Gynae Handbook Cases

Contents of AMC Handbook (Gynae)
Condition 009 Contraceptive advice ............................................................................................... 1

Condition 010 Rape of a 20-year old Woman ................................................................................ 4
Condition 038 Primary amenorrhoea .............................................................................................. 8
Condition 064 Investigation for male factor infertility ................................................................. 10
Condition 079 Vaginal bleeding in a 23 year old woman ............................................................ 14
Condition 080 Cessation of periods in OCP use........................................................................... 18
Condition 082 Vaginal bleeding ................................................................................................... 21
Condition 105 Abdominal pain and vaginal bleeding .................................................................. 23
Condition 122 Sterilization in intellectually disabled child.......................................................... 27
Condition 123 Blood transfusion consent ..................................................................................... 29
Condition 128 Urinary incontinence in a 50-year-old woman ..................................................... 32
Condition 009 Contraceptive advice
You are working in a general practice. A 24-year-old woman has come to see you for advice as
to the most appropriate pill she should go on for contraception for the next two to three years.
She knows that various types of pills are available and wants to know how to decide which is
the most appropriate pill for her.
TASKS
Take a further relevant and focused history.
Ask the examiner about findings you wish to elicit on general and gynaecological examination.
Advise the patient of the appropriateness of oral contraceptive pill (OCP) therapy, which pill
should be given, and how it should be administered.
APPROACH
History
Hi Jane, I'm Dr. ______ your GP today. I understand from the notes that you are here today for
advice regarding pill use, is that correct? Is it alright if I ask you a few questions so we'd know
which pill would be most appropriate for you?
Exclude absolute contraindications to OCP use:
Deep vein thrombosis: (ADD COST VMPF)
Do you take any over the counter or prescription medications? Have you taken contraceptive
pills before?
What is your occupation?
Have you had any surgeries in the past 3 months, or any trauma?
Do you smoke, drink alcohol or take recreational drugs?
Any recent travel, especially greater than 12 hours? Did you walk around during the flight?
Have you noticed any prominent veins in your legs? Any calf pain? Any previous DVT?
Are you sexually active? Do you have a stable partner? Do you use contraception? Any previous
pregnancy before? Any chance that you might be pregnant right now?
Any family history of DVT or any coagulation disorders?
Any recent fractures?
Breast cancer:
Any weight loss, loss of appetite, lumps and bumps around the body?
Have you noticed any lumps in your breast? Any breast tenderness?
Active liver disease or previous cholestatic jaundice:
Have you noticed any yellowing of your skin? Any abnormal striae in your abdomen? Any
palmar erythema, finger clubbing?
Unexplained vaginal bleeding: do you have any bleeding from down below?
Focal migraines: any history of migraine?
Exclude relative contraindications to OCP use:
Hypertension and diabetes: Do you experience frequent thirsts? Do you have to urinate more
than usual?
Very irregular cycles or oligomenorrhea:
Period history: When was your last menstrual period? Are your cycles regular? What is the
average duration of your period? Is your bleeding mild, moderate and severe? Any pain or clots
during periods? Any bleeding in between periods? When did you last do your pap smear and
what was the result?
Cigarette smoking: Do you smoke, drink alcohol or use recreational drugs?
Any previous history of heart disorders, liver disorders, stroke, high blood pressure, diabetes,
breast malignancy or severe depression?
Physical Examination
General appearance:
What is the BMI of my patient?
Any pallor, icterus, cyanosis, lymph node enlargement, edema, poor skin turgor, dry mucous
membranes, delayed capillary refill time? Any abnormal hair growth?
Vital signs: What is the BP, PR, RR, Temp and Sats of my patient?
Systemic examination:
CVS: How are the heart sounds? Is the rhythm regular? Any murmurs?
R/S: Is air entry equal? Any adventitious breath sounds?
CNS: How is the motor and sensory exam of the upper and lower limbs? (stroke symptoms)
Abdomen: Is there any visible distention or mass of the abdomen? Is there any
hepatosplenomegaly, any mass or tenderness?
Musculoskeletal: Any edema or tenderness of the lower leg?
Breast: Any palpable breast lumps, tenderness or visible distortion or dimpling?
Pelvic exam:
Inspection of the vulva and vagina: Are there any visible lesions in the vulva and vagina? Any
discharge or bleeding? Any rash or vesicles?
Speculum exam: is the cervix healthy? Is there any bleeding or discharge from the cervix?
Per vaginal exam: CMT, uterine size and tenderness, adnexal mass and tenderness
Office tests: I'd like to do a urine dipstick test and a blood sugar level.
Management
Okay, it seems like it would be possible for you to start on combined OCPs. I would recommend
you to take a low dose estrogen pill. This has a low breakthrough bleeding and low failure rate.
And because your cycles are irregular, it would be better to choose a triphasic preparation as
this has less post pill amenorrhea or cessation of periods after taking the pill. Combined OCPs
contain 2 hormones, estrogen and progesterone which is normally present in your body which
regulates your periods. What it does is it inhibits ovulation, the release of egg from the ovary.
To a lesser extent, it increases the thickness of your cervical secretions so the sperm will find it
difficult to get through. And just in case fertilization happens, it changes the lining of your
womb so that implantation does not happen, because only after implantation does a full bloom
pregnancy happen.
(TAKE PILL PACK) In a pill pack, there are 28 pills, 21 are hormonal pills, 7 are sugar-coats or
dummy pills. Starting taking the hormonal pill from the 1st day of your next period, 1 pill a day,
at the same time every day. Continue the hormonal pills for 21 days and then on starting the
sugar pills, you get your periods. However if you want to start taking the pill right away without
waiting for your next period, you may, but use alternate methods like condoms for 7 days.
Contraceptive efficacy is satisfactory after seven hormone tablets have been taken.
While taking the pill, you may experience side effects such as nausea and vomiting, abdominal
bloating and breast tenderness. Breakthrough bleeding or bleeding in between periods will
usually settle in 3-4 months. Your breasts will just feel sore in the first 1-2 cycles. Major side
effects such as DVT, stroke and MI could happen but are rare with low dose pills, such as what
you will be taking.
Advantages of the pill include periods become more regular, lighter and shorter. There is less
dysmenorrhea. There is decreased incidence of benign breast lumps and pelvic inflammatory
diseases, decreased incidence of endometrial and ovarian cancer, and thyroid disorders.
However, you must remember that OCPs do not protect against sexually transmitted infections,
so you must use condoms along with it just in case you're concerned about STIs.
If you experience diarrhea and vomiting within 2 hours of taking the pill, take a pill again and
keep going with the rest. You need to use condoms as long as the diarrhea and vomiting lasts. If
you go to a doctor or pharmacist, make sure you tell them that you're on pills as there are
medications that decrease the efficacy of pills like vitamin C, some antibiotics or antifungals,
and anti-epileptics. If you miss a pill for more than 24 hours, take the recently missed pill and
just keep going with the rest even if it means taking 2 pills on the same day. If you keep going
with the rest, and the dummy pill period falls within 7 days of missing the pill, skip taking the
dummy pills and start the hormonal pills from the next pack. This will mean that you will miss
having your periods. Alternate methods of contraception like condoms should be used for 7
days after missing the pill.
I will need to follow-up with you in about three months after starting on the pill so I could check
your blood pressure and to check whether the pills are working well for you or it needs to be
changed because of any problems. I will give you some reading materials about combined OCPs
for further insight.
KEY ISSUES
Ability to take an adequate history to exclude absolute contraindications to the OCP and facts
that would influence the pill chosen, and its dose.
Ability to advise a patient as to how to take the pill, the timing of its effectiveness and the likely
problems during its use.
CRITICAL ERRORS
Failure to exclude absolute contraindications to OCP use.
IMPORTANT POINT FROM THE COMMENTARY

