Obs and Gynae Flashcards
Define Pelvic Organ Prolapse?
Descent of the pelvic organs into the vagina.
What is the pathology of a Prolapse?
The result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.
What types of prolapse can result from a weakness in the Apical Vaginal Wall?
- Uterine prolapse
- Vaginal Vault Prolapse
what is a Uterine Prolapse?
Where the uterus itself descends into the vagina
What is a Vaginal Vault Prolapse?
Occurs in women that have had a hysterectomy and no longer have a uterus.
The top of the vagina (the vault) descends into the vaginal canal
What types of Prolapse can result from a weakness in the Posterior Vaginal Wall?
- Enterocele
- Rectocele
What is an Enterocele?
Defect in the posterior vaginal wall allowing the small intestine to prolapse forwards into the vagina
What is a Rectocele?
Defect in the posterior vaginal wall allowing the rectum to prolapse forwards into the vagina
What type of prolapse can result from a weakness in the Anterior Vaginal Wall?
- Cystocele
- Urethrocele
- Cystourethrocele
What is a Cysteocele?
Prolapse of the bladder backwards into the vagina due to a defect in the anterior vaginal wall
What is a Urethrocele?
Prolapse of the Urethra backwards into the vagina due to a defect in the anterior vaginal wall
What is a Cystourethrocele?
Prolapse of both the bladder and the urethra into the vagina through the anterior vaginal wall.
What is the Epidemiology of Pelvic Organ Prolapse?
- Common condition
- More common in Postmenopausal women
- More common in those who have undergone childbirth
- Prevalence increases with age
What are some risk factors for developing pelvic organ prolapse?
- Multiple vaginal deliveries
- Increasing age
- Instrumental, prolonged or traumatic delivery
- Hysterectomy
- Advanced age and postmenopausal status
- Obesity
- Chronic respiratory disease causing coughing
- Chronic constipation causing straining
- Heavy lifting
- Connective tissue disorders
What are the clinical features of a pelvic organ prolapse?
Depend on the type and severity
- Pelvic discomfort or Sensation of Heaviness or Sensation of something coming down
- Visible protrusion of tissue from the vagina
- Urinary Symptoms such as Incontinence, recurrent UTIs or voiding difficulties
- Defecatory symptoms such as Constipation or incomplete bowel emptying
- Sexual Dysfunction
- Women may notice a lump or mass that they will often push back up themselves.
What clinical features are Rectoceles particularly associated with?
Constipation
- Women can develop Faecal loading in the part of the rectum that ha prolapsed.
- This may lead to significant constipation and urinary retention
What are some differential diagnoses for pelvic organ prolapse?
- Gynaecologic malignancy: associated with abnormal vaginal bleeding, weight loss, and pelvic pain
- Cervicitis: characterized by vaginal discharge, bleeding, and pelvic pain
- Urethral diverticulum: presents with dysuria, recurrent UTIs, and a palpable anterior vaginal mass
What are the investigations for a Pelvic Wall Prolapse?
Detailed Pelvic Examination
- Left lateral or Dorsal position
- Sim’s Speculum
- Ask the woman to cough or bear down
Imaging Studies
- Ultrasound or MRI
Urodynamic Studies
What is used to examine the pelvis when investigating for Pelvic organ prolapse?
Sim’s Speculum
- U shaped speculum that is used to support the anterior or posterior vaginal wall whilst the other walls are examined.
- Women are asked to cough or bear down to assess the full decent of the prolapse.
- Dorsal and Left Lateral position are used.
How is a uterine prolapse graded?
Pelvic organ prolapse quantification system (POP-Q):
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
A prolapse extending beyond the introitus can be referred to as uterine procidentia.
What is the management for Pelvic Organ Prolapse?
If asymptomatic or Mild prolapse then Conservative only
- Conservative management:
- Physiotherapy (pelvic floor exercises)
- Weight loss
- Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
- Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
- Vaginal oestrogen cream
- Vaginal Pessaries: Inserted into the vagina to provide extra support to the pelvic organs.
- Surgery: Definitive option for treating Pelvic organ prolapse but must consider the risk and benefits of each individual.
What conservative management options are there for Pelvic Organ Prolapse?
- Physiotherapy (pelvic floor exercises)
- Weight loss
- Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
- Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
- Vaginal oestrogen cream
What are some options for Vaginal Pessaries?
- Ring pessaries are a ring shape, and sit around the cervix holding the uterus up
- Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
- Cube pessaries are a cube shape
- Donut pessaries consist of a thick ring, similar to a doughnut
- Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.
What is some key information about Vaginal Pessaries?
- Should be removed and cleaned or changed periodically (every 4 months)
- Can cause vaginal irritation and erosion over time
- Oestrogen cream helps protect the vaginal walls from irritation
What are some possible complications of Pelvic Organ Prolapse Surgery?
- Pain, bleeding, infection, DVT and risk of anaesthetic
- Damage to the bladder or bowel
- Recurrence of the prolapse
- Altered experience of sex
Define Urinary Incontinence?
Involuntary passage of urine
Define Overactive Bladder Syndrome?
A chronic condition that results rom hyperactivity of the detrusor muscle. This is primarily characterised by urinary urgency and urge incontinence
What are the clinical features of Overactive Bladder Syndrome?
- Urinary Urgency
- Urge Incontinence
- Frequency
- Nocturia
What is a typical presentation of Overactive Bladder syndrome and Urge incontinence?
- Typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs.
- Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access.
- This can have a significant impact on their quality of life, and stop them doing work and leisure activities.
What are some differential diagnoses for Overactive Bladder Syndrome?
- Urinary tract infections: Characterised by dysuria, urgency, frequency, suprapubic pain and haematuria.
- Bladder stones: Symptoms include lower abdominal pain, dysuria, intermittent stream, and blood in the urine.
- Interstitial cystitis: Presents with symptoms such as chronic pelvic pain, a persistent, urgent need to urinate, and frequent urination.
- Diabetic neuropathy: Can cause bladder dysfunction, resulting in symptoms like frequent urination and incontinence.
What are the investigations for Overactive Bladder Syndrome?
- Urinalysis and culture: To rule out infection
- Frequency/volume chart: To assess the severity of the condition
- Urodynamics: To evaluate bladder muscle function
What is the management for Overactive Bladder Syndrome?
First Line: For at least 6 weeks:
- Bladder retraining: Which aims to increase the interval between voids, and suppress the urinary urge
- Behavioural modifications: Such as reducing oral fluid intake, and avoiding caffeine and alcohol
Second Line:
- Anticholinergic drugs: Like oxybutynin, Tolterodine and solifenacin
- Mirabegron: An alternative to anticholinergics
- Vaginal oestrogens: Used if urogenital atrophy is a likely contributory factor
Invasive options when medical treatments fail
- Botulism toxin: Used specifically for refractory cases
Give some anticholinergic drugs used to treat an Overactive Bladder?
- Oxybutynin
- Tolterodine
- Solifenacin
What are some side effects of Anticholinergic Mediations?
- Dry mouth and eyes
- Urinary Retention
- Constipation
- Postural Hypotension
- Cognitive decline and memory problems
- Worsening of Dementia
What is Mirabegron?
A beta 3 agonist that stimulates the sympathetic nervous system causing relaxation of the bladder.
What is a contraindication of Mirabegron?
Uncontrolled Hypertension.
- Since it stimulates the sympathetic nervous system it can lead to a raised blood pressure and can result in a hypertensive crisis!
- Can also increase the risk of stroke and TIA
What are some examples of Invasive options to treat Overactive Bladder Syndrome when the bladder has failed to respond to medication?
- Botulinum toxin type A injection into the bladder wall
- Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves
- Augmentation cystoplasty involves using bowel tissue to enlarge the bladder
- Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen
Define Urinary Incontinence
The loss of control of urination leading to involuntary passage of urine
What is the Physiology of the Storage phase (filling) of Continence?
Bladder function:
- Detrusor muscle remains relaxed to allow the bladder to fill with urine.
- This relaxation is primarily mediated by the sympathetic nervous system (via the hypogastric nerve, which releases noradrenaline), acting on β-adrenergic receptors in the bladder wall.
Urethral function:
- The internal urethral sphincter (smooth muscle) remains contracted, and the external urethral sphincter (skeletal muscle) maintains voluntary closure, preventing urine leakage.
- The sympathetic system helps keep the internal sphincter closed
- The somatic nervous system (via the pudendal nerve) controls the external sphincter.
Nervous control:
- The pontine storage centre in the brainstem inhibits detrusor contraction during bladder filling
- while sensory signals from the bladder stretch receptors are sent to the brain, indicating fullness without triggering voiding.
What is the Physiology of the Voiding phase of Continence?
Bladder function:
- When the bladder reaches a certain level of fullness, signals from the brain initiate the voiding phase.
- The parasympathetic nervous system (via the pelvic nerve) stimulates the detrusor muscle to contract, increasing pressure in the bladder.
Urethral function:
- At the same time, the internal urethral sphincter relaxes, and the external urethral sphincter voluntarily relaxes to allow urine to flow through the urethra.
Nervous control:
- The pontine micturition centre coordinates this process,
- Bladder contraction and sphincter relaxation.
- Voiding occurs when detrusor pressure overcomes urethral resistance.
Give a summary of the neurology involved in continence?
Sympathetic - T10-L2 hypogastric - detrusor relaxation, IUS closing
- Parasympathetic - S2-4 pelvic splanchnic - detrusor contraction, IUS opening
- Somatic afferent - S2-4 pudendal - sensation of bladder fullness
- Somatic efferent - S2-3 pudendal - closes / opens EUS.
What are the continence mechanisms in response to a raised intra-abdominal pressure?
- Reflexive contraction of the pelvic floor muscles elevates the IUS.
- Augmentation of pelvic floor muscle closure by suspensory ligaments.
- Urethrovaginal sphincter and compressor urethrae muscle contraction assists with urethral closure
What are the different types of Urinary Incontinence?
- Stress incontinence
- Urge incontinence
- Overflow incontinence
- Functional incontinence
- Mixed incontinence
What is Urge incontinence?
Caused by Overactivity of the detrusor muscle.
This is also known as overactive bladder syndrome
What is Stress incontinence?
Leaking of urine when intra-abdominal pressure is raised that puts pressure on the bladder. The pressure overcomes the mechanisms to maintain continence.
This occurs due to weakness of the pelvic floor and sphincter muscles
What are some risk factors for Stress incontinence?
- Childbirth (Especially vaginal)
- Hysterectomy
What are some triggers for Stress incontinence?
Anything that can increase abdominal pressure sufficiently
- Coughing
- Laughing
- Sneezing
- Exercising
What is the management for Stress incontinence?
Lifestyle Advice:
- Avoid caffeine, fizzy and sugary drinks
- Avoid excessive fluid intake
- Pelvic floor exercises (8x contractions x3 per day)
Medical Management:
- Duloxetine (only recommended if conservative management fails and the patient is not a surgical candidate)
Surgical Management:
- Pessaries
- Bulking agents placed at the bladder neck
- Colposuspension and fascial slings
- Mid urethral slings
What is the gold standard treatment for Stress incontinence?
Mid-urethral slings is the gold standard surgical treatment of stress incontinence.
It compresses the urethra against a supportive layer and assists in closing the urethra.
What is Functional incontinence?
Individual has the urge to pass urine but for whatever reason they are unable to access the necessary facilities and are aw a result incontinent.
What are some potential causes of Functional Incontinence?
- Sedating Medications
- Alcohol
- Dementias
What is Overflow incontinence?
Occurs when small amounts of urine leak without warning.
This may happen when the pressure within the bladder overcomes the pressures of the outlet structure and thus urine leaks
What are some causes of Overflow incontinence?
- Underactivity of the detrusor muscle such as from neurological damage
- Urinary outlet pressures are too high Such as in constipation or prostatism
- Chronic urinary retention due to an obstruction.
- Anti-cholinergic medications.
What is Mixed incontinence?
A combination of urge incontinence and stress incontinence.
It is crucial to identify which of the 2 is having the more significant impact and address this first.
What are the investigations of Incontinence?
First Line:
- Medical history and Assessment
- Physical Examination
- Bladder Diary: tracking fluid intake, episodes of urination and incontinence over at least 3 days
- Urinalysis and Urine-Dip stick: To look for infection or other pathology
Second Line:
- Urinary Stress Tests: Cough stress test, empty supine stress test
- Cystometry and Cystogram: Bladder scan to assess for bladder pressures when voiding or fistulas
- Urodynamics
What information should be obtained from a Medical history assessment for Incontinence?
Differentiate between Stress or Urge:
- Urinary leakage with coughing, laughing or sneezing (Stress)
- Urinary leakage due to sudden urge to pass with loss of control (Urge)
Assess for Modifiable lifestyle factors:
- Caffeine consumption
- Alcohol consumption
- Medications (anticholinergics)
- BMI
Assess the Severity:
- Frequency of urination
- Frequency of incontinence
- night-time urination
- Use of pads and changes of clothing.
What should be done during a Physical examination to look for incontinence?
Assessment of Pelvic Tone:
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
Also examine for
- Pelvic organ prolapse
- Atrophic vaginitis
- Urethral diverticulum
- Pelvic masses
- urinary incontinence (asking the patient to cough)
What are the indications for Urodynamic testing?
- Patients with Urge incontinence not responding to first line medical treatments
- Difficulties urinating
- Urinary retention
- Previous surgery in and around the pelvis
- Unclear diagnosis
What is done in Urodynamic testing for incontinence?
- Patients should stop taking anticholinergic and bladder related medications for 5 days before testing.
- A catheter is inserted into the bladder and the rectum and they measure the pressures for comparison. The bladder is filled with liquid and different measurements are taken.
What are each of these measurements for?
- Cystometry
- Uroflowmetry
- Leak Point Pressure
- Poist-void residual bladder volume
- Video urodynamic testing
- Cystometry measures the detrusor muscle contraction and pressure
- Uroflowmetry measures the flow rate
- Leak Point Pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence.
- Poist-void residual bladder volume tests for incomplete emptying of the bladder
- Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.
Define Urolithiasis?
Urinary tract stones or Urolithiasis refer to solid concretions or crystal aggregations formed in the urinary system from substances present in the urine
Define Renal Colic?
A condition characterised by severe pain caused by the presence of a stone in the urinary tract
What is the epidemiology of Urinary tract stones?
- Common condition affecting 2-3% of western population
- More common in males
- More common in people younger than 65
What is the aetiology of renal stones?
Calcium oxalate stones:
- Represent 85% of stones. They are radiopaque, formed in variable urine pH, and majorly linked to hypercalciuria.
Calcium phosphate stones:
- Account for 10% of stones. They are radiopaque and linked to renal tubular acidosis type 1 & 3, leading to increased urine pH and supersaturation of calcium and phosphate in the urine.
Cystine stones:
- Make up 1% of stones. Characterised by a semi-opaque “ground glass” appearance, they result from inherited recessive inborn errors of metabolism causing disruption in cystine transport and decreased absorption from the renal tubule.
Uric acid stones:
- Comprise 5-10 of stones. They are radiolucent, formed due to acid produced from purine metabolism and precipitate when urinary pH is low. They can be linked to diseases causing extensive tissue breakdown.
Struvite stones:
- Account for 2-20% of stones. They are radiopaque and formed from magnesium, ammonium, and phosphate, often associated with chronic UTIs from urease producing bacteria like ureaplasma, proteus.
Indinavir stones:
- Associated with the antiretroviral protease inhibitor Indinavir used in HIV treatment. It can crystallize in renal tubules and result in renal stones. These stones are radiolucent on CTKUB.
What is the most common cause of Renal stones?
Hypercalcaemia/Hypercalciuria
Patients may present with symptoms of hypercalcaemia (renal stones, painful bones, abdominal groans and psychiatric moans)
3 Main causes of Hypercalcaemia:
- Calcium supplementation
- Hyperparathyroidism
- Cancer (Myeloma, Breast, Lung)
What are the risk factors for Nephrolithiasis?
Modifiable risk factors include:
- Obesity
- Dehydration
- Diet rich in oxalate-rich foods like fruits, nuts, and cocoa
Non-modifiable risk factors include:
- Previous stone disease
- Anatomical abnormalities of the collecting system
- Family history
Underlying medical conditions, such as:
- Hyperparathyroidism
- Renal tubular acidosis
- Myeloproliferative disorders
- All chronic diarrhoeal conditions
What is Staghorn Calculus?
Where the stone forms in the shape of the renal pelvis giving it a similar appearance to the antlers of a deer stag.
Often associated with Struvite stones
What are the clinical features of Renal Colic?
- Unilateral Colicky loin to groin pain that can be excruciating (“worse than childbirth”)
- Haematuria
- Nausea or vomiting
- Reduced urine output
- Symptoms of sepsis (Fever), if infection is present
cancerWhat are some differential diagnoses for Renal Colic?
- Pyelonephritis: Presents with fever, flank pain, and urinary symptoms such as frequency, urgency, and dysuria.
- Appendicitis: Presents with right lower quadrant pain, nausea, vomiting, and possibly fever.
- Diverticulitis: Presents with left lower quadrant pain, fever, nausea, vomiting, and changes in bowel habits.
- Ovarian torsion: Presents with acute lower abdominal pain, nausea, vomiting, and sometimes fever.
- Ectopic pregnancy: Presents with lower abdominal pain, vaginal bleeding, and a positive pregnancy test.
- Abdominal aortic aneurysm: Presents with central abdominal pain, pulsatile/expansile abdominal aorta and if ruptured, haemodynamic instability.
What are the investigations for Renal Colic?
Bedside investigations:
- Urinalysis to detect haematuria
- Urine MC+S as there may be a co-existing infection/precipitant.
- Observations to look for any signs of sepsis
Blood tests:
- Full Blood Count to detect any inflammatory response
- Urea and Electrolytes to assess any impairment in renal function.
- Calcium & Uric acid to identify underlying metabolic conditions predisposing to stone formation.
Radiological investigations:
- A non-contrast helical CT KUB, the gold standard for identifying renal calculi.
- An x-ray for managing renal colic if there’s a confirmed stone on CT KUB, necessary for the use of extracorporeal shockwave lithotripsy.
What is the initial and gold standard investigation for Renal Colic?
Non-contrast CT Kidney, Ureter and Bladder (CTKUB) is both the initial and Gold standard investigation
- NICE recommend a CT within 24 hours of presentation
- BAUS recommend a CT within 14 hours of admission
What is the management for Renal Colic?
- Analgesia: NSAIDs such as IM Diclofenac
- Anti-emetics: Metoclopramide, Cyclizine
- Antibiotics: If infection is present
- Medical Expulsive Therapy: Uses Tamsulosin to help passage of distal ureter stones < 5mm
- Watchful Waiting: If stones are less than 5mm
- Surgical Intervention: required in larger stones 10mm or more or ones that do not pass spontaneously. Also required if there is complete obstruction or infection.
What are some surgical options for Renal Colic?
Stones < 2cm
- Extracorporeal shockwave lithotripsy (ESWL): shock waves fragment the stone to then be passed
- Ureteroscopy: Treatment of choice for middle or distal ureteric stones and for Pregnant women
Stones > 2cm
- Percutaneous nephrolithotomy: for large stones or complex calculi like staghorn or cysteine.
- Open Stone surgery: when other options have failed.
What is a complication of renal stones?
- Significant risk of recurrent episodes
- Obstructive infection
- Sepsis
- Renal Failure
What advice can be given to reduce the risk of recurrent stones?
- Increase oral fluid intake (2.5 – 3 litres per day)
- Add fresh lemon juice to water (citric acid binds to urinary calcium reducing the formation of stones)
- Avoid carbonated drinks (cola drinks contain phosphoric acid, which promotes calcium oxalate formation)
- Reduce dietary salt intake (less than 6g per day)
- Maintain a normal calcium intake (low dietary calcium might increase the risk of kidney stones)
Define Oligomenorrhea?
Infrequent/irregular menstrual periods (fewer than 6-8 per year)
Define Amenorrhoea?
Primary
Secondary
Absence of a menstrual period
Primary: absence of a period at age 15 in the presence of normal secondary sexual characteristics or at age 13 with no secondary sexual characteristics
Secondary: Absence of a period for 3 consecutive cycles in a women with a previously established menstrual cycle
What are some causes of Primary Amenorrhoea?
- Constitutional delay (Familial)
- Imperforate hymen
- Endocrinological: Hypo-hyperthyroidism, Hyperprolactinaemia, Cushing’s Syndrome
- Androgen Insensitivity Syndrome
- Turners syndrome
What are some causes of Secondary Amenorrhoea?
- Pregnancy (most common cause)
- Breastfeeding
- Menopause
- Intrauterine adhesions leading to outflow tract obstruction (Asherman’s syndrome)
- Polycystic ovary syndrome (PCOS)
- Drug-induced amenorrhoea (e.g. contraceptive use)
- Functional Hypothalamic Amenorrhoea: Physical stress, excess exercise, and weight loss
- Pituitary gland pathology: such as Sheehan syndrome or hyperprolactinaemia
- Hypothyroidism or hyperthyroidism
Define Androgen Insensitivity Syndrome?
An X-linked Recessive genetic condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors This results in Genetic Males with a Female Phenotype
What is the pathophysiology of Androgen Insensitivity Syndrome?
- Mutation in Androgen receptor gene on the X chromosome results in cells becoming unable to respond to androgens.
- Excess androgens are converted to Oestrogen resulting in female secondary sexual characteristics
(Previously known as Testicular feminisation syndrome) - Males are genetically XY with a female phenotype
What is the anatomy of a patient with Androgen Insensitivity Syndrome?
- Female External Genitalia and Breast Development
- Testes located within the abdomen or inguinal canal.
- Absence of Female internal organs (Uterus, upper vagina, cervix, fallopian tubes and ovaries) due to the testes producing anti-Mullerian hormone.
- Patients are taller than female average, with a lack of pubic hair, facial hair and male type muscle bulk.
What is a risk of patients with Androgen Insensitivity Syndrome?
High risk of Testicular cancer unless the testes are removed
What is the Presentation of Androgen Insensitivity Syndrome?
- Often presents in infancy with Inguinal hernias containing testes
- May present at puberty with Primary Amenorrhoea
What are the investigations for Primary Amenorrhoea?
Exclude pregnancy with urinary or serum bHCG
Full blood count - anaemia
Urea & electrolytes
Coeliac screen
Thyroid function tests
Gonadotrophins (LH/FSH):
- 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 for Hyperprolactinaemia
Androgen levels
- Raised levels may be seen in PCOS
Oestradiol
Second Line:
- Genetic Testing: Identify chromosomal or genetic abnormalities
- Imaging: To identify structural abnormalities
What are the results of hormonal tests in Androgen Insensitivity Syndrome?
- Raised LH
- Normal or raised FSH
- Normal or Raised Testosterone levels (For a male)
- Raised Oestrogen levels (For a male)
What is the management of Primary Amenorrhoea?
Depends on the underlying cause
- Hormone replacement therapy: For hormonal imbalances
- Surgery: For structural abnormalities
- Psychological support: For conditions related to stress or eating disorders
- Lifestyle modifications: For issues related to excessive exercise or low body weight
- Monitoring and regular follow-ups: To assess effectiveness of treatment and adjust as necessary
What is the management of Androgen Insensitivity Syndrome?
MDT Specialist Coordination: Paediatrics, Gynaecology, Urology, Endocrinology, Clinical Psychology
- Bilateral Orchiectomy: To avoid testicular tumours
- Oestrogen Therapy
- Vaginal Dilators or Vaginal Surgery: To create and adequate length vagina
Generally patients are raised as female but this is tailored to the individual
What is responsible for the embryological development of the upper vagina, cervix, uterus and fallopian tubes?
They develop from the paramesonephric ducts (Mullerian ducts)
Why do males not develop female gentalia?
The testes in a male foetus produce Anti-Mullerian hormone which suppresses the growth of the paramesonephric ducts and so they do not form.
What ae some Congenital structural Abnormalities for the Female Reproductive Tract?
- Bicornuate Uterus
- Uterus Agenesis
- Imperforate Hymen
- Transverse vaginal Septae
- Vaginal Hypoplasia and Agenesis
What is a Bicornuate Uterus?
- Uterus has 2 horns giving it a heart shaped appearance.
- This can be associated with adverse pregnancy outcomes however successful pregnancies are generally expected.
What are some complications of a Bicornuate Uterus?
- Miscarriage
- Premature Birth
- Malpresentation
What is an Imperforate Hymen?
Where the hymen at the entrance of the vagina is fully formed without an opening.
How does an Imperforate Hymen Present?
- May be discovered when the girl starts to menstruate, and the menses are sealed in the vagina.
- This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding.
What is the management of an Imperforate Hymen?
- Diagnosed during a clinical examination
- Treatment is a Surgical incision to create an opening in the hymen.
What is a complication of an Imperforate Hymen?
- If not treated then retrograde menstruation could occur leading to endometriosis
- Amenorrhoea
What is a Transverse Vaginal Septae?
Caused by an error in development, where a septum (wall) forms transversely across the vagina.
This septum can either be perforate (with a hole) or imperforate (completely sealed).
What is the Presentation of a Transverse Vaginal Septae?
- Perforate Septae: Girls will menstruate but can have difficulty with intercourse or tampon use
- Imperforate Septae: Presents similarly to an Imperforate Hymen
What are some complications of a Transverse Vaginal Septae?
- Infertility
- Pregnancy related complications
- Vaginal Stenosis
- Recurrence of the Septae
What is the management of a Transverse Vaginal Septae?
- Diagnosis is by Examination, Ultrasound or MRI
- Treatment with with Surgical Correction
What is Vaginal Hypoplasia and Agenesis?
Hypoplasia: An Abnormally small vagina
Agenesis: An absent vagina
These occur due to failure of the Mullerian ducts to properly develop and are often associated with an absent uterus and cervix
What is the difference between Vaginal Hypoplasia and Agenesis and Androgen Insensitivity Syndrome?
The Mullerian Ducts fail to develop but not due to Anti-Mullerian Hormone.
Therefore patients do not have Testes (like in AIS) but do have Ovaries
What is the management of Vaginal Hypoplasia and Agenesis?
- Vaginal Dilator over a prolonged period of time to create and adequate vaginal size
- Vaginal Surgery may be necessary
Define Menarche?
The first occurrence of Menstruation
At what age does Menarche normally occur?
Mean age 13
11-15 usually.
Define Menopause?
This term describes the permanent cessation of menstruation, characterised by at least 12 months of amenorrhoea in otherwise healthy women over the age of 45 who are not using hormonal contraception.
When does Menopause typically occur?
Between the ages of 45-55 with the average age being around 51-52 years old.
Define Perimenopause?
- The time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods.
- Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards.
- This is typically in women older than 45 years.
Define Postmenopause?
The period from 12 months after the final menstrual period
Define Early Menopause?
Menopause between the ages of 40-45 years old.
Premature Menopause is the menopause occuring prior to the age of 40 and is due to ovarian insufficiency
What is the Aetiology of Menopause?
Caused by ovarian failure which leads to oestrogen deficiency
What is the physiology of Menopause?
- Primordial follicles mature into primary and secondary follicles independently of the menstrual cycle.
- FSH stimulates secondary follicle development at the start of the menstrual cycle, leading to increased oestrogen production (granulosa cells).
- At Menopause primordial follicle number is depleated leading to a decline in follicle development, reducing oestrogen production.
- As oestrogen declines, the lack of negative feedback causes increased LH and FSH levels from the pituitary gland.
- Reduced follicular development leads to anovulation, irregular cycles, amenorrhoea, and perimenopausal symptoms due to low oestrogen.
- Without Oestrogen the endometrium does not develop eventually leading to a lack of menstruation (amenorrhoea)
What is the cause of the perimenopausal symptoms?
Lower levels of Oestrogen
What are some perimenopausal symptoms?
Vasomotor Symptoms:
- Hot flushes
- Night sweats
- Irregular periods, Heavy or lighter periods
- Joint Pains
Sexual Dysfunction:
- Vaginal dryness and atrophy
- Reduced libido
- Problems with Orgasm
- Dyspareunia
Psychological Symptoms:
- Depression
- Anxiety
- Mood Swings, Low mood and emotional lability
- Lethargy
- Reduced Concentration
What are some risks of menoupause?
Reduced oestrogen increases the risk of certain conditions:
- Cardiovascular disease and stroke
- Osteoporosis due to increased bone turn over since normal oestrogen levels inhibit osteoclast activity
- Pelvic Organ Prolapse
- Urinary Incontinence
What are some differential diagnoses for Menopause?
- Thyroid disease: symptoms can include hot flushes, sweating, palpitations, and changes in menstrual cycle
- Depression: exhibits mood swings, lethargy, reduced concentration
- Premature ovarian insufficiency: can cause hot flushes, night sweats, vaginal dryness, and reduced libido
What are the investigations for Menopause?
Diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms without performing any investigations
NICE Guidelines (2015) recommend FSH Blood test to help with Diagnosis:
- Women under 40 years with suspected premature menopause
- Women aged 40-45 with menopausal symptoms or a change in menstrual cycle
- Elevated FSH level (>30 IU/L) may predict impending menopause after several months of amenorrhoea
How long after the last menstrual period before the menopause should women continue to use contraception?
Two years after the last menstrual period in women under 50
One year after the last menstrual period in women over 50
What is the relationship between hormonal contraceptives and menopause?
Hormonal contraceptives do not affect the menopause, when it occurs or how long it lasts, although they may suppress and mask the symptoms.
This can make diagnosing menopause in women on hormonal contraception more difficult.
What are some good contraceptive options for women approaching menopause?
Barrier methods
Mirena or copper coil
Progesterone only pill
Progesterone implant
Progesterone depot injection (under 45 years)
Sterilisation
What are 2 main side effects of the progesterone depot injection?
Weight Gain and Reduce bone mineral density (osteoporosis)
This is why this form of contraception is unsuitable for women Over 45 years old
What is the management of Perimenopausal Symptoms?
Vasomotor symptoms likely resolve after 2-5 years without treatment
Management of Symptoms depends on severity, personal circumstances and response to treatment
First Line: Lifestyle Measures
- Regular Exercise
- Weight Loss (as necessary)
- Avoidance of triggers (Smoking, alcohol, spicy food)
Second line: Hormone replacement therapy (HRT)
- Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
- Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors for flushing
- Cognitive behavioural therapy (CBT)
- SSRI antidepressants, such as fluoxetine or citalopram
- Testosterone can be used to treat reduced libido (usually as a gel or cream)
- Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)
- Vaginal moisturisers, such as Sylk, Replens and YES
What is the purpose of HRT?
Oestrogens: Overcome oestrogen deficiency
Progesterone’s: Required for endometrial protection from unopposed systemic oestrogens
- HRT can be given cyclically (for perimenopause) or continuously (for post menopause)
What are some benefits and risks of HRT?
Benefits
- Relief of Vasomotor symptoms
- Relief of urogenital symptoms
- Reduced risk of Osteoporosis
Risks
- Increased risk of Breast Cancer
- Increased risk of Endometrial Cancer (if given oestrogen alone)
- Increased risk of VTE
What are some Absolute Contraindications to HRT?
B – Breast cancer (current or history of)
R – Recent heart attack (myocardial infarction)
E – Endometrial cancer (current or untreated)
A – Active liver disease
S – Stroke (recent or history of)
T – Thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism)
C – Clotting disorder (e.g., thrombophilia, protein C/S deficiency)
L – Liver disease (severe or active)
O – Oestrogen-sensitive cancer (like ovarian cancer)
T – Thrombosis risk (high risk for clot formation)
Define Adenomyosis?
Refers to a condition where endometrial tissue is inside the myometrium (muscle layer of the uterus)
What is the Epidemiology of Adenomyosis?
- More common in later reproductive years
- More common in those who have had several pregnancies (Multiparous)
- Occurs in around 10% of women
- May occur alone or alongside endometriosis or fibroids
What is the Aetiology of Adenomyosis?
Not fully Understood
- Multiple factors involved including Sex hormones, trauma and inflammation
- Condition is hormone dependent
What are the clinical features of Adenomyosis?
- enlarged, boggy uterus
- Painful periods (dysmenorrhoea)
- Heavy periods (menorrhagia)
- Pain during intercourse (dyspareunia)
- Infertility or pregnancy related complications
- 1/3 of patients are asymptomatic
What are the investigations for Adenyomyosis?
First Line:
- Transvaginal Ultrasound of the pelvis
- MRI and Transabdominal ultrasound are alternatives if transvaginal is unsuitable
Gold Standard:
- Histological examination of the uterus after a hysterectomy
- Not usually a suitable way of establishing the diagnosis for obvious reasons
What is the management of Adenomyosis?
Depends on symptoms, age and plans for pregnancy
Women does NOT want contraception
- Tranexamic Acid when there is no pain associated (antifibrinolytic)
- Mefenamic Acid when there is pain associated (NSAID)
Women DOES want Contraception:
- Mirena coil - First Line
- Combined Oral Contraceptive Pill (COCP)
- Cyclical oral progestogens
Other options considered by specialist
- GnRH analogues to induce menopause like state
- Endometrial ablation
- Uterine artery embolisation
- Hysterectomy
What are some pregnancy complications associated with Adenomyosis?
- Infertility
- Miscarriage
- Preterm birth
- Small for gestational age
- Preterm premature rupture of membranes
- Malpresentation
- Need for caesarean section
- Postpartum haemorrhage
Define Asherman’s Syndrome?
Where adhesions form within the uterus (intrauterine adhesions) following damage to the uterus that lead to outflow tract obstruction.
What is the Aetiology of Asherman’s syndrome?
Anything that creates scar tissue within the uterus causing adhesions that are normally not connected
- Pregnancy related dilation and Curettage procedure
- Treatment of retained productions of conception (removing placental tissue left behind after birth)
- Uterine surgery (myomectomy)
- Pelvic infection (endometritis)
What is the pathophysiology of Asherman’s Syndrome?
- Damage to the uterus causing scar tissue formation and subsequent adhesions.
- Adhesions form Physical Obstructions and distort the pelvic organs
- Leads to menstruation abnormalities, infertility, recurrent miscarriages
What are the clinical features of Asherman’s Syndrome?
Presents following recent dilatation and curettage, uterine surgery or endometritis with:
- Secondary amenorrhoea
- Significantly lighter periods
- Dysmenorrhoea
- Infertility
Incidentally found adhesions that are asymptomatic are not classed as Asherman’s Syndrome
What are the investigations for Asherman’s Syndrome?
History of uterine surgery
Hysteroscopy is Gold Standard investigation and can involve dissection and treatment of adhesions.
Others:
- Hysterosalpingography when contrast is injected into the uterus and imaged with X-rays
- Sonohysterography uterus is filled with fluid and pelvic USS is performed
- MRI Scan
What is the management of Asherman’s Syndrome?
- Dissecting the adhesions during hysteroscopy.
- Reoccurrence of the adhesions after treatment is common
What are the clinical features of Secondary Amenorrhea?
The primary symptom of secondary amenorrhoea is the absence of menstrual periods for six months or longer.
Additional symptoms, depending on the underlying cause, may include:
- Pregnancy symptoms: nausea, breast tenderness, increased urination, food cravings or aversions
- Menopause symptoms: hot flashes, night sweats, sleep problems, mood changes
- Symptoms of PCOS: acne, weight gain, hirsutism (excessive body hair), thinning hair
- Symptoms of pituitary gland issues: headaches, vision problems, unexplained weight gain or loss
What are the investigations for Secondary Amenorrhoea?
- Pregnancy test
- Hormone level checks: including FSH, LH, TSH, prolactin, and testosterone
- Ultrasound or other imaging studies, to identify potential structural abnormalities
- Hysteroscopy, in cases where intrauterine adhesions are suspected
What is the management of Secondary Amenorrhoea?
Management of secondary amenorrhoea is determined by the underlying cause:
- Pregnancy: regular prenatal care
- Menopause: hormone replacement therapy (HRT) if symptoms are troublesome
- PCOS: lifestyle changes, hormonal contraceptives, and potentially metformin
- Asherman’s syndrome: surgical removal of adhesions and hormone therapy
- Drug-induced amenorrhoea: discontinuing the offending drug if possible and safe to do so
- Conditions related to physical stress, weight loss, or excessive exercise: lifestyle modifications and nutritional counselling.
Define Lichen Sclerosus?
A chronic inflammatory skin condition that presents with patches of Porcelain-white skin.
It typically affects the genital and anal regions of the body: labia, perineum, perianal skin, foreskin and glans penis
What is the epidemiology of Lichen Sclerosus?
- Typically affects women
- Can affect men
- Considered to be an autoimmune condition and therefore is associated with T1DM, Alopecia, hypothyroid and vitiligo
What is the Aetiology of Lichen Sclerosus?
The cause of lichen sclerosus is currently unknown, but it is likely multifactorial.
Potential contributing factors could include autoimmune condition, genetic predisposition, and hormonal factors.
Some studies suggest a possible link with previous skin damage or trauma.
What is Lichen in medicine?
Lichen refers to a flat eruption that spreads.
*It is important not to get lichen sclerosus confused with lichen simplex or lichen planus.
Define Lichen simplex
Chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.
Define Lichen planus
Autoimmune condition (All the P’s)
Purple planar polygonal papules on extensor surfaces of the hand and Wickham striae in the mouth
What is a typical presentation of Lichen Sclerosus?
Woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva
The condition may be asymptomatic, or present with several symptoms:
- Itching
- Soreness and pain possibly worse at night
- Skin tightness
- Painful sex (superficial dyspareunia)
- Erosions
- Fissures
What is the Koebner phenomenon?
The appearance of new skin lesions on areas of pre-existing dermatosis and cutaneous injury (skin trauma)
This occurs with Lichen Sclerosus
What is the appearance of Lichen Sclerosus?
Changes affect the labia, perianal and perineal skin. There can be associated fissures, cracks, erosions or haemorrhages under the skin.
The affected skin appears:
- “Porcelain-white” in colour
- Shiny
- Tight
- Thin
- Slightly raised
- There may be papules or plaques
What are some differential diagnoses for Lichen Sclerosus?
- Lichen planus: Characterized by purplish, itchy, flat-topped bumps, and white lacy patches in the mouth or on the skin.
- Psoriasis: Manifests as red patches with silver scales, typically on the scalp, elbows, knees, and lower back.
- Vitiligo: Presents as patchy loss of skin color, usually first on sun-exposed areas of the skin.
What are the investigations for Lichen Sclerosus?
Primarily Clinical Diagnosis based on characteristic appearance of skin lesions
- Skin biopsy may be performed to confirm diagnosis
- Blood tests may rule out other potential autoimmune conditions
What is the Management of Lichen Sclerosus?
Lichen Sclerosus cannot be cured but symptoms are controlled and should be followed up every 3-6 months
First Line
-
Potent Topical Steroids: Clobetasol propionate 0.05% (dermovate)
- Steroids used long term to control symptoms
- Once daily for 4 weeks. Then gradually reduce frequency every 4 weeks to alternate days then twice weekly.
- Daily steroids when condition flares
- Emollients should be used regularly both with steroids and as part of maintenance
- Avoidance of soaps in affected areas to prevent further irritation.
What are some complications of Lichen Sclerosus?
- 5% risk of developing squamous cell carcinoma of the vulva
- Pain and discomfort
- Sexual dysfunction
- Bleeding
- Narrowing of the vaginal or urethral openings
Define Atrophic Vaginitis?
vulvovaginal atrophy is inflammation and thinning of the genital tissues, dryness and atrophy of the vaginal mucosa due to reduced oestrogen levels
What is the Aetiology of Atrophic Vaginitis?
Decrease in oestrogen levels most commonly due to menopause
What are the clinical features of Atrophic Vaginitis?
Presents in post-menopausal women with:
- Itching and dryness
- Loss of pubic hair
- Dyspareunia (discomfort or pain during sex)
- Post coital Bleeding due to localised inflammation
- recurrent UTIs or Stress incontinence
- Pelvic organ prolapse may also occur.
What are some differential diagnoses for Atrophic Vaginitis?
- Postmenopausal bleeding: malignancy, endometrial hyperplasia
- For genital itching/discharge: sexually transmitted infection, vulvovaginal candidiasis, skin conditions such as lichen sclerosis, lichen planus, diabetes
- For narrowed introitus: female genital mutilation
- For urinary symptoms: urinary tract infection, bladder dysfunction, pelvic floor disfunction, cystitis
- For dyspareunia: malignancy, vaginismus
What are the investigations for Atrophic Vaginitis?
Clinical Diagnosis
- Clinical examination, including speculum examination if tolerated, to look for vaginal signs of atrophy
Other tests:
- Transvaginal ultrasound and endometrial biopsy, if necessary, to exclude endometrial cancer
- An infection screen if itching or discharge is present
- A biopsy of any abnormal skin lesions, if needed
What would be seen on examination in Atrophic Vaginitis?
- Pale mucosa
- Thin skin
- Reduced skin folds
- Erythema and inflammation
- Dryness
- Sparse pubic hair
What is the management of Atrophic Vaginitis?
Hormonal treatment:
-
Topical oestrogen preparations:
- Estriol cream
- Estriol pessaries
- Estradiol Tablets
- Estradiol ring
Non-hormonal treatments:
- Lubricants such as Sylk, Replens, YES:, which provide short-term improvement to vaginal dryness, alleviating symptoms such as dyspareunia
- Moisturisers, which should be used regularly
What are some contraindications to Topical Oestrogens?
- Active or history of hormone-dependent cancers
- Undiagnosed vaginal bleeding.
- Known hypersensitivity.
- Severe liver disease
Define Vulval Cancer?
Malignant growth that primarily affects the skin of the vulva (the external part of the female genitalia).
It can be host to various types of Skin cancers however Squamous Cell Carcinoma is the most prevalent.
What is the Epidemiology of Vulval cancer?
- Rare gynaecological cancer accounting for 4%
- Most commonly found in older women >60 (but can occur at any age)
- 90% are Squamous Cell Carcinomas
What are some risk factors for Vulval Cancer?
- Advanced age (particularly over 75 years)
- Human papilloma virus (HPV) infection
- Vulval intraepithelial neoplasia (VIN)
- Immunosuppression
- Lichen sclerosus
What are the different types of Vulval Cancer?
- Squamous Cell Carcinoma (90%)
- Malignant Melanomas
- Basal Cell Carcinoma
What are the clinical features of Vulval Cancer?
- Vulval lump
- Lymphadenopathy in the groin
- Itching
- Ulceration
- Bleeding
- Pain
What region of the Vulva is most common affected in Vulval Cancer?
Labia Majora
What are some differential diagnoses for Vulval Cancer?
- Vulval intraepithelial neoplasia: This precancerous condition can cause itching, burning, skin changes, and discomfort.
- Lichen sclerosus: This condition can cause itching, pain, and white patches on the vulva.
- Bartholin’s cyst: This may present as a lump or swelling on the vulva, and can cause discomfort or pain.
What are the investigations for Vulval Cancer?
Physical Examination
Suspected vulval cancer should be referred on a 2-week-wait urgent cancer referral.
Establishing the diagnosis and staging involves:
- Biopsy of the lesion
- Sentinel node biopsy to demonstrate lymph node spread
- Further imaging for staging (e.g. CT abdomen and pelvis)
What is system is used to stage Vulval Cancer?
International Federation of Gynaecology and Obstetrics (FIGO)
Management of Vulval Cancer depends on the stage
What is the Management of Vulval Cancer?
Depends on the Stage
- Wide local excision to remove the cancer
- Groin lymph node dissection
- Chemotherapy
- Radiotherapy
What is Vulval Intraepithelial Neoplasia?
- VIN is a premalignant condition affecting the squamous epithelium of the skin.
- VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia)
What are the different types of Vulval Intraepithelial Neoplasia?
- High grade squamous intraepithelial lesion: A type of VIN associated with HPV infection that occurs in younger women aged 35-50 years.
- Differentiated VIN: Type of VIN associated with lichen Sclerosus and typically occurs in older women aged 50-60 years.
How is Vulval intraepithelial neoplasia diagnosed?
A biopsy
What are the management options for Vulval Intraepithelial Neoplasia?
- Watch and wait with close follow-up
- Wide local excision (surgery) to remove the lesion
- Imiquimod cream
- Laser ablation
Define Cervical Cancer?
Malignant proliferation of the cells of the Cervix (the lower part of the uterus that connects to the vagina)
What is the Epidemiology of Cervical Cancer?
- 3rd most common cancer worldwide and 4th biggest cause of cancer death
- Strongly associated with Human papilloma virus (HPV)
What are the different types of Cervical Cancer?
- Squamous Cell Carcinoma (80%)
- Adenocarcinoma (10-20%)
- Very rarely, Small cell Cancer
What are some risk factors for Cervical Cancer?
Increased risk of catching HPV occurs with:
- Early sexual activity
- Increased number of sexual partners
- Sexual partners who have had more partners
- Not using condoms
Non-engagement with cervical screening is a significant risk factor.
Other risk factors are:
- Smoking
- HIV (patients with HIV are offered yearly smear tests)
- Combined contraceptive pill use for more than five years
- Increased number of full-term pregnancies
- Family history
- Exposure to diethylstilbestrol
What is the Human Papilloma Virus?
- HPV is a Sexually Transmitted Infection of the virus that is associated with anal, vulval, vaginal, penile, mouth and throat cancers
- There are over 100 strains but theHPV 16 and 18 are responsible for 70% of cervical cancers
- HPV Infection spontaneously resolves within 2 years in 90% of women. At this point the risk returns to baseline.
Which strains of HPV are targeted in the HPV vaccine and when is the vaccine given?
Current NHS vaccine is Gardasil protecting against HPV 6, 11, 16, 18, 31, 33, 45, 52, 58
- HPV 6 and 11 cause Genital Warts
- HPV 16 and 18 cause Cervical Cancer (plus others)
- Girls and boys are given the HPV vaccine around age 12-13 years old
How does HPV promote cancer development?
- HPV 16 and 18 produces two proteins (E6 and E7) that inhibit tumour suppressor genes respectively
- HPV 16 - E6 inhibits p53
- HPV 18 - E7 inhibits pRb
- These cause dysregulated cell cycle regulation leading to the formation of a pre-malignant monoclonal cell population
- This cell population is cervical intraepithelial neoplasia (CIN) which subsequently mutates further to become an invasive carcinoma
What is Cervical Intraepithelial Neoplasia?
What is Cervical Intraepithelial Neoplasia (CIN) is a grading system for the level of dysplasia and premalignant change in the cells of the cervix
CIN is diagnosed at Colposcopy (not with cervical screening)
What are the grades of Cervical Intraepithelial Neoplasia?
- CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
- CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
- CIN III: severe dysplasia, very likely to progress to cancer if untreated
CIN III is sometimes called cervical carcinoma in situ.
What is the typical presentation of Cervical cancer?
Most cases are picked up asymptomatically during cervical screening or smears.
- Abnormal bleeding (post-coital/intermenstrual/post menopausal)
- Abnormal discharge
What are some clinical features of Cervical Cancer?
- Vaginal discharge
- Abnormal Vaginal Bleeding (e.g. postcoital or with micturition or defaecation)
- Dyspareunia
- Vaginal discomfort
- Urinary or bowel habit change
- Suprapubic pain
- Abnormal white/red patches on the cervix.
- Pelvic bulkiness on PV examination
- Mass felt on PR examination
What are some differential diagnoses for Cervical Cancer?
- Vaginitis: itching, burning, pain, and abnormal discharge
- Cervical Ectropion
- Nabothian cyst
- Cervicitis: abnormal discharge, pelvic pain, and postcoital bleeding
- Endometrial cancer: abnormal vaginal bleeding, pelvic pain, and unintentional weight loss
- Cervical polyps: abnormal vaginal bleeding, discharge, and pain during intercourse
What are the investigations for Cervical Cancer?
- Clinical History prompting Cervix examination with Speculum +/- Swabs to exclude infection
If there is an abnormal appearance of the cervix suggestive of cancer:
- First line investigation is an Urgent cancer referral for Colposcopy for visualisation and biopsy of the cervix.
- HPV testing
- CT Chest, Abdomen and Pelvis is used for Cancer Staging
What is Colposcopy?
- Involves inserting a speculum and using equipment (a colposcope) to magnify the cervix. This allows the epithelial lining of the cervix to be examined in detail.
- Stains such as Acetic acid and Iodine solution are used to identify abnormal areas
- A Punch biopsy or LLETZ Biopsy can be performed to get a tissue sample
What is seen on staining during Colposcopy?
Acetic Acid Stain:
- Abnormal cells appear white (Acetowhite)
Schiller’s Iodine Test:
- Stains healthy cells of the cervix a brown colour.
- Abnormal areas/cells will not stain
What may be seen on examination of the cervix that may suggest cervical cancer?
- Ulceration
- Bleeding
- Inflammation
- Visible tumour
What may be seen on Colposcopy that is suspicious of Cervical Cancer?
- Abnormal vascularity
- White change with Acetic Acid
- Exophytic Lesions
What are the Stages of Cervical Cancer?
FIGO system
Stage 1: Confined to cervix
Stage 2: Extending into the uterus or upper 2/3 of the vagina
Stage 3: Extending into lower third of the vagina or pelvic wall
Stage 4: Spread beyond true pelvis or bladder / rectum involvement
What is the management of Cervical Cancer?
Cervical intraepithelial neoplasia and early-stage 1A:
- LLETZ or cone biopsy
Stage 1B – 2A:
- Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B – 4A:
- Chemotherapy and radiotherapy
- Bevacizumab (VEG-F inhibitor)
Stage 4B:
- Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
What is the Prognosis for Cervical Cancer?
5 year survival drops significantly with an advanced stage.
- Stage 1a: 98% 5 year survival
- Stage 4: 15% 5 year survival
What is Bevacizumab (Avastin)?
- Monoclonal antibody used in combination with other chemotherapies in the treatment of Metastatic or Recurrent Cancers.
- It is a Vascular Endothelial Growth Factor A Inhibitor (VEGF-A) to reduce the development of new blood vessels from the cancer.
What is a Cone Biopsy?
- A cone biopsy is a treatment for cervical intraepithelial neoplasia (CIN) and very early-stage cervical cancer.
- It involves a general anaesthetic.
- The surgeon removes a cone-shaped piece of the cervix using a scalpel.
- This sample is sent for histology to assess for malignancy
What are the main risks of a Cone Biopsy?
- Pain
- Bleeding
- Infection
- Scar formation with stenosis of the cervix
- Increased risk of miscarriage and premature labour
What is a Large Loop Excision of the Transformation Zone (LLETZ)?
Also called a Loop Biopsy
- Involves a Local Anaesthetic
- Often performed during a Colposcopy procedure
- Involves a wire loop with electrical current (diathermy) to remove the abnormal epithelial tissue on the cervix.
- Electrical current cauterises the tissue and stops bleeding
What are the main risks of Large Loop Excision of the Transformation Zone (LLETZ)?
- Bleeding and Abnormal discharge can occur for several weeks following a LLETZ procedure
- Intercourse and tampon use after the procedure should be avoided to reduce infection
- May increase the risk of Preterm labour
Who is Eligible for the Cervical Screening Program?
- For all Women and People (Transmen) with a cervix between the age of 25-64 years
- Cervical sample is taken and tested for High -risk HPV viruses (hrHPV)
What are the normal intervals for Cervical Screening?
- 3 yearly for women aged 25-49
- 5 yearly for women aged 50-64
What is involved in the Cervical Screening tests?
Aims to pick up precancerous changes in epithelial cells of the cervix.
- Involves a smear test performed by a qualified practice nurse
- Test consists of a Speculum examination and collection of cells from the cervix using a small brush.
- The samples are initially tested for high-risk HPV before examination.
- The cells are then examined under a microscopy using liquid based cytology (LCB) for precancerous changes (dyskaryosis)
If the HPV is negative then the cells are not examined
What do the results of the Cervical Smear Test indicate?
Smear Test for hrHPV:
- Positive: further testing is indicated with LBC
- Negative: Return to normal recall (age based intervals)
1st Positive hrHPV:
- Use LBC to detect cellular atypia
- Cytology Positive: Colposcopy is indicated
-
Cytology Inadequate: Cytology is repeated in 3 months
- Repeat cytology inadequate - refer for colposcopy
- If Colposcopy is normal - test hrHPV in 12 months
- Cytology Negative: Perform 2nd hrHPV test in 12 months
2nd hrHPV:
- Negative: return to normal recall
- Positive: Offer 3rd hrHPV test in a further 12 months (24 months after first positive test)
3rd hr HPV:
- Negative: Return to normal Recall
- Positive: Refer to Colposcopy
What are some different Cytology results that may be seen following a smear test and liquid based cytology for cervical screening?
- Inadequate
- Normal
- Borderline changes
- Low-grade dyskaryosis
- High-grade dyskaryosis (moderate)
- High-grade dyskaryosis (severe)
- Possible invasive squamous cell carcinoma
- Possible glandular neoplasia
- Infections such as bacterial vaginosis, candidiasis, trichomoniasis
Which groups of people may have exceptions to the normal Cervical Screening Program?
- Women with HIV are screened annually
- Women over 65 may request a smear if they have not had one since aged 50
- Women with previous CIN may require additional tests (e.g. test of cure after treatment)
- Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
- Pregnant women due a routine smear should wait until 12 weeks post-partum
Define Menorrhagia?
Clinical condition defined as Heavy menstrual bleeding (excessive blood loss) during a menstrual period to the extent that it is affecting a woman’s quality of life
What level of blood loss is considered menorrhage?
It used to be 80ml.
Now it is based on the subjective opinion of the woman
What is the epidemiology of Menorrhagia?
- Common gynaecological complaint
- 50% of cases no underlying pathology is found and the condition is called Dysfunctional Uterine/endometrial bleeding
Define Dysfunctional Endometrial Bleeding?
Menorrhagia (heavy menstrual periods) where there is no underlying pathology identified
What is the Aetiology of Menorrhagia?
Local:
- Dysfunctional Uterine Bleeding
- Fibroids
- Adenomyosis
- Endometrial polyps
- Endometriosis
- Pelvic inflammatory disease
- PCOS
- Contraceptives such as copper coil
- Endometrial cancer (be highly suspicious of this if there is postmenopausal bleeding)
Systemic:
- Bleeding disorders
- Hypothyroidism
- Liver and kidney disease
- Obesity
What is the Clinical Presentation of Menorrhagia?
Heavy or prolonged menstrual bleeding
Other features: (Due to Iron deficiency Anaemia)
- Fatigue
- Weakness
- Shortness of Breath
What are some differential diagnoses for Menorrhagia?
Differentials that include abnormal uterine bleeding:
- Fibroids: Often asymptomatic, but can cause heavy or prolonged periods, pelvic pain or pressure, and frequent urination.
- Adenomyosis: Symptoms can include prolonged, heavy menstrual bleeding, severe menstrual cramps, and pain during intercourse.
- Endometrial polyps: Can cause irregular menstrual bleeding, bleeding between periods, excessively heavy periods, or postmenopausal bleeding.
- Endometrial cancer: Symptoms include abnormal vaginal bleeding, pelvic pain, and pain during intercourse.
What are the key things to ask in any presentation with a gynaecological problem?
- Age at menarche
- Cycle length, days menstruating and variation
- Intermenstrual bleeding and post coital bleeding
- Contraceptive history
- Sexual history
- Possibility of pregnancy
- Plans for future pregnancies
- Cervical screening history
- Migraines with or without aura (for the pill)
- Past medical history and past drug history
- Smoking and alcohol history
- Family history
What investigations should be performed in Menorrhagia?
Initial tests
Imagining
Additional
Comprehensive History about bleeding
- Laboratory investigations such as FBC
- Pelvic examination with a speculum: Should be performed unless there is a straightforward history without other risk factors or symptoms or they are young and not sexually active
Imaging Studies if Indicated:
- Hysteroscopy (outpatient)
- Pelvic and Transvaginal Ultrasound
Additional Tests based on features:
- Swabs if there is evidence of infection (e.g. abnormal discharge or suggestive sexual history)
- Coagulation screen if there is a family history of clotting disorders (e.g. Von Willebrand disease) or periods have been heavy since menarche
- Ferritin if they are clinically anaemic
- Thyroid function tests if there are additional features of hypothyroidism
What may indicate the need for an Outpatient Hysteroscopy in Menorrhagia?
