Fertility and Menses

Problem Primary and Secondary Infertility
Goals
  1. Know when to diagnose and start investigating for infertility
  2. Knowledge about the basic investigations for infertility including the interpretation of results
  3. Basic knowledge about the various treatment options available and costs involved
Knowledge
Topics to be covered
  1. Normal physiology of menstruation (see module on Menstrual Disturbances), ovulation and conception (Only broad principles required)
  2. How to recognise and start investigations for infertility
  3. What are the common causes of infertility
    1. Male
    2. Female
  4. History taking – understand the principle of evaluating the couple together
    1. Relevant questions to help identify the cause of infertility
  5. Examination
    1. Female
      1. General
      2. Breast
      3. Abdominal
      4. Pelvic
    2. Male – if required
  6. Investigations
    1. Female
      1. Assessment of ovulation
      2. Assessment of tubes – when & how
      3. Assessment of uterine abnormalities
      4. Laparoscopy
    2. Male
      1. Seminal analysis
  7. Management – to know the various modalities available for the treatment of:
    1. Ovulatory dysfunction
    2. Tubal factor
    3. Endometriosis
    4. Male factor
  8. To be able to explain the various treatment options available (from simple strategies to IVF-ICSI)
Key figures & facts
  1. Prevalence of infertility in Singapore: 10-15%
  2. Relative contributions of all the causative factors
    1. Male factor – approximately 1/3
    2. Female factor – approximately 1/3
    3. Both male and female – approximately 1/3
    4. Unexplained – 10%
  3. Success rates of treatment options
    1. Timing of ovulation with Clomiphene *
    2. TOO + intrauterine insemination 10% – 15%
    3. IVF-ICSI (clinical pregnancy rate / embryo transfer) 30% – 40%
  4. Costs of various modalities of treatment
    1. IVF: $8,000 – $10,000
    2. IUI: $500 (approx)
    3. Gonadotrophin stimulation: $1,000 – $2,000
Skills
Procedures to be observed/taught
  1. Interpret the lab results of basic investigations
    1. Hormonal tests
    2. Semen analysis
  2. Interpret hysterosalpingogram
Attitudes
Professionalism
  1. Recognise the problem of infertility and start investigations, refer to specialist for treatment
  2. Counsel regarding potential complications eg, multiple pregnancies, OHSS and prematurity
Ethics
  1. No gender / sex selection allowed
Communication
  1. Encourage fertility management – recognise the emotional stress associated with infertility
  2. Have a compassionate approach toward the infertile couple
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC ed. Infertility and Assisted Reproductive Technologies. Essentials of Obstetrics and Gynaecology, 5th ed.Philadelphia: Saunders Elsevier 2004; 371-378
Suggested reading
  1. Speroff L, Glass RH, Kase NG. Regulation of the menstrual cycle. In Clinical gynecologic endocrinology and infertility. 6th Edition Baltimore, USA Williams & Williams. Also chapters on: The ovary; Anovulation
Problem Amenorrhoea
Goals
  1. To recognise amenorrhoea and correlate the clinical presentation with the underlying causes
  2. To be familiar with principles of investigation and the various modalities of treatment
Knowledge
Topics to be covered
  1. Normal Physiology of Menstrual Cycle
    1. Only broad principles required generally
    2. Must know details of:
      1. Follicular phase
      2. Luteal phase changes
      3. Menstrual phase
  2. Primary Amenorrhoea
    1. Definition
    2. Etiology of primary amenorrhoea
    3. Chromosomal abnormalities
      1. Turner's syndrome
    4. Genetic abnormalities
      1. Androgen insensitivity
      2. Kalman's syndrome
      3. Mullerian agenesis
    5. Outflow tract abnormalities
      1. Vaginal atresia
      2. Imperforate hymen
  3. Secondary Amenorrhoea
    1. Definition
    2. Etiology of secondary amenorrhoea
    3. Physiological causes
      1. Pregnancy and pregnancy-related states need to be excluded
      2. Physiological menopause
    4. Hypothalamic causes
      1. Low GnRH pulsatility due to stress, weight loss/gain, exercise
      2. Drugs
      3. Tumours
    5. Pituitary causes
      1. Hyperprolactinaemia & tumours
    6. Ovarian disorders
      1. Ovarian failure
      2. PCOS
        • Oligo or vanovulation
        • Clinical and/or biochemical signs of hyperandrogenism
        • Polycystic ovaries
    7. Endocrinopathies
      1. Thyroid abnormalities
    8. History and examination
    9. Investigations
    10. Complications
    11. Management
Key figures & facts
  1. Primary Amenorrhoea:
    1. No menstruation by 16 years
    2. If no secondary sexual characteristics by 14 years, start investigation
  2. Secondary Amenorrhoea:
    1. Cessation of menstruation for more than 6 months and not due to pregnancy
Skills
Procedures to be observed/taught
  1. Examination of secondary sexual characteristics (refer to Puberty & Adolescence module)
Attitudes
Communication
  1. Sensitive communication of genetic disorders resulting in infertility and sexual ambiguity
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Amenorrhea, Oligomenorrhea, and Hyperandrogenic Disorders. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 355-367
Suggested reading
  1. Speroff L, Glass RH, Kase NG. Regulation of the menstrual cycle. In Clinical gynecologic endocrinology and infertility. 6th Edition Baltimore, USA Williams & Williams; 201-246
Problem Menstrual Disturbances
Goals
  1. To understand the physiology of normal and abnormal menstruation.
  2. To correlate the clinical presentation with the underlying causes.
  3. To be familiar with principles of investigation and the various modalities of treatment.
knowledge
Topics to be covered
  1. Physiology of normal menstruation
    1. Correlating clinical features with endocrine changes
    2. Changes under the control of the Hypothalmo-Pituitary-Ovarian-Endometrium axis
  2. How to classify menstrual disorder according to pattern of menstrual irregularities: oligomenorrhoea, menorrhagia, metrorrhagia, polymenorrhoea
  3. How to take a menstrual history
  4. Regular but heavy/prolonged :
    1. Organic causes – usually benign ( including fibroids, adenomyosis)
    2. Non-organic cause: Ovulatory DUB
  5. Irregular menses:
    1. Need to exclude pregnancy
    2. Organic causes
      1. Uterine/cervical causes
        • Endometrial polyps
        • Malignancy and pre-malignancy of cervix / uterus
        • Chronic pelvic infection
      2. Endocrine disorders
      3. Others: systemic diseases, blood disorders, drugs
    3. Non-organic causes (dysfunctional uterine bleeding)
      1. Anovulatory DUB – hyperplasia and management
  6. Diagnosis
    1. Abdominal exam and vaginal exam
    2. Imaging: pelvic ultrasound
    3. Outpatient endometrial sampling
    4. Hysteroscopy, dilatation and curettage
  7. Management of the common causes of menstrual disturbances:
    1. Medical
    2. Surgical
Key figures & facts
  1. Dysfunctional uterine bleeding – excessive non-cyclical bleeding not related to anatomical lesions or to systemic disease
  2. Oligomenorrhoea – menstrual cycles greater than 35 days in length
  3. Polymenorrhoea – menstrual cycles less than 21 days in length
  4. Menorrhagia – regular menstrual cycles with excessive or prolonged bleeding. It is technically defined as blood loss greater than 80 ml per cycle
  5. Metrorrhagia – Irregular menstrual bleeding of normal/reduced volume
  6. Menometrorrhagia – Irregular menstrual cycle with prolonged / excessive bleeding.
  7. Uterine fibroids - A fibroid rarely transforms into leiomyosarcoma (< 0.1%)
Skills
Procedures to be observed/taught
  1. Abdominal and pelvic examination
  2. Physical examination of enlarged uterus (size, shape, regularity, mobility)
Attitudes
Professionalism
  1. Duty to discuss and provide the most appropriate treatment modality for the particular woman
Ethics
  1. Communication Ability to convey the purpose, mechanism and risks of complications of each treatment modality
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Disorders of menstruation. Fundamentals of Obstetrics and Gynaeclology, 8th ed. Philadelphia: Elsevier; 2005; 223-232.
Suggested reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Dysfunctional uterine bleeding. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 368-370.
  2. Speroff L, Glass RH, Kase NG. Regulation of the menstrual cycle. In Clinical gynecologic endocrinology and infertility. 6th Edition Baltimore, USA Williams & Williams.
Problem Dysmenorrhoea
Goals
  1. To understand the definition of dysmenorrhoea and the common cause(s)
  2. To be able to provide initial treatment for primary dysmenorrhoea
  3. To understand the approaches in the management of the common causes of secondary dysmenorrhoea
  4. To be able to counsel on basic side effects and complications of the different modes of treating endometriosis and adenomyosis
Knowledge
Topics to be covered
  1. Definition of Dysmenorrhoea
  2. Classification of Dysmenorrhoea:
    1. Primary
    2. Secondary
  3. Primary Dysmenorrhoea
    1. Features
    2. Cause
    3. Management
  4. Secondary Dysmenorrhoea
    1. Features
    2. Common causes:
      1. Endometriosis
      2. Adenomyosis
      3. Uterine fibroid (refer Menstrual Disturbances module)
      4. Chronic PID (refer PID module)
      5. IUCD (refer Family Planning module)
  5. Diagnosis:
    1. History
    2. Examination
    3. Pelvic ultrasound
    4. Laparoscopy if indicated
  6. Management
    1. Conservative management by:
      1. Oral analgesia and NSAIDS
      2. Hormonal therapy
      3. Danazol and GnRH
  7. Surgical therapy including:
    1. Surgical ablation and excision of endometriosis (laparoscopic/open)
    2. Hysterectomy for adenomyosis
    3. Pelvic clearance for frozen pelvis
  8. To understand the common complications of laparoscopic procedures
  9. To be aware of menstrual-related disorders like the premenstrual syndrome
Key figures & facts
Skills
Procedures to be observed/taught
  1. Clinical assessment of the common causes of dysmenorrhoea: endometriosis and adenomyosis on pelvic examination
  2. Observe laparoscopy set-up and how it is performed
Attitudes
Professionalism
  1. Understand that dysmenorrhoea is a significant morbidity
Ethics
  1. Not Applicable
Communication
  1. To be empathic towards women with chronic pelvic pain and dysmenorrhea.
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Pelvic Pain. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 256-264.
  2. Llewellyn-Jones D, ed. Endometriosis and Adenomyosis, Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 277-284.
Suggested reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Menstrual Cycle-influenced Disorders. Essentials of Obstetrics & Gynecology. 5th ed. Philadelphia: Saunders Elsevier 2004; 386-392.
Problem Family Planning
Goals
  1. To be able to counsel patients regarding various types of contraception
Knowledge
Topics to be covered
  1. Define what constitutes a contraceptive method
  2. Understand physiology of conception
  3. How to determine the ideal contraceptive method for the individual woman
  4. Describe the types of contraceptive methods available and the route of administering the different contraceptive methods
    1. Reversible
    2. Irreversible
  5. Understand the indications and contraindications for use of each method
  6. Discuss the benefits and side effects of different contraceptive methods, and manage the side effects
  7. Emergency contraception
  8. Sterilisation
Key figures & facts
  1. Theoretical and user effectiveness
  2. Pearl index for the various types of contraceptive methods (Refer to Index 1)
Skills
Procedures to be observed/taught
  1. How to advise women on the usage of various contraceptive methods
  2. To be able to perform pelvic examination and visualise the thread of the intrauterine device
  3. Observe insertion of IUCD and implants
  4. Recognise various contraceptive devices
  5. Observe sterilisation being performed
Attitudes
Professionalism
  1. Ability to discuss various methods and allowing the woman to make her choice
Ethics
  1. Use of contraception in various religious / cultural groups
Communication
  1. Provide contraceptive advice for women
  2. Advice on compliance of contraception
  3. Dealing with failure of contraceptive method
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Conception control, Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 245-254.

