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Vaginal Discharge Details About Causes , Color , Smell , Consistency , Treatment ) 2012 Past Years OSCE Answers Group C2 ( 2012) “this was taken from the past OSCE exams and answerd to add tome more notes to the Focus Hx notes that we have “ ا ا ا 1– Typical case scenario for preterm delivery ( 35 year pregnant , 34 week Gestational age , Multipara , previous 2 deliveries in early pregnancy , and now she has lower abdominal pain ) History 1- Age, Gravidity, Parity & Blood group 2- LMP & EDD to determine GA 3- Singleton or multiple 4- Analysis of the contractions 5- Associated abdominal pain, back pain, rupture of membranes, vaginal bleeding ( recurrent ) or fever 6- Any change in fetal movements 7- History of previous preterm labor (in this pregnancy or previous) 8- Known U/S findings in this pregnancy (multiple gestation, placenta previa, fetal anomalies, uterine anomalies & GA by U/S) 9- Risk assessment - DM or HTN - Surgery - Smoking - Low body mass index ( BMI < 20 ) --------------------------------------------------------------------------------------------------------- 2- Typical case for DUB ( Dysfunctional uterine bleeding ) …. 48 year old female , Multipara , excessive abnormal bleeding …. History Profile (age, parity, marital status & work) History of present illness & Gynecologic history Analysis of previous normal cycle : duration, regularity, duration of menstrual flow, no. & size of pads, soaked, presence of clots, associated dysmenorrhea & its type Analysis of the abnormal bleeding Pattern Amount, color, clots Severity (number & size of pads, soaked, symptoms of anemia, impact on life) Associated post-coital bleeding Associated symptoms : pelvic mass, symptoms of cancer & metastases Possibility & symptoms of pregnancy History of PID or STD Taking contraceptives or IUD Last Pap smear Symptoms of fibroid (urinary symptoms, constipation, mass) History of fibroid, endometriosis, malignancy Symptoms of thyroid disease Obese or not Past history DM, thyroid disease or bleeding disorder HTN History of breast diseases Drug history Anticoagulants or Tamoxifen Family history Endometrial cancer, breast cancer, colon cancer Cervical or ovarian cancers ---------------------------------------------------------------------------------------------------------- 3- Scenario-based station , between you and examiner A- Large for gestational age ( how to asses the GA by exam and the Sonar ? …. Give your DDx ? ) ULTRASONIC ESTIMATION OF EDD: 1ST TRIMESTER: · CRL (+/- 5 days) 2ND TRIMESTER: Bi-Parietal Diameter ( BPD ) – Head Circumference ( HC ) – Abdominal Circumference ( AC ) - Femur Length ( FL ) And by examination … Fundal Height Fundal height: Measuring large for GA: 1- Wrong date (corrected by US) 2- Loose abdominal muscles, as in multiparous women 3- Having uterine fibroids 4- Multiple pregnancy 5- Polyhydramnios 6- Tall stature of mother 7- Baby position is high above the pelvis, this occurs in case of breech presentation and in placenta previa 8- Macrosomia of diabetic mother. 9- Simply carrying a big healthy baby (Constitutional) ………………………………………………………………………………………….. B – Vaginal Discharge details about causes , color , smell , consistency , treatment ) 1 - Causes for abnormal vaginal discharge: Infectious Fungal and yeast bacterial Protozoa viruses Non infectious Foreign bodies Neoplasm Atrophic vaginitis Poor hygiene 2 - Types of discharge White (at first and end of the cycle) Clear and stretchy (mean ovulation) Clear and watery (heavy exercise, after cycle) Brown (after period) Spotting blood (mid cycle) Yellow or green (infection) -3 Clinical Presentations The vaginal discharge is heavier , thicker than usual (pus -like) White and clumpy discharge. Greenish ,yellowish, or blood –tinged discharge. Foul smelling (fishy or rotting meat) discharge. Accompanied by itching ,burning ,rash, or soreness. -4 Treatment Candida ---- Flucanazole or Ketoconazole Bacterial vaginosis --– Metronidazole and Clindamycin cream Trichomonus vaginals ---- Metronidazole Done by : Ahmad Shhadeh Case1 endometriosis The Dr gave typical history of endometriosis ( secondary dysmenorrheal , lower abdominal pain , deep dyspareunia , infertility ….. ) 1.what is your diagnosis ? endometriosis 2.what investigations to confirm ? biopsy is confirmatory , tumor marker C125 may be elevated ( from lecture ) 3.what is the most definitive diagnostic way ? the definitive diagnosis is be visualization of the lesion by laparoscopy 4.what are the lines of treatment ? 