- Suspected submucosal fibroids
- Suspected endometrial pathology, such as endometrial hyperplasia or cancer
- Persistent intermenstrual bleeding
What may indicate the need for Pelvic and Transvaginal Ultrasound in Menorrhagia?
- Possible large fibroids (palpable pelvic mass)
- Possible adenomyosis (associated pelvic pain or tenderness on examination)
- Examination is difficult to interpret (e.g. obesity)
- Hysteroscopy is declined
What is the Management of Menorrhagia?
Exclude underlying pathology/Treat pathology first
Women does NOT want Contraception:
- Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
- Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
Women DOES want Contraception:
- Mirena coil (first line)
- Combined oral contraceptive pill
- Progesterone only contraception can be tried
Medical management Failed:
- Hysterectomy
- Endometrial Ablation
Referral to Secondary Care:
- If treatment is unsuccessful
- Symptoms are Severe
- Large fibroids (>3cm)
Define Endometrial Cancer?
Malignant proliferation that originals from the endometrium (the inner lining of the uterus)
It is an Oestrogen Depending cancer meaning that oestrogen stimulates the growth of Endometrial cancer cells
What is the epidemiology of Endometrial Cancer?
- 6th Most commonly diagnosed cancer in women
- 15th most common cancer
- 80% of cases are adenocarcinoma
What is Endometrial Hyperplasia?
a precancerous condition that involves thickening of the endometrium
- The risk factors, presentation, investigations are similar to Endometrial cancer
- Most cases of Endometrial Hyperplasia will return to normal over time and <5% become endometrial cancer.
What are the types of Endometrial Hyperplasia?
- Hyperplasia without atypia
- Atypical Hyperplasia
How can Endometrial Hyperplasia be treated?
Without Atypical Cells:
- Reversal of risk factors: Weight loss, stopping HRT
- Intrauterine System (IUS/Mirena coil)
- Continuous Oral Progestogens (Medroxyprogesterone)
With Atypical Cells:
- Total Hysterectomy with Bilateral Salpingo-oophorectomy (TAH and BSO)
What are the risk factors for Endometrial Cancer?
Anything that causes increased Exposure to Unopposed Oestrogen (Oestrogen without progesterone):
- Increased Age
- Nulliparity (never given birth or carried child)
- Obesity
- Diabetes
- Early menarche
- Late menopause
- Polycystic ovary syndrome
- Oestrogen-only hormone replacement therapy
- Tamoxifen
How does PCOS increase your risk of Endometrial Cancer?
Polycystic ovarian syndrome leads to increased exposure to unopposed oestrogen due to a lack of ovulation.
Anovulation/oligoovulation means follicles don’t develop
No corpous luteum so no progesterone
Unopposed oestrogen acting on endometrium
What should be given to women with PCOS for Endometrial Protection?
Progestrogens
One of:
- Combined Contraceptive Pill
- Intrauterine System (Mirena coil)
- Cyclical Progestogens
How does Obesity increase the risk of Endometrial Cancer?
Obesity is a crucial risk factor because adipose tissue (fat) is a source of oestrogen.
Adipose tissue is the primary source of oestrogen in postmenopausal women.
Adipose tissue contains aromatase, which is an enzyme that converts androgens such as testosterone into oestrogen
This extra Oestrogen is unopposed in women that are not ovulating (PCOS/post-menopause)
How does Tamoxifen increase the risk of Endometrial Cancer?
Tamoxifen has an anti-oestrogenic effect on breast tissue however it has an oestrogenic effect on the endometrium increasing the risk of endometrial cancer.
What are some protective factors for Endometrial Cancer?
- Combined Contraceptive Pill
- Mirena Coil
- Increased Pregnancies
- Cigarette Smoking
What are the clinical features of Endometrial Cancer?
Features vary but commonly include:
- Postmenopausal Bleeding
- Postcoital bleeding
- Intermenstrual bleeding
- Unusually heavy menstrual bleeding
- Abnormal vaginal discharge
- Dyspareunia
- Abdominal discomfort or bloating
- Weight Loss
- Haematuria
- Anaemia
- Raised platelet count
What must you think about in women with postmenopausal bleeding?
This is endometrial cancer until proven otherwise
Other key risk factors include obesity and diabetes
What are some differential diagnoses for Endometrial Cancer?
- Uterine fibroids: Characterised by heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation.
- Endometrial polyps: Symptoms may include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual periods, and vaginal bleeding after menopause.
- Cervical cancer: Signs can include abnormal vaginal bleeding, postmenopausal bleeding, and pelvic pain.
What is the Referral Criteria for Endometrial Cancer?
Guidelines for a 2 week wait urgent Endometrial cancer referral:
- Postmenopausal Bleeding more than 12 months after the last menstrual period.
NICE also recommends referral for Transvaginal Ultrasound in women Over 55 years with:
- Unexplained vaginal discharge
- Visible haematuria Plus raised platelets, anaemia, or elevated glucose levels
What are the investigations for Endometrial Cancer?
1st line
Gold standard
- First Line: Transvaginal Ultrasound: for endometrial thickness (normal is less than 4mm post menopause)
- Second Line: Endometrial Biopsy
- Pipelle Biopsy: highly sensitive for endometrial cancer
- Hysteroscopy with endometrial biopsy
What are the stages of Endometrial Cancer?
FIGO System:
Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis
What is the Management for Endometrial Cancer?
- Progesterone: May be used as a hormonal treatment to slow the progression of the cancer
Stage 1 and 2 Endometrial Cancer:
- Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy (TAH and BSO): Removal of uterus, cervix and adnexa
Later stages spread outside of the uterus:
- Combination of Hysterectomy, Radiotherapy, Chemotherapy
Define Endometriosis?
A gynaecological condition where ectopic endometrium-like tissue (Glands and stroma) , which typically lines the uterus, proliferates outside the uterine cavity.
Endometrioma: A lump of endometrial tissue outside the uterus
Chocolate Cysts: Endometriomas in ovaries
Adenomyosis: Endometrial tissue within the myometrium of the uterus
What is the Epidemiology of Endometriosis?
*Approximately estimated to affect 10% of women in their reproductive years
What is the Aetiology of Endometriosis?
No clear cause but several theories:
- Genetic component: Though no specific genes are identified
- Retrograde menstruation
- Coelomic metaplasia: Cells outside of the uterus somehow change via metaplasia into endometrial cells
- Lymphatic or vascular dissemination of endometrial cells: Cells spread similarly to cancer
What are the clinical features of Endometriosis?
- Cyclical abdominal or pelvic pain
- Dysmenorrhoea
- Dyspareunia
- Sub/infertility
- Cyclical bleeding from other sites (eg. rectal bleeding o haematuria)
- Urinary and bowel symptoms
- Palpable mass on examination (endometriomas)
- Fixed retroverted uterus
What is the pathophysiology theories for the cause of endometriosis?
- Retrograde menses/Sampsons
- Metaplasia/Meyers
- Haematogenous spread
What are some differential diagnoses for endometriosis?
- Primary dysmenorrhoea: characterised by crampy pelvic pain at the onset of menses with no identifiable pelvic pathology.
- Uterine conditions (e.g. fibroids, adenomyosis): these can cause heavy menstrual bleeding and pelvic discomfort.
- Adhesions: pelvic pain and possible bowel obstruction.
- Pelvic inflammatory disease (PID): presents with lower abdominal pain, fever, abnormal vaginal discharge, and possible dyspareunia.
What are the investigations for Endometriosis?
Clinical Examination: May identify endometriomas or deep nodules.
Transvaginal/Pelvic Ultrasound scan: Often unremarkable however they may reveal large endometriomas or chocolate cysts
Referral to gynaecology for ultrasound or Laparoscopy: Patients with severe persistent or recurrent symptoms of endometriosis should be referred.
Laparoscopic Surgery (Gold Standard): Definitive diagnosis is established with a biopsy of lesion during Laparoscopy. Surgeons may also remove deposits of endometriosis to potentially improve symptoms.
What is the Gold Standard investigation for Endometriosis?
Laparoscopic Surgery
This however comes with risks of complications such as bowel perforation and therefore is not the first line initial investigation
What is the management of Endometriosis?
Initial management involves:
- Establishing a diagnosis
- Providing a clear explanation
- Listening to the patient, establishing their ideas, concerns and expectations and building a partnership
- First Line: Analgesia as required for pain (NSAIDs and paracetamol)
Hormonal management options can be tried before establishing a definitive diagnosis with laparoscopy:
- First line: Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
- Progesterone only pill
- Medroxyprogesterone acetate injection (e.g. Depo-Provera)
- Nexplanon implant
- Mirena coil
- Second Line: GnRH agonists (Goserelin (Zoladex) or Leuprorelin (prostap))
Surgical management options:
- Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
- Bilateral oophorectomy +/-Hysterectomy
Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.
Define Fibroids?
Benign smooth muscle tumours (uterine leiomyomas) originating from the myometrium of the uterus.
What is the Epidemiology of Fibroids?
- Most prevalent benign uterine tumour in women
- Leading cause for Hysterectomy
- Very common affecting 40-60% of women in later reproductive years
- More common in black women
What is the Aetiology of Fibroids?
Unknown but thought to be related to hormonal and environmental factors
Oestrogen sensitive meaning they grow in response to oestrogen
What are the different types of Fibroid?
- Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
- Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
- Submucosal means just below the lining of the uterus (the endometrium).
- Pedunculated means on a stalk.
What are the clinical features of Fibroids?
Often Asymptomatic
Symptoms:
- Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
- Prolonged menstruation, lasting more than 7 days
- Abdominal pain, worse during menstruation
- Bloating or feeling full in the abdomen
- Urinary or bowel symptoms due to pelvic pressure or fullness
- Deep dyspareunia (pain during intercourse)
- Reduced fertility
- Palpable mass on abdominal or pelvic exam
What are some differential diagnoses for Fibroids?
Other causes of Menorrhagia and Dysmenorrhoea:
- Endometrial polyps: Present with irregular menstrual bleeding and spotting
- Endometriosis: Characterized by dysmenorrhoea, deep dyspareunia, chronic pelvic pain, and infertility
What are the investigations for Fibroids?
First Line:
- Transvaginal/Pelvic/Abdominal Ultrasound scan
- Hysteroscopy is initial investigation for submucosal fibroids presenting with menorrhagia
Second Line:
- MRI scan if ultrasound does not provide enough detail before considering surgical options
What is the management of Fibroids?
Smaller Symptom
Smaller Surgical
Larger Symptom
Larger Surgical
Fibroids < 3cm:
- Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus
- Symptomatic management with NSAIDs and tranexamic acid
- Combined oral contraceptive
- Cyclical oral progestogens
Surgical options for managing smaller fibroids
- Endometrial ablation
- Resection of submucosal fibroids during hysteroscopy
- Hysterectomy
Fibroids > 3 cm
women need referral to gynaecology for investigation and management.
- Symptomatic management with NSAIDs and tranexamic acid
- Mirena coil – depending on the size and shape of the fibroids and uterus
- Combined oral contraceptive
- Cyclical oral progestogens
Surgical options for larger fibroids are:
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
What are some complications for Fibroids?
- Heavy menstrual bleeding, often with iron deficiency anaemia
- Reduced fertility
- Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
- Constipation
- Urinary outflow obstruction and urinary tract infections
- Red degeneration of the fibroid
- Torsion of the fibroid, usually affecting pedunculated fibroids
- Malignant change to a leiomyosarcoma is very rare (<1%)
What is Red Degeneration of Fibroids?
Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.
in pregnancy the fibroid outgrows blood supply causing Ischaemia and Infarction.
Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy.
How does Red Degeneration of Fibroids Present?
Look out for the pregnant woman (2nd/3rd trimester) with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.
- Severe abdominal pain
- Low grade fever
- Tachycardia
- Vomiting
What is the Management of Red Degeneration of Fibroids?
Supportive management
- Rest
- Fluids
- Analgesia
What is a Typical exam patient for Red Degeneration of Fibroids?
Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.
Define Hydatidiform Mole?
What spectrum is it a part of?
What are the features of this spectrum?
A type of tumour that grows like a pregnancy inside the uterus. This is known as a Molar Pregnancy
It forms part of a spectrum of disorders known as gestational trophoblastic disease
- Complete Hydatidiform Mole
- Partial Hydatidiform Mole
- Choriocarcinoma (cancer in the placenta)
What are the different Types of Hydatidiform Mole?
Complete Mole:
- Occurs when two sperm cells (or 1 which duplicates DNA) fertilise an ovum that contains no genetic material (an “empty ovum”).
- These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole (46YY)
- No foetal material will form.
Partial Mole:
- Occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time.
- The new cell now has three sets of chromosomes (triploidy (69 XXX or 69 XXY)
- The cell divides and multiplies into a tumour called a partial mole.
- In a partial mole, some foetal material may form.
What is the Epidemiology of a Molar Pregnancy?
Women at highest risk of developing a molar pregnancy are at the extreme ends of the fertility age range, specifically those under 16 years of age and over 45 years of age.
What are the clinical features of a Hydatidiform Mole?
Molar pregnancy behaves like a normal pregnancy. Periods will stop and the hormonal changes of pregnancy will occur. There are a few things that can indicate a molar pregnancy versus a normal pregnancy:
- More severe morning sickness
- Vaginal bleeding
- Increased enlargement of the uterus
- Abnormally high hCG
- Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
What are some differential diagnoses for a Hydatidiform Mole?
- Ectopic pregnancy: Symptoms include lower abdominal pain, vaginal bleeding, and amenorrhea.
- Miscarriage: Symptoms include vaginal bleeding, abdominal pain, and passage of tissue.
- Normal pregnancy: Typically characterized by a positive pregnancy test, absence of menstruation, and possible morning sickness.
What are the investigations for a Molar Pregnancy?
Initial Ix and findings?
Definitie Ix
Molar pregnancy behaves like a normal pregnancy However some indications include:
- B-hCG Levels are often significantly higher than normally expected
- Transvaginal Ultrasound: May show a snowstorm appearance of pregnancy, low resistance of blood vessel flow and absence of a foetus
- Histology may be used to confirm after mole evacuation
What is the management of a Molar Pregnancy?
