- Infertility
- Ectopic – ↑ risk of future ectopics
- PID - chlamydia is most common cause – ↑ risk of ectopic
The rest of the history
Past Medical History and Past Surgical History
Drug History
 Pregnancy medication - folates, iron, anti-emetics, antacids
 Teratogenic drugs – avoid at all costs - ACEi, Retinoids, Sodium Valproate, Methotrexate
 OTC Drugs - make sure to ask patient about these, to ensure nothing unsafe
 ALLERGIES
Family History
 Medical conditions - gestational diabetes
 Inherited genetic conditions – CF
 Pregnancy Loss - recurrent miscarriages in mother & sisters
 Pre-eclampsia - in mother or sister? – increased risk
Social history
 Smoking, Alcohol, Drug use
 Living Situation, Relationship Status
 Occupation
Systems review
Other Important Questions
 How do her symptoms affect her life
 What support does she have at home – do not
assume she is married!
 Is there anything else that you are worrying about?
 Is there anything else that you’d like to ask me?
EXAMINATION
The Physical Examination
 Examination
 Abdomen:
Gravid
 Non-pregnant
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Pelvic examination
Speculum
 Swabs
 Smear
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To complete my examination
Blood pressure
 Pregnancy test
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The Pelvic Examination
 Brief abdominal examination
 Inspect vulva
 Inspect cervix using Cusco’s speculum
 Take smears and swabs if required
 Withdraw speculum
 Bimanual examination
 Cervix
 Uterus
 Adnexae
 Inspect fingers for blood or discharge
What is this?
The Obstetric Examination
 Inspection “There is an abdominal mass consistent
with pregnancy”
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Linea nigra
Striae
Scars
Fetal movements
 Measure symphysio-fundal height
 Palpate – use ballottement
 Assess amniotic fluid volume
 Fetal lie
 Presentation
 Engagement (fifths palpable)
The Obstetric Examination cont.
 Fetal heart sounds
 BP and urinalysis
 Antenatal notes
CLINICAL SKILLS
Clinical Skills
 Blood Pressure
 Urine dipstick
 Pregnancy test
Gynae:
 Vaginal swabs
 Cervical smears
Obstetrics:
• CTG
Blood Pressure
 Make sure you know how to use a sphyngomanometer
 Roughly determine systolic BP using the radial pulse
 Start 20mmHg above this and measure BP
 Korotkoff sounds
Urine Dip
 Use gloves
 Expiry date
 Remove a strip, then close the bottle
 Dip the strip into the urine and wipe any excess
urine on the side of the bottle
 Compare the strip to the bottle
label
Pregnancy test
 Perform in almost every woman of
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childbearing age
Detects βhCG
Dipsticks vs pipette urine
Control line
Test line
Confirm result with another member
of staff
Vaginal Swabs
Bug
Swab
Other
Treatment
Candida
albicans
High vaginal
swab
Mycelial filaments on
microscopy
Clotrimazole cream
or oral fluconazole
Bacterial
vaginosis
High vaginal
swab
Whiff test positive, clue
cells, alkaline pH
Metronidazole or
clindamycin cream
Trichomonas
vaginalis
High vaginal
swab
Motile flagellated protozoa Metronidazole
on microscopy, alkaline pH
Chlamydia
trachomatis
Endocervical
swab
Nucleic acid amplification
tests (NAATs) eg. PCR
Doxycycline or
azithromycin
Neisseria
gonorrhoea
Endocervical
swab
Gram negative diplococci
Ceftriaxone
Cervical screening programme
 Aim: identification of CIN and initiating early
treatment before the development of cervical
carcinoma
NOT a test for cancer!
 Age range:
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25-49 every 3 years
50-64 5 yearly
60+ if not screened since 50 or recent abnormal results
 Technique: Rotate brush in the external os to pick
up loose cells over the TZ for liquid based cytology
Cervical screening programme
DYSKARYOSIS:
Cytology – smear
Cervical
Intraepithelial
neoplasia:
Histology - biopsy
Management
Can spontaneously
regress
6 month follow up. If
persists then colposcopy
mild
CIN1
moderate
CIN2
Colposcopy + treatment
CIN3
Immediate colposcopy +
treatment
severe
Counselling and explaining the process/results/follow up!
Cardiotocography
 DR – Define Risk
 C – Contractions
 BRA – Baseline Rate – mean rate over 5 – 10
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mins. Normal = 110 – 160 bpm
V – Variability – should be >5 bpm
A – Accelerations – rise in fetal heart rate by at
least 15 bpm lasting at least 15 secs.
D – Decelerations – fall in fetal heart rate by at
least 15 bpm lasting at least 15 secs
O – Overall
INVESTIGATIONS
Investigations
General tips:
 Importance of observations and bedside tests
 Do not mention lists of investigations unless you are able
to justify why you want them
 Hit the jackpot early (but don’t show off)
 Think outside the box – pregnant women get non-
pregnant diseases
Investigations
Gynae:
 Cervical smears
 Interpret hormone levels: FSH, LH,TFT’s
 Urodynamics
 Ultrasound: endometrial thickness
 Surgery: endometrial biopsy, laparoscopy, lap + dye
 Contraceptive methods: IUD
 Hysteroscopy
Investigations
 Obstetrics:
 Pregnancy test (in A+E)
 Glucose Tolerance Test
 Cardiotocographs
 Partogram
 Pelvic USS
 Screening tests
 Amniocentesis/chorionic villus sampling
MANAGEMENT
Management
What everyone does worst on!
Don’t forget:
 Resus +
CONSERVATIVE
MEDICAL
SURGICAL
And VERY importantly
ASK FOR HELP!
RED FLAGS
Red Flags - Obstetrics
Condition
Symptoms
Placenta praevia
Painless PV bleeding late in pregnancy
Placental abruption
Painful PV bleeding late in pregnancy
(Ruptured) ectopic pregnancy
Early pregnancy, pelvic pain, PV
bleeding +/- faintness, shoulder-tip pain
Obstetric cholestasis
Itchy hands and feet during pregnancy
Shoulder dystocia
Delayed delivery after delivery of the
head
Cord Prolapse
Umbilical cord descends below the
presenting part following rupture of
membranes
Amniotic fluid embolism
Dyspnoea, hypotension, hypoxia,
seizures, heart failure
Red Flags – Obstetrics cont.
Condition
Symptoms
Uterine rupture
Acute, severe pain during labour or, if epidural,
sudden maternal hypotension, cessation of
contractions, fetal hypoxia
Uterine inversion
Post-partum haemorrhage, pain and profound
shock
Pre-eclampsia
Hypertension, proteinuria, oedema
Eclampsia
Pre-eclampsia with RUQ pain, headaches, tonic
clonic seizures, blurred vision
PE
SOB, chest pain, hypoxia, cardiac arrest
DVT
Acute leg pain, redness, swelling, heat, +/-SOB
Primary and Secondary PPH
Primary ≥ 500 ml of blood loss within 24 hours
of delivery.
Secondary - abnormal or excessive bleeding
between 24 hours and 12 weeks postnatally.
Red Flags - Gynaecology
Condition
Symptoms
Ovarian cyst torsion/accident
Severe pelvic pain associated with
hypovolaemic shock
Endometrial carcinoma
Abnormal uterine bleeding, especially
PMB
Ovarian carcinoma
Non-specific symptoms of abdominal
distension, pain, abnormal bleeding,
weight loss
Cervical carcinoma
IMB, PCB, PMB, offensive vaginal
discharge
PID
PV discharge, pelvic pain, fever,
abnormal bleeding
COUNSELLING
Counselling
 Shared decision making
 MDT
 Empathy
 Active listening
 Use of silence
 Avoid jargon
 Ideas, concerns, expectations
Counselling cont.
 Congenital abnormalities e.g. Downs, Turners
syndrome
 Cervical smear results
 Ectopic pregnancy
 Miscarriage
 Contraception
LAW AND ETHICS
Law and Ethics
 Everyone ignores but is very important!
 Most sued specialty
 Extremely sensitive issues: cultural, religious, personal
Important principles:
 Gillick competence
 The Abortion Act
 The Mental Capacity Act
Law and Ethics
 Everyone ignores but is very important!
