TOP 5 OBSTETRICS AND GYNAECOLOGY

Facing an obstetric or gynaecology case in the final clinical examinations can be a

challenge for even the most conscientious and confident of medical students. Compared to
medicine and surgery, a fraction of the undergraduate curriculum is dedicated to O&G and
students often feel underprepared and uncomfortable. In their short O&G block in the last
year or two of medical school, students try to become accomplished at history and
examination, whilst facing unfamiliar clinical presentations and differential diagnosis. This
can understandably seem overwhelming.
This guide is not intended, and could never be, a substitute for a sound understanding
of the applied basic sciences in obstetrics and gynaecology. Nor could it be an alternative to
spending time with patients, taking histories, clinical examination and presenting cases to
senior colleagues. The TOP 5 approach provides a useful framework for organising ones
learning in preparation for clinical examinations. I hope that these lists will make learning
easier, and provide a way to categorise and understand some of the clinical scenarios you
have encountered.
The obstetrics part of this guide is divided into four sections. The first outlines an
example marking scheme for obstetric examination, including a description of examination
technique and possible findings. The second deals with normal pregnancy. The third looks
at problems on the labour ward. Lastly, the fourth section lists common presentations in
maternity assessment or in the ante-natal clinic.
The gynaecology section is structured in a similar way. The first section outlines a
potential marking system for examination of a patient with a gynaecological complaint. The
second looks at common presenting complaints, and their causes, encountered in the
gynaecology clinic. The third section deals with emergency gynaecology presentations. The
last section includes miscellaneous lists, such as tumour markers.
On a final note, I have written this guide some years after graduation, with experience
as a trainee in O&G. However, I can easily recall the daunting prospect of medical school
finals. The memory of my obstetric OSCE station, during which I fumbled my way through
consent for external cephalic version, still feels very uncomfortable. I trust that you will feel
more prepared than I did, and I hope you consider the following approach to be useful.

Good luck



SECTION ONE: HISTORY AND EXAMINATION

FINALS OBSTETRIC EXAMINATION /18

Introduces self/obtains consent 1

General examination
General inspection 1
Weight, height and BMI 1
Blood pressure 1
HR, RR, and temperature 1


Abdominal examination
Inspection
Note the distension of abdomen 1
Comment on any scars 1
Comment on any cutaneous signs of pregnancy 1
Palpation
Measure the fundo-symphyseal height (cm) 1
Determine number of fetuses 1
Lie 1
Presentation 1
Engagement 1
Comment on any tenderness, or guarding 1
Comment on any palpable uterine contractions 1
Auscultation
Auscultation of the fetal heart 1

Urinalysis 1

Summary 1
Proposed plan of management 1

General inspection should be brief. Comment on whether the patient looks well or
unwell, shows any signs of anaemia, and if looks comfortable at rest. BMI is usually
calculated and recorded at booking, but it is important to show that you know it forms an
important part of the examination. Blood pressure is an essential part of the obstetric
examination and is recorded at each antenatal visit. If it is an unscheduled antenatal review,
for instance, at maternity assessment, then all observations would be taken.
A general statement such as the abdomen is distended in keeping with pregnancy of
estimated gestation.
Any abdominal scars should be noted and correlated with the clinical history. They
might include suprapubic transverse for previous Caesarean section, appedicectomy, or a
midline laparotomy scar.
Cutaeneous signs of pregnancy include linea nigrans, abdominal striae and distended
superficial veins.
In order to calculate the fundo-symphyseal height, palpate the highest point of the
uterus. Use the ulnar aspect of your left hand to move down from xiphisternum until the
fundus is located. Measure from here to the upper border of the bony symphysis. From 20
weeks gestation, the distance in cm is equivalent to gestational age (i.e. 20 cm = 20 weeks)
until 36 weeks.
The number of fetus is determined by palpating the the fetal poles, and assessing if
there is more than one fetal back.
The lie of the fetus describes its relationship between its longitudinal access and the
longitudinal access of the mother. It may be described as longitudinal, transverse or oblique.
The presentation of the fetus describes the part of the fetus that is the presenting part
to the mothers pelvis. If the lie is longitudinal, the presentation may be cephalic (head first)
or breech (bottom, or foot first). If the lie is transverse or oblique, there may be no presenting
part, or it may be shoulder, arm or umbilical cord. With transverse or oblique lies, a vaginal
delivery is not possible unless the fetus spontaneously changes, or is turned by external
cephalic version, to longitudinal lie, preferably with a cephalic presentation.
Uterine activity is assessed by palpation. Braxton Hicks contractions are painless
tightenings which come and go. This is a normal finding in late second and third trimester.
Uterine contractions associated with labour are painful tightenings which come and go. A
vaginal examination is then required, if not contra indicated, to diagnose and assess stage of
labour. A tense, tender uterus is abnormal and signals serious pathology, such as placental
abruption or uterine rupture.
Auscultation of the fetal heart can be done with pinard stethoscope or doptone. This
is best heard by palpating for and listening over the anterior fetal shoulder. A normal rate is
120-160.
Urinalysis is done at every antenatal visit, routine or unscheduled. It may suggest
urinary tract infection, or show significant proteinuria indicative of pre-eclampsia.
A summary should include the pertinent details of the history and examination,
including age, parity, gestation, pertinent points from the history, and a summary of the
positive and any important negative examination findings.
You should be able to present a plan for your patient. This will vary hugely,
depending on the problem. It may be that the woman has no presenting complaint as such,
and is completely well in a normal pregnancy. An appropriate plan in that situation would be
to schedule a routine review at the antenatal clinic. A plan for a woman with ante partum
haemorrhage at 35 weeks might be CTG, admission, IV access, FBC and group & save, USS
for placental site and speculum examination once placenta praevia is excluded.