A young woman needs to be fully informed of all the benefits and side effects and risks of
taking the OCP
She also needs to be carefully assessed to ensure that she has no condition making her
unsuitable to take the pill
Any patient prescribed the OCP must have a full explanation of how to commence taking the
pill, when it becomes effective as a contraceptive, and what to do if a pill is missed accidentally.
As part of the assessment of a patient who is to be prescribed the OCP, the type of pill and its
cost, should be taken into account as part of the advice to the patient.
Having excluded absolute and relative contraindications to use of the OCP (as is the case in this
patient), an appropriate low dose oestrogen pill should be advised with a low breakthrough
bleeding rate and low failure rate. Alternatively a triphasic preparation could be used which has
less post-pill amenorrhoea.
Common problems likely with candidate performance are:
failing to advise patients as to when contraception will be achieved following the
commencement of therapy
what to do if a pill is missed or the patient gets diarrhoea
failing to advise the common side effects.
Condition 010 Rape of a 20-year old Woman
You are a Hospital Medical Officer (HMO) in the Emergency Department of a metropolitan
general hospital. Your patient is a 20-year old university student who is brought to the
Emergency Department of the hospital because she was raped by a man that she met at a disco
and who offered her a lift home. The rape occurred six hours ago after he had stopped the car
in an undeveloped area. She has decided not to involve the police as the person concerned is
known to her family. She has had no previous operations or illness and no pregnancies
TASKS
Take any further relevant history you require
Ask the examiner about the appropriate findings likely to be evident on initial general and
gynecologic examination
Advise the patient of the investigations required and the management you would propose.
APPROACH
I am very sorry to hear that you have been raped. Let me assure you that there is a lot of
support for you and you are not alone in this moment of crisis. Do you want me to call someone
to be with your right now before we proceed with this consultation?
I really want to help you with your condition. However, I need to ask you some questions
revolving what happened to you and some personal questions to assess for possible risks. I
assure you everything will be kept confidential between us, unless it poses harm to you or to
others. Is that alright?
HISTORY
Were you hurt anywhere else?
PERIOD HISTORY
When was your last period?
Do you get it every month? How many days do you usually bleed?
PARTNER
Are you sexually active? In a stable relationship? Any history of STI?
I'm sorry to ask about this, but do you know if the man suffered from any STIs?
Did you see any discharge or lesions over his private part?
Did he use a condom during the incident?
PILL
Are you on any forms of contraception? When were you last on the pill?
PREGNANT
Have you ever been pregnant before?
PAP
When did you have your last pap smear?
Do you have any history of bleeding disorders, hypertension, migraine, vaginal bleeding, or
breast cancer? Do you have any allergies? Do you take any medications?
Does anyone else know about this? Are you planning to take legal action about this?
I respect your decision but I would like to get samples from you during my examination later,
and keep these in the hospital just in case you will change your mind later. We will have a strict
chain of security and continuity in handling all of these specimens if the results of these are to
be admissible in court
I know it can be very distressing for you to be checked on your private parts. However, I need to
perform the examination on you to see for further evidence of injuries. With your consent, I
would perform a full examination of your private parts, involving me to take a look outside,
look using a speculum, and get swabs from your private parts to get possible DNA samples, and
to check for signs of possible sexually transmitted infections, and also feeling for any soreness
or masses in your private parts. Will that be okay?
PE
GA
VS
Check for any other signs of physical abuse in other parts of the body: bruising, rashes,
lacerations
PELVIC examination WITH CONSENT and with a chaperone (in the case, the patient initially
refused to do this! That's why I included a statement prior to the PE to explain about why a
pelvic & speculum exam is necessary)
Inspection: lacerations, bleeding, bruises, discharge
Speculum: cervix bleeding or not? Any lacerations? Discharge? Bleeding from anywhere else?
Per vaginal: CMT, uterine size, mobility, masses, tenderness? Adnexal tenderness?
CVS, RESPI, CNS, ABDOMEN
PE FROM BOOK
GA: no evidence of bruising or trauma
Vulva: looks normal--not bruised and not bleeding
Speculum exam and per vaginal have not yet been done. The candidate should now discuss
these with the patient and advise on the management plan.
INVESTIGATIONS AND MANAGEMENT

I can imagine how this can be a very difficult situation for you, again we are here to give
whatever support you'll need. As for now, I can suggest a management plan for you, which
includes a medical and psychological plan to support you during these times.
Due to the nature of what happened to you, I'm really concerned about the possible sexually
transmitted infections which you could have acquired from your experience. Because of this,
and with your consent, I would like to take blood samples from you to test for HIV, syphilis,
hepatitis B&C, HSV, and take urine samples to test for chlamydia for PCR. I will also give you an
antibiotic (Azithromycin 1g SD) now to cover for possible STIs.
I will refer you to our rape crisis team or our medical social worker to give you more support. I
will also refer you to a psychologist where you can undergo a talk therapy to help you cope up
with this situation.
As you are already in the late phase of your cycle, I'm also concerned for a possible pregnancy
that might occur because of what happened to you. Because of this, I would like to give you
medications for emergency contraception. These medications contain the hormones that we
normally have in our body, but just in doses enough to prevent a pregnancy. We have two
options to do it. First, I can give you the Postinor pill (Levonorgestrel), you can take 2 pills
(0.75mg) 12 hours apart, or 1 pill (1.5mg) given up to 5 days from today, but this is best taken
within 72 hours since the incident. This has 85% efficacy if taken properly.
Another option is the Yuzpe method (50mcg estrogen + 250mcg progesterone), where you will
take 2 tablets now and then 2 tablets after 12 hours. This has an 75% efficacy if taken properly.
But then again, there are still chances of becoming pregnant despite these interventions.
Because of that, I will arrange a review with you in 3 weeks to check whether you have
conceived and also to review tests results and decide if these need to be repeated. The
screening tests that we'll do for syphilis and HIV will need to be repeated in 3 months' time to
check if you have been infected or not.
"will I still become pregnant?"
Yes, you can still become pregnant as what happened to you will not affect a subsequent
pregnancy if ever you decide to become pregnant
Again, we are here for you and we will give you all the support you need to recover from this
crisis in your life.
SIDE NOTES
If you'll choose to refer the patient to the rape crisis center immediately, a summary of what
needs to be done with her (as what is indicated above) should be given to her prior to the
referral.
KEY ISSUES
Ability to assess a patient who has recently been raped
Ability to arrange the appropriate follow-up, investigations and care
CRITICAL ERRORS
Failure to consider need for post-rape contraceptive methods and management
Failure to refer to appropriate clinic or to discuss taking appropriate swab to exclude sexually
transmissible infections (STI) and taking specimen for DNA analysis
Failure to consider use of prophylactic antibiotics to prevent pelvic inflammation with an STI
IMPORTANT POINTS FROM THE COMMENTARY

Great empathy and support
No indication to collect forensic specimens as she does not want to involve the police
BUT it would be appropriate to preserve any specimens collected in case she changes this
decision
Needs full explanation as to the reasons for your examination (to exclude trauma and STI)
Need support of a social worker or a rape crisis counsellor
Explain that pregnancy might occur as a result of the rape, and that the time of the incident in
her menstrual cycle should be established, as well as the possible use of post-coital
contraception to prevent conception
Review of testing in 3 months to follow-up from the initial potential infections
Antibiotics SHOULD BE GIVEN against STI
Condition 038 Primary amenorrhoea
You are working in a general practice. Your next patient is an 18 year old woman who is
concerned because she has never had a menstrual period.
TASKS
Further relevant history
PE findings from examiner
Investigations and provisional diagnosis
Counsel the patient
APPROACH
I understand that you are a bit concerned now because you haven't had your menstrual period.
Let me just ask you a few questions for me to find out what is causing the problem. Is that
alright with you?
Assess patient's pubertal status:
Have you had a growth spurt already?
Have you noticed changes in your breast already?
Have you noticed any hair growth in your armpit and private areas?
How do you compare in height with your peers in school?
Have you had any history of tummy pain or pain down below?
Differential diagnoses questions
Constitutional delay in puberty: Any family history of early or delayed menarche? Any of your
family members experience the same problem?
When did your mom had her first menstrual period?
Do you have a sister? How old is she? When did she have her first menstrual period? Did she
already have changes in her breast development?
Pregnancy: Are you sexually active? Do you have a stable partner? Do you use any form of
contraception?
Do you smoke, drink alcohol, or use recreational drugs?
Any history of medical and surgical illnesses? Any history of irradiation to the pelvic area?
Thyroid disease: any weather preferences? Have you experienced any sweating, feel your heart
racing, diarrhea or constipation, tremors?
CNS tumor: any significant headaches or vision changes?
PCOS/CAH/Cushing: have you noticed any excess hair growth anywhere in your body? Any
problems with acne?
Physical Exam
General appearance
What is the BMI of the patient?
Vital signs
Systemic exam
Assess for tanner stage of breasts, axillary and pubic hair
Vulval inspection - is the hymen intact? Is it imperforate?
Vaginal inspection - any lesions, deformities?
DO NOT DO A PER VAGINAL EXAM. PATIENT IS VIRGINAL.
Investigations
Ultrasound examination (abdominopelvic ultrasound NOT VAGINAL because patient is virginal)
to check the development of uterus and vagina
Hormone tests: FHS, LH, prolactin, estradiol levels
Chromosome analysis IF uterus is NOT normal and hormone levels are deranged to check for
Turner syndrome
Management
From history and examination, most likely the reason for the absence of your menses is just a
physiological delay or a normal delay in the start of your menses. I can say this because I have
not found anything abnormal in your examination. However, I would arrange for some
investigations to rule out any other causes of the absence of your menses. Usually, the first
period occurs two years after the first breast development but can be delayed for 3 years or
longer as normal variation in menarche. I will review you again once the results of the
investigations come in, and again in 12 months time if your period has still not occurred by that
time, and we will re-evaluate and repeat the measurement of your female hormone levels.
Do you have any questions at this point?
KEY ISSUES
Ability to define the most likely cause of primary amenorrhoea (delayed menarche).
Ability to arrange the appropriate investigations.
CRITICAL ERROR
Inadequate history to evaluate current pubertal status.
Performance of pelvic vaginal examination as she is virginal. Requesting that pelvic examination
should be done would be a significant and potentially failing error.
Failure to order abdominal ultrasound. Pelvic (vaginal) ultrasound is also inappropriate
Failure to order hormonal analyses of FSH, prolactin and oestradiol

