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OSCE Cases: Obstetric & Gynaecological Conditions

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🔴 TOPIC 1 — CHRONIC HYPERTENSION IN PREGNANCY

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CASE 1

1. Take a focused history (5 min)
2. Interpret the BP reading in the context of pregnancy
3. Outline your immediate management plan

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• Duration and severity of hypertension; pre-pregnancy readings
• Current antihypertensive medications (teratogenic agents?)
• End-organ involvement: headaches, visual changes, chest pain, urinary symptoms
• Previous pregnancy complications (superimposed preeclampsia, IUGR, stillbirth)
• Comorbidities: diabetes, renal disease, connective tissue disorders
• Family history of hypertension, preeclampsia
• Smoking, alcohol, weight

• BP 148/96 mmHg at <20 weeks = chronic hypertension (not gestational hypertension or preeclampsia)
• Defined as BP ≥140/90 mmHg predating pregnancy or detected before 20 weeks on at least two occasions (Comprehensive Clinical Nephrology, 7e)
• Risk of superimposed preeclampsia (responsible for 15–30% of hypertensive disease in pregnancy) (Textbook of Family Medicine, 9e)

• Continue methyldopa (safe in pregnancy); alternatives: labetalol, nifedipine
• Avoid ACE inhibitors / ARBs (teratogenic)
• Baseline investigations: FBC, U&E, LFTs, urinalysis (24-hr urine protein), uric acid
• Serial growth scans from 28 weeks (IUGR risk)
• Low-dose aspirin 75–150 mg daily from 12 weeks to reduce preeclampsia risk
• MDT: obstetrics + maternal–fetal medicine + nephrology if renal disease present
• Threshold for treatment: maintain BP <140/90 mmHg

• Superimposed preeclampsia = new onset proteinuria / end-organ features after 20 weeks in chronic hypertensive
• Home BP monitoring recommended to exclude white-coat effect (office BP ≥140/90 but home BP <135/85)

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CASE 2

1. What is the diagnosis? Justify.
2. What additional investigation is most urgent?
3. Outline immediate management.

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• Hemolysis: low Hb + fragmented RBCs on film
• Elevated Liver enzymes: AST 89 U/L
• Low Platelets: 98 × 10⁹/L
• BP >160/110 = severe range; symptoms (headache, epigastric pain) (Textbook of Family Medicine, 9e)
• HELLP occurs in 5–10% of patients with preeclamptic symptoms

• LDH (marker of hemolysis), full LFTs, coagulation screen (DIC risk), repeat FBC, serum uric acid, fetal CTG

• Admit to HDU/ITU
• IV magnesium sulfate: loading dose 4 g over 15–20 min, then 2 g/hr infusion for seizure prophylaxis
• Antihypertensive: IV labetalol (or IV hydralazine) to keep diastolic <110 mmHg
• Corticosteroids (betamethasone) for fetal lung maturity at 32 weeks
• Delivery is definitive treatment — aim to deliver within 24–48 hours
• Postpartum: MgSO₄ for 24–48 hours

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🟠 TOPIC 2 — PREECLAMPSIA

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CASE 3

1. Diagnose and explain the diagnosis to the patient
2. What further features would indicate preeclampsia vs gestational hypertension?
3. Counsel on monitoring and risks

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• ~25% of cases progress to preeclampsia (Comprehensive Clinical Nephrology, 7e)

• Proteinuria: uPCR >30 mg/mmol or 24-hr urine >0.3 g
• Maternal organ dysfunction: headache, visual disturbances, RUQ/epigastric pain, elevated transaminases, AKI, thrombocytopenia, pulmonary oedema
• Uteroplacental dysfunction: fetal growth restriction, abnormal umbilical Doppler, oligohydramnios

• Explain that preeclampsia complicates 5–10% of all pregnancies; risk highest in nulliparous, younger, African-American women (Textbook of Family Medicine, 9e)
• Bed rest + close surveillance for development of complications
• Serial BPs, urine protein, fetal growth scans
• Signs to report immediately: severe headache, visual changes, RUQ pain, decreased fetal movement
• Delivery is the only cure — timing depends on severity and fetal maturity
• Reassure that gestational hypertension usually resolves by 12 weeks postpartum

