ObGyn Flashcards
Barrier Methods of Contraception
Diaphragm
Cervical cap
Male and Female Condoms
Sponge
When should a diaphram be refitted?
After full-term pregnancy (and should not be used postpartum until uterine involution is complete);
Abdominal or pelvic surgery,
Miscarriage or abortion after 14 weeks of pregnancy (and should not be used until 6 weeks after a second-trimester abortion)
Weight change after pregnancy of 20 percent or more.
Diaphram: how to used?
filled with spermicide and inserted into the upper vagina covering the cervix creating a spermicidal barrier at the cervical opening.
Diaphrag must be left in the vagina for 6 to 8 hours after intercourse and removed after this period (24h max)
Cervical cap can be left in place for up to 48 hours. It is not recommended for use during menstruation.
Considerations about natural animal condoms
No protection against STIs
How to use female comdoms?
It can be inserted up to 8 hours before intercourse and it should be removed and discarded immediately after.
Female and male condoms should not be used simultaneously because they can adhere to each other and cause slippage or breakage of one or both devices.
Vasectomy: technques?
No-scalpel vasectomy (NSV) - most common
No-needle/no-scalpel vasectomy (NNV)
NSV is considered the standard of care. In NSV, the physician uses a small needle to inject anaesthesia into the skin and vas deferens. In NNV, the physician uses a piston-like instrument to force anaesthetic into the tissues. After anesthetizing the area, the provider creates a small opening (a few millimetres) in the skin of the scrotal sac and locates the vas deferens. The vas are then ligated or cauterized; there is no need for sutures.
Vasectomy: considerations
Sexual activity may be resumed about 1 week after the procedure or the time at which the patient feels comfortable.
A backup contraceptive method is needed until the patient has had at least one negative sperm check at least 3 months after the procedure and at least 20 ejaculations.
Female sterilization: techniques and considerations?
Surgical tubal occlusion may be done as a laparoscopic procedure or as mini-laparotomy.
These procedures are usually selected for sterilization after childbirth and can be performed on an outpatient basis as ambulatory surgery.
Laparotomy, or an open tubal ligation, requires a hospital stay and is less commonly performed for sterilization purposes.
After the outpatient procedures, women may resume having sexual intercourse as soon as they feel comfortable.
Fertility Awareness: considerations?
A variety of contraceptive methods known variously as fertility awareness, natural family planning, rhythm, and other names may be suitable choices for couples who are highly motivated to abstain from vaginal intercourse or who use a barrier method during “fertile” days.
All fertility awareness methods are based on identifying the fertile days in a woman’s menstrual cycle by counting the days in the menstrual cycle and/or noting changes in fertile signs such as cervical mucus and basal body temperature (BBT).
Most effective for women who have reliably regular menstrual periods, between 26 and 32 days in length.
!!!! Women who have two or more periods differing from this length within a single calendar year are not good candidates for these methods !!!!!
Lactation as contraceptive: criteria?
Only for women who meet all three of the following conditions:
she is less than six months postpartum,
she is breastfeeding exclusively,
she is amenorrheic.
Lactation as contraceptive: mechanis?
A delay in resumption of ovulation postpartum due to prolactin-induced inhibition of pulsatile gonadotropin-releasing hormone (GnRH) release from the hypothalamus.
Spermicides: considerations?
Spermicides can be applied up to 1 hour before intercourse and must be reapplied with each act of intercourse.
There is an increased risk of vaginal irritation, yeast infection, bacterial vaginosis, UTI and HIV transmission with frequent use (twice daily or more)
Copper IUD: contraindications?
Pregnant or thing they may be pregnant,
have septic pregnancy or abortion
have unexplained abnormal vaginal bleeding,
have untreated cervical cancer,
have malignant gestational trophoblastic disease,
have uterine cancer or an abnormal uterus,
have had a pelvic infection or STI within the past 3 months
have pelvic tuberculosis.
BBT method: considerations?
Avoid intercourse if rise in 0,3-0,4ºC compared to the six previos day.
Restart sex after 48h in normal BBT
Copper IUD: Considerations?
It’s not the best option for women who still want to return to fertility, specially fast return, or who doesn’t have any children yet.
COC overview
combined low does synthetic oestrogen (ethinyl estradial 20 – 35 µg) and progestin (norethinedrone, norgestrel, levonorgestrel, dosogestrel, norgestimate, dospirenone) that is taken once a day most commonly for 21 days followed by a seven day break.
Acts at the level of the hypothalamic-pituitary axis to suppress the woman’s levels of FSH and LH to basal levels. This prevents the natural surge of LH that occurs mid-cycle and stops ovulation from occurring. In addition, it causes the decidualization of the endometrium and thickens the cervical mucus resulting in decreased sperm penetration.
Aside from being an effective contraceptive, the OCP can be used in patients to treat dysmenorrhoea, menorrhagia and in some cases, endometriosis.
Risks and side effects of the combined oral contraceptive
Higher oestrogen dose oral contraceptives are associated with estrogenic side effects such as breast tenderness, nausea and abdominal bloating. Very low dose oestrogen oral contraceptives are associated with higher rates of bleeding disruptions including breakthrough bleeding — the most common side effect
The number of bleeding or spotting days is highest in the first three months of use and decreases thereafter
Cancer increase and decrease risks
risks were significantly lower for colorectal, endometrial and ovarian cancer
The incidence of breast cancer was similar in pill users and patients who had never used the OCP
Significant trends of increasing risk of cervical cancer
Patients on OCP with high doses of oestrogen are also at an increased risk for venous thromboembolism. In addition, COC have been associated with the development of hypertension, myocardial infarction and CVA, hepatic adenomas, and hypertriglyceridemia-induced acute pancreatitis.
COC - what’s the most important caution?
It’s mandatory to check if the patient is
pregnant before starting (Beta-HCG)
Thrombophilia screening can be considered, if there’s history
Check the patient in 3 months after starting to see if there’s any symptoms.
COC contraindications
Absolute: 2w post partum, history of TE or cerebrovascular disease, migraine with Aura, estrogen-dependent tumors like breast cancer, impaired liver function test or policythemia,
Relative: heavy smoking + >35yo, breastfeeding, HAS, hiperlypidaemia, depression, BMI >35,
COC - About use and forgetting:
Shall be used on the same time everyday. If not: alternate contraception method for 7 days
If forgeting to use but remembered within 24h, take the pill ASA remember.