 

 

Index 1 (Reference: Gallo MF et al, Cochrane Database Syst Rev 2002)

Contraceptive method Pearl Index pregnancies per 100 women during 1st year of use - perfect use
Barrier contraception 3.0
Combined oral contraceptive pills 0.1
Progestogen only pill 0.5
Depoprovera 0.3
Contraceptive rod (Implanon) 0.07
Contraceptive patch 0.88
Intrauterine contraceptive device 0.1 – 1.5
Female sterilisation 0.5
Male sterilisation (vasectomy) 0.1
Problem Unplanned Pregnancy
Goals
  1. To be able to counsel patients requesting for termination of pregnancy
Knowledge
Topics to be covered
  1. Be aware of abortion laws in Singapore
    1. Compulsory pre-procedure counselling
  2. Indications for induced abortions
  3. How to assess women before the abortion
    1. Confirmation of intrauterine pregnancy
    2. Rhesus status
    3. Parity
    4. Gestation
  4. Outline methods of abortion depending on the period of gestation.
    1. Medical vs surgical
    2. First trimester vs second trimester
  5. Describe the possible complications of various methods of abortion.
  6. Outline the follow-up following abortion, including advice regarding contraception
Key figures & facts
  1. Abortion trends in Singapore
  2. Abortion-related maternal morbidity/mortality
    1. 19 million women experience an unsafe abortion worldwide each
    2. 68 000 women die from complications of unsafe abortion each year – mostly in developing countries
Skills
Procedures to be observed/taught
  1. Observe the pre-abortion counselling video
  2. Observe surgical induced abortion
  3. Post-abortion advice
    1. Immediate / delayed complications
    2. Contraceptive Use
Attitudes
Professionalism
  1. Discuss options available for an unwanted pregnancy and allowing women to make a choice
Ethics
  1. Issues of consent and confidentiality for women requesting induced abortion
  2. Legal limits for abortion
  3. Religious issues
Communication
  1. Learn to counsel patients requesting for induced abortion in a non-judgemental manner
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Miscarriage and abortion – induced abortion, Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005;109-110.
Suggested reading
  1. UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP)
  2.   Prevention of unsafe abortion.
Problem Menopause
Goals
  1. Know the consequences of menopause – short and long term
  2. Know about health screening of menopausal women
  3. Know risks and benefits of HRT
Knowledge
Topics to be covered
  1. Normal Physiology of Menopause
    1. Only broad principles required
    2. Must know:
      1. Hormonal changes associated with menopause
      2. Physiological basis of menopausal symptoms
      3. Health problems associated with menopause – osteoporosis, CHD
  2. History Taking
    1. Peri-menopausal menstrual irregularities
    2. Post-menopausal bleeding
    3. Symptoms – vasomotor, urogenital, mood changes, etc
    4. Other health problems associated with aging: DM, CHD, CVA etc..
    5. Family/ Past history of gynaecological, breast cancer
  3. Examination
    1. General
    2. Breast
    3. Abdominal
    4. Pelvic
  4. Investigations
    1. Confirmation with hormonal levels
    2. Screening: When and how frequently to repeat
      1. Pap smear
      2. Mammogram
      3. BMD
    3. Investigations for post-menopausal bleeding
      1. Ultrasound – transvaginal scan
      2. Endometrial sampling
      3. Hysteroscopy, D&C – gold standard
  5. Able to Answer FAQs on Menopause
    1. Potential risks and benefits of HRT especially in relation to breast cancer and heart disease
  6. Management of Menopause
    1. Symptoms – HRT vs non-hormonal Rx
    2. Health related issues:
      1. Osteoporosis: HRT vs non-hormonal Rx
  7. Basic knowledge about the various modalities of treatment available and their use including indication and monitoring
    1. Conventional HRT –
      1. Estrogen alone
      2. E+P – sequential, combined continuous
    2. Tibolone
    3. Herbal preparations
    4. Raloxifene
    5. Biphoshonates
Key figures & facts
  1. Key figures from WHI study
Skills
Procedures to be observed/taught
  1. Interpretation of investigation reports
    1. Hormones
    2. Mammogram
    3. BMD
    4. Pap smear
Attitudes
Professionalism
  1. Epidemiology
    1. Importance of menopause – ageing population
  2. Do not dismiss symptoms in peri-menopausal women
  3. Knowledge about the recent studies on menopausal women
Ethics
  1. Educate women about menopause and respect their choices (non-directive counselling)
Communication
  1. Compassionate approach to management of the menopausal woman
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Hypertensive Disorders of Pregnancy, Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 173-182
Suggested reading
  1. NUH guidelines on the practical management of menopause
  2. MOH guidelines on health screening
References
  1. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA. 2002 Jul 17;288(3):321-33
Problem Well Women Screen
Goals
  1. Know the important women health issues in Singapore
  2. Know which conditions are suitable for screening
  3. Know the various modalities of health screening for these conditions in women
Knowledge
Topics to be covered
  1. Important health issues in Singaporean women
    1. Cancers
      1. Breast – most common
      2. Ovarian
      3. Cervical
      4. Endometrial
    2. Menopause associated osteoporosis
  2. History taking –
    1. Menstrual history, post-menopausal bleeding, HRT use
    2. Medical history – DM, hypertension, corticosteroid use, fragility fractures
    3. Family history esp. of relevant cancers, fragility fractures.
    4. Social history to identify high risks
  3. Examination –
    1. General – including BP
    2. Breast – clinical breast examination
    3. Abdominal – for ascites and masses
    4. Pelvic – VE and Pap smear

 

Recommendations for screening

Breast Cancer – most common cancer in women

  1. Changing age pattern – peak incidence now 55-59 years.
    1. Asymptomatic women, with no increase in the risk of breast cancer
      1. Below 40 years – No need for mammogram, or any other imaging modality for screening
      2. 40-49 years – Annual mammogram,
      3. 50-64 years – 2 yearly mammogram,
      4. 65 years – Screening mammography may be less beneficial. If individual screening is performed, it should be at two- yearly intervals.
    2. Women on HRT
      1. Women on conventional HRT have a slightly increased risk of breast cancer
      2. They should have regular screening mammography
      3. Those aged 40-49 should be screened annually
      4. Those aged 50-65 every 2 years for up to 5 years after cessation
    3. Women who are at very high risk of breast cancer by virtue of being a BRCA gene carrier, or a very strong first-degree family history of breast cancer, should perform
      1. Monthly breast self examination
      2. 6-monthly clinical breast examination and ultrasound
      3. Annual mammography
    4. Screening should start 5 years before the age of onset of breast cancer in the youngest family member.

 

Cervical cancer

Fifth most common cancer in Singapore women

Second most common gynaecological cancer in Singapore

  1. Know the high risk groups for development of cervical neoplasia
    1. Screening : Pap smear
      1. Sexually active – from the age of 25 years; discharged from screening at 65 years of age if the smear taken at 65 years is negative and the previous smears were negative
      2. Women who have never had sexual intercourse need not have Pap smear screening.
      3. Frequency of screening: Pap smear screening should be performed at least every 3 years
      4. The mean sensitivity of the Pap smear as a screening test is 58% while the mean specificity is 69%

 

Endometrial cancer

Seventh most common cancer in Singapore women

Third most common gynaecological cancer in Singapore

  1. Know the high risk groups for development of endometrial cancer – Hereditary non polyposis colonic cancer.
  2. Early evaluation of post-menopausal bleeding with judicious use of hysteroscopy and endometrial biopsy is important for the early detection of endometrial cancer
  3. Screening
    1. How to manage thickened ET on ultrasound
    2. There is no indication that screening is warranted for women who are not at high risk for endometrial cancer

 

Ovarian cancer

Fourth most common cancer in Singaporean women

Most common gynaecological cancer in Singapore

  1. Know the high risk groups for the development of ovarian cancer
  2. Screening
    1. Routine population screening for ovarian cancer by ultrasound, the measurement of tumour markers, or pelvic examination is not recommended.
    2. There is insufficient evidence to recommend screening of asymptomatic women at increased risk of developing ovarian cancer.
  3. Osteoporosis
    1. See Menopause module
Key figures & facts
  1. Incidence of the various cancers in Singapore women: Crude rate / ASR* per 100,000 per year
    1. Breast : 67.3 / 54.9
    2. Ovarian : 12.9 / 11.0
    3. Cervical : 12.6 / 10.6
    4. Endometrial : 11.0 / 9.4

* Age Standardised Rate (Singapore Cancer Registry)