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CASE 4

1. What is the diagnosis?
2. Give the immediate management in sequence.
3. What is the definitive treatment?

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• Eclampsia = seizure activity in a woman with preeclampsia (Comprehensive Clinical Nephrology, 7e)
• Uncommon in high-income countries (~0.3% of hypertensive pregnancies)

1. Airway: position lateral (recovery position), supplemental O₂, call for help
2. Stop seizure: IV/IM magnesium sulfate 4 g IV over 5–10 min (first-line anticonvulsant; NOT diazepam)
3. BP control: IV labetalol or hydralazine — target diastolic <105–110 mmHg
4. Monitoring: continuous BP, O₂ sat, urine output (Foley catheter), fetal CTG
5. Blood tests: FBC, U&E, LFTs, coagulation, G&S
6. Maintenance MgSO₄: 2 g/hr infusion; monitor for toxicity (reflexes, respiratory rate, urine output)
7. MgSO₄ recurrence dose: 2 g bolus if further seizure

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🟡 TOPIC 3 — MISCARRIAGE (SPONTANEOUS ABORTION)

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CASE 5

1. Classify the types of miscarriage and apply to this case
2. What USS findings would confirm each type?
3. What are the management options?

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• Viable IUP (cardiac activity present) = threatened; reassure, monitor
• Anembryonic: GSD >25 mm without embryonic pole
• Embryonic demise: CRL >7 mm without cardiac activity (Berek & Novak's Gynecology)

1. Expectant: natural passage; suitable if stable, no infection
2. Medical: misoprostol (prostaglandin E1 analogue)
3. Surgical: manual vacuum aspiration or ERPC (evacuation of retained products)

• Risk of spontaneous abortion in subsequent pregnancy after one loss: 13–20%; after three consecutive losses: 33–43%

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CASE 6

1. What investigations would you request and why?
2. Counsel her on causes and prognosis.

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• Chromosomal anomalies: ~50% of early miscarriages are aneuploid
• Antiphospholipid antibody syndrome (treatable with LMWH + aspirin)
• Uterine structural anomalies
• Endocrine: luteal phase defect, thyroid disease, poorly controlled DM
• Infections: Toxoplasma, Mycoplasma, Listeria, certain viruses
• Immune (fetal-maternal immune imbalance)
• In majority of cases, no cause identified

• Even after 3 losses, chance of successful pregnancy in next attempt is ~60–70%
• Patients should be reassured that in most cases, spontaneous abortion does not recur (Berek & Novak's Gynecology)

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CASE 7

1. What is the diagnosis?
2. How is this different from an embryonic demise?
3. What is your management plan?

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• GSD >25 mm by TVS with no embryonic pole = anembryonic gestation, a nonviable IUP (Berek & Novak's Gynecology)
• The embryo failed to develop

• Anembryonic gestation: GSD >25 mm, NO embryo present
• Embryonic demise: Embryo present with CRL >7 mm + no cardiac activity

1. Expectant management: await spontaneous passage (may take weeks; ~80% complete by 8 weeks); suitable if no infection or haemodynamic compromise
2. Medical management: misoprostol 800 mcg vaginally; may need repeat dose; ~85% complete within 2 weeks
3. Surgical management: manual vacuum aspiration or ERPC under general anaesthesia; most complete and predictable

• All options have similar long-term fertility outcomes
• Offer psychological support and bereavement care
• Routine Rh testing and anti-D prophylaxis if Rh negative

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🟢 TOPIC 4 — ECTOPIC PREGNANCY

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CASE 8

1. What is the most likely diagnosis? Justify.
2. How do you manage this immediately?
3. What is the definitive treatment?

