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PG OGSSI revision course.pptx
- 1. C GYNEC OSCE INSTRUMENTS SPECIMENS CHARTS X RAY DRALKA, Dr MIRUNALINI ASSISTANT PROFESSOR OBGYN, SRIHER
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- 5. PARTS – SIMSDOUBLE BLADE SPECULUM
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- 7. USES - BOTH OBSTETRICUSES • 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.
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- 11. MATTHEW DUNCAN DILATOR ROUNDTIP HANDLE WITH NUMBER NO CALIBERATIONS LIKE THE UTERINE SOUND
- 12. USES – uterinesound / 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.
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- 14. NAME SOME CONDITIONSWHERE DILATATION ALONE IS DONE ?
- 15. CONDITIONS WHERE ONLYDILATATION IS NEEDED PRIMARY DYSMENORRHOEA BEFORE INSERTING RODS FOR RADIOTHERAPY PYOMETRA ,HEMATOMETRA
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- 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.
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- 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 1. To remove products of conception 2. To remove uterine polyp 3. To remove foreign body in vagina .
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- 21. USES ALLIS TISSUE HOLDINGFORCEPS – 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
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- 23. In which procedurespost lip of cervix held To diagnose enterocele Colpotomy Culdoscentesis
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- 25. • This forcepsis 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 OBSTETRICUSE Artificial rupture of Membranes GYNECOLOGY USES TAH – Clamping the cardinal ligament
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- 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
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- 30. KARMAN’S SUCTION CANNULA #UTERINE PERFORATION IS LESS # BLOOD LOSS IS MINIMAL # INCOMPLETE EVACUATION IS LESS LIKELY ADVANTAGE OVER metal CURETTAGE ?
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- 32. HYSTERO SALPINGO GRAPHY Which day of cycle ? 6 to 8th 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 ECTOPICGESTATION INTRA UTERINE GESTATION PELVIC INFECTION SENSITIVITY TO CONTRAST MEDIUM
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- 36. • 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 Cx • 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.
- 37. Urinary catheters • Metalcatheter • 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.
- 38. • Bakri balloontamponade • Mechanical method of management of PPH. • Maximum instilled water – 350 ml • 24 F catheter.
- 39. • 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
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- 41. Sim’s Curette Blunt end -obs Sharp end - gynec
- 42. Sims anterior vaginalwall retractor
- 43. • Cervical punch biopsyforceps
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- 45. BALFOUR SELF RETAININGRETRACTOR GYNEC ONCOLOGY Staging laparotomy
- 46. Retraction of intraperitonealstructures during operations : Deaver’s Retractor
- 47. Doyen’s retractor Retract thebladder during ceaserean section
- 48. LANDONS BLADDER RETRACTOR Retractskin / other structures
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- 51. A dropof 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
- 52. 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
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- 57. Basic principles • Describegross appearance based on • Shape • Pathological findings • Cut section • Diagnosis
- 58. Identify Fibroid uterus Probable questions? Medical management Mifepristone GnRH How does GnRH act? Hypogonadal state • Medical oophorectomy • Medical menopause
- 59. 1. Identify • Ca.endometrium 2. Corpus cancer syndrome ? 3. Familial hereditary syndrome associated with Ca endometrium. 4. How will you diagnose? Fractional curettage
- 60. Identify • TYPES • Tumourmarker • RMI score • Investigations • treatment BENIGN OVARIAN CYST
- 61. Identify • Type • Components •Tumour marker • treatment MATURE CYSTIC TERATOMA
- 62. • IDENTIFY • CaOvary • Staging laparotomy • Tumour marker • RMI score • chemotherapy
- 63. IDENTIFY TUBAL Ectopic pregnancy .Whatis 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
- 64. Department of Obstetricsand 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.
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- 66. • A 27year 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..?
- 67. ANTRAL FOLLICULAR COUNT •No. of visible follicles(2-8mm) on day 2/3 • Better predictor than AMH
- 68. PCOS Criteria ROTTERDAM ESHRE/ASRM • 24Years unmarried girl with irregular cycles • USG picture as given, comment • Criteria for diagnosing this condition • Clinical implications and treatment
- 69. 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
- 70. • Comment onthis picture • Endometrial grading
- 71. • Gonen andcasper 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- 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 hyperechogenic line and inner hypo-echogenic or black region
- 72. • 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.
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- 74. IOTA SIMPLE USGRULES FOR OVARIAN MASSES
- 75. • 44 yrold 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
- 76. • USG criteriafor ADENOMYOSIS • Diffuse uterine enlargement • Diffusely heterogenous myometrium • Asymmetrical thickening of myometrium • Poor defining of endometrial –myometrial borders • Inhomogenous hypoechoic areas • Focal probe tenderness
- 77. • Identify thispicture • What modality of investigation is better for the diagnosis • Specific complaints • Management
- 78. • Identify • FIGOclassification • STEP-W….???
- 79. • 47 yrs,multiparous women with heavy menstrual bleeding • Imaging shows this picture • Diagnosis • Treatment • Role of medical management • Prerequisites for myomectomy
- 80. • Comment onthis picture • Indications and contraindications • Procedure
- 82. Comment on thesepictures
- 83. • 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.
- 85. • Screening tests •Diagnostic tests - 3D TVS and MRI • The diagnostic accuracy of 3D - 97.6% • Sensitivity- 98.3% and specificity -99.4%
- 86. • Angle ofdivergence: <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.
- 87. 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
- 88. Tvs pelvis • Uterine morphology Internal contourExternal 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
- 90. CLINICAL IMPLICATIONS OFSEPTATE UTERUS • Infertility • Frequency of ectopic 27.34% as compared to 13.3% otherwise • Abortions • First trimester – 28-45% • Second trimester-5% • Preterm deliveries
- 91. Comment on thispicture How to manage..?
- 92. HSG findings inGenital 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
- 97. 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)
- 99. • Criteria forconservative management, medical management • SAM • RUBINS CRITERIA • STUDDFORD CRITERIA • SPIEGELBERG CRITERIA
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- 101. • CDC Criteriafor diagnosis • 1st line regimen for outpatient and inpatient treatment • Complications / clinical implications
- 102. • Identify • Clinicalsymptoms and management…?
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