This case illustrates the situation where a slightly delayed menarche can be a normal situation
particularly where there is a familial trait. It is therefore essential to obtain an appropriate
history, both in regard to her own history and that of other family members.
Recognize that normal puberty is occurring. Therefore the cause of the primary amenorrhoea is
likely to be just a slight delay in the first period with everything else being normal.
Other less likely possible causes are obstruction to the outflow of blood from the uterus to the
exterior by an intact hymen or vaginal septum or an absence of development of the uterus.
Ultrasound examination is essential to make these latter diagnoses.
Advise review in 12 month's time if a period has still not occurred
Condition 064 Investigation for male factor infertility
A married couple (husband 25, wife 23 years) have been trying to conceive for the last 12
months. Examination of both the husband and the wife is normal. Investigations arranged by
you, from a general practice setting, have shown she is ovulating each month, and has patent
Fallopian tubes.
The husband's recent semen analysis is not normal. His result is as follows
SEMEN ANALYSIS
Collected after three days of abstinence
Examined 30 minutes after collection by masturbation, normal values in brackets
VOLUME 6ml (2-6ml)

Count 2 million/ml (greater than 20 million/ml)
Motility 20% (greater than 40%)
Velocity 20 (Greater than 30
microns/second microns/second)
Abnormal morphology (Less than 80%)
95%
Antisperm antibodies Nil (Nil)
The husband has come to see you today for the result of the semen specimen. His wife is aware
of her results. She was unable to come today.
When you examined him previously, you found no abnormality on general or genital
examination. Both testes were normal in size (20ml estimated value), felt normal in
consistency, there was no indication of a varicocele or hydrocele.
TASKS
Take any further relevant focused history from the husband in regard to the results obtained
Advise the husband regarding the couple's fertility problem.
IDIOPATHIC/UNEXPLAINED: 40-50% of cases
Testicular: Varicocoele: 35-40% of infertile males
Meds: cytotoxic agents, GnRH agonists, anabolic steroids, nitrofurantoin, sulfasalazine,
spironolactone, alpha-blockers
Drugs; Alcohol, tobacco, cocaine, marijuana
Exposure: radiation, heavy metals
APPROACH
I understand that you are here to discuss your test results with me. But before we go through
that, I need to ask you some more questions to assess for possible factors that might affect
your fertility. Will that be okay?
I might also ask you some personal and sensitive questions in this consultation, but rest assured
everything will be kept between us unless it poses harm to you or to others. Is that okay?
HISTORY
SEXUAL HISTORY
How long have you trying for a baby?
I'm sorry to ask you this but I need to know, Have you or your wife have any kids from previous
relationships?
How often do you engage in sexual intercourse? Do you live with your wife?
Do you or your wife experience any difficulty during intercourse?
Does she have any pain on penetration?
DO you have any difficulties in maintaining an erection? DO you think you are able to ejaculate
completely?
Do you or your wife have a history of STIs?
SAD
Do you smoke, drink alcohol, or engage in recreational drugs like marijuana or hashish?
Do you take any medications? Steroid use?
WORK AND EXPOSURE
What is your occupation? Have you been ever exposed to certain chemicals?
Any stresses or concerns at work?
INJURIES/CONDITION TO THE TESTES
Do you have any history of hernias, undescended testes, or surgeries to your lower tummy and
genital area? Have you ever had any injuries to your genital area?
Did you have any other medical illnesses, suffered from frequent URTIs (Kartagener's syndrome
and Cystic fibrosis), especially mumps?
PSYCHOGENIC
How is your mood lately?
ADVICE
I have the results of your semen analysis that was done for you. This contains information
about the number, shape, and function of your sperm which may affect your fertility. In your
case, the sperm count and motility is low, and the number of abnormal shapes is high. Please
don't worry too much about this.
As sometimes, certain conditions can affect the functioning of your testes like stress, febrile
illnesses, certain medications. Usually these are temporary and on repeating the tests, the
sperm count usually reaches the normal level. Because of this, we need to repeat another
sperm analysis test in about three months' time. If an abnormal test again is found, we will
repeat the test again for a third time in another 3 months. I will give you written instructions
regarding how to obtain a sample. You will need to follow them carefully as they can affect the
outcome of the test.
And if these show the same findings as the first and a second one, then clearly there is a
problem which is almost certainly a major factor that contributes to your infertility. Even if you
see that there are still sperm present, it still does not reach the optimum number needed and
activity that a sperm must have in order to successfully fertilize the egg cell.
However if the semen analysis results improves spontaneously with time, the possibility of
achieving a pregnancy is increased.
We will also perform other investigations to identify possible causes of your low sperm count.
This will include blood tests which include serum FSH, LH, testosterone, and prolactin levels.
We will also do an ultrasound of both your testes to check for its size and to rule out any
masses or conditions that may cause obstruction to the flow of sperm.
But in most cases unfortunately, the exact cause of an abnormal sperm analysis is still
unknown. And in terms of treatments or medications, there is no documented evidence for use
of any treatment in improving the semen specimen.
Now, in the case we'll not have good results with these investigations, it seems that there is a
definite place for the use of in-vitro fertilization (IVF) with intracytoplasmic sperm injection, or
what we call an IVF with ICSI. Sorry for the medical term but let me explain this procedure to
you. This involves getting a sperm sample from you and getting the egg cell of your wife and
injecting the sperm to the egg cell in the laboratory for fertilization to take place. This
procedure is done by a fertility specialist and has a pregnancy rate of about 20-40% per cycle.
Just doing IVF without ICSI has poor results compared if it is done with ICSI. Are you open to
consider this procedure?
Another consideration is a use of a donor sperm and performing artificial insemination, again
sorry for the use of the medical terms. The pregnancy rate is about 20% per cycle of
insemination, and this use is cheaper and more straightforward than other methods of
treatment. However, the baby would not contain any of your genetic material if we do this
method.
I'm afraid that if we use your sperm for intrauterine insemination it would have a very poor
success rate (1-2%) as your sperm
Again please don't stress yourself too much about this, as we will still do a repeat sperm
analysis test and we have pending results for the investigations that we plan to do to determine
the causes of your low sperm count. I will arrange another review with you once results
become available and it is best if you bring your wife along. For now, I would like to give you
reading materials to give you more insight about your condition and about IVF with ICSI. Rest
assured, I will do my best to look after you and support you for whatever decisions you make
with regard to your plans of having a child.
KEY ISSUES
Need for appropriate history from husband
Knowledge of appropriate tests to assess him, and of the possibility of improvement with time
Need for empathetic counselling
Ability to understand that a definitive cause is unlikely to be found
CRITICAL ERRORS
Failure to advise that at least a second semen specimen (3 months after the first) must be
examined
Failure to recognise that persisting severe abnormality of the semen specimen as currently
obtained will result in a very low pregnancy rate
Failure to understand that ICSI (within IVF) is the best method of achieving pregnancy using his
genetic material

MUST be recognized that a single sperm test is UNRELIABLE
MUST be repeated 2-3months later and preferably again after further 3 months
Common problems
Failure to repeat the semen specimen analysis
Failure to ask questions to define the possible causes of abnormal semen specimen
Failure to ask whether the use of donor semen would be acceptable, as this is very effective
and cheap, though the child produced would not obtain DNA from the husband
Condition 079 Vaginal bleeding in a 23 year old woman
You are working in a hospital emergency department. Your next patient is a 23-year old
nulliparous woman who has been trying to conceive, and she believes she is pregnant. She has
developed vaginal bleeding after eight weeks of amenorrhea.
TASKS
Ask the examiner about the findings you would look for on general and gynecological
examination and the results of any leads you would expect to be available at the time you are
seeing the patient
Advise the patient of the probable diagnosis and subsequent management you would institute,
including any further investigations you would arrange.
APPROACH
I'm sorry to hear that you currently have bleeding. But before we proceed further with this
consultation, may I ask if you have any pain right now? Can you point to me where exactly is
the pain? From a scale of 1-10, 10 being the most painful, how bad is your pain right now? Do
you have any allergies? I will talk to my examiner first, and get back to you, is that alright?
I would like to offer some pain killers for my patient. And I would like to know what is her BP
and is there a postural drop, pulse and its rhythm, respiratory rate and oxygen saturation, and
temperature?
If not stable, transfer to resuscitation room, insert IV lines and draw blood
Before we proceed further, I am going to ask you some sensitive and personal questions to help
me assess your condition. Rest assured everything will remain confidential between us, unless it
poses harm to you or to others. Is that alright with you?
I understand from your notes that you have vaginal bleeding and had been trying to get
pregnant. Can you tell me more about it?
ASK ABOUT VAGINAL BLEEDING (PERIOD HISTORY)
When did it start? What were you doing before this started? Is it continuous (always there) or is
it on and off? Is it getting worse (has it increased in amount since it started)? What is its color?
Is it smelly or not? How many pads did you use up until now? Did you pass any clots? Did you
feel any dizziness? Has this happened before? Any tiredness or dizziness? Any fever or
discharge from down below? Any rash or skin lesions noted?
Do you know your blood group?
Do you have any pain associated with this bleeding? If yes, ask details about the pain, especially
if the pain preceded the bleeding.
Do you have any bleeding or bruising from anywhere else in your body?
PERIOD DETAILS
When was your last period? Do you get it every month? How long do you usually bleed? Do you
usually have a light, moderate, or heavy flow? Do you have any pain or dizziness with your
menses?
How does this bleeding episode compare with your usual period/menstrual bleeding?
ASK ABOUT PREGNANCY DETAILS (PREGNANCY & PARTNER & CONTRACEPTIVE HISTORY)
I understand that you are sexually active and has been trying to get pregnant, is that correct?
Are you on a stable relationship?
Prior to this occurrence, were you on any forms of contraception?
When were you last on the pill?
Is there any chance that you are pregnant now?
Have you had a pregnancy test done? When was it done and what was the result?
Have you ever been pregnant before? (If yes, ask for details)
Do you have any nausea, vomiting, or breast tenderness? (early pregnancy symptoms)
In case you're pregnant now, will you have support for this pregnancy?
Any history of sexually transmitted infections?
PAP SMEAR
When did you have your last pap smear, and what was the result? (must be within 2 yrs)
If not within 2 yrs, I will arrange another review with you to arrange for your pap smear.
R/O DDX (triggers for the bleeding) -- **FOR COMPLETION, BUT THE CASE SUGGESTS THAT
THIS WILL ONLY TAKE YOUR TIME. JUST FOCUS ON THE 5Ps
How is your waterworks? Any burning or stinging sensation?
Are there any changes in your bowel movement?
Do you have any cough or colds, or headache?
Any recent falls or injuries?
SADMA**FOR COMPLETION, BUT THE CASE SUGGESTS THAT THIS WILL ONLY TAKE YOUR
TIME. JUST FOCUS ON THE 5Ps
Do you smoke? Drink alcohol? Engage in recreational drugs?
If positive: "It's best to stop smoking/drinking alcohol/engage in recreational drugs now, as this
will be harmful to you, and especially to the baby in case you're pregnant.:
Any intake of prescription or over the counter medications?
Any allergies?
Do you have previous illnesses or surgeries?
Do you have any family history of bleeding disorders, thyroid disorders, or womb conditions
such as myoma, polyps, etc?
PHYSICAL EXAMINATION
General appearance: what is the BMI? Any pallor, cyanosis, lymphadenopathies, edema,
dehydration?
VS - already asked in the beginning
Run through ENT, CVS, RESPI, CNS exam
ABDOMEN: any distention or visible masses? Any palpable masses or tenderness?
PELVIC:
Inspection: any bleeding or discharge from the vulva or vagina? Any rashes or vesicles present?
Speculum: is the cervical os open/closed? Any discharge or bleeding coming from the cervical
os and the vagina?
Per vaginal: is there cervical motion tenderness? Is the cervix firm/soft?
What is the size and position of the uterus? Is it mobile? Any palpable masses or tenderness?
Any tenderness and palpable masses over the adnexa?
I would like to end my examination by performing a urine pregnancy test, Urine dipstick, blood
sugar level.
PE EXAMINATION FINDINGS:
PULSE: 80/min, regular
BP 120/80, not distressed
Pelvic exam: cervix closed, firm, no blood in the vagina
Uterus retroverted, enlarged to the size of an 8th week pregnancy
Adnexa: no mass or tenderness
Pregnancy test positive previously, confirmed on spot urine testing now
RH negative patient
MANAGEMENT
Hello Mary, based on my history and examination findings, it seems that most likely you are
having a threatened miscarriage. Do you have any idea what it is? Let me explain this to you.
Your pregnancy test result came out positive.
(ILLUSTRATE) Normally, the baby inside your womb is attached to you through a cord, which we
call as the placenta. Sometimes, because of the attachment of the placenta to your womb,
some bleeding can happen. It is quite common, especially during the early period of pregnancy.
In majority of cases, this bleeding is quite harmless. It will stop on its own within a few days,
and your pregnancy may continue without any problems.
However, because of your bleeding, we may have to admit you in the hospital to monitor you
and your baby, and do investigations to further confirm your pregnancy and to check for other
reasons why you are having this bleeding. I will refer you to an obstetrician as well. The tests
include basic blood tests such as an FBE, UEC, Blood group, (urine mcs if positive urine findings).
We need to do an ultrasound to fully confirm your pregnancy, to check the sac surrounding the
baby, the liquor volume or the amount of water that the baby needs to thrive, and to check for
the presence of the baby's heart sounds. We need all of these to be done, and if everything
comes out normal--meaning that you have no infections, and that the baby is thriving well
inside your womb, the OB might advise you to just take some rest, and we confirm the
condition of you having a threatened miscarriage with a good prospect of continuing your
pregnancy. If this is truly a threatened miscarriage, you will only be subjected to bed rest and to
avoid stressors in your life. Unfortunately, there is no specific medication effective in improving
the pregnancy outcome. Again, providing the ultrasound examination is normal, the chance of a
successful pregnancy is between 90-95%. If this bleeding continues, we will do serial ultrasound
checks to see the condition of the baby.
As you have an O- blood test result, we will also check your blood for an indirect coombs test. It
checks some factors in the blood that if present, might affect the development of your baby
during your next pregnancies. We will arrange medications for you (anti-D) in case you turn out
positive for it.
Do you have any questions?
Rest assured, we will do our best to manage your condition the best way we can. Here are
some reading materials for you to give you more insight to your condition.
KEY ISSUES
Ability to define the diagnoses needing to be considered in the presence of eight weeks of
amenorrhea
Ability to appropriately investigate a woman with these symptoms
CRITICAL ERRORS
Failure to confirm pregnancy by pregnancy testing
Failure to arrange ultrasound to check site and visibility of pregnancy
Failure to consider the use of anti-D in view of Rhesus negative state

In all cases of bleeding in EARLY pregnancy, the MOST CRITICAL EXAMINATION FINDINGS are:
UTERINE SIZE, THE STATE OF THE CERVIX (OPEN OR NOT), and the PRESENCE OR ABSENCE OF
PELVIC TENDERNESS.
Reliance on ultrasound exam alone is inappropriate
Ultrasound in this case will enable the viability of the pregnancy to be assessed, to reassure the
patient with confidence
If pregnancy test NEGATIVE: : Most likely, this is a delayed period. Sometimes, due to stress and
with the use of the pill, your periods can become irregular. If it continues for the next 2 or 3
cycles, you will need to see the specialist gynecologist. She might decide to start you on regular
OCPs to regulate the cycle.
Condition 080 Cessation of periods in OCP use
Your patient is a 30-year-old woman who is taking the oral contraceptive pill (OCP). She has
come to see you in a general practice because she did not have a period following the last two
courses of pills.
TASKS:
Take a further focused history.
Ask the examiner about the findings you wish to elicit on general and gynaecological
examination.
Advise the patient of the diagnosis and subsequent management (including any investigations
you would arrange).
APPROACH
History
I understand from the notes that you are here because you have not been getting your periods
after taking your pills. Can you tell me more about it? When did your periods stop? Was it a
gradual reduction in your periods? Did you have similar episodes before you took contraceptive
pills?
Period history: When was your last menstrual period? Before this, were your periods regular?
How long were your cycles? Usual number of days of periods? Is your bleeding mild/moderate
or severe? Any pain or clots during periods?
How long have you been on the pill? Are you taking your pills regularly? Do you think you might
have missed your pill anytime? Are you experiencing side effects with the pill? Are you taking
any other medications aside from the contraceptive pill?
Sexual history: are you sexually active? Do you have a stable partner? Any problems with sexual
activity? Any chance that you might be pregnant right now? When was your last pap smear and
what was the result?
Rule out causes of secondary amenorrhea:
Pregnancy: Do you experience any nausea, vomiting, breast enlargement or nipple discomfort?
PCOS: any recent weight gain, acne, abnormal hair growth?
Hypothyroidism: any weather preferences, puffy face, edema?
Eating disorder/exercise induced: do you ever feel guilty about your weight? How often do you
exercise?
Hyperprolactinemia: any breast discharge, headache, nausea and vomiting?
Asherman syndrome: any previous gynecological procedures or currettage?
Stress: do you experience any excessive stress at home or at work?P
Post-Pill Amenorrhea
Have you ever been diagnosed of any medical or surgical illness?
Do you smoke, drink alcohol, take recreational drugs?
Physical Exam
General appearance: look for visible hirsutism, acne, puffy face or edema, BMI
Vital signs
Vision: visual fields, fundoscopy, visual acuity
Neck: thyroid enlargement
Breast examination: nipple discharge
Abdomen: any visible distention? Palpable mass or tenderness?
Pelvic exam:
Inspection: discharge, atrophic vagina
Speculum: discharge, bleeding from the cervix
Bimanual exam: size, position and mobility of the uterus, adnexal masses, CMT
Office test: urine dipstick, BSL, pregnancy test
Diagnosis and Management