If forgeting for >24H, take the missed pill e continue. But, if the dummy period starts within 7 days, skip it and alternate contraception method for 7 days
If 2 pills missed in the first week, emergency contraception if sex in the previous week in the free pill period or in the current week.
If pills are missed in the 2nd week, no need
If pills are missed in the 3rd week, the next pack must be started withou free period
COC - Most common side effect?
Breakthrough bleeding (20-30% of women have i).
It settles in 24 months. If not or if it worries the woman, consider:
- change to higher oestrogen dose pill, but never 50 mcg of ethyniloestradiol because enhances risk of TE
Progestin-only Pill (POP)(“minipill”)
- Overview
Contains only progesterone (e.g. Micronor® 0.35 mg norethindrone) once a day at the same time every day with only a three hour leeway and no pill free days.
It works by thickening cervical mucus and creating a hostile environment for sperm.
In 60% of women, ovulation is inhibited
In non-breast-feeding women, only 30% will ovulate with the mini-pill.
POP - Risks and Side effects
menstrual irregularities are common. Unscheduled bleeding, spotting and amenorrhoea are common menstrual patterns.
flaring of acne and headaches
POP have little effect on coagulation factors, blood pressure or lipid levels. They lower the overall risk of ectopic pregnancy as well as intrauterine pregnancy and endometrial cancer.
POP - forgetting
If it is taken more than three hours late, it is not protective and alternative contraception should be used for the next three days.
Depot medroxyprogesterone acetate (DMPA) (Depo-Provera®) - overview
It is usually initiated within 5 days of beginning of normal menses, immediately post-partum in breastfeeding and non-breastfeeding women
It is a particularly good choice in women in whom an oestrogen-containing contraceptive is either contraindicated or causes additional health concerns.
It works by inhibiting follicular development and preventing ovulation primarily. The progestogen decreases the pulse frequency of GnRH release by the hypothalamus which decreases the release of FSH and LH by the anterior pituitary. Decreased levels of FSH inhibit follicular development preventing an increase in oestrogen levels. Progestogen negative feedback and the lack of oestrogen positive feedback on LH release prevent a LH surge thus preventing ovulation. A secondary mechanism of action is inhibition of sperm penetration by changes in the cervical mucus. Inhibition of ovarian function causes the endometrium to become thin and atrophic therefore theoretically also preventing implantation.
With correct use, the probability of pregnancy in the first year is <1% whereas with typical use, it is 6%.
Contraceptive vaginal ring - Oestrogen-progestin contraceptive ring (NuvaRing®) - overview
Are based on the principle that the vaginal epithelium can absorb steroids and steroids in turn can be released from a silicone elastomer into the vagina at a constant rate. Avoiding gastrointestinal absorption and hepatic first pass metabolism allows use of lower hormone does to achieve contraceptive effects.
With perfect use, the failure rate is 0.3% while with typical use, it is 9%.
Until what age is consedered safe to use COC?
50 YO
After -> increased risk of CV disease, breast and cervix cancer, VTE
Fibroids - epidemiology and overview
Fibroids are a benign tumour of the myometrium. They are currently the most common benign tumour in females and close to half of all women over 40 years of age will have at least one fibroid.
It’s the most common cause of hysterechtomy
The cause is unknown
In a very small percentage (0.1-.0.5%) fibroids can transform into a malignant tumour.
Fibroids - risk factors?
Nulliparity (never having given birth)
Being overweight or obese.
Polycystic ovarian syndrome
Family history
African
Fibroids - investigation?
Pelvic or TV ultrasound - most useful
Histeroscopy - best way to diagnose
MRI - most accurate (when that are multiple or cancer is suspected)
Fibroids - treatment
If asymptomatic, nothing is needed
IUD Mirena (not if nulliparous)
Fibroids will recur in up to 60% of women after a laparotomy and in up to 25% after a laparoscopic surgery.
Thyroid disease effects on periods?
Hyperthyroidism - less periods
Hypothyroidism - more periods
What is pelvic congestion?
Swelling and inflammation of the connective tissue in pelvic ligaments due to hormone influencie.
Causes Pain NOT related to periods
Most common cause of dysmenorrhea?
Shift from anovulatory to ovulatory periods due to higher sensitivity to prostaglandines
Menorrhagia - definition?
Menstrual blood loss (MBL) exceeding 80mL
An average of 35 mL of menstrual blood is lost during a menstrual period.
!!! Is the most frequent cause of iron deficiency anaemia in Australian women !!!
Hysteroscopy is the gold-standard investigation for endometrial pathology and excessive bleeding, but are generally not first-line investigations. When should they be performed?
In women aged over 45,
Intermenstrual bleeding or persisting menorrhagia despite medical therapy
If abnormality is detected on US or endometrial thickness exceeds 12 mm
Menorrhagia - treatments?
First line:
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Tranexamic acid (^^^^ risk of VTE)
- Combined oral contraceptive pill: choice in patients with anovulatory menorrhagia, as it lowers the risk of endometrial cancer.
- Oral progestogens
- Levonorgestrel Intrauterine System (LNG-IUS): Around 30% of women are amenorrhoeic after 12 months.
Second line:
- Danazol - has virilising effects
- Surgical: in patients who have failed medical therapy and completed their family.
- Endometrial ablation
- Hysterectomy
Dysmenorrhoea - pathophysiology and epidemiology
Increased prostaglandin F2a (PGF2a), which stimulates uterine contractions. Blood flow is reduced causing ischaemia.
The production of PGF2a requires progesterone, which explains the association between dysmenorrhoea and ovulatory cycles.
Primary dysmenorrhoea affects 71.7% of Australian women, with 15.0% of women experiencing severe pain.
Dysmenorrhoea - risk factors
Less than 30 years of age,
Having a low body mass index,
Menarche at less than 12 years of age,
Longer and heavier menstrual periods, smoking,
Alcohol,
history of sexual abuse,
sterilisation,
suspected pelvic inflammatory disease psychological symptoms
Dysmenorrhoea - Investigations, diagnosis and differential diagnosis
Primary dysmenorrhoea can be diagnosed on the basis of history and examination but Endometriosis and pelvic inflammatory disease should be excluded.
Investigations include high vaginal and endocervical swabs to exclude pelvic inflammatory disease and transvaginal pelvic ultrasound scans to identify endometriomas or adenomyosis.
Laparoscopy is the gold standard for the evaluation of dysmenorrhoea. It is performed in suspected endometriosis, or when previous investigations have been normal.
Dysmenorrhoea - treatment
Lifestyle & Alternative Treatments
- Low-fat, vegetarian diets and heat in the form of topical abdominal patches have been shown to improve dysmenorrhoea. Also Vitamin B1, magnesium and Chinese herbal medicine
Medical
NSAIDs - first-line treatment. Should be given two days before menstruation and taken for the first three days of menstruation. Suggested doses include mefanamic acid 500mg orally, three times daily or ibuprofen 200 to 400mg orally, 3 times daily.
COCP - induce anovulation and reduce endometrial prostaglandin production
Levonorgestrel-releasing intrauterine system - stimulating endometrial atrophy.
Postmenopausal bleeding (PMB) - definition and etiology
Vaginal bleeding occurring 12 months after the last period.
10% of all patients presenting with PMB will have endometrial carcinoma
Other causes include atrophic vaginitis, endometrial hyperplasia, endometrial polyps, and uterine fibroids.
Irregular vaginal bleeding is common in the first six to twelve months of starting HRT, but PMB persisting one year after HRT initiation requires further investigation.
Postmenopausal bleeding (PMB) - Investigations, diagnosis and differential diagnosis
PMB is endometrial cancer until proven otherwise.
The first-line investigation is transvaginal ultrasound assessing endometrial thickness. Endometrial thickness exceeding 5 mm warrants endometrial biopsy Biopsy is also indicated in patients with persistent PMB despite normal ultrasound findings.
Tamoxifen causes irregular, cystic thickening of the endometrium. As such, patients with PMB on tamoxifen should proceed straight to hysteroscopy and endometrial biopsy.
Postmenopausal bleeding - Causes and Treatment
Atrophic vaginitis - Local vaginal oestrogen
Cervical polyps - Resection under speculum examination
Endometrial polyps - Hysteroscopic resection
Endometrial hyperplasia - Progestins (e.g. oral or LNG-IUS) or hysterectomy
Endometrial cancer -
Appropriate treatment is dependent on the stage and grade of endometrial cancer
Menopause - pathophysiology
During the menopausal transition, the number of ovarian follicles decline. The remaining ovarian follicles are less responsive to FSH levels and ovarian inhibin production subsequently falls. With the loss of negative feedback from the ovary, FSH levels rise. Despite stimulation from FSH, the declining supply of functioning ovarian follicles cause oestrogen levels to further decrease. Anovulatory cycles become increasingly frequent. With each subsequent menstrual cycle, fewer ovarian follicles are recruited until eventually no follicles are recruited at all. FSH and LH remain persistently elevated while oestradiol levels stabilize, falling below 20 pg/mL.
Menopause - Diagnosis
Clinical and retrospective
But, FSH levels above 40 mIU/mL are also diagnostic of menopause.
Menopause - Treatment
Lifestyle modification:
- Smoking cessation to reduce exacerbation of vasomotor symptoms.
- LIfestyle changes include stress management, regular exercise and weight optimization.
- Vasomotor triggers, such as caffeine, alcohol, hot drinks and spicy food, should be avoided.
Hormonal Therapies
- HRT should only be reserved for very symptomatic patients.
- Avoid HRT in patients with a history of breast cancer, venous or arterial thromboembolic disease, pre-existing cardiovascular and cerebrovascular disease and uncontrolled hypertension.
Synthetic steroid
Tibolone is a synthetic steroid. It has oestrogenic, progestogenic and weak androgenic effects and can be used for vasomotor and urogenital symptoms, but is less effective when compared to combined HRT. It offers bone protection but may increase the risk of recurrent breast cancer and stroke.
Selective serotonin and noradrenaline reuptake inhibitors
Venlafaxine (SNRI) and paroxetine (SSRI) are considered the most effective SSRIs for vasomotor symptoms.
!! Paroxetine should be avoided if taking Tamoxifen for breast cancer
Relief of Urogenital Symptoms
Local vaginal oestrogen is the treatment of choice for women with vaginal symptoms only. Progestogens are usually not required, but are recommended if the dose of oestradiol is over 0.5mg daily due to possible systemic absorption.
HRT in menopause: overview
It is recommended that the lowest dose of HRT that allows adequate symptom control should be prescribed for the minimum duration. Most guidelines advise 4 to 5 years for duration of HRT use.
Women should be reviewed every 6 to 12 months for follow-up of symptoms and need for continuing HRT.
Transdermal therapy may be preferred in patients with limited oral absorption or with risk factors for thromboembolic disease.
Oestrogen-only preparations may be used in women after hysterectomy - doesn’t enhance breast cancer risk if used only UP TO SEVEN YEARS
Progesterone is required in women with an intact uterus to reduce the risk of endometrial hyperplasia and cancer.
Avoid IF: history of breast cancer, venous or arterial thromboembolic disease, pre-existing cardiovascular and cerebrovascular disease and uncontrolled hypertension.
Factors associated with earlier onset of menopause
Smoking
Advances age of menopause by 2 years
Nulliparity
Pelvic surgery, radiation and chemotherapy Leads to artificial menopause.
Family history of early menopause Ethnicity
Black and Hispanic women undergo menopause around 2 years earlier than their Caucasian counterparts
Lower educational attainment
Being separated, widowed or divorced Being unemployed
History of heart disease
Breast cancer - risk factors
Family history – there is a 3 to 4 fold increase in developing breast cancer in women who have a first degree relative with a history of breast cancer.
BRCA 1 gene mutation found on chromosome 17 is found in families with early onset breast cancer and ovarian cancer. BRCA 2 gene mutation on chromosome 13 is also associated
Early menarche and late menopause
Nulliparity and late age of first pregnancy The highest risk group in this regard are found in women who have their first child after 35.
PRE CONCEPTION CARE - Diet (what to avoid), vaccination
- Unpasteurised dairy products, soft cheese
(Risk of Listeria- foetal mortality- 30-50%) - Raw meat ( risk of toxoplasma )
- Mantain good exercise routine and avoid SAD (alcohol)
- Reduce caffiene intake (IUGR) up to 2 cups of tea / 1cup coffee per day is permissible.
- Ensure rubella and chicken pox immunity- - check for rubella antibodies. If IgG negative (< 10IU/L) give 1 dose MMR + or- varicella vaccine and Advice not to become pregnant at least for 1 mnth preferably for 3 months. Test for seroconversion after 3 mths.
PRE CONCEPTION CARE - medications
5 Folic acid 0.5 mg/day 3 months before and 3 months after pregnancy.
High dose of 5 mg/day if on enzyme inducing medications like antiepileptics, in history of neural tube defects, family H/O neural tube defects and also in women with DM, coeliac disease and sickle cell anaemia.
Folic acid decreases incidence of neural tube defects and spina bifida in baby.
Beta-HCG - when is it detected in blood and urine? When it peaks? Reference value for positive teste?
Detected by blood test about 11 days after conception and 12- 14 days by urine test.
Doubles every48- 72 hours, reaches peak in 8-11 weeks, then declines and levels off for rest of pregnancy.
HCG level above 25mIU/ml is considered positive for pregnancy.
First antenatal visit - what to do?
Confirm pregnancy by period history and urine/blood Beta HCG.
Book into hospital/ OP department
Complete O&G history- previous pregnancies/ miscarriages.
Medical/surgical history, family history, social history, medications/ allergy.
Establish EDC- by obstetric calendar- from first day of last period subtract 3 from months and add 7 to days. Naegele’s rule- add 7 days and 9 months.
If patient not quite sure of her LMP, do U/S at 8weeks to determine EDC ( dating scan)
Offer Down’s syndrome screening.
When to do USG to determine delivery predicted date?
8 w
Calculating the Estimated delivery date?
by obstetric calendar- from first day of last period subtract 3 from months and add 7 to days.
Naegele’s rule- add 7 days and 9 months.
First antenatal visit - Antenatal Investigations
Blood tests- FBE( Hb),UCE, Blood group and Rh, coagulation profile, Vit D, antibodies for rubella, chicken pox.
STI screen-HepB, Hep C, HIV, syphilis with patient’s consent.
Urine microscopy/ C&S.
PAP smear- if not taken during last 2 years. Safe up to 20 weeks but some recommend up to 24wks.
Pregnancy investigations: when to do US and screenings (and which ones)?
U/S at 18- 20 and 32 weeks. (first = 8w if patients doesn’t remember last menses)
Diabetic testing at 26/ 28 weeks.
GBS testing at 36 weeks.
First trimester screening tests for Down syndrome (9-12 weeks):
- Ultrasonography for nuchal translucency (>0.5mm)
- Maternal serum biomarkers: Increased free beta hCG with decreased pregnancy-associated plasma protein
How many antenatal visits are expected and when?
Average 12.
First trimester- 8-10 weeks.
Up to 28 weeks- every 4-6 weeks.
Up to 36 weeks- every 2 weeks
Up to delivery- every week.
What to look for every visit? (measures, examinations)
During each visit:
- Record weight, BP.
- Fundal height - if corresponds to gestational age +/- 2cm.
Up to umbilicus in 20-22 weeks and xiphi sternum in 36-38wks.
If greater think about wrong dates, poly hydramnios, multiple gestation, hydatidiform mole, big baby( DM), birth defects.
If less, wrong dates, oligo hydramnios, IUGR, birth defects. - Foetal heart - 120-160 beats/min. Usually with hand held Doppler.
If altered, CTG ( cardiotocographic monitoring) - Presentation - usually cephalic/vertex. Breech is the most common abnormal presentation. Face and brow are other abnormal presentations.
- Normal lie is longitudinal. Other lies- transverse and oblique.
Malpositions - Abnormal positions of vertex relative to maternal pelvis. Normal position is left occipitoanterior. - Occipito posterior( commonest abnormal position). occipito transverse.
Diet concerns during pregnancy
Eat most- cereals and bread, fruits and vegetables.
Eat moderate- diary products, meat and fish.
Eat least- sugar and refined carbs, polyunsaturated fats.
Could gain around 12 kg during pregnancy.
If healthy diet, no need for iron, calcium supplements. Only folic acid and iodine.
> > > > According to NHMRC, all women considering pregnancy, pregnant and breast feeding should take 150 micrograms/ day of iodine.
Iodine deficiency leads to defects in the brain, nervous system of the fetus and a reduced IQ in infants.
Dietary sources- fortified bread, dairy products and seafood except seaweed.
Requirement of iodine during pregnancy- 220 micrograms/day.
Requirement during breast feeding- 270 micrograms/day.
If patient is vegan, give folic acid, iron and iodine as supplements.
SAD
Avoid SAD during pregnancy.
No safe limit for drinking during pregnancy.
Effects of alcohol in pregnancy.
1 Miscarriage.
2 Premature birth.
3 Fetal alcohol syndrome- 2 in 1000 live births. Due to teratogenic effects of alcohol.
Vegan pregnant woman - recomendations
If patient is vegan, give folic acid, iron and iodine as supplements.
Requirement of iodine during pregnancy- 220 micrograms/day.
Requirement during breast feeding- 270 micrograms/day.
FEATURES OF FAS - Fetal Alcohol Syndrome
Microcephaly.
Facial defects- narrow forehead, short palpebral fissures, upturned nose, low set ears, long, smooth philtrum, thin upper lip, micrognathia.
Congenital heart disease.
Skeletal abnormalities.
Central nervous system dysfunction and mental retardation.
Markedly underweight till puberty.
Hyperactivity.
SMOKING IN PREGNANCY - complications
1 Ectopics.
2 Miscarriage.
3 Placenta praevia.
4 Abruptio placentae.
5 Low birth weight.
6 Premature labour.
7 SIDS.
SMOKING AND BREAST FEEDING
1 Decreased breast milk.
2 Decreased Vit C in breast milk.
Effect of smoking in the later life of child.
1 Asthma.
2 Obesity.
Quitting of smoking- First and foremost, behavioural therapies. Then if necessary, NRT (Nicotine replacement therapy)
Safest time to travel during pregnancy? Worst?
2nd trimester
Unadvised during 3rd
OFF after 36w
Weight gaing during pregnancy?
Weight gain
1st trimester- 1-2 kg.
2nd trimester and 3rd up to 36 weeks- 500gm/week.
Then levels off after 36 weeks.
Foetal movements - when
First in primi- 17- 20 wks.
In multi- 16-18 weeks.
Ideally it should be 10 or more per day.
VAGINAL BLEEDING IN EARLY PREGNANCY - Overview
Incidence in normal pregnancy- 10%.
Total incidence is around 25%.
Causes of normal light vaginal bleeding in early pregnancy
Hormonal - could trigger bleeding at the time of periods.( break through bleeding)
Embryo embedding into uterus.(implantation bleeding)
Cervical irritation- due to softening of cervix.
OTHER CAUSES:
Polyps.
Fibroids.
Clotting disorders
Recurrent/habitual abortions - incidence, causes
- 3 consecutive pregnancy losses prior to 20 weeks.
- Incidence- 1-2%.
- Causes:
Chromosomal abnormalities.- first trimester
Immunologic- antiphospholipid antibody syndrome.
Anatomical- uterine abnormalities, cervical incompetence.
Endocrine- DM, thyroid.
Haematologic- Thrombophilia.
Infections.
Miscarriage - types, causes
Causes
First trimester- chromosomal abnormalities, APAS.
Second trimester- cervical incompetence, uncontrolled DM, infections.
TYPES
Missed abortion - Pregnancy lost but retained. Non viable retained intrauterine pregnancy.
Features - amenorrhea + non progressive pregnancy.
Threatened abortion
Symptoms - Minimal bleeding P/V + Minimal cramps.
Examination - Cervical os closed.
Pregnancy corresponds to gestational age.
50% might stop bleeding and have normal pregnancy.
Inevitable abortion
Symptoms - severe bleeding PV+ severe abdominal cramps.
Examination - Cervical os open.
Products at lower uterine segment.
Uterine size less.
Incomplete abortion
Symptoms - severe bleeding PV+ abdominal cramps+passage of POC.
Examination - Cervical os open.
Tissues protruding through os.
Uterine size less.
Complete abortion
Symptoms - bleeding PV+ abdominal cramps+ all POC lost.
So later bleeding subsides.
Examination - Cervical os closed.
Uterus empty.
ADMINISTER ANTI D GLOBULIN IF PATIENT IS Rh NEGETIVE after doing an indirect Coombs test and if it is negative.
Risk of recurrence- 1%
Risk in general population- 10- 20%.
Miscarriage - magement
In threatened- limit activities, admit and observe till bleeding stops. Rest not found to be very effective. U/s after 1 week.
Try to remove POC by sponge forceps in incomplete abortion.
Medical- by misoprostol (PGE1 analogue) orally/ vaginally. Brings cervical softening and induces uterine contractions. Usually before 9 weeks.
Surgical- dialatation and evacuation
ECTOPIC PREGNANCY - definition, most common sites
Implantation of blastocyst at sites other than endometrium.
Incidence - 1-2%
Sites-
1 Fallopian tube- most common site
2 Uterine cornua.
3 Ovary
4 Cervix
5 Abdominal/ pelvic cavity.
Most common part of tube for ectopics- ampulla.
Most common part of tube prone for early rupture- isthmus.
ECTOPIC PREGNANCY - RISK FACTORS
Tubal abnormalities - previous ectopic ( 10-25% chance of recurrence), H/O PID, tubal surgeries including ligation.
IUCD/ IUS.
Pregnancy due to GIFT, ZIFT.
Smoking.
Prior induced abortion.
ECTOPICS - INVESTIGATIONS
Urine pregnancy test- NEGATIVE in minority, weakly positive or positive.
Serum beta HCG estimation- shows decreased rise in Beta HCG levels.
Trans vaginal Ultrasound- Most important tool to diagnose ectopics. Around 5-6weeks.
Becomes positive only when Beta HCG level reaches 1500-1800 mIU/ml.
Findings in U/S- Empty uterus.
Adnexal mass.
Fluid in the POD.
Laparoscopy- criterion standard for diagnosis.
ECTOPICS - SYMPTOMS
Classic triad
Abdominal pain.( most common)
Amenorrhea.
Vaginal bleeding.( prune juice bleeding. Absent in 10-15%)
PRE RUPTURE SYMPTOMS
Cramping pain in one or more iliac fossa radiating to rectum,(lavatory sign) vagina or leg.
Vaginal bleeding.
RUPTURED ECTOPIC
Generalised, excruciating abdominal pain, shoulder pain.
Features of shock.
ECTOPICS - MANAGEMENT
Medical - Methotrexate - for unruptured.
DOSE - Single (50mg/m2) or multiple I/M injections or under ultrasonic guidance through hysteroscopy directly into sac. Considered more in ectopics in cervix, ovary and interstitial or cornual part of tube.
Action - interferes with DNA synthesis and disrupts cell multiplication.
Pre requesits - haemodynamically stable, no severe/ persisting abdominal pain, normal LFT and RFT.
Beta HCG <5000, no foetal cardiac activity.
CONTRAINDICATIONS
Absolute - Intrauterine pregnancy, sensitivity to methotrexate, immunodeficiency ,tubal rupture, breast feeding, liver/renal dysfunction, haematologic variations.
Relative - Beta HCG >5000, foetal cardiac activity, ectopic sac greater than 3.5- 4 cm in size, significant free fluid in the POD.
ECTOPICS - SURGERY
LAP with linear salpingostomy- especially for ampullary ectopics.
LAP with salpingectomy- damaged tubes, previous ectopic in the same tube, family completed.
LAP and segmental resection followed by delayed microsurgical re anastomosis.
ECTOPICS - FOLLOW UP
1 Serial Beta HCG estimation after 1 week until level is 0.
If decreasing- treatment effective.
If remaining same- consider another injection of
methotrexate.
If increasing- surgery.
COC until BHCG normalizes!!!
Hydatidiform mole - TYPES
Also called vesicular mole.
Incidence - 1:1200.
Gestational trophoblastic disease.
Abnormal placental development.
Types - Complete moles - has no foetal tissue. When a sperm fertilises an empty egg.
Partial mole - some foetal tissue is present. When 2 sperms fertilise 1 normal ovum.
Invasive mole - when it invades the uterus. Are not malignant.
Chorio carcinoma - when they turn cancerous
MOLE - PRESENTATION,
Cause
Exact cause unknown.
Diet deficient in carotene and animal fat may be a risk factor.
Risk of recurrence- 1-2%.
Clinical presentation
Vaginal bleeding- most common. Associated passage of vesicles/ grape like material.
Hyperemesis- due to high levels of beta HCG.
Exaggerated pregnancy symptoms.
Hyperthyroidism- due to stimulation of thyroid by high levels of Beta HCG.
Hypertension.
Asymptamatic.– diagnosed by U/S.
Examination.
Uterus large for dates.
MOLE - Investigations
Beta HCG- Very high. May be greater than 100,000mIU/mL.
FBE- anaemia.
Coagulation profile- coagulopathy.
LFT.
RFT.
TFT.
S. inhibin and S.activin- higher.
Pelvic U/S- Is the criterion standard. Shows snow storm appearance due to hydropic chorionic villi.
MOLE - Treatment
DRABCDE and stabilise patient if in shock.
SURGERY- Dialatation, suction evacuation and curettage. I/V oxytocin after dialatation of cervix, at the initiation of suction and continued post op to reduce bleeding.
Follow up
Prophylactic chemotherapy not recommended.
Serial beta HCG estimation weekly until 0, then monthly for 12 months. Pregnancy to be avoided for 1yr after Beta HCG becomes normal.
Contraception during follow up period- any contraceptive method - AT LEAST 1 YEAR AVOIDING PREGNANCY
If beta HCG levels plateau/rise, it could be an invasive mole or chorio carcinoma.
CHORIOCARCINOMA - RISK FACTORS, TREATMENT, SITES OF MTX
Risk factors
Age greater than 40 .
Complete mole.
Beta HCG above 100,000 IU/l.
Theca lutein cysts greater than 6 cm.
SITES OF METASTASIS
Lung- most common site.
Brain, liver, vagina.
Treatment
Chemo therapy- methotrexate with folic acid.
Follow up.
HYPEREMESIS GRAVIDARUM - PRESENTATION, CAUSES
Severe nausea, vomiting, dehydration, electrolyte disturbance and weight loss during pregnancy.
Commonest symptom is severe, constant nausea.
Subsides by 12 weeks.
Hyperemesis in normal pregnancy.
Hormonal- due to beta HCG and oestrogen.
Mechanical- due to decreased gastric peristalsis and emptying.
Emotional.
Causes
Normal pregnancy- 10%.
Mole
Multiple pregnancy.
Urinary infection.
HYPEREMESIS GRAVIDARUM - investigation and treatment
Investigations
Urine analysis- M/ C&S and also for ketones.
2 Blood - U&E, S.creatinine.
3 LFT.
4 U/S - exclude v.mole, multiple pregnancy.
Treatment
Admit if electrolyte disturbances.
Bed rest.
Nil orally.
Start I/V infusion- 0.9% NaCl or Hartmann’s.
Nasogastric feeding.
Antiemetic medications- metoclopramide 10mg I/v then 10mg tds.
Vitamins- Pyridoxine 25mg 1tab tds. Decreases nausea.
Small, frequent meals.
CARPAL TUNNEL SYNDROME IN PREGNANCY - CAUSE, TTX
Symptoms
Pain especially at night, tingling and numbness in the thumb, index finger, middle finger and radial half of ring finger.
Cause
Due to fluid retention caused by hormones.
Usually goes away after delivery.
Treatment
General measures- Rest, limit activities with affected hand, Ice application.
Splint or brace to maintain wrist in neutral position.
Surgery of volar carpal ligament is the last resort.
Prevelance of neural tube defects among non- indigenous population is double than in Aboriginal and Torres Islander babies -T OR F
TRUE
When can USG detect pregnancy?
Around 5-6w
If sack absent in uterus, consider echtopic
Pre-ovulatory follicle - size?
1.8 - 2.0 cm when about to burst
Multiloculated ovarian - benign or malignant?
Probably malignant. Mostly if containing solid elements.
Bening cyst are unilocular, thin walled
Normal blood loss during delivery?
600-800ml
Signs of hemorrhagic shock unjustifiable with the amount of per vaginal haemorrhage - Diagnosis? Risk factor?
Uturine rupture
Previous C-section is a risk factor
What heart condition can lead to death during pregnancy if present?
Mitral valve stenosis
The pregnancy-induced increase in blood volume, cardiac output, and tachycardia can increase the trans-mitral pressure gradient and cause pulmonary oedema in women with mitral stenosis.
Pregnancy associated with long-standing mitral stenosis may result in pulmonary hypertension.
Pregnant women with mitral stenosis are at increased risk for the development of atrial fibrillation and other tachyarrhythmias.
Uturine rupture - overview
Sudden abdominal pain followed by the cessation of contractions, the termination of the urge to push, and vaginal bleeding.
Abdominal examination shows no fetal heart activity, and signs of a fluid collection like the fluid thrill and shifting dullness are present. This fluid is blood, and it usually enters into the peritoneum after the rupture of the uterus.
Vaginal examination in such patients reveals a range of cervical dilatation with evidence of cephalopelvic disproportion.
The most common site of spontaneous uterine rupture is the anterior lower transverse segment. Patient with tachycardia and hypotension is in shock due to blood loss and requires urgent resuscitation.
Until when it’s normal to find bloody lochia?
Bloody lochia can persist for up to 2 weeks without indicating an underlying pathology; however, if bleeding continues beyond 2 weeks, it may indicate placental site subinvolution, retention of small placental fragments, or both.
At this point, appropriate diagnostic and therapeutic measures should be initiated.
The physician should first estimate the blood loss and then perform a pelvic examination in search of uterine subinvolution or tenderness. Excessive bleeding or tenderness should lead the physician to suspect retained placental fragments or endometritis.
When fetal heartsounds can be heard by doppler auscultation?
The fetal heart tones are audible in most patients at 10 weeks.
If no fetal heart tones are audible by Doppler auscultation and the patient is 10 weeks or more, an ultrasound of the pregnancy should be ordered.
Oligohydramnios - overview
Oligohydramnios is associated with an increased risk for fetal or neonatal death, which may be related to the underlying cause of the reduced amniotic fluid volume or due to sequelae of the reduced amniotic fluid volume. The volume of amniotic fluid reflects the balance between fluid production and movement of fluid out of the amniotic sac. The most common mechanisms for development of oligohydramnios are fetal oliguria/anuria and fluid loss due to rupture of membranes. A reduction in the egress of lung fluid and increased swallowing do not play major roles. Idiopathic cases (ie, idiopathic oligohydramnios) may be due to alterations in the expression of water pores (aquaporin 1, aquaporin 3) in fetal membranes and placenta.
Causes of oligohydramnios
Maternal
Medical or obstetric conditions associated with uteroplacental insufficiency (eg, preeclampsia, chronic hypertension, collagen vascular disease, nephropathy, thrombophilia)
Medications (eg, angiotensin converting enzyme inhibitors, prostaglandin synthetase inhibitors, trastuzumab)
Placental
Abruption
Twin to twin transfusion (ie, twin polyhydramnios-oligohydramnios sequence)
Placental thrombosis or infarction
Fetal
Chromosomal abnormalities
Congenital abnormalities, especially those associated with impaired urine production
Growth restriction
Demise
Postterm pregnancy
Ruptured fetal membranes
Infection
Idiopathic
First trimester — The etiology of first trimester oligohydramnios is often unclear. Reduced amniotic fluid prior to 10 weeks of gestation is rare because gestational sac fluid is primarily derived from the fetal surface of the placenta, transamniotic flow from the maternal compartment, and secretions from the surface of the body of the embryo.
Second trimester — By the beginning of the second trimester, fetal urine begins to enter the amniotic sac, and the fetus begins to swallow amniotic fluid. Therefore, disorders related to the fetal renal/urinary system begin to play a prominent role in the etiology of oligohydramnios. These anomalies include intrinsic renal disorders (eg, cystic renal disease) and obstructive lesions of the lower urinary tract (eg, posterior urethral valves, urethral atresia). Maternal and placental factors, as well as rupture of the fetal membranes (traumatic or nontraumatic), are also common causes of oligohydramnios in the second trimester
Third trimester — Oligohydramnios first diagnosed in the third trimester is often associated with PPROM or with uteroplacental insufficiency due to conditions such as preeclampsia or other maternal vascular diseases. Oligohydramnios frequently accompanies fetal growth restriction related to uteroplacental insufficiency. Fetal anomalies and abruptio placentae also play a role at this gestational age. Amniotic fluid volume normally decreases postterm, so oligohydramnios may develop in these pregnancies. In addition, many cases of third trimester oligohydramnios are idiopathic. (Refer to individual topic reviews on these subjects).
There may be an association between pregnancy during the summer season and oligohydramnios, likely related to suboptimal maternal hydration in hot weather.
Maternal TORCH (toxoplasma gondii, rubella virus, cytomegalovirus, herpes simplex virus) and parvovirus B19 infections that infect the fetus may be associated with second- or third-trimester oligohydramnios, often in association with other evidence of fetal infection
Initial evaluation of mixed urinary incontinence?
A voiding diary to classify predominant type of urinary incontinence (eg, stress, urgency) and to determine optimal treatment.
All patients with mixed incontinence generally require bladder training with lifestyle changes (eg, weight loss, smoking cessation, decreased alcohol and caffeine intake) and pelvic floor muscle exercises (eg, Kegels). Patients who have limited or incomplete symptom relief with bladder training may benefit from pharmacotherapy or surgery, depending on predominant type:
In patients with urgency-predominant incontinence, oral antimuscarinics and timed voiding (eg, urinating on a fixed schedule, rather than based on a sense of urgency) are used .
In patients with stress-predominant incontinence due to weakened pelvic floor muscles (eg, cystocele), surgery with a midurethral sling is performed
Spinal epidural abscess - overview
Spinal epidural abscess
Epidemiology
Staphylococcus aureus (65%)
Immunosuppression (HIV, diabetes mellitus, alcohol use, old age)
Inoculating sources
Distant infection (eg, cellulitis, joint/bone)
Spinal procedure (eg, epidural catheter)
Injection drug use
Manifestations
Classic triad
Fever (~50%)
Focal/severe back pain
Neurologic findings (eg, motor/sensory change, bowel/bladder dysfunction, paralysis)
Diagnosis
↑ ESR
Blood & aspirate cultures
MRI of the spine
Treatment
Broad-spectrum antibiotics (eg, vancomycin plus ceftriaxone)
Emergency aspiration/surgical decompression
Lumbar back pain, low-grade fever, and lower-extremity neurologic symptoms (eg, weakness, tingling, numbness), raises strong suspicion for spinal epidural abscess.
Most cases arise via hematogenous spread of a distant infection, contiguous spread from an adjacent infection (eg, vertebral osteomyelitis), or following direct inoculation during spinal/epidural anesthesia.
The epidural space is a vertical, contiguous area that contains fat, arteries, and a venous plexus; infections tend to affect multiple spinal levels and cause progressive neurologic impairment due to direct spinal cord compression, thrombophlebitis of the draining venous plexus, and/or interruption of the arterial blood supply. Although patients classically have the triad of fever, spinal pain, and neurologic symptoms, all 3 are present in a minority of cases. Most patients have fever, malaise, and neurologic symptoms that typically progress in the following fashion (due to worsening spinal cord compression):
Focal back pain → Nerve root pain (eg, shooting, electric-shock sensation) → Motor weakness, sensory changes, bowel/bladder dysregulation → Paralysis
Early diagnosis is crucial to prevent paralysis and death; MRI of the affected spinal area
Kleihauer-Betke testing - definition and indication
Measures the amount of fetal blood mixed into maternal circulation following trauma, which helps guide anti-D immunoglobulin dosing in Rh-negative patients (ie, to prevent Rh-alloimmunization).
Rh-positive patients are not at risk for Rh-alloimmunization, and testing does not change management.
Pregnant patient with abdominal pain, contractions, and vaginal bleeding following blunt abdominal trauma (eg, motor vehicle collision) likely has ?
Abruptio placentae (ie, placental abruption).
Due to the volume of blood supplied to the uterus, abruptio placentae can cause hypovolemic shock from hemorrhage (ie, hemorrhagic shock), as seen in this patient with hypotension, tachycardia, and cool extremities.
Management of the trauma patient with hemorrhagic shock requires rapid resuscitation with replacement of intravascular volume, transitioning from crystalloid to blood products as soon as possible. In addition, pregnant patients are placed in a left lateral decubitus position (if the spine is stable) to displace the uterus off the aortocaval vessels and maximize cardiac output.
If hemorrhage or hemodynamic instability continues despite initial resuscitation efforts, massive transfusion protocol (MTP) should be activated. MTP is the administration of packed red blood cells, platelets, and fresh frozen plasma in a 1:1:1 ratio to avoid coagulopathy from dilution of platelets and clotting factors.
Emergency cesarean delivery after maternal trauma may be indicated for imminent fetal compromise
rare side effect of oxytocin that can lead to seazure, confusion and lethargy?
Hyponatremia
Oxytocin, commonly used for induction of labor and postpartum hemorrhage management, has a similar structure to antidiuretic hormone (vasopressin); therefore, elevated levels can stimulate the renal collecting ducts to increase free water absorption. This leads to acute hyponatremia, decreased serum osmolality, and increased free water movement into the brain cells with resultant cerebral edema and seizure.
> > The risk of this rare but life-threatening side effect is increased with excessive or prolonged oxytocin administration, as seen in this patient who had a 48-hour oxytocin infusion followed by a bolus.
Management of oxytocin-induced hyponatremia includes cessation of oxytocin infusion and gradual administration of hypertonic saline (eg, 3% saline) in symptomatic patients (eg, seizures) to raise serum osmolality and reverse cerebral edema.
CMV - Overview during pregnancy
CMV(a DNA virus) is the most common cause of intrauterine infection and the most common viral cause of birth defects. Primary infection of the mother is often asymptomatic but may present as flue-like symptoms. Up to 50% of pregnant women are CMV lgG seropositive.
Vertical transmission from mother to fetus occurs mainly during the viremia of a primary infection. However, since the result of primary infection is predisposition to a residual life -long latency. fetal infection can occur with reactivation as well.
Transplacental fetal infection is 50% with primary infection, regardless of the gestational age but less than 1% with reactivation of a latent infection.
The infected newborn will be symptomatic in 10 % of cases, but of these 10% almost 90% carry a risk of sequelae including:
Microcephaly
Ascites
Hydrops fetalis
Oligo or polyhydramnios
Hepatomegaly
Pseudomeconium ileus
Hydrocephalus (ventricular dilation)
Intrauterine growth restriction(IUGR)
Pleural or pericardial effusions
lntracranial calcification
Abdominal calcification
Hearing loss
Serologic testing for cytomegalovirus is recommended for the following women in pregnancy:
History suggestive of CMV illness
Exposure to known CMV infected individual or blood product
lmmunocompromised
Abnormalities on routine antenatal ultrasound (usually at 18 weeks)
The serology results are interpreted as follows:
A patient with positive lgG but negative lgM has a had past exposure
Changing from an lgG-negative to an lgG-positive state (seroconversion) or a significant rise in lgG indicates a recent primary CMV infection
If the patient has a positive lgM with or without a positive lgG, the result is equivocal and the test should be repeated in 2-4 The reasons for this include:
lgM can remain positive for over one year after an acute infection; therefore, presence of CMV lgM is not helpful for timing of the onset of infection
lgM is only positive in only 75-90% of women with acute infection
lgM can revert from negative to positive in women with CMV reactivation or reinfection with a different strain
NOTE– Interpretation of CMV lgM results in pregnancy requires specialist opinion.
Fetal diagnosis is best achieved by a combination of fetal ultrasound, amniocentesis+/- fetal serology; however, the definite diagnosis of fetal infection is by amniocentesis and PCR or the amniotic fluid for CMV. It should be born in mind that positive results do not predict any degree of fetal damage.
Since this woman is 16 weeks pregnant. amniocentesis for definite diagnosis is the most appropriate option. Amniocentesis is performed in the rather small window of 15-18 (up to 20) weeks. However, repeating the test in 2-4 weeks was the most appropriate option if it was an option.
CMV - Fetal diagnostic evaluation?
Fetal diagnosis is best achieved by a combination of fetal ultrasound, amniocentesis+/- fetal serology; however, the definite diagnosis of fetal infection is by amniocentesis and PCR or the amniotic fluid for CMV. It should be born in mind that positive results do not predict any degree of fetal damage.
Since this woman is 16 weeks pregnant. amniocentesis for definite diagnosis is the most appropriate option. Amniocentesis is performed in the rather small window of 15-18 (up to 20) weeks. However, repeating the test in 2-4 weeks was the most appropriate option if it was an option.
Listeria monocytogenes infection durting pregnancy - worst outcomes?
Fetal demise
Listeria monocytogenes is a common foodborne infection due to consumption of contaminated food (eg, unpasteurized milk, deli meats) and typically causes a self-limited gastroenteritis. During pregnancy, L monocytogenes can cause transplacental fetal infection and possible intrauterine fetal demise.
Infection acquired in early pregnancy (eg, first and second trimesters) typically results in granulomatosis infantiseptica (ie, disseminated abscesses/granulomas) and possible intrauterine fetal demise. Infection in the third trimester may be less severe and present as fetal distress, preterm delivery, or early-onset neonatal sepsis.
How late can a breech baby turn?
36-37 weeks
If spontaneous version to cephalic presentation has not occurred consider following steps:
-External cephalic version.
-If external cephalic version is unsuccessful, consider Cesarean section or vaginal delivery at 38-39 weeks of gestation.
Types of breech presentation
Types of breech presentation include:
-Frank breech:
The fetal hips are flexed, and the knees extended (pike position).
-Complete breech:
The fetus seems to be sitting with hips and knees flexed.
-Footling breech:
One or both legs are completely extended and present before the buttocks.
-Kneeling breech:
The baby is in a kneeling position, with one or both legs extended at the hips and flexed at the knees
Fetal position is a transverse lie if the fetal long axis is oblique or perpendicular rather than parallel to the maternal long axis.
Shoulder-first presentation requires cesarian delivery unless the fetus is the 2nd twin.
Pelvic congestion - pain pattern? CF? Definition?
Swelling and inflammation of connective tissues in ligaments in pelvis due to hormones
Pain NOT RELATED to periods
Connection between thyroid and periods
Hypothyroidism - Heavier and more periods
Hyperthyroidism - Less periods