Immediate referral to a specialist centre for treatment
- Evacuation of the uterus to remove the mole (using suction curettage) which is sent for histological examination
- Hysterectomy is a possibility if fertility preservation is not a concern
- Systemic Chemotherapy: may be required if the mole has metastasised
What surveillance should be done in a Molar Pregancy?
- Bimonthly serum and urine hCG testing until levels are normal.
- In the case of a partial mole, a repeat hCG test is done 4 weeks later - if normal, the patient is discharged from surveillance.
- In the case of a complete mole, monthly repeat hCG samples are sent for at least 6 months.
Define a Prolactinoma?
Pituitary tumours characterized by excessive production of prolactin (leading to hyperprolactinaemia), a hormone that plays a crucial role in lactation.
What is the epidemiology of prolactinomas?
- The most common hormone-secreting tumours originating in the pituitary gland.
- Can affect people of any age but more commonly diagnosed in adults
What genetic condition is associated with Prolactinomas?
Multiple Endocrine Neoplasia (MEN) Type I
What are the different types of Prolactinoma?
Microprolactinomas – smaller than 10 mm
Macroprolactinomas – larger than 10 mm
What are the clinical features of Prolactinomas?
Both Genders:
- Reduced Libido
- Headaches
- Visual Field Defects (bitemporal hemianopia)
Women:
- Oligomenorrhoea/Amenorrhoea
- Galactorrhoea (breast milk production outside of pregnancy or breastfeeding)
- Infertility
- Vaginal dryness
Men:
- Erectile dysfunction
- Reduced facial hair growth
- Gynaecomastia
What are the investigations for a Prolactinoma?
- Pregnancy Test: Essential in women with childbearing potential presenting with breast milk production
- Blood Tests: Serum Prolactin, U&Es, LFTs, TFTs
- MRI scan is investigation of choice for diagnosing pituitary tumours
What is the management of Prolactinomas?
Pharmacological:
- Dopamine Agonists (e.g. Cabergoline or Bromocriptine): These drugs reduce serum prolactin levels, alleviate galactorrhea, and restore gonadal function.
- Trans-sphenoidal Surgical Resection is indicated when medical treatment fails to manage the tumour effectively. Definitive treatment
- Radiotherapy: Reserved for cases where other treatments are unsuccessful.
What are some complications of Prolactinomas?
- Hormonal imbalances
- Recurrence of the tumour
- Risks associated with surgical and radiation interventions
Define Ovarian Cancer?
Malignant proliferation originating from various cell types within the ovary
* 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas
What are the different types of Ovarian Tumour?
- Epithelial Cell Tumours
- Germ Cell Tumours
- Sex Cord-Stromal tumour
- Malignant (Krukenberg Tumour)
What are Epithelial Cell Ovarian Tumours?
- Originate from the epithelium which lines the fimbria of the fallopian tubes or the ovaries
- Epithelial tumours are partially cystic, and the cysts can contain fluid
- The initial metastatic spread typically involves the peritoneal cavity, with seeding particularly affecting the bladder, paracolic gutters and the diaphragm
- Around 90% of ovarian cancers are epithelial ovarian tumours.
What are the subtypes of Epithelial Cell Ovarian Tumours?
- Serous tumours (the most common)
- Endometrioid carcinomas
- Clear cell tumours
- Mucinous tumours
- Undifferentiated tumours
What are Germ Cell Ovarian Tumours?
Also known as
Contents
Spread
Affect
Markers
- Originate from the germ cells in the embryonic gonad (Teratomas)
- May contain various tissue types such as Skin, teeth, bone and hair
- Spread predominantly via the lymphatic route
- Common in young women
- Tumour markers include alpha-fetoprotein and sometimes beta human chorionic gonadotrophin (B-HCG).
What are Sex Cord-Stromal Tumours?
- Originate Granulosa/Theca (in women) or Leydig/Sertoli cells (In males) or are Fibromas
- Make up less than 5% of tumours
Often produce Hormones:
- Granulosa: Oestrogen leading to precocious puberty
- Leydig: Androgens leading to masculinising features and associated with Peutz Jegher Syndrome
- Fibroma: Associated with Meigs Syndrome
What is a Krukenberg Tumour?
Characteristic cells?
Ovarian Tumours may be due to metastasis from a cancer elsewhere in the body
- A Krukenberg tumour refers to a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach.
- Krukenberg tumours have characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy.
Where do Ovarian Cancers typically metastasise to?
Occurs via Trans coelomic routes (Across a body cavity) and thus can spread to the liver, bowel and associated mesentery
What are some risk factors for Ovarian Cancer?
- Advanced age (peak age 60 years)
- Smoking
- Increased number of ovulations (early menarche, late menopause, no pregnancies)
- Genetic predisposition (BRCA 1 and 2 genes and family history)
- Obesity
- Hormone replacement therapy (HRT)
- Recurrent use of clomiphene (fertility drug)
What are some protective factors for Ovarian Cancer?
Factors that reduce lifetime ovulations
- Childbearing (parity)
- Breastfeeding
- Early Menopause
- Combined oral contraceptive pill
What are the clinical features of Ovarian Cancer?
Often present late in disease progression with Non-specific symptoms
- Abdominal bloating
- Early satiety (feeling full after eating)
- Loss of appetite
- Pelvic pain
- Urinary symptoms (frequency / urgency)
- Weight loss
- Abdominal or pelvic mass
- Ascites (due to VEGF increasing vessel permeability)
Why may a patient with Ovarian Cancer present with Hip or Groin Pain?
An Ovarian mass may press on the obturator nerve causing referred hip or groin pain.
What are some differential diagnoses for Ovarian Cancer?
- Gastrointestinal conditions (e.g., irritable bowel syndrome): Characterised by abdominal pain, bloating, and changes in bowel habits
- Fibroids: May cause heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation
- Ovarian cysts: Can cause pelvic pain, fullness or heaviness in the abdomen, and bloating
- Other cancers (e.g., bladder, endometrial): May present with symptoms such as abnormal bleeding, pelvic pain, and urinary symptoms
When should Suspected Ovarian Cancer prompt an Urgent 2 Week Wait Referral or Carry out further investigations before Referral
Direct Urgent 2-Week-Wait Referral
- Ascites
- Pelvic Mass
- Abdominal Mass
Carry out further Investigations before referral Starting with CA125 blood test
- New symptoms of IBS/change in bowel habit
- Abdominal Bloating
- Early Satiety
- Pelvic Pain
- Urinary frequency or urgency
- Weight loss
What are the investigations for Ovarian Cancer?
initial
Secondary care
What else should be calculated?
What should be done for women under 40 years?
Initial Investigations:
- CA125 Blood Test: (> 35IU/ml is significant)
Then
- Urgent Pelvic and Abdominal Ultrasound Scan
Secondary Care:
- CT scan to establish the diagnosis and stage the cancer
- Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy
- Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells
Diagnosis is difficult and often done with diagnostic Laparoscopy
Risk of Malignancy Index
Women Under 40 years with complex ovarian mass:
- AFP and hCG tumour markers for possible Germ cell tumour
What are some causes of a Raised CA125?
CA125 is a tumour marker for epithelial cell ovarian cancer.
It is not very specific, and there are many non-malignant causes of a raised CA125:
- Endometriosis
- Fibroids
- Adenomyosis
- Pelvic infection
- Liver disease
- Pregnancy
How is Ovarian Cancer Staged?
Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)
What is the management of Ovarian Cancer?
Managed by specialist gynaecology oncology MDT
Surgery: Radical Hysterectomy, BSO, Infracolic omentectomy are options if early stage
Chemotherapy: Used an adjuvant to surgery.
**Bevacizumab (anti-VEGF) may also be used
Define Ovarian Cysts
Fluid filled sac that develops within or on the surface of an ovary
They can range in size and occur as a normal part of the menstrual cycle or as a result of an underlying condition.
What is the Epidemiology of Ovarian Cysts?
- Very common in premenopausal women with most women experiencing at least one
- Cysts in postmenopausal women are more concerning for malignancy and need further investigation
- Majority of cysts in premenopausal women are benign
What is the Aetiology of Ovarian Cysts?
Can be caused by a variety of factors, including:
- Hormonal imbalances
- Endometriosis,
- Pregnancy
- Pelvic infection
What is a String of pearls appearance?
Patients with multiple ovarian cysts may have a String of pearls appearance to the ovaries
This is not PCOS unless they have other features of the condition
What are the clinical features of Ovarian Cysts?
Most ovarian cysts are Asymptomatic
May Cause:
- Pelvic pain (often acute unilateral pain)
- Bloating
- Fullness in the abdomen
- Palpable pelvic mass
- Intra-peritoneal haemorrhage with haemodynamic compromise
What are the different types of Ovarian Cyst?
Functional Cysts:
- Follicular Cysts: Most common and harmless. they form due to failure to the follicle failing to rupture and release an egg.
- Corpus Luteum Cysts: Occur when the corpus luteum fails to break down and fills with fluid. Often seen in early pregnancy
Non-Functional Cysts:
- Serous Cystadenoma: Benign tumours of the epithelial cells
- Mucinous Cystadenoma: Can become huge and cause psuedomyoxma peritoni
- Endometrioma: occurs with endometriosis
- Malignant cysts: Dermoid/ Sex cord/Stromal
What are some differential diagnoses for Ovarian Cysts?
- Ovarian torsion: Characterised by sudden, severe pain, often accompanied by nausea and vomiting.
- Ectopic pregnancy: Symptoms include abdominal pain, amenorrhea, and vaginal bleeding.
- Appendicitis: Presents with abdominal pain that begins near the navel and then moves lower and to the right, loss of appetite, nausea, and vomiting.
What are the investigations for Ovarian Cysts?
Detailed History and Examination: to establish for features that may suggest malignancy
Pregnancy test: Exclude ectopic pregnancy
Ultrasound Scan if less than 5cm in premenopausal women then no further investigation needed.
Tumour Markers: CA125, AFP, LDH, B-hCG
What are features from the history that may suggest malignancy?
- Abdominal bloating
- Reduce appetite
- Early satiety
- Weight loss
- Urinary symptoms
- Pain
- Ascites
- Lymphadenopathy
What is the Risk of Malignancy Index?
Estimates the risk of an ovarian mass being malignant, taking account of three things:
- Menopausal status
- Ultrasound findings
- CA125 level
What is the management of Ovarian Cysts?
Simple ovarian cysts in premenopausal women can be managed based on their size:
- Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.
- 5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.
- More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist
When there is a raised CA125, this should be a two-week wait suspected cancer referral
- Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.
What are some complications of Ovarian Cysts?
- Torsion
- Haemorrhage into the cyst
- Rupture, with bleeding into the peritoneum
What is Meig’s Syndrome?
Triad of:
- Ovarian fibroma (benign ovarian tumour)
- Pleura effusion
- Ascites
Treatment is removal of the tumour
Define Ovarian Torsion?
A condition where the ovary twists in relation to the surrounding connective tissue, the fallopian tube (Adnexa) and blood supply.
Adnexal torsion: when the fallopian tube is involved
What is the aetiology of Ovarian torsion?
- Usually due to an ovarian mass (often > 5cm) such as a cyst or tumour.
- Can occur with normal ovaries in girls before menarche when girls have a longer infundibulopelvic ligaments
What are some risk factors for Ovarian Torsion?
- Ovarian mass: present in around 90% of cases of torsion
- Being of a reproductive age
- Pregnancy
- Ovarian hyperstimulation syndrome
What is the pathophysiology of Ovarian Torsion?
- Ovary twists around the adnexa and blood supply
- Leads to ischaemia of the Ovary
- If torsion persists then necrosis will occur and the function of the ovary will be lost
- Ovarian torsion is an emergency where treatment delay can have significant consequences
What are the clinical features of Ovarian Torsion?
-
Sudden onset severe unilateral pelvic pain
- Constant getting progressively worse
- Associated with Nausea and Vomiting
- Localised tenderness
- May have a palpable mass
- Vaginal examination may show adnexial tightness
What are the investigations for Ovarian Torsion?
Pelvic Ultrasound initial investigation of choice
- Transvaginal is Ideal but Transabdominal can be used if transvaginal is not possible.
- May show “Whirlpool sign of free fluid” in the pelvis and Oedema of the ovary
Laparoscopic Surgery is definitive diagnostic investigation
What is the management of Ovarian Torsion?
- Patients need emergency admission under gynaecology for urgent investigation and management.
- Depending on the duration and severity of the illness they require laparoscopic surgery to either:
- Un-twist the ovary and fix it in place (detorsion)
- Remove the affected ovary (oophorectomy)
What are some complications of Ovarian Torsion?
- Delayed treatment can lead to loss of function of that ovary
- If necrotic ovary is not removed it may lead to infection, abscess formation and sepsis
Define Polycystic Ovarian Syndrome (PCOS)?
PCOS is the most common endocrine condition in women of reproductive age.
The disorder is characterised by failure of follicles to release eggs leading to anovulation, hyperandrognism features and enlarged/multicystic ovaries
Define these words:
Anovulation
Oligoovulation
Amenorrhoea
Oligomenorrhoea
Androgens
Hyperandrogenism
Hirsutism
Insulin Resistance
- Anovulation: refers to the absence of ovulation
- Oligoovulation: refers to irregular, infrequent ovulation
- Amenorrhoea: refers to the absence of menstrual periods
- Oligomenorrhoea: refers to irregular, infrequent menstrual periods
- Androgens: are male sex hormones, such as testosterone
- Hyperandrogenism: refers to the effects of high levels of androgens
- Hirsutism: refers to the growth of thick dark hair, often in a male pattern, for example, male pattern facial hair
- Insulin Resistance: refers to a lack of response to the hormone insulin, resulting in high blood sugar levels
What is the Epidemiology of PCOS?
- Prevalent condition affecting up to 1/3 of women during their reproductive years
What is the Aetiology of PCOS?
Complex and Multifactorial (still unclear)
- Hormone imbalances, low oestrogen, high androgens and high insulin (with insulin resistance) leads to increased circulating androgens
What criteria is used to make a diagnosis of PCOS?
Rotterdam Criteria: requires at least 2 out of 3 key features:
- Oligoovulation or Anovulation
- Biohemical evidence of Hyperandrogenism (hirsutism and acne)
- Polycystic Ovaries on Ultrasound (> 12 cysts on imaging or ovarian volume > 10 cm3)
Having only one feature such as multiple ovarian cysts does not qualify for diagnosis of PCOS
What are some key clinical features in PCOS?