SECTION TWO: NORMAL PREGNANCY and LABOUR

Top 5 physiological changes in normal pregnancy

1. Cardiac
a. Increase Stroke Volume and slight increase HR
b. Therefore, increased CO (HRxSV =CO)
2. Respiratory
a. RR unchanged
b. Tidal volume increases
3. Endocrine
a. Increased thyroxine demand
b. Impaired glucose tolerance
4. Haematological
a. Increased clotting factors
b. Increased iron consumption, and increased plasma, therefore iron deficiency
anaemia common
5. GI
a. Delayed gastric emptying
b. Reduced peristalsis causing constipation

Top 5 components of the 12 week booking appointment*

1. Full PMH
2. Past obstetric history (POH)
3. Offer of screening blood tests
a. FBC
b. Group and save
c. Syphilis
d. Rubella
e. HIV
4. Dating scan to confirm ongoing pregnancy and estimated date of delivery (EDD)**
5. Offer of screening tests and discussion of diagnostic tests
a. Some hospitals are able to offer nuchal translucency scans with
b. Other hospitals just offer serum screening in isolation. Blood test done at
15+5 20 weeks is called the AFP/HCG test to give low risk or high risk for
spina bifida and Downs syndrome
c. Fetal anomaly scan doen at 20 weeks to look for fetal structural anomalies

* usually at 12 weeks but can often range from 11-16 weeks
**note any women with a dating scan after 24weeks is known as a late booker and EDD is
not reliable. The dating scan may also show multiple pregnancy, or problems like
anencephaly

Top 5 components of each return appointment
Primigravida women should have 10 antenatal checks at 16, 25, 28*, 31, 34*, 36, 38, 40 and
also at 41 weeks if undelivered.
Parous women should have 7 antenatal checks at 16, 28*, 34*, 36, 38 and 41 weeks.
1. Ask about general well being/oedema/awareness of fetal movement
2. BP
3. Urinalysis
4. Palpation of fundal height, fetal lie, presentation and assessment of liquor
5. Ausculation of the fetal heart using Pinnards stethoscope or doptone
*FBC and antibodies are repeated outinely at 28 and 34 weeks. If patient is rhesus negative,
routine anti-D prophylaxis is given as IM injection at 28 weeks

Top 5 common complaints in normal pregnancy
1. GI
a. Nausea and vomiting
b. Heartburn
c. Constipation
d. Haemorrhoids
2. Urinary
a. Frequency
b. Urinary tract infection
3. General
a. Weight gain
b. Fatigue
c. Peripheral oedema
4. Musculoskeletal
a. Backpain
b. Symphysis pubis dysfunction
5. Breast tenderness

3 pathways of antenatal care

1. GREEN low risk
2. AMBER moderate risk
3. RED high risk
There are only three!

Top 5 High risk factors identified at time of screening
1. Co existing maternal co morbidities
a. Obesity
b. Renal
c. Cardiac
d. Respiratory
e. Previous DVT/PE
f. Psychiatric
g. Inflammatory bowel disease
h. Previous extensive abdominal surgery
i. Endocrine (Diabetes, thyroid disease, Addisons)
j. Infections
2. Previous antenatal complication
a. Pre eclampsia
b. Gestational Diabetes
c. Ante partum haemorrhage
3. Previous intra partum or post natal complication
a. Previous caesarean section
b. Previous pre term labour or pre term ruptured membranes
c. Previous third degree tear
d. Previous severe post partum haemorrhage
e. Previous intra uterine death or neonatal death
4. Social problems
a. Domestic/drug/alcohol abuse
b. Asylum seeker
5. Family history of fetal anomaly or genetic disorder

Top 5 signs of normal labour
Labour is the process by which the contents of the uterine cavity are expelled after 24
completed weeks (stage of viability). It is defined as regular, painful uterine contractions
with progressive cervical dilatation and effacement (shortening and retraction of cervix).
This is described as at term if it occurs after 37 completed weeks.
1. Persistent backpain
2. Painful, regular uterine contractions
3. PV Show
4. Spontaneous rupture of membranes (only if in association with cervical
dilatation)
5. Nausea/vomiting/diarrhoea

Three Stages of labour

1. First stage
The first stage commences with the onset of labour and ends when the cervix has
reached full dilatation.
2. Second stage
The second stage begins at full cervical dilatation and ends with delivery of the
baby.
3. Third stage

The third stage begins with the delivery of the baby and ends with the expulsion
of the placenta.

There are only three stages.

5 stages of normal vaginal delivery

1. Descent and flexion of fetal head
2. Internal rotation
3. Extension and delivery of fetal head
4. Restitution
5. External rotation and delivery of shoulders

Top 5 analgesics in labour
1. Non pharmaceutical (bath, birthing pool, relaxation techniques, TENS)
2. Entonox (50/50 mixture of nitrous oxide and oxygen)
3. Diamorphine IM
4. Epidural
5. Pudendal and perineal infiltration
SECTION THREE: PROBLEMS ON THE LABOUR WARD

Top 5 Maternal labour ward emergencies
1. Ante partum haemorrhage (APH)
2. Post partum haemorrhage (PPH)
3. Eclampsia
4. Maternal collapse
5. Uterine inversion
Top 5 Fetal labour ward emergencies
1. Shoulder dystocia
2. Cord prolapsed
3. Fetal distress (hypoxia/acidosis)
4. Malpresentation
5. Failed operative delivery

Top 5 causes of APH
The definition of APH is bleeding from the vaginal tract after 24 weeks pregnancy until
completion of second stage of labour.
1. Uteroplacental causes
a. Placental abruption
b. Placental praevia*
c. Uterine rupture
2. Cervical lesions
a. Cervical erosion
b. Cervicitis
c. Cervical polyp
d. Cervical cancer
3. Vaginal infections
4. Vasa praevia**
5. Unexplained
*Note, a digital vaginal examination is contraindicated in women with APH until placenta
praevia is excluded. If a previous scan at around at least 20 weeks gestation showed the
placenta is not low lying, the placenta will not then become low after this.
**Fetal bleeding



Top 5 causes of PPH
Primary bleeding from vaginal tract in excess of 500ml after second stage of labour, until 24
hours of delivery
Secondary excessive vaginal blood loss in puerperium after 24 hours until 6 weeks after
delivery

1. ATony
a. Failure of the uterus to contract well after delivery
2. Trauma
a. Perineal/vaginal wall tear
b. Cervical tear
c. Extension of uterine incision and broad ligament tear can occur at time of
caesarean section
3. Tissue
a. Retained Placenta
b. Retained pieces of placenta or membrane
4. Thrombin
a. Clotting factor deficiencies can precede PPH or be due to severe PPH
5. UTerine inversion
a. Prolapse of uterus though vagina causes severe maternal shock and is
mercifully rare.

Top 5 risk factors for PPH
1. Uterine distension
a. Big baby
b. Multiple pregnancy
c. Polyhydramnios
2. Prolonged labour and/or operative delivery
3. Fibroids
4. Grand multiparity
5. APH
Top 5 principles of PPH management

1. Call for help
2. ABC
a. Oxygen
b. Large bore IV access x 2
c. FBC, coag, XM 4 units
d. Urinary catheter
3. Identify cause(s) of PPH
4. Control bleeding
5. Replace the blood loss

5 stages in PPH management algorithm

1. Ensure 3
rd
stage complete if not MROP
2. Rub uterine fundus to stimulate contraction +/- bimanual compression if required to
stop uterine bleeding
3. Assess for cervical/vaginal wall/perineal tears if present, repair
4. Medical management of atony with oxytocic medicines
a. Syntocinon
b. Ergometrine
c. Carboprost
d. Misprostol
5. Surgical management
a. Intra uterine balloon device
b. B lynch suture if at Caesarean section
c. Uterine artery embolisation/ligation
d. Hysterectomy

Top 5 complications of 3rd stage of labour
1. Retained placenta
2. Post partum haemorrhage
3. Uterine inversion
4. Third/fourth degree tear
5. Amniotic fluid embolisation

Top 5 reasons for Elective Lower Uterine Segment Caesarean Section (El LUSCS)
1. Previous LUSCS
2. Breech presentation or abnormal lie
3. Multiple pregnancy with non cephalic presentation of first twin
4. Previous traumatic delivery and/or maternal request
5. Placenta praevia
Top 5 indications for emergency LUSCS (Em. LUSCS)
These can be divided into Fetal and Maternal indications, although clearly there can be
considerable overlap.
Fetal
1. Fetal distress in first stage of labour
2. Fetal distress in second stage of labour and any contra indication to instrumental
delivery
3. Malpresentation
a. Breech
b. Shoulder
c. Arm
d. Brow
e. Face
4. Cord prolapse
5. Prolonged second stage and any contra indication to instrumental delivery
Maternal
1. APH
2. Maternal morbidity during labour e.g sepsis
3. Maternal cardiac arrest
4. Absolute/relative cephalopelvic disproportion
5. Uterine rupture

Top 5 LUSCS complications
1. Haemorrhage +/- blood products
2. Infection
3. DVT/PE
4. Damage to bladder/bowel/ureter/vessel
5. Injury to baby

Top 5 indications for instrumental delivery
1. Prolonged second stage
2. Fetal distress in second stage
3. To prevent undue maternal effort in women with cardiac or respiratory conditions
4. Malposition of the fetal head (occipito-trasnverse or occipito-posterior)
5. After coming head in breech delivery or delivery of head at caesarean section
Top 5 pre requisites for instrumental delivery
1. Full dilatation of cervix
2. Cephalic presentation
3. Vertex at least at level of ischial spines
4. No more than 1/5
th
palpable abdominally
5. Adequate analgesia
Top 5 risk factors for shoulder dystocia*
1. Suspected big baby or post dates pregnancy
2. Gestational diabetes
3. Previous shoulder dystocia
4. Prolonged labour+/-instrumental delivery
5. Maternal short stature
*Note most cases of shoulder dystocia are unpredicted
Top 5 Maternal complications of shoulder dystocia
1. PPH
2. Third/fourth degree perineal tear
3. Uterine rupture
4. Rectovaginal fistula
5. Symphyseal separation and associated neuropathy