1- medical treatment : a-symptomatic ( analgesics , NSAIDS ) b- hormonal :the aim is to stop the ovulatory cycle , we use : 1 COCP : prevent ovulation by –ve feedback on pituitary so LH and FSH will drop When estrogen and progesterone are given at the same time they will have no effect on endometriosis 2 danazol : 17 alpha ethinyl testestrone , not used anymore , has sever androgenic side effects 3 gestrinone : androgen derivative 4 we can use high dose of progesterone 5 GnRH analogues : inhibit LH FSH ( pseudo-menopause ) 2- Surgical treatment A – conservative surgery : if there is endometroma we remove it , if there are adhesions we excise them , we use this method in young patient who need their fertility B – radical surgery : hestrectomy and oopherctomy and removing all the endometrial spots and adhesions , for old patient Factors that affect the choice of treatment are : age , symptoms , the extent of the disease , the reproductive wishes , certainty of the Dx and damage to other organs Case2. Normal labor , induction of labor 1. What do u want to see in ur examination ? ass lie , presentation , engagement , bishop score and pelvic adequacy 2. When to decide to do cesarean ? normal vaginal delivery is contraindicated in the following : a- Absolute : 1-placenta previa 2-previous 2 CS , previous one due to recurrent cause , previous classical CS 3-abnormal antenatal CTG 4-transverse or oblique lie 5-active genital herpes infection 6-absolute contracted pelvis 7-tumor occupies the pelvis 8-cervical carcinoma 9-successful pelvic floor repair and successful surgical treatment of stress incontinence b- Relative : 1-severe preeclampsia 2-breech presentation 3-multiple pregnancy 4-grand multipara 5-polyhydramnios 6-presenting part above the pelvic inlet For more information go to Dr Fayez hand out page 4 Case3. ( partogram ) Go to morning sessions summary Case4. Answered Done By : Mohamad Gasaymeh Hx for GDM • Ask about GDM risk factors , including : Check list ☺ • Age > 30 » • Family history of DM ( esp 1 st degree relatives ) • Diabetes in a previous pregnancy; • Previous macrosomic infant; • Previous unexplained fetal demise • Unexplained Intrauterine Fetal Death and Neonatal death • History of polycystic ovarian disease • Congenital abnormalities • Recurrent miscarriages • Large babies > 90 th centile for their age • Obesity • Hypertension • Recurrent infections • Significant Glycosuria • Ask about DM symptoms Check list ☺ polyurea polyphagia ketoacidosis polydypsia coma wt loss infections “esp UTI “ or fungal infections MANEGMENT & TESTS : • for hight risk population we start screening as soon as 1 st trimister • for NO risk group we can start screening at about 24-28 w • we start by 50gm OGTT if result is above 7.8 mmol ( that means pt is at hight risk of GDM • so we do the 75gm OGTT ( if fasting B sugar was more than 6 ) or ( after 2 hrs from 75gm glucose blood sugar was more than 9 then we diagnose as GDM ) __________________________ • manegment must start from preconseption by • 1) controling B sugar aby keeping HBA1c less than 6 • 2) by giving folic acid supply • Insulin ( must be given in case of GDM ) ( by one of 2 methods ) • 1) 3 x a day as ( short acting insulin ) + 1 x ( intermediat acting insulin at the evening ) or • 2) 2x a day ( as mixed short and intermediat acting insulin • Calculate daily dose .6 units x wt 1st trimester .7 X wt 2nd trimester .8 X wt 3ed trimester Vaginal discharge Causes itching Causes swelling Trichomonas vaginalis Has a bad odor Clinical presentation: Is green, yellow, or gray in color No symptoms may be noted in up to one -half of Looks foamy or like cottage cheese women vaginal discharge redness Foul smell dysuria, pain Pain or dysurea and dyspareunia vulvar Candidal Vaginitis yellow or pruritus green. clolr Risk factors • Contraceptive practices On exam >> strowberry spots ( diagnostic for • Use of systemic steroids trichomonas insfection ) Use of antibiotics • Laboratory tests: • Undiagnosed or uncontrolled -1 The vaginal pH is usually between 5.0 and 7.0. diabetes mellitus -2 Saline wet mount of the vaginal discharge • Diagnosis: -4 Pap smear • #Diagnosis is made by history, physical examination, and microscopic examination of Tretment >>> metronidazol the vaginal discharge in saline and 10% KOH. Treatment Antifungal drugs >>>> fluconazol ( -AZOL antifungals ) Bacterial vaginosis Bacterial vaginosis Reisk factors LabReisk diagnosis factors 1-Oral sex -A The vaginal pH is generally between 5.0 -1 Oraland 5.5.sex 2-Douching -B Wet mount preparations with saline reveal -2 Douching a CLUE CELL 3-Black race -3 Black race -C Application of 10% KOH to the wet mount specimen 4-Cigarette smoking -4 Cigarette smoking produces a fishy odor, indicating a positive WHIFF 5-Sex during menses -5 Sex during menses test. 6-Intrauterine device -D A gray, homogenous, malodorous -6 Intrauterine discharge device is present. 7-Early age of sexual intercourse -7 Early age of sexual intercourse Treatment: metroidazol // clindamycin 8-New or multiple sexual partners -8 New or multiple sexual partners 9-Sexual activity with other women -9 Sexual
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