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OSCE stations in Obstetrics and Gynecology

Q. Take a focused history form infertile couples?

Answer:

1.  Age of both partners
2.  Occupation of both partners
3.  If they previously had children
4.  Duration of infertility since marriage or last child born.
5.  Sexual history: Frequency of intercourse, pain during intercourse, any

method of contraception previously used

6. Mesntrual cycle history: Menarche, regularity, duration of cycle and

menses, menorrhagia, dysmenorrhea

7.  PCOS history: Oligo/amenorrhoea, hirsutism, obesity, diabetes
8.  Past medical history: Hypothyroidism, hyperprolactinemia, SLE
9.  Past surgical history: Abdominal surgery
10.

Past obstetrical: Previous abortion, Previous post partum

hemorrhage

11.

Drug history: Steroids, chemotherapy, radiotherapy

12.

Family history of infertility

13. Smoking

Q. A 27 year old lady with monochorionic monochorionic twin
pregnancy, what are the complications that may occur in pregnancy?
What is the mode of delivery?

Answer:

1.  Miscarriage and severe preterm delivery
2.  Increased perinatal mortality in twins
3.  Death of one fetus in a twin pregnancy
4.  Fetal growth restriction
5. Fetal abnormalities
6.  Chromosomal defects and twinning
7.  Twin to twin transfusion syndrome (unique to monochorionic twins)
8.  Cord acciedents (unique to monoamniotic twins)

Mode of delivery is Cesarean section

Q. A pregnant lady had hemorrhage after the delivery of her baby?
What is the diagnosis?

- Give
- Give
- Give

Answe
Diagno

3 causes
3 immed
3 further

er:

osis is prim

iate steps

r steps in

mary post

s in mana

managem

partum he

agement
ment

emorrhag

Assess
Feel th

1.  M
2.  O
3. In
4. In
5.  B
6.  R
7.  U
8.  L

In case
In case

s the level

e pulse fo

Massage
Oxytocin, M

ntrauterin
ntrautrine

B-lynch su
Radiograp
Uterine or
Last resort

e of perine
e of retain

l of the ute

or shock

Methergin

e balloon

packing

uture techn

phic embo

internal il

t is hyster

eal lacerat

ed tissue

erus and

nique

lization
iac artery

rectomy

tion then

then man

feel it

y ligation

suture an

nual remo

nd repair
oval and ccurettage

Q. Fibroid specimen
- What is this? Define it?
- Give 3 presentations
- Give 2 intraoperative complications
- Give 4 complications in pregnancy
- What is the percentage of malignant transformation?

Answer:
A fibroid is a benign tumour of uterine smooth muscle, termed a
‘leiomyoma
Presentations:

1. Asymptomatic
2. Mass
3. Pain
4. Pressure symptoms especially urinary frequency
5. Menorrhagia
6. Infertility

Intraoperative complications:

1. Excessive bleeding
2. Loss of demarcation if previously treated with GnRH agonist
3. Injury to bowel, bladder, ureters, or Fallopian tubes

Complications in pregnancy:

1. Red degeneration
2. Malposition and malprestation
3. IUGR
4. Preterm labour
5. Prolonged labour
6. PPH
7. Placental abruption

Percentage of malignant transformation is 0.5 %

Q. Mention important points in history, investigations, and treatment
of urinary incontinence?

Answer:
History:

1. Age; looking for menopause
2. Parity; NVD or C/S
3. Duration of incontinence

4. Time; at day or night
5. Irritative symptoms: Dysuria, urgency, frequency, polyuria
6. Risk factors: Obesity, Chronic cough, ascites, intrabdominal

malignancy

7.  Related to posture, Does it disturb her lifestyle
8.  Prolapsed mass, Back pain
9.  Past medical hx
10.

Past surgical history; pelvic surgery

11.

Drug hx including radiation

12. Family

history

13. Smoking

Investigations:

1. Midstream urine specimen
2. Urinary diary
3. Pad test
4. Uroflowmetry
5. Cystometry
6. Videocystourethrography
7. Intravenous urography
8. Ultrasound
9. Magnetic resonance imaging
10. Cystourethroscopy
11.