- Oligomenorrhoea or amenorrhoea
- Sub/Infertility
- Obesity (in about 70% of patients with PCOS)
- Hirsutism
- Acne
- Acanthosis Nigricans
- Mood changes including Anxiety and depression
- Hair loss in a male pattern
What other features may women with PCOS experience?
- Insulin resistance and diabetes
- Acanthosis nigricans
- Cardiovascular disease
- Hypercholesterolaemia
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
What are some differential diagnoses for PCOS?
- Menopause: characterised by cessation of menstruation, hot flashes, vaginal dryness, mood changes, and sleep problems.
- Congenital adrenal hyperplasia (CAH): presenting with signs of androgen excess like hirsutism, acne, and irregular periods.
- Hyperprolactinaemia: symptoms include irregular periods, galactorrhoea, and infertility.
- Androgen-secreting tumours: may cause virilisation, amenorrhoea, and hirsutism.
- Cushing’s syndrome: characterised by weight gain, purple stretch marks, and easy bruising.
What are some differential diagnoses for Hirsutism?
- Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
- Ovarian or adrenal tumours that secrete androgens
- Cushing’s syndrome
- Congenital adrenal hyperplasia
What is the relationship between Insulin Resistance and PCOS?
When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body.
Insulin promotes the release of androgens from the ovaries and adrenal glands.
Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone).
Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver.
SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS.
The high insulin levels contribute to halting the development of the follicles in the ovaries
This leads to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan).
Diet, exercise and weight loss help reduce insulin resistance.
What are the investigations for PCOS?
Blood tests
Addition for DDx
Imaging
Blood Tests:
- LH: Raised
- LH:FSH Ratio increased >2 aids in differentiating from menopause (ratio is normal)
- SHBG is normal or low
- Total and Free Testosterone: Raised
Other Blood Tests for Exclusion of conditions
- Insulin resistance (Fasting and OGTT)
- Oestrogen Levels: Normal or Raised
- TFTs: Exclude thyroid dysfunction
- 17 Hydroxyprogesterone: Exclude CAH
- Prolactin levels: Exclude hyperprolactinaemia
- 24 Hour urinary cortisol: Exclude Cushing’s
Imaging: Pelvic Ultrasound
- Transvaginal Ultrasound is Gold Standard
- String of Pearls Appearance
- 12 or more developing follicles in one ovary
- Ovarian Volume > 10 cm3
What is PCOS a significant risk factor for?
Endometrial Cancer
Within the syndrome of PCOS it has multiple risk factors for Endometrial cancer including:
- Obesity
- Diabetes
- Insulin Resistance
- Amenorrhoea
What is the General Management of PCOS?
General advice
Endometrial risk
Infertility
Hirsuitism
Acne
General Advice:
- Education and reduction of increased risks of CVD, DM, Endometrial cancer, Obesity
- Weight Loss,
- Orlistat may be used in BMI >30
- Exercise,
- Smoking cessation,
- Antihypertensives (if required),
- Statins (if QRISK >10%)
Managing risk of Endometrial Cancer:
> 3 month gap between periods or abnormal bleeding - A withdrawal bleed required every 3-4 months
- Pelvic USS to measure endometrial thickness
- If Contraception wanted: Mirena coil/COCP
- If no Contraception wanted: Medroxyprogesterone Acetate 10mg OD for 14 days
Manage Infertility:
- 1st Line: Weight Loss
- 2nd line: Clomifene/Letrozole (Metformin may also help)
- 3rd line: IVF
Managing Hirsuitism:
- 1st Line: Shaving/hair removal
- 3rd Gen COCP (co-cyprindiol/Dianette)
- Topical Elfornithine
Managing Acne:
- 1st Line: COCP
- Topical Benzoyl Peroxide
- Oral Tetracycline
How is the Risk of Endometrial Cancer reduced in PCOS?
- Weight loss
- Mirena coil
-
Inducing a withdrawal bleed at least every 3-4 months using:
- Cyclical Progestogens (medroxyprogesterone acetate 10mg OD for 14 days)
- COCP
How can Infertility be managed in PCOS?
1st Line: Weight loss is the initial step for improving fertility
2nd Line:
- Letrozole
- Clomiphene - induces ovulation by inhibiting oestrogen feedback on hypothalamus so increase FSH
3rd Line:
- Laparoscopic Ovarian Drilling
- IVF
How can Hirsutism be managed in PCOS?
Weight loss may improve the symptoms of Hirsutism
- Co-cyprindiol (Dianette) is a COCP liscenced for hirsutism and acne with anti-androgenic effects
Others:
- Topical Eflornithine
- Electrolysis
- Laser hair removal
How can Acne be managed in PCOS?
Combined Oral Contraceptive Pill (COCP) is First line (Co-cprindiol).
Other treatments:
- Topical Adapalene (retinoid)
- Topical Antibiotics (clindamycin + Benzoyl peroxide)
- Topical Azelaic acid 20%
- Oral Tetracycline antibiotics (lymecycline)
What is a major side effect of Co-cyprindiol (Dianette)?
Significantly increased risk of Venous Thromboembolism
- This contraindicated in increased risk of clots
- Medication usually stopped after 3 months of use.
Define Pelvic Inflammatory Disease (PID)
Inflammation and infection of the organs of the pelvis, caused by infection spreading up the vagina through the cervix and into the upper genital tract.
It is a significant cause of tubular infertility and chronic pelvic pain
Define these words:
Endometritis
Salpingitis
Oophoritis
Parametritis
Peritonitis
- Endometritis: is inflammation of the endometrium
- Salpingitis: is inflammation of the fallopian tubes
- Oophoritis: is inflammation of the ovaries
- Parametritis: is inflammation of the parametrium, which is the connective tissue around the uterus
- Peritonitis: is inflammation of the peritoneal membrane
What is the Aetiology of PID?
Most commonly via Sexually Transmitted Pelvic Infections:
- Neisseria gonorrhoeae (produces more severe PID)
- Chlamydia trachomatis
- Mycoplasma genitalium
Less commonly via non-sexually transmitted infections:
- Gardnerella vaginalis (associated with bacterial vaginosis)
- Haemophilus influenzae
- Escherichia coli
What are the risk factors for PID?
- Not using barrier contraception
- Multiple sexual partners
- Younger age
- Existing sexually transmitted infections
- Previous pelvic inflammatory disease
- Intrauterine device (e.g. copper coil)
What are the clinical features of PID?
Women may present with symptoms of:
- Pelvic or lower abdominal pain
- Abnormal vaginal discharge
- Abnormal bleeding (intermenstrual or postcoital)
- Pain during sex (dyspareunia)
- Fever
- Dysuria
Examination findings may reveal:
- Pelvic tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
What are some differential diagnoses for PID?
- Appendicitis: Presents with right lower quadrant abdominal pain, fever, nausea, and vomiting.
- Ectopic Pregnancy: Symptoms may include unilateral lower abdominal pain and vaginal bleeding. A positive pregnancy test is a key distinguishing factor.
- Endometriosis: Chronic pelvic pain, dysmenorrhea, and dyspareunia are common. Pain typically worsens during menstruation.
- Ovarian Cyst: Symptoms can include unilateral lower abdominal pain, bloating, and a palpable mass on examination.
- Urinary Tract Infection: Symptoms usually include dysuria, frequency, urgency, suprapubic pain, and possible fever.
What are the investigations for PID?
Pelvic Examination
High vaginal Swabs for causative organisms:
- NAAT swabs for gonorrhoea and chlamydia
- NAAT swabs for Mycoplasma genitalium (if available)
- HIV Test
- Syphilis test
High vaginal swab for BV, trichomoniasis and Candidiasis
Microscopy for Pus cells
Blood Tests: Inflammatory markers (CRP/ESR) can help support diagnosis
Pregnancy test: To exclude ectopic pregnancy
Transvaginal Ultrasound May be used
What is the management of PID?
Combination Antibiotics
- Ceftriaxone IM 1g Single dose (Cover for gonorrhoea)
- Doxycycline 100mg BD for 2/52 (cover for chlamydia and Mycoplasma)
- Metronidazole 400mg BD for 2/52 ( Cover for Gardnerella)
Alternative regime is Ofloxacin + Metronidazole
Analgesia may be required
Contact Tracing
What are the complications of PID?
- Chronic pelvic pain (in around 40% of cases)
- Infertility (approximately 15%)
- Ectopic pregnancy (about 1%)
- Sepsis
- Abscess
- Fitz-Hugh-Curtis Syndrome (about 10%)
What is Fitz-Hugh-Curtis Syndrome?
Complication of PID, chlamydia and gonorrhoea where adhesions form between the liver capsule and the peritoneum causing inflammation and infection of the liver capsule (Glisson’s capsule)
This results in right upper quadrant pain in about 10% of patients
What is the management of Fitz-Hugh-Curtis Syndrome?
Investigations include abdominal ultrasound to exclude stones.
laparoscopy to diagnose, visualise and treat adhesions by Adhesiolysis
Define Baby Blues (Postpartum Blues)?
A transient mood disorder that typically manifests around three days after childbirth.
It is characterized by irritability, anxiety about parenting skills, and tearfulness.
The condition typically resolves within two weeks without medical intervention.
What is the Epidemiology of Baby Blues?
- Very common affecting up to 80% of women after childbirth
- More commonly affects first time mothers
- 10% of these women may develop a more severe form: Postnatal Depression
What is the Aetiology of Baby Blues?
not fully understood
- Likely due to hormonal changes that occur after childbirth including a rapid drop in oestrogen and progesterone.
- Fatigue/sleep deprivation, physical discomfort after delivery and stress/challenges of caring for a new baby likely also contribute
what are the clinical features of Baby Blues?
Presents within the first week after childbirth
- Mood swings
- Low mood
- Anxiety (about parenting)
- Irritability
- Tearfulness
What are some differential diagnoses for Baby Blues?
Postpartum blues should be differentiated from other postnatal mood disorders such as postnatal depression and postpartum psychosis. The primary distinguishing symptoms are:
- Postnatal depression: Persistent feelings of sadness, anxiety, or emptiness; difficulty bonding with the baby; severe mood swings; trouble eating, sleeping, or concentrating; and thoughts of harming oneself or the baby.
- Postpartum psychosis: Severe confusion and disorientation, hallucinations and delusions, paranoia, and attempts to harm oneself or the baby.
What are the investigations for Baby Blues?
Clinical Diagnosis
- Routine screening at medical appointments is recommended by NICE to identify the approximately 10% of women who may develop postnatal depression following postpartum blues.
- Use of tools such as the Edinburgh Postnatal Depression Scale
What is the management of Baby Blues?
Supportive measures and reassurance (that the condition is common)
- Symptoms are usually mild and only last a few days.
- Baby blues tend to resolve within two weeks of delivery without any treatment being required
- Mothers should be encouraged to seek help if they have symptoms persisting beyond 2 weeks
What is the definition of Postpartum depression?
It’s a significant mood disorder that can develop at any time up to one year after the birth of a baby.
This condition represents a considerable aspect of maternal mental health and extends beyond the common “baby blues”.
Typically presenting with persistent depressive symptoms that may interfere with daily functioning and parenting.
What is the Epidemiology of Postpartum Depression?
- Affects approximated 10-20% of mothers within 1 year of childbirth
- Rates vary depending on population, geographic location, socioeconomic status (low), History of mental health and lack of social support
- Typically women are affected around 3 months after birth
What causes Postpartum depression?
Development of postpartum depression is multifactorial with a combination of Biological, Psychological, and Social factors all contributing.
What biological factors contribute to the development of postpartum Depression?
- Hormonal fluctuations post-delivery, including sudden drops in progesterone, estrogen, and thyroid hormones.
- Alterations in melatonin and cortisol rhythms and immune-inflammatory processes
- Genetic predispositions
What Psychological factors contribute to the development of postpartum Depression?
- A history of mood or anxiety disorders
- Previous episodes of postpartum depression
- Certain personality traits such as neuroticism
- Psychological stress from the transition to parenthood
- Unrealistic expectations of motherhood
What Social Factors contribute to the development of postpartum depression?
- Lack of social support
- Relationship issues,
- Life stressors
- Low socioeconomic status
What are the signs and symptoms of postpartum depression?
Classic triad of:
- Low Mood
- Anhedonia: reduced enjoyment or interest in activities.
- Lowering of energy levels.
Others:
- Biological symptoms of depression like poor appetite and disturbed sleep patterns (not associated with normal disturbed sleep patterns with a baby)
- Concerns related to bonding with the baby, caring for the baby, and in extreme circumstances, thoughts about harming oneself or the baby.
What are some differentials for postpartum depression?
Baby blues
Characterised by mild mood swings, irritability, anxiety, and tearfulness. However, these symptoms usually present within the first two weeks after birth and resolve spontaneously.
Postpartum Psychosis
Adjustment disorders
These disorders may develop in response to a major life change or stressor, such as having a baby, but the emotional or behavioural symptoms are less severe than in depression.
Generalized Anxiety Disorder (GAD)
What is the main screening tool for Postpartum depression?
Edinburgh Postnatal Depression Scale (EPDS) assess how the mother has felt over the past week with 30 questions.
A cut-off score of over 10 is used as a positive result.
What is the management of postpartum depression?
First-line treatments:
- Self-help strategies and psychological therapies e.g. Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT).
Pharmacological treatments
- Antidepressants (SSRIs) considered in high risk cases
In severe cases admission to a mother and baby inpatient mental health unit might also be necessary.
What antidepressants are preferred to be used in Postpartum Depression?
SSRIs such as:
- Paroxetine
- Sertraline
Due to their safety profile in breastfeeding as they have a low milk:plasma ratio
Fluoxetine shouldn’t be used due to its long half life
What is the definition of Postpartum Psychosis?
Also known as Puerperal Psychosis
It’s a serious psychiatric disorder that typically develops within the first two weeks following childbirth.
It is characterised by a range of psychological symptoms, including paranoia, delusions, hallucinations, mania, depression, and confusion.