Skills
Procedures to be observed/taught
  1. How to perform
    1. Clinical breast examination
    2. Pap smear
    3. Endometrial sampling
  2. How to interpret
    1. Pap smear report
    2. Pipelle sampling report
    3. Mammogram
    4. Tumor marker panel report
    5. BMD report
Attitudes
Professionalism
  1. Duty to report notifiable disease
Ethics
Communication
  1. Ability to convey abnormal Pap smear report
References
Compulsory reading
  1. MOH clinical practice guidelines on Health screening: Chapters on Breast, Ovarian, Cervical, Endometrial cancers, Osteoporosis
Suggested reading
  1. Singapore Cancer Registry – available online at   www.hpb.gov.sg
Problem Puberty and Adolescence
Goals
  1. To understand the normal physiological and endocrinological changes that occur during puberty and adolescence
  2. To understand common disorders that occur in puberty and adolescence and management of these disorders
Knowledge
Topics to be covered
  1. Definitions
    1. Adolescence – period of physical, mental, emotional, social and sexual maturation;10-20 years for girls
    2. Puberty – refers only to physical growth, occurring from 10-16 years for girls
  2. Physiology of Normal Puberty
    1. Definition and sequences of puberty:
      1. Pubertal growth spurt
      2. Gonadarche (activation of H-P-O axis)
      3. Clinically presented as Thelarche, Pubarche and Menarche
      4. Peak of skeletal growth/maturation, occurs from 12-16 years for girls
      5. Standards for Singapore girls for body growth, breast and pubic hair development, menarche, US ovarian growth/volume
  3. Abnormal Conditions
    1. Precocious Puberty:
      1. Recognise signs, basic investigations, team up with paediatric endocrinologist for treatment
  4. Pubertal Amenorrhoea:
    1. Primary Amenorrhoea (Delayed puberty):
      1. Definition, causes, basic investigations, treatment
      2. Important: 40% will have life time
      3. Consequences: infertility, dependence on
      4. Medications, operative procedures
      5. Turners Syndrome, Androgen Insensitivity Syndrome
    2. Secondary Amenorrhoea
      1. Causes, basic investigations and management
      2. 26% will turn on into PCOS important connection
    3. Hyperandrogenism: PCOS, Hirsutism, Acne
    4. Juvenile DUB:
      1. Basic investigations and management
      2. Important 1/4 will become permanent PCOS
      3. Early assessment of menstrual aberrations and when needed treatment
    5. Dysmenorrhoea:
      1. Causes, investigations and treatment
    6. Psychosexual Development and Sexuality of Adolescents:
      1. Sex education, contraception, teenage abortions and childbearing, sexual assault
    7. Eating Disorders:
      1. Anorexia, bulimia, obesity
Key figures & facts
  1. Normal age and sequences of puberty: pubertal growth spurt, Thelarche, Pubarche, Menarche
  2. Majority of menstrual disorders in adulthood, PCOS, hirsutism and impaired reproductive performances have their origins in adolescence
  3. Juvenile DUB Important 1/4 will become permanent PCOS (Ref)
Skills
Procedures to be observed/taught
  1. Good history taking, assessment of body height and weight, staging of breast and pubic hair development
  2. Instruct patients on use of menstrual calendar
Attitudes
Professionalism
  1. A lot of patients with high respect for privacy and shyness of young patients
Ethics
  1. Promote co-operation with parents / partners
Communication
  1. Female doctor more acceptable for this age group of patients
  2. Be aware of psychosexual problems and eating disorders in dealing with young girls
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Gynaecological problems in childhood and adolescence. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 327-330
Suggested reading
  1. Hacker NF, Moore JG, Gambone JC, ed. Puberty and Disorders of Pubertal Development. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 345-354.
  2. Hacker NF, Moore JG, Gambone JC, eds. Family and Intimate Partner Violence, and Sexual Assault. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 322-331.
  3. Clinical approach to Adolescent Gynaecology, Chapters 2, 7, 9, 10, 13

 