Urethral pressure profilometry

Treatment:

1. Prevention: Shortening the second stage of delivery and reducing

traumatic delivery may result in fewer women developing stress
incontinence

2. Conservative management:

Physiotherapy is the mainstay of the conservative treatment of
stress incontinence. Biofeedback techniques, e.g. perineometry and
weighted cones

3. Surgery:

 to provide suburethral support;

•

restoration of the proximal urethra and bladder neck to the zone of intra-

abdominal pressure transmission;

•

to increase urethral resistance;or

a combination of both.

The choice of operation depends on the clinical and urodynamic features of
each patient, and the route of approach.

Options:

1. Colposuspension
2. TVT
3. TOT

Q. A patient collapsed 30 minutes after giving birth. Give 4 DDx and
mention the management of uterine inversion?

Answer:
DDx:

1. PPH
2.  Acute uterine inversion
3. Chorioamnionitis
4. Pulmonary embolism
5.  Amniotic fluid embolism
6. Shock including hemorrhage, sepsis, anaphylaxis
7. Cardiac causes, e.g.myocardial infarct
8.  Intracranial events – bleeds, thrombosis
9.  Biochemical causes e.g. hypoglycemia
10. Anesthetic

events

Management of acute uterine inversion:
1.ABC for resuscitation
2. Replacement of uterus quickly.
3. Administer tocolytics (MgSO4, terbutaline) to relax the uterus.
4. Replacement is undertaken (with placenta still attached) by slowly and
steady pushing upwards, hydrostatic pressure (500 cc normal saline + IV
line), or surgically
5. Epidural or spinal anesthesia can be used in the management of acute
inversion when the patient has a stable cardiovascular condition.
6. After replacement, uterine contraction is maintained with an oxytocic.

Q. 60 year old woman with 6 weeks hx of vaginal bleeding. Take
history, examination, and investigations.

Answer:
History:

1. Risk factor for endometrial CA e.g. nulliparity, early menarche, late

menopause, impaired glucose tolerance, obesity, unopposed
estrogen therapy, pelvic irradiation

2.  Hx of trauma
3.  Past medical history: Bleeding disorder, hypertension
4. Previous gynecologic surgery
5.  Drug hx: Tamoxifen, warfarin, HRT
6.  Family hx of uterine, ovarian, and cervical CA

Examination:

1. General examination:

General look, BMI looking for obesity, wasting (cachexic), pallor, vital
signs,

2. Abdominal examination:

Looking for masses

3. Pelvic speculum examination and pap smear

Investigations:

1.  U/S to assess endometrial thickness
2. Endometrial biopsy
3. Hysteroscopy
4.  D & C
5.  CBC, blood film, and ESR

Q. COCP?Types, mechanism of action, and side effects:

Answer:
Types:
Most COC contains progestogens that are classed as second or third
generation. Second generation pills contain derivatives of norethindrone
and levonorgestrel. The third generation pills include desogestrel,
gestodene and norgestimate. Pills containing the newer progestogens,
drospirenone and dienogest, are also available in the UK

Mechanism of action:

1. Inhibtion of ovulation
2.  Alteration of tubal motility
3.  Endometrial atrophy and impaired uterine receptivity
4.  Changes in cervical mucus interfering with sperm transport.