 Most sued specialty
 Extremely sensitive issues: cultural, religious, personal
Important principles:
 Gillick competence
 The Abortion Act
 The Mental Capacity Act
The Abortion Act
 Permits termination of pregnancy by a registered
practitioner subject to certain conditions.
 Must be performed by registered medical
practitioner in an NHS hospital or DoH approved
location (e.g. British Pregnancy Advisory Service
Clinics)
 An abortion may be approved for the following
reasons:
A
The continuance of pregnancy would involve risk to the life of the
pregnant woman greater than if the pregnancy was terminated.
B
The termination is necessary to prevent grave permanent injury
to the physical or mental health of the pregnant woman.
C
The continuance of the pregnancy would involve risk, greater than if
the pregnancy were terminated, of injury to the physical or
mental health of the pregnant woman.
D
The continuance of the pregnancy would involve risk, greater than if
the pregnancy were terminated, of injury to the physical or
mental health of any existing children of the family of the
pregnant woman
E
There is a substantial risk that if the child were born it would
suffer from physical or mental abnormalities as to be
seriously handicapped, or in emergency, certified by the operating
practitioners as immediately necessary
F
To save the life of a pregnant woman
G
To prevent grave permanent injury to the physical or mental
health of the pregnant woman.
The Human Fertlisation & Embryology Act 1990
 Section 37 of the HFEA made changes to the 1967
abortion act:
 Time limit of abortion is 24 weeks under statutory
grounds C and D
 Statutory grounds A, B and E are now without time
limit
Fraser Guidelines (Gilllick Competence)
Those <16 may be prescribed contraception without parental
consent if:
 They understand the doctor’s advice
 The young person cannot be persuaded to inform their
parents that they are seeking contraceptive advice
 They are likely to begin or continue intercourse with or
without contraceptive treatment
 Unless the young person receives contraceptive treatment
their physical or mental health is likely to suffer
 The young person’s best interests require that the doctor
gives advice and/or treatment without parental consent
THE EXAM
O&G PACES
 6 stations in total
 O&G probably 2/6 stations
 Combined with other specialities and GP
 15 mins/station
5th Year PACES
4 domains of marking:
1. Clinical skills
2. Formulation of clinical
issues
3. Discussion of Management
4. Professionalism and
Patient centred approach
Practice Case
 Miss Sarah Jones, 25 years old 13/02/1988, has
come to the antenatal clinic for her screening test
results.
 Candidate Instructions:
 Please take a brief history and explain the results of
her test: 6 mins
 Discuss further investigations and management
options: 3 mins
 Discussion with examiner: 4 mins
Past stations: Obstetrics
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15 year old wanting TOP
Missed miscarriage + speculum
Pre-eclampsia
VBAC counseling
Recurrent miscarriages + antiphospholipid syndrome
HIV and pregnancy (in multiple circuits)
PE in pregnancy (confused a lot of people)
Gestational diabetes
Down’s syndrome screening
Small for dates- young smoker
Alcohol and pregnancy
Multiple pregnancy
Abnormal lie and ECV
Counseling a patient with molar pregnancy
PV discharge in pregnancy
Contraceptive advice post-pregnancy
Pre-term rupture of membranes
Hyperemesis gravidarum
Antenatal check
Past stations: Gynaecology
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Abnormal bleeding
Menopause
Amenorrhoea and infertility
Underage/pressured sex
Sexually transmitted infections
Urogynae – incontinence, self esteem
Vaginal discharge
Pelvic pain
Subfertility
Contraception
Gynae oncology
Ethics
How to prepare
 Clerk and examine as many patients on the wards
and in clinic as possible
 Preparing for the written exam will improve your
performance in PACES
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Textbook eg. Impey - the summary pages at the end of each
chapter and the end of the book are really helpful
 PACES groups
 EMQ: books, questions
 Use the RCOG Greentop/ NICE Guidelines
 Online bank of questions – intranet and PasTest
Recommended Books
Thanks for listening!
Good luck!!
Any questions?