Top 5 Fetal complications of shoulder dystocia
1. Fetal hypoxia
2. Fetal death
3. Brachial plexus injury
4. Fracture of clavicle
5. Fracture of humerus



Top 5 shoulder dystocia management
**CALL FOR HELP**
1. Evaluate for episiotomy and put patient into McRoberts position (knee-chest position)
2. Suprapubic pressure behind impacted shoulder
a) Continuous initially
b) Then rocking movement like CPR
3. Internal rotation
a) Tries to release impaction of anterior shoulder, by rotating to oblique
plane
4. Remove posterior arm
5. Turn over onto all fours and repeat

Top 5 principals of management in eclampsia
1. Call for help and place in left lateral position if still antenatal (reduces vena cava
compression)
2. ABC resuscitation
a. Oxygen
b. BP, HR, RR, O2sats, temp, BM
c. Large bore IV access
d. FBC, Coag, U&Es, LFTs, Urate, Group and save
3. Control seizure
a. Magnesium sulphate 4grams (8mls) as loading dose then maintenance infusion
4. Control Blood pressure
a. Labetalol loading dose IV then maintenance infusion
5. Control Fluid balance
a. Urinary catheter
b. Fluid restrict to maximum 85 mls/hour
c. Patient high risk of developing pulmonary oedema if overloaded








SECTION FOUR: In MATERNITY ASSESSMENT (A&E for pregnancy!)

Top 5 common presentations to Materbaity Assessment
1. ?Labour/preterm labour
2. ?Spontaneous rupture of membranes/preterm pre labour rupture of membranes
3. Reduced fetal movement
4. Abdominal pain
5. Ante partum haemorrhage
Top 5 causes of pre term labour (PTL)
1. Cervical incompetence
2. Infection
3. Obstetric complication
a. Polyhydramnios
b. Placental abruption
4. Multiple pregnancy
5. Maternal morbidity
a. Intra abdominal surgery e.g. appendicectomy
b. UTI

Top 5 principals of PTL management
1. Assess maternal and fetal well being (immediate delivery may be required if either
compromised)
2. IM steroids to promote fetal lung maturity, if delivery not imminent
3. IV Antibiotics to protect fetus against Group B streptococcus
4. Tocolysis (if less than 34 weeks gestation, and no contraindication)
5. Ensure neonatal staff aware of patient and cot available in special care baby unit

Top 5 risk factors for preterm pre labour rupture of membranes (PPROM)
1. Polyhydramnios
2. Previous history of PPROM
3. Bicornuate uterus
4. Infection (bacterial vaginosis)
5. Fetal anomaly

Top 5 principals of PPROM management
1. Assess maternal and fetal well being
a. Confirm PPROM with speculum examination to assess if liquor clear
b. Determine if delivery imminent
c. CTG
d. Maternal observations, FBC, CRP, G&S
2. Steroids IM if delivery not imminent
3. PO Erithromycin
4. Fetal surveillance with weekly USS for growth, liquor volume and umbilical cord
dopplers
5. Maternal review with daily temperature and twice weekly FBC and CRP

Top 5 causes for large for dates
1. Macrosonia
2. Polyhydramnious
3. Increased maternal BMI
4. Multiple pregnancy
5. Increased weight gain in pregnancy
Top 5 causes of small for dates
1. Constitutionally small
2. Intrauterine growth restriction
3. Fetal anomaly
4. Smoking/drug abuse
5. Pre eclampsia
Top 5 risk factors for pre eclampsia
1. Essential hypertension (Hypertension before pregnancy or diagnosed before twenty
weeks) or pre existing diabetes or renal disease
2. Primigravida
3. Age < 20 years or >35 years
4. Previous history in previous pregnancy, or family history in first degree relative
5. Fetal hydrops

Top 5 clinical manifestations of pre eclampsia*
1. Asymptomatic (on routine antenatal screening with BP measurement and urinalysis)
2. Headache
3. Visual disturbance
4. Epigastric pain
5. Irritabilitiy and decreased consciousness
*there is a wide clinical spectrum in pre eccampsia, with varying hypertension,
proterinuria, oedema and complications. Mild to moderate pre eclampsia may be
characterised by BP >140/90 and <160/110, or mean arterial blood pressure <125,
and ++proteinuria. Severe pre ecampsia is indicated by BP >160/110, or MAP
>125, with > ++ proteinuria.

Top 5 maternal complications of pre eclampsia
1. Eclampsia
2. Cerebral vascular damage
3. Renal and liver failure
4. HELLP (haemolysis, elevated liver enzymes, low platelets)
5. DIC (disseminated intravascular coagulation)
Top 5 fetal complications of pre eclampsia
1. IUGR
2. Intra uterine death
3. Iatrogenic pre term delivery
4. Hypoglycaemia in neonatal period if mother treated with labetalol
5. Thrombocytopenia if mother affected HELLP
Top 5 investigation and management of pre-eclampsia
See also management of eclampsia in LW section
1. 24 hour urinary protein collection
2. FBC, U&Es, LFTs, urate (and coagulation if indicated)
3. Anti hypertensive medication if required
4. Maternal observation
a. Regular BP measurement
b. Check reflexes and presence of clonus (hyper reflexia ++ in severe pre
eclampsia)
c. Fundoscopy if headache/visual disturbance
d. IM steroids
e. Consider induction/delivery if indication
5. Fetal surveillance
a. CTG
b. USS for growth, liquor volume and umbilical cord doppler