Advantages:

1. Menstrual cycle becomes more regular and menstrual blood is lighter

and shorter

2.  Less dysmenorrhea and less PMS
3.  Decreased incidence of Iron deficiency anemia
4.  Decreased incidence of functional ovarian cysts, endometriosis,

acne, and PID

5. Decreased incidence of benign breast lumps
6. Protect against endometrial and ovarian CA

Side effects:

Contra
Absolu

1. IH
2.  A
3.  A
4.  P
5.  F
6.  E
7.  U

Relativ

1.  G
2.  L
3.  D

indication

te:

HD, CVA,

Arterial or
Acute or s
Pregnancy
Focal migr
Estrogen d
Undiagnos
ve:
Generalize
Long term
DM, obesit

ns:

significan
venous th

evere live

raine

dependen
sed genita

ed migrain

immobiliz

ty, and he

nt hyperte

hrombosis

er disease

nt neoplas

al tract ble

zation

eavy smok

ension, pu

e, hyperlip

sm e.g. Br

eeding

king

ulmonary

pidemia

reast CA

hypertenssion

Q. Sim
examin

Answe
Sim’s s

1.  D
2.  D
3.  R
4.  G
5.  T

ms specul

nation

speculum:

D & C
D & E
Routine ex
Genital tra
Taking bio

um and C

: Left later

xamination

act prolaps
opsy from

Cusco’s s

ral positio

se and inc

the genita

speculum

on (Sim’s p

continenc

al tract

m. Uses a

position)

e (need fu

and the p

ull bladde

osition o

er)

Cusco’s bivalve speculum: Dorsal and lithotomy position

1. Taking biopsy from the cervix
2. IUCD insertion
3. Routine examination

Q. Regarding oxytocin, what is the mechanism of action, which
endogenous organ secrete it, on which muscles it work, what are the
indications, S/Es and contraindication? What is the trade name?

Answer:
Oxytocin is a neurohypophyseal hormone that is synthesized by the
hypothalamus and secreted through the posterior pituitary.

It acts on the myometrium causing uterine contractions and inducing labor
It acts on the breast myoepithelial cells causing milk ejection

Indications:

1. Active Mx of 3

stage of labor

2. Induction of labor
3. PPH
4. Incomplete or missed miscarriage
5. After molar pregnancy

Side effects:

1. Uterine rupture
2. PPH
3. Water intoxication and fluid overload
4. Fetal distress

Contraindications:

1. CPD
2. Previous classical uterine scar
3. Fetal distress
4. Abnormal presentation (brow or shoulder)

Trade names: Pitocin, syntocinon

Q. P
use
man
diag

Answ
Invs

Pre-eclam

fulness?

ny metho
gnose pre

wer:

setigations

mpsia? Gi

Every ho

ods for me

e-eclamp

ive 3 inve

ow long y

easuring

psia?

estigation

you meas

the bloo

ns and m

ure the b

od pressu

mention th

blood pre
ure? How

heir

essure? H

w you

How

Bloo

pre-e
recorde
in the p
arising
normot
week.

Q. Nam
the ute
manag

Answe
Suppor

1. L
2. L

3. P

Risk fa

1.  C
2.  C
3.  A

od pressu

eclampsia

ed on at le

presence

novo a

tensive wo

me the pr

erus to th

gement?

rt structur

Ligaments
Levator an
position;
Posterior a
abdominal

ctors:

Congenita
Childbirth
Ageing

re should

a is define

east two s

of at least

after the 2

oman and

rolapse?

he pelvis?

res:

s and fasc

ni muscles

angulation

pressure

and raise

be meas

ed a

s hyp

separate o

t 300 mg

20th week

d resolving

Give the

? Give 3 r

cia, by sus

s, by cons

n of the va

e causing

d intrabdo

sured ever

pertension

occasions

protein in

k of pregn

g complet

names o

risk facto

spension f
stricting an

agina, whi

closure o

ominal pre

ry 15 minu

n of at leas

s and at le

n a 24 hou

nancy in a

tely by the

of the liga

ors? Wha

from the p
nd thereb

ich is enh

of the ‘flap

essure

utes

st 140/90

east 4 hou

ur collectio

a previous

e sixth po

aments th

at is the

pelvic side

by maintai

hanced by

p valve’.

mmHg

urs apart a

on of urine

sly

stpartum

hat suppo

e walls;

ning orga

y rises in

and
e,

ort

4. Pregnancy and menopause
5. Postoperative

Management:
Medical Rx:
Prior to specific treatment, attempts should be made to correct obesity,
chronic cough or constipation. If the prolapse is ulcerated, a 7-day
course of topical oestrogen should be administered.

For prevention: Shortening the second stage of delivery and reducing
traumatic delivery may result in fewer women developing a prolapse.

Specific Rx:

1. Pelvic floor physiotherapy
2. Silicon rubber-based ring pessaries

Surgical Rx:

Q. Defi

Answe
Presen
canal o

Positio
part to
position

ine posit

ntation: Po

or in close

n: Relatio

the right o

ion and p

ortion of th

est proxim

onship of a

or left side

presentat

he fetal bo

mity to it. N

an arbitra

e of the b

tion

ody that is

Normal pre

rily chose
irth canal

s either fo

esentation

en portion

. Normal:

oremost w

n: cephalic

of the fet
Occiput a

within the b

tal presen

birth

ting

Q. IUCD.. What is this? Other types? Mechanism of action?
Complication? Contraindications

Answer:
This is Copper bearing IUCD
Other types:

1. Plastic inert devices such as Lippes loop
2. Hormone-releasing IUS such as levonorgestrel-releasing IUS

(mirena)

Mechanism of action:
All IUCDs induce an inflammatory response in the endometrium that
prevent implantation, Cu-bearing IUCD has a toxic effect on sperm that
prevent fertilization, Hormone releasing IUS prevent pregnancy by a local
hormone effect on CX mucous & endometrium.

Complications:
1. Increased menstrual blood loss
2. Increased dysmenorrhea
3. Increased risk of pelvic infection following insertion
4. Perforation
5. Expulsion
6. Ectopic pregnancy

Contraindications:
1. Previous PID.
2. Previous ectopic pregnancy.
3. Known malformations of uterus.
4. Copper allergy.
5. Endometrial and cervical CA
6. Malignant trophoblastic disease

Q. Mention 4 DDx for large for date baby? How to differentiate
between them?

Answer:

1. Wrong date:
2.  Macrosomic baby: Suggested by diabetic mother. Confrim by U/S
3.  Multiple pregnancy: Family hx of twins. Confirm by U/S
4.  Polyhydramnios: Difficult to feel the fetal parts. Confirmed by U/S

5. Fibroids: Risk factors for fibroids. Abnormal lie and presentation.

Confirmed by U/S

6. Molar pregnancy: Risk factors for molar pregnancy. Rapidly enlarging

uterus. Snowstorm appearance on U/S

7. Placental abruption: Antepartum hemorrhage and severe abdominal

pain.

Q. Arey’s spatula and brush uses? Staging and management of CIN?

Answer:
Uses:

1.  Collect cells from the ecto and endocervix for pap smear
2.  Collect cells from the vaginal wall for vaginal swab
3.  HPV typing can be done in liquid based cytology

Staging:
English classification:

1.  CIN I: Only the deepest third of the epithelium from the basal layer
2.  CIN II: Two thirds of the epithelium
3.  CIN III: Affect the full thickness of the epithelium.

American classification:

1. Low grade SIL: CIN I and HPV cellular changes
2. High grade SIL: CIN II and CIN III

Management:

1. CIN I: Repeating the test (Pap smear + Colposcope) every 3-6

months until 1 year because the rate of regression of CIN I is high.
Also give folic acid to increase the integrity of the epithelium.

2. Persisten CIN I for more than 1 year, CIN II, and CIN III:

A. Excisional methods:

LEEP
LASER TZ excision
Cone biopsy

B. Ablative methods:

Electrodiathermy
Cold coagilation

Q. Reccurent miscarriage: Investigations? DDx? Uterine causes?
Management?

Answer:
Investigations:

1.  Parental karyotype, karyotype of products of conception
2.  Antiphospholipid Abs: Anticardiolipin Ab and lupus anticoagulant
3.  Screening for thrombophilia and thyroid disease
4.  Pelvic U/S to assess the ovarian and uterine appearance
5.  Transvaginal U/S to assess the cervical length
6.  Hysterosalpingography and hysteroscopy for suspected anomalies

