O&G Common Conditions

Question 1

Placenta previa

Answer 1

• Clinical Features:
  
  • Sudden, painless vaginal bleeding: Placenta previa is often characterized by painless, bright red vaginal bleeding, which can be sudden and profuse.
  • Third-trimester bleeding
  • Soft, non-tender uterus
• Risk Factors:
  
  • Previous placenta previa: Women who have had a previous placenta previa are at a higher risk of experiencing it again in subsequent pregnancies.
  • Advanced maternal age: The risk of placenta previa increases with maternal age, especially after the age of 35.
  • Previous uterine surgeries: Women who have undergone previous cesarean sections, uterine surgeries, or dilation and curettage (D&C) procedures have an increased risk of placenta previa.
  • Multiple pregnancies: Placenta previa is more common in pregnancies with twins, triplets, or other multiples.
• Examination:
  
  • Abdominal examination: Palpation of the abdomen to assess for tenderness, uterine size, and fetal position.
  • Vaginal examination: Digital examination of the cervix to evaluate for the presence of the placenta at or near the cervical opening.
    
    • **Should not be performed unless TVUS has ruled out placenta previa****
• Investigations:
  
  • Ultrasound: Transabdominal or transvaginal ultrasound is performed to confirm the diagnosis of placenta previa and assess the placental location and degree of coverage over the cervical os.
  • Fetal monitoring: Continuous electronic fetal monitoring may be recommended to assess the well-being of the fetus and detect any signs of distress.
• Management:
  
  1. Incidental finding on ultrasound
     
     • Serial US: monitor placental placement
     • If PP persists after 32 weeks:
       
       • Repeat at 36 weeks
       • Schedule caesarian delivery at 36-37 weeks’ gestation
  2. Presenting with antepartum hemorrhage
     
     • Management of bleeding:
       
       • Unstable: ABCDE approach and immediate hemodynamic support, including blood transfusion protocol
       • Perform maternal and fetal status assessment
     • ≥ 37 weeks: immediate C-section delivery
     • <37 weeks: pre-term delivery or expectant management
       
       • Severe, active bleeding or fetal distress: emergency C-section
       • Light, no bleeding and no fetal distress: expectant management
         
         • Tocolytics to inhibit uterine contractions
         • Prepare for preterm labor - MgSO4 (fetal neuroprotection), Corticosteroid (fetal lung maturity)

Question 2

Placental abruption

Answer 2

• Clinical Features:
  
  • Maternal symptoms:
    
    • Sudden onset of continuous vaginal bleeding
    • Abdominal or back pain: sudden and intense abdominal pain, often described as sharp or stabbing.
    • Uterine tenderness
    • Uterine contractions: Placental abruption can cause uterine contractions, leading to a sensation of tightness or cramping in the abdomen.
  • Fetal distress: The baby may show signs of distress, such as decreased fetal movement or an abnormal heart rate pattern.
• Risk Factors:
  
  • Maternal hypertension
  • Trauma: Abdominal trauma, such as from a fall or motor vehicle accident
  • Cigarette smoking and substance use
  • Advanced maternal age: The risk of placental abruption tends to increase with maternal age, especially over 35 years.
• Examination:
  
  • Abdominal examination: Palpation of the abdomen to assess for uterine tenderness, rigidity, or contractions.
  • Vital signs: Measurement of blood pressure, heart rate, and respiratory rate to evaluate for signs of shock or maternal instability.
• Investigations:
  
  • FBE and coagulation studies
  • Ultrasound: An ultrasound may be performed to assess the placental location and fetal well-being.
  • Fetal monitoring: Continuous electronic fetal monitoring is essential to assess the baby’s heart rate and detect any signs of fetal distress.
    
    • Decelerations on fetal heart monitor due to acute placental insufficiency
• Management:
  
  • All patients: immediate management of bleeding
    
    • If unstable: ABCDE approach and immediate hemodynamic support, including blood transfusion protocol
    • Monitoring and supportive care: Close monitoring of the mother and baby is crucial. If the pregnancy is not at term and the abruption is mild, hospitalization with continuous monitoring may be required. Medications may be given to prevent preterm labor and to promote fetal lung maturity if delivery becomes necessary.
  • Hemodynamically unstable or moderate-severe bleeding: emergency C-section
  • Hemodynamically stable with mild bleeding:
    
    • <34 weeks: expectant management and observation
      
      • Consider tocolytics to delay delivery
      • Other management for potential preterm labour
      • Aim for normal delivery
    • 34-36 weeks:
      
      • Active uterine contractions: vaginal delivery
      • No active uterine contractions: expectant management and observation
    • > 36 weeks: immediate delivery

Question 3

Vasa previa

Answer 3

• Clinical Features:
  
  • Painless vaginal bleeding: Vasa previa is often characterized by painless, bright red vaginal bleeding, which can be sudden and profuse.
  • Bleeding during labor: The bleeding may occur during labor, often with the rupture of membranes or the start of contractions.
  • Fetal distress:
    
    • such as decreased fetal movement or an abnormal heart rate pattern.
    • abnormal fetal heart rate patterns, including bradycardia (slow heart rate) or sudden decelerations.
  • Preterm labor: Vasa previa is associated with a higher risk of preterm labor and premature rupture of membranes.
• Risk Factors:
  
  • Velamentous cord insertion: Vasa previa is more likely to occur when the umbilical cord inserts into the fetal membranes away from the placenta instead of directly into the placenta.
  • Multiple gestations: Vasa previa is more common in pregnancies with twins, triplets, or other multiples.
  • Bilobed or succenturiate-lobed placenta: These placental abnormalities increase the risk of vasa previa.
  • Uterine abnormalities: Certain uterine abnormalities, such as a bicornuate uterus or uterine septum, can increase the risk of vasa previa.
• Examination:
  
  • Vaginal examination: Digital examination of the cervix may reveal exposed fetal vessels or a velamentous cord insertion.
  • Fetal monitoring: Continuous electronic fetal monitoring is essential to assess the baby’s heart rate and detect any signs of fetal distress.
• Investigations:
  
  • Ultrasound: Transabdominal or transvaginal ultrasound is performed to confirm the diagnosis of vasa previa and assess the location of fetal vessels relative to the cervix.
• Management:
  
  • Antenatal diagnosis: Early detection of vasa previa through ultrasound allows for appropriate management and delivery planning
  • Scheduled cesarean section: A planned cesarean delivery is the standard management for vasa previa to avoid fetal vessel rupture and hemorrhage
    
    • Timing of delivery: The timing of the cesarean section depends on factors such as gestational age, severity of vasa previa, and fetal well-being.
    • Corticosteroids: If preterm delivery is anticipated, corticosteroids may be administered to enhance fetal lung maturity.
  • If there are signs of fetal distress:
    
    • Emergency cesarean delivery
    • Blood transfusion: In cases of significant bleeding

Question 4

Ectopic pregnancy

Answer 4

• Clinical Features:
  
  • Abdominal pain and guarding: commonly presents with sharp or stabbing pain on one side of the abdomen, may be persistent or intermittent.
  • Vaginal bleeding
  • ****Pregnancy signs:**** amenorrhea, nausea, breast tenderness, etc
  • ****Cervical motion tenderness and enlarged uterus****
  • Signs of shock: Severe internal bleeding from a ruptured ectopic pregnancy can cause symptoms of shock, such as lightheadedness, fainting, or low blood pressure.
• Risk Factors:
  
  • Previous ectopic pregnancy: Women who have had an ectopic pregnancy in the past are at higher risk of experiencing it again.
  • Pelvic inflammatory disease (PID): Infections of the reproductive organs, such as PID, can cause scarring and damage to the fallopian tubes, increasing the risk of ectopic pregnancy.
  • Previous fallopian tube surgery: Surgical procedures on the fallopian tubes, such as tubal ligation or tubal reconstruction, can increase the risk of ectopic pregnancy.
  • Assisted reproductive technology (ART): Women who undergo procedures such as in vitro fertilization (IVF) have a slightly higher risk of ectopic pregnancy.
  • Smoking: Tobacco use has been associated with an increased risk of ectopic pregnancy.
  • Age: Ectopic pregnancy is more common in women of reproductive age, especially those over 35 years old.
• Examination:
  
  • Abdominal examination: Palpation of the abdomen to assess for tenderness, guarding, or rebound tenderness.
  • Pelvic examination: A pelvic exam may reveal tenderness or a mass in the pelvic region.
• Investigations:
  
  • ****FBE:****** screen for anemia
  • Blood type and screen
  • LFTs and UEC: assess liver and renal function (before starting methotrexate therapy)
  • Pregnancy test: A urine or blood pregnancy test can confirm the presence of pregnancy.
  • Transvaginal ultrasound: Ultrasound imaging can help identify the location of the pregnancy and determine if it is ectopic.
    
    • If unstable, perform POCUS to identify intraperitoneal fluid or confirm intrauterine pregnancy
    • TAUS to rule out other differentials (e.g. appendicitis)
• Management
  
  • Pharmacological Management:
    
    • Methotrexate: stops the growth of the pregnancy and allows the body to reabsorb it. Usually for early, unruptured ectopics
  • Surgical Management:
    
    • Laparoscopic surgery:
      
      • Salpingostomy: remove the ectopic pregnancy by making an incision in the fallopian tube and removing the pregnancy while preserving the tube - preferable for women who wish to preserve fertility.
      • Salpingectomy
    • Laparotomy:
      
      • Emergency laparotomy: In cases of severe internal bleeding, hemodynamic instability, etc
  • Conservative Management:
    
    • Expectant management:
      
      • In rare cases of spontaneous resolution or very early ectopic pregnancies with low-risk features, expectant management may be considered with close monitoring of hCG levels and serial ultrasounds.
  • Follow-up and Monitoring:
    
    • Regular monitoring of hCG levels: ensure successful resolution of the ectopic pregnancy.
    • Ultrasound examinations: monitor the health of the fallopian tube or assess for any remaining pathology.
  • Counseling and support services

Question 5

Uterine atony

Answer 5

• Clinical Features:
  
  • Excessive postpartum bleeding: Uterine atony is characterized by excessive bleeding after childbirth. The bleeding may be more than what is considered normal.
  • Soft and enlarged uterus: Upon examination, the uterus may feel soft and larger than expected. It may not contract adequately after delivery.
  • Signs of hypovolemic shock
• Risk Factors:
  
  • Uterine overdistension: The risk of uterine atony increases with excessive stretching of the uterus, such as in cases of multiple pregnancies, polyhydramnios, or macrosomic babies.
  • Prolonged labor or rapid labor: Prolonged or rapid labor can affect the muscle tone of the uterus and increase the risk of uterine atony.
  • Use of certain medications: Certain medications used during labor and delivery, such as oxytocin, can increase the risk of uterine atony.
• Examination:
  
  • Uterine assessment: Manual palpation of the uterus is performed to assess its tone, size, and consistency.
  • Vital signs: Measurement of blood pressure, heart rate, and respiratory rate to evaluate for signs of shock or maternal instability.
  • **Bimanual pelvic exam**
  • ****Speculum exam:****** look for other sources of extrauterine bleed
• Management:
  
  • Acute Management:
    
    • First-line Interventions:
      
      • Uterine massage and bimanual compression: promote contractions and reduce bleeding.
      • Administration of oxytocin or misoprostol to stimulate uterine activity
      • ******Tranexamic acid:****** stop fibrinolysis and reduce mortality
    • Surgical Interventions:
      
      • Uterine artery embolization or ligation
      • Uterine tamponade: Placement of balloon devices to apply pressure and control bleeding.
      • Uterine compression sutures: provide mechanical compression and control bleeding.
      • Hysterectomy: In severe cases where conservative measures fail or when fertility preservation is not a concern
    • Conservative Management:
      
      • Selective arterial embolization: Interventional radiology technique involving the injection of embolic agents into specific uterine arteries to reduce blood flow to the uterus and control bleeding.
      • Ligation of uterine or hypogastric arteries: Surgical ligation of the uterine or hypogastric arteries to reduce blood supply to the uterus and manage bleeding.
  • Supportive Management:
    
    • Intravenous fluid resuscitation and blood transfusion
    • Monitoring: Regular monitoring of vital signs, blood loss, hematocrit levels, and urine output to assess response to treatment and detect any complications.

Question 6

PPH (general)

Answer 6

• Clinical Features:
  
  • Excessive postpartum bleeding: defined as blood loss of 500 mL or more for a vaginal delivery or 1,000 mL or more for a cesarean delivery.
  • Signs of hypovolemic shock: Severe cases of PPH can lead to signs of hypovolemic shock
• Risk Factors:
  
  • Uterine atony: Conditions that increase the risk of uterine atony, such as multiple gestations, polyhydramnios, macrosomia, and prolonged labor, are associated with an increased risk of PPH.
  • Placental abnormalities: Placenta previa, placental abruption, and placenta accreta are conditions that can increase the risk of PPH.
  • Operative delivery: Cesarean section, instrumental deliveries (forceps or vacuum-assisted), and episiotomy are associated with an increased risk of PPH.
  • Coagulation disorders: Women with bleeding disorders or those taking anticoagulant medications are at higher risk of PPH.
• Examination:
  
  • Clinical assessment: A thorough physical examination is conducted to assess the signs and symptoms associated with postpartum hemorrhage, including vital signs, uterine tone, and vaginal bleeding.
  • Bimanual uterine examination: A bimanual examination may be performed to assess the size, position, and consistency of the uterus and to identify any retained placental tissue or uterine atony.
  • Perineal examination: Examination of the perineum and vaginal area to identify lacerations or tears that may be contributing to the bleeding.
• Investigations:
  
  • Complete Blood Count (CBC): A CBC is ordered to assess hemoglobin and hematocrit levels, providing information about the severity of blood loss and the need for blood transfusion.
  • Coagulation profile
  • Blood typing and cross-matching: Determination of blood type and cross-matching for potential blood transfusion.
  • Other blood tests: Additional blood tests may be conducted to assess renal and liver function, electrolyte levels, and to identify any underlying medical conditions that could impact management.
  • Ultrasound: Ultrasonography may be utilized to evaluate the uterus, placenta, and identify any retained placental tissue or other abnormalities contributing to the hemorrhage.
• Acute Management:
  
  • General measures: control blood loss and ensure adequate perfusion
    
    • Monitor vital signs and urine output
    • Oxygenation
    • Two large-bore IVs
    • Fluid therapy and/or blood transfusions
  • First-line Interventions:
    
    • Uterine massage: Gentle massage and stimulation of the uterus to promote uterine contractions and control bleeding.
    • Uterotonic medications: Administration of uterotonic medications, such as oxytocin, misoprostol, or ergot alkaloids, to enhance uterine contractions.
    • Bimanual compression: Applying manual pressure to the uterus using both hands internally and externally to control bleeding and promote contraction.
  • Surgical Interventions:
    
    • Uterine artery embolization or ligation
    • B-lynch suture: Placement of a suture around the uterus to compress it and control bleeding.
    • Hysterectomy: In severe or life-threatening cases where conservative measures fail or when fertility preservation is not a concern,

Question 7

Placenta accreta

Answer 7

• Clinical Features:
  
  • Abnormal uterine bleeding: Women with placental accreta may experience persistent or heavy vaginal bleeding during pregnancy or after delivery.
  • Uterine enlargement
  • Signs of postpartum hemorrhage: including excessive bleeding, rapid heart rate, low blood pressure, and signs of shock.
• Investigations:
  
  • Ultrasound: Transabdominal and transvaginal ultrasound are commonly used for the diagnosis and evaluation of placental accreta. Ultrasound can help identify placental abnormalities, evaluate the depth of placental invasion, and assess the proximity of the placenta to the uterine wall.
• Acute Management:
  
  • Preoperative planning: Anticipation and preparation for potential complications, including assembling a skilled surgical team and ensuring availability of blood products.
  • Elective cesarean delivery: Planned cesarean section is usually recommended for cases of known or suspected placental accreta to allow for careful surgical management.
  • Hysterectomy: In severe cases of placental accreta with uncontrollable bleeding or when fertility preservation is not a concern, removal of the uterus (hysterectomy) may be necessary.
  • Selective arterial embolization: Interventional radiology technique involving the injection of embolic agents into specific uterine arteries to reduce blood flow to the placenta and control bleeding.
• Supportive Management:
  
  • Blood transfusion: Administration of blood or blood products, such as packed red blood cells, fresh frozen plasma, or platelets, to replace lost blood and correct anemia.
  • Intravenous fluid resuscitation: Administration of intravenous fluids, such as crystalloids or colloids, to restore blood volume and stabilize the patient.
  • Monitoring: Regular monitoring of vital signs, blood loss, hematocrit levels, and urine output to assess response to treatment and detect any complications.
• Long-Term Management:
  
  • Follow-up care: Regular follow-up visits with healthcare providers to assess the recovery, monitor any potential complications, and address any ongoing health concerns.
  • Counseling and support

Question 8

Hypertension in Pregnancy

Answer 8

• Clinical Features:
  
  • Edema and/or weight gain: Swelling, especially in the hands, face, or legs, may occur
  • Headaches: Persistent or severe headaches, often frontal or temporal
  • Visual disturbances: Visual changes, such as blurred vision, flashing lights, or temporary loss of vision, may occur in pre-eclampsia.
  • Abdominal pain: Upper abdominal pain, particularly in the right upper quadrant, may be a sign of liver involvement in severe pre-eclampsia.
  • Reduced fetal movements: Pre-eclampsia can affect placental function, leading to decreased fetal movements.
  • Neurological symptoms and tonic-clonic seizures: in eclampsia
  • Non-specific: nausea, vomiting, headache, lethargy,
• Risk Factors:
  
  • First pregnancy:
  • Maternal age: Being younger than 20 or older than 35 years increases the risk
  • History of pre-eclampsia: Women who had pre-eclampsia in a previous pregnancy are at higher risk of developing it again in subsequent pregnancies.
  • Multiple gestations: Twins, triplets, or other multiple pregnancies increase the risk of pre-eclampsia.
  • Chronic hypertension: pre-existing high blood pressure or chronic HTN
• Examination:
  
  • Blood pressure measurement: Regular monitoring of blood pressure is essential to diagnose and manage pre-eclampsia.
  • Urine dipstick test: Testing for proteinuria to assess kidney function
  • Edema assessment: Evaluation of peripheral edema, particularly in the hands, face, or legs.
• Investigations:
  
  • FBE, UEC, LFTs, coagulation profile: to assess kidney function, liver function, and blood clotting parameters.
    
    • Pre-eclampsia: increased creatinine, proteinuria, impaired renal and liver function, pulmonary edema
    • HELLP: hemolysis (reduced Hb, increased LDH, increased indirect bilirubin), elevated liver enzymes, low platelets
  • Ultrasound: An ultrasound examination may be conducted to assess fetal growth, placental function, and blood flow to the placenta.
  • Non-stress test (NST): CTG monitoring may be performed to evaluate fetal well-being and assess the response to movement.
  • Doppler velocimetry: Doppler ultrasound may be used to assess blood flow in the uterine arteries and umbilical cord.
  • Others:
    
    • increased LDH and peripheral smear (showing hemolysis) may indicate HELLP syndrome
    • CT head - rule out intracranial hemorrhage and other alternatives
• Management:
  
  • Management:
    
    • Initial approach:
      
      • Regular monitoring of BP and symptoms
      • IV access using 2 large-bore lines
      • Take blood samples
      • IDC for urine output measurement and fluid balance assessment
    • Pharmacological:
      
      • Antihypertensives in pregnancy: labetalol, methyldopa, nifedipine
      • MgSO4: seizure prophylaxis
      • Low-dose aspirin between 12-20w gestation: pre-eclampsia prophylaxis
      • Corticosteroid: fetal lung maturity
    • Approach:
      
      • Monitor for vitals, BP, oxygenation, and urine output
      • Treat any complications:
        
        • Urgent control of BP:
          
          • Parenteral labetalol or hydralazine
          • Nifedipine
        • Eclamptic seizures:
          
          • place patient in left lateral decubitus to reduce risk of hypoperfusion and aspiration
          • Administer MgSO4 (first-line)
        • HELLP syndrome:
          
          • administer blood products (platelets, PRBCs, FFP)
      • Assess for need of immediate delivery
        
        • Immediate delivery: if eclampsia, signs of fetal distress, pulmonary edema, etc
        • Based on gestational age:
          
          • > 34 weeks: deliver
          • 24-34 weeks:
            
            • assess maternal and fetal status
            • consider expectant management: administer corticosteroid followed by delivery
          • <24 weeks: termination of pregnancy