Top 5 indications for induction of labour
1. Post estimated date of delivery (after Term+10 days)
2. Suspected uteroplacental insufficiency
a. Reduced fetal movements at term
b. Oligohydramnious
c. Intr uterine growth restriction
3. Previous intra uterine death/neonatal death at term
4. Multiple pregnancy
5. Maternal complication
a. Gestational diabetes
b. Essential hypertension/Pregnancy induced hypertension/pre eclampsia/HELLP
syndrome
c. Obstetric cholestasis
Top 5 points in consent for external cephalic version (ECV)
ECV is a procedure which is done to try to turn a fetus, by applying abdominal pressure, to a
cephalic presentation. It can be attempted for breech presentations, and also to correct a
transverse or oblique lie.
1. 50 % chance success
2. May revert to breech/unstable lie
3. Uncomfortable during procedure
4. Can avoid need of LUSCS and associated risk
5. Fetal monitoring with CTG before and 1/2 hour after to ensure no fetal distress
suspected.
Top 5 contraindications to ECV
1. Planned or previous c/s
2. Multiple pregnancy
3. Placenta praevia or history of APH
4. Fetal anomaly
5. Oligohydramnios
Top 5 causes of post natal pyrexia
1. UTI
2. Endometritis
3. Retained products of conception
4. Wound infection (Caesarean/perineal)
5. Mastitis





SECTION ONE: GYNAECOLOGY EXAMINATION
FINALS GYNAECOLOGY EXAMINATION /22

Introduces self, explains examination, obtains consent and ensures chaperone 1

General examination
(HR, BP, RR, temperature, O2sats in gynaecology emergency setting) 1
Anaemia 1
BMI 1
Cachexia 1
Distribution of facial and body hair 1

Abdominal examination
Inspection 1
Palpation 1
Description of mass 1
Percussion 1
Bowel sounds 1

Pelvic examination
Speculum (Cuscos)
Inspect appearance of vulva and urethral meatus 1
Inspect cervix 1
If present, describe prolapse 1
Bimanual palpation
Palpate cervix 1

Palpate uterus 1
Palpate pouch of douglas and for adnexal masses 1
If pelvic mass, aim to differentiate between uterine or ovarian 1

Urinalysis and urinary HCG 1

Summary 1
Differential diagnosis 1
Proposed management plan 1

The abdomen should be inspected for distension, scars, striae and hernia. During palpation,
comment on tenderness, guarding and rebound tenderness. A mass should be described as
fixed or mobile, smooth or irregular, and if arising from the pelvis (unable to palpate the
lower edge above the pubic bone). Percussion is useful if ovarian cyst or ascites is suspected.
In a large ovarian cyst, there is central dullness and resonance in the flanks. If there is
ascites, there is central resonance and dullness in the flanks. The presence, or absence, of
bowel sounds is important to note in the acute abdomen or post operative abdominal
distension.
The vulva should be inspected for discharge, redness, ulceration and old scars. To
insert the speculum, you should part the labia with the left hand, gently insert to top of vagina
and open the blades to inspect the cervix. Presence of discharge, bleeding, polyps, ulceration
and ectropion should be noted and swabs if indicated. Examination in the left lateral position
with a Sims speculum may be required for inspection of prolapse.
Bimanual examination involves digital vaginal and abdominal examination. The
abdominal hand is used to compress the pelvic organs on to the examining vaginal hand. The
cervix has the consistency of the cartilage of the tip of the nose (although may be softer in
parous women). The size, shape, consistency and position of the uterus must be noted. The
uterus is most commonly anterverted, but may be retroverted in about 10% of women. The
pouch of douglas is palpated for thickening (e.g. endometriosis) and the lateral vaginal
fornices are palpated for adnxal masses.
Urinalysis is included in the examination to emphasise the importance of excluding
pregnancy, particularly in an any acute gynaecology presentation, unless there is a good
reason (e.g. a 80 year old patient with a previous hysterectomy!)


SECTION TWO: GYNAECOLOGY CLINIC

Top 6 Presenting complaints at the Gynaecology clinic (impossible to keep to 5!)

1. Pain
a. Chronic pelvic pain
b. Dysmenorrhoea
c. Dyspareunia

2. Menstrual problems and unexplained vaginal bleeding
a. Menorrhagia
b. Amenorrhoea and oligomenorrhoea
c. PMS
d. Intermenstrual bleeding
e. Post coital bleeding
f. Post menopausal bleeding

3. Pelvic mass

4. Vulvo-vaginal problems
a. Prolapse (Something coming down)
b. Vulval itch/discomfort
c. Abnormal discharge
d. Vulval swelling

5. Urinary incontinence
a. Urge
b. Stress

6. Fertility problems
a. Subfertility
b. Recurrent miscarriage





Top 5 causes of chronic pelvic pain
1. Chronic pelvic inflammatory disease (PID)
2. Endometriosis
3. Pelvic adhesions
4. Pelvic congestion
5. Other
a. Bowel (IBS, constipation)
b. Musculoskeletal
c. Unexplained

Dysmennorhoea is painful menstruation.
Primary dysmennorhoea occurs in the absence of any significant pathology and usually starts
within 2 years of menarche
Secondary dysmennorhoea is caused by pelvic pathology, and usually stars many years after
menarche.