General Gynaecology

Problem Vaginal Discharge and Pruritus
Goals
  1. To understand the approach to the diagnosis and management of abnormal vaginal discharge and pruritus
Knowledge
Topics to be covered
  1. Making the diagnosis
    1. First episode or recurrent
    2. Previous treatment
    3. Characteristic of discharge, including relationship to menses
    4. Risk factors
    5. Investigations
  2. Management
    1. Symptomatic therapy
    2. Definitive therapy
    3. Personal hygiene
    4. Psychological aspects
    5. Exclude malignancy
    6. Treatment of partner/contacts
  3. Vulvovaginitis
  4. Cervical infections
  5. Urethritis
  6. Upper genital tract infections
    1. Generally present with discharge, fever and pain
Key figures & facts
  1. Should know causative organism for the various infections
Skills
Procedures to be observed/taught
  1. To do pelvic exam:
    1. Speculum examination
    2. Bimanual examination
  2. To observe specimen collection
Attitudes
Professionalism
  1. Be able to confidently assess and effectively manage vaginal discharge and pruritus
Ethics
  1. Maintain patient confidentiality
  2. Maintain a non-judgemental approach when eliciting sexual history and practices
  3. Contact tracing
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Infections of the genital tract. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 261-272.
Problem Post Coital & Postmenopausal Bleeding
Goals
  1. To know the appropriate management of women presenting with postcoital and postmenopausal vaginal bleeding
  2. To know the current management of endometrial cancer
Knowledge
Topics to be covered
  1. Approach to PCB and PMB
    1. High risk situations
    2. Evaluation
  2. Postcoital bleeding
    1. Vaginal
    2. Cervical
  3. Postmenopausal bleeding
    1. Vulval
    2. Vaginal
    3. Cervical
    4. Endometrial
      1. US for ET
      2. Endometrial sampling with Pipelle
      3. Hysteroscopy
      4. D&C
    5. Endometrial cancer
      1. Features
      2. Screening
      3. Diagnosis
      4. Staging
      5. Management
      6. Follow up
      7. Prognosis
Key figures & facts
  1. Evaluation of postcoital bleeding should involve examination of the entire lower tract covering the vulva, urethra, vagina and cervix
  2. Evaluation of postmenopausal bleeding should include the lower tract and endometrium
  3. Postmenopausal bleeding is cancer until proven otherwise (commonest cause - atrophic vaginitis)
  4. Trauma / lacerations should prompt evaluation for sexual assault, domestic violence, at risk sexual practices
  5. Sores / ulcers should prompt evaluation for
    1. STDs (eg, HSV, syphilis, LGV)
    2. Vulval malignancies: consider biopsy of no obvious infectious cause
Skills
Procedures to be observed/taught
  1. Pelvic exam:
    1. Speculum examination
    2. Bimanual examination
  2. To observe:
    1. Colposcopic examination
    2. Hysteroscopy D&C
    3. Outpt endometrial sampling (Pipelle)
Attitudes
Professionalism
  1. Be able to confidently assess and effectively manage postcoital and postmenopausal bleeding
Ethics
Communication
  1. Breaking bad news
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Uterine Corpus Cancer. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004 ; 428-434.
Suggested reading
  1. Llewellyn-Jones D, ed. Premalignant and malignant conditions of the female genital tract. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 297-310.
  2. Hacker NF, Moore JG, Gambone JC, eds. Principles of Cancer Therapy. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 393-401.
Problem Abnormal Cervical Smear
Goals
  1. To understand what cervical smear results mean
  2. To appropriately manage women with abnormal cervical smears
  3. To know the current management of cervical cancer
Knowledge
Topics to be covered
  1. Anatomy of the Cervix
    1. Origin of old SCJ
    2. New SCJ
    3. Transformation zone
    4. Process of columno-squamo metaplasia
  2. Concept of a Screening vs Diagnosis
    1. Concept of cytology and histology
  3. Morphological Characteristics of Dysplastic Cells
    1. Brief outline
  4. Different Grading Systems for Cervical Dysplasia
    1. Classic Pap (Class system)
    2. CIN
    3. Bethesda
  5. Concept of Colposcopic Triage
    1. Satisfactory colposcopy
    2. Colposcopically directed biopsy
    3. Colposcopic features of dysplasia and invasive malignancy
  6. Treatment of Dysplasia or Preinvasive Lesions
    1. Ablative techniques
    2. Resective techniques
    3. Indications for each
  7. HPV DNA Typing in the Triage of Abnormal Cervical Smears
  8. Cervical cancer
    1. Features, etc
    2. Prevention – vaccine, behaviour
Key figures & facts
  1. 90% of dysplastic lesions arise in the transformation zone
  2. 90% of cancer is associated with high-risk HPV types
  3. But only 5% of HPV positive patients develop cancer
  4. Cervical cancer – 2nd commonest gynae cancer
Skills
Procedures to be observed/taught
  1. Speculum examination
  2. Pap smear
  3. Observe colposcopy & colposcopic therapies
Attitudes
Professionalism
  1. Screen women appropriately
  2. Emphasise preventive medicine
Ethics
Communication
  1. Be able to explain abnormal Pap smear results clearly
  2. Be able to clearly outline natural history of cervical dysplasia for patient education
  3. Be able to educate women on natural history of HPV
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Cervical Dysplasia and Cancer. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 402-411.
Suggested reading
  1. Llewellyn-Jones D, ed. Premalignant and malignant conditions of the female genital tract. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier 2005; 297-310.
  2. Hacker NF, Moore JG, Gambone JC, ed. Principles of Cancer Therapy. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 393-401.
Problem Pelvi-abdominal Masses
Goals
  1. To approach the diagnosis of a pelvi-abdominal mass sensibly
  2. To be able to discuss the appropriate management of :
    1. Uterine fibroids
    2. Ovarian tumours
Knowledge
Topics to be covered
  1. Differential diagnoses of pelvi-abdominal masses
    1. Gastrointestinal etiologies
    2. Urologic etiologies
    3. Retroperitoneal masses
  2. Gynaecologic etiologies
    1. Uterine masses
    2. Ovarian masses
    3. Adnexal masses
  3. Initial evaluation of pelvi-abdominal masses
    1. Physical examination
    2. Diagnostic imaging
    3. Serum tumour markers
  4. Features suggestive of malignancy in adnexal masses
  5. Management of gynaecologic masses
    1. Uterine fibroids
    2. Ovarian benign tumours
      1. Asymptomatic cysts
      2. Acute presentation and ovarian accidents
    3. Ovarian cancer
      1. Principles of
        • Screening
        • Diagnosis
        • Staging
        • Treatment
        • Follow-up
        • Prognosis
Key figures & facts
  1. All women of reproductive age presenting with a pelvi-abdominal mass should have a pregnancy test
  2. All women presenting with a pelvi-abdominal mass, especially those with bowel symptoms must be investigated for a GI primary tumour
  3. Most common gynaecological etiology for a pelvi-abdominal mass is uterine fibroids
  4. Most common gynaecological cancer in Singapore – ovary (11 per 100,000)
  5. Most common stage of presentation for ovarian cancer – Stage 3/4
  6. Most common type of ovarian cancer:
    1. Epithelia: ~80%
    2. Others: germ cell tumors and sex cord tumors
  7. Ovarian cancers are staged surgico-pathologically
  8. Ovarian cancer treatment is usually a combination of surgery and chemotherapy
Skills
Procedures to be observed/taught
  1. Physical examination:
    1. Supraclavicular nodes
    2. Breast
    3. Abdomen
    4. Pelvic
    5. Rectovaginal examination
  2. To observe:
    1. Abdominal hysterectomy
    2. Laparotomy for abdomino-pelvic mass
Attitudes
Professionalism
  1. Not to miss pelvi-abdominal masses on routine examination of women
  2. Referral and co-management with sub-specialists when appropriate
Ethics
  1. Maintain patient confidentiality
Communication
  1. Be empathetic and cognizant of patient anxiety when found to have a pelvi-abdominal mass
  2. Be able to clearly convey the differential diagnoses of a pelvi-abdominal mass
  3. Be able to communicate the investigation of a pelvi-abdominal mass
  4. Be able to convey the findings of investigations in a simple, clear manner
  5. Be able to counsel patients effectively and prepare them for specialist management of a pelvi-abdominal mass
References
Compulsory reading
  1. Llewellyn-Jones D, Benign tumours, cysts and malformations of the genital tract. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 285-296.
  2. Hacker NF, Moore JG, Gambone JC, eds. Ovarian Cancer, Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 412-419.
Suggested reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Principles of Cancer Therapy. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 393-401.
Problem Genital Prolapse and Urinary Problems
Goals
  1. To understand the health impact of pelvic organ prolapse and urinary incontinence.
  2. To be able to elicit the symptoms of pelvic organ prolapse, recognise and counsel appropriately the options of treatment.
  3. To understand the different types of urinary incontinence and the approaches to management.
Knowledge
Topics to be covered
  1. Basics
    1. Brief outlines of:
      1. Normal pelvic anatomy and support
      2. Physiology of control of urinary and faecal continence
  2. Pelvic Organ Prolapse
    1. Types of pelvic organ prolapse
    2. Etiology of pelvic organ prolapse
    3. How to grade genital prolapse (anterior, superior and posterior compartments) using the Baden Walker Halfway system
  3. Principles/How to Manage Genital Prolapse
    1. Symptoms are the main indication for treatment
      1. Non-surgical
        • Pessaries
        • PFE
      2. Surgical treatment
        • Anterior vaginal repair
        • Posterior vaginal repair
        • Enterocoele repair
        • Manchester operation
        • Vaginal hysterectomy
  4. Stress Incontinence
    1. Etiology of stress incontinence
    2. How to evaluate a woman with stress incontinence:
      1. History
      2. Demonstrate stress incontinence
      3. Basic investigations
      4. Refer for urodynamic investigations
    3. Understanding the various treatment modalities of stress incontinence:
      1. Pelvic floor exercises
        • Woman with moderate stress incontinence should undergo a programme of pelvic floor exercises (3-6 months) before considering surgical treatment
      2. Brief outline of:
        1. Non-surgical management
        2. Surgical management
          • Burch colposuspension
          • BN suspension
  5. Urge Incontinence
  6. Understanding the concept of the overactive bladder
  7. Evaluating a woman with overactive bladder:
    1. Bladder diary
    2. Neurological examination
    3. Urodynamic inx
  8. Know the various treatment modalities:
    1. Fluid management
    2. Bladder re-training
    3. Pharmacotherapy
Key figures & facts
  1. Definition (according to the International Continence Society 2002)
    1. Urgency is the complaint of a sudden compelling desire to pass urine which is difficult to defer.
    2. Urinary incontinence is the complaint of any involuntary leakage of urine.
    3. Stress urinary incontinence is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing.
    4. Urge urinary incontinence is the complaint of involuntary leakage accompanied by or immediately preceded by urgency.
    5. Mixed urinary incontinence is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing.
    6. Overflow incontinence is any involuntary loss of urine associated with over-distension of the bladder.
  2. Grading genital prolapse by the Baden-Walker Halfway system.
    1. Vaginal/Uterine prolapse:
      1. 0 = Normal
      2. 1 = descent to half way to the hymen
      3. 2 = progression to the hymenal
      4. 3 = progression half way through the hymen
      5. 4 = maximal progression through hymen
    2. Enterocoele:
      1. 0 = normal
      2. 1 = herniation to 1/4 of distance towards the hymen
      3. 2 = herniation to 1/2 of distance towards the hymen
      4. 3 = herniation to 3/4 of distance towards the hymen
      5. 4 = herniation to the hymen
Skills
Procedures to be observed/taught
  1. Ability to assess the severity of stress leak with cough impulses in the supine position with a full bladder
  2. Ability to detect the presence of urogenital prolapse by inspection for introital gaping and uterovaginal bulging on abdominal straining/valsalva
  3. Knowing how to use a Sims speculum is not essential for undergraduates
Attitudes
Professionalism
  1. Dysfunction affecting quality of life should not be attributed to aging and brushed aside.
Ethics
  1. NA
Communication
  1. Available options of management are to be discussed, emphasising that each option has its limitations and complications.
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Uterovaginal displacements, damage and prolapse. Fundamentals of Obstetrics and Gynaeclology, 8th ed. Philadelphia: Elsevier; 2005: 311-316.
  2. Llewellyn-Jones D, ed.The urinary tract and its relationship to gynaecology. Fundamentals of Obstetrics and Gynaeclology, 8th ed. Elsevier; 2005: 317-322.
Problem PID and STD
Goals
  1. To be able to diagnose and manage PID and STD
Knowledge
Topics to be covered
  1. STDs that affect the genital tract
    1. Vulva: herpes, syphilis
    2. Vagina: trichomonas
    3. Cervix: chlamydia, GC
    4. Tubal: ascending/superimposed infection
    5. Must know details of:
      1. Microbiology
      2. Presentation
      3. Signs
      4. Treatment
      5. Screening
  2. Acute PID
    1. Features
    2. Causes
    3. Diagnosis
      1. Appropriate collection and culture/transport media
    4. Management
      1. Outpatient
      2. Inpatient
  3. Management of sepsis
    1. What symptoms and signs to elicit
    2. Resuscitation, investigations
    3. Management: medical and surgical
  4. Management of chronic PID / STD
    1. Possible sequelae: pain, infertility, ectopic
    2. Implications in pregnancy
    3. Treatment modalities
  5. Able to answer FAQs
    1. Mode of transmission
    2. Prevention
    3. Importance / sequelae of PID
Key figures & facts
  1. Incidence of PID in UK: about 1 in 200
  2. Majority of PID caused by chlamydia or GC
  3. After one episode of acute PID, the risk of ectopic pregnancy and infertility is about 10% – 15%
Skills
Procedures to be observed/taught
  1. Observe how to perform HVS/ endocervical swab
Attitudes
Professionalism
  1. Duty to report notifiable disease
Ethics
  1. Advice regarding need for contact tracing / treatment of sexual partner
Communication
  1. Able to inform patient adequately on the risks of STDs / prevention methods
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Infections of the genital tract. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005: 261-272
Suggested reading
  1. Simms I and Stephenson JM. Pelvic inflammatory disease epidemiology: what do we know and what do we need to know? Sex Transm Inf, Apr 2000; 76: 80-87. (Available free online)
Problem Acute Abdomen in Gynaecology
Goals
  1. To be aware of the common causes of acute abdomen in women
  2. To have a sound approach to the management of acute abdomen
Knowledge
Topics to be covered
  1. Acute abdomen in gynaecology:
    1. Only broad principles required generally
    2. Differential diagnosis
    3. Must know details of:
      1. Gynaecological and non-gynaecological causes (PID will be covered separately in Q&A)
      2. Presentation/ symptomatology
      3. Management principles
  2. How to diagnose and manage ectopic pregnancies
    1. Clinical presentation
    2. Resuscitation and stabilisation if required
    3. Role of ultrasound, quantitative hCG
    4. Laparotomy vs laparoscopy (vs medical mx – non acute)
    5. Salpingectomy vs salpingostomy
    6. Post-operative surveillance
    7. Long term sequelae
  3. How to diagnose and manage adnexal pathology
    1. Role of ultrasound
    2. Role of laparoscopy (diagnostic)
    3. Cystectomy vs oophorectomy
  4. Able to manage post-operative care
Key figures & facts
  1. Incidence of ectopic pregnancy: 1%
Skills
Procedures to be observed/taught
  1. How to examine a gynae patient:
    1. Abdominal signs
    2. Pelvic signs
  2. Video on laparoscopic management of ectopic pregnancy/ adnexal mass
Attitudes
Professionalism
  1. High index of suspicion required to exclude ectopic pregnancy, one of the main causes of maternal mortality
  2. Early referral for specialist management
Ethics
  1. Confidentiality issues
Communication
  1. Counselling women with suspected ectopic pregnancies
  2. Counselling with regard to surgical management
  3. Able to counsel about appropriate family planning as well as sequelae of ectopic pregnancy
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Ectopic Pregnancy. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 290-297.
Suggested reading
  1. Royal College of Obstetricians and Gynaecologists. The management of tubal pregnancy, Guideline No. 21. London: RCOG Press; 2004.
Problem Office Procedures in Gynaecology
Goals
  1. To impart knowledge and skills on the type of outpatient gynaecological procedures that are commonly performed
Knowledge
Topics to be covered
  1. Endometrial Sampling
    1. broad principles
    2. recognise instruments used for endometrial sampling and how they work
    3. must know indications, advantages, disadvantages / limitations and other options available
      1. Procedure and instrument
      2. Indications
      3. Advantages
      4. Disadvantages, problems and limitations
      5. Alternative / complementary procedures
  2. Hysteroscopy
    1. broad principles
    2. must know indications (both diagnostic and therapeutic uses), advantages, disadvantages / limitations as well as other options available
    3. able to recognise instrument as well as hysteroscopic view of uterine cavity
      1. Procedure and equipment
      2. Pre-requisites
      3. Indications
      4. Contraindications
      5. Advantages
      6. Disadvantages, problems and limitations
      7. Alternative/ complementary procedures
  3. IUCD / Mirena IUS Insertion and Removal
    see module on Family Planning
  4. Implanon Insertion and Removal
    see module on Family Planning
  5. Pap Smear
    see module on Abnormal Cervical Smear
  6. Colposcopy +/- punch biopsy / LEEP / Endocervical Curettage / PAP
    see module on Abnormal Cervical Smear
Key figures & facts
  1. Pipelle endometrial sampling
    1. endometrial surface area sampled 5-15%
    2. detection rates for endometrial cancer 80% (higher in postmenopausal)
    3. specificity 98% to 100%
    4. Insufficient or no sample <5%
  2. D&C
    1. endometrial surface sampled 50%
Skills
Procedures to be observed/taught
  1. To do
    1. Pap smear
  2. To observe
    1. Outpatient hysteroscopic procedure
    2. Endometrial sampling procedure
    3. IUCD/ Mirena IUS insertion and removal
    4. Implanon insertion and removal
    5. Colposcopy +/- punch biopsy / LEEP / endocervical curettage
Attitudes
Professionalism
  1. Appreciate the need to exclude endometrial malignancy in women with abnormal vaginal bleeding with risk factors.
Ethics
  1. Consent for procedures
Communication
  1. Counselling involved before proceeding with the office procedure, including the possible problems, limitations, chance of failure and the potential need for further investigations.
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, ed. Gynecologic Procedures. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 332-344.
Suggested reading
  1.  Dijkhuizen FP, Mol BW, Brolmann HA, Heintz AP The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis. Cancer. 2000 Oct 15;89(8):1765-72.

