How to attempt SEQs

Dr.Shahnaz Kouser Assistant Professor Gynae Unit-1,

AIMC/ JHL
Question
A 26 years old PG has presented at 6 weeks of
gestation with mild P/V spotting. A transvaginal
ultrasound confirms right sided tubal pregnancy.
Outline the criteria for expectant management?
Answer
Expectant management is an option for
clinically stable women with minimal symptoms. No
medical/surgical T/M. just follow up & monitoring.
Criteria; Asymptomatic women (detailed history &
examination)
TVS; less than 100 ml fluid in POD sac size 3 cm
Serum -hCG 1000 iu/L
Expectant M/X contd
Compliance of Patient; Pt should know the possibility
of progression of disease i.e rupture & the need for
further T/M.She should have easy access to hospital. Pt
should be compliant to regular follow-up which involves
weekly TVS & twice/weekly hCG until 20 iu/L.
Question
A 20 years old married woman presents to the OPD with
H/O burst condom during sexual intercourse (or if COC

has been forgotten). Her husband is a university student

& they can not afford pregnancy.
1. What will you advise her? 2. What are the treatment
options available to her?
Answer
1. She will be advised to use emergency contraception
(EC). Option will be decided after detailed history &
examination.
2. Options; Hormonal ECLevonorgestel (single dose 150
mg within 72 hrs), Combination pills (Emkit, postinor,
COCP).
CU-IUCD(within 5 days of coitus)
Question
A booked PG at 39+6 weeks of gestation presented in
labour ward with H/O labour pains since 5 hours.
How will you manage her labour?
Answer
Detailed historyfrequency, duration & intensity of
contractions, membranes ruptured or not, colour of
liqour, abnormal vaginal discharge or bleeding, fetal
movements, coexistent medical problems.
Detailed examinationGPE, Abdominal exam for FHT, lie,
presentation, degree of engagement, EFW, FHS,
assessment of contractions, Vaginal examination for

cervical dilatation, effacement, condition of membranes,

color of liqour & station of presenting part.
Labour management contd
InvestigationsCBC, C/E urine, blood group & Rh factor,
BSL-R, viral serology, Obstetric USG. Any other acc to
situation. Subsequent management; Latent
phaseMobilize, pain relief, reassure & reassess, light
diet & rest. First stage; Monitoring of progress of labour.
Maintain partogram. Fetal monitoring Adequate pain
relief & hydration. Care of bladder. Patient
communication Active intervention (oxytocin & rupture
of membranes) only when indicated.
Labour management contd
2nd & 3rd stage Fetal monitoring Pushing & valsalva
manoeuvre only when urge develop. Management of
actual delivery process & delivery of placenta. Active
M/X of 3rd stage of labour.
Question
A 22 years PG came 8 hours back in labour room with
labour pains. She is now fully dilated for 1 hour. Vx is
between -1 & 0 station.
1. What are the probable causes? 2. What should be
done?
Answer
This is prolonged/delayed 2nd stage 1.
Causessecondary uterine inertia(due to epidural,

maternal dehydration & ketosis), fetal malposition (deep

transverse arrest & POP), Android pelvis & CPD (big baby
etc).
2. Treatment acc to cause; For uterine inertiaMaternal
rehydration, syntocinon augmentation & bladder
evacuation. For POP & DTA instrumental delivery /
LSCS. For android pelvis & CPD LSCS.
Question
A 28 years old lady presents in OPD with vaginal
discharge & multiple painfull ulcers on her vulva.
Examination reveals bilateral inguinal adenopathy. The
provisional diagnosis of herpes genitalis was made.
1. How will you confirm the diagnosis? 2. Outline the
management?
Answer
Confirmation of diagnosisexamination under electrone
microscope, culture of vesicle secretion, serum antibodies
(IgM & IgG), PCR.
Managementanalgesics, saline bath, local application of
xylocain gel, Antiviral therapy (acyclovir 200 mg 5
times/day), acyclovir ointment for local application
Question
A 38 years old woman P5+ 2 comes with C/O heavy
regular periods.
1. What investigations will you carry out?

2. What is the D/D?

3. How will you manage the patient medically?
Answer
1. InvestigationsCBC, TVS for myometrium, endometrial
thickness, fibroids, ovarian pathology. Other
investigations acc to associated medical conditions. 2.
D/DFibroids, endometrial polyp, thyroid disease, use of
IUCD, bleeding disorders. 3. Medical T/MNSAIDs,
tranexamic acid, hormonal therapy i.e progestogens,
COCP, LNG-IUS, danazol, Gestrinone, GnRh analogues.
Question
A 25 years old lady P1 presents with urinary incontinence
on 10th post-op day of LSCS carried out for obstructed
labour.
1. What is your diagnosis? 2. How you will confirm the
diagnosis?
Answer
1. DiagnosisUrinary fistula (vesicovaginal fistula). 2.
Confirmation of diagnosis; Detailed history; (continuous
dribbling. No urge to pass urine). Local
examinationSurface excoriation of perineal area due to
urine leakage. P/V & P/S exam location of site & size of
fistula. 3 swab test (methyline blue in bladder) for type
& site of fistula. Intravenous pyelogram
Question

A 26 years old patient with known case of mitral stenosis

comes in early labour at term.
How will you manage her labour?
Answer
Management; Detailed history of antenatal period. Ask for
shortness of breath, exercise tolerance, palpitations,
duration of contractions, associated ROM, FM. Detailed
drug & T/M history.Review the record & all investigations
sp. Echocardiography. Detailed examination for pulse
rate, rhythm, BP, edema, SFH, FHS & presentation, pelvic
exam for stage of labour. Heart & lung examination.
Investigations; CBC, C/E urine, BSL, ECG,
Echocardiography. Intrapartum management; Use
prophylactic antibiotics. Ensure fluid balance &
restriction. If required give concentrated oxytocin
infusion. Avoid supine position. Give adequate
analgesia. Keep 2nd stage short. Do not give
ergometrine in 3rd stage of labour. Vigilant post
delivery monitoring for pulmonary edema.
Question
A primigravida came at 38 weeks of pregnancy with BP of
160/110 mm Hg & proteinuria ++. Induction of labour
(IOL) has been decided.
1. How this pt should be evaluated before induction of
labour? 2. What are the methods of induction? 3. Enlist
the complications of IOL?

Answer
Pre-induction evaluation; Confirm duration of pregnancy
Review previous antenatal record. Abdominal exam
for presentation, liqour volume & estimated fetal weight.
Pre induction CTG. Assessment of bishop score.
Decision about mode of induction. Methods of induction;
If bishop score6Prostaglandin pessaries, gel and oral
tablets (misoprostol), extraamniotic foleys, catheter
insertion. If bishop score 6ARM, syntocinon infusion,
membrane sweepening.
Answer IOL contd.
Complications of IOL; Failure of IOLEm LSCS. Uterine
hyperstimulation Fetal asphyxia (long labour) Cord
prolapse (in case of ARM) Long duration of labour
More analgesia required Uterine rupture(with previous
scar & grand multipara) More assisted vaginal delivery.
Post-partum hemorrhage (long labour & uterine atony)
Question
You are attending a patient in outdoor who had vaginal
hysterectomy & anterior colporraphy 2 months back.
1. How will you evaluate & examine her? 2. What
problems and/ or complications she may present with?
Answer
1. EvaluationDetailed history to know any symptoms
related with surgery (urinary retention or incontinence,
UTI), vaginal discharge, dyspareunia, bleeding P/V.

Examinationgeneral condition, for healing of repair,

vaginal vault collection, vaginal discharge/bleeding. 2.
Complicationsurinary retention or incontinence due to
anterior repair, UTI, vaginal vault hematoma, Vaginal
discharge or bleeding/spotting, recurrence of cystocele,
vault prolapse.
Question
A 29 years old woman presents to accident & emergency
department with a 24 hour H/O abdominal pain
accompanied by vaginal discharge, nausea & fever.
1. What investigations will you carry out? 2. How will you
treat her?
Answer
1. InvestigationsCBC, C/E urine, antibodies against
chlamydia & gonorrhoea, endocervical swabs for
culture/sensitivity, USG (pelvic), HVS, Laparoscopy. 2.
Treatment; Pts presenting with acute peritonitis &
systemic upset usually have gram ve aerobic organisms.
I/V antibiotics2nd or 3rd generation cephalosporins,
augmentin, quinolones followed by oral therapy.
Sometimes combination with genticyn & metronidazole is
required for more severe cases. Public education for
STD prevention Partner treatment. Avoid using IUCD.
Surgery in case pelvic abcess is diagnosed.
Question