Top 5 causes of secondary dysmennorhoea
1. Endometriosis
2. Adenomyosis
3. Intra uterine causes
a. endometrial polyp*
b. sub mucousal fibroid*
4. Infections
5. Copper IUD
*these can cause colicky pain during menstruation as uterus tries to expel polyp/fibroid.

Top 5 causes of dyspareunia
Dyspareunia is defined as painful intercourse and may be superficial or deep.
Superficial
1. Vulvovaginitis
a. Candida
b. Trichomonas
2. Narrowing of the introitus
a. Vaginal stenosis
b. Narrow hymenal ring
c. Female genital mutilation
d. Over suturing of episiotomy
3. Atrophic vaginitis (post menopausal oestrogen deprivation)
4. Lichen scleroris
5. Funcational (lack of lubrication)
a. Inadequate sexual stimulation
b. Emotional problems
Deep
1. Acute or chronic PID
2. Retroverted uterus and prolapsed ovaries
3. Endometriosis
4. Cervical cancer
5. Post operative scarring resulting in narrowing of the vault
a. Vaginal repair
b. High vaginal tear

Top 5 causes of menorrhagia
1. Dysfunctional uterine bleeding (no uterine or systemic cause)
2. Uterine causes
a. Fibroids
b. Endometrial polyp/cancer
c. Adenomyosis*
3. Endometriosis
4. Copper intra uterine device
5. Medical causes
a. Hyper or hypothyroidism
b. Coagulopathy

*a condition characterised by the invasion of endometrial glands and stroma into the
myometrium

Top 5 investigations in menorrhagia
1. FBC
2. TFTs
3. TAS/TVS*
4. Hysteroscopy*
5. Endometrial biopsy*
a. Pipelle biopsy can be done in clinic
b. Curettage biopsy is done at time of hysteroscopy under anaesthetic
*Unless otherwise indicated, these are reserved for investigation of menorrhagia or irregular
vaginal bleeding in women over the age of 40, or for post menopausal bleeding.

Top 5 managment options for menorrhagia
1. Non hormonal treatment
a. Tranexamic acid
2. Hormonal medication
a. OCP
b. Norethisterone tablets
3. Mirena intra uterine system
4. Endometrial ablation
5. Hysterectomy

Top 5 specific management of uterine fibroids
1. All non hormonal and hormonal treatment options for menorrhagia (see above)
2. GnRH analogues
3. Uterine artery embolisation
4. Myomectomy
5. Hysterectomy

Top 5 causes of intermenstrual bleeding (IMB)
1. Cervical
a. Ectopy
b. CIN
c. Carcinoma
d. Post cervical smear/treatment
2. Uterine
a. Endometrial polyp
b. Endometrial cancer
3. Infection
a. Cervicitis
b. Vaginitis
4. Hormonal
a. Contraception (OCP, POP, Depot, Implanon, IUS, Levonelle)*
b. Tamoxifen
c. Oestrogen secreting ovarian tumours
5. Vaginal adenosis
*This is more accurately described as breakthrough bleeding

Top 5 causes of post menopausal bleeding (PMB)
PMB is defined as bleeding from the genital tract, 12 months after the menopause.
1. Hormone replacement therapy
2. Atrophic vaginitis
3. Cervical cancer
4. Endometrial cancer
5. Infection

Top 5 causes of amenorrhoea and oligomenorrhoea
Primary (1) amenorrhoea is the failure to menstruate by the age of 16 years, or 14 in the
absence of the other features of puberty.
Secondary (2) amenorrhoea is the complete cessation of menstrual cycles for at least 6
months.
Oligomenorrhoea is defined as five or fewer periods in a year.
In practice, the causes of each are often similar, apart from a few specific causes in primary
amenorrhoea.
1. Ovarian
a. Polycystic ovarian syndrome
b. Primary ovarian failure
i. Premature failure
ii. Destruction by surgery, radiotherapy and chemotherapy
iii. Turners syndrome
2. Hypothalamic dysfunction
a. Congenital GnRH deficiency (1)
b. Hypothalamic functional disorders
3. Pituitary dysfunction
a. Primary failure
i. Sheeans syndrome
b. Hyperprolactineamia
i. Pregnancy and lactation
ii. Prolactinoma
4. Thyroid/Adrenal disease
5. Anatomical causes
a. Congenital Mullerian duct disorders (1)
b. Imperforate hymen (1)
c. Ashermans syndrome (endometrial fibrosis)

Top 5 causes of a pelvic mass
1. Ovarian cyst
2. Uterine
a. Fibroids
b. Pregnancy
3. Pelvic abscess
4. Bowel
a. Faecal loading
b. Carcinoma
c. Inflammatory bowel
5. Urological
a. full bladder
b. Pelvic kidney

Top 5 symptoms of an ovarian cyst
1. Abdominal distension/bloating
2. Bowel obstructive symptoms
3. Urinary frequency/obstruction
4. Pain
a. Torsion
b. Rupture
c. Haemorrhage into cyst
5. Altered menstrual cycle/virilisation in hormone secreting tumours
Top 5 types of utero-vaginal prolapse
Prolapse is the protrusion of a structure beyond its normal anatomy. The supports of the
pelvic floor include levator ani, coccygeus and piriformis muscles, and the perineal muscles.
These structures support the uterus, bladder and rectum. In addition, the uterus is also
supported by the uterosacral ligaments and the cardinal ligaments.
1. Cystocele (upper anterior vaginal wall and bladder)
2. Urethrocele (lower anterior vaginal wall)
3. Rectocele (middle part of the posterior vaginal wall and rectum)
4. Enterocele (upper part of posterior vaginal wall containing loops of small bowel)
5. Uterine prolapse
a. Vault prolapse can occur in patients who have had a hysterectomy

Top 5 risk factors for prolapse
1. Congenital pelvic floor weakness (e.g. spina bifida)
2. Pregnancy and long labour
3. Multiparity
4. Oestrogen deprivation (menopause)
5. Increased abdominal pressure
a. Pulmonary disease
b. Constipation
c. Pelvic mass or ascites

Top 3 management options for prolapse
1. Physiotherapy to improve pelvic floor muscles
2. Vaginal pessary
3. Surgical repair (the operation will depend on type and extent of prolapse)
(there are only three)

Top 5 causes of vulvo-vaginal pain/itch
1. Infection
a. HSV
b. Candida
c. Gonorrhoea
d. Chlamydia
e. Syphilis
2. Atrophic vaginitis
3. Vulval dermatoses
a. lichen sclerosis
b. ezcema
4. Vulvodynia
5. Vulval carcinoma

Top 5 causes of vaginal discharge
1. Physiological
2. Infections
a. Candida
b. Chlamydia trachomatis
c. Neisseria gonorrhoea
d. Trichomonas vaginalis
e. Gardnerella vaginalis
3. Neoplasms
a. Usually blood stained
4. Local causes
a. Retained foreign body
b. Fistulae
5. Other
a. Trauma
b. Allergy

Top 5 stress incontinence
Urinary stress incontince is the involuntary loss of urine during an increase in intra abdominal
pressure.
1. Childbirth is the most common association
2. May require to be investigated with urodynamic studies
3. Occurs often during coughing, sneezing, laughing, exercise and lifting
4. Conservative management aims to treat exacerbating factors and improve pelvic floor
support with physiotherapy
5. Surgical management includes colposuspension, tapes and sling procedures to
support the urethra

Top 5 urge incontinence
Strong and urgent desire to void, and may be followed by urge incontinence.
1. Multiple causes
a. Pregnancy
b. Pelvic mass
c. Prolapse
d. UTI
e. Diuretics
2. Input/output chart useful in assessing patients
3. Avoid bladder stimulents useful in treatment
4. Behavioural therapy (bladder retraining)
5. Anti cholinergic medication can be used



Top 5 causes of subfertility
1. Anovulation
a. Most commonly PCOS
2. Tubal pathology
3. Endometriosis
4. Male factor
5. Unexplained

Top 5 investigations for subfertility
1. Mid luteal phase progesterone (a test of ovulation)
2. Hormone levels in anovulation
3. Tubal patency
4. Semen analysis
5. Chromosomal analysis

Top 5 causes of recurrent miscarriage
1. Idiopathic
2. Mechanical
a. Cervical incompetence
b. Uterine anomalies
3. Lupus inhibitor/antiphospholipid syndrome
4. Balanced translocations in parents
5. Hypothyroidism









SECTION THREE: GYNAECOLOGY EMERGENCY

Top 5 presenting complaints in emergency gynaecology

1. Pelvic pain and/or PV bleeding in early pregnancy
a. Threatened miscarriage
b. Ectopic pregnancy
or following termination of pregnancy or miscarriage
c. Retained products of conception
d. Endometritis

2. Acute pelvic pain (pregnancy test negative)
a. Ovarian cyst torsion or rupture
b. Acute pelvic inflammatory disease
c. Tubo-ovarian abscess
d. UTI
e. Acute appendicitis

3. Post operative complication
a. Wound infection or dehiscence
b. Haematoma
c. Urinary retention
d. Peritonitis from bladder or bowel injury
e. Prolonged ileus

4. Vulval swelling

5. Hyperemesis







Top 5 types of miscarriage
1. Threatened miscarriage (PVB with a closed cervical os)
2. Inevitable/incomplete miscarriage (PVB with an open cervical os)
3. Complete miscarriage
4. Septic miscarriage
5. Missed miscarriage (silent miscarriage, asymptomatic, diagnosed on USS)
Top 3 management options for non continuing pregnancy
1. Conservative management
2. Medical management with prostaglandin pessaries
3. Surgical evacuation of uterus
(there are only three)

Top 5 locations for ectopic pregnancy
Ectopic pregnancy =extra uterine
1. Tubal
a. 99% of ectopic pregnancies
2. Ovarian
3. Cervical
4. Peritoneal
5. Pregnancy of unknown location

Top 5 risk factors for ectopic pregnancy
1. History of PID
2. Previous tubal surgery
3. Failed sterilisation
4. Intra uterine contraceptive device
5. Previous ectopic pregnancy

Top 5 clinical presentations of ectopic pregnancy
1. Pain
2. PV spotting
3. Shoulder tip pain (subdiagphragmatic irritation)
4. Syncope
5. In cases of ruptured ectopic, signs of shock and peritonism