From my history and examination, most likely the cessation of your periods is due to
endometrial atrophy secondary to the combined pill. Do you have any idea what this is?
The tissue lining your womb is called endometrium. Each menstrual cycle, part of it grows and
becomes filled with blood and then is shed as a period. However in your case, there is thinning
of the lining of the womb. This thinning is due to the progestogen component of the combined
pill that you are taking. However, although unlikely, it is prudent for us to do a pregnancy test
to exclude the possibility of pregnancy.
But do not worry, this pill-induced endometrial atrophy does not cause any serious problems or
affect your fertility, and your periods will come back once you discontinue the pill. However if
you are really concerned about this, we can change your current pill to a higher estrogen
containing pill such as Microgynon 50 or a triphasic pill such as Triguilar which can increase the
menstrual loss, or we can cease the combined pill altogether and you can use some other
method of contraception such as condoms. I will give you reading materials regarding post-pill
amenorrhea for further insight and will review you regularly.
KEY ISSUES
Ability to diagnose the cause of amenorrhoea when on the OCP.
Ability to counsel the patient appropriately.
CRITICAL ERRORS
Failure to perform a pregnancy test (/J-hCG) to exclude the unlikely possibility of a pregnancy
occurring whilst taking the OCP.

The reduction in the amount of withdrawal bleeding whilst a patient is on the oral
contraceptive pill is not uncommon. The cause is due to a progressive endometrial atrophy
(progestogen-induced) over the period of time the patient is taking the pill.
The key to the situation is generally the history of gradual reduction of menstrual flow over a
period of time prior to the complete cessation of withdrawal bleeding.
Whilst the likelihood of pregnancy is very low, a pregnancy test is appropriate to reassure the
patient — as conception is possible whilst a patient is taking the oral contraceptive pill.
Common problems likely with candidate performance are:
Inadequate history concerning the progressive reduction in the menstrual loss whilst on the
OCP.
Inadequate advice concerning the natural history of this symptom after cessation of the OCP.
Condition 082 Vaginal bleeding
Your patient is a 25-year-old married nulliparous woman who presents to you in a general
practice with vaginal bleeding after eight weeks of amenorrhoea. Her cycles are often irregular
with the periods occurring at intervals of 4-8 weeks.
TASKS:
Take a further focused history.
Ask the examiner about the findings you wish to elicit on general and gynaecological/obstetric
examination.
Advise the patient of the probable diagnosis and subsequent management, including any
investigations you would arrange.
APPROACH
History
I understand from the notes that you are because of vaginal bleeding. Is it alright if I ask you a
few questions?
When did the bleeding start? Is this the first episode of the bleed? What is the colour of the
bleed? Does it have any offensive smell? Is there clots? How heavy is the bleed? How many
pads do you soak in a day? Is it fully soaked? Is it a continuous bleed? Is it associated with pain?
Is it associated with sexual activity?
Period history: when was your last menstrual period? Are your cycles regular? What is the usual
length of your cycles? What is the usual duration of your periods? Any pain or clots during your
periods?
Sexual history: are you sexually active? Do you have a stable partner? Do you use any
contraception? Any chance that you might be pregnant right now? When was your last pap
smear and what was the result?
Symptoms of pregnancy: Do you experience any nausea, vomiting, breast enlargement or
nipple discomfort?
Any previous medical or surgical illness especially bleeding disorders?
Any family history of any gynecological disorders?
Do you smoke, drink alcohol, take recreational drugs?
Do you take any prescription or over the counter medications? Any allergies?
Physical Exam
General appearance: pallor, edema, lymph node enlargement, BMI
Vital signs
Systemic examination
CNS/CVS/Respiratory
Abdomen: any visible distention? Any palpable mass or tenderness?
Pelvic examination
Inspection of the vulva and vagina
Speculum: is the cervix closed or open? Is there discharge or bleeding?
Per vaginal exam: what is the size and position of the uterus? Any tenderness? Any mass or
tenderness in the adnexa?
Office tests: Pregnancy test
Diagnosis, Investigations and Management
From the history and examination, the cause of your vaginal bleeding is still unclear. However,
the most important thing that I want to confirm if whether you are pregnant or not. To confirm
this, I would first like to do a beta Hcg to see if you are pregnant. If beta Hcg is negative, your
bleeding might just be a late period, and we will just wait and observe the pattern of your
periods. If your periods remain irregular, then we can order some hormonal tests such as FSH,
LH, prolactin and thyroid function tests to look for other causes of your irregular periods, and
plan subsequent treatment accordingly. However, if beta Hcg is positive, we will do an
estimation of the beta Hcg level. If it is greater than 1000 U/L, then we will do an ultrasound to
check the site and normality of the pregnancy, and the gestation and due date. We will also
investigate the cause of the vaginal bleeding in relation to the pregnancy, and manage
accordingly.
I will review you once the results of the tests are available.
KEY ISSUES
Ability to evaluate a patient with bleeding after amenorrhoea.
Ability to confirm or exclude pregnancy as a cause.
CRITICAL ERRORS
Failure to consider non-pregnancy as well as pregnancy causes.
Failure to arrange ultrasound if pregnant and β -hCG is greater than 1000 U/L.

It is important to differentiate whether this woman could be pregnant, or whether she simply is
having one of her longer, irregular menstrual cycles. Therefore, symptoms suggesting
pregnancy, and tests for pregnancy, must be discussed in the management of this case.
It is also important to remember that where pregnancy is proven not to exist, further
investigations for the irregular menstrual cycles should be considered.
Condition 105 Abdominal pain and vaginal bleeding
Your patient is a 39 year old woman who has been married for 12 months and suffered a
spontaneous abortion at eight weeks of gestation six months ago. This was her only previous
pregnancy.
An ambulance has brought her to the hospital today because of severe lower abdominal pain
and heavy vaginal bleeding for the last 12 hours. Her last period was nine weeks ago. You are
seeing her in the Emergency Department at the local hospital.
TASKS
Take any further relevant history you require (it should not take you more than 3-4 minutes to
do this)
Ask the examiner for the appropriate findings you would look for on general and gynecological
examination, and then ask for any investigation results you feel are necessary to enable you to
make a diagnosis
Advise the patient, in lay terms, of the diagnosis and the subsequent management required.
APPROACH
I'm sorry to hear that you have been suffering from tummy pain and vaginal bleeding. Are you
comfortable enough to go through this consultation or do you want me to do something about
the pain first? From the scale of 1-10, 10 being the most painful, how bad is your pain? Do you
have any allergies?
To examiner: I would like to offer painkillers to my patient (morphine) and I would like to know
what is her BP and is there a postural drop, pulse and rhythm, respiratory rate, oxygen
saturation, and temperature of my patient?
If not stable: I would like to transfer my patient to the resuscitation room, insert large bore iv
lines, and draw some blood for investigations: FBE, UEC, blood group with cross-matching,
indirect coombs test.
If stable, go with the history
HISTORY
Which came first? Abdominal pain or the bleeding?
ABDOMINAL PAIN Q
Can you point to me where exactly is the pain? When did it start, what were you doing before it
started? was it sudden or gradual? Is it always there or does it come and go? Is it cramping,
stabbing? Does the pain go anywhere else? Is there anything that makes the pain better or
worse?
Any recent injuries before the pain started?
Do you feel any stinging or burning sensation when you pass urine?
Any fever, cough, or colds?
VAGINAL BLEEDING
When did it start? What were you doing before this started? Is it continuous (always there) or is
it on and off? Is it getting worse (has it increased in amount since it started)? What is its color?
Is it smelly or not? How many pads did you use up until now? Did you pass any clots or tissues?
Did you feel any dizziness? Has this happened before? Any tiredness or dizziness? Any fever or
discharge from down below? Any rash or skin lesions noted?
Do you know your blood group?
Do you have any bleeding or bruising from anywhere else in your body?
PERIOD DETAILS
When was your last period? Do you get it every month? How long do you usually bleed? Do you
usually have a light, moderate, or heavy flow? Do you have any pain or dizziness with your
menses?
How does this bleeding episode compare with your usual menses?
ASK ABOUT PREGNANCY DETAILS (PREGNANCY & PARTNER & CONTRACEPTIVE HISTORY)
I understand that you are sexually active and has been trying to get pregnant, is that correct?
I'm sorry to hear that you just had a miscarriage six months ago. I would just like to ask if there
were any procedures done to you or any medications given to you during that time? (ask if she
underwent D&C or just took meds, etc)
And have you been actively trying to get pregnant since then?
Do you have any nausea, vomiting, or breast tenderness? (early pregnancy symptoms)
In case you're pregnant now, will you have support for this pregnancy?
Any history of sexually transmitted infections?
PAP SMEAR
When did you have your last pap smear, and what was the result? (must be within 2 yrs)
If not within 2 yrs, I will arrange another review with you to arrange for your pap smear.
SADMA**FOR COMPLETION, BUT THE CASE SUGGESTS THAT THIS WILL ONLY TAKE YOUR
TIME. JUST FOCUS ON THE 5Ps
Do you smoke? Drink alcohol? Engage in recreational drugs?
If positive: "It's best to stop smoking/drinking alcohol/engage in recreational drugs now, as this
will be harmful to you, and especially to the baby in case you're pregnant."
Any intake of prescription or over the counter medications?
Any allergies?
Do you have previous illnesses or surgeries?
Do you have any family history of bleeding disorders, thyroid disorders, or womb conditions
such as myoma, polyps, etc?
GA: is she alert, drowsy, rousable? Any signs of pallor, icterus, cyanosis, lymphadenopathy,
edema present?
Dehydration: what is the CRT? Is there oral mucosa dry or moist? How is the skin turgor?
VS: BP, HR with rhythm, RR with saturation, Temperature
CVS, RESPI, CNS: level of consciousness?
ABDOMEN:
Any distention or visible masses? Any guarding or rigidity? Any palpable masses or tenderness?
PELVIC:
Inspection: any bleeding or discharge from the vulva or vagina? Any rashes or vesicles present?
Speculum: is the cervical os open/closed? Any discharge or bleeding or products of conception
coming from the cervical os and the vagina?
Per vaginal: is there cervical motion tenderness? Is the cervix firm/soft?
What is the size and position of the uterus? Is it mobile? Any palpable masses or tenderness?
Is the cervix dilated? By how much is it dilated?
Any tenderness and palpable masses over the adnexa?
I would like to end my examination by performing a blood sugar level test.
DO NOT REQUEST FOR A URINE PREGNANCY TEST OR AN ULTRASOUND IF THERE ARE
PRODUCTS OF CONCEPTION PRESENT ON THE PELVIC EXAM. YOU WILL BE MARKED DOWN!
PE FINDINGS FROM THE CASE
GA: clammy, pale, obviously distressed and in pain
CVS: pulse 90/min, BP 80/50 mmhg
Abdomen: Lax, non-tender, no mass or viscus palpable
Speculum: cervix open, products of conception in cervical os (if candidate does not ask if the
cervix is open or closed, do not give this information but comment on the uterine size alone)
Pelvic: uterus enlarged to size of an eighth week of pregnancy, anteverted, and mobile. Cervical
os is open and easily admits tip of one finger. No adnexal masses or tenderness
Investigations:
Blood group: O Rh negative, indirect coombs test negative
Hb 112 g/L
DIAGNOSIS AND MANAGEMENT
From my history and examination, I am sorry to say that you are having a miscarriage. Most
miscarriages occur without any obvious reasons, and this loss was probably because of a
genetic abnormality of the fetus itself especially during miscarriages occurring in the first 14
weeks. Unfortunately these cases become more common as women get older. But let me
reassure you that this is not your fault. You did not do anything wrong so please do not feel
guilty about this.
Since you are actively bleeding and your vitals still unstable as of now, I will have to admit you. I
have informed the OB registrar and sent all the bloods for investigations. Your bleeding is
caused by retained tissues of the fetus inside your womb, causing you to bleed more as long as
it stays there. Thus, they will probably do a procedure called curettage as soon as possible to
control your bleeding. This essentially involves inserting a small instrument we call curette
(ILLUSTRATE) inside your womb to scrape out the remaining tissues that causes you to bleed.
This will be done under anesthesia and is basically a pain free procedure.
As we are waiting, fluids have been started in your IV line, and we will also give you medicines
for your womb to contract to control your bleeding (IV ergometrine or a similar oxytocic agent).
We will also give you an injection called anti-D immunoglobulin as we have seen your blood to
be O negative to prevent future bleeding to you and to your child during your next pregnancy.
If your blood pressure remains low despite these interventions, it is possible that we give you
more IV fluids or a possible blood transfusion, depending on specialist advice.
You will still get pregnant, but it is advisable to wait for at least one normal period to occur
before trying to get pregnant again.
The likelihood of having a miscarriage in your next pregnancy is probably about 25-30%. But do
not stress too much about this, there is still a good chance that you will become pregnant.
Thus, in your next pregnancy, we will do a regular review for you as your advanced age also
increases the risk of having fetal abnormalities for your baby. We will do an ultrasound as early
as seven weeks as well as blood tests for screening and confirmation of congenital disorders to
provide reassurance that all is normal.
I can imagine how this must be very hard for you. But let me reassure you that we will do what
we can to provide you the best care possible. Do you want me to call anyone for you? Do you
have enough support?
KEY POINTS
Ability to define the likely cause of the symptoms and the low blood pressure found
Ability to recognize that no investigations are required in this patient other than urgent
determination of blood group, as the diagnosis can clearly be made on clinical grounds
Ability to define the subsequent management plan
CRITICAL ERRORS
Inappropriate investigation requested such as pregnancy test after results of physical
examination are known, ultrasound examination, or coagulation screen
Failure to recognize the need to remove POC from cervix
Failure to check blood group to see if anti-D antibody was indicated

Importance of speculum and vaginal examination
Recognize the products of conception trapped in the cervical os opening, causing 'cervical'
shock
Importance of removing products of conception and administering ergometrine to contract the
uterus and prevent/reduce further bleeding
Avoid irrelevant history: irrelevant past hx, social hx
Adequate diagnosis and resuscitation havefirst priority
IF CERVIX IS CLOSED, ULTRASOUND IS REQUIRED TO DEFINE WHETHER THE PREGNANCY IS
PRESENT IN THE UTERUS, AND WHETHER IT IS VIABLE
Don't forget to advise the cause of the miscarriage and the likely outcome of future pregnancies
Condition 122 Sterilization in intellectually disabled child
You are working in a general practice. Mrs Davis is a widow and has been a patient of yours for
approximately twelve years. She has a 14-year-old daughter Evelyn, who has a significant
intellectual disability. Evelyn has also been a patient under your care since the family moved to
the suburb 12 years ago. Evelyn also suffers from epilepsy, has an ataxic gait and significant
behavioural problems. While able to dress and feed herself Evelyn requires significant
assistance with washing and is not capable of any form of independent living. Mrs Davis, now
54 years old, is concerned that Evelyn's behavioural problems will be exacerbated with the
onset of menstruation. Mrs Davis is also extremely anxious as to her own ability to care for
Evelyn during her menstrual cycle and has the clear view that Evelyn would be intellectually
incapable of understanding the physiological changes to her body in addition to being physically
incapable of meeting her own hygiene needs. As Evelyn has been cared for solely by her
mother, and requires high levels of supportive care, Mrs Davis has decided that she will
approach you to organise for Evelyn to undergo a hysterectomy and oophorectomy. Today Mrs
Davis has made an appointment to talk to you about this operative procedure for Evelyn.
TASKS:
Respond to the mother's questions and provide information to her about the consent required
prior to the operative procedures she is seeking for her daughter.
APPROACH
Good morning Mrs. Davis. I understand that you have some concerns about Evelyn. Can you
please tell me more about it?
How is your daily situation with Evelyn? What are your concerns about this?
Has Evelyn started her periods already? Does she already exhibit any other signs of puberty
such as enlargement of the breasts, armpit and pubic hair? How did she react to these changes
in her body?
I understand your concerns Mrs. Davis, and I can only imagine how hard it must be for you to
manage all these by yourself. I understand that you want Evelyn to undergo a permanent
sterilization for reasons you have stated, however the decision or consent to undergo
sterilization needs to be determined through legislation or the case law. Even if you are the
mother and sole guardian of Evelyn, you do not have the legal authority to give consent to the
sterilization of Evelyn because this procedure is outside the scope of a parent's legal authority
to validly consent to medical treatment of your child. Even in this circumstance that your child
has intellectual disability and incapable of giving a valid consent, a procedure such as
sterilisation cannot be carried out lawfully without the authority of the Family Court, or similar
legal body such as a Guardianship Board. I understand and acknowledge that Evelyn has some
intellectual disability, however, this does not deprive her of the legal and ethical right to be
treated medically as would any other patient, so a procedure would not be carried out unless it
was medically indicated for the best interests of the patient, and this sterilization procedure
might predispose Evelyn to some form of harm or risks.
Question from the mother:
'Why can't you have her admitted for the surgery? When Evelyn needed her appendix out you
admitted her to hospital.'
Yes, at that time, I admitted her to the hospital because an appendectomy can be a medical
emergency, and that decision was made for the best interest of the patient.
KEY ISSUES
Recognise that medical procedures like sterilisation, are different in nature from those
procedures for which a parent has the legal authority to consent on behalf of their child.
Identify that parents do not have the legal authority to consent to sterilisation of their child.
Identify that the doctor does not have the legal authority to consent to sterilisation of the child.
Recognise the need for a valid consent before the procedure can be undertaken.
Recognise that only the Australian Family Court or in some states the Guardianship Board has
the jurisdiction to authorise the carrying out of the procedure in the particular circumstances.
Articulate the 'harm' that potentially flows from the sterilisation of a minor and the recognition
of the issues associated with discrimination in relation to individuals with disabilities.
CRITICAL ERRORS
To agree Evelyn's parent can give a legally valid consent for Evelyn to undergo such surgery.
To agree that the candidate, as the treating medical practitioner, can give a legally valid consent
to the procedure.
To fail to recognise that even though Evelyn has an intellectual disability, a valid consent is
necessary.

The case raises the legal and ethical issues surrounding consent.
As a general proposition the parents of a child have the legal authority to consent to treatment
on behalf of their minor children provided they do so in 'the best interests' of the child (Family
Law Act [Commonwealth]). However there are limitations to this authority. In the Australian
case of Re Marion the parents of a 14-year-old intellectually disabled child applied to the Family
Law Court for an order permitting a hysterectomy and oophorectomy to be carried out on their
child or a declaration that they could lawfully consent to the surgical procedure. The issue
before the court was whether the parents of the child had the legal authority to consent to
their child's sterilisation? The majority decision of the High Court of Australia determined that
the procedure required the authority of the court, expressly stating that the performance of a
sterilisation procedure was a 'special case' that took the decision outside what would be
considered as the ordinary scope of a parent's authority to consent.
The ethical considerations include recognition of the principle of autonomy and the fact that in
circumstances where patient capacity is compromised, patients may not be able to participate
in decisions about their health care as autonomous decision-makers. The degree to which they
are able to make autonomous decisions will be determined by both their level of incapacity (in
terms of their ability to understand) and the degree of complexity or invasiveness of the
procedure. The ethical principle of 'harm' and the right of all patients to the protection of their
body integrity is pivotal to the facts presented in the scenario. Patients, regardless of their level
of intellect, are entitled to medical treatment that is based upon sound and knowledgeable
clinical practice. All patients are entitled to be treated equally and not be discriminated against
based on factors such as their level of disability.
Condition 123 Blood transfusion consent
A 33 year old woman, Miriam, has just come to see you in the Emergency Department of a
major urban hospital with a severe antepartum hemorrhage. She is seven months old (30
weeks) pregnant, and prior to this time, has been fit and well. This is her second pregnancy--her
first baby is alive and well.
On examination, she is conscious and able to speak. Her appearance is pale and sweaty, she is
tachycardic and her blood pressure is 80/45mmHg. The hemorrhage is continuing. An
emergency ultrasound suggest central placenta previa.
You start to take appropriate measures, including insertion of an intravenous cannula, and
taking blood for grouping and cross-matching. You have begun transfusion with Hartmann
balanced electrolyte solution. You explain to her that she will need an emergency blood
transfusion as part of her treatment, and that this will start as soon as possible while
preparations are made for an emergency Cesarean section.
She says that she is a Jehovah's Witness and will not accept a blood transfusion. Her husband is
also a Jehovah's Witness. He is overseas at the moment and cannot be contacted.
TASKS
Ascertain fully the patient's views about her treatment by blood transfusion
Explain the risks and benefits of the suggested treatment for both Miriam and the baby
After six minutes, answer the examiner's questions.
APPROACH
Good morning/afternoon, Miriam. It seems that you have a condition that we call an
antepartum hemorrhage or a severe bleeding during pregnancy because of the very low
attachment of the placenta to your womb which we call as placenta previa which we have seen
on your ultrasond examination. Sorry for using a medical term, but let me explain this to you.
(ILLUSTRATE) Inside the womb, the baby is attached to the mother through an organ we call as
the placenta, which provides nutrition and blood to the baby. Normally this is attached way
above your cervix and vaginal canal. However in your case, it seems that the placenta is lying in
the way of your baby. Because of its placement the placenta is prone to be pushed by the baby
constantly or is forced to contract by the womb muscles causing bleeding episodes. This
condition presents as a common cause of bleeding in pregnancy, and it usually presents with a
causeless, painless, recurrent bleeding. Sometimes it can present with severe life-threatening
bleeding, unfortunately as in your case, which can adversely affect you and your baby.
I can imagine how this can be very distressing for you. Would you like me to call anyone to be
with you right now, or is it okay to for me to continue explaining what we can do to address
your condition?
Currently we can see that your BP is low and your pulse is fast, with you being sweaty and
having cold hands and feet, and shortness of breath. These are signs of what we call as
hemorrhagic shock due to blood loss. This means that your organs may not be receiving the
adequate oxygen they need to optimally function because of the blood loss, as blood carries
oxygen to our organs and to your baby. With your symptoms, it seems that most likely you lost
at least 30% of your blood volume and still you are actively bleeding. This is an indication for a
blood transfusion to increase the chances of survival both for you and for your baby.
NO DOCTOR, I DON’T WANT TO BE TRANSFUSED!
It is your right to refuse the treatment. However, it is important for me to explain the possible
outcomes, the advantages and disadvantages of these procedure so that you can make an
informed decision. We can discuss your treatment options in private, as I understand you are a
Jehovah's witness. It that okay with you?
Right now, the best chances we have to save your baby is by doing an emergency cesarean
section--that is, we operate on your tummy and womb to deliver your baby as soon as possible.
Your bleeding will stop as soon as we empty your womb and remove your placenta. However,
the operation itself is associated with blood loss (500ml) and may worsen your condition if
blood transfusion is not given BEFORE and AFTER this procedure. Do you understand so far?
We can maximize giving you fluids and use synthetic blood substitutes (Haemaccel) which can
reduce the shock. However, if the bleeding continues and once 40% blood loss has occurred,
the biggest problem we'll have is oxygen deprivation (Hypoxia) for both you and your baby, as
these blood substitutes cannot carry oxygen to your organs, thereby shutting down your organs
which can lead to death. And the only way we can address this is to have blood transfusion as
only blood has the capacity to carry oxygen throughout your body.
NO DOCTOR, I STILL DON'T WANT TO BE TRANSFUSED
Can you please tell me if you fully understand all the possible consequences which may arise
without the blood transfusion? The baby may survive if the operation is done immediately, but
the chances of you dying is markedly increased without transfusion, and without proper
preparation for Do you have any questions for me so far?
I respect and understand your decision. We will do our best to save you and your baby's life
without the blood transfusion.
TO THE EXAMINER
Summarize the legal and ethical issues in this situation
The case raises the issues of a legally valid consent. It is a process for ensuring that patients can
have control over what happens to them, and ensuring that they are competent to decide and
have sufficient information to understand the implications of their decisions
LEGAL ISSUES
Every competent patient has the legal right for autonomy -- or to accept or refuse treatment.
She has the right as an adult of sound mind to self-determine her treatment.
Even if the patient's rights can be restricted by a potential damage to a third person--as in this
case her baby, in Australia, the fetus/unborn baby has "no rights" justifying treatment being
forced on the mother against her wishes.
Australian law does not protect the unborn child from maternal decisions regarding care.
Human Tissue Act (1982) allows children to be transfused without parental consent providing
that without a transfusion the child was likely to die, and providing two medical practitioners
concurred in that opinion before administration of the blood transfusion. However, this does
not apply as the child is still unborn
ETHICAL ISSUES
Miriam's right to be an autonomous decision-maker is not actually restricted by any impact her
decision will have on her baby, although it would be restricted if the decision was one involving
blood transfusion to her baby following delivery if this was necessary to preserve life.
What will you do--how will you manage this situation?
Respect patient's decision
Aggressive IV fluids and synthetic blood alternatives to be given to prepare the patient for an
emergency caesarean section
KEY POINTS
Ability to deal with strong religious views in a respectful manner
Ability to recognize the priorities in this emergency situation and respond appropriately
Recognizing that urgent Caesarean section is required as the bleeding is continuing and causing
persisting shock and urgent operation is the only way of controlling persisting bleeding, despite
the risks which an operation would entail
CRITICAL ERRORS
Not finding out Miriam's definitive wishes about treatment
Indicating they would transfuse Miriam without obtaining a valid consent (either from Miriam
or from her husband if Miriam was no longer conscious and capable of providing any opinion,
for example, after Miriam had lost consciousness)

Most points from the commentary were already applied in the explanations to the patient and
examiner above.
If the patient loses consciousness, respect her decision
If husband is present, ask for husband's consent
Condition 128 Urinary incontinence in a 50-year-old woman
Your next patient is a 50-year-old woman with three children aged 29, 25, and 22 years. She
comes to see you in a general practice setting because of a problem of urinary incontinence
necessitating her to wear a pad all the time
TASKS
Ask the examiner about relevant findings likely to be evident on general and gynecological
examination
Advise the patient of the diagnosis and subsequent management including any investigations
you would advise
Causes of incontinence (DIAPPEERSS)

D – Delirium
I – infection of UT
A - Atrophic urethritis
P – Pharmacological (diuretics)
P – Psychological (acute distress)
E – Endocrine (hypercalcemia)
E – Environmental (unfamiliar surrounding)
R – Restricted mobility
S – Stool impaction
S – Sphincter damage or weakness
Risk factors:
UTI
Obesity
Smoking
Caffeine
Constipation
Chronic cough
Multiparity
Menopause
APPROACH
HISTORY
I'm sorry to hear you are having urinary incontinence as this can be very distressing. But don't
worry I am here to help you and look after you today. Can you tell me more about your
incontinence?
ASK ABOUT URINARY SYMPTOMS (identify the type of incontinence)
How much urine usually flows? Is it a small or large amount during episodes? How many pads
have you used in a day?
Do you tend to rush to the toilet or else you'll have incontinence? (URGE)
Do you feel urine leaking when you cough, sneeze, laugh or strain? (STRESS)
Do you have constant dribbling? (OVERFLOW)
Any feeling of a mass bulging down below?
Do you have any burning or stinging sensation while you urinate? Do you go to the toilet more
than the usual? Any frothy or smelly urine? Any changes in the color of your urine?
Any discharge or rashes from down below?
Any fever? Abdominal pain? (r/o UTI/infections)
Any weight loss? Do you feel thirsty all the time (r/o DM)
ASK ABOUT RISK FACTORS
I am going to ask you some private and sensitive questions to identify some factors which could
have lead to your condition. Is that okay with you?
Pregnancy history: I can see from your notes that you had three children. So you had three
pregnancies, is that correct? Did you have a difficult labor for all pregnancies? Do you
remember the weight of your babies? What type of delivery did you have, any instruments
used? Are you aware if you had an episiotomy/repair of lacerations?
Periods: when was your last period?
If menopause: at what age did you have your menopause? Any mood swings, hot flushes?
Are you on any hormone replacement therapy?
Partner: are you sexually active? Are you in a stable relationship? Do you have any pain during
intercourse? Bleeding during intercourse? Any history from STIs?
When was your last Pap smear? Did you already have your mammography?
Do you have any cough?
Any changes in your bowel motion? Do you have any hard stools?
SADMA
Do you smoke, drink alcohol, or engage in recreational drugs?
Do you drink coffee (caffeine as risk factor), how many cups do you usually take in a day?
Do you take any medications? Any allergies?
How is your situation at home?
What's your occupation? Any stresses at work?
PMHx: Have you been diagnosed with any illnesses? Did you have any surgeries, especially
done down there?
FHx
GA: BMI**, dehydration** any edema, lymphadenopathy?
VITALS: Temperature, BP
Chest/Heart: r/o infections
Abdomen: any distention, visible masses? Tenderness? Is there renal angle tenderness?
PELVIC
INSPECTION: any bleeding, discharge, rashes, or vesicles? Is any prolapse visible (third degree
already visible)
Vagina: any thin, dry, atrophic vagina?
SPECULUM: is the cervix healthy or not, any discharge or bleeding that you can see?
Can you cough or bear down/STRAIN? ==> CHECK IF THERE IS ANY PROLAPSE (CYSTOCOELE IN
THIS CASE)
Is incontinence present?
DEGREES OF PROLAPSE
First degree: remains inside the vagina (coming down, but does not reach the introitus)
Second degree: cervix comes at or near the introitus***
Third degree: most of the uterus and cervix lie outside the vagina
PER VAGINAL
UTERINE SIZE, TENDERNESS
ADNEXA: MASS, TENDERNESS
OFFICE TESTS: BSL, URINE DIPSTICK
DIAGNOSIS AND MANAGEMENT
From your history and examination, it seems that most likely you have a condition called stress
incontinence. Have you heard about it? Let me explain this to you. (ILLUSTRATE) Because you
are already in menopause, you have decreased levels of estrogen and this estrogen is needed
to maintain a good tone of your lower pelvic muscles. Moreover, with your history of having
several vaginal deliveries and with your increased weight, your pelvic muscles tend to become
lax and loose thus causing the anterior vaginal wall (the part of the vaginal wall with the
urethra/urine passage) to go out of your vagina, causing involuntary loss of urine whenever
there is increased pressure inside your abdomen--that is when you tend to cough and strain.
However, it is also likely that you have an "urge" incontinence, that is incontinence associated
with a sudden need to void. Due to the mixed nature of your incontinence, we need to do
further investigations to confirm your diagnosis, and to see which component appears to be
worse.
I can imagine how this can be very distressing for you, but let me reassure you that this is a
manageable condition.
I will refer you to a specialist who will do a urodynamic assessment to confirm your diagnosis.
When results of this assessment are available, decisions can be made on non-operative care.
We will also do basic blood tests (FBE, UEC, CRP, ESR, RFTs), and urine microscopy and culture
to identify other possible causes of your incontinence.
For now, this is what we can do. As your symptoms present more as a stress incontinence, you
can do pelvic floor exercises and I will refer you to a physiotherapist to teach you. You can do it
in a sitting, standing, or a lying down position. Contract your bottom muscles for a count of 8,
relax it for the same amount of time you have contracted your muscles, and do it 8 times at a
go, 3 times a day. Eventually, you can slowly increase the time you can do this
You can also use a pessary to correct the prolapse you have. You have to maintain bladder
diary.
It is very important that you lose weight to help reduce the pressure you have to your pelvic
muscles. I can refer you to a dietitian to assist you in your diet. And you should engage in
exercise, for 30 minutes at least once a day. You should also stop smoking, as the latter will
certainly reduce your coughing episodes that will reduce your abdominal pressure thus
minimizing your symptoms.
In case we see any instability of the muscle of your bladder (illustrate--detrusor instability), the
specialist may start some medications that can control your symptoms (propantheline,
imipramine, or oxybutynin). Bladder retraining will also be done, so that it can accept a larger
amount of urine before it will empty out.
Hormone replacement therapy can also be commenced to reduce the laxity of your pelvic floor
muscles, and also reduce your menopause symptoms.
However, if these interventions will not work out for you, the specialist might consider surgery
where he will elevate, support and buttress the bladder neck to reduce your symptoms.
Do you understand so far? Do you have any questions?
KEY ISSUES
Knowledge of the causes and types of urinary incontinence which occur in middle aged women
Knowledge of the investigations required to assess such incontinence and the general principles
of the management programmes available
Ability to recognize the probability that this is not just stress incontinence, that urodynamic
assessment is advisable, and treatment will depend on results obtained
CRITICAL ERRORS
Failure to arrange urine microscopy and culture to exclude urinary infection

Urinary incontinence with urgency causes
Urinary tract infection
Unstable bladder
Genuine stress incontinence associated with vaginal prolapse
Urodynamic studies performed to identify the cause, as the management may be medical or
surgical
Non-surgical treatments
Bladder retraining and pelvic floor exercises
weight loss
cessation of smoking (reduce cough!)
pharmaceutical agents that improve detrusor instability
HRT
Antispasmodics/anticholinergics
Surgical treatments
Retropubic or transvaginal suspension -- support bladder neck and urethra
Anterior colporrhaphy with bladder neck buttressing
Sling procedures (aldridge)
Local injections of collagen
Common problems
Failure to ask about incontinence features
Large volumes = Urgency incontinence
Small volumes on straining = STRESS incontinence (S - S -S)
Continuous loss - fistula or overflow incontinence
Failure to recognize that incontinence is related to menopause, and to enquire about the use of
HRT
Failure to advise about non-operative interventions

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Contents of AMC Handbook (Gynae)

Condition 009 Contraceptive advice ............................................................................................... 1

Condition 009 Contraceptive advice

IMPORTANT POINT FROM THE COMMENTARY

Condition 010 Rape of a 20-year old Woman

INVESTIGATIONS AND MANAGEMENT

IMPORTANT POINTS FROM THE COMMENTARY

IMPORTANT POINTS FROM THE COMMENTARY

VOLUME 6ml (2-6ml)

IMPORTANT POINTS FROM THE COMMENTARY

IMPORTANT POINTS FROM THE COMMENTARY

Diagnosis and Management

IMPORTANT POINTS FROM THE COMMENTARY

IMPORTANT POINTS FROM THE COMMENTARY

IMPORTANT POINTS FROM THE COMMENTARY

IMPORTANT POINTS FROM THE COMMENTARY

Condition 123 Blood transfusion consent

IMPORTANT POINTS FROM THE COMMENTARY

Causes of incontinence (DIAPPEERSS)

IMPORTANT POINTS FROM THE COMMENTARY

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