Obs and gyn Flashcards
Post-partum haemorrhage
Postpartum haemorrhage (PPH) is defined as blood loss of > 500mls and may be primary or secondary
Primary PPH
occurs within 24 hours
affects around 5-7% of deliveries
most common cause of PPH is uterine atony (90% of cases). Other causes include genital trauma and clotting factors
Risk factors for primary PPH include*: previous PPH prolonged labour pre-eclampsia increased maternal age polyhydramnios emergency Caesarean section placenta praevia, placenta accreta macrosomia ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)
Management
ABC including two peripheral cannulae, 14 gauge
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost
if medical options failure to control the bleeding then surgical options will need to be urgently considered
the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
Secondary PPH
occurs between 24 hours - 12 weeks**
due to retained placental tissue or endometritis
*the effect of parity on the risk of PPH is complicated. It was previously though multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor
**previously the definition of secondary PPH was 24 hours - 6 weeks. Please see the RCOG guidelines for more details
Infertility
Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years
Causes male factor 30% unexplained 20% ovulation failure 20% tubal damage 15% other causes 15%
Basic investigations
semen analysis
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
Interpretation of serum progestogen
Level Interpretation
< 16 nmol/l Repeat, if consistently low refer to specialist
16 - 30 nmol/l Repeat
> 30 nmol/l Indicates ovulation
Key counselling points folic acid aim for BMI 20-25 advise regular sexual intercourse every 2 to 3 days smoking/drinking advice
Gravidity
number of times that a woman has been pregnant.
Parity
number of times that she has given birth to a fetus with a gestational age of 24 weeks or more, regardless of whether the child was born alive or was stillborn.
Hyperemesis gravidarum
It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks*.
Associations multiple pregnancies trophoblastic disease hyperthyroidism nulliparity obesity
NICE Clinical Knowledges Summaries recommend considering admission in the following situations:
Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
Hyperemesis gravidarum diagnostic criteria
- 5% pregnancy weight loss
- dehydration
- electrolyte imbalance
Management of hyperemesis gravidarum
- Antihistamines (promethazine or cyclizine)
- Ondansetron/metoclopromide
- Ginger/p6 acupressure
- Admission may be needed for IV hydration
Antenatal care: timetable
10 antenatal visits in the first pregnancy if uncomplicated
7 antenatal visits in subsequent pregnancies if uncomplicated
women do not need to be seen by a consultant if the pregnancy is uncomplicated
8 - 12 weeks (ideally < 10 weeks)
Booking visit
general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
BP, urine dipstick, check BMI
Booking bloods/urine
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
hepatitis B, syphilis
HIV test is offered to all women
urine culture to detect asymptomatic bacteriuria
10 - 13+6 weeks
Early scan to confirm dates, exclude multiple pregnancy
11 - 13+6 weeks
Down’s syndrome screening including nuchal scan
16 weeks
Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick
18 - 20+6 weeks
Anomaly scan
25 weeks (only if primip)
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
28 weeks
Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
31 weeks (only if primip)
Routine care as above
34 weeks
Routine care as above
Second dose of anti-D prophylaxis to rhesus negative women*
Information on labour and birth plan
36 weeks
Routine care as above
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, ‘baby-blues’
38 weeks
Routine care as above
40 weeks (only if primip)
Routine care as above
Discussion about options for prolonged pregnancy
41 weeks
Routine care as above
Discuss labour plans and possibility of induction
Oligohydraminos
abnormally low volume of amniotic fluid
amniotic fluid is mainly derived from foetal urine
premature rupture of membranes fetal renal problems e.g. renal agenesis intrauterine growth restriction post-term gestation pre-eclampsia
Post-partum contraception
- women require contraception after 21 days post-partum
Progesterone only pill post-partum
POP can be started at any point postpartum
after day 21 additional contraception needed for first 2 days
small amount of progesterone enters breastmilk - but not harmful
COCP postpartum
- absolute contraindication UKMEC 4 if breastfeeding <6 weeks postpartum
- UKMEC 2 - if breastfeeding 6 weeks - 6 months
- Do not use in first 21 days due to venous thromboembolism risk
- after day 21 additional contraception should be used for the first 7 days
- COCP may reduce breast milk production in lactating women
Intrauterine device postpartum
- can be inserted within 48 hours of childbirth or after 4 weeks
Lactational amenorrhea method (LAM) for contraception
98% effective providing woman is fully breastfeeding (no supplementary feeds), amenorrheic, and less than 6 months postpartum
What is the recommended time inter to wait between pregnancies
Less than 12 months between childbirth and conceiving is associated with increased risk of preterm birth, low birth weight, and small for gestational age babies
Ectopic pregnancy
Pregnancy outside of the uterine cavity
Risk factors of ectopic pregnancy
- Smoking
- History PID
- In-vitro fertilisation
- Gynecologic surgery
- Current IUD
- Tubal Ligation
- Previous ectopic pregnancy
DIagnosis of ectopic pregnancy
- Varies based on health
1. If hemodynamically unstable - SURGERY
- Haemodynamically stable (vital signs normal) - no hypertension or tachycardia
A. Serial HCG testing (levels should double every 2 days in a normal early pregnancy)
B. TV USS Intrauterine pregnancy (visible by weeks 5-6) and excess fluid
Conservative management of ectopic pregnancy
Indicated if:
- Hemodynamically stable
- Diagnosed early
- HCG declining
Perform serial HCG measurements and no additional tings
Medical management of ectopic pregnancy
Methotrexate
Surgical management of ectopic pregnancy
Salpingotomy
= the creation of an opening into the fallopian tube, but the tube itself is not removed in this procedure
Salpingectomy - which the affected Fallopian tube is removed,
Emergency contraception
- Levonorgestrel
- Ulipristal
- Copper IUD
Levonorgestrel
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
should be taken as soon as possible - efficacy decreases with time
must be taken within 72 hours of unprotected sexual intercourse (UPSI)*
single dose of levonorgestrel 1.5mg (a progesterone)
the dose should be doubled for those with a BMI >26 or weight over 70kg
84% effective is used within 72 hours of UPSI
levonorgestrel is safe and well-tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 3 hours then the dose should be repeated
can be used more than once in a menstrual cycle if clinically indicated
hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception
Ulipristal
a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
concomitant use with levonorgestrel is not recommended
Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
caution should be exercised in patients with severe asthma
repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle
breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
Intrauterine device (IUD)
a copper IUD is the most effective method of emergency contraception and should be offered to all women if they meet the criteria
if the criteria for insertion of a copper IUD are not met or is not acceptable to the woman, oral emergency contraception should be considered
in practice the vast majority of women choose oral emergency contraception, but it is important to offer the choice to all women given how effective copper IUDs are
must be inserted within 5 days of UPSI, or
if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
may inhibit fertilisation or implantation
prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
is 99% effective regardless of where it is used in the cycle
may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
Placenta accreta
Placenta accreta describes the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage.
Risk factors
previous caesarean section
placenta praevia
Strictly speaking, there are 3 different types of placenta accreta, depending on the degree of invasion although this is quite small print:
accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
increta: chorionic villi invade into the myometrium
percreta: chorionic villi invade through the perimetrium
Amenorrhoea
primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
Primary amenorrhea
gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
testicular feminisation
congenital malformations of the genital tract
functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
congenital adrenal hyperplasia
imperforate hymen
Secondary amenorrhoea (after excluding pregnancy)
hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
Termination of pregnancy
Key points
two registered medical practitioners must sign a legal document (in an emergency only one is needed)
only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
The method used to terminate pregnancy depend upon gestation
less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) 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’)
1967 Abortion Act
Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith
that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
Medical termination of pregnancy
Oral mifepristone, followed by vaginal misoprostol.
Mifepristone is a progestogen antagonist that is used to ripen the cervix for medical termination of pregnancy and sensitise the myometrium to prostaglandin analogues. Misoprostol is a uterotonic prostaglandin analogue that initiates expulsion of pregnancy tissue, given 48 hours after mifepristone. Misoprostol may have to be given multiple times to ensure adequate expulsion of pregnancy tissue from the uterus. Mifepristone is only licensed for oral use in medical termination of pregnancy, while misoprostol may be given orally, sublingually, or vaginally.
Preeclampsia
- New-onset hypertension of >140/90 mmHg after 20 weeks and 1 of the following
- Proteinuria
- Other organ involvement (e.g. renal insufficiency (creatinine > or = 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction)
Potential consequences of pre-eclampsia
eclampsia
other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
fetal complications
intrauterine growth retardation
prematurity
liver involvement (elevated transaminases)
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure
Features of severe pre-eclampsia
hypertension: typically > 160/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
Reducing the risk of hypertensive disorders in pregnancy
Women with the following should take aspirin 75-150 mg daily from 12 weeks gestation until the birth
≥ 1 high risk factors
≥ 2 moderate factors
High risk:
- hypertensive disease in a previous pregnancy
- chronic kidney disease
- autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
- type 1 or type 2 diabetes
- chronic hypertension
Moderate risk:
- first pregnancy
- age 40 years or older
- pregnancy interval of more than 10 years
- body mass index (BMI) of 35 kg/m² or more at first visit
- family history of pre-eclampsia
multiple pregnancy
Preeclampsia assessment and management
Initial assessment
- NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
- Women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
Further management
- oral labetalol is now first-line following the 2010 NICE guidelines.
- Nifedipine (e.g. if asthmatic) and hydralazine may also be used
Delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario
Group B Streptococcus
Group B Streptococcus (GBS) is the most common cause of early-onset severe infection in the neonatal period. It is thought around 20-40% of mothers have GBS present in their bowel flora and may therefore be thought of as ‘carriers’ of GBS. Infants may be exposed to maternal GBS during labour and subsequently develop potentially serious infections.
Risk factors for Group B Streptococcus (GBS) infection:
prematurity
prolonged rupture of the membranes
previous sibling GBS infection
maternal pyrexia e.g. secondary to chorioamnionitis
GBS
The Royal College of Obstetricians and Gynaecologists (RCOG) published guidelines on GBS in 2017.
The main points are as follows:
universal screening for GBS should not be offered to all women
the guidelines also state a maternal request is not an indication for screening
women who’ve had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive
if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date
IAP should be offered to women with a previous baby with early- or late-onset GBS disease
IAP should be offered to women in preterm labour regardless of their GBS status
women with a pyrexia during labour (>38ºC) should also be given IAP
benzylpenicillin is the antibiotic of choice for GBS prophylaxis
Uterine fibroids
Fibroids are benign smooth muscle tumours of the uterus. They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.
Associations
more common in Afro-Caribbean women
rare before puberty, develop in response to oestrogen
Features of uterine fibroids
may be asymptomatic
menorrhagia
may result in iron-deficiency anaemia
lower abdominal pain: cramping pains, often during menstruation
bloating
urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility
rare features:
polycythaemia secondary to autonomous production of erythropoietin
Diagnosis of fibroids
Transvaginal USS
Management of fibroids
Asymptomatic fibroids
no treatment is needed other than periodic review to monitor size and growth
Management of menorrhagia secondary to fibroids
levonorgestrel intrauterine system (LNG-IUS)
useful if the woman also requires contraception
cannot be used if there is distortion of the uterine cavity
NSAIDs e.g. mefenamic acid
tranexamic acid
combined oral contraceptive pill
oral progestogen
injectable progestogen
Treatment to shrink/remove fibroids
medical
GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
ulipristal acetate has been in the past but not currently due to concerns about rare but serious liver toxicity
surgical
myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
hysteroscopic endometrial ablation
hysterectomy
uterine artery embolization
Hormone replacement therapy (HRT)
Involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.
HRT side effects
nausea
breast tenderness
fluid retention and weight gain
Complications of HRT
increased risk of breast cancer
increased by the addition of a progestogen
in the Women’s Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
the increased risk relates to the duration of use
the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
increased risk of endometrial cancer
oestrogen by itself should not be given as HRT to women with a womb
reduced by the addition of a progestogen but not eliminated completely
the BNF states that the additional risk is eliminated if a progestogen is given continuously
increased risk of venous thromboembolism
increased by the addition of a progestogen
transdermal HRT does not appear to increase the risk of VTE
NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal)
increased risk of stroke
increased risk of ischaemic heart disease if taken more than 10 years after menopause
Injectable contraceptives - Depo Provera
Depo Provera is the main injectable contraceptive used in the UK*. It contains medroxyprogesterone acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions**
The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning.
Disadvantages include the fact that the injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months)
Adverse effects
irregular bleeding
weight gain
may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
not quickly reversible and fertility may return after a varying time
Contraindications
breast cancer: current breast cancer is UKMEC 4, past breast cancer is UKMEC 3
Urinary incontinence
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.
Risk factors advancing age previous pregnancy and childbirth high body mass index hysterectomy family history
Overactive bladder (OAB)/ Urge incontinence
- Frequency and urgency
- due to detrusor overactivity
Stress incontinence
- leaking small amounts when coughing or laughing
Mixed incontinence
Both urge and stress
overflow incontinence:
due to bladder outlet obstruction, e.g. due to prostate enlargement
functional incontinence
comorbid physical conditions impair the patient’s ability to get to a bathroom in time
causes include dementia, sedating medication and injury/illness resulting in decreased ambulation
Initial investigation
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
urodynamic studies
Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
bladder stabilising drugs: antimuscarinics are first-line
NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
Immediate release oxybutynin should, however, be avoided in ‘frail older women’
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
If stress incontinence is predominant:
pelvic floor muscle training
NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine may be offered to women if they decline surgical procedures
a combined noradrenaline and serotonin reuptake inhibitor
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
Risk factor for placental abruption
ABRUPTION
A - Abruption previously
B - Blood pressure (hypertension or pre-eclempsia)
R- Ruptured membranes, either premature or prolonged
U for Uterine injury (Trauma to abdomen)
P for Polyhydramnios
T for Twins or multiple pregnancies
I for Infection (to uterus, especially chorioamionitis)
O for old age (35 and older)
N for Narcotic us (smoking, cocaine, amphetamines)
Vaginal discharge
Common causes:
- physiological
- Candida
- Trichomonas vaginalis
- bacterial vaginosis
Less common causes:
- Gonorrhea
- Chlamydia
- ectropion
- foreign body
- cervical cancer
Cottage cheese discharge
Vulvitis
Itch
candida
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
Trichomonas vaginalis
Offenside, thin. white/grey, fishy dishy discharge
Bacterial vaginosis
The GMC good medical practice advice about contraception in those aged 0-18 years states
‘You can provide contraceptive, abortion and STI advice and treatment, without parental knowledge or consent, to young people under 16 provided that:
They understand all aspects of the advice and its implications
You cannot persuade the young person to tell their parents or to allow you to tell them
In relation to contraception and STIs, the young person is very likely to have sex with or without such treatment
Their physical or mental health is likely to suffer unless they receive such advice or treatment, and
It is in the best interests of the young person to receive the advice and treatment without parental knowledge or consent
You should keep consultations confidential even if you decide not to provide advice or treatment (for example, if your patient does not understand your advice or the implications of treatment).’
In this question, the young girl fulfils the Frazer guidelines, thus you should prescribe her the pill. So answers 2, 3 and 5 are clearly wrong. This leaves us with answer 1 and 4.In answer 4 this involves breaking confidentiality, which the GMC guidelines states we should not do. This leaves us with the correct answer - 1.
False Labor
Occurs in the last 4 weeks of pregnancy
Presentation: contractions felt in the lower abdomen. The contractions are irregular and occur every 20 minutes. Progressive cervical changes are absent.
Ovarian cysts
Benign ovarian cysts are extremely common. They may be divided into physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours.
Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.
Vulval carcinoma
Around 80% of vulval cancers are squamous cell carcinomas. Most cases occur in women over the age of 65 years. Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year.
Other than age, risk factors include: Human papilloma virus (HPV) infection Vulval intraepithelial neoplasia (VIN) Immunosuppression Lichen sclerosus
Features
lump or ulcer on the labia majora
inguinal lymphadenopathy
may be associated with itching, irritation
Placental abruption vs placenta praevia
Placenta abruption presents with painful vaginal bleeding whereas placenta praevia is usually painless
A woody, hard uterus may be palpable in placenta abruptio - this is because retroplacental blood tracks into the myometrium. The fetal heart is often absent and the woman may be shocked. Resuscitation is vital in these cases and the baby will need urgent delivery when stable. There is an increased risk of postpartum haemorrhage.
COCP
protective against ovarian and endometrial cancer
increased risk of breast and cervical cancer
Shoulder dystocia
Shoulder dystocia is a complication of vaginal cephalic delivery. It entails the inability to deliver the body of the fetus using gentle traction, the head having already been delivered. It usually occurs due to impaction of the anterior fetal shoulder on the maternal pubic symphysis. Shoulder dystocia is a cause of both maternal and fetal morbidity.
Key risk factors fetal macrosomia (hence association with maternal diabetes mellitus) high maternal body mass index diabetes mellitus prolonged labour
Management of shoulder distocia
Senior help should be called as soon as shoulder dystocia is identified and McRoberts’ manoeuvre should be performed:
this manoeuvre entails flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen
this rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery.
An episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres. Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options. Oxytocin administration is not indicated in shoulder dystocia.
Levonorgestrel
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
should be taken as soon as possible - efficacy decreases with time
must be taken within 72 hours of unprotected sexual intercourse (UPSI)*
single dose of levonorgestrel 1.5mg (a progesterone)
the dose should be doubled for those with a BMI >26 or weight over 70kg
84% effective is used within 72 hours of UPSI
levonorgestrel is safe and well-tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 3 hours then the dose should be repeated
can be used more than once in a menstrual cycle if clinically indicated
hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception
Ulipristal
a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
concomitant use with levonorgestrel is not recommended
Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
caution should be exercised in patients with severe asthma
repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle
breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
Intrauterine device (IUD)
a copper IUD is the most effective method of emergency contraception and should be offered to all women if they meet the criteria
if the criteria for insertion of a copper IUD are not met or is not acceptable to the woman, oral emergency contraception should be considered
in practice the vast majority of women choose oral emergency contraception, but it is important to offer the choice to all women given how effective copper IUDs are
must be inserted within 5 days of UPSI, or
if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
may inhibit fertilisation or implantation
prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
is 99% effective regardless of where it is used in the cycle
may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
Intrahepatic cholestasis of pregnancy
Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) affects around 1% of pregnancies in the UK. It is associated with an increased risk of premature birth.
Features
pruritus - may be intense - typical worse palms, soles and abdomen
clinically detectable jaundice occurs in around 20% of patients
raised bilirubin is seen in > 90% of cases
Management
induction of labour at 37-38 weeks is common practice but may not be evidence based
ursodeoxycholic acid - again widely used but evidence base not clear
vitamin K supplementation
Recurrence of intrahepatic cholestasis of pregnancy is 45-90% in subsequent pregnancies.
Complete hydatidiform mole
Features
vaginal bleeding
uterus size greater than expected for gestational age
abnormally high serum hCG
ultrasound: ‘snow storm’ appearance of mixed echogenicity
short episodes (< 40 minutes) of decreased variability on CTG
foetus is asleep.
However, if the decreased variability lasts for more than 40 minutes, we start to worry. Other causes of decreased variability in foetal heart rate on CTG are due to maternal drugs (such as benzodiazepines, opioids or methyldopa - not paracetamol), foetal acidosis (usually due to hypoxia), prematurity (< 28 weeks, which is not the case here), foetal tachycardia (> 140 bpm, again not the case here) and congenital heart abnormalities.
Monitoring in Labour
FHR monitored every 15min (or continuously via CTG)
Contractions assessed every 30min
Maternal pulse rate assessed every 60min
Maternal BP and temp should be checked every 4 hours
VE should be offered every 4 hours to check progression of labour
Maternal urine should be checked for ketones and protein every 4 hours
Eclampsia may be defined as the development of seizures in association pre-eclampsia. To recap, pre-eclampsia is defined as:
condition seen after 20 weeks gestation
pregnancy-induced hypertension
proteinuria
Magnesium sulphate is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop. Guidelines on its use suggest the following:
should be given once a decision to deliver has been made
in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload
Vaginal candidiasis
Vaginal candidiasis (‘thrush’) is an extremely common condition which many women diagnose and treat themselves. Around 80% of cases of Candida albicans, with the remaining 20% being caused by other candida species.
The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop: diabetes mellitus drugs: antibiotics, steroids pregnancy immunosuppression: HIV
Features of vaginal candida infection
Features
‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen
Management of vaginal candidiasis
Management
options include local or oral treatment
local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
Recurrent vaginal candidiasis
BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
compliance with previous treatment should be checked
confirm the diagnosis of candidiasis
high vaginal swab for microscopy and culture
consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus
consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
Vesicovaginal fistulae
should be suspected in patients with continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services.
Indications of induction of labour
Indications
prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start
diabetic mother > 38 weeks
pre-eclampsia
rhesus incompatibility
Endometrial cancer
is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection
The risk factors for endometrial cancer are as follows
obesity nulliparity early menarche late menopause unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously diabetes mellitus tamoxifen polycystic ovarian syndrome hereditary non-polyposis colorectal carcinoma
Features of endometrial cancer
postmenopausal bleeding is the classic symptom
premenopausal women may have a change intermenstrual bleeding
pain and discharge are unusual features
Expectant management for ectopic pregnancy
Indications: Low b HCG, no symptoms, tubal ectopic pregnancy measuring less than 35 mm with no heartbeat
INdications for medical management for ectopic pregnancy
The National Institute for Health and Care Excellence (NICE) states that if a woman has a small (<35mm) unruptured ectopic pregnancy with no visible heartbeat, a serum B-hCG level of <1500 IU/L, no intrauterine pregnancy and no pain, then first line treatment should be with methotrexate as long as the patient is willing to attend for follow-up.
Methotrexate
antimetabolite chemotherapeutic drug. It interferes with DNA synthesis and disrupts cell multiplication thus preventing the pregnancy from developing.
Surgical management of ectopic
laparoscopic salpingectomy (or salpingotomy where there is risk of infertility). This should be offered where the ectopic is larger than 35mm, is causing severe pain or if the B-hCG level is >1500. There is a risk of infertility if a problem arises with the remaining Fallopian tube in the future.
Pregnancy anaemia cut off to get iron therapy
First trimester <110 g/L
Second/third <105 g/L
Postpartum <100 g/L
Management: oral ferrous sulfate or ferrous fumarate treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished
Pre-eclempsia
New-onset blood pressure of >140/90 mmHg after 20 weeks of pregnancy, AND 1 of the following:
- proteinuria
- organ involvement (renal insufficiency (creatinine >90 umol/L), liver, neurological, haematological, uteroplacental dysfunction)
Consequences of pre-eclempsia
eclampsia
other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
fetal complications
intrauterine growth retardation
prematurity
liver involvement (elevated transaminases)
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure
Severe pre-eclempsia
hypertension: typically > 160/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
HIgh risk factors for pre-eclemspia
hypertensive disease in a previous pregnancy
chronic kidney disease
autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension
Moderate risk factors for pre-eclempsia
first pregnancy age 40 years or older pregnancy interval of more than 10 years body mass index (BMI) of 35 kg/m² or more at first visit family history of pre-eclampsia multiple pregnancy
Reducing the risk of hypertensive disorders in pregnancy
women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth
≥ 1 high risk factors
≥ 2 moderate factors
Management: Initial assessment of anyone suspected to have pre-eclempsia
NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
Further management of pre-eclemspia
oral labetalol is now first-line following the 2010 NICE guidelines.
Nifedipine (e.g. if asthmatic) and hydralazine may also be used
delivery of the baby is the most important and definitive management step.
The timing depends on the individual clinical scenario
Down’s syndrome: antenatal testing
the combined test is now standard
nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)
these tests should be done between 11 - 13+6 weeks
Down’s syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower
if women book later in pregnancy either the triple or quadruple test should be offered between 15 - 20 weeks
triple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin
quadruple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin-A
Rhesus negative pregnancy
A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies
along with the ABO system the Rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus system
around 15% of mothers are rhesus negative (Rh -ve)
if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur
this causes anti-D IgG antibodies to form in mother
in later pregnancies these can cross placenta and cause haemolysis in fetus
this can also occur in the first pregnancy due to leaks
Prevention rhesus neg mums
test for D antibodies in all Rh -ve mothers at booking
NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks
the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used ‘depending on local factors’
anti-D is prophylaxis - once sensitization has occurred it is irreversible
if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present
Ovarian cancer
Ovarian cancer is the fifth most common malignancy in females. The peak age of incidence is 60 years and it generally carries a poor prognosis due to late diagnosis.
Pathophysiology
around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas
interestingly, it is now increasingly recognised that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers
Risk factors
family history: mutations of the BRCA1 or the BRCA2 gene
many ovulations*: early menarche, late menopause, nulliparity
Clinical features are notoriously vague abdominal distension and bloating abdominal and pelvic pain urinary symptoms e.g. Urgency early satiety diarrhoea
Investigations
CA125
NICE recommends a CA125 test is done initially. Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level
if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered
a CA125 should not be used for screening for ovarian cancer in asymptomatic women
ultrasound
Diagnosis is difficult and usually involves diagnostic laparotomy
Management
usually a combination of surgery and platinum-based chemotherapy
Prognosis
80% of women have advanced disease at presentation
the all stage 5-year survival is 46%
*It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.
Risk malignancy index (RMI) prohnosis in ovarian cancer is based on
- US findings
- Menopausal status
- CA125 levels
COCP
If 1 pill is missed (at any time in the cycle)
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
f 2 or more pills missed
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
Differentiate cholestasis of pregnancy from fatty liver of pregnancy
Cholestasis of pregnancy
- severe pruritis
Acute fatty liver of pregnancy has predominantly non-specific symptoms (e.g. malaise, fatigue, nausea).
Intrahepatic cholestasis of pregnancy
- generally seen in third trimester
- most common liver disease in pregnancy
- Features: Pruritus, no rash, raised bilirubin
Management of cholestasis of pregnancy
- ursodeoxycholic acid
- LFT monitoring weekly
- Women typically induced at 37 weeks
- Increased rate of stillbirth
Acute fatty liver of pregnancy
Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery.
Features abdominal pain nausea & vomiting headache jaundice hypoglycaemia severe disease may result in pre-eclampsia
ALT is typically elevated to 500 u/l
Acute fatty liver of pregnancy management
- support care
- once stabilised delivery is the definitive management
HELLP
Haemolysis
Elevated Liver enzymes
Low Platelets
Management for intrauterine fibroids
Conservative:
Asymptomatic - no treament needed - perioidc review to monitor size and growth
Managemet of menorrhagia secondary to fibroids:
- levonorgestrel intrauterine system (LNG-IUS)
(useful if women also requires contraception - cannot be used if distortion in uterine cavity)
- NSAIDS (mefenamic acid)
- tranexamic acid
- COCP
- Oral progesterone
- Injectable progesterone
Treatment to shrink fibroids:
- Medical
GnRH agonists to reduce the size of the fibroids shrt-term
- Surgical Myomectomy Hysteroscopic endometrial ablation Hysterectomy Uterine artery embolisation
FIBROIDS prognosis and complications
Fibroids generally regress after the menopause.
Some of the complications such as subfertility and iron-deficiency anaemia have been mentioned previously.
Other complications
red degeneration - haemorrhage into tumour - commonly occurs during pregnancy
Complete hydatidiform mole
Features
vaginal bleeding
uterus size greater than expected for gestational age
abnormally high serum hCG
ultrasound: ‘snow storm’ appearance of mixed echogenicity
Trisomy 21 - Down syndrome
The following results would be expected in a trisomy 21 (Down’s syndrome) pregnancy:
Low alpha fetoprotein (AFP)
Low oestriol
High human chorionic gonadotrophin beta-subunit (-HCG)
Low pregnancy-associated plasma protein A (PAPP-A)
Thickened nuchal translucency
Ovarian tumours 4 types
surface derived tumours
germ cell tumours
sex cord-stromal tumours
metastasis
Ovarian tumours =
Surface derived tumours
These account for around 65% of ovarian tumours, including the greatest number of malignant tumours.
Serous cystadenoma
Hormone replacement therapy (HRT)
- involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.
Side-effects
nausea
breast tenderness
fluid retention and weight gain
Hormone replacement therapy: adverse effects
Potential complications
increased risk of breast cancer
increased by the addition of a progestogen
in the Women’s Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
the increased risk relates to the duration of use
the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
increased risk of endometrial cancer
oestrogen by itself should not be given as HRT to women with a womb
reduced by the addition of a progestogen but not eliminated completely
the BNF states that the additional risk is eliminated if a progestogen is given continuously
increased risk of venous thromboembolism
increased by the addition of a progestogen
transdermal HRT does not appear to increase the risk of VTE
NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal)
increased risk of stroke
increased risk of ischaemic heart disease if taken more than 10 years after menopause
Amenorrhoea
primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
Primary amenorrhoea
gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
testicular feminisation
congenital malformations of the genital tract
functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
congenital adrenal hyperplasia
imperforate hymen
Secondary amenorrhoea (after excluding pregnancy)
hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
Investigation and management of amenorrhea
Initial investigations
exclude pregnancy with urinary or serum bHCG
full blood count, urea & electrolytes, coeliac screen, thyroid function tests
gonadotrophins
low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
raised if gonadal dysgenesis (e.g. Turner’s syndrome)
prolactin
androgen levels
raised levels may be seen in PCOS
oestradiol
Management
primary amenorrhoea:
investigate and treat any underlying cause
with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner’s syndrome) are likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etC)
secondary amenorrhoea
exclude pregnancy, lactation, and menopause (in women 40 years of age or older)
treat the underlying cause
*hypothyroidism may also cause amenorrhoea
Ashermanns
Asherman’s syndrome, or intrauterine adhesions, may occur following dilation and curettage. This may prevent the endometrium responding to oestrogen as it normally would.
Sheehans syndrome
Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock.
Features may include: agalactorrhoea amenorrhoea symptoms of hypothyroidism symptoms of hypoadrenalism
Hypothalamic amenorrhoea
For many women, the cause of irregular or absent menstruation is functional hypothalamic amenorrhea (FHA). FHA is a hormonal imbalance related to stress, exercising too much or consuming too few calories (like with an eating disorder).
Congenital adrenal hyperplasia
Congenital adrenal hyperplasia (CAH) refers to a group of genetic disorders that affect the adrenal glands, a pair of walnut-sized organs above the kidneys. The adrenal glands produce important hormones, including: Cortisol, which regulates the body’s response to illness or stress.
Congenital adrenal hyperplasia (CAH) refers to a group of genetic disorders that affect the adrenal glands, a pair of walnut-sized organs above the kidneys. The adrenal glands produce important hormones, including: Cortisol, which regulates the body’s response to illness or stress.
Polycystic ovarian syndrome: management
Polycystic ovarian syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. Management is complicated and problem based partly because the aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.
Cervical ectropion
On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix
The term cervical erosion is used less commonly now
This may result in the following features
vaginal discharge
post-coital bleeding
Twin pregnancies
The incidence of multiple pregnancies is as follows
twins: 1/105
triplets: 1/10,000
Twins may be dizygotic (non-identical, develop from two separate ova that were fertilized at the same time) or monozygotic (identical, develop from a single ovum which has divided to form two embryos). Around 80% of twins are dizygotic
Monoamniotic monozygotic twins are associated with:
increased spontaneous miscarriage, perinatal mortality rate
increased malformations, IUGR, prematurity
twin-to-twin transfusions: recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)
The rate of monozygotic twins is fairly constant. The incidence of dizygotic twins is increasing mainly due to infertility treatment. Predisposing factors for dizygotic twins include:
previous twins
family history
increasing maternal age
multigravida
induced ovulation and in-vitro fertilisation
race e.g. Afro-Caribbean
Antenatal complications polyhydramnios pregnancy induced hypertension anaemia antepartum haemorrhage
Fetal complications - perinatal mortality (twins * 5, triplets * 10)
prematurity (mean twins = 37 weeks, triplets = 33)
light-for date babies
malformation (*3, especially monozygotic)
Labour complications
PPH increased (*2)
malpresentation
cord prolapse, entanglement
Management
rest
ultrasound for diagnosis + monthly checks
additional iron + folate
more antenatal care (e.g. weekly > 30 weeks)
precautions at labour (e.g. 2 obstetricians present)
75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks
Premature ovarian failure
Premature ovarian failure can be diagnosed in women less than 40 years of age with menopausal like symptoms and increased levels of FSH measured twice with at least a month between measurements. There are numerous causes, it can be inherited such as in cases of fragile X syndrome or acquired for example from radiation exposure. In premature ovarian failure, the pituitary responds to low levels of oestrogen by increasing the production of gonadotropins in an attempt to stimulate the production of oestradiol in the ovary but fails to do so. Caroline’s case does not display these features.
Venous thromboembolism in pregnancy
Pregnancy is a risk factor for developing venous thromboembolism (VTE). By assessing a womans individual risk during pregnancy then appropriate prophylactic measures can be initiated. A risk assessment should be completed at booking and on any subsequent hospital admission.
A woman with a previous VTE history is automatically considered high risk and requires low molecular weight heparin throughout the antenatal period and also input from experts.
A woman at intermediate risk of developing VTE due to hospitalisation, surgery, co-morbidities or thrombophilia should be considered for antenatal prophylactic low molecular weight heparin.
The assessment at booking should include risk factors that increase the womans likelihood of developing VTE. These risk factors include: Age > 35 Body mass index > 30 Parity > 3 Smoker Gross varicose veins Current pre-eclampsia Immobility Family history of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy
Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal. If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.
Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy. Direct Oral Anticoagulants (DOACs) and warfarin should be avoided in pregnancy.
Hyperemesis gravidarum
Whilst the majority of women experience nausea (previously termed ‘morning sickness’) during the early stages of pregnancy it can become problematic in a minority of cases. The Royal College of Obstetricians and Gynaecologists (RCOG) now use the term ‘nausea and vomiting of pregnancy’ (NVP) to describe troublesome symptoms, with hyperemesis gravidarum being the extreme form of this condition.
It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks*.
Associations multiple pregnancies trophoblastic disease hyperthyroidism nulliparity obesity
Smoking is associated with a decreased incidence of hyperemesis.
Chorioamnionitis
Chorioamnionitis (which can affect up to 5% of all pregnancies) is a potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency. It is usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta. The major risk factor in this scenario is the preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens. Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.
Ruptured ovarian cyst
- sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity
fetal movements starts
Generally women can feel their babies move around 18-20 weeks, but this can be earlier especially in multiparous women. Reduced fetal movements can be a worrying sign of fetal distress and hypoxia. While singular episodes can often be harmless, they can also be an indication of stillbirths and restricted growth. Absent movements is very concerning and requires further investigation. The 24 week cut off is set by the Royal College of Obstetricians and Gynaecologists (RCOG).
Fetal movement
Fetal movements are usually based solely on maternal perception, though it can also be objectively assessed using handheld Doppler or ultrasonography.
As per RCOG Green-top guidelines, investigations are dependent of gestation at onset of RFM.
If past 28 weeks gestation:
Initially, handheld Doppler should be used to confirm fetal heartbeat.
If no fetal heartbeat detectable, immediate ultrasound should be offered.
If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise.
If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used. Ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement
If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat.
If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used.
If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.
If RFM are recurrent, further investigations are also required to consider structural or genetic fetal abnormalities.
HRT
UNOPPOSED OESTROGEN INCREASES RISK OF ENDOMETRIAL CANCER
GESTATIONAL DIABETES NOT MEETING TARGETS ON DIET/METFORMIN
Pregnant women with GDM should be advised to maintain their CBGs below the following target levels: fasting: 5.3mmol/L AND 1 hour postprandial: 7.8 mmol/L or 2 hours postprandial: 6.4 mmol/L
If these targets are not met with diet, exercise and metformin, then insulin should be offered as add-on therapy.
Combined oral contraceptive pill: missed pill
The advice from the Faculty of Sexual and Reproductive Healthcare (FSRH) has changed over recent years. The following recommendations are now made for women taken a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol
If 1 pill is missed (at any time in the cycle)
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
If 2 or more pills missed
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
Placenta praevia vs placental abruption
The bleeding associated with placenta praevia is painless and usually bright red. Meanwhile the bleeding associated with placental abruption is associated with pain and is usually dark red. The pattern of previous bleeding also favours placenta praevia. Though vasa praevia can also present with painless vaginal bleeding other expected features would include fetal bradycardia and membrane rupture.
HELLP
Haemolysis, elevated liver enzymes and low platelets
Vulval carcinoma
Around 80% of vulval cancers are squamous cell carcinomas. Most cases occur in women over the age of 65 years. Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year.
Other than age, risk factors include: Human papilloma virus (HPV) infection Vulval intraepithelial neoplasia (VIN) Immunosuppression Lichen sclerosus
Features
lump or ulcer on the labia majora
inguinal lymphadenopathy
may be associated with itching, irritation
ABdo pain Obs and gyn
The history of tearing pain and haemodynamic compromise in a women of child bearing years should prompt a diagnosis of ectopic pregnancy.
Medication that is a risk factor for endometrial hyperplasia
Tamoxifen
Endometrial hyperplasia develops due to the presence of unopposed oestrogen. Oestrogen stimulates endometrial growth while progesterone stimulates shedding of this tissue.
Tamoxifen is used for oestrogen receptor-positive breast cancer, in the breast, it has anti-oestrogenic effects. However, on the endometrium, it has pro-oestrogenic effects. This effect, if unopposed by progesterone, can result in endometrial hyperplasia.
Endometrial hyperplasia
Endometrial hyperplasia may be defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer
Types simple complex simple atypical complex atypical
Features
abnormal vaginal bleeding e.g. intermenstrual
Management
simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
atypia: hysterectomy is usually advised
Hysterectomy
Common long term complications of vaginal hysterectomy with antero-posterior repair include enterocoele and vaginal vault prolapse. Urinary retention may occur acutely following hysterectomy, but it is not usually a chronic complication.
Combined oral contraceptive pill
increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer
increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer
Ovarian cysts: types
Benign ovarian cysts are extremely common. They may be divided into physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours.
Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.
Physiological cysts (functional cysts)
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
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
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
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%
Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei
Transdermal HRT
Transdermal HRT does not appear to increase the risk of VTE (vs. oral)
Drugs to be avoided during breastfeeding
The following drugs should be avoided: antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone
Ovulation
Ovulation disorders are the cause of infertility in approximately one-quarter of couples who have difficulty conceiving naturally, and whilst ovulation may occur sometimes, natural spontaneous conception is usually unlikely. Therefore, for these couples, ovulation induction is often required and will typically depend on the cause of anovulation in the first place.
Normal ovulation requires the close functioning of a number of positive and negative feedback loops between the hypothalamus, pituitary gland and ovaries
The early follicular phase requires an increase in gonadotropin-releasing hormone (GnRH) pulse frequency which increases the release of follicle-stimulating hormone (FSH) and luteinising hormone (LH), to allow for stimulation and development of multiple ovarian follicles, and usually only one of which will become the dominant ovulatory follicle in that menstrual cycle.
In the mid-follicular phase, FSH gradually stimulates estradiol production, following which estradiol itself produces a negative feedback loop on the hypothalamus and pituitary gland to suppress FSH and LH concentrations.
In the luteal phase, there is a unique switch from negative to positive feedback of estradiol, resulting in a surge of LH secretion and this leads to subsequent follicular rupture and ovulation.
Categories of ovulatory disorders
Before understanding the process of ovulation induction, it is paramount to understand the main causes of ovulatory dysfunction first There are three main categories of anovulation: Class 1 (hypogonadotropic hypogonadal anovulation) - notably hypothalamic amenorrhoea (5-10% of women) Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome (80% of cases) Class 3 (hypergonadotropic hypoestrogenic anovulation) - premature ovarian insufficiency (5-10% of cases). In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive
Goals of ovulation induction
It is ideal to start with the least invasive and simplest management option first, and work the way up to more complicated and intensive treatment
For most women, it is the goal to induce mono-follicular development and subsequent ovulation as opposed to multi-follicular development, and this is to ultimately lead to a singleton pregnancy, which tends to be far lower risk and therefore preferable
Forms of ovulation induction
Exercise and weight loss
Typically this is the first-line treatment for patients with polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest 5% weight loss
Therefore, particularly for overweight or obese women with polycystic ovarian syndrome, this should be trialled solely first, and then artificial ovulation induction be considered
Letrozole
According to UptoDate, this is now considered the first-line medical therapy for patients with PCOS, due to the reduced risk of adverse effects on endometrial and cervical mucous compared to clomiphene citrate
Mechanism of action: letrozole is an aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development
The rate of mono-follicular development is much higher with letrozole use compared to clomiphene, which is a key goal in ovulation induction
Side effects: fatigue (20%), dizziness (10%)
Clomiphene citrate
While most women with PCOS will respond to clomiphene treatment and ovulate (80% of women), the rates of live birth are higher with letrozole therapy, hence why it has become a first-line treatment instead
Mechanism of action: clomiphene is a selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development
Side effects: hot flushes (30%), abdominal distention and pain (5%), nausea and vomiting (2%)
Gonadotropin therapy This tends to be the treatment used mostly for women with class 1 ovulatory dysfunction, notably women with hypogonadotropic hypogonadism For women with PCOS, this tends to be only considered after attempt with other treatments has been unsuccessful, usually after weight loss, letrozole and clomiphene trial This is because the risk of multi-follicular development and subsequent multiple pregnancy is much higher, as well as increased risk of ovarian hyperstimulation syndrome Mechanism of action: pulsatile GnRH therapy involves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump, leading to endogenous production of FSH and LH and subsequent follicular development
Ovarian hyperstimulation syndrome
Ovarian hyperstimulation syndrome (OHSS) is one of the potential side effects of ovulation induction, and unfortunately can be life-threatening if not identified and managed promptly
In OHSS, ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space, which has the potential to result in multiple life-threatening complications including:
Hypovolaemic shock
Acute renal failure
Venous or arterial thromboembolism
This is a rare side effect which varies in severity, with the risk of severe OHSS occurring in less than 1% of all women undergoing ovarian induction
Depending on the severity, the management includes:
Fluid and electrolyte replacement
Anti-coagulation therapy
Abdominal ascitic paracentesis
Pregnancy termination to prevent further hormonal imbalances
Puerperal pyrexia
Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.
Causes: endometritis: most common cause urinary tract infection wound infections (perineal tears + caesarean section) mastitis venous thromboembolism
Management
if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
cocp
Combined oral contraceptive pill
increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer
This is a commonly asked question in obstetric operating theatres or in surgical vivas. A clear confident answer demonstrates a good knowledge of local anatomy and what structures need to be incised before reaching the fetus. During a lower segment Caesarian section, the following lies in between the skin and the fetus:
Superficial fascia Deep fascia Anterior rectus sheath Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba) Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus
