O&G Cases 11, 13, 14

Question 1

What is puerperal sepsis?

Answer 1

Septic shock of the mother that develops in the time between the rupture of membranes (ROM) and 6 weeks postpartum.

Question 2

What are the possible causes of post partum fever?

Answer 2

● Lower urinary tract infection
● Endometritis
● Soft tissue/wound infection
● Mastitis
● Septic pelvic thrombophlebitis
● Infection of other body systems (pneumonia, gastroenteritis…)
● Spinal infections

Question 3

What are the common organisms of puerperal sepsis?

Answer 3

● S. pyogenes
● E. coli
● S. aureus/MRSA
● S. pneumoniae
● C. septicum

Question 4

What are the important initial steps in assessing and managing puerperal sepsis?

Answer 4

● ABCDE
● Sepsis 6
○ (Blood cultures, IDC, Fluids, Broad-spectrum antibiotics)
● FBC, U+Es, CRP, Cr
● Relevant imaging based on history: e.g. CXR, pelvic U/S, pelvic CT
● Throat swab if signs of pharyngitis, Stool culture if diarrhoea, MRSA screening
● NSAID sparing analgesia (anti-inflammatory and nephrotoxic)

Question 5

What are the important components of a routine postnatal check of a mother?

Answer 5

Hx:
- General wellbeing
- Mental health
- Breast feeding: Difficulties?

○ PV discharge/bleeding
○ Discussion about contraception (Lactational amenorrhoea OR medical)
● O/E: Episiotomy + C-section scar examination
○ BP/ Vital check (esp. if gestational HTN or preeclampsia)
○ Examine perineum for tears, blood or clotting
○ Abdo. exam (Uterine involution, Tenderness, Soft)

Question 6

What are the important components of a routine postnatal check of a newborn?

Answer 6

● Hx:
○ Has the baby been unwell/ ill?
○ Feeding and growing well? (Tired or increased WOB when feeding?)
○ Do they appear to respond to sounds (cry, blink, look up…) and follow people with
their eyes

● O/E: Does the baby appear well? Good colour? Jaundice?
○ Growth parameters - plot.
○ CV exam: Signs of HF, organomegaly or other congenital disease.
○ Abdo. exam
○ DDH exam: Barlow and Ortolani
○ Neuro exam: Cranial nerves(nystagmus+strabismus)
○ Red reflexes(congenital cataract, retinoblastoma, retinopathy if prem)

Question 7

Why do we encourage women to breastfeed?

Answer 7

● Breast milk has all the required nutrition for the baby during the first six months of life
● IgA antibodies provide immune support
● Decrease the incidence of SIDS
● Breastfeeding also helps new mothers develop a strong bond to their babies
● Preventative for certain types of cancers

Question 8

What questions should you ask for a gynae hx?

Answer 8

● Menstrual cycle – age of menarche, cycle length, cycle regularity (#/year), length of menstruation, intermenstrual bleeding, associated symptoms (pain).
● Pain with intercourse
● Abnormal vaginal discharge – colour, smell, associated symptoms such as itch, lump
● Pelvic pain – character/frequency, acute/chronic, previous investigations
● Contraception history
● Smear history.

Question 9

What is normal fecundity? What lifestyle factors may affect it?

Answer 9

Fecundity is the capacity to conceive and is measured as the monthly probability of conception.
● 20% in normal fertile couples .

Lifestyle factors affecting fecundity;
● Obesity (BMI>35 kg/m2).
● Underweight (BMI<18 kg/m2)
● Smoking
● Alcohol
● Illicit drugs
● Toxins, solvents
● Decreased frequency of intercourse.

Question 10

How are primary and secondary infertility defined?

Answer 10

Primary infertility is defined as failure to conceive after 12 months of regular unprotected intercourse.

Secondary infertility refers to couples who have had at least one previous pregnancy, but are now unable to conceive.

Question 11

What are the main disorders that cause infertility?

Answer 11

● Disorders of ovulation (25-35%)
● Seminal abnormalities (25-30%)
● Disorders of fallopian tube and/or endometriosis (25-35%)
● Others: both male and female factor (15%), unexplained (20-30%) and more than one cause
(30- 40%)

Question 12

What primary care investigations would you recommend for a couple with infertility?

Answer 12

Maternal:
● Full antenatal blood screen
● Cervical smear test, if appropriate
● Urinalysis – PCR ?infection

Paternal:
● Blood screen – hepatitis B antigen, hepatitis C antibodies and HIV status.

Question 13

What symptoms and signs may suggest a diagnosis of polycystic ovarian syndrome?

Answer 13

Symptoms include:
● Oily skin and acne (face and back)
● Hirsutism
● Thinning of hair
● Weight gain
● Irregular periods

Signs include:
● Elevated total or free testosterone
● Oligoovulation/chronic anovulation (<9 menses/year)
● Alopecia.

Question 14

Whats the diagnositc criteria for PCOS?

Answer 14

Rotterdam criteria
- 12+ Follicles on USS
- Clinical hyperandrogenism
- Chronic anvoluation / oligiomeonorrhea

Question 15

How can PCOS affect a woman’s long term health?

Answer 15

Women are at increased risk of:
● Infertility, if not managed
● Metabolic complications;
○ Impaired glucose tolerance,T2D, Dyslipideamia,Pro-thrombotic state, HTN
● Obstructive sleep apnoea (OSA)
● Anxiety, depression and worsened quality of life
● Endometrial hyperplasia and carcinoma.

Question 16

What are your ddx for lower abdo pain in a young women?

Answer 16

● Gynae
○ Dysmenorrhea
○ Adnexal torsion
○ Ovarian cyst rupture
○ Fibroids → pressure symptoms (not pain)
○ Endometriosis
○ PID
● Obstetric *less likely in this case
○ Ectopic
○ Miscarriage
○ Labour
○ Abruption
○ Symphysis pubis dysfunction (PID)
● Gastric
○ Appendicitis
○ IBD
○ Hernia
○ Ileus
○ Constipation
● GU
○ UTI
○ Pyelonephritis
○ Colic

Question 17

What are the differentials for PID?

Answer 17

● Pregnancy complications (ectopic, spontaneous)
● Appendicitis
● UTI
● Ruptured ovarian cyst

Question 18

What is PID?

Answer 18

● Describes upper genital tract infection in women
● Infection may involve the endometrium, with or without the fallopian tubes and peritoneal
space
● PID is usually a sexually transmitted condition
● Organisms mostly involved are Chlamydia trachomatis, Neisseria gonorrhoeae,
mycoplasmas, mixed anaerobes and actinomyces

Question 19

What are the risk factors for PID?

Answer 19

● Age<30
● Recent change in sexual contact
● Multiple sexual contacts
● Previous STI
● In addition to sexual transmission, PID may follow:
○ IUD insertion
○ Termination of pregnancy
○ Postpartum states
○ Upper genital tract infection

Question 20

What are the signs and symptoms of PID?

Answer 20

Signs and symptoms:
● Estimated 60% subclinical
● May present with
○ Lower abdominal pain
○ Deep dyspareunia
○ Abnormal vaginal bleeding or discharge

Question 21

What would you find upon exam for PID?

Answer 21

Examinations findings:
● Cervical motion tenderness
● Uterine and/or adnexal tenderness
● Cervicitis or fever

Question 22

What examination findings would you suspect if it was PID?

Answer 22

Examinations findings:
● Cervical motion tenderness
● Uterine and/or adnexal tenderness
● Cervicitis or fever

Question 23

What investigations might you do if you suspect PID?

Answer 23

● Urinalysis
● Bloods
○ FBC
○ CRP
○ LFTs
○ Beta HCG → ectopic
● High vaginal swab/VV → trichomoniasis, bacterial vaginosis, candida
○ VV → picks up some of the bugs as they fall into vagina so can pick up chlamydia and gonorrhea on self-swabs
● Endocervical → Chlamydia, gonorrhea
● Serology → HIV, syphilis
● Serology for hep B and C if known risk factor
● USS (gold standard)
○ Adnexal torsion
○ Appendicitis
○ Tubo Ovarian abscess
● CT imaging - if suspected pelvic pathologies and surgical conditions

Question 24

How is PID diagnosied?

Answer 24

● Diagnosis is clinical
● No single swab is diagnostic (STI tests may be negative)
● Low threshold for treatment due to important sequelae and diagnostic uncertainty
● Initiate treatment if lower abdominal pain associated with any positive sign of examination

Question 25

What are the potential complications of PID?

Answer 25

● Tubo ovarian abscess
● Sepsis (with PID)
● IfGroupAorBstrep→DIC
● Perhihepatitis (Fitz-Hugh Curtis syndrome)
○ Liver capsule inflammation leading to the creation of adhesions
● Chronic pelvic pain
● Adhesions
○ Longterm;
■ Complications during pregnancy ■ Ectopic

Question 26

What is the tx for PID?

Answer 26

Ceftriaxone 500mg IM STAT + Azithromycin 1g PO STAT
Followed by, Doxycycline 100mg PO Q12H + Metronidazole 400mg PO Q12H for 2 weeks

● Ceftriaxone (cephalosporin) IM stat→ covers gonorrhea
● Metronidazole → covers trichomoniasis
● Doxycycline → covers chlamydia
Can give stat dose of azithromycin instead of doxycycline (if worried about compliance)
IUD → actinomyces (bug that sticks to IUD)→ susceptible to penicillin (remove IUD and long term penicillin use)

Question 27

How effective are barrier contraceptive methods at protecting men and women from STIs?

Answer 27

Condoms 98% effective, and expected to provide different levels of protection for STIs with different modes of transmission
Greater protection against STIs transmitted only by genital fluids
● Chlamydia
● Gonorrhea
● Trichomoniasis
● HIV
Less so for skin-skin contact spread
● Genital herpes
● HPV
● Syphilis