GOSH Flashcards
Laparatomy
a surgical incision into the abdominal cavity, for diagnosis or in preparation for major surgery
Laparoscopy
a small tube with a camera is put into the stomach area
hysteroscopy
a TRANSVAGINAL procedure used to examine the inside of the womb (uterus). It’s carried out using a hysteroscope, which is a narrow telescope with a light and camera at the end.
fibroids/leimyomata definition and RF
benign tumours of myometrium
if they have a pendunculated stalk ==> a polyp
RF: afro-carribean and FHx. injectable progestogens and COCP are protective!
fibroids/leimyomata aeitiology
Grow in response to oestrogen (and progesterone) therefore shrink after meno pause and variable changes during preg
Sx of fibroids/leimyomata
usually site dependent rather than size, and usually asymptomatic
- menorrhagia
- dysmenorrhoea
- IMB
- They only cause pain if torsion or red degeneration
NB/ if big e/n, may cause bladder retention or frequency
red degeneration
Result of an inadequate blood supply - pain and uterine tenderness. Common in preg
fibroids/leimyomata complications
torsion, degenerations, malignancy
fibroids/leimyomata ix
USS but MRI or laparoscopy may be required to distinguish the fibroid from an ovarian mass
Need to differentiate fibroids and adenomyosis w MRI
fibroids/leimyomata tx
small - no tx
large - serially measured by examination or USS (?malig)
MEDICAL Mx = GnRH agonists cause temporary amenorrhoea and fibroid shrinkage but nto for F trying to conceive. SURGICAL Mx = hysteroscopic resection hysterectomy Uterine artery embolisation
Adenomyosis definition
aka endometriosis interna
= presence of endometrium within the myometrium
Adenomyosis associations
40yo
asso/w endometriosis and fibroids (need to differentiate from fibroids!)
Usually asx but can present w painful, regular, heavy menstruation. O/E mildly enlarged and tender uterus. Sx subside after menopause
Ix: MRI
MEDICAL Mx = IUS or COCP w or w/o NSAIDs to control menorrhagia and dysmenorrhoea
SURGICAL Mx = hysterectomy
Endometritis aeitiology
often secondary to STI, instrumentation of uterus (eg. surgery, IUD), pregnancy/miscarriage/TOP (RPOC)
infx in postmenopausal –> malignancy
Endometritis sx
- persistent and heavy PV bleed + pain
- tender uterus
- open os
Tx = broad sepc abx and ERPC if req
Intrauterine polyps
benign tumours in the uterus
40-50yo when oestrogen levels v high or postmenopausal F on tamoxifen for breast carcinoma
cause menorrhagia, IMB, and may prolapse through the cervix
Tx = resection or diathermy can cure bleeding problems
Endometrial carcinoma RF and PC
90% ADENOCARCINOMA
RF: exogenous oestrogen w/o progesterone obesity PCOS nulliparity and late menopause ovarian tumours Tamoxifen is a oestrogen agonist in the uterus!
Hx of COCP and pregnancy is protective
Presents w PCB +/- abnormal smears
Endometrial carcinoma ix and tx
USS
endometrial bx w Pipelle or hysteroscopy
MRI and CXR (to exclude rare pulmonary spread) req
NB/ staging is only possible following a hysterectomy
Mx of Endometrial carcinoma:
1. hysterectomy + bilateral salpingooophrectomy (BSO) –> XRT for pt w high risk LN involvement
‘Only XRT’ is for those w high risk of extrauterine and evidence of wide spread disease.
Menorrhagia definition and tx
heavy menstrual bleed (subjectively or objectively >80ml)
Tx:
1st line = IUS
2nd line = Tranexamic acid (antifibrinolytics) or mefanamic acid (NSAIDs = PG inihibitors)
3rd line = COCP
4th line = high dose progestogens or GnRH analogues –> amenorrhoea
When to do an endometrial bx (Pipelle or hyseroscopy)
>10mm in pre-menopausal, >4mm in post-menopausal >40yo menorrhagia w IMB USS suggests polyp prior to endometrial ablation/diathermy before insertion of IUS if irreg cycles
causes of PCB
cervical Ca
cervical ectropion
cervical polyps
cervicitis/vaginitis
Ambiguous development and intersex
A) increased androgen fx in a genetic F
- Congenital adrenal hyperplasia is recessively inherited. Usually presents at birth w ambiguous genitalia. Tx = mineralcorticoid and cortisol replacement
B) reduced androgen fx in a genetic M
- appears to be female and dx is when ‘she’ presents w amenorrhoea
- absent uterus and rudimentary testes
PMS sx and tx
cyclical nature
tension, irritability, loss of control, bloatedness
GI upset and breast pain
tx = SSRI
cervical ectropion/erosion
= is when the columnar epithelium of the endocervix is visible as a red area around the os
Normal in preg, younger F or if on COCP
PC: PV d/c and PCB
Tx = cryotherapy AFTER smear (and colposcopy) has excluded Ca
Cervicitis
usually from STI
Cervical polyps
= benign tumours of endocervical epithelium
> 40yo
asx or cause IMB/PCB
Mx of abnormal smear
normal –> repeat every 3 years
mild dyskaryosis/borderline changes –> repeat in 6 months. if still present then colposcopy
mod dyskaryosis –> colposcopy
severe dyskaryosis –> urgent colposcopy
cervical glandular –> colopscopy, if abnormality not found then hysteroscopy
prevention of cervical Ca
- HPV vaccination
2. barrier contraceptive education
prevention of invasive cervical Ca
- LLETZ aka diathermy loop excision (complications incl: post-op haemorrhage and increased risk of pre-term delivery)
cervical Ca sx (if any)
MOST ARE SQUAMOUS CELL CARCINOMAS (some are adenocarcinomas)
- PCB
- offensive vaginal d/c
- IMB
(- PMB)
pain is NOT an early feature
tx of cervical Ca
- microinvasive ie.stage 1Ai –> cone bx (A cone biopsy is done less often than LLETZ. It: is a minor operation to cut out a cone-shaped piece of tissue containing the abnormal cells. only tends to be used if a large area of tissue needs to be removed.)
- -> simple hysterectomy - stage 1Aii-1Bi –> laparoscopic lymphadenectomy initially and if positive then straight to chemo-XRT.
Radical trachelectomy is for F who wish to preserve fertility.
NB/ Wertheine’s hysterectomy involves pelvic node clearance - other stage 1&2A: if LN -ve –> radical hysterectomy
if LN involved –> chemo-XRT - stage 2B+ or +ve LN –> chemo-XRT alone
Indications for chemo-XRT
o LN+ve on MRI or after lymphadenectomy
o alternative to radical hysterectomy even when LN -ve
o surgical margins unclear
o palliative XRT for bone pain or haemorrhage
Ovarian cyst accidents
= rupture of ovarian cyst contents into peritoneal cavity
- intense pain, esp w demoid cyst and endometrioma. Also caused by haemorrhage into a cyst or the peritoneal cavity (if severe e/n can cause hypovolaemic shock). As does torsion of pedicle
Common ovarian masses- pore and post menopausal
PREMENOPAUSAL OVARIAN MASS - benign epithelial tumour, follicular/lutein cysts, dermoid cysts, endometriomas
POSTMENOPAUSAL OVARIAN MASSES - benign epithelial tumour, malignancy
Endometriotic cyst/endometriomas = blood-filled chocolate cysts if seen in the ovaries, that are characteristic of endometriosis
Functional cysts = follicular (persistently enlarged follicles) and lutein cysts (persistently enlarged corpora lutea) are only in pre-menopausal F. COCP protects against functional cysts by inhibiting ovulation. Risk of malig so if >5mm for more than 2 months then CA125 levels measured and laparoscopy considered to remove or drain the large cyst
ovarian Ca
SILENT killer Ca presenting at stage 3-4;
- abdo distention/palpable mass
- pain or abnormal bleeding
- Breast and GI sx - commonly secondary ovarian met from breast or GIT Ca
RF = FHx, nulliparity, early menarche, late menopause
NB/signet ring = Krukenberg tumours
ovarian Ca mx
TAH w bilateral salpingo-oophrectomy (BSO) at staging laparotomy
Debulking all advanced tumours
Follow up w chemo (unless bordlerline or stage 1A)
Do not offer routine ‘second-look’ laparoscopy, but can monitor relapse using CA125 and CT
Causes of pruritus vulvae
o Candidiasis o vulval warts o pubic lices, scabies o derm eg.eczema, psoriaisis, lichen simplex [long hx of itching and soreness, inflamed labia majora, thickened w hyper/hypopigmentation, Avoid irritants such as soapUse emollients and steroid creams], lichen planus [causes irritation w flat, papular, purplish lesions in anogenital area, also affects hair, nails and mucous mem. Tx = high potency steroid creams], lichen sclerosis [Usually post-menopausal. ?AI co-existing w thyroid disease and vitiligo, soreness and pruritus, pink-white papules which coalesce to form skin resembling old-scribe papers w fissures. Can be ass/w malignancy, Tx = ultra potent topical steroids], contact dermatitis o Ca or premalignant stage
Bartholin’s glands if blocked –> cyst and abscess formation
If infx occurs (Staph and E.Coli) - acutely painful and large tender red swelling near the inner wall (because bartholin glands are behind the labia minora)
tx = incision and drainage, marsupialization
Congenital cysts
commonly arise in vagina
smooth white appearance
can be golf ball size and often mistaken for prolapse
tx = only excise of sx eg.dyspareunia
Vulval Ca causes
MOST ARE SQUAMOUS CELL CARCINOMAS
premalignant disease is VIN = presence of atypical cells in the vulval epithelium. 2x types of VIN
a) caused by HPV - responsible for the rare Ca in <45yo. Warty and basaloid lesion b) lichen sclerosis - major cause in >45yo, lesion is keratinizing
Although VIN is premalignant, vulval Ca often arises de novo and is ass/w lichen sclerosis, immunosuppression, smoking and Paget’s disease of vuvla
Vulva Ca sx, ix and tx
Primary vaginal Ca mainly in older F (PC = bleeding, d/c, mass, ulcer)
Clear cell adenocarcinoma of vagina in late teenage years
PC - pruritus, bleeding, d/c, mass
ix - bx
1A –> wide local excision w/o lymphadenectomy
others –> wide local excision w separate groin node dissection
post op XRT if LN +ve, or pre-op to shrink or for palliation
Prolpase RF and sx
RF = childbirth, vaginal birth, oestrogen deficiency, obesity and chronic cough, congenital weakness, pelvic masses
dragging/lump sensation - worse at end of day
o severe prolapse may interfere w sexual intercourse, bleed, d/c or ulcerate. Cystocele –> urinary freq and incomplete bladder emptying.Rectocele –> difficulty defecating.
BACK PAIN IS UNUSUAL
Prolapse mx
conservative - weight loss, stop smoking,
(Ring usually, shelf if severe) pessaries for those unfit for surgery; they act like artificial pelvic floor, changed yearly
uterine prolapse –> vaginal hysterectomy (sacrohysteroplexy if want to maintain fertility)
Cystocele –> anterior repair
Rectocele –> posterior repair NB/cystoceles and rectoceles are collectively known as vaginal wall prolapses
Vault prolapse –> sacrocolpoplexy
‘Tape’ surgery for genuine stress incontinence
Genuine stress incontinence definition
= involuntary loss of urine when bladder pressure exceeds maximum urethral pressure in the absence of detrusor contraction
dx only confirmed after ruling out overactive bladder using cystometry
SUI RF
Hx: ask about faecal incontinence as well! ADL - ask pt to prioritise the sx as tx varies!
pregnancy vaginal delivery (esp prolonged or instrumental labour) obesity incr age prolapse commonly co-exists previous hysterectomy
Mx of SUI
conservative - weight loss, stop smoking, treat chronic cough or constipation
1, PFE +/- vaginal cones for at least 3 months
- cystometry to exclude OAB
- ‘Tape’ surgery
- Surgery = Open Burch Colposuspension
- Medical = Duloxetine (serotonin reuptake inhibitor)
Genuine stress incontinence vs SUI
GSI = a DISORDER diagnosed only after cystometry, of which stress incontinence is the major sx
stress incontinence is a SYMPTOM, can be due to GSI, OAB or overflow incontinence
OAB definition
= urgency w or w/o urge incontinence, usually w freq or nocturia in the absence of proven infx. SUI is common. Leakage at night or at orgasm. Faecal urgency. Hx of childhood enuresis. High caffeine/energy drink intake.
Whereas…
Detrusor overactivity is a urodynamic dx char by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked by coughing
OAB mx
- conservative - if excessive, reduce caffeine/fluid intake
Commence bladder training for at least 6 weeks (void by the clock at regular intervals rather than at desire). Stop smoking and reduce weight. - medical - antimuscarinic eg. oxygbutynin or tolterodine
- Botox lasts for 6 months or sacral nerve stimulation
Acute urinary retention
pt unable to pass urine for 12hr; it is painful and catheterisation is maintained for 48hr while the cause is treated
Painful bladder syndrome
and interstitial cystitis
PBS = pt experiences suprapubic pain related to bladder filling, accompanied by freq and nocturia, in the absence of proven pathology
Interstitial cystitis is confined to pt w painful bladder sx who have characteristic cystoscopic and histological features. Tx = TCA, baldder trainig, analgesics.
Endometriosis
result of retrograde menstruation
= growth of endometrial tissue outside the uterus; oestrogen dependent therefore regresses after the menopause and during pregnancy
accumulated altered blood is dark brown –> chocolate cysts aka endometrioma in the ovaries
Endometriosis can cause inflammation, progressive fibrosis and adhesions (serious enough to render all pelvic organs to be immobile!)
Endometriosis sx
- Chronic pelvic pain - CYCLICAL
- dysmenorrhoea (painful periods) before onset of menstruation…may be relieved by period
- DEEP dyspareunia
- subfertility
- dyschezia (the ectopic tissues can be anywhere!) during menses
- subfertility (due to the adhesions! if v severe, may req IVF)
Rupture of a chocolate cyst (blood filled sac) can cause acute pain
O/E: tenderness and thickening behind the uterus or in the adnexa on VE. Uterus may be retroverted and immobile (due to adhesions)
Endometriosis ix
can only be diagnosed w visualisation (laparoscopy) +/- bx. Active lesions are red vesicles or punctate marks on the peritonium.
TVUS to exclude ovarian endometrioma
MRI to exclude adenomyosis
Endometriosis ddx
Adenmyosis
Chronic PID
Chronic pelvic pain
IBS
Endometriosis mx
asx –> no tx
Can just use analgesics. OR
Trial of hormonal drug to suppress ovarian activity (based on the evidence that sx regress during pregnancy [prescribe COCP or progestogens eg, ED pill or IUS], post-menopausally [GnRH analogues induces a temporary menopausal state] or androgenic [danazol but rarely used due to severe SE]).
NB/COCP is often taken back-to-back w/o a break to reduce the freq of painful w/d bleeds.
MEDICAL TX DOES NOT IMPROVE FERTILITY|!!!
Surgical - Ablation (using either diathermy, laser, microwave or balloon) can be used at time of laparoscopy (‘see and treat’) - this improves fertility! Laser ablation +/- adhesiolysis
Other radical surgeries are dissection of adhesions and removal of ovarian endometriomata, or even a hysterectomy w BSO (LAST RESORT - usually if severe and older F!)
Progestogens
Progesterone is the natural type of progestogen, which is a class of hormones that also includes all of the other synthetic progestogens
systemic progestogen SE
fluid retention
erratic bleeding
PMS
weight gain
Chronic pelvic pain
= intermittent or constant pain in lower abdo or pelvis of at least 6 months, not occurring exclusively w menstruation or intercourse
- migraine
- low back pain
Exclude endometriosis, adenomyosis, IBS [trial of antispasmodics], psych factors. Prescribe analgesic. F w cyclical pain –> COCP or GnRH for 3-6 months before diagnostic laparoscopy.
Candidiasis/thrush
= infx w Candida Albicans (fungus). NON-sexually transmitted
RF = pregnancy, DM, abx use
- asx or cottage cheese d/c w vulval irritation and itching
- superficial dyspaneuria and dysuria might occur
- inflamed and red vagina/vulva
tx = topical imidazoles eg.Canesten or oral fluconazole
Bacterial Vaginosis (BV)/ Gardnerella/anaerobic vaginosis
= overgrowth of mixed vaginal flora incl anaerobes eg.Gardnerella and mycoplasma hominis. NON-sexually transmitted
- grey white d/c
- fishy odour (from amines released by bacteria)
- vulva and vagina NOT red NOR itchy
dx by raised pH, fishy grey white d/c, positive ‘whiff’ test, clue cells on microscopy
tx = metronidazole or clindamycin cream
chlamydia trachomatis
= a bacterial infx
- usually asx but can cause urethritis and vaginal d/c
dx = NAAT or PCR, NOT seen on microscopy
chlamydia -> PID (tubal damage, subfertility,chronic pelvic pain)
-> Reiter’s syndrome (urethritis, conjunctivitis, arthritis)
tx = doxycycline or azithromycin
Neisseria Gonorrhoeae
= a bacterial infx
- usually asx but can cause urethritis, vaginal d/c, bartholinitis, cervicitis
dx = gram - diplococcus on microscopy + endocervical swabs
gonorrhoeae -> bacteraemia
-> acute septic arthritis
tx = penicillin, ciprofloxacin, or CEFTRIAXONE
Genital warts/Condylomata acuminata
= HPV 6&11 viral infx
- can range from looking like tiny flat patches on vulval skin to cauliflower (papilliform) swellings
tx = podophyllin or imiquimod cream
cryotherapy or electrocautery for resistant warts
high reccurence rate
Genital herpes
= herpes simplex virus type 2 infx (type 1 causes cold sores)
- primary infx w MULTIPLE small PAINFUL vesicles and ulcers around the introitus
- local lymphadenopathy
- dysuria
- systemic sx
- reactivation w secondary infx is less painful and preceeded by localised tingling
tx = aciclovir
Syphilis
= Spirochaete infx by treponema pallidum
- primary Syphilis is a Solitary painleSS vulval lucer (chancre)
- untreated secondary syphilis may develop weeks later w a rash, flu-like sx, warty genital or perioral growths (condylomata lata)
- Latent syphilis follows, as does tertiary/neurosyphilis
tx = parenteral (usually IM) penicillin
Trichomoniasis
= flagellate protozoan infx of trichomonas vaginalis
- offensive grey-green d/c
- vulval irritation
- superficial dyspareunia
- cervicitis w a punctate erythematous ‘strawberry’ appearance
tx = metronidazole
genital ulcer causes
herpes (HSV type 2) syphilis chancroid (haemophilus ducreyi) lymphogranuloma venereum (subtype of chlamydia trachomatis) donovanosis/granuloma inguinale
HIV RF
NB/ CD4 <200 or development of opportunistic infx/Ca eg.cervical is diagnostic of AIDS
multiple sexual partners partners and self from high prevalence countries partner w known HIV status failure to use barrier contraception presence of other UTIs CSW or been paid for sex IVDU sexual contact w high risk men eg.MSM
Acute pelvic infx or PID
RF = younger, sexually active nuliliparous F
is an inflammatory and infectious disease, and is a complication of a sexually transmitted disease; ascending infx of the bacteria in the vagina and cervix - usually chlamydia
Endometritis usually co-exists, as might bilateral salpingitis
- perihepatitis presents w RUQ pain (due to adhesions)
- asx (esp chlamydial)
- bilateral lower abdo pain
- vaginal d/c
- signs of lower abdo peritonism w bilateral adnexal tenderness and cervical excitation
- fever, raised WCC and raised CRP
Acute PID ix
Endocervical swab for chlamydia
blood cultures if signs of infx
pelvic USS to exclude abscess or ovarian cyst
laparoscopy w fimbrial bx and culture is gs
Acute PID tx
- parenteral cephalosporin eg. IM ceftriaxone
- followed by doxycyclin/oflaxcin + metronidazole
- analegesic
febrile pt should be admitted for IV therapy. Pelvic absecess may req draining
compl of PID -> abscess formation or pyosalpinx
- > tubal obstruction and subfertility, chronic pelvic infx, chronic pelvic pain - > ectopic pregnancy
causes of vaginal d/c
physiological candidiasis BV atrophic vaginitis cervical eversion and ectropion
chronic PID
results of untreated/inadequately treated acute PID
- dense pelvic adhesions and obstructed fallopian tubes, possibly dilated w fluid or pus
- chronic pelvic pain
- dysmenorrhoea
- deep dyspareunia
- heavy and irregular menstruation
- chronic vaginal d/c
- subfertility
- OE similar to endometrosis w abdo and adnexal tenderness and a fixed retroverted uterus
tx = analgesics, sometimes adhesiolysis and salpingectomy is required
subfertility definition
conception has not occured after a year of regular unprotected intercourse
PCOS
many PCOS pt have fhx of T2DM: peripheral insulin resistance and insulin incr androgen production.
2 out of 3:
o PCO = 12+ follicles in an enlarged ovary, on USS
NB/PCO is genetic
o irregular periods = >35 days apart
o hirsutism = clinically w acne or XS body hair, OR biochemically w raised serum testosterone
PCOS sx
- subfertility (one of the PCOS criteria is irregular periods)
- oligomenorrhoea oe amenorrhoea
- hrisutism (acne or XS body hair)
- obesity
- m/c
PCOS ix
TVUS
Anovulation is investigated w FSH (raised in ovarian failure, low in hypothalamic diesase, normal in PCOS)
LH (not much use), TSH
low luteal phase progesterone if anovulatory
prolactin (to exclude prolactinoma)
hirsutism is investigated w serum testosterone levels (raised in androgen secreting tumour or congenital adrenal hyperplasia)
fasting lipids and glucose to screen for complications
PCOS complications
infertility
obesity
m/c
LONG TERM RISKS
T2DM
Endometrial Ca (if persistent amenorrhoea/anovulation due to unopposed oestrogen action)
PCOS symptomatic tx (other than subfertility)
weight reduction
balanced diet
COCP will regulate menstruation and treat hirsutism, at least 3-4 bleeds/yr
antiandrogen acetate or spironolactone for hirsutism
metformin reduces insulin levels therefore reducing levels of androgens and hirsutism
Causes of anovulation
PCOS
Premature ovarian failure (no ovarian folllicles present; bone protection w HRT or COCP req)
hypothalmic hypogonadism (reduction in GnRH release which reduces stimulation of pit gland to produce FSH and LH) - common in AN
hyperprolactinaemia (in turn reduces GnRH release)
thyroid disease
Advice for induction of ovulation
normal weight
stop smoking
folic acid and risk of multiple pregnancies w ovulation induction
tx of specific causes
PCOS tx (re: ovulation induction)
- Clomifene (max 6 month use) - for ovulation induction; = anti-oestrogen at the hypothalamus and pit gland therefore incr release of FSH and LH. Need USS monitoring in case of multiple follicle maturation
If clomifene resistance…
- Metformin (insulin sensitising drug)
- gonadotrophins
- Laparosocopic ovarian diathermy
- IVF
hypothalamic hypogonodism tx (re: ovulation induction)
reduce weight
if weight normal, then gonaotrophins
hyperprolactinaemia (re: ovulation induction)
bromocriptine or cabergoline
Azoospermia
NO sperm present
ix = examine for presence of vas deferens, check karyotype eg.Klinefelter’s 47XXY, CF, hormone profile
tx = surgical sperm retrieval then IVF + ICSI or donor insemination
Oligospermia
reduced sperm count
tx = intrauterine semination, IVF +/- intracytoplasmic sperm injection (ICSI)
Asthenospermia
astheno = w/o strength
poor motility sperm
Teratospermia
terato = monster
morphologically defective sperms
leucospermia
infection
semen analysis
last ejaculation 2-7 days ago
if abnormal, repeat after 70 days, examine the scrotum, reduce smoking, drinking, drug use eg.sulfasalazine for RA or anabolic steroids
reduce exposure to industrial chemicals
wear loose clothing and testicular cooling
Causes of fertilization failure
tubal damage
- infx eg.PID from chlamydia –> adhesiolysis and salpigostomy (incr rate of ectopic!)
- endometriosis –> laparoscopic surgery to remove endometriotic deposits
- adhesions from surgery
cervical problems
sexual problems
Detection of tubal damage in subfertility
- Firstly hysteroscopy needs to be performed first to assess the uterine cavity for abnormalities
- Laparoscopy and dye test allows visualisation and assessment of fallopian tubes. methylene blue dye is injected through the cervix from the outside and can see if it enters or spills from the tubes to test if they are patent
- hysterosalpingogram - w/o anaesthetic radio-opaque contrast is injected through the cervix to look for spillage using XR. A variant of this is HyCoSy where TVUS and US opaque liquid is used instead, reserved for F w no RF for tubal disease
Indications for assisted conception
when all other methods have failed unexplained subfertility male factor subfertility [ICSI] tubal blockage [IVF] Genetic disorders
Assisted conception methods
intrauterine insemination IVF intracytoplasmic sperm injection oocyte or sperm donation surrogacy
can offer preimplantation genetic diagnosis to >37yo F
Complication of assisted conception
Superovulation leading to multiple pregnancies
egg collection can lead to intraperitoneal haemmorhage and pelvic infx
incr risk of ectopic preg
PCOS tx overview
if infertility –> clomifene, +metformin, ovarian diathermy, , gonadotrophins, IVF
if menstrual problems –> COCP
if acne/hirsutism –> cosmetic tx, COCP +/- cyproterone acetate, spironolactone, eflornithine facial cream
Common progestogenic SE
BREAST TENDERNESS mood changes like depression erratic bleeding or amenorrhoea acne weight gain reduced libido
Common oestrogenic SE
nausea
headache
BREAST TENDERNESS
fluid retentino and weight gain
COCP missed pill rule
vomit w/i 2hr –> take another pill and follow MPR
severe diarrhoea –> continue pills and follow MPR
MPR =
one or two missed pills anywhere in the cycle is ok.
take the missed pill asap, even if 2 at the same time. then continue the pack as normal.
if more than 2 pills missed then use condoms for 7 days.
COCP and pre-op
stop 4 weeks before surger due to prothrombotic risks
COCP complications
VTE CVA - MI and strokes HTN focal migraines jaundice liver, cervical and breast Ca
risk is increased by smoking, incr age and obesity
absolute CI to COCP
- hx of VTE
- inherited thrombophilia
- > 35yo smoker >15/day
- BMI>40
- DM w vascular complications
- hx of MI/stroke, IHD, severe HTN
- migraine w aura
- active breast/endometrial Ca
- active/chronic liver problems
Relative CI to COCP
age >40yo chronic inflammatory disease renal impairment, DM BMI 35-40 BF and upto 6 months post partum (because lactation is partly suppressed so the piil in CI in puperium is relative CI upto 6 months post partum)
common minor SE to COCP
nausea, headache, BREAST TENDERNESS
breakthrough bleeding in firth few months but tends to settle shortly
Benefits to COCP
3 per 1000 women get pregnant
regular, less painful and lighter periods
improves acne and hirsutism
protects again ovarian, endometrial and bowel Ca
POP (progestogen-only pill)/ED pill/ mini pill
An alternative to COCP because no CI ;D
same time every day w/o a break
common SE: period changes (erratic or amenorrohoea), weight gain, mood changes eg.depression or PMS, breast tenderness
MPR = take next one as soon as possible. if >3hr late, use condoms for 2 days
complications of intrauterine devices
E and the 6P’s
expulsion - usually w/i 1st month
Perforation - of uterine wall at time of insertion
Pain
Period changes - heavier or more painful (except w progestogenic devices)
PID incr risk
Pregnancy more like to be ectopic
Progestogenic effects on period…
LIGHTER! But may be heavier or more erratic
Absolute CI to intrauterine devices
Endometrial or cervical Ca
undiagnosed PV bleed
Active/recent pelvic infx
current breast Ca (for progestogenic IUS only)
Relative CI to intrauterine devices
Previous ectopic preg
young/nuliparous
immunocompromised incl HIV +ve
Depot progestogens
IM depo-provera every 3 months
S= progestogenic + prolonged amenorrhoea and reversible bone loss
IUD
prevents implantation
can be kept in upto 10 years, but replaced b/t 5-10yr
cause of PMB
endometrial Ca endometrial hyperplasia +/- atypia and polyps cervical Ca atrophic vaginitis cervicitis ovarian Ca Cervical polyps
menopause
Premature menopause
permanent cessation of menstruation; 12 consecutive months of amenorrhoea
premature if <40yo
PMB ix
bimanual
speculum
cervical smear
TVUS
Early menopause effects
Psychological sx eg.depression, mood swings
vasomotor sx eg.hot flushes, night sweats –> sleep disturbance,
Intermediate menopause effects
skin atrophy
hair thinning
vaginal atrophy can cause burning, itching or pain during sex
urinary sx eg.freq, urgency, nocturia, recurrent infx
Late menopause effects
CVA eg. MI and strokes (due to oestrogen deficiency) and cardiac disease
osteoporosis ie. weak bones that predispose to an incr risk of fracture (osteopenia = weak bones)
RF for osteoporosis development
FHx of # low BMI Early menopause (due to oestrogen deficiency) cigarette smoking ETOH abuse Low Ca intake Corticosteroids disease eg.PA, malabsorption syndromes, hyperthyroidism
ix in menopause
raised FSH = few oocytes left
May consider TFT as thyroid disease can cause hot flushes. Catecholamines and 5-hydroxyindolacetic acid to dx chromocytoma and carcinoid syndrome. Low progesterone may be secondary to PCOS, DEXA scan for bone density.
Menopause tx
- oestrogen and oestriol, oestradiol (natural oestrogens)
- ethinyl oestradiol (synthetic oestrogen)
- progestogens eg.levonorgestrel, norethisterone
- tibolone = inert synthetic steroid that is is converted in vivo. For F who want amenorrhoea and treat vasomotor, psychological and libido problems
oestrogen only in F who have no uterus
oestrogen PLUS PROGESTERONE (to protect uterus lining from endometrial Ca) in F w uterus
PO (tablets), transdermally (patch or gel), SC (implant)
NB/ progesterone still need to be given to F who had endometrial ablation as not all had been removed, Progestogen can be given sequentially (regular bleeds) or continuously. (amenorrhoea)
Perimenopausal –>cyclic HRT
Menopausal –> continuous HRT
HRT pros and cons
Temporarily treats menopausal sx, protects against osteoporosis, reduces urinary sx, improves hair and skin
BUT oestrogenic and progestogenic SE, incr risk of breast Ca and VTE
Disorders of early pregnancy
Spontaneous m/c Recurrent m/c TOP Ectopic preg Hyperemesis gravidarum Gestational trophoblastic neoplasia
Threatened m/c
bleeding but foetus is alive
uterus is size expected from the dates
os is closed
inevitable m/c
heavy bleeding
foetus may still be alive
os is open
ie.m/c is about to occur
incomplete m/c
os is open
bleeding might have happened but gradually stopped now. And while some foetal parts have passed there is still some remaining
complete m/c
all foetal tissues have passed, no evidence of foetus in uterus
uterus is no longer enlarrged
bleeding has diminished
os is closed
septic m/c
= contents of uterus are infected causing endometritis
offensive vaginal loss, tender uterus, absent fever
abdo pain and peritonism if pelvic infx
missed m/c
= “foetus has not developed in utero, but this is not recognised until bleeding occurs or USS is performed.”
uterus small than expected
closed os
Mx of spontaneous m/c
NB/ if infx becomes systemic, endotoxic shock occasionally ensues w hypoT, renal failure, ARDS and DIC
Lon term conception rates do not differ b/t the m/x options
admission to ix
resus may be required if XS bleeding
RPOC in cervical os cause pain, bleeding and vasovagal shock and are removed via a speculum using forceps
IM ergometrine to reduce bleeding (by contracting the uterus, but is only used if foetus is non-viable)
swabs if ?infx
A) expectant - w/i 2-6 weeks. large intact sac ass/w low success rate
B) medical - prostaglandin, sometimes preced by antiprogesterone mifepristone
C) surgical - evacuation of RPOC under anaesthetic using vacuum aspiration
Go for ERPC if heavy bleeding or infx!
Counselling after m/c
“not result of anything they did or did not do and it could not have been prevented”
“I would like to reassure you that there is a high chance of successful further pregnancies”
“Refer you to support groups for emotional support”
“m/c is unfortunately v common and further ix are reserved for F who have had 3+ m/c”
recurrent m/c (3 or more in succession)
serial USS in early preg for reassurance
emotional support is vital
ANTIPHOSPHOLIPID AB SCREEN (causes thrombosis in the placental circulation)- tx w aspirin and LWMH
Karytype both parents for chromosomal defects
Pelvic USS and hysterosalpingogram for uterine abnormalities
Grounds for TOP
A. Continuing preg involves risk to pregnant mother
B. to prevent grave permanent physical or MH injury to mother
C. pregnancy <24wk and pregnancy would involve risk or injury to pregnant mother
D. preg <24wk would involve risk or injury to existing children
E. susbstantial risk that if child was born, it would suffer from physical or mental abnormalities
Methods of TOP
o Remember to take bloods for Hb, blood group, rhesus status and haemoglobinopathies
o Rhesus -ve F to receive anti-D w/i 72hr of TOP
o screen for chlamydia
o discuss contraception
[<7wk, but also 7-9/52] mifepristone (antiprogesterone) + misopristol or gemporst (PG analogues) 2 days later
[7-13/52] –> Suction curretage
[13+/52] –> dilatation and evacuation (D&E), preceded by cervcal preparation
[13-24/52] –> medical abortion as in early stage
[22+/52] –> feticide (= KCl into umbilical vein/foetal heart to prevent live birth)…. usually only if there is foetal abnormality
complications of TOP
- haemorrhage
- infx
- uterine perforation
- failure
ectopic preg aetiology
no cause is evident but any factor which damages the tubes can cause fertilised oocytes to be caught eg.PID from Chlamydia, assisted conception or pelvic/tubal surgery
Ectopic sx
scanty dark PV bleed
lower abdo pain (initially colicky as the tube tries to extrude the sac, and then becomes constant)
collapse and shoulder tip pain suggests intraperitoneal bleed
+ve PT
amenorrhoea of 4-10weeks
O/E rebound tenderness, cervical motion tenderness, maybe tender adnexa
uterus is smaller than expected
closed os
ectopic ix
hCG PT serum hcG (should be visible if >1000, if lower but rises by more than 2/3 in 48hr then probably an early intrauterine preg, declining/slow rising/pleateauing = non-viable preg or ectopic. USS (if intrauterine preg is not present, could be <5/40, complete m/c or ectopic
Mx of symptomatic ?ectopic
Ectopics must be followed up until hcG <20IU/ml to confirm complete resolution
Admit NBM FBC & cross-match IV access PT, USS, serum hcG
Tx of ?ectopic
laparoscopy/laparotomy –> during which you do either a salpingectomy or salpingostomy
if criteria met…
o unruptured ectopic w no cardiac activity
o hcG < 3000
Can treat medically w methotrexate
if ectopic is…..
- small and unruptured
- location of pregnancy is not clear (not visualiesd in uterus or adnexae)
- hcG <1000 and decling
Can conservatively observe as rupture is unlikely
Hyperemesis gravidarum mx
o usually multiparious F
o seldom persists beyond 14wk
exclude multiple and molar pregnancy
IVF w antiemetics and thiamine
gestational trophoblastic neoplasia
2 forms of hyadatidiform mole: complete (entirely paternal origin = sperm + empty egg) and partial (triploid = 2 sperm + 1 egg). If the proliferation is only in the uterus is it an invasive mole, if metastases then it is a choriocarcinoma
- (heavy) PV bleed
- severe vomitting
- large uterus
- early pre-eclampsia and hyperthyroidism
- snowstom appearance (of swollen villi w complete moles) on USS
- V.high hCG - persistent or rising
mx of trophoblastic disease
NB/ molar preg only precede 50% malignancies as the rest are preceded by miscarriages
- trophoblastic tissue is removed by suction curretage (ERPC)
- Remember to register w supraregional centre for F/U. Pt are scored into low risk [give methotrexate] and high risk [combination chemotherapy] according to prognostic variables.
- Avoid preg and COCP until hCG levels are normal because may incr the need for chemo.
Types of hysterectomy
TAH = removal of uterus and cervix through abdo incision
Laparoscopic hysterectomy is an alternative to TAH
vaginal hysterectomy = removal of uterus and cervix after incising the vagina from below
Wertheim’s radical hysterectomy = removal of parametrium, upper 1/3 of vagina and pelvic L. Usually Wertheim’s is performed for stage 1Aii - stage 2 cervical carcinoma
complications of hysterectomy
immediate: haemorrhage, bladder or ureter damage
post-op: VTW, pain, infx
long term: prolapse, stress incontience, pain, psychosexual problems
Dilatation and curettage (D&C)
cervix is dilated and endometrium is scraped to bx it.
D&C is a diagnostic procedure
not commonly performed
ERPC
cervix is dilated and retained non-viable foetus or placental tissue is removed using a suction curette (=scrap).
similar procedure used for surgical TOP <12/40
large loop excision of the transformation zone (LLETZ)
involves using cutting diathermy under LA to remove the transformation zone of the cervix where CIN is present
cone bx
= removal of transformation zone PLUS much of the endocervix by making a circular cut w a scalpel in the cervix, under epidural or spinal
a tx option for stage 1Ai
Risk: cervical incompetence
operation for fibroid
myomectomy - done through the cervix or abdominally
Uterine A embolisation - alternative to hysterectomy for F who want to preserve fertility
Estimation of gestational age
- from LMP
- [7-14/40] - measure crown rump length (if >1wk dif b/t LMP and scan, use scan)
(3. [14-20] - biparietal diameter or femur length if no early scans or LMP known)
measurements to calculate gestational age are of little use beyond 20 weeks
common causes of polyhydramnios
GDM/DM
foetal abnormalities ie.not swallowing or XS urination
idiopathic
obstetric abdo exam
- general appearance, looking for any swelling of ankles and face, possible anaemia areas assessed.
- Ask for BP and urinalysis
- Now ask pt to lie flat, semi prone if big belly
uterus is palpable at 12-14/40. At 20wk the fundus is at the umbilicus. At sternum at 36wk. - inspect the pregnant uterus for striae, linea nigra and scars, esp in the suprapubic area
- palpate the fundus using the ulnar border. Measure symphysis-fundal height if >24wk
- palpate foetal parts (head is ballotable b/t two hands (breech is softer and less easy to define and cannot be balloted), back is firm) and estimate the liquor volume
If fingers need to dip in far to feel anything, ?polyhydramnios - lie [= relationship b/t foetus and long axis of uterus]
THIS POINT CAN SAY IF IT IS A SINGLETON OR NOT - presentation - breech VS head
- station/engagement of head - more than 2/5 palpable means not engaged “my aim is to determine whether majority of the head lies in the abdomen or the pelvis”
- auscultate over the ant shoulder w pinard’s stethoscope, should be ~110-160bpm
antenatal care schedule
- booking visit at 9-11wk
- booking scan at 11-13wk; to confirm gestation and viability, and diagnose multiple pregnancy. ALSO chromosomal screening [nuchal translucency, hCG, PAPPA)
- anomaly scan at 20wk; to detect structural foetal abnormalities. Doppler of uterine A can be used as screening test for IUGR and PE
Booking bloods
- FBC - for pre existing anaemia
- Ab screen eg.Anti-D - identify risk of intrauterine isoimmunisation
- Blood glucose
- blood test for syphilis. HIV and hep B counselling and screening
- rubella immunity - vaccination offered postnatally if req
- urinalysis for glucose, protein and nitrites
- MC&S - for asx bacturaemia
- screen for infx implicated in preterm labour eg.chlamydia, BV
- Hb electrophoresis in F at risk of sickle cell anaemia (Afro-carribean) or thalassaemia (mediterranean)
pregnancy health promotion
- continue meds and ideally adjusted pre-conception
- folic acid supplementation, Vit D if minimal exposure to sunlight
- coitus is not CI unless proven placenta praevia
- avoid ETOH and smoking
- reduce risk of infx by only drinking pasteurised milk, avoid soft and blue cheeses, pate and uncooked or partially cooked food
- exercise is advised
- traveling - risk of VTE is reduced by adequate hydration and compression stockings
- additional antenatal classes
Common ‘minor’ conditions of pregnancy
o itching o symphysis pubis dysfx o heartburn o backache o constipation o ankle swelling o leg cramps o carpel tunnel syndrome o vaginitis due to candidiasis
physiological changes
weight gain, icr blood vol and RBC, but reduced Hb.
WCC incr, incr CO and reduced peripheral resistance.
incr tidal vol and no change in RR
incr renal blood flow so Cr/urea decr
delayed gastric emptying
thyroid enlargement
Klinefelter’s syndrome
47XXY
normal intellect
small testes and infertile
Turner’s syndrome
45XO
normal intellect
infertile
Structural abnormalities - neural tube defect.
Most common NTDs are …
Reduce risk by…
NTD is suggest by…
spina bifida and anencephaly
Reduce risk by preconceptual folic acid supplementation for 3 months
Raised AFP levels and 20 week anomaly scan
Structural abnormalities - cardiac abnormalities
most common cardiac defect is…
RF…
VSD
more common in F w congenital cardiac disease, DM and prev children w cardiac disease
20 week anomaly scan
Polyhydramnios
Sx: maternal discomfort, large for dates, taut uterus, foetal parts difficult to palpate
aietiology: idiopathic, twins (esp twin-twin syndrome), maternal disorders (eg.renal failure, DM), foetal disorders (eg.upper GI obstructions, inability to swallow, myotonic dystrophy)
= XS amniotic fluid (liquor pool >10cm)
complications of polyhydramnios:
- preterm
- abnormal lie and presentation
mx:
1. reduce liquor –> if <34/40 and severe then perform amnioreduction OR use NSAIDs to reduce foetal urine output
- steroids if <34/40 and can deliver vaginally
Exomphalos
= partial extrusion of abdo content within the peritoneal sac
Remember to offer amnio as commonly linked to chromosomal defects
Gastrochisis
= free loops of bowel in the amniotic cavity
Diaphragmatic hernia
= abdo content herniate into chest
many neonatal deaths eg. from pulmonary hypoplasia
foetal hydrops
= XS fluid accumulation in 2 or more areas in the foetus
Can be immune (due to anaemia, haemolysis due to rhesus) or non-immune secondary to another cause (chromosomal abnormalities, structural abnormalities, cardiac abnormalities, cardiac failure due to anaemia eg.Parvovirus, twin-twin transfusion syndrome)
ix of foetal hydrops
mx depends on the cause
USS, specialist cardiac scan and assessment of middle cerebral A
Maternal blood tested for Kleihauer and parvovirus immunoglobulin M testing
FBS if ?anaemia
amniocentesis for karyotyping
pregnancy infx suitable for screening
Syphilis, HIV, hep B
Rubella
+ chlyamydia, BV, beta-haemolytic strep
TORCH syndrome is a group of 5 infectious diseases that are screened for prenatally
Toxoplasmosis (teratogenic) Others eg.syphilis (teratogenic) Rubella (teratogenic) CMV (teratogenic) Herpes
prevention of vertical transmission of group B strep
IV penicillin in labour
mx (and prevention of vertical transmission) of HIV in pregnancy
maternal antiretroviral therapy elective CS avoid BF neonatal antiretroviral therapy for 6 weeks screen for other infx
if poor resources then nevirapine during labour and for BF…
CMV in pregnancy
maternal dx from IgM, IgG
(foetal dx from amniocentesis at 20+ wk - not advised because most aren’t seriously affected)
10% of neonates are sx at birth: o severe neuro problems eg. DEAFNESS (even asx neonates are at risk of DEAFNESS), visual and mental impairment o IUGR o pneumonia o thrombocytopenia
no treatment, screening or vaccination
Rubella aka German measles in pregnancy
Rubella in children causes a mild febrile illness w macular rash
if <16/40, offer TOP
High % of foetuses are affected
o deafness
o cardiac disease
o eye problems
o mental impairment
screening identifies those in need of postnatal immunisation (as it is live therefore cannot be given during pregnancy)
Toxoplasmosis during pregnancy
caused by TOXOPLASMA GONDII following contact w cat faeces, soil, or eating infected meat. more common in mainland Europe
screening not routine in UK
maternal dx from IgM
foetal dx from amniocentesis at 20+ wk. USS may show hydrocephalus
o mental impairment
o convulsions
o spasticity
o visual impairment
Mx: proven toxoplasmosis treated w spiramycin asap
foetal toxoplasmosis treated w combination therapy
Syphilis in pregnancy
caused by treponema pallidum
o m/c or still birth
o severe congenital disease
prompt tx w benzylpenicillincan prevent congenital syphilis
Herpes simplex virus (HSV) during pregnancy
neonatal infx is rare but motality
high risk of neonatal herpes if primary infx w/i 6 weeks of delivery or active vesicles at time of labour (therefore CS is indicated)
o mother will have typical clinical sx
mx: screening is of little benefit
1. refer to GUM
2. CS indicated if primary infx w/i 6 weeks of delivery or active vesicles at time of labour (therefore CS is indicated)
3. daily aciclvir in late preg?
NB/ the risk is v low for F w recurrent herpes
Group B strep during pregnancy
foetus can be infected during labour after ROM
RF = preterm, prolonged labour, maternal pyrexia
ix: positive 3rd trimester screen
mx: know GBS carriers (high maternal carrier rate!) and those at high risk are given high dose IV penicillin throughout labour
Herpes zoster during pregnancy
severe maternal illness in pregnancy
can be teratogenic
infx 4 weeks prior to delivery can cause severe neonatal infx
mx: immunoglobulins are given to prevent if non-immune
oral acyclovir given to treat
give neonatal immunoglobulin if delivery was near time of infx
Hepatitis B during pregnancy
universal screening identifies neonates in need of immunoglobulin
the child may become a carrier of hep B
CHLAMYDIA in pregnancy
o neonatal conjunctivitis
o preterm labour
chlamydia is treated w azithromycin or erythromycin
gonorrhoea is treated w cephalosporin (as commonly resistant to penicillin)
BV in pregnancy
= overgrowth of normal vaginal lactobacilli by anaerobes eg.Gardnerella vaginalis and mycoplasma hominis
ass/w preterm labour and late m/c
screening and if previous preterm or positive BV infx <20/40 –> oral clindmycin
parvovirus [slapped cheek + arthralgia]
can lead to foetal death if infx < 20/40
o foetal anaemia
o hydrops
if IgM positive, surveillance for anaemia w middle cerebral A Doppler and US
HIV in pregnancy
can lead to stillbirth, pE, IUGR and prematurity
mx: regular CD4 and viral load tests
if low CD4 –> prophylaxis against pneumocystic carinii pneumonia (PCP)
screen for other STIs, esp CHLAMYDIA
Assessment of foetal anaemia
Only severe anaemia is detectable as foetal hydrops or XS foetal fluid
ix: doppler US of foetal MCA (used fortnightly in at risk pt) –> if suspicious, do FBS [risk of foetal loss, if done after 28 wk, need to be in a place w facilities for immediate delivery if complications arise]
tx = in utero transfusion until 36 weeks, at which delivery should be done
Potential sensitising events
TOP or ERPC after m/c Ectopic PV bleeding <12/40 or heavy PV bleed ECV amniocentesis or chorionic villus sampling Intrauterine death Delivery
RBC isoimmunisation
production of maternal anti-D can be prevented by administration of exogenous anti D which ‘mops up’ foetal RBC that have crossed the placenta
Prevention of rhesus disease
Anti-D 500 for all rhesus negative F at 28 and 34 week, and postnatally if baby was rhesus postive
Anti D w/i 72hr of any sensitising event
Kleihauer test performed postnatally to assess no of foetal cells in the maternal circulation (to detect larger feto-maternal haemorrhages)
pre-eclampsia is due to blood vessel endothelial damage in ass/w an exaggerated maternal inflammatory response –> vasospasm, incr capillary permeability and clotting dysfx
dx = >140/90 PLUS >0.3g OR 30mg proteinuria/24hr
vasospasm –> headache
incr vasc resistance –> HTN
incr capillary permeability –> proteinuria
clotting dysfx
reduced placental blood flow –> IUGR
reduced cerebral perfusion –> drowsiness, visual disturbance, N&V, eclampsia
Degree of PE
mild: proteinuria + <170/110
mod: proteinuria + 170+/110
severe: <32weeks or w maternal complication
RF for PE
nulliparity prev hx, FHx older mum chronic HTN DM twin pregnancy AI disease renal disease obesity
assessment of urinary protein
- bedside urinalysis 1+ proteinuria (nb/trace is usually insignificant!)
- protein:Cr ratio >30mg/mmol
- 24hr collection > 0.3g/24hr confirms PE
Haemolysis signs
dark urine
raised lactic dehydrogenase (LDH)
anaemia
Elevated liver enzymes
Epigastric pain
liver failure
abnormal clotting
Low platelet
normally self limiting
Complications of PE
maternal
- eclampsia
- CVA
- coagulation problems (HELLP) and DIC
- liver and renal failure
foetal
- IUGR
- preterm
- placental abruption
- hypoxia
ix if ?PE
MSU
urine protein measurement
full set of bloods
screening
observation of high risk, uterine A doppler
nb/ aspirin has limited role
mx of PE
assess all women w new HTN >140/90 in ANDU
A) no proteinuria and <170/110 are managed as OP, BP and urinalysis repeated twice/week. USS fortnightly
B) if 1+ proteinuria only, then quantification and subsequent r/v 2 days later
C) criteria for admission: o symptomatic o 2+ proteinuria on dipstick or >0.3g/24hr o mod/severe PE o ?foetal compromise
AntiHTN if BP reaches 17/110.
- Methyldopa is best of maintenance but causes drowsiness
- oral nifedipine for initial control w IV labetalol as second line w severe HTN
- MgSO4 (incr cerebral perfusion) used for tx of eclampsia
Steroids are given if risk of preterm
DELIVERY: USUALLY CS, CONTINUOUS CTG MONITORING.
1) mild HTN w/o foetal compromise –> monitored for deterioration. Induction of labour at term
2) Mod or severe HTN –> deliver if >34-36wk. if <34wk, steroids and observe in a specialist unit until labour w daily CTG and assessment and freq blood testing
3) severe PE w complcications or feotal distress –> immediate delivery
NB/ergometrine can incr BP therefore use oxytocin for active mx of 3rd stage
postnatal PE care
bloods esp liver enzymes, platelets and renal fx
fluid balance monitoring due to ?pulm oedema nad ?resp failure
BP measurement and treated for several weeks w b-blocker. 2nd line is nifedipine and captopril.
mx of essential HTN
change from ACEi and b-blockers to 1st line = methyldopa, 2nd line = nifedipine
GDM aietiology
placenta affects glucose tolerance (pregnancy is ‘diabetogenic’) plus lower threshold for excreting glycosuria so develop GDM
GDM RF
prev hx of GDM or FHx PCOS previous baby >4kg unexplained stillbirth obesity (>100kg) polyhydramnios persistent glycosuria
Complications of GDM
maternal
- hypoglycaemia (rarely ketoacidosis)
- PE
- infx
- incr chance of instrumental or operative delivery
mx of GDM
Anomaly and cardiac US
induction/LSCS by 39 WEEKS unless v well controlled
- lifestyle
- metformin
- insulin
pt education glucose monitoring and insulin adjustment
anomaly and cardiac US and foetal surveillance
pre-conceptual care of F w DM
assess renal fx, BP and retina
optimise glucose control
prescr folic acid 5mg/day
Cardiac diseases in preg
A) mild abnormalities eg.mitral valve prolapse, PDA, VSD, ASD do not cause complications
B) PULMONARY HTN EG.EISENMENGER’S SYNDROME is CI in pregnancy and usually terminated due to 40% mortality rate
C) aortic stenosis and mitral valve disease should both be corrected before getting pregnant
criteria for Antiphospholipid syndrome
1 death > 10wk IUGR
3 deaths <10wk VTE
LUPUS/Anti-lupin Ab mesure on 2 occasions 3 months apart
Common complic incl recurrent m/c, IUGR and PE
tx= aspirin + LMWH; serial USS and elective induction of labour by TERM. Then post natal anticoagulation is recommended to prevent VTE
VTE risks (pregnancy is a prothrombotic state due to incr blood clotting factors, reduced fibrinolytic activities, altered blood flow by mechanical obstr and immobility)
?PE –> CT or VQ scan
?DVT –> doppler exam leg and venogram
mx of VTE: WARFARIN IS TERATOGENIC!
Antenatal VTE prophylaxis w LMWH + aspirin is only for F w very high risk
But post partum VTE is the cause of most maternal deaths…
6 week of LMWH post partum if previous or strong FHx of VTE, known prothrombotic tendency, CS performed, or 3+ mod RF
o >35yo
o high parity
o obesity
o immobilty or major current illness
o gross varicose veins
o PE
o infx
high risk VTE ==> 1 week of LMWH
prothrombotic disorders
- activated protein C resistance
- prothrombin gene variant
- protein S and C deficiency
- antithrombin III deficiency
pre-existing
- Previous VTE
- FHx of VTE
- thrombophilia
- incr age/parity
- maternal illness
- obesity
pregnancy related
- CS
- prolonged labour
- severe haemorrhage
- hyperemesis
- immobility
Anaemia in pregnancy
- Sickle cell disease in Afro-Carribbeans. Incr perinatal mortality, thrombosis and sickle crises. Mx = exchange transfusion, folic acid, avoid iron. Can test partner and offer prenatal dx if carrier
- thalassaemia in south-east asians (beta in mediterranean). Mx = folic acid, avoid iron. Can test partner and offer prenatal dx if carrier
- only treat IDA if <11 - reduced MCV, MCH and ferritin
- Folic acid deficiency anaemia is v rare
dietary advice to avoid anaemia
food rich in iron
- meat esp kidney and liver
- eggs
- green veg
food rich in folic acid
- lightly cooked or raw green veg
- fish
Preterm prevention
A) cervical incompetence (short or v scarred/not strong enough). cervical stitch is only suture if sig shortened, hx of RF suggestive of cervical weakness and electively at 12-14wk
B) infx eg.BV, STI, UTI
C)foetal reduction offered at 10-14wk
D) tx of polyhydramnios
E) progesterone suppositories from early preg
mx of preterm labour
can give birth vaginally (reduced risk of resp distress syndrome) but a lot are in breech so many are CS. otherwise the normal CS reasons applies. VENTOUSE IS CI IN PRETERM.
give abx for delivery to preterm due to risk of GBS
steroids give once b/t 24-34 weeks. As steroids take 24hr to act, delivery is often artificially delayed using tocolysis eg.nifedipine or atosiban (oxytocin receptor antagonist) but these should not be used for >24hr
Remember to call the paediatrician
Chorioamniocentesis sx
mx: immediate delivery whatever the gestation
o contractions or abdo pain o fever o tachycardia o uterine tenderness o coloured or offensive liquor
PPROM complications
ix: to look for infx, perform HVS, FBC, CRP
foetal well-being assessed w CTG
principle complication is preterm delivery
chorioamnionitis = infx of foetus or placenta … this could have been the cause!
PPROM presentation
AVOID VE But sometime performed to exclude cord prolapse IF the presentation is not cephalic
o gush of clear fluid, followed by further leaking
o pool of fluid in the posterior fornix
APH (=bleeding after 24wk) causes
common
- unknown
- placental abruption
- placenta praevia
rarer
- uterine rupture
- vasa praevia
2 x types placenta praevia:
marginal
major
marginal placenta praevia = placenta in lower segment, NOT over the os
major placenta praevia = placenta completely or partially overlying the os
RF for placenta praevia
NB/ a lot of ‘low-lying’ placenta at 20weeks but only 1 in 10 become praevia at term. USS repeated at 34wk to exclude praevia
twins
high parity
older F
if uterus is scarred
complications of placental praevia
C section req
(if placenta implants in a prev CS scar it may be so deep as to prevent placental separation = placenta accreta
or even penetrate the uterine wall into surrounding structures eg.bladder = placenta percreta)
haemorrhage may be severe and prolonged after delivery, worsened by placenta accreta and placenta percreta because the lower segment is less able to contact –> may need hysterectomy
placenta praevia sx
intermittent PAINLESS bleeds - incr in freq and intensity over weeks
breech presentation
transverse lie
foetal head is high and not engaged
placenta praevia mx
PV bleed –> admission, USS to confirm –> stay until delivery because of risk of massive haemorrhage
asx placenta praevia, admission can be delayed until 37 week
THEN elective CS at 39weeks.
inflatable balloon or hysterectomy commonly needed for placenta accreta
RF for placental abruption
- IUGR
- PE
- AI disease
- maternal smoking
- cocaine usage
- prev hx of placental abruption
- multiple preg
- high parity
- trauma and ECV
placental abruption sx
V. high foetal mortality rate
constant painful bleeding w exacerbation - inconsistent to level of shock
tachycardia (+/- hypoT)
tender and contracting, hard woody uterus
difficult to palpate foetus
ix in placental abruption
CTG
FBC, coag screen, cross-match, U&E
early delivery w blood products ready
mx of placental abruption
admit on the basis of PAIN + UTERINE TENDERNESS (even w/o PV bleed)
foetal distress –> urgent LSCS
no foetal distress + term –> IOL w amniotomy. If foetal distress ensues then go for LSCS
foetal death –> labour induced and blood products given (high chance of coagulopathy)
ruptured vasa praevia
-painless moderate pv bleed at amniotomy/ROM + severe foetal distress
CS usually isn’t fast enough to save foetus
vasa praevia = vessels running in the membrane in front of os/presenting part (usually when the um cord attaches to the mem rather than the placenta)…
when the mem ruptures, vessels may rupture too w massive foetal bleeding
uterine rupture
usually in F w scarred or congenitally abnormal uterus
?small for date VS ?IUGR
serial measurements of symphysis-funal height
BP and urine check due to ass b/t IUGR and PE
serial USS
serial umbilical A doppler - oligohydramnios w foetal redistribution –> ‘head sparing’
mx of SFD or IUGR
SFD –> recheck growth fortnightly
SFD+abnormal doppler values –> delivery if >36wk, preterms req r/v w um A doppler at least twice a week to weigh out risks and benefits. Admit if absent end-diastolic flow
1st degree tear
injury to perineal skin only
mx: no need to suture unless haemostasis is a problem
2nd degree tear
injury to perineum involving perineal muscles only
w/o involvement of anal sphincter
mx: need to be sutured to ensure correct appoistion of perineal muscles and skin, by m/w
3rd degree tear
3A
3B
3C
injury to perineum involving anal sphincter
mx: sutured in theatre w adequate analgesia, by obs reg+
anal sphincter must be repaired to avoid incontinence
3A <50% external anal sphincter torn
3B >50% EAS torn
3C BOTH EXTERNAL AND INTERNAL anal sphincter torn
4th degree tear
involving anal spincter AND anal epithelium
mx: sutured in theatre w adequate analgesia, by obs reg+ and general surgeon if req
RF of ob anal injury
3rd and 4th degree tears can lead to faecal incontinence if not recognised
>4kg bb persistent occipoposterior position nulliparity IOL epidural prolonged 2nd stage >1hr shoulder dystocia midline episiotomy instrumental delivery
Multiple pregnancies…
Maternal risks: incr surveillance for anaemia, GDM and pe
Most common foetal compl: preterm and IUGR and late m/c
aetiology incl: assisted conception, fhx, incr maternal age, parity
present w vomiting more marked in early preg, larger uterus and palpable before 12 week
Twin-twin transfusion syndrome
the ‘donor’ is volume depleted –> anaemia, IUGR, oligohydramnios
‘recipient’ gets fluid overloaded –> polycythaemia, cardiac failure, polyhydramnios
Selective reduction for triplets+ discussed at 12 weeks (after booking at 11-13?)
incr early m/c rate but reduces chance of preterm (and therefore CP)
reduction not advised from twins to singleton
method of multiple delivery
vaginal if first baby is cephalic
induction/CS at around 37-38 weeks (after which time perinatal mortality is increased)
mechanism of labour: POWER
once in established labour, uterus contracts for 1 min, every 2-3mins –> pulls the cervix up (effacement)
there may be poor uterine contractility in nuliparous F
PASSAGE and stations
pelvic inlet: transverse diameter of 13cm
mid-cavity: AP diameter of 11cm hence the internal rotation
pelvic outlet: AP diameter 12.5cm
station 0 = head is at level of ischial spine
station +2 = 2cm below ischial spine
station -2 = 2cm above ischial spine
PASSENGER and attitude and position
NB/ presenting part is either cephalic or breech
attitude = degree of flexion of the head on the neck.
maximal flexion is called vertex (feel more of the posterior Y fontanelle)
extension is called brow (anterior 3 way fontanelle is more central)
hyperextension is called face (face feel features of the face)
NB/the sagittal suture runs b/t ant and post fontanelles
position = degree of rotation of the head: occipito -transverse/anterior/posterior
Movements of the head
- engagement in occipito-transverse (OT) entering the pelvic inlet as the transverse diameter is longest
- desent and flexion (measured by station)
- rotation 90o to occipito-anterior position in midcavity as transverse and AP diameters are both 11cm therefore like a square and longest diameter is the diagonal one…
- then it ends in occipito-anterior position in the outlet as the AP diameter is longest
- descent and extension to delivery
- restitution: head externally rotates 90o to enable…
- delivery of anterior –> posterior shoulders
effacement
= when cervix is drawn up into the lower segment until flat. Commonly accompanied by a ‘show’ or mucus plug from the cervix or ROM
Augmentation –>
- ARM
- PG gel into posterior vaginal fornix
- artifical oxytocin
dilatation of cervix should be around 1cm/hr
first stage should be completed in 12hr. if first dilatation not achieved w/i 12hr then proceed to LSCS
active pushing of 2nd stage should be w/i 1hr
meconium is not a reliable indicator of foetal well being but req CTG monitoring because…
a) risk of meconium aspiration
b) more like to exp hypoxia
foetal HR auscultation
first stage - every 15 mins
second stage -every 5 mins
if abnormalities are detected –> CTG
FBS
<7.20 –> CS
7.2-7.25 –> recheck in 10-30 mins
>7.25 –> reassuring
Analgesia in labour
non-medical
- back rubbing
- TENS
- immersion in water (NOT water birth!)
- Entonox/NO inhalation agents (can cause light headedness, nausea, hyperventilation)
- diamorphine IM (may feel drowsy or confused) + anti-emetics
- Anaesthetics (spinal, pudendal nerve block (quick pain relief to the perineum, vulva, and vagina), epidural anaesthesia)
CI to epidural
Sepsis Coagulopathy or anticoag therapy (unless just LWMH) Active neurological disease Spinal abnormalities Hypovolaemia
compl of epidural
hypotension
spinal tap = inadvernt puncture of the dura mata causing CSF leak
PDH
dx of labour
painful contractions w effacement and dilatation of cervix
OR
painful contr w show or ROM
labour progress monitoring
2-4 hourly PV exams
Retained placenta definition
3rd stage > 30mins
mx = oxytocin infusion and 10 units injected into the vein of the cord.
leave for 1hr
placenta manually removed if it has not happened yet. Cross match blood and give IV abx.
IOL
prostaglandin gel into posterior vaginal fornix eg. MISOPROSTOL. Can repeat in 6hr providing there is no uterine activity.
when cxdil >3cm –> amniotomy
oxytocin can also be used after any ROM
Common indications for IOL
post date ?IUGR pPROM pe medical disease eg.HTN, GDM
CI to IOL
acute foetal compromise
abnormal lie ie.oblique or transverse
pelvic obstruction eg.pelvic mass, pelvic deformity
relative CI are prev CS
compl of IOL
failure –> instrumental/CS
hyperstimulation –> foetal distress or uterine rupture
amniotomy –> cord prolapse
incr risk of PPH
Absolute CI for CS
Vertical uterine scar
multiple prev CS
safety of VBAC
safest option is vaginal, least safe is emergency CS and elective CS lies in b/t. So overall maternal safety depends on chance of req emergency CS.
Mx of labour after CS
in hospital and CTG req due to risk of scar rupture
Avoid IOL w PG due to risk of rupture
CS is preferred unless amniotomy and cervix is ripe or foetal head is engaged
scar rupture usually presents as foetal distress, scar pain, cessation of contractions, PV bleed or maternal collapse –> immediate CS
pPROM
gush of clear fluid followed by uncontrollable intermittent trickle
can ?urinary incontinence
cord prolapse is usually a complication of…
transverse lie or breech presentation
mx of pPROM
speculum to look for pooling of fluids NO VE check lie and presentation vaginal swab to screen for infx CTG or foetal auscultation for foetal distress
After 18-24hr –> prescr abx
a) Evidence of meconium or infx warrants immediate induction
b) Wait - 80% go into spontaneous laboutr w/i 24hr. Measure maternal temp and pulse, foetal HR, measured every 4hr
c) IOL - especially if mother is GBS carrier
ventouse
attaches by suction allowing traction (pulling) and if req, w rotation into OA
Non rotational forceps eg. Simpson’s, Neville-Barnes
for traction only
therefore only suitable if OA
have a cephalic curve for head and a pelvic curve
Rotational forceps eg.Kielland’s
no pelvic curve
allows rotation into OA before traction is applied
compl of instrumental delivery
instrumental delivery is indicated if >1hr of active 2nd stage ie.active pushing
or if mother is exhausted
or foetal distress during 2nd stage
prophylactic use of instrumental delivery is indicated to in F w medical problems who should avoid pushing eg.HTN, cardiac disease
- failure
- vaginal laceration
- third degree tears
- blood loss
for the foetus
- ‘chignon’ = swelling of scalp where the suction was applied. Diminishes over hours but mark might still be there for days.
- facial bruising or facial nerve damage
Scalp laceration, cephalhaematoma and neonatal jaundice are more common w ventouse
occipito-transverse positions in the mid cavity…
need to be rotated therefore descent is achieved w ventouse. Maybe Keilland’s
occipito-posterior positions in the mid cavity…
180o rotation Kielland’s forceps (or alt ventouse)
Pre-requisites for ventouse or forceps delivery
head not palpable abdominally ie. deeply engaged head at/below ischial spines FULLY DILATED cervix ie. in 2nd stage KNOWN position of head Adequate analgesia Bladder emptied
Common reasons for CS
elective
- prev CS
- breech
- placenta praevia
emergency
- failure to progress
- foetal distress
Urgency of CS
Peri/post-mortem
- for foetus and mother during maternal arrest/for foetus after maternal death
Elective
- planned
Urgent
- maternal/foetal compromise but not immediately life-threatening
Emergency
- immediate threat to mother or foetus
compl of CS
- haemorrhage
- uterine/wound sepsis
- VTE
anaesthetics
Shoulder dystocia
–> Emergency CS
= when additional manouvres are req after normal downward traction has failed to delivery the shoulders after the head has delivered
RF = large bb > 4kg
prev shoulder dystocia
incr maternal BMI, maternal DM
Mx:
XS traction is uselss and will cause Erb’s palsy
1. senior help
2. McRoberts’ manouvre (legs hyperextended onto abdo)
3. apply suprapubic pressure
90% success rate… otherwise
4. episiotomy for internal moanouvres eg.Woodscrew’s manouvre
5. grasp the posterior arm and bring the hand down
6. symphisiotomy and Zavenelli manouvre (replacement of head back into abdo and proceed w CS)
Cord prolapse
occurs after ROM (more than half occur at artificial amniotomy!)
= umbilical cords presenting below the presenting part (cephalic or breech)
Untreated, the cord will be compressed or go into spasm –> foetal hypoxia
RF = preterm breech polyhydramnioss abnormal lie twin preg
dx: abnormal foetal HR + cord palpated vaginally or appears at the introitus
mx:
- cord is pushed up by the examining finger to prevent it from getting compressed
- ?tocolytics eg.terbutaline
- if the cord is already out of the introitus (ie. into the external environment), do not force it back inside but keep it warm
- get pt into ALL-FOURS toa void compression
- CS (instrumental if low head and fully dilated cervix)
Erbs’ palsy
–> ‘waiter’s tip’ position
amniotic fluid embolism
Usually occurs at ROM (but maybe during labour, at CS or TOP)
= when liquor enters the maternal circulation –> sudden SOB, hypoxia, hypoT, seizures and cardiac arrest. Can lead to DIC, pulm oedema and adult RDS
RF = particularly strong contractions in the presence of polyhydramnios
often mistaken for pe or other causes of collapse
Mx = resus and supportive, O2, blood test, order blood and FPP. Then transfer to ICU
Uterine rupture
uterus tearing, either out of the blue or from opening of old CS scar.
If the foetus is expelled, the uterus contracts and bleeds from the ruptured site –> acute foetal hypoxia and massive internal maternal haemorrhage. Can occur while foetus is in utero though
RF = prev CS, congenital uterine abnormality,
dx: foetal HR abnormality
- constant lower abdo pain
- vaginal bleeding
- cessation of contractions
- maternal collapse
mx = maternal resus w IVF and blood. May need urgent laparotomy
Uterine inversion
= when fundus inverts into the uterine cavity (dips into the womb)
follows traction fo the placenta
dx: haermorrhage, pain and profound shock
mx:
- brief attempt to immediately push the fundus up via the vagina
- GA then replacement where hydrostatic pressure of several litres of warm saline is ran past a clenched fist at the introitus into the vagina
advantages of BF
NB/ early feeding should be on demand
bonding cost saving can't give XS protection against infx in neonates proection agaist Ca (for mother)
postnatal contraception
usually 4-6 weeks after delivery
progesterone-only preparations are safe for BF
COCP suppresses lactation and CI in BF
IUD is safe but screen for infx first. Can be inserted at end of 3rd stage or at 6wk puerperium
PPH
causes: aTony Tissue eg.RPOC, clots Thrombus ie.clotting disorder Trauma eg.perineal tears or high vaginal tear (esp after instr vaginal delivery)
> 500ml loss of blood <24hr of delivery
RF = prev PPH prev CS instrumental or CS APH multiple preg or polyhydramnios grand multiparity uterine malformation or fibroids prolonged and induced labour
mx of PPH
- resus by lying the pt flat, obtain IV access, cross-match blood
- remove RPOC manually if there is bleeding or if it is not expelled w/i 60mins of delivery
- PV to exclude uterine inversion and to bi-manually compress the uterus
- identify and treat the cause
- IV ergometrine/oxytocin if no obvious trauma
- EUA (examination under anaesthetics) is performed where the uterus is explored manually for RPOC and tears looked for which wil be sutured
- if uterine atony persists, PG is injected into the myometrium
- persistent haemorrhage may req surgery for Rusch balloon, brace suture, uterine A embolization
- hysterectomy
secondary PPH
usually due to endometritis +/- retained placental tissue
give abx
do evacuation of retained products of contraception (ERPC) if no improvement
Evacuation of retained products of conception (ERPC)
cervix is dilated and a retained non-viable foetus or placental tissue is removed using a suctino curette. similar to surgical therapeutic abortion before 12/40
treatment for endometriosis
- mefanamic acid
2. hormonal contraception, Mirena, COCP
Prophylactic aspirin given to high for HTN
prev PE
renal disease
lupus
DM and obesity
Another word for congenital deformity
BIRTH DEFECT
If day 21 progesterone is low it is a …
anovulatory problem!
dysmenorrhoea
painful periods
dyschezia
painful defecation
menorrhagia
heavy periods