Top 5 diagnosis and management of ectopic pregnancy
1. Serum HCG tracking
a. Less than 66% increase in HCG levels over a 48 hour period is suspicious of
ectopic pregnancy (or non continuing pregnancy)
2. Pelvic USS
a. Empty uterus
b. Adnexal mass
c. Free fluid
3. Diagnostic laparoscopy
4. Medical management with methotrexate
5. Surgical management
a. Salpingectomy
b. Salpingotomy

Top 5 clinical presentation of acute PID
1. Pelvic pain
a. Usually bilateral
2. PV discharge
3. Deep dyspareunia
4. Abnormal menstrual bleeding
5. Signs of sepsis

Top 5 Acute PID treatment
1. Antibiotic triple therapy
a. Cefalexin
b. Metronidazole
c. Doxycycline
2. Admission for IVFs and analgesia if unwell
3. Partner testing and treatment
4. Laparoscopy if treatment doesnt improve symptoms
5. Laparotomy and drainage/resection of abscess

Top 5 sequelae of PID
1. Subfertility
2. Recurrent PID
3. Ectopic pregnancy
4. Chronic pelvic pain and dyspareunia
5. Tubo ovarian abscess

Top 5 causes of vulval swelling
1. Sebaceous cyst
2. Epithelial inclusion cysts
3. Wolffian duct cysts
4. Bartholins cyst
5. Benign solid tumours
a. Fibromas
b. Lipomas
c. Hidradenomas

Top 5 clinical assessment of patients with hyperemesis
1. History and examination
2. Urinalysis
a. ? suggestive of UTI
b. Presence of ketones
3. MSSU
4. Bloods
a. U&Es
b. TFTs
5. USS
a. To exclude molar and multiple pregnancy

Top 5 management of hyperemesis
1. Fluid replacement
2. Anti emetics
3. Thromboprophylaxis
4. Vitamin replacement
5. Dietician review





SECTION FOUR: MISCELLANEOUS LISTS IN GYNAECOLOGY

Tumour markers
Top 5 tumour markers in gynaecology
1. Ca 125
2. CEA
3. AFP
4. HCG
5. Other rare markers
a. Mllerian inhibiting substance (MIS)
b. Carbohydrate antigen 19-9

Top 5 causes of a raised Ca 125
1. Ovarian cancer (epithelial tumours)
2. Other cancers
a. Endometrial
b. GI tract
c. Breast
d. Lung
e. Fallopian tube
3. Benign disease
a. Endometriosis
b. Benign ovarian disease
4. Pregnancy
5. Peritoneal inflammation

Cervical disease
Top 5 risk factors for cervical cancer
1. Human papilloma virus infection
2. Multiple sexual partners
3. Cigarette smoking
4. Young age at first intercourse
5. High parity

Top 5 cervical screening results
Invasive cervical disease is preceded by cervical intraepithelial neoplasia (CIN). Routine
smears are every three years from age of 20 onwards. Screening is now in conjunction with
HPV vaccination in teenage girls. Negative results result in routine repeat in three years.
Other results:
1. Unsatisfactory.or insufficient
a. Repeat 3 months
2. Borderline
a. Repeat 6 months
3. Mild dyskaryosis
a. Repeat 6 months
4. Moderate dyskaryosis
a. Refer to colposcopy
5. Severe dyskaryosis
a. Refer to colposcopy

Ovarian disease
Top 5 types of benign ovarian disease
1. Functional cysts of the ovary
a. Follicular cysts
b. Luteinised cysts
2. Epithelial tumours
a. Serous cystadenomas
b. Mucinous cystadenomas
c. Brenner cell tumours
3. Sex cord stromal tumours
a. Granulosa cell tumours
b. Androblastomas
4. Germ cell tumours
a. Dermoid cyst (mature cyctic teratoma)
5. Other
a. Fibroma
b. Endometriotic cysts
c. Pregnancy luteomas




Top 5 risk factors for ovarian cancer
Increased risk factors
1. Genetic
2. Nulliparity
3. Unsuccessful treatment for infertility
Protective effect
4. Oral contraceptive pill
5. Breast feeding

Top 5 of malignant ovarian tumours
1. Tumours of low malignant or borderline potential
a. Cytological changes in keeping with malignancy (e.g. increased mitosis) but
without invasion
2. Epithelial type tumours (cystadenocarcinomas)
a. Serous (40% of ovarian carcinoma)
b. Mucinous
c. Endometrioid
d. Clear-cell
e. Brenner
3. Sex cord stromal tumours
a. Granulosa cell tumours
b. Sertoli-leydig cell tumours
4. Germ cell tumours
a. Dysgerminomas
b. Teratomas
c. Yolk sac tumours
5. Secondary ovarian tumours
a. Breast
b. Genital tract
c. GI tract

Family planning and sexual health
Top 5 contraception
1. Barrier method
2. Pill
a. Combined oral contraceptive pill
b. Progestogen only pill
3. Implant (lasts 3 years) or injection (every three months)
a. Long acting progestogens
4. Intrauterine
a. Copper intra uterine device
b. Mirena intra uterine system
5. Sterilisation
a. Female
i. Application of sterilisation clips to tubes laparoscopically
ii. Tubal ligation (e.g. at time of caesarean section)
b. Male
i. Vasectomy

Top 5 sexually transmitted infections
1. Chlamydia trachomatis
2. Neisseria gonnorrhoea
3. Genital warts (human papilloma virus)
4. Genital herpes (herpes simplex virus)
5. Other
a. Trichomoniasis
b. Syphilis
c. HIV