A 30 years old nullipara has presented with secondary

amenorrhoea of 6 weeks, severe lower abdominal pain &
vaginal spotting.
1. What is differential diagnosis? 2. How you will confirm
a definitive diagnosis? 3. Outline criteria of medical
management?
Answer
1. D/D Ectopic pregnancy, Threatened abortion, Missed
abortion. 2. Confirmation of diagnosis clinical signs of
pallor, tachycardia, hypotention,abdominal tenderness/
cervical motion tenderness &/or adnexal mass. Serum hCG & TVS for absence of intrauterine gestational sac,
presencew of extrauterine gest.sac/ or adnexal mass &
free fluid in peritoneal cavity.
3. Criteria of medical MX size of gest.sac 3 cm, serum
-hCG3000 iu/L, absent cardiac activity & no free fluid.
Question
A 48 years old P8 presents in gynecological OPD with a
single episode of postmenopausal bleeding.
1. What are the possible causes?
2. How will you investigate & manage this patient?
Answer
1. D/D Atrophic vaginitis, Endometrial polyp,
endometrial carcinoma.

2. Investigations(Detailed history & Local examination)

TVS for ET & uterine/adnexal pathology, D&C.
Management depends upon cause, topical estrogen for
atrophic vaginitis, polypectomy for polyp, TAH & BSO for
endometrial CA.
Question
A 16 years old girl presents with cyclical abdominal pain
and primary amenorrhoea.
1. What is the most likely diagnosis?
2. How you will confirm the diagnosis?
Answer
1. Imperforate hymen/Vaginal septum
2. Diagnosis detailed history, secondary sex characters
and local examination for bluish bulging membrane,
lower abdominal mass. Investigation, pelvic USG for
hematocolpos/hematometra.
Question
A 25 years old girl presents in gynae OPD complaining
of infrequent periods, weight gain & hirsutism.
Outline the steps you would take in the management of
this patient?
Answer
History including relevant points for polycystic ovarian
disease. Examinationhair distribution,BMI,

galactorhoea & pigmentation. Investigations USG

(TVS), Hormone profile including FSH/LH, serum prolactin,
& testosterone. T/M planweight reduction, cosmetic
measures, antiandogens & metformin. Surgical T/M
include laparoscopic ovarian drilling & diathermy.
Question
A woman is readmitted to hospital at 8 weeks
gestation with severe hyperemesis gravidarum. This is
her 3rd admission to hospital in the past 2 weeks.
1. Enumerate the causes in order of poriority? 2. What
investigations would you carry out? 3. What are
treatment options?
Answer
1. Causes Molar pregnancy, Multiple gestation, Urinary
tract infection, peptic ulceration, pancreatitis.
2. InvestigationsCBC,C/E urine, serum electrolytes, LFTs,
RFT,s.
3. Treatmentemotional & psychological support Fluid
& electrolyte balance by I/V hydration Antiemetics &
parenteral B-complex Corticosteroids & parenteral
nutrition In very severe & rare cases and in molar
pregnancy termination of pregnancy.
Question
A 52 years old P5, asthmatic & obese presents in
gynae OPD with H/O feeling of a lump down below and
backache. She has difficulty in emptying her bladder.

1. What is the most likely diagnosis?

2. What risk factors contribute to development of such
condition?
Answer
1. Diagnosis Uterovaginal prolapse
2. Risk factors; Difficult prolonged vaginal delivery
(which damage nerves, endopelvic fascia & levator ani).
Mutiparity Overweight & Chronic cough (cause raised
intraabdominal pressure). Aging/ menopausal
Congenital.
Question
A 33 years old P3 presents in OPD with the history of curd
like thick vaginal discharge, pruritis & vulval soreness.
1. What is most likely diagnosis?
2. How will you treat this lady?
Answer
1. Diagnosis Vaginal candidiasis 2. T/M; Patient should
improve her personal hygine. Treat coexistent
conditions (e.g DM) Treat partner. For uncomplicated
candidiasis, give local therapy with single dose
clotrimazole 500 mg. For oral therapy give single 150
mg tab of antifungal (fluconazole). For recurrent cases
give antifungal (oral) once or twice a month for few
months.
Questions

A 32 years old P4 becomes unconscious 2 hours after

delivery.
1. What are the causes of pospartum collapse?
2. What will be the basic life support skills in this case?
Answer
Causes Simple faint, Epileptic faint, Hypoglycemia,
profound hypoxia, intracerebral bleed, cerebral infarction,
cardiac pathology, pulmonary embolism, major
hemorrhage & hypovolemia, septic shock, eclampsia & AF
embolism.
BLS skills Shake & shout, Airway & breathing, maintain
circulation, treat hypovolemia by aggressive fluid
therapy, stop hemorrhage, stabilize & seek the cause,
senior multidisciplinary assistance throughout.
Questions??