DDx:
1. Ectopic pregnancy
2. Molar pregnancy

Uterine causes:
1.  Congenital: Septate, bicornuate, and arcuate uterus
2.  Acquired: Fibroids or Asherman’s syndrome, cervical incompetence

especially in the second trimester

Management:
1. Psychological support
2. Treatment of the underlying cause

For uterine abnormalities:
Congenital abnormalities: Metroplasty
Fibroids: Myomectomy
Asherman’s syndrome: Hysteroscopic resection of adhesions
Cervical incompetence: Cervical cerclage

Q. Small for date DDx and complications?

Answer:
DDx:

1. Wrong date
2. Transverse lie
3. Oligohydramnios
4. IUGR
5. Dead fetus

Complications:

1. IUD

2.  Early neonatal morbidity and mortality
3.  High incidence of mental and physical handicap
4.  Congenital abnormalities if the cause is chromosomal abnormality or

congenital infection

5. Adult incidence of both hypertension and diabetes

Q. Case of Turner syndrome? Dx? Karyotype? Investigations? How
gonads look like? What 1 hormone should be given? How to Dx it
during pregnancy?

Answer:
Karyotype: 45XO
Mosaic forms (e.g. 45XO/46XX or 45XO/46XY) and
Partial deletions of an X chromosome.

Dx: Most have typical clinical features including short stature, webbing of
the neck and a wide carrying angle. Associated medical conditions include
coarctation of the aorta, inflammatory bowel disease, sensorineural and
conduction deafness, renal anomalies and endocrine dysfunction, such as
autoimmune thyroid disease. Diagnosis is usually made at birth or in early
childhood from the clinical appearance of the baby or due to short stature
during childhood. However, in about 10 per cent of women, the diagnosis is
not made until adolescence with delayed puberty.

Investigations:
Abdominal U/S
FSH, LH, and estrogen levels
Karyotype analysis

Gonads:
External genitalia are normal, uterus is present, breasts are absent with
widely spaced nipples. Ovaries are streak gonads.

Hormone:
In childhood, treatment is focused on growth, but in adolescence it focuses
on induction of puberty. So we give estrogen to induce puberty.

Dx during pregnancy:
It causes 1

trimester miscarriage so it will be diagnosed by maternal

karyotype. For proper pregnancy, the woman needs egg donation

Q. Cas
drugs?

Answe
Confirm

1. S

2. N

While a
So nitra
False p

3. F

d
p

Investig

1. U
2. V

3.  C
4.  C
5.  a

c
G

DDx:

Drugs:

1.  T
2.  S
3.  A
4.  D

se of PPR

? Percent

mation:

Speculum
posterior fo
Nitrazine te

amniotic f

azin pape

positive te

Blood, sem
Ferning tes
dry and vie
producing

gations:

U/S to ass
Vaginal sw
amniotic fl
CTG
CBC and C
amniocent
chorioamn
Gram stain

Tocolytics
Steroids
Antibiotics
Drugs for i

ROM? How

tage of de

examinat

ornix eithe

est:
luid has a

er changes
est result f

minal fluid

st: a samp

ewed und

ferning pa

sess the a
wab: testin

uid such a

CRP. Urin
tesis some

nionitis, so

n , C&S te

: e.g. Rito

nduction

w to conf

eveloping

tion: We s
er sponta

alkaline PH

s to blue i

from:

, infection

ple of fluid

er micros

attern.

mniotic flu

ng substa

as fetal fib

ne culture

e time nee

o sample o

est.

odrine. Ma

of labor a

firm it? 3

g preterm

see poolin

neously o

H (7-7.5)

if amniotic

d is place

scope –cry

uid volum

nces whic

bronectin

eded to c

of amnioti

agnesium

after 34 we

investig

m labor af

ng of amn

or after fun

c fluid pre

d on glas

ystallizatio

me and exc

ch are pre

, B-HCG

onfirm the

ic fluid tak

sulfate, n

eeks

ations? 2

fter 10 da

iotic fluid

ndal press

esent in th

s slide an

on of NaC

clude plac

esent in hi

e diagnos
ken and s

nifedipine,

2 DDx? 3
ays?

in the

sure

he vagina

nd allowed

Cl occur

centa prev

igh conc.

sis of
send for

Atosiban

d to

via

Percentage: 90 %

Q. Methergine? Biological effect? Indications? Contrindications?
Route? Dose?

Answer:
Biological effect:

Methylergometrine is an ergot alkaloid and a partial agonist/antagonist
on

serotonergic

dopaminergic

and

alpha-adrenergic

receptors. Its specific

binding and activation pattern on these receptors leads to a highly, if not
completely, specific contraction of smooth uterus muscle via

serotonin receptors,

[6]

while blood vessels are affected to a lesser

extent compared to other ergot alkaloids

Indications:

Bleeding in PPH or following spontaneous or elective abortion

Active management of 3

stage

Expulsion of retained products of conception after missed abortion

Prevention and acute treatment of migraine

Contraindications:

1. Hypertension and pre-eclampsia
2. Heart disease
3. Pregnancy and birth
4. During abnormal lie
5. Cord prolapse

Side effects:

Fetal distress

Uterine rupture

Retained placenta

Cholinergic

effects such as nausea, vomiting, and diarrhea

Dizziness

Coronary artery vasoconstriction

Severe systemic hypertension (especially in patients
with

preeclampsia

)

Convulsions

Route:

Injections: (IM or IV). IV form is used in obstetrics
Oral: Tablets or in liquid form

Dose: 0.5 mg/ml

Q. DM Counselling? Whether to get pregnant or not? Complications?
Prepregnancy counselling

Answer:

The risk of problems for you and your baby can be greatly reduced by the
following advice:



Avoid unplanned pregnancies. It is very important to plan any
pregnancy and so contraception is very important.



Good control of blood sugar (glucose) levels before and during
pregnancy reduces the risks of stillbirth, miscarriage, congenital
malformation and neonatal death.



It is essential to follow the dietary advice, weight control and exercise
advice given to all people with diabetes.



Make sure you are regularly checked for any complications of diabetes,
including regular eye assessments and other assessments and
appointments with your practice nurse, GP or specialist.



If you are planning to become pregnant then you should take 5 mg
of

folic acid

daily until 12 weeks of pregnancy to reduce the risk of birth

defects in your baby.



Ketone testing strips should be used to test for ketones if you become
unwell. Ketones are substances the body makes if there is a lack of
insulin in the blood.



If you smoke then it is even more important to

stop smoking

before

pregnancy.



Reduce or cut down on the amount of

alcohol you drink



Think very positively about

breast-feeding

because it improves blood

glucose control and makes it easier to lose weight after giving birth.

Hyperg
organo
pregna
pregna
abnorm
pregna
is simil
congen
and ad
therapy
pre-me
creatin
function

Effect o

1. P
2. In

glycaemia

ogenesis –
ancy is me
ancycorrel
mality. Onc
ancy is aro

ar. Pre-pr

nital malfo

equate

y pre-preg

eal

glucos

ine conce

of diabete

Pre-eclam

nfection

a exerts its

– the first

edically

ates well

ce HbA1c

ound

30 p

regnancy

ormation. T

ontracepti

gnancy sh

e levels o

entrations

es on the m

psia and

s teratoge

42 days o

onfirmed.

with the r

c is _10 pe

per cent, w

care coul

Therefore

ion used u

hould be to

of 4–7 mm

, the

highe

mother: In

eclampsia

enic effect

pregnan

The level

risk of ear

er cent,

while the r

d significa

iabetes

until gluco

maintain

mol/L. The

er the risk

ncreased

a especia

ts during

ncy – ofte

of HbA1c

rly fetal los

he risk of f

risk of con

antly

redu

s therapy

ose contro

n HbA1c

e higher

k of perma

incidence

ally in pre-

the period

en before

c in early

ss andcon
fetal loss

ngenital m

uce the ra

y should b

ol is good

at 6.5 per

he pre-pre

anent loss

e of

-existing D

d of

the

ngenital

during

malformati

tes of
e intensif

.Targets f

r cent and

egnancy

s of renal

ied

for

3. Traumatic delivery and C/S
4. Polyhydramnios
5. PPH

Effect of diabetes on the fetus:

1.  Intrauterine death due to hypoxia and acidosis
2.  Neonatal morbidity and mortality
3.  Neonantal hypoglycemia, hypocalcemia, polycythemia, and

hyperbilirubinemia

4. RDS
5. Congenital anomalies (NTD and sacral agenesis)

Q. Lower abdominal pain: Examination? 3 uterine and 3 extrauterine
causes?

Answer:

1. General examination
2. Abdominal examination
3. Pelvic examination

Uterine causes:

1. Fibroids
2. Endometriosis and adenomyosis
3. PID
4. Ectopic pregnancy
5. Ovarian cysts

Extrauterine causes:

1. Acute Appendicitis
2. Acute Cholecystitis
3. UTI
4. Renal stones
5. Diverticulitis

Q. Iron deficiency anemia? History? Examination? DDx?
Investigations?

Answer:
History:

1. Symptoms of anemia:

General: Pallor, fatigue, malaise, weakness
CVS: palpitation, dyspnea, syncope
Neurological: Headache, vertigo, tinnitus, loss of concenteration
Specific for IDA: Pica

2. Dietary history
3.  Anorexia and weight loss
4. Recent pregnancy
5. Chronic diarrhea
6.  Bleeding source especially GIT and genitalia
7.  Past medical history: Liver disease, renal disease, thyroid disease,

malabsorption

8. Past surgical history: Gastrectomy, blood transfusion
9. Drug hx: Aspirin, NSAIDs, sulfa drugs, chloramphenicol
10.

Exposure to radiation

11.

Family history of anemia, ethnicity

Examination:

1. General examination:

Vital signs
Pallor of skin and mucus membranes
Jaundice
Glossitis and angular stomatitis
Nails for koilonychia
Lymphadenopathy
Bleeding spots

2. CVS:

Tachycardia
Wide pulse pressure
Systolic flow murmur
Sometimes evidence of CHF

3. Abdominal examination

Splenomegaly

4. Neurological examination for B12 deficiency

DDx:

1. Microcytic hypochromic: IDA is the most common cause
2. Normochromic normocytic
3. Macrocytic

Investigations:

1.  CBC, reticulocyte count, and blood film
2. Iron studies
3. Hb electrophoresis
4.  B12 and folate levels
5. Coombs test
6.  Osmotic fragility test
7.  RBC enzyme studies
8.  Bone marrow aspirate and biopsy.

Q. PCOS? Criteria? Complications in future? Treatment of hirsutism
and infertility?

Answer:
Criteria:

1. Oligomenorrhoea/amenorrhoea
2. Clinical and/or biochemical hyperandrogenism
3. Polycystic ovaries by U/S:

Ovary with 12 or more follicles measuring 2-9 mm in diameter and
increased ovarian volume (≥ 10 cm

)

Comlications in future:
Medical: DM and cardiovascular disease
Gynecological: Endometrial hyperplasia and CA

Treatment of hirsutism:

•

Eflornithine cream (Vaniqua™) applied topically;

•

Cyproterone acetate (Dianette™, anti-androgen

contraceptive pill);

•

Metformin: improves parameters of insulin

resistance, hyperandrogenemia, anovulation and
acne in PCOS;

•

GnRH analogues with low-dose HRT: this regime

should be reserved for women intolerant of other
therapies;

•

Surgical treatments, e.g. laser or electrolysis.

Treatment of infertility:



Life style modification with diet and exercise to achieve weight
reduction



Clomiphene citrate



Parenteral gonadotrophins or laparoscopic ovarian diathermy