What is the Aetiology of Postpartum Psychosis?
unknown but thought to be a combination of:
- Genetic susceptibility
- Hormonal Changes
- Psychosocial stressors
- Prior history of severe mental illness significantly increases the risk
What are the risk factors for Postpartum Psychosis?
- Prior history of severe mental illnesses such as schizophrenia or bipolar affective disorder
- Family history of postpartum psychosis
- Previous episode of postpartum psychosis
What is the clinical presentation of Postpartum Psychosis?
Often between 2-3 weeks post partum
- Paranoia
- Delusions (including Capgras Delusions)
- Hallucinations
- Manic episodes
- Depressive episodes
- Confusion
What is the main differential for Postpartum Psychosis?
Postpartum depression with psychotic features
How is Postpartum depression diagnosed?
Diagnosis is predominantly clinical, based on the presenting signs and symptoms.
It requires a thorough psychiatric evaluation.
Consideration should be given to other medical conditions that may cause similar symptoms, such as thyroid disorders or sepsis.
How is Postpartum psychosis managed?
Women with Postpartum Psychosis need urgent assessment and input from specialist mental health services
- Admission to mother and baby unit
- Cognitive behavioural Therapy
- May require pharmacotherapy with:
- Antidepressant medications
- Antipsychotic medications
- Mood stabilisers in some instances
Potential referral to a specialist mother and baby inpatient mental health unit in very severe cases (when the mother experiences command hallucinations, thoughts of self-harm or suicide, or delusional beliefs regarding the baby’s role or identity).
What needs to be considered when prescribing medications for Postpartum Psychosis?
The mother’s breastfeeding status and the potential for the transfer of drugs to the nursing infant.
What is the Mother and Baby Unit?
The mother and baby unit is a specialist unit for pregnant women and women that have given birth in the past 12 months.
They are designed so that the mother and baby can remain together and continue to bond. Mothers are supported to continue caring for their baby while they get specialist treatment.
How can mothers prepare for Postnatal Depression/Psychosis?
Women with existing mental health concerns before or during pregnancy are referred to perinatal mental health services.
Advice and input from specialists can help manage decisions around ongoing medications such as SSRIs, antipsychotics and lithium during pregnancy.
They also ensure that mothers are closely followed up after giving birth so management can be put in place early should these conditions occur.
What is a risk of taking SSRIs during pregnancy?
Neonatal abstinence syndrome/neonatal adaptation syndrome
- Presents in first few days after birth
- Symptoms include irritability and poor feeding
- Neonates are monitored for this after delivery
- Treatment is supportive management
Define Ectopic Pregnancy?
Gynaecological Emergency
Where a fertilised egg or embryo implants and begins to grow Outside of the uterine cavity.
Most common site is the fallopian tube
What are the regions where an Ectopic Pregnancy may occur?
- Fallopian tube (most common (97%))
- Ovary
- Cervix
- Abdomen
What are some risk factors for an Ectopic Pregnancy?
- Previous ectopic pregnancy
- Previous pelvic inflammatory disease, STIs or Salpingitis (tubal inflammation)
- Previous surgery to the pelvis (Especially the fallopian tubes)
- Intrauterine devices in situ (coils)
- Endometriosis
- Older age
- Smoking
What is the pathophysiology of an Ectopic Pregnancy?
- Fertilisation of the oocyte typically takes place in the ampulla of the fallopian tube; the conceptus must then travel into the endometrial cavity.
- This occurs due to tubal peristalsis alongside ciliary motion and tubal fluid flow.
- Any dysfunction in the tubal peristalsis above due to e.g. tubal surgery, salpingitis, PID can prevent the conceptus from implanting in the correct place.
- A pregnancy that implants in the fallopian tube will grow and eventually lead to rupture and catastrophic bleeding.
- Most tubal ectopics implant in the ampulla (widest point).
When do Ectopic pregnancies typically present?
Around 6-8 weeks gestation
What are the clinical features of an Ectopic Pregnancy?
- Pelvic or abdominal pain Often unilateral to the side of the ectopic (RIF/LIF)
- Abnormal vaginal bleeding: missed period or intermenstrual bleeding
- Cervical motion tenderness (Chandeller sign) where pain occurs when moving the cervix during a bimanual examination
- Haemodynamic instability caused by blood loss if the ectopic ruptures
- Dizziness or Syncope (due to blood loss)
- Shoulder tip pain (blood irritating the diaphragm causing referred pain)
What are some differential diagnoses for Ectopic Pregnancies?
- Miscarriage
- Appendicitis
- Ovarian Torsion
What are the investigations for an Ectopic Pregnancy?
Any female of childbearing age presenting with abdominal pain should be offered a UPT (urine pregnancy test) to exclude ectopic pregnancy
- Urine Pregnancy Test (First Line)
- Transvaginal Ultrasound Scan is investigation of choice to locate the pregnancy
- Serial serum B-hCG if no pregnancy found of USS.
What are the ultrasound findings in an ectopic pregnancy?
- A mass representing a tubal ectopic pregnancy moves separately to the ovary.
- It may appear similar to the corpus luteum however this will move with the ovary
Other features indicative:
- An empty uterus
- Fluid in the uterus (may be mistaken as a gestational sac)
What is the Management of an Ectopic Pregnancy?
women with pelvic pain/tenderness and a positive pregnancy test need to be referred to an Early Pregnancy Assessment Unit (EPAU)
All ectopic pregnancies need to be terminated (they are not viable)
Options for terminating an Ectopic Pregnancy:
- Expectant management (awaiting natural termination)
- Medical Management (methotrexate)
- Surgical management (Salpingectomy or Salpingotomy)
What is the Expectant Management for an Ectopic Pregnancy?
Criteria:
- Follow up needs to be possible to ensure successful termination
- The ectopic needs to be unruptured
- Adnexal mass < 35mm
- No visible heartbeat
- No significant pain
- HCG level < 1500 IU / l
Women with Expectant management need careful follow up with close monitoring of hCG levels and quick/easy access to services if their condition changes
What is the Medical Management for an Ectopic Pregnancy?
Criteria: Injection of Methotrexate
- Follow up needs to be possible to ensure successful termination
- The ectopic needs to be unruptured
- Adnexal mass < 35mm
- No visible heartbeat
- No significant pain
- HCG level < 5000 IU / l
- Confirmed absence of intrauterine pregnancy on ultrasound
Methotrexate is highly teratogenic and is given as an IM Injection to halt the progress of pregnancy and results in spontaneous termination
Women treated with Methotrexate are advised to not get pregnant for 3 months following treatment as the harmful effects of methotrexate may last this long
What are the monitoring criteria for Expectant or Medical management of Ectopic Pregnancies?
- Measure beta-hCG on days 0, 2, 4, and 7
- If drop of more than 15% from previous measurement, repeat weekly until beta-hCG is less than 20IU/L.
- If not, refer for further management.
What are some common side effects of using Methotrexate as medical management for an ectopic pregnancy?
- Vaginal Bleeding
- Nausea and Vomiting
- Abdominal Pain
- Stomatitis (inflammation of the mouth)
What is the Surgical Management for an Ectopic Pregnancy?
Anyone that does not meet the criteria for expectant or medical management requires surgical
Criteria for Surgical:
- Patient is haemodynamically unstable
- Pain
- Adnexal mass > 35mm
- Visible heartbeat
- HCG Levels > 5000 IU/l
Surgical Options:
- Laparoscopic salpingectomy (first line treatment for ectopic pregnancy)
- Laparoscopic salpingotomy (used in women at increased risk of infertility due to damage to other fallopian tube)
Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy
What is the problem with Laparoscopic salpingotomy as a treatment for ectopic pregnancies?
Increased risk of failure to remove the ectopic pregnancy with salpingotomy compared to salpingectomy.
- 1 in 5 women having salpingotomy may need further treatment with methotrexate or salpingectomy
Define Pregnancy of Unknown Origin/location?
Diagnosed when a woman has a positive pregnancy test, but there are no signs of an intrauterine or extrauterine pregnancy on transvaginal ultrasound.
What is the Aetiology of Pregnancy of Unknown Origin/Location?
- An early viable or failing intrauterine pregnancy
- A complete miscarriage
- An ectopic pregnancy
What are the differentials for a Pregnancy of Unknown Origin/Location?
Early viable or failing intrauterine pregnancy
- Signs and symptoms: Mild cramping, spotting or delayed menstruation.
Complete miscarriage
- Signs and symptoms: Severe abdominal pain, heavy bleeding, passage of tissue or clot-like material.
Ectopic pregnancy
- Signs and symptoms: Sharp or stabbing pain in the abdomen, light vaginal bleeding, dizziness or fainting.
What are the Investigations for Pregnancy of Unknown Origin/Location?
Serum hCG is tracked over time to monitor Pregnancy of Unknown Origin/Location
Serum hCG level is repeated after 48 hours to measure change from baseline
Monitoring the clinical signs and symptoms is more important than tracking the hCG level, and any change in symptoms needs careful assessment.
The developing syncytiotrophoblast of the pregnancy produces hCG. In an intrauterine pregnancy, the hCG will roughly double every 48 hours. This will not be the case in a miscarriage or ectopic pregnancy.
Rise of more than 63%:
- After 48 hours likely indicates an Intrauterine pregnancy.
- Repeat Ultrasound scan after 1-2 weeks to confirm intrauterine pregnancy
- Pregnancy should be visible on USS once hCG > 1500 IU/ L
Rise of Less than 63%
- May indicate an Ectopic pregnancy. This patient needs close monitoring and review
Fall of More than 50%
- Likely to indicate a miscarriage
- Urine pregnancy test should be performed after 2 weeks (confirms miscarriage is complete)
Define Miscarriage?
Miscarriage is defined as the spontaneous loss/termination of a pregnancy prior to 24 weeks gestation.
Early Miscarriage: Before 12 weeks gestation
Later Miscarriage: Between 12 and 24 weeks gestation
What is the Epidemiology of Miscarriage?
- 10% of recognised pregnancies end in miscarriage.
- Number is likely higher as many occur without the women realising she in pregnant
What is a missed miscarriage?
thT foetus is no longer alive, but no symptoms have occurred and thus the miscarriage is often missed as the mother did not know that something was wrong.
- a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
- mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
- cervical os is closed
- when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
What is a threatened miscarriage?
vaginal bleeding with a closed cervix and a foetus that is alive
What is an Inevitable miscarriage?
vaginal bleeding with an open cervix. Due to the cervix being open the miscarriage is inevitable.
What is an Incomplete miscarriage?
retained products of conception remain in the uterus after the miscarriage
- not all products of conception have been expelled
- pain and vaginal bleeding
- cervical os is open
What is a complete miscarriage?
A full miscarriage has occurred, and there are no products of conception left in the uterus
What is an Anembryonic pregnancy?
a gestational sac is present and is >25mm but contains no embryo
What are the various causes of Miscarriage?
Often Idiopathic
Foetal Pathology:
- Genetic disorder
- Abnormal development
- Placental failure
Maternal Pathology:
- Uterine abnormality (Bicornuate uterus, Cervical insufficiency)
- Cervical incompetence
- Polycystic ovary syndrome
- Poorly controlled diabetes
- Poorly controlled thyroid disease
- Anti-phospholipid syndrome, Factor V Leiden
- Infections: Toxoplasmosis, Syphilis
What are some risk factors for a miscarriage?
- advanced maternal age, with women over 35 having a significantly higher risk
- a history of previous miscarriages
- previous large cervical cone biopsy
lifestyle factors:
- smoking
- alcohol consumption
- obesity
Medical conditions:
- uncontrolled diabetes
- thyroid disorders,
What are the clinical features of a miscarriage?
May be Asymptomatic
- Vaginal Bleeding
- Pelvic Pain - Often reported to be worse than the pain of a usual period
- Vaginal tissue loss
What is the main differential for a miscarriage?
Main other differential for vaginal bleeding before 24 weeks gestation is an Ectopic Pregnancy
- Both can present with pain and vaginal bleeding
- Pain is often the first symptom in an ectopic
- Vaginal bleeding is usually larger in miscarriage
What are the investigations for a Miscarriage?
What parameters are you looking for?
Transvaginal Ultrasound Scan: Investigation of choice
Viability of Pregnancy features:
- Mean Gestational Sac Diameter
- Foetal pole and crown-rump length
- Foetal Heart Beat
When does a foetal pole develop?
- A foetal pole is expected once the mean gestational sac diameter is 25mm or more.
- When there is a mean gestational sac diameter of 25mm or more, without a foetal pole, the scan is repeated after one week before confirming an anembryonic pregnancy.
When does the foetal heart beat become visible?
- A foetal heartbeat is expected once the crown-rump length is 7mm or more.
- When the crown-rump length is less than 7mm, without a foetal heartbeat, the scan is repeated after at least one week to ensure a heartbeat develops
- When there is a crown-rump length of 7mm or more, without a foetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.
Pregnancy is considered viable when there is a foetal heart beat
What is the Management of a possible miscarriage at less than 6 weeks gestation
Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be managed expectantly
- Provided they have no pain and no other complications or risk factors (e.g. previous ectopic).
What is the Expectant Management option in a miscarriage in women less than 6 weeks gestation?
Expectant management before 6 weeks gestation involves:
- Awaiting the miscarriage without investigations or treatment.
- An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen.
- A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed.
- When bleeding continues, or pain occurs, referral and further investigation is indicated.
What is the Management of a Miscarriage at More than 6 weeks gestation?
When do you need to perform monitoring?
What determines if you do expectant, medical or surgical management
NICE 2019 suggests referral to an early pregnancy assessment service (EPAU) for women with a positive pregnancy test (more than 6 weeks’ gestation) and bleeding.
Expectant Management: Watch and Wait
- First line for women without risk factors for heavy bleeding or infection
- 1-2 weeks are given to allow the miscarriage to occur spontaneously
- repeat UPT preformed 3 weeks after bleeding and pain settle to confirm miscarriage is complete
- Persistent or worsening bleeding require further assessment
Medical Management: 200mg Mifepristone followed by 800ug Misoprostol 48 hours later
- Used for a Missed Miscarriage
- Can be a vaginal suppository or Oral dose
Surgical Management: Third line:
- Surgical Options Include:
- Manual Vacuum aspiration: under local anaesthetic as outpatient
- Electric vacuum aspiration: under general anaesthetic
- Prostaglandins (misoprostol) are given before surgