O&G Flashcards
Primary amenorrhoea?
Failure to start menstruating by age 16
- Needs Ix in 15y/o
OR 14 with no breast development
Secondary amenorrhoea?
Causes?
Periods stop for >6 months
Causes:
Physiological - Pregnancy/lactation
Drugs: Progestogens, GnRH analogues and antipsychotics
Premature menopause
PCOS (oligomenorrhoea)
Hyperprolactinaemia: Pituitary hyperplasia or benign adenoma (mx bromocriptine, cabergoline or surgery)
Sheehan’s
Hypothalamic hypogonadism:
- psychological, low weight/anorexia / excessive exercise
GnRH, FASH, LH and oestradiol are ALL reduced
Hypo/hyperthyroidism
CAH
Turner’s
Gonadal dysgenesis
Outflow tract obstruction (eg. imperforate hymen, Asherman’s syndrome, cervical stenosis)
Ovarian insufficiency
Primary: eg. genetic: turner’s syndrome
Secondary to chemo/radio
Most common cause of oligomenorrhoea during reproductive years
PCOS
Dysmenorrhoea?
Primary dysmenorrhoea - pain without organ pathology
- Excess PG causes painful uterine contractions
Rx: NSAIDs eg. mefenamic acid; paracetamol
Secondary dysmenorrhoea
- Associated with pathology eg. Adenomyosis, endometriosis, fibroids
- Appears later in life
Intermenstrual bleeding
Follows midcycle fall in oestrogen production
Other causes: Cervical polyps Ectropion Carcinoma Fibroids Hormonal contraception
Mx: IUS or COCP
Post-coital bleeding causes?
Cervical trauma/ectropions
Benign Polyps
Invasive cervical cancer
Cervicitis
Vaginitis
Atrophy of vaginal walls
Mx: Full H+E
Cryotherapy for ectropion
Refer to colposcopy to exclude malignancy
Post-menopausal bleeding causes?
Ix?
Bleeding >1yr after LMP
Causes:
Endometrial carcinoma
Endometrial hyperplasia/atypia/polyps
Cervical/vulval/ovarian carcinoma
Cervical polyps
Atrophic vaginitis
Foreign bodies
Ix: Cervical smear, TVUS +- endometrial biopsy & hysteroscopy (if thick endometrium or multiple bleeds
PCOS diagnostic criteria?
Rotterdam criteria: 2 out of 3 of:
1) Clinical or biochemical hyperandrogenism
2) Oligomenorrhea (10cm^3)
PCOS Sx?
Acne
Male pattern baldness
Hirsutism
Acanthosis nigricans on neck
and skin flexures
Raised LH + Test
Subfertility
Insulin resistance
Hyperinsulinaemia
What is Stein-Leventhal syndrome?
Obese hirsute women with PCO
PCOS Ix + Mx?
IX: US
Mx: Conservative Avoid smoking Treat any dibaetes, hypertension, dyslipidaemia, sleep apnoea Encourage weight loss + exercise
Medical
Metformin improves insulin sensitivity, menstrual disturbance and ovulatory function
Clomifene - induces ovulation BUT risk of multiple pregnancy/ ovarian cancer
COCP: controls bleeding
Cyproterone (anti-androgen) : for hirtsutism
Menorrhagia causes?
Dysfunctional uterine bleeding - heavy/irregular bleeding in absence of pathology. Associated with anovulatory cycles. Diagnosis of exclusion if PV normal & organ pathology ruled out
IUCD
Fibroids (O/E - Irregular enlargement of fibroids)
Endometriosis
Adenomyosis (O/E Uterine tenderness)
Pelvic infection
Polyps
Endometrial carcinoma
Menorrhagia Mx?
Medical:
1st: Progesterone containing IUS eg. Mirena, especially if wanting contraception
2nd: - Antifibrinolytics eg. tranexamic acid
- Anti-prostaglandins eg. mefanamic acid
- COCP
3rd: Progestogens IM or norethisterone 5mg TDS PO days 5-26 of menstrual cycle
- GnRH analogues
Surgical:
- Polyp removal, endometrial ablation, endometrial resection, myomectomy, hysterectomy, uterine artery embolisation
Menopause features?
- Caused by oestrogen levels
- Menstrual cycle irregularity - cycles become anovulatory
before stopping - Vasomotor disturbance (Sweats, palpitations, flushing)
- Atrophy of oestrogen dependent tissues and skin
- Cardio disease
- Urogenital problems:
Vaginal atrophy, frequency, urgency, nocturia, incontinence and recurrent infection
Osteoporsis
Menopause Mx?
Conservative:
- Counselling for psychosocial/physical sx
- Treat menorrhagia
- Use contraception until 1y> amenorrhoea if >50y or 2y> if
HRT?
Oestrogen
May help flushes and atrophic vaginitis
Postpones menopausal bone loss but no longer recommended for osteoporosis prevention
No cardiovascular benefits or protection against dementia
Increased stroke and thromboembolism risk
Increased BREAST cancer and ENDOMETRIAL cancer risk – greater risk when combined oestrogen/progesterone preparations are used compared to oestrogen alone
Progestogens
- Cyclical
- Reduce incidence of endometrial carcinoma
SE
- Increased weight
- Premenstrual syndrome
Mx:
Discuss risk of breast cancer with each pt considering HRT
Document this discussion in the Pts notes
Encourage breast awareness and to report breast change
warn that it is symptomatic Tx at the lowest dose needed to control sx for the shortest time possinle - sx often return on stopping
Be way with FH of breast cancer
HRT CI?
Oestrogen dependent cancer
Past PE
Undiagnosed PV bleedng
Raised LFTs
Pregnancy
Breastfeeding
Phlebitis
TOP: Law?
Abortion Act 1967 (amended 2002) and HFEA 1990 allow TOP IF:
A) Risk to mother’s life if pregnancy continues
B) TOP necessary to prevent permanent grave injury to physical/mental health of woman
C) Continuance of pregnancy risks injury to the physical/mental health of woman greater than if terminated (And foetus not >24wks)
D) Continuance risks injury to physical/mental health of existing children greater than if terminated (and fetus not >24wks)
E) Substantial risk that if child were born, he/she would suffer such physical or mental abnormalities as to be seriously handicapped.
97% for C
- 2 doctors must sign certificate HSA1
- If pts less than 16, try to get consent to involve parents
- TOPs after 23 weeks may only be carried out in NHS hospitals
What to do before TOP?
- 2 doctors must sign certificate HSA1
- If pts less than 16, try to get consent to involve parents
- TOPs after 23 weeks may only be carried out in NHS hospitals
Before TOP decision:
- Offer counselling
- Confirm pregnancy
- Give information on choice of methods
Before TOP:
- Screen for chlamydia and other STIs
- Abx prophylaxis: Metronidazole 1g PR/800 PO at TOP
- Discuss contraception
- If RhD -ve, give anti-D
- Assess VTE risk
TOP Methods?
less than 9 weeks: mifepristone (an anti-progestogen, often followed 48 hours later by prostaglandins to stimulate uterine contractions
less than 13 weeks: surgical dilation and suction of uterine contents
more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
Medical TOP
Antigestagen: eg. mifepristone used to disimplant feotus, followed by a prostaglandin eg. misoprostol
Highly effective after 6 weeks
For early TOPs, arrange follow up and scan 2/52 after procedure
5% will need surgical evacuation
NSAID pain relief
May need narcotic analgesia if gestation > 13 weeks
Surgical TOP
- Vacuum aspiration and dilatation
- May need cervical priming with misoprostol 400ug PV or sublingual 3h pre-op
- NSAID pain relief
- Less bleeding and pain than with medical TOP
Vacuum aspiration: Used from 7-16 weeks
LA safer than GA
Dilatation & Evacuation: surgical forceps may be used at 13-24 weeks after cervical priming
Complications:
- Failure to terminate
- Infection
- Haemorrhage
- Uterine perforation
- Uterine rupture
- Cervical trauma
Miscarriage? Mx?
Loss of pregnancy before 24wks gestation
20-40% pregnancies miscarry, mostly in first trimester
Most PC with PV bleeding
Pregnancy remains positive for several days after foetal death
Ix: TVUS
Mx:
- Remove blood/products from cervical canal
- Assess os & Uterine size
Where does bleeding come from?
- Need for anti-D?
- if profuse bleeding –> Ergometrine 0.5mg IM
- If severe bleeding/pain or retained tissue on ultrasound : ERPC (evacuation of retained products of conceptions)
- Medical mx with misoprostol when volume of retained products is 15-50mm across on TVUS
Miscarriage types
1) Threatened
- Mild symptoms/closed os
- 75% will settle, rest advice
- Associated with subsequent risk of PROM and preterm delivery
2) Inevitable
- Severe symptoms/ Os open
- Incomplete miscarriage, but most of products of conception have passed
3) Missed miscarriage:
- Foetus dies but is retained
- PC: Bleeding
- Uterus is small for dates
- Confirm with US
Mx: Medical if uterus small; surgical if uterine products >5cm in transverse plane
4) Mid-trimester MC:
- usually due to mechanical causes eg. cervical incompetence, uterine abnormalities or chronic maternal disease
- Incompetent cervix can be strengthened by a cervical cerclage suture at 14 weeks
5) Miscarriage with infection:
- Presents as acute salpingitis
Rx: Broad spectrum Abx eg. coamoxiclav + Metro
6) Septic miscarriage
- contents of uterus infected causing endometritis
Sx: Offensive vaginal D/C + Tender uterus
Recurrent spontaneous miscarriage?
3 or more consecutive miscarriages before 24wks
Affects 1% of women
Causes:
- APS
- Chromosomal defects
- Uterine abnormalities
- Infection
- Obesity
- Smoking
- PCOS
- Excess caffeine intake
- Higher maternal age
- Thrombophilia
- Alloimmune causes
Ix: APS antibodies screen
- karyotyping of both parents
- Pelvic US
- hysterosalpingogram
Ectopic pregnancy: Predisposing factors?
Sites?
Dmg to tubes (Salpingitis, previous surgery) Previous ectopic Endometriosis IUCD POP
Site: Tubal 97%
isthmus 25%
Ovary/cervix/peritoneum 3%
Ectopic: Sx, OE, MX?
Sx: D+N+V
Dark/fresh PV blood
Tubal colic causes abdo pain
Gradually increasing PV bleeding and bleeding into peritoneum producing shoulder tip pain due to diaphragmatic irritation and pain on defecation/urination
Rupture - sudden severe pain, peritonism and shock
OE: Faint, tender abdo, enlarged uterus, cervical excitation, adnexal mass
Mx: Anti-D prophylaxis
- Urinary/serum B-HCG
US
expectant management: option in those without acute symptoms/falling bHCG
Early ectopics - medical mx: Methotrexate
Surgical Mx: Salpingectomy/salpingotomy (Creating an opening in the tube to remove ectopic) via laparoscopy/laparotomy
Hydatidiform mole?
Complete hydatidiform mole
Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin
Features
bleeding in first or early second trimester
exaggerated symptoms of pregnancy e.g. hyperemesis
uterus large for dates
very high serum levels of human chorionic gonadotropin (hCG)
hypertension and hyperthyroidism* may be seen - B-HCG resembles TSH. Thyrotoxic storm can occur at evacuation
Management
urgent referral to specialist centre - evacuation of the uterus is performed
effective contraception is recommended to avoid pregnancy in the next 12 months
Around 2-3% go on to develop choriocarcinoma
In a partial mole a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen
Choriocarcinoma
2-3% of molar pregnancies go onto develop choriocarcinoma
Sx: May be yrs after pregnancy general malaise Uterine bleeding Sx from mets Nodules on CXR Pulmonary artery obstruction due to tumour emboli
Rx: Methotrexate based chemo
Ectropion?
Red ring around the os as endocervical epithelium has extended over the ectocervical epithelium
Due to eversion
Occurs temporarily under hormonal influence during puberty, with the COCP and during preggers
Prone to bleeding, excess mucus production and infection
Normal finding in young women, particularly if pregnant or on COCP
Rx: No Tx usually, cryocautery can be used after taking a smear
Nabothian cyst?
Mucus retention cysts found on cervix
Harmless
Rx: cryotherapy if discharging
CIN?
CIN - preinvasive cervical cancer
–> Atypical cells present within the squamous epithelium
CIN I - mild dysplasia - lower basal 1/3 of cervical epithelium. Commonly regress. Assoc. with HPV 6,11
CIN II (Moderate dysplasia) - 2/3 of thickness of epithelium. Associated with HPV 16/18 --> Less likely to regress, and significant number develop into invasive SCC of cervix.
Cervical screening?
1st smear taken aged 25
3 yearly from 25 yr, 5 yearly from 50 – 64 yr
Only screen after 65 if one of last 3 was abnormal
HIV +ve should have annual smears
Borderline/mild dyskaryosis - original sample tested for HPV
- -ve - routine recall
+ve - refer to colposcopy
Moderate dysk - consistent with CIN II. refer to colposcopy
Severe dysk - Consistent with CIN III - refer to colposcopy
Suspected invasive cancer - refer for urgent colposcopy (within 2 weeks)
Inadequate - repeat smear. If 3 inadequete samples, colposcopy
Cervical cancer vaccine?
1 Gardasil targets HPV 6, 11, 16 & 18
3 IM does, 0.5mL (deltoid/lateral thigh). Age range: 9–18yrs (9–26 ). Dose 2 is ≥1 month after dose 1, and dose 3 ≥4 months after dose 1. CI: pregnancy, bleeding disorders
Cervarix (bivalent; HPV16 & 18).
Cervical carcinoma risk factors?
Prolonged COCP use High parity > 4 sexual partners Early first coitus HIV other STDs smoking
Cervical carcinoma: Sx
Sx: post-coital bleeding, offensive DC, intermenstrual/PMB. Later features: involvement of ureters, bladder, rectum and nerves cause uraemia, haematuria, rectal bleeding and pain
O/E: Ulcer/mass may be visible/palpable on cervix
CIN Mx
Mx of pre-invasive cancer:
- Colposcopy
- Abnormal epithelium has characteristic blood vessel patterns and stains white with acetic acid
- take punch biopsies for histology
CIN I - observe
CIN II & III - destroyed by cryotherapy, laser, cold coagulation or large loop excision of transformation zone (LLETZ)
- Annual smears for atleast 10 years
- If the squamo-columnar junction cannot be seen or if small-volume invasive carcinoma is found on histology, the abnormal tissue is removed by cone biopsy which may be curative
nb. Colposcopy does not detect adenocarcinoma
Cervical carcinoma Staging & Mx?
Staging: most are SCC, 15-30% are Adenocarcinoma
Stage I - confined to cervix
Stage IIaextended locally to upper 2/3 of vagina
Stage IIb Extended locally to parametria
Stage III - IIIa - lower 1/3 of vag, IIIb to pelvic wall
Stage IV - IVa: Bladder or rectum IVb: spread to distant organs
MX
Stage Ia: cervical cone biopsy/cold knife excision
Stage Ia2/Ib1 - radical hysterectomy with pelvic lymphadenectomy or radiotherapy
Stage II/III/IV: Chemoradiation
Endometritis?
Uterine infection possibly involving fallopian tubes and ovaries
Uncommon
Usually seen after miscarriage, TOP, childbirth, IUCD insertion or surgery
Often secondary to STIs
Sx: lower abdominal pain, fever, uterine tenderness on bimanual palpation
Ix: cervical swabs and blood cultures
Rx: Abx doxycycline & metronidazole
Endometrial US thickness?
TVUS gives better resolution than transabdominal
If thickness >5mm, consider endometrial Ca
Vaginal carcinoma?
Usually squamous
Commonest in the upper third of the vagina
Sx: bleeding Spread: local by lymphatics Rx: radiotherapy
Lichen sclerosus?
5% associated with VIN, 4% have cancer in 12.5 yrs, 1/3 assoc with sq cell hyperplasia
Most- post-menopasual but can affect children and young women
Classical lesion- fig of 8 crinkled parchment like appearance (around vulva and anal region)
Pruritis, irritation, ulceration
Bx may be needed to confirm diagnosis and rule out VIN/ invasion
Rx- testosterone propionate/ cypropionate
2%/ colbetasol propionate
VIN?
Demographic?
Ix?
Associations?
Mx?
Average age 40 years, increasing incidence in last 20 years (particularly in under 35s)
VIN1 mild, VIN2 mod, VIN3 severe
30% associated with invasion
Ix: Colposcopy, 5% acetic acid or 1% toluidene blue, biopsy
Associated with HPV DNA- 16, 18, 31, 33, 35, 51
Mx
May be multifocal
Surgical excision/ laser Rx
Vulval cancer?
Demographic
Sx
Ix
Uncommon cancer - mostly postmenopausal women (mean = 65)
SCC accounts for 90% of cases
Dual aetiology; HPV vs chronic irritation (lichen sclerosus)
Sx: vulval lump/mass
Long history pruritis, vulval bleeding, Discharge , dysuria
Fibroids
- What are they
- Associations
- Pregnancy?
Benign smooth muscle tumours of the uterus
Often multiple
Start as lumps in the wall of the uterus but may grow to bulge out of the wall so that they lie under the peritoneum or under the endometrium
Fibroids are common fq increases with age and in non-Caucasians
Associated with mutation in gene for fumarate hydratase
Oestrogen dependence – enlarge in pregnancy, on the COCP and on HRT; atrophy after the menopause
May enlarge or degenerate gradually or suddenly
Red degeneration: pain and uterine tenderness;
haemorrhage and necrosis occur
May calcify – womb stones
May undergo sarcomatous change rarely – causes pain, malaise, bleeding and increase in size
Cause heavy periods due to increased endometrial surface, dysfunctional endometrium, impaired uterine contractility.
Fibroids in pregnancy?
Premature labour
Malpresentations
Transverse lie
Obstructed lie
PPH
Red degeneration common
Fibroids types?
Intramural
Subserosal
Submucosal
Pedunculated submucosal
5% are submucous, hysteroscopic resection is tx of choice
Type 0 – pedunculated without intramural extension
Type 1 – sessile fibroid w intramural extension 50%
Fibroids Sx, Ix and Mx?
Sx: Asymptomatic, menorrhagia, dysmenorrhoea, fertility problems, pain, mass, frequency, urinary retention
Ix: US, MRI, hysteroscopy/hysterosalpingogram
Mx:
Menorrhagia: Tranexamic acid, mefanamic acid or progestogens
Surgical resection:
- pretreatment with GnRH analogues can shrink fibroids and make resection easier
Myomectomy
Hysterectomy
Adenomyosis?
Presence of endometrial tissue within the myometrium
Age: 40
Cause: endometrium grows into the myometrium; pockets of menstrual blood can be seen in the myometrium
Sx: asymptomatic; painful, regular, heavy menstruation
OE: uterus is mildly enlarged and tender
Ix: MRI
Mx: IUS or COCP with or without NSAIDs for menorrhagia Mefanamic acid Tranexamic acid COCP Mirena IUS Endometrial ablation Uterine artery embolisation Hysterectomy
Endometrial carcinoma? Risk factors?
Usual PC = Postmenopausal bleeding - initially scanty and occasional, and then heavy and frequent. May also PC as intermenstrual bleeding or menorrhagia.
- Most are adenocarcinomas of columnar endometrial gland cells
- Others are adenosquamous carcinomas (poorer prognosis)
- Related to excessive exposure to oestrogen unopposed by progesterone
Risk factors:
- Obesity
- Unopposed oestrogen (PCOS)
- FH of breast, ovary or colon Ca
- Nulliparity
- LAte menopause
- DM
- Tamoxifen, tibolone
- Pelvic irradiation
- Lynch syndrome type II (HNPCC)
Endometrial Ca Ix, Staging and Rx?
Ix: Cervical smear, uterine ultrasound, uterine sampling/curettage, hysteroscopy
Staging: I = body of uterus only II = body + Cervix III = advancing beyond uterus but not beyond pelvis IV = extending outside pelvis
Mx:
stage I/II - total hysterectomy + bilateral salpingo-oopherectomy +- radiotherapy
Stage III and IV: radiotherapy and/or high dose progestogens
Recurrent disease: Medroxyprogesterone, surgical exoneration & radiotherapy
Benign Ovarian tumours types?
Physiological cysts (functional cysts)
1) Follicular cysts
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles
2)Corpus luteum cyst
during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts
Benign germ cell tumours
1) Dermoid cyst
also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
most common benign ovarian tumour in woman under the age of 30 years
median age of diagnosis is 30 years old
bilateral in 10-20%
usually asymptomatic. Torsion is more likely than with other ovarian tumours
Benign epithelial tumours
Arise from the ovarian surface epithelium
1) Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%
2) Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei
Commonest ovarian cyst?
Follicular cyst
Commonest benign ovarian tumour in women
Dermoid cyst
Most common benign epithelial tumour?
Serous cystadenoma
Ovarian tumour types?
1) Surface derived tumours (65%)
- Serous cystadenoma (B)
- Serous cystadenocarcinoma (M)
- Mucinous cystadenoma (B)
- Mucinous cystadenocarcinoma (M)
- Brenner tumour (B)
2) Germ cell tumours (15-20%)
- Teratoma (Mature - B, immature M)
- Dysgerminoma (M)
- yolk sac tumour (M)
- Choriocarcinoma (M)
3) Sex cord-stromal tumours
- Granulosa cell tumour (M)
- Sertoi-leydig cell tumour (B)
- Fibroma (B) - Meig’s
4) Mets
- Krukenberg tumour (M) - Mets from a GI tumour result in a mucin-secreting signet ring cell adenocarcinoma, most commonly from pylorus. 80% bilateral
What is Meig’s syndrome?
Ascites , pleural effusion + ovarian fibroma
Ovarian Ca?
Rare
In ~80% it causes few symptoms until it has metastasized
5 year survival
Ovarian Ca Sx , Ix & pattern of spread
Sx: Initially vague or asymptomatic persistent abdo distention Early satiety/loss of appetite Pelvic or abdo pain Increased urinary urgency/frequency Similar to Sx of IBS
Ix: Histology, ascites, ultrasound/CT, CA-125
Risk of malignancy index (US score, menopausal status & CA125 levels) - if RMA>250 refer to MDT
Pattern of spread:
- Transcoelomic
- Lymphatic spread to pelvic and paraaortic nodes
Ovarian Ca Staging and Rx?
Staging:
I - disease limited to 1 or both ovaries
II - Beyond ovaries but in pelvis
III - ovary and peritoneal implants outside pelvis/ +ve retroperitoneal or inguinal nodes
IV - distant mets
Rx: Adenocarcinomas (89%) - Curative surgery - total hysterectomy + bilateral salpingo-oppherectomy + partial omentetomy
+ Chemo
–> unless very early disease with low grade histology
Follow up levels of Ca125 and CT
Pelvic infection?
90% sexually acquired - mostly chlamydia
10% follow childbirth/instrumentation
Acute Salpingitis - Pain, fever, spasm of lower abdo muscles, cervicitis, purulent/bloody vag DC
MX: endocervical & urethral swabs
IV ABx : Ceft + Doxy followed by doxy + Metro
Complications:
- Abscess
- chronic infection
- Long term tubal blockage
- Increased rate of ectopic pregnancy
Chronic salpingitis?
Unresolved acute salpingitis
- Inflammation leads to fibrosis leading to adhesions
- Tubes may be distended with pus/fluid
Sx: Pelvis pain, menorrhagia, sexondary dysmenorrhoea, discharge, deep dyspareunia
Ix: Laparascopy
Endometriosis?
Endometrial glandular tissue occuring outside uterine cavity eg. on ovary
- If foci found in uterine wall muscle - adenomyosis
10% of all women, 35-50% of women with subfertilitiy
Foci are under hormonal influence with waning in pregnancy and menopause and bleeding during menstruation.
Endometriosis Sx?
OE
Asymptomatic, pelvic pain (particular at the time of periods. Constant if adhesions), secondary dysmenorrhea, deep dyspareunia, thigh pain, pain on defecation, menorrhagia (especially with adenomyosis), subfertility
OE: VE - tenderness or thickening behind uterus/adnexa, fixed retroverted uterus or uterosacrl ligament nodules and general tenderness.
Retroverted uterus
Everything stuck together
Endometriosis Ix and Rx?
Complications?
Ix: Laparoscopy
Rx: Medical - analgesia NSAIDs hormonal therapy: COCP/progestogens GnRH analogues IUS
Surgical:
- surgical excision or laser ablation
- Total hysterectomy & bilateral salpingo-oopherectomy
- -> Important to do medical first as endometriosis can recur after excision
Complications:
- Obstruction
- Ovarian endometroid and clear cell cancers
- Hodgkin’s lymphoma
- Melanoma
Subfertility?
Defined as failure to get pregnant after 2 years of regular (2-3wk) UPSI)
Offer investigation after 1 year of trying to conceive In subfertile couples consider: Production of ova Production of sperm Meeting of ova and sperm Implantation of embryo
Ix: Blood tests for anovulation Serum mid-luteal progesterone Day 5 FSH & LH TFT Prolactin Semen analysis Volume Sperm count/morphology Infection Hysterosalpingogram Rx: intrauterine insemination,
bromocriptine for hyperprolactinaemia,
Pulsed GnRH/clomifene/IVF for anovulation,
surgery for tubal problems,
IUI/IVF with or without ICSI for male infertility
NB. NO FERTILITY TX ON NHS IF STILL SMOKING
Uterine prolapse - Types
Descent of uterus and/or vaginal walls beyond normal anatomical confines
Occurs as a result of weakness in supporting structures
Types:
Urethrocoele – prolapse of lower anterior vaginal wall involving urethra only
Cystocoele – prolapse of upper anterior vaginal wall involving the bladder
Apical prolapse – prolapse of uterus, cervix and upper vagina
Enterocoele – prolapse of the upper posterior wall of the vagina; resulting pouch usually contains loops of small bowel
Rectocoele – prolapse of the lower posterior wall of the vagina involving the anterior wall of the rectum
Uterine prolapse risk factors?
Delivery (large infants, prolonged second stage & instrumental delivery)
Ehlers danlos
Menopause
Chronically raised intra-abdominal pressure eg. obesity, chronic cough, constipation, heavy lifting or pelvic mass, pelvic surgery eg. hysterectomy or continence procedures
Uterine prolapse Sx, IX and Mx?
Sx: asymptomatic, heavy dragging sensation/sensation of a lump
Worse at the end of day or when standing up
May interfere with intercourse, urinary frequency or incomplete bladder emptying
Sims speculum
Ix: Pelvic ultrasound, urodynamic testing
Mx:
Conservative: lose weight, treat chest problems eg. quit smoking
Pessaries - ring/shelf pessary if pt unfit for surgery
Surgery: Hysteropexy; hysterectomy ; sacrocolpopexy
Pregnant abdo palpation - what do you feel?
Uterus not felt until 12 wks
16 weeks - Fundus halfway between symphysis pubis and umbilicus
20-24wks: fundus reaches umbilicus
36 wks: Fundus under ribs
From 16wks SFH increases 1cm/wk
nb. Foetal HS heart from doppler from 12 weeks & Pinard from 24
Reasons for discrepency between fundal height & dates?
Inaccurate menstrual history
Multiple gestation
Fibroids
Polyhydramnios
Adnexal mass
Maternal Size
Hydatidiform mole
Foetal movements?
1st noted by mothers at 18-20 weeks
Increase until 32 weeks and then plateau
Average 31/h
Foetuses sleep for 20-40min cycles day and night
Reduced foetal movements: advise lying semi-recumbent for 2h; if
Mechanisms of labour?
1) Descent, with head in left/right lateral position. Flexion
2) Further descent and internal rotation of head
3) Complete internal rotation of head, beginning extension due to sacral curve
4) Complete extension as head delivered
5) Restitution (external rotation of head)
6) internal rotation + delivery of anterior shoulder
7) Delivery of posterior shoulder
Mechanisms of labour?
1) Flexed fetus descends - head very flexed on spine, descends and engages
2) Internal rotation: Whole fetus internally rotates its facing towards maternal back - head at level of ischial spines
3) Extension of head - head extends around pubis symphysis due to sacral angle until delivered
4) Restitution (external rotation) - after head delivered, fetus rotates back to its original position (Shoulders AP)
5) Delivery of shoulders - Anterior shoulder comes out first, then rest in pelvic axis (ie. anteriorly)
What is CTG?
Normal trace?
CTG - US detects fetal heart beats + tocodynamometer over uterine fundus recording any contractions
Normal trace:
- Baseline: 110-160
- Variability: >5bpm
- Accelerations: >2 of 15bpm over 15 minutes
How to interpret a CTG?
DR C BRaVADO
DR - Define risk
C - Contractions per 10 min - hyperstimulation = >5 contractions in 10 mins
BRa - Baseline rate (should be 110-160bpm)
V - Variability > 5BPM
A - Accelerations of the foetal heart with contractions/movement is reassuring
D - Decels:
- Early - synchronous with contractions - normal response to head compression
- Late - persist after contraction - suggestive of fetal hypoxia
- Variable: reflect cord compression
O - overall assessment
Intrapartum fetal HR monitoring
- Aims to detect patterns known to be associated with fetal distress - diagnosis supported by fetal hypoxia on blood sampling
- Intermittent auscultation at the end of contractions with doppler/Pinard used for low risk labours
- 1st stage - every 15 mins
- 2nd stage - every 5 mins
Continuous FHR monitoring only if abnormality noted or intrapartum problems occur
- -> poor predictive value
- -> over diagnosis of fetal distress
Indications for continuous FHR monitoring
High risk pregnancy
Use of oxytocin
Decelerations noted after a contraction (Late)
Rate 160
Fresh meconium passed
Maternal pyrexia
Fresh bleeding in labour
Maternal requests
Mx of a poor trace?
Management of a poor trace
Lie mother on left side and give O2
Stop oxytocin
If there is uterine hypercontractility -> terbutaline 0.25mg SC
Take foetal blood sample
Foetal blood sampling
Used to check for hypoxia in presence of pathological CTG trace
Not used in acute compromise
Take with mother lying in left lateral position
Foetal acidosis reflects hypoxia
pH >7.25 – normal; repeat in 1 hour if CTG remains pathological
pH 7.21 7.2 – call consultant obstetrician and deliver immediately
CTG: Loss of baseline variability?
Baseline variability of >5 beats/min shows response to vagal tone, sympathetic stimuli, and catecholamines in a well-oxygenated fetal brainstem
Loss of baseline variability may reflect a preterm fetus who is asleep, drug effects (e.g. diazepam, morphine, phenothiazine), or hypoxia.
CTG: Baseline tachycardia?
Heart rate >170 beats/min is associated with maternal fever, or β- sympathomimetic drug use, chorioamnionitis (loss of variation too), and acute/subacute hypoxia
Persistent rates >200 are associated with fetal cardiac arrhythmia
CTG: Baseline bradycardia?
Rarely associated with fetal hypoxia (except in placental abruption)
It may reflect ↑ fetal vagal tone, fetal heart block, or, if spasmodic, cord compression
CTG: Decelerations
Early decelerations
Coinciding with uterine contractions reflect increased vagal tone as fetal intracranial pressure rises with the contraction
Late decelerations
When the nadir of the deceleration develops some 30sec after the peak of the uterine contraction, reflect fetal hypoxia, the degree and duration reflecting its severity
Variable decelerations,
Both in degree and relation to uterine contractions, may represent umbilical cord compression around the limbs or presenting part
Pathological CTG pattern?
2 or more non-reassuring features:
- Baseline rate 100–109 or 161–180 beats/minute
- Variability 50% contractions, occurring over 90 minutes
- Prolonged deceleration of 180 beats/minute
Variability 50% contractions, or late decelerations, both over 90 minutes
Single prolonged deceleration of >3 minutes
US in pregnancy?
Early in pregnancy:
Confirm ectopic or viable intrauterine pregnancy (4 weeks +3 days for regular 28 day cycle) with transvaginal scan
Estimate gestation, ascertain viable foetus or diagnose twins
Exclude hydatidiform mole
Estimating gestation:
Crown-rump length measured at 6-12 weeks
From 12 weeks biparietal diameter can be measured
From 14 weeks femur length can be measured
Foetal abnormality
Routine scans to find abnormality at 18-20 weeks
Indications:
Family history of neural tube defect
Maternal diabetes
Maternal epilepsy
Oligohydramnios
Multiple pregnancy
Foetal echocardiography:
Offered to high risk groups at 22-24 weeks
Physiological changes in pregnancy?
Hormonal:
- Progesterone - decreased smooth muscle excitability (Uterus, gut, ureters) and raises body temp
- Oestrogens (90% oestriol) - increased breast and nipple growth, water retention and protein synthesis
Haemodynamic:
- Blood volume - rises from week 10-32 - dilutional anaemia
- WCC, platelets, ESR, cholesterol, B-globulin and fibrinogen raised
- Albumin/ Y-globulin fall
- Urea + creatinine fall
Cardiovascular:
- CO rises from 5 –> 6.5-7L/min in first 10 weeks (increased SV + HR)
- BP falls during 2nd trimester, rises to non-pregnancy levels by term
Aorto-caval compression
- from 20wks, gravid uterus compresses IVC in supine women reducing VR. This reduces CO by 30-40% (supine hypotension) –> relieved by lying in left lateral position
Other changes:
- Ventilation increased by 40% - Gut motility reduced –> Constipation
- GFR increases by 60^
- Skin pigmentation
Prenatal diagnosis?
High risk pregnancies:
Maternal age >35 (chromosomal defects)
Previous abnormal baby or family history of inherited condition
Ultrasound:
11-13 - weeks screens for nuchal translucency (foetal heart failure) and chorionicity
18 weeks – anomaly scan
AFP
Amniocentesis
CVS
Foetoscopy
Down’s screening?
Combined test standard (11-13+6wks):
1) Nuchal tranlucency
2) Serum B-HCG
3) Pregnancy associated plasma protein A
High risk - 1 in 150 or more
If women book later, either triple or quadruple test should be offered between 15-20 weeks
Triple test at 16: AFP + unconjugated oestriol + B-HCG
Quadruple also has inhibin A
Confirm diagnosis with amniocentesis or CVS
Prenatal diagnosis: Amniocentesis & CVS?
Amniocentesis
Foetal loss rate is 1% at 16 weeks gestation but 5% for early amniocentesis at 10-13 weeks
Amniotic fluid AFP is measured and cells in the fluid are cultured for karyotyping
Chorionic villus sampling
At 10 weeks the placenta is sampled by transcervical or transabdominal approach under continuous ultrasound control
Use up to 20 weeks
Does not detect neural tube defects, may cause foetal malformation and is not recommended in dichorionic multiple pregnancy
Prenatal diagnosis: AFP
Glycoprotein synthesised by the foetal liver and GI tract
Foetal levels fall after 12 weeks; maternal levels continue to rise to 30 weeks
Maternal AFP measured at 17 weeks
In 10% with high AFP there is a foetal malformation e.g. neural tube defect
In 30% with no malformation there is an adverse outcome e.g. placental abruption or 3rd trimester death
Non-specific test on its own
Foetoscopy?
Carried out at 18 weeks with ultrasound guidance to find external malformations, do foetal blood samples or biopsy
Foetal loss rate is 4%
Placenta previa?
Placenta lies in the lower uterine segment
Risk of significant haemorrhage by mother and foetus
Avoid PV examinations and advise against penetrative intercourse