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• Classic triad: amenorrhea (6 weeks) + abdominal pain + irregular vaginal bleeding (Textbook of Family Medicine, 9e)
• Positive hCG = pregnant
• Haemodynamic instability (BP 88/52, HR 122) = haemoperitoneum
• Shoulder-tip pain = diaphragmatic irritation from haemoperitoneum
• Guarding/rigidity = peritonism
• Ectopic pregnancy is the most common obstetric cause of maternal death in the first trimester (Roberts and Hedges' Clinical Procedures in Emergency Medicine)
• 95% of ectopic pregnancies are tubal

• Call for help (surgeon + anaesthetist)
• Large-bore IV access × 2; IV fluid resuscitation (crystalloid/blood products)
• FBC, G&S (cross-match), U&E, β-hCG, coagulation
• Nil by mouth + anaesthetic review for urgent surgery
• Do NOT delay surgery for USS if haemodynamically unstable

• Emergency laparoscopy (or laparotomy if unstable):
  • Salpingectomy (tube removal) on affected side
  • Salpingotomy (tube conserving) — only if contralateral tube damaged AND patient stable
• Anti-D immunoglobulin if Rh negative
• β-hCG follow-up to confirm resolution

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CASE 9

1. What risk factors does she have and why are they important?
2. What serum investigations do you request? Interpret expected findings.
3. What TVS findings would confirm ectopic pregnancy?

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• History of PID/salpingitis (most important): PID causes intense tubal inflammation → scarring of tubal mucosa and lumen → impaired ovum transport. Rate of ectopic in women with known PID history is 6–10× higher than in women without (Textbook of Family Medicine, 9e)
• Previous pelvic/tubal surgery
• Progestin-bearing IUD
• Chlamydial infection (commonest cause of PID)

• β-hCG (serial, 48 hrs apart): Normal IUP doubles every 48 hrs. Ectopic/abnormal IUP shows a plateau or sub-optimal rise (<66% rise)
  • The "discriminatory zone" is the hCG level above which a gestational sac should be visible on TVS (usually >1500–2000 IU/L); empty uterus above discriminatory zone = ectopic until proven otherwise
• Serum progesterone:

  • 25 ng/mL → likely normal IUP (<4% ectopic)

  • <15 ng/mL → likely abnormal pregnancy (81% of ectopics, 93% of abnormal IUPs)
  • (Textbook of Family Medicine, 9e)

• Empty uterus (no IUP) + adnexal mass/ring sign
• Fetal cardiac activity outside uterus (definitive but uncommon)
• Free fluid in pouch of Douglas (suggests rupture)
• Absence of intrauterine gestational sac when β-hCG above discriminatory zone

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CASE 10

1. Is she suitable for medical management? What are the criteria?
2. Explain the methotrexate protocol and follow-up.
3. When is surgery indicated instead?

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• Haemodynamically stable
• No fetal cardiac activity on USS
• Adnexal mass <3.5 cm
• β-hCG <5000 IU/L (some use <3000 IU/L)
• No contraindications: renal failure, hepatic disease, blood dyscrasia, immunodeficiency, active pulmonary disease, unreliable follow-up
• Patient willing and able to comply with follow-up

• Methotrexate 50 mg/m² IM
• Serial β-hCG on day 4 and day 7: expect 15% fall between day 4–7
• If <15% fall → repeat dose or surgery
• Weekly β-hCG until undetectable
• Avoid folate supplements, NSAIDs, alcohol, UV exposure during treatment
• Contraceptive advice for 3 months post-treatment (teratogenic)
• Warn of "separation pain" (transient increase in pain days 3–7 = normal)

• Haemodynamic instability / suspected rupture
• Fetal cardiac activity seen
• β-hCG >5000 IU/L or rising rapidly
• Failed medical management (rising/plateau β-hCG after methotrexate)
• Patient unable to comply with follow-up
• Contraindications to methotrexate

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🔵 TOPIC 5 — ABNORMAL UTERINE BLEEDING

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CASE 11

1. Take a targeted history
2. Generate a differential diagnosis using the PALM-COEIN classification
3. What initial investigations would you request?

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• Onset: since menarche (important — suggests anovulatory/hypothalamic immaturity)
• Quantify: pads/tampons per day, clots, flooding, pad change at night
• Systemic symptoms: easy bruising, epistaxis (coagulopathy screen)
• Medications: anticoagulants, OCP
• Thyroid symptoms
• FH of von Willebrand disease, bleeding disorders
• Psychosocial impact

• FBC (anaemia, platelets)
• Coagulation screen: PT, APTT, fibrinogen; von Willebrand panel (vWF antigen, ristocetin cofactor, Factor VIII) — ~20% of adolescents with HMB have vWD
• TSH
• Urine β-hCG (sexually active patients)
• Pelvic USS if structural cause suspected

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CASE 12

1. What are the concerns in this patient?
2. What investigations are mandatory before treatment?
3. Outline a management plan.

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• Endometrial cancer risk: age >35, perimenopausal, obesity (adipose conversion of androgens to oestrogen = unopposed oestrogen → endometrial hyperplasia/carcinoma), smoking, endometrial thickness 14 mm (Robbins & Kumar)
• Fibroids as structural cause of AUB-L: submucosal fibroids distort the endometrial cavity and cause heavy menstrual bleeding (Goldman-Cecil Medicine)
• Anaemia from chronic blood loss

• Endometrial biopsy (Pipelle sampling) — mandatory in women >35 with AUB or any age with risk factors for endometrial carcinoma (Goldman-Cecil Medicine)
• Alternatively, hysteroscopy + biopsy if Pipelle insufficient

• FBC (assess anaemia → iron if needed)
• Coagulation screen
• Thyroid function, fasting glucose
• MRI pelvis (fibroid mapping if surgical planning)

• Combined OCP (if no contraindications) for cycle control
• Tranexamic acid (antifibrinolytic) for heavy bleeding
• Levonorgestrel IUS (Mirena) — effective for AUB due to fibroids and reduces endometrial thickness

• Normal endometrium: hysteroscopic resection of submucosal fibroid (myomectomy)
• Endometrial hyperplasia without atypia: progesterone therapy/LNG-IUS; repeat biopsy in 3–6 months
• Atypical hyperplasia/cancer → gynaecological oncology referral
• Hysterectomy if fertility not desired and medical management fails

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CASE 13

1. What is the immediate management?
2. What hormonal therapy can be used to stop acute bleeding?
3. When would blood transfusion be indicated?

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• Large-bore IV access × 2
• IV fluids (crystalloid bolus for BP)
• FBC, G&S/cross-match, coagulation, U&E, β-hCG (already negative)
• Continuous monitoring: BP, HR, O₂ sats
• Urinary catheter (urine output monitoring)

• Combined OCP (off-label): one pill every 6 hours for 5–7 days → bleeding should cease within 24 hours
  • Warn patient: heavy withdrawal bleed 2–4 days after stopping
  • (Goldman-Cecil Medicine, 26e)
• Norethisterone (oral progestogen): high-dose regimen can stabilise endometrium
• IV conjugated oestrogens: if OCP not tolerated or severe haemorrhage; promotes rapid endometrial growth to stop acute bleeding
• Tranexamic acid: IV or oral antifibrinolytic, adjunct therapy

• Hb <70 g/L with symptoms of anaemia / haemodynamic instability (this patient: Hb 72 with hypotension → transfuse)
• Haemodynamically unstable despite fluid resuscitation
• Ongoing rapid blood loss

• After stabilisation: investigate for coagulopathy (von Willebrand disease common in adolescents with severe AUB)
• Long-term: OCP or LNG-IUS for cycle regulation and prevention of recurrence
• Iron supplementation for iron-deficiency anaemia

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Quick Reference Summary Table

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What's Included

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Key Facts to Memorise Across All Cases

• Chronic HTN: BP ≥140/90 before 20 weeks; avoid ACE/ARBs; aspirin from 12 weeks
• Preeclampsia: New HTN after 20 weeks + proteinuria OR end-organ dysfunction; MgSO₄ loading = 4 g IV over 15–20 min → 2 g/hr maintenance
• HELLP: Hemolysis + Elevated LFTs + Low Platelets — deliver within 24–48 hrs
• Eclampsia: MgSO₄ is the anticonvulsant of choice (NOT diazepam)
• Miscarriage: Anembryonic = GSD >25 mm no embryo; Embryonic demise = CRL >7 mm no cardiac activity
• Ectopic: Classic triad = amenorrhoea + pain + bleeding; progesterone <15 ng/mL = abnormal pregnancy; methotrexate criteria = stable, no cardiac activity, β-hCG <5000, mass <3.5 cm
• AUB: PALM-COEIN classification; endometrial biopsy mandatory in women >35 with AUB; acute bleed → OCP every 6 hours for 5–7 days stops bleeding within 24 hrs