 

Pregnancy

Problem Routine Antenatal Care
Goals
  1. To provide antenatal care for a mother that will result in a good outcome
  2. To be aware of risk factors in pregnancy and to identify high risk pregnancies
  3. To prepare mothers for labour, delivery and lactation
Knowledge
Topics to be covered
  1. First Trimester
    1. Siting of antenatal care
    2. Diagnosis of pregnancy (signs and symptoms)
    3. Common complications
      1. Miscarriage
      2. Ectopic pregnancy
      3. Hyperemesis
    4. Components of the routine antenatal visit
      1. Blood pressure
      2. Urine dipstix
      3. Weight
      4. Abdominal examination
    5. Routine Investigations
      1. Dating the pregnancy
      2. Maternal screening
      3. Antenatal foetal screening
    6. Initial counselling
    7. Nutrition
    8. Folate supplementation
    9. Common minor complaints
    10. Identification of high risk mothers and appropriate referral / co-management
  2. Second Trimester
    1. Assessing foetal movement
    2. Foetal anomaly scan (refer Prenatal Screening module)
    3. Early growth scan for selected patients
    4. Identification of GDM, PIH, other complications
    5. Antenatal classes
    6. Discussion on breastfeeding
  3. Third Trimester
    1. Assessing foetal growth and well-being
    2. Counselling
      1. Timing and mode of delivery
      2. How to recognise onset of labour and what to do when labour begins
      3. Labour analgesia
      4. Reinforce benefits of breastfeeding
Key figures & facts
  1. Miscarriage rate
    1. 10%-15% in 1st trimester (clinical pregnancy)
    2. 1%-2% in 2nd trimester
  2. Ectopic pregnancy rate
    1. ~1%
Skills
Procedures to be observed/taught
  1. Obstetric abdominal examination
    1. Palpation of foetal poles
    2. Detecting foetal heartbeat
  2. Recognition of labour onset
    1. Symptoms and signs
Attitudes
Professionalism
  1. Respect for mother's choices regarding labour and delivery
  2. Pregnancy is a physiological state; to work with the mother to optimise the experience of pregnancy and childbirth
Ethics
  1. Offer of antenatal screening
Communication
  1. Discuss minor problems, common complications that may occur at each trimester
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Antenatal Care. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 39-54.
Problem Bleeding in Early Pregnancy
Goals
  1. To be able to make a diagnosis for women presenting with bleeding in early pregnancy
  2. To know the initial management of women presenting with bleeding in early pregnancy
Knowledge
Topics to be covered
  1. Aetiology of spontaneous abortion
    1. Only broad principles required
  2. How to diagnose common types of spontaneous abortion:
    1. Threatened miscarriage
    2. Inevitable miscarriage
    3. Incomplete miscarriage
    4. Complete miscarriage
    5. Missed abortion
    6. Ectopic pregnancy
  3. Management
    1. Immediate measures, including resuscitative measures
    2. Confirm diagnosis
    3. Definitive treatment
  4. Follow-up of women with spontaneous abortion:
    1. Detection of immediate / delayed complications
    2. Psychological support
  5. Be aware that gestational trophoblastic disease usually presents as bleeding in early pregnancy
    1. Gestational trophoblastic disease and tumours
    2. Diagnosis
    3. Management of molar pregnancies
    4. Management of gestational trophoblastic tumours
Key figures & facts
  1. 30% of mothers present with bleeding in early pregnancy
  2. 15% of clinically diagnosed pregnancies end as an abortion
  3. Foetal abnormalities account for up to 80% of cases of spontaneous abortions
Skills
Procedures to be observed/taught
  1. How to perform a gynaecological examination
    1. General examination
    2. Abdominal examination
    3. Pelvic examination
Attitudes
Professionalism
  1. Be aware of need for grief management
  2. Counselling of women with suspected ectopic pregnancy with non-specific signs and symptoms
Ethics
  1. Religious issue regarding disposal of abortus
Communication
  1. Check for psychological problems following spontaneous abortion
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Miscarriage and abortion. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005: 103-110.
  2. Hacker NF, Moore JG, Gambone JC, eds. Gestational Trophoblastic Neoplasia. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 435-442.
Problem Recurrent Pregnancy Loss
Goals
  1. To understand the common causes of pregnancy loss
  2. To have an evidence-based approach to the management of recurrent pregnancy loss
  3. To be aware of the need and resources available to help parents cope with their grief
Knowledge
Topics to be covered
  1. Recurrent miscarriage is defined as the loss of three or more pregnancies
  2. Be aware that recurrent miscarriage is a heterogeneous condition that has many possible causes; more than one contributory factor may underline the recurrent pregnancy losses
  3. Causes of recurrent pregnancy loss include:
    1. genetic abnormalities, hormonal and metabolic disorders, uterine anatomic abnormalities, infectious causes, environmental and occupational factors, thrombophilia and autoimmune disorders in recurrent pregnancy loss
  4. Differentiate early from midtrimester pregnancy loss
  5. Investigation and Management
    1. Testing for parental balanced chromosome abnormalities
    2. Pelvic ultrasound to assess uterine anatomy and morphology
    3. Hysteroscopic evaluation and resection of uterine septum
    4. Testing for lupus anticoagulant and anticardiolipin antibodies and treating with heparin and low-dose aspirin if two positive tests at least 6 weeks apart
  6. The following interventions are not recommended:
    1. Cultures for bacteria or viruses
    2. Routine screening for occult diabetes and thyroid disease with OGTT and TFT in asymptomatic women presenting with recurrent miscarriage is uninformative
    3. Tests for antibodies to infectious agents, antinuclear antibodies, paternal human leukocyte antigen status, and maternal antipaternal antibodies
    4. Mononuclear cell (leukocyte) immunisation and intravenous immune globulin (IVIG)
    5. Luteal phase support with progesterone (no current evidence to support this although it is still widely practised)
Key figures & facts
  1. Recurrent miscarriage is a distressing problem that affects 1% of all women
  2. A definitive cause of recurrent pregnancy loss can be established in only 50% of the cases
  3. 2-4% of couples with RPL have a major chromosomal rearrangement, usually a balanced translocation
  4. RPL related to APS can achieve a live birth rate of 70-85% if treatment with low dose aspirin + heparin
  5. Women with unexplained recurrent miscarriage have an excellent prognosis for future pregnancy outcome without pharmacological intervention if offered supportive care
Skills
Procedures to be observed/taught
  1. Communication
Attitudes
Professionalism
  1. Investigate and manage recurrent pregnancy loss using an evidence-based approach
  2. Grief for a pregnancy loss requires support, counselling, and follow up
Ethics
  1. Interventions at the limits of foetal viability
Communication
  1. Breaking bad news
  2. Dealing with grieving parents
  3. Be aware that RPL is one of the most frustrating and difficult areas in reproductive medicine because the etiology is often unknown and there are few evidence-based diagnostic and treatment strategies
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Miscarriage and abortion. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 103-110.
Suggested reading
  1. ACOG Releases Recommendations for Management of Recurrent Miscarriage.
  2. RCOG Green Top Guideline: The Investigation and Treatment of Couples with Recurrent Miscarriage (17) – May 2003 http://www.rcog.org.uk/index.asp?PageID=530
Problem Prenatal Screening and Diagnosis
Goals
  1. Know the difference between screening and diagnostic tests
  2. Know the appropriate screening and diagnostic tests for chromosomal, monogenetic and multifactorial disorders
  3. Know the appropriate actions and options available to couples with affected foetuses
Knowledge
Topics to be covered
  1. Invasive diagnostic testing for chromosomal and single gene disorders:
    1. Amniocentesis
    2. Chorion villus sampling
    3. Fetal blood sampling
  2. Non-invasive screening for multifactorial disorders (structural malformations) using midtrimester ultrasonongraphy
  3. Non-invasive screening for chromosomal disorders using:
    1. Nuchal Translucency
    2. Combined Test
    3. Maternal Serum Screening
  4. Genetics and prenatal diagnosis of thalassaemia as a model of single gene disorders in the local population
  5. Some discussion on newer rapid molecular diagnostic testing using fluorescence in situ hybridisation (FISH) and polymerase chain reaction (PCR)
Key figures & facts
  1. Without prenatal screening/diagnosis, 1 in 50 babies are born with serious physical or mental handicap, and as many as 1 in 30 with some form of congenital malformation
  2. The traditional method for screening for trisomy 21 using maternal age has a sensitivity of 30% at a 5% false positive rate
  3. Maternal serum screening (combined with maternal age) has a sensitivity of up to 70% at a 5% false positive rate
  4. Fetal Nuchal Translucency (NT, combined with maternal age) has a sensitivity of 80% at a 5% false positive rate
  5. Fetal Nuchal Translucency and maternal serum free beta-hCG and PAPP-A (combined with maternal age) has a sensitivity of 90% at a 5% false positive rate
  6. Risk of miscarriage following amniocentesis is 0.5% greater than the background rate
  7. Risk of miscarriage following CVS is 1% greater than the background rate
  8. Midtrimester ultrasound is best for detecting anomalies of the central nervous system, and less reliable for detecting cardiac defects (overall 60-70% of abnormalities detected – Eurofetus study)
  9. Use of folic acid 5 mg daily 12 weeks before till 12 weeks after conception reduces the risk of neural tube defects in the foetus.
Skills
Procedures to be observed/taught
  1. Discuss the need for prenatal screening
Attitudes
Professionalism
  1. Every mother should be offered prenatal diagnosis
  2. Adequate documentation of discussions with mother and partner
Ethics
  1. The management of an affected foetus when the affliction is:
    1. lethal
    2. treatable in utero
    3. treatable postnatally
Communication
  1. Explaining the difference between screening and diagnostic tests to the patient presenting in the first half of pregnancy.
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Antenatal Care (Antenatal Screening). Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 39-54.
References
  1. Avgidou, K. et al. (2005). Prospective first-trimester screening for trisomy 21 in 30,564 pregnancies. Am J Obstet Gynecol 192(6): 1761-7.
  2. Harper P. Practical genetic counselling (5th Edition). Oxford: Butterworth-Heinemann; 1998.
  3. Wald NJ, Law MR, Morris JK, Wald DS. Quantifying the effect of folic acid. Lancet 2001;358:2069-2073/
Problem Common Medical Disorders in Pregnancy I – Hypertension
Goals
  1. To understand the risks of hypertension during pregnancy
  2. To be able to differentiate between the different types of hypertension in pregnancy
  3. To know the principles of management of chronic hypertension, pre-eclampsia and eclampsia
Knowledge
Topics to be covered
  1. Definition and Classification of Hypertension in Pregnancy (Sibai 2003)
  2. Chronic Hypertension
    1. Causes – primary and secondary
    2. Problems
    3. Principles of management
  3. PIH (Gestational Hypertension) and Pre-eclampsia
    1. Why important (complications)
    2. Risk factors
    3. Basic etio-pathology
    4. Classification
      1. PIH – mild and severe
      2. Pre-eclampsia – mild and severe
      3. Impending eclampsia
      4. Eclampsia
      5. HELLP
    5. Principles of management
    6. Indications for
      1. Hospital admission
      2. Control of hypertension
      3. Monitoring mother
      4. Monitoring foetus
      5. Indication / timing / mode of delivery
  4. Eclampsia
    1. Clinical presentation
    2. Principles of management
Key figures & facts
  1. Incidence of PIH (gestational hypertension) 5%-8%
  2. Criteria for diagnosing
    1. PIH (gestational hypertension)
    2. Pre-eclampsia
    3. Severe pre-eclampsia
Skills
Procedures to be observed/taught
  1. Interpreting laboratory investigation results
    1. Significant Proteinuria (>0.3 G/24 hrs)
    2. Abnormal Creatinine Clearance (<50 ml/min)
    3. Abnormal Platelet count (<100 X 109/dl)
    4. Abnormal Transaminases
  2. Pre-eclampsia chart
Attitudes
Professionalism
  1. Timely referral for tertiary care
  2. Proper documentation of care in case notes and transfer records
Ethics
  1. Severe pre-eclampsia / eclampsia at borderline gestation (24-26 weeks) – "Mother comes first" principle
Communication
  1. Convincing an asymptomatic pre-eclampsia patient regarding admission
  2. Explaining the symptoms of worsening disease
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Hypertensive Disorders of Pregnancy. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 173-182.
Suggested reading
  1. Sibai, B. Diagnosis and Management of Gestational Hypertension and Pre-eclampsia. (High Risk Pregnancy Series: An Expert's View). Obstetrics & Gynecology, 2003; 102: 181-192.
Problem Common Medical Disorders in Pregnancy II – Anaemia in Pregnancy
Goals
  1. To understand the importance / risks of anaemia during pregnancy
  2. To be able to diagnose and treat common causes of anaemia during pregnancy
Knowledge
Topics to be covered
  1. Definition of Anaemia
  2. Common causes of anaemia during pregnancy
    1. Iron deficiency anaemia
    2. Folic acid deficiency anaemia
    3. Combined iron / folic acid deficiency anaemia
    4. Thalassaemia
  3. Risks of anaemia to mother and foetus
  4. Work-up of a mother with anaemia
    1. Haemoglobin
    2. Peripheral blood film
    3. MCV, MCHC
    4. Iron, ferritin, TIBC
    5. Folic acid
    6. Haemoglobin electrophoresis
    7. Stools of ova / occult blood
    8. Urine microscopy
  5. Management of iron deficiency anaemia
    1. Oral iron
    2. Parenteral iron
    3. Blood transfusion (Indications, Risks)
    4. Prophylactic iron supplementation
  6. Management of folate deficiency anaemia
    1. Oral folic acid
    2. Prophylactic folic acid supplementation
  7. Thalassaemia
    1. Screening (Why screening is important)
    2. Prenatal diagnosis of major thalassaemias
    3. Management
Key figures & facts
  1. Prevalence of anaemia – 15-20% of pregnancies (Singh et al 1998)
  2. Definition of Anaemia – < 11g/dL (WHO)
Skills
Procedures to be observed/taught
  1. Interpretation of FBC report
Attitudes
Professionalism
  1. N/A
Ethics
Communication
  1. Dietary advice for a patient with iron deficiency anaemia
  2. Counselling for prenatal diagnosis of haemoglobinopathy
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Cardiovascular, respiratory and haematological and neurological disorders in pregnancy. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 127-134.
Reference
  1. Singh K, Fong YF, Arulkumaran S. Anaemia in pregnancy--a cross-sectional study in Singapore. Eur J Clin Nutr. 1998 Jan; 52(1):65-70.

 

Problem Common Medical Disorders in Pregnancy II – Diabetes in Pregnancy
Goals
  1. To understand the importance / risks of pre-gestational (established) DM and gestational DM (GDM) during pregnancy
  2. To be able to screen and diagnose DM during pregnancy
  3. To know the principles of management of DM during pregnancy
Knowledge
Topics to be covered
  1. Pre-gestational Diabetes
    1. Effect of pregnancy on diabetic control
    2. Risks to the foetus
    3. Risks to the mother
  2. Gestational Diabetes
    1. Who to screen
    2. Screening tests
    3. How to diagnose (75g OGTT – fasting & 2 hours)
    4. Risks to the foetus
    5. Risks to the mother
  3. Management of pre-gestational DM/gestational DM during pregnancy
    1. What is good glycemic control (targets)
    2. Screening for maternal complications in pre-gestational DM
    3. Diet
    4. Insulin
    5. Monitoring of control
    6. Foetal assessment
  4. Timing of delivery
  5. Postpartum management
    1. For GDM, OGTT at 6 weeks
Key figures & facts
  1. Abnormal values for 75g OGTT (WHO criteria)
    1. Fasting blood glucose ≥ 7 mmol/l or 2-hr post-prandial blood glucose ≥ 7.8 mmol/l
  2. Targets of good glycemic control
    1. Blood glucose (fasting 4.4 -5.5 mmol/l, PP 5.5 -6.5 mmol/l)
    2. HbA1C (<6%)
Skills
Procedures to be observed/taught
  1. Interpretation of OGTT
  2. Interpretation of blood glucose profile
Attitudes
Professionalism
  1. Referral and co-management with endocrinologists
Ethics
  1. N/A
Communication
  1. Pre-pregnancy counselling for established diabetics
  2. Diet counselling for diabetics during pregnancy
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Common Medical and Surgical Conditions Complicating Pregnancy. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 191-218.
  2. Booklet on 'Healthy eating for diabetes' by NUH Dietetics
Problem Autoimmune disease, Cardiac disease, DVT
Goals
  1. To understand how pregnancy affects chronic medical conditions
  2. To understand how medical conditions affect pregnancy
Knowledge
Topics to be covered
  1. SLE
    1. Diagnostic criteria for SLE
    2. Symptomatology
    3. Effects of pregnancy on SLE
    4. Effects of SLE on pregnancy outcome
    5. Pre-pregnancy counseling
  2. Antiphospholipid syndrome
    1. Clinical features
    2. Laboratory criteria
    3. Effects on pregnancy
    4. Management
Key figures & facts
Skills
Procedures to be observed/taught
  1. To interpret SLE/APS investigation results
Attitudes
Professionalism
  1. Referral and co-management
Ethics
Communication
  1. Counseling about advisability of future pregnancy in women with severe disease
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC ed. Common Medical and Surgical Conditions Complicating Pregnancy. Essentials of Obstetrics and Gynaecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 191-218.

 

Problem Common Medical Disorders in Pregnancy V – Cardiac Disease
Knowledge
Topics to be covered
  1. Cardiovascular changes in pregnancy
  2. Etiology of cardiac disease – congenital, acquired
  3. NYHA grading of cardiac function
  4. Factors associated with high mortality – pulmonary hypertension, cyanosis, NYHA grade III and IV
  5. Pre-pregnancy counseling
  6. General principles of management
  7. Multidisciplinary approach
  8. Frequent consultations
  9. Low threshold for hospitalisation
  10. In labour – antibiotic prophylaxis, fluid management, choice of analgesia, cutting short the second stage of labour
Key figures & facts
Skills
Procedures to be observed/taught
  1. To look for the signs of cardiac failure
Attitudes
Professionalism
  1. Appropriate referral and co-management
Ethics
Communication
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, ed. Common Medical and Surgical Conditions Complicating Pregnancy. Essentials of Obstetrics and Gynaecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 191-218.

 

Problem Common Medical Disorders in Pregnancy VI – Deep Vein Thrombosis
Knowledge
Topics to be covered
  1. Pro-thrombotic physiological state
  2. Signs and symptoms of DVT
  3. Investigations: D-dimers, ultrasound Doppler, venography
  4. Prophylactic management- pharmacological and non-pharmacological, indications for prophylaxis
  5. Treatment
Key figures & facts
  1. Major cause of maternal mortality in developed countries
Skills
Procedures to be observed/taught
  1. To assess the signs of DVT
Attitudes
Professionalism
  1. Referral and co-management
Ethics
Communication
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, ed. Common Medical and Surgical Conditions Complicating Pregnancy. Essentials of Obstetrics and Gynaecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 191-218.
Problem
  1. The At-Risk Foetus
    1. Multiple Pregnancies
    2. Smaller than Dates
    3. Others including reduced foetal movement, poor obstetric history
Goals
  1. To identify the high risk foetus and refer for further management
  2. To understand the problems associated with multiple pregnancies / FGR / reduced foetal movement
Knowledge
Topics to be covered
  1. Identify the At-Risk Foetus
    1. Multiple Pregnancies
      1. Definition
      2. Causes
      3. Chorionicity and its effect on pregnancy outcome
      4. Making the diagnosis of multiple pregnancies – clinical / ultrasound
      5. Antenatal follow-up
        • Maternal complications
        • Fetal complications
        • Fetal surveillance
        • Counselling for mode of delivery
        • Surveillance for preterm labour
      6. Intrapartum / postpartum management
      7. Assisted twin deliveries
      8. Caesarean section
      9. Postpartum haemorrhage
      10. Neonatal problems
    2. Foetal Growth Restriction (FGR)
      1. Definition
      2. Risk factors for FGR
      3. Complications of FGR
      4. Diagnosis
      5. Foetal surveillance
      6. Timing and mode of delivery
    3. Others
      1. Reduced foetal movement
        • Monitoring of foetal movement
        • Routine
        • High risk
        • Foetal surveillance
      2. Poor obstetric history
        • Definition
        • Management
Key figures & facts
  1. Foetal Growth Restriction: any foetus that grows at less than its genetic growth potential (<10th centile AC or EFW at given gestational age)
Skills
Procedures to be observed/taught
  1. How to do abdominal examination in an obstetric patient to diagnose
    1. – ut < date FGR
    2. – ut > date multiple pregnancies
Attitudes
Professionalism
  1. To be vigilant for high risk pregnancies
  2. To make parents aware of long term morbidity for child as well as economic considerations
Ethics
  1. Borderline viability
  2. Choosing to conserve pregnancy at extremes of viability
Communication
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Abnormal Fetal Presentations. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 165-176.
  2. Llewellyn-Jones D, ed. The low-birthweight Infant. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 219-222.
Problem Previous Caesarean Section
Goals
  1. To understand the common indications for Caesarean Section (CS)
  2. To understand intrapartum complications due to previous CS
  3. To know how to monitor a patient with a previous CS during labour
Knowledge
Topics to be covered
  1. Indications for Elective CS
    1. Medical
      1. Maternal
      2. Foetal
    2. Social
  2. Common Causes of Emergency CS
    1. poor progress
    2. foetal distress
    3. malpresentation
    4. previous LSCS
    5. others
  3. Management of Patients with Previous CS
    1. Check details of previous caesarean section
    2. Must know details of
      1. onset of labour
      2. progress of labour
      3. stage of labour
    3. Causes
      1. recurrent
      2. non recurrent
    4. Types of uterine incision
      1. transverse lower segment
      2. lower vertical
      3. classical
    5. Post operative complications
    6. Antenatal management
    7. Counselling
    8. Options of management
      1. trial of scar
        • success rate for VBAC
        • risk of scar rupture
      2. elective LSCS
        • anaesthetic complications
        • surgical complications
    9. Decision making/discussion of mode of delivery by 36 weeks
    10. Exclude contraindication for vaginal delivery
  4. Intrapartum Management of VBAC
    1. How to induce labour safely
    2. How to manage labour
    3. How to recognise symptoms /signs of scar rupture
  5. Caesarean Section in General
    1. Elective vs Emergency CS
    2. How to diagnose and manage complications of caesarean section
    3. Postoperative management
Key figures & facts
  1. Current incidence of CS locally 20-25%
  2. Successful VBAC rates - 60%-80% of women who opt for trial of scar have successful outcomes
  3. Incidence of scar rupture:
    1. 1x previous LSCS (spontaneous labour): 0.5%
    2. 1x previous LSCS (IOL without prostaglandins): 0.8%
    3. 1x previous LSCS (IOL with prostaglandins): 2.5%
    4. 1x previous classical CS 4-9%
Skills
Procedures to be observed/taught
  1. Observe caesarean section
  2. Postoperative review of mother
    1. History/Examination
    2. Review of charts
Attitudes
Professionalism
  1. Non-directive counselling for mode of delivery
    1. Documentation of option of management in antenatal notes
  2. Intrapartum documentation
    1. Counselling for emergency CS
Ethics
  1. To have good indications for CS
  2. To counsel adequately regarding elective CS
Communication
  1. To keep mother/partner informed of plans and progress
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Obstetric Procedures. Essentials of Obstetrics & Gynecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 219-227.
Suggested reading
  1. Llewellyn-Jones D, ed. Obstetric operations. Fundamentals of Obstetrics and Gynaecology. 8th ed. Philadelphia: Elsevier; 2005;193-203.
References
  1. Guise JM, Berlin M et al. Safety of vaginal birth after cesarean: a systematic review. Obstetrics and Gynecology, 2004 Mar;103(3):420-9.
  2. Lydon-Rochelle M, Holt VL et al. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001 Jul 5;345(1):3-8.
Problem Common Obstetric Problems I – Antepartum Haemorrhage
Goals
  1. Know the differential diagnosis for antepartum haemorrhage
  2. Describe the management plan of a woman who presents with antepartum haemorrhage
Knowledge
Topics to be covered
  1. Definition of antepartum haemorrhage
  2. Differential diagnosis of antepartum haemorrhage
  3. Pathology of placenta praevia and abruptio placentae
  4. Clinical characteristics and diagnosis of placenta praevia and abruptio placentae
  5. Management of placenta praevia and abruptio placentae
  6. Minimal discussion of other causes of antepartum haemorrhage
Key figures & facts
  1. Definition of antepartum haemorrhage: bleeding from the genital tract after the 24th week of pregnancy
  2. Foetal viability occurs beyond 24 weeks' amenorrhoea
  3. Foetal lung maturity occurs beyond 34 weeks' amenorrhoea
  4. Prevalence of antepartum haemorrhage: 5% of all pregnancies
  5. Prevalence of placenta praevia: 0.5% of all deliveries
  6. Prevalence of abruptio placentae: 1% of all deliveries
  7. Diagnosis of placenta praevia relies on history and ultrasound examination (pelvic examination is not advisable until placenta praevia has been excluded)
  8. Diagnosis of abruptio placentae relies on history and clinical examination
  9. Placenta praevia classification
Attitudes
Professionalism
  1. Provide adequate information when transferring between hospitals
Ethics
  1. Occasionally the decision to resuscitate a neonate born at the threshold of viability poses an ethical dilemma
Communication
  1. Explain the management options to the mother, and discuss issues of prematurity
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Antepartum Haemorrhage. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 117-120.

 

Problem Common Obstetric Problems II – Malpresentation and Abnormal Lie
Goals
  1. Be aware of the different types of malpresentation and abnormal lie
  2. Be aware of the predisposing factors
  3. Be aware of the possible associated complications
Knowledge
Topics to be covered
  1. Malpresentation includes:
    1. Breech presentation
    2. Shoulder presentation
    3. Brow presentation
    4. Face presentation
  2. Abnormal Lie includes:
    1. Transverse lie
    2. Oblique lie
    3. Breech presentation
    4. Transverse or oblique lie
  3. Causes of breech presentation and abnormal lie
  4. Possible complications of malpresentation and abnormal lie
  5. Diagnosis of breech presentation and abnormal lie by clinical examination
  6. Investigation: Ultrasound scan
  7. Management of breech presentation and abnormal lie at term
  8. Be aware of the contraindications and possible complications of ECV
Key figures & facts
  1. Incidence of breech presentation varies with gestational age; the earlier the gestation, the higher the incidence:
    1. Incidence of breech presentation at 30 weeks: 15%
    2. Incidence of breech presentation at term: 3%
    3. Incidence of abnormal lie at term: 1%
Skills
Procedures to be observed/taught
  1. Abdominal palpation to diagnose breech presentation and abnormal lie
  2. External cephalic version
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Abnormal fetal presentations. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 165-176.

 

Labour & Puerperium

Problem Normal and Abnormal Labour
Goals
  1. To understand the three stages of labour, physiological processes and normal variants
  2. To recognise abnormal labour progress and their causes
  3. To understand the complications of abnormal labour progress, treatment and prevention
  4. To understand normal foetal heart patterns in labour and recognise foetal distress
Knowledge
Topics to be covered
  1. Normal & Abnormal Labour Progress
    1. Normal Labour
      1. 3 stages of normal labour
      2. Components of labour:
        • Passenger, passage, powers – inter-relationship
      3. Mechanism of labour:
        • Flexion, internal rotation, extension, restitution, external rotation
      4. Processes governing labour progress and deviation from norm
        • 1st stage, latent and active phases, variations in duration between primiparae and multiparae
        • 2nd stage of labour, variations in duration between primiparae and multiparae
        • 3rd stage of labour, normal process of placental separation and uterine contraction
    2. Abnormal Labour
      1. Recognition of prolonged 1st and 2nd stages
      2. Common causes of prolonged labour
      3. Complications:
        • maternal
        • foetal
    3. Management of Normal Labour
      1. Maternal support
      2. Foetal monitoring
      3. Active management of labour
      4. Partogram and monitoring of labour progress
    4. Management of Abnormal Labour
      1. 1st stage
      2. 2nd stage
      3. 3rd stage (see lecture on Puerperium)
  2. Foetal Distress
    1. The foetal cardiotocogram [CTG]
      1. Ultrasound signals indicate frequency of foetal heart valve activity
      2. Parameters – baseline, variability, accelerations, decelerations, contractions
    2. Electronic foetal monitoring during labour
      1. External monitoring
      2. Internal monitoring
      3. The primary aim of monitoring is to detect foetuses at risk for acidosis resulting from hypoxia, where timely intervention can prevent foetal neurological injury and death.
    3. Foetal heart rate patterns
      1. Normal and abnormal
      2. Sensitivity and specificity of CTG
    4. Anciliary tests
    5. To distinguish the well-compensated foetus from the decompensated foetus at risk for neurological injury/death
      1. Fetal scalp blood sampling
      2. Others (eg Fetal ECG (STAN)
    6. Management of intrapartum FHR abnormalities
      1. Determine if there is a reversible factor contributing to non-reassuring FHR
      2. Correction of factors and improvement of foetal oxygenation
      3. Determine if operative delivery is needed and the urgency for this to be carried out
Key figures & facts
  1. Pelvic diameters
  2. Foetal head diameters
  3. Definitions of 1st stage (latent and active), 2nd and 3rd stages
  4. Accepted duration:
    1. Latent phase: variable
    2. Active phase: from ≥ 3cm
    3. Duration     Nullipara   Multipara

      1st stage (active) 1cm/hour   1cm/hour

      2nd stage     < 2 h     < 1 h

      3rd stage     30 min     30 min

  5. Maternal short stature <150cm height
  6. *With epidural, an extra one hour is normally given
  7. Partogram and action line
  8. CTG
  9.  

    ...

Skills
Procedures to be observed/taught
  1. To do:
    1. Abdominal and cervical assessment in labour
    2. Reading of CTG
    3. Charting progress on partogram
  2. To observe:
    1. Recognition of labour abnormalities on partogram
    2. Observe instrumental delivery
    3. Observe and assist 1 LSCS
Attitudes
Professionalism
  1. Keeping mothers informed about their labour progress and management
  2. Reading and recognising normal and abnormal CTGs
Ethics
Communication
  1. Counselling mothers about need for emergency LSCS
  2. Counselling patients about foetal distress and understanding the decision making process with respect to delivery
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Abnormal labour (dystocia) and prolonged labour. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005:177-186.
References
  1. Reference: American College of Obstetricians and Gynecologists. Dystocia and augmentation of labor. ACOG Practice Bulletin # 49, American College of Obstetricians and Gynecologists, Washington, DC 2003.
  2. The Use of Electronic Fetal Monitoring: the use and interpretation of cardiotocography in intrapartum fetal surveillance. Evidence based clinical guideline no 8. Clinical effectiveness support group. RCOG
Problem Preterm Labour and Pre-Labour Rupture of Membranes
Goals
  1. Know the normal duration of pregnancy
  2. Understand the burden of complications posed by preterm birth
  3. Understand the principles of prolonging the pregnancy and ensuring foetal maturity
Knowledge
Topics to be covered
  1. Normal duration of pregnancy
  2. Preterm Labour
  3. Definition of preterm labour, delivery and prematurity
    1. Incidence
    2. Causes and risk factors
    3. Complications for Mother and Baby – antepartum and postpartum
  4. Diagnosis of preterm labour
    1. Clinical diagnosis
    2. Investigations
  5. Management of preterm labour and prevention of preterm delivery
    1. Tocolysis
    2. Antepartum steroids
    3. Use of antibiotics (intact or ruptured membranes)
    4. Maintenance care and follow-up
    5. Differences in management for pregnancies < 34 weeks and pregnancies ≥ 34 weeks
  6. Preterm delivery and associated problems
    1. Malpresentation
    2. Mode of delivery
    3. Immediate care of the preterm neonate and recognition of neonatal complications
    4. Long term morbidity / mortality of prematurity
  7. PPROM
  8. Definition of preterm pre-labour rupture of membranes
  9. Causes and risk factors
  10. Diagnosis
    1. Clinical
    2. Investigations
  11. Management
    1. Role of antibiotics
    2. Role of tocolytics and steroids
    3. Differences in management for pregnancies < 34 weeks and pregnancies ≥ 34 weeks
Key figures & facts
  1. Period of viability = 24 weeks*
  2. Normal duration of pregnancy 37-42 weeks (from LMP)
  3. Incidence of preterm births: 5%
Skills
Procedures to be observed/taught
  1. Observe speculum examination for PPROM
  2. Observe delivery and resuscitation of preterm neonate
Attitudes
Professionalism
  1. Adequate information provided during in utero transfer
Ethics
  1. Foetal viability ethical and economic considerations
Communication
  1. Counselling parents about management procedures, neonatal resuscitation and outcome
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Variations in the duration of pregnancy. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005: 151-155.
Suggested reading
  1. Kenyon SL, Taylor DJ, Tarnow-Mordi W; ORACLE Collaborative Group. Broad-spectrum antibiotics for preterm, prelabour rupture of fetal membranes: the ORACLE I randomised trial. ORACLE Collaborative Group. Lancet. 2001 Mar 31;357(9261):979-88.
  2.  Crowley P, Chalmers I, Keirse MJ. The effects of corticosteroid administration before preterm delivery: an overview of the evidence from controlled trials. Br J Obstet Gynaecol. 1990 Jan;97(1):11-25.
Problem Foetal Demise
Goals
  1. To identify high risk pregnancies which have increased risk of foetal demise
  2. To diagnose foetal demise and refer for further management
  3. To understand emotional and psychological issues
  4. To be able to counsel, communicate, and properly document
Knowledge
Topics to be covered
  1. Perinatal mortality
  2. Must know definitions of
    1. perinatal mortality
    2. crude perinatal mortality
    3. corrected perinatal mortality
  3. Causes of perinatal mortality
    1. Antenatal causes
      1. foetal
      2. maternal
      3. placental
    2. Intrapartum causes
      1. identify high risk group
      2. significance of intrapartum monitoring and management
    3. Social demographic factors – in the perinatal mortality
      1. social class
      2. maternal age / parity
      3. ethnic groups
    4. Nutrition and environmental factors
  4. How to diagnose foetal demise
    1. clinical examination
    2. confirmation by ultrasound
  5. Investigations to find causes for foetal demise
  6. Management
    1. General
      1. Grief counselling & support
    2. Definitive
      1. Immediate – especially if cause is associated with maternal danger
      2. Delayed
  7. Management options
    1. Induction of labour (avoid ARM) / await spontaneous labour
    2. Intrapartum management
      1. Prevent infection
      2. Adequate analgesia
      3. Avoid caesarean section if possible
  8. Postnatal management
    1. Suppression of lactation
    2. Bereavement counselling and support
    3. Funereal arrangements
    4. Counselling for post-mortem
  9. Follow-up
    1. Medical
    2. Psychological support
  10. Future pregnancy
    1. Family planning
    2. Pre-pregnancy preparations
Key figures & facts
  1. Perinatal mortality in Singapore
    1. 4-6/1000 : Singapore
  2. Perinatal mortality in comparison with other developing countries
  3. Definitions of perinatal mortality / stillbirth, etc
Skills
Procedures to be observed/taught
  1. Breaking bad news
  2. communication skills
  3. To be able to derive various mortality indices from statistics tables
Attitudes
Professionalism
  1. Duty to understand preventable causes of perinatal mortality and how to reduce this
Ethics
  1. Post-mortem
Communication
  1. Bereavement counselling and support
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Miscarriage and Abortion. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 103-110.
  2. Llewellyn-Jones D, ed. The epidemiology of obstetrics. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 205-209.
Problem Induction of Labour
Goals
  1. To understand the differences between spontaneous and induced labour
  2. To understand the indications for inducing labour
  3. To understand need for cervical favourability, and methods of induction
Knowledge
Topics to be covered
  1. Definitions
    1. Define normal duration of pregnancy (see Preterm Module)
    2. Define prolonged pregnancy
    3. Priming, induction, augmentation
    4. Medical and surgical induction
  2. Factors to Consider Before Priming or Induction
    1. Indications
      1. Medical
        • Maternal
        • Fetal
      2. Social
    2. Timing of labour induction
    3. Cervical favourability
    4. Factors associated with successful labour induction
      1. Period of gestation
      2. Parity
      3. Cervical favourability
      4. Preparation of mother for labour
  3. Management
    1. Methods for cervical priming
    2. Methods for labour induction
    3. Complications of labour induction, including:
      1. Higher rates of caesarean section, instrumental delivery, epidural analgesia
Key figures & facts
  1. Modified Bishop score
    1. Dilatation
    2. Length
    3. Position
    4. Consistency
    5. Station
  2. When compared with labour of spontaneous onset, elective labour induction in nulliparous women is associated with significantly more operative deliveries (Cammu et al 2002):
    1. Caesarean delivery (9.9% vs 6.5%),
    2. Instrumental delivery (31.6% vs 29.1%),
    3. Epidural analgesia (80% vs 58%)
Skills
Procedures to be observed/taught
  1. Able to do:
    1. Work out the modified Bishops score when given the vaginal examination findings
    2. Chart progress of labour on a partogram
  2. Must observe
    1. Surgical induction of labour being performed
Attitudes
Professionalism
  1. Have good indications for induction
Ethics
  1. Appropriate discussion with mothers/partners
Communication
  1. Keeping mothers informed of plan and progress
References
Compulsory reading
  1. Hacker NF, Moore JG, Gambone JC, eds. Normal Labour, Delivery, and Postpartum Care. Essentials of Obstetrics and Gynaecology, 5th ed. Philadelphia: Saunders Elsevier 2004; 91-118.
Suggested reading
  1. Llewellyn-Jones D, ed. Obstetric operations. Fundamentals of Obstetrics and Gynaecology, Philadelphia: Elsevier; 2005; 193-203.
Reference
  1. Cammu H, Martens G, Ruyssinck G, Amy JJ. Outcome after elective labor induction in nulliparous women: a matched cohort study. FAm J Obstet Gynecol 2002 Feb;186(2):240-4.
Problem Complications at Delivery
Goals
  1. To recognise obstetric emergencies that can occur at delivery
  2. To anticipate potential complications in high risk situations
  3. To understand principles of management of such emergencies
Knowledge
Topics to be covered
  1. Normal events in the 2nd and 3rd stages of labour
  2. Complications of 2nd stage
    1. Prolonged 2nd stage
    2. Foetal distress
    3. Maternal exhaustion/poor effort
    4. Shoulder dystocia
  3. Complications of 3rd stage
    1. Primary PPH
    2. Birth canal trauma
    3. Retained placenta/products of conception
    4. Uterine inversion
  4. Prevention of complications
    1. Analgesia
    2. Proper preparation of mother for labour
    3. Proper management of labour
    4. Foetal monitoring
    5. Correct positioning for delivery/episiotomy
    6. Assisted delivery/emergency caesarean section
    7. Active management of 3rd stage of labour
  5. Management of specific obstetric emergencies
    1. Primary PPH
    2. Shoulder dystocia
    3. Retained placenta
    4. Uterine inversion
  6. Risk management after complications
  7. Neonatal issues
    1. Hypoxia
    2. Birth trauma
Key figures & facts
  1. PPH incidence approx 4% with active management of 3rd stage
  2. Shoulder dystocia is often unpredictable
Skills
Procedures to be observed/taught
  1. How to review a mother in the 2nd and 3rd stages
  2. To be able to review progress of labour on partogram
  3. To assess descent of presenting part in 2nd stage
  4. To recognise foetal distress on CTG in 2nd stage
  5. To perform 2 normal vaginal deliveries
  6. To make and repair an episiotomy
  7. Controlled cord traction
  8. To check for amount of bleeding and contraction of uterus
  9. To assess for birth canal trauma
  10. To check for completeness of placenta/membranes
  11. Immediate post-natal care
  12. Review of neonate at birth
  13. APGAR score
Attitudes
Professionalism
  1. Women in labour – approach with kindness, empathy
  2. Counselling the couple regarding complications
Ethics
  1. Informed consent for procedures
Communication
  1. Keep the couple informed about progress and anticipated complications
  2. Risk management after complications
References
Compulsory reading
  1. Llewellyn-Jones D, ed. Course and management of childbirth. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 69-88.
Problem Puerperium and Lactation
Goals
  1. To be able to explain to a mother the normal changes in her body after delivery
  2. To be able to diagnose and manage the common complications of the puerperium
  3. To be able to help mothers to establish and maintain breastfeeding
Knowledge
Topics to be covered
  1. Normal physiology of puerperium:
    1. Only broad principles required generally
    2. Must know details of:
      1. Morphological changes of uterus
      2. Lochial changes
      3. Onset and establishment of lactation
  2. Normal management of the puerperal woman:
    1. What symptoms and signs to elicit to ensure normality of puerperium
    2. Analgesia
    3. Perineal care
    4. Postnatal follow up
    5. Family planning
  3. How to diagnose and manage common abnormalities in the puerperium:
    1. 2o PPH
    2. Puerperal fever
    3. Pain
      1. Perineum
      2. Uterus
      3. Back
    4. Bladder/bowel problems
    5. Postnatal blues/depression
  4. Able to answer FAQs on newborns:
    1. Care of umbilical cord
    2. Jaundice
    3. Changes in stool colour
    4. Infant feeding
  5. Know how to advise mothers on the basics of breastfeeding:
    1. Benefits to baby and mother
    2. Recommend exclusive breastfeeding for 6 months in accordance with AAP Policy Statement
    3. Preparation for breastfeeding
    4. Normal course of initiation and establishment of lactation
    5. Common mistakes and problems
    6. Complications
      1. Pathological engorgement (early)
      2. Sore or cracked nipples
      3. Acute mastitis & breast abscess (late)
    7. Maintenance
      1. How to continue breastfeeding after returning to work
      2. How to continue breastfeeding when separated temporarily from baby
      3. What to do if advised to stop breastfeeding temporarily
    8. Medical reasons for supplementation
    9. Cessation or suppression of lactation
Key figures & facts
  1. Incidence of NNJ in Singapore: 20%
  2. Level of neonatal serum bilirubin above which:
    1. baby needs to be observed in hospital: variable
    2. baby needs phototherapy: 260
  3. Lactogenesis II takes place on Day 3
  4. Well-hydrated / fed neonate will generally have:
    1. 4-6 wet diapers per day in first few days
    2. transition from meconium to yellow stools
    3. 6-8 diaper changes per day after 1st week
  5. US Healthy People 2010 goal:
    1. Breastfeeding initiation – 75% (Singapore 95%; 2001)
    2. 6 months- 50% (Singapore 21%; 2001)
    3. 12 months- 25%
Skills
  1. How to review a mother after delivery:
    1. Day 1
    2. Weeks 1-2
    3. Weeks 6-8
  2. Teaching mothers how to latch baby on for breastfeeding and proper breastfeeding technique
Attitudes
Professionalism
  1. Duty to promote and protect breastfeeding
Ethics
  1. Know that it is against the SIFECS code to promote infant formula in any way
  2. Appreciate cultural practices during confinement
Communication
  1. Advise breastfeeding during antenatal visit
  2. Check for postnatal blues
  3. Able to counsel about family planning confidently
References
Compulsory reading
  1. Llewellyn-Jones D, ed. The puerperium. Fundamentals of Obstetrics and Gynaecology, 8th ed. Philadelphia: Elsevier; 2005; 89-98.
Suggested reading
  1. American Academy of Paediatrics Policy statement: Breastfeeding and the Use of Human Milk. Work Group on Breastfeeding. Pediatrics 2005;115: 496-506.
  2. SIFECS. Code of Ethics on the Sale of Infant Foods in Singapore, HPB; July 2002.
  3.  American Academy of Paediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108: 776-89.
Reference
  1. Foo LL, Quek SJS, Ng SA, Lim MT, Deurenberg-Yap M. Breastfeeding prevalence and practices among Singaporean Chinese, Malay and Indian mothers. Health Promot Int 2005 Apr 6.

 

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