PG OGSSI revision course.pptx

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1. GYNEC OSCE INSTRUMENTS SPECIMENS CHARTS X RAY DR ALKA, Dr MIRUNALINI ASSISTANT PROFESSOR OBGYN, SRIHER

2. INSTRUMENTS

3. IDENTIFY HOW ARE THESE TWO DIFFERENT ?

4. J.MARION SIMS

5. PARTS – SIMS DOUBLE BLADE SPECULUM UPPER BLADE GROOVE HANDLE LOWER BLADE

6. CUSCO’S bivalve SPECULUM UPPER BLADE LOWER BLADE THUMB SCREW THUMB HOLDER HANDLE

7. USES - BOTH OBSTETRIC USES 1 ) To confirm diagnosis of PROM. 2) During cervical encirclage procedure. GYNEC USES 1) to take Pap smear 2) during vaginal hysterectomy. 3) To exam the anterior vaginal wall for diagnosis of vesico -vaginal fistula. 4) To diagnose pelvic organ prolapse.

8. ADVANTAGES & DISADVANTAGES – OVER SIMS SPECULUM Self retaining instrument – needs no assistant Cannot be used for procedures involving the anterior and posterior vaginal wall.

9. * Identify * uses?

10. SIMPSON’S UTERINE SOUND OLIVE TIP CALIBERATED HANDLE 150 DEGREE

11. MATTHEW DUNCAN DILATOR ROUND TIP HANDLE WITH NUMBER NO CALIBERATIONS LIKE THE UTERINE SOUND

12. USES – uterine sound / Matthew Duncan UTERINE SOUND measure uterocervical length. Know AV/ RV uterus. MATTHEW DUNCAN For dilatation and curettage. Only 1 size per instrument For Anteversion of uterus during lap cases.

13. Any other dilator ?

14. NAME SOME CONDITIONS WHERE DILATATION ALONE IS DONE ?

15. CONDITIONS WHERE ONLY DILATATION IS NEEDED PRIMARY DYSMENORRHOEA BEFORE INSERTING RODS FOR RADIOTHERAPY PYOMETRA ,HEMATOMETRA

16. Identify….

17. Mayo artery forceps Uses…… This is a hemostat. For clamping bleeding vessels. For grasping tissue at the time of operation. (Opening and closing peritoneum) . To hold stay sutures. 2 types- straight and curved.

18. IDENTIFY

19. USES SPONGE HOLDING FORCEPS Preparation of parts with antiseptic solution To hold a sponge to mop from a distance For blunt dissection with a gauze To hold cervix in pregnancy during – cerclage, diagnosis & repair of cervical tear, D&E OVUM FORCEPS To remove products of conception To remove uterine polyp To remove foreign body in vagina .

20. IDENTIFY

21. USES ALLIS TISSUE HOLDING FORCEPS Hold edges of vaginal wall during Colporrhaphy TAH Vaginal wall cyst excision Myomectomy Hold the rectus sheath Hold the uterine edges in ceaserean section BABCOCK’S To hold soft tissues during surgery Fallopian tubes Bladder Bowel appendix

22. Identify vulsellum

23. In which procedures post lip of cervix held To diagnose enterocele Colpotomy Culdoscentesis

24. IDENTIFY GREEN ARMYTAGE FORCEPS

25. This forceps is used as a hemostatic instrument in caesarean operation. As the tips are broad wide area can be compressed. In LSCS the cut uterine edges bleed . This forceps is applied to the two angles and lower and upper edge of the incision. uses

26. Identify KOCHERS FORCEPS OBSTETRIC USE Artificial rupture of Membranes GYNECOLOGY USES TAH – Clamping the cardinal ligament

27. Identify HEANEY’S hysterectomy clamp

28. USE – TAH Serrations are oblique – risk of tissues slipping is less No tooth at the tip – risk of tissue trauma is less Advantages over kochers

29. IDENTIFY ?

30. KARMAN’S SUCTION CANNULA # UTERINE PERFORATION IS LESS # BLOOD LOSS IS MINIMAL # INCOMPLETE EVACUATION IS LESS LIKELY ADVANTAGE OVER metal CURETTAGE ?

31. Identify Leech Wilkinsons Cannula

32. HYSTERO SALPINGO GRAPHY Which day of cycle ? 6 to 8 th day What DYE ? Uro graffin / 60% Sodium Iotalamate or (60%methylglucaminediatrizoate(water soluble) Alternatives to HSG ? Laparoscopic chromotubation Advantage over lap chromotubation Site of block

33. Contraindications SUSPECTED ECTOPIC GESTATION INTRA UTERINE GESTATION PELVIC INFECTION SENSITIVITY TO CONTRAST MEDIUM

34. Any other cannula ??

35. Ayre ’ s Spatula – for taking the smear from cervix, posterior vaginal wall, upper 1/3 of lateral vaginal wall Cyto Brush – used to take smear from the cervical canal Solution used is 95% ethanol Indications of Pap smear CIN/Ca C x Follow up after Wertheim ’ s hysterectomy Hormonal cytology from upper 1/3 of lateral vaginal wall Buccal smear for Barr bodies Liquid based cytology suspension of cells from the sample and this is used to produce a thin layer of cells on a slide. The ThinPrep method requires an instrument and special polycarbonate filters. After the instrument immerses the filter into the vial, the filter is rotated to homogenize the sample. Cells are collected on the surface of the filter when a vacuum is applied. The filter is then pressed against a slide to transfer the cells into a 20 mm diameter circle.

36. Urinary catheters Metal catheter Intermittent bladder drainage Uses Prior to any vaginal procedures Foleys catheter Size – 16 F Uses – Gynec – Continous bladder drainage – major surgical procedures. Obs – Control haemorrhage (balloon Tamponade) Induction of labour.

37. Bakri balloon tamponade Mechanical method of management of PPH. Maximum instilled water – 350 ml 24 F catheter.

38. Cryo probe Treatment of LSIL or CIN 1 Freeze thaw freeze technique. -70 C Cryotherapy – mechanism of action Side effects – profuse vaginal discharge post procedure Loop electro excision procedure (LEEP ) Conisation – surgical technique wherein cone shaped cervix removed with the help of the cautery. 8 – 10 mm cervical tissue

39. RAPID FIRE

40. Sim’s Curette Blunt end - obs Sharp end - gynec

41. S ims anterior vaginal wall retractor

42. Cervical punch biopsy forceps

43. MYOMA SCREW IDENTIFY ?

44. BALFOUR SELF RETAINING RETRACTOR GYNEC ONCOLOGY Staging laparotomy

45. Retraction of intraperitoneal structures during operations : Deaver’s Retractor

46. Doyen’s retractor Retract the bladder during ceaserean section

47. LANDONS BLADDER RETRACTOR Retract skin / other structures

48. IDENTIFY ENDOMETRIAL BIOPSY( PLASTIC CANNULA)

49. LAPAROSCOPE

50. A drop of saline is placed on hub of the needle sucked in to peritoneal cavity Saline can be injected in to needle freely and cannot be reaspirated CONFIRM ENTRY INTO PERITONEAL CAVITY VEREES NEEDLE

51. TROCAR & CANULA Trocar is put into the canula – then entered into abdominal cavity. Size – 10 mm – camera 7 mm – band applicator instrument 5 mm – working port Trumphet – prevent gas leak Opening to connect the gas

52. UROGYNAEC

53. IDENTIFY

54. TVT –O (Trans Obturator Tape) TVT (Tension free Vaginal Tape)

55. SPECIMENS

56. Basic principles Describe gross appearance based on Shape Pathological findings Cut section Diagnosis

57. Identify Fibroid uterus Probable questions ? Medical management Mifepristone GnRH How does GnRH act? Hypogonadal state Medical oophorectomy Medical menopause

58. Identify Ca. endometrium Corpus cancer syndrome ? Familial hereditary syndrome associated with Ca endometrium. 4. How will you diagnose? Fractional curettage

59. Identify TYPES Tumour marker RMI score Investigations treatment BENIGN OVARIAN CYST

60. Identify Type Components Tumour marker treatment MATURE CYSTIC TERATOMA

61. IDENTIFY Ca Ovary Staging laparotomy Tumour marker RMI score chemotherapy

62. IDENTIFY TUBAL Ectopic pregnancy .What is SAM? Surgically Administered Medical therapy .Pre-requisites for methotrexate? beta HCG < 1500 IU Tubal mass <3.5cms FH ABSENT MOA – methotrexate Side effects Multi dose regimine

63. Department of Obstetrics and Gynaecology, SRMC&RI IDENTIFY Hydatiform mole Karyotype of partial mole – Triploid Treatment - S & E How will you follow up this patient? Weekly till normal for three weeks Monthly for six months.

64. Charts

65. A 27 year nulliparous lady (marital life 5 yrs ) had come for infertility treatment Her usg shows this picture Comment on this Any other tests for the same..?

66. ANTRAL FOLLICULAR COUNT No. of visible follicles(2-8mm) on day 2/3 Better predictor than AMH

67. PCOS Criteria ROTTERDAM ESHRE/ASRM 24 Years unmarried girl with irregular cycles USG picture as given, comment Criteria for diagnosing this condition Clinical implications and treatment

68. 30 yrs , primary infertility for 3yrs , undergone ovulation induction and now has come with pain abdomen and vomiting and her USG showed this picture Diagnosis Classification Management and prevention

69. Comment on this picture Endometrial grading

70. Gonen and casper in 1990.  Type a : entirely homogeneous, hyperechogenic pattern, without a central echogenic line Type b : intermediate iso-echogenic pattern, with the same reflectivity as the surrounding myometrium and a non-prominent or absent central echogenic line Type c :  multilayered ‘triple-line’ endometrium consisting of a prominent outer and central hyperechogenic line and inner hypo-echogenic or black region

71. APPLEBAUM SCORING The endometrial and periendometrial areas are divided into the following four zones Zone 1: A 2-mm thick area surrounding the hyperechoic outer layer of the endometrium. Zone 2: The hyperechoic outer layer of the endometrium. Zone 3: The hypoechoic inner layer of the endometrium. Zone 4: The endometrial cavity.

72. Simple cyst Haemorrhagic cysts Endometrioma Dermoid cyst Ovarian cysts

73. IOTA SIMPLE USG RULES FOR OVARIAN MASSES

74. 44 yr old multiparous lady came with heavy menstrual bleeding and pain abdomen. Examination revealed bulky and tender uterus, bilateral fornices free Her USG showed this pic Diagnosis Management

75. USG criteria for ADENOMYOSIS Diffuse uterine enlargement Diffusely heterogenous myometrium Asymmetrical thickening of myometrium Poor defining of endometrial –myometrial borders Inhomogenous hypoechoic areas Focal probe tenderness

76. Identify this picture What modality of investigation is better for the diagnosis Specific complaints Management

77. Identify FIGO classification STEP-W….???

78. 47 yrs , multiparous women with heavy menstrual bleeding Imaging shows this picture Diagnosis Treatment Role of medical management Prerequisites for myomectomy

79. Comment on this picture Indications and contraindications Procedure

80. Comment on these pictures

81. Uterine anomalies Classification AFS (1988)- lacked specific diagnostic criteria ESHRE (2013) - based primarily on uterine anatomy with cervical vaginal anomalies. Classes: U0–U6 , C0–C4, V0–V4. 3D-based diagnostic criteria for septate and bicornuate uterus ASRM (2021)- Nine classes: Mullerian agenesis, cervical agenesis, unicornuate , uterus didelphys, bicornuate, septate, longitudinal vaginal septum, transverse vaginal septum, complex anomalies .

82. Screening tests Diagnostic tests - 3D TVS and MRI The diagnostic accuracy of 3D - 97.6% Sensitivity- 98.3% and specificity -99.4%

83. Angle of divergence: <75 External contour normal or mild indentation Angle of divergence >105 Indentation>10mm Intervening cleft >1cm Intercornual distance >5cm Bicornuate uterus Septate uterus Limitation External uterine contour cannot be evaluated In cases of non-communicating rudimentary uterine horn may be missed.

84. 1- interostial line 2- Parallel line over the fundus 3-uterine thickness 4-septal indentation Troiano and mccarthy formula A line joining both the horns If it cosses the fundus or <5mm- bicornuate >5mm- septate

85. Tvs pelvis Uterine morphology Internal contour External contour Normal Straight or convex Uniformly convex or with indentation < 10 mm Arcuate Concave fundal indentation with central point of indentation at obtuse angle (>90◦ ) Uniformly convex or with indentation < 10 mm Subseptate Presence of septum, which does not extend to cervix, with central point of septum at an acute angle (<90) Uniformly convex or with indentation < 10 mm Septate Presence of uterine septum that completely divides cavity from fundus to cervix Uniformly convex or with indentation < 10 mm Unicornuate Single well-formed uterine cavity with a single interstitial portion of fallopian tube and concave fundal contour Indentation >10mm if rudimentary horn is present Bicornuate Two well-formed uterine cornua Indentation>10mm dividing 2 cornu T shaped T-shaped uterine cavity

86. CLINICAL IMPLICATIONS OF SEPTATE UTERUS Infertility Frequency of ectopic 27.34% as compared to 13.3% otherwise Abortions First trimester – 28-45% Second trimester-5% Preterm deliveries

87. Comment on this picture How to manage..?

88. HSG findings in Genital TB FALLOPIAN TUBES Specific findings Beaded tube Golf club appearance Pipestem app Floral app Leopard skin app Non specific findings Hydrosalphinx Mucosal thickening Peritubal adhesions (tobacco pouch app, loculated spill, cockscrew app

89. PARARECTAL SPACE Medial- rectum Lateral- internal iliac artery Anterior- uterine artery Roof- posterior leaf of broad ligament Floor- levator ani The ureter further divides the pararectal space into the medial and lateral pararectal spaces Medial pararectal space- OKABAYASHI SPACE Lateral pararectal - LATZKO SPACE Clinical implications : (superior hypogastric plexus)nerve-sparing radical hysterectomy, as well for nerve-sparing fertility preserving procedures (endometriosis) PARAVESICAL SPACE Medially- bladder, Laterally- pelvic walls Inferiorly -uterine artery The  paravesical  space is divided into medial and lateral paravesical spaces by the obliterated hypogastric artery or the lateral umbilical ligament medial paravesical space dissection - optimum oncological clearance lateral paravesical space - obturator and pelvic lymph nodes(pelvic lymphadenectomy)

90. Criteria for conservative management, medical management SAM RUBINS CRITERIA STUDDFORD CRITERIA SPIEGELBERG CRITERIA

91. Identify this image

92. CDC Criteria for diagnosis 1st line regimen for outpatient and inpatient treatment Complications / clinical implications

93. Identify Clinical symptoms and management…?

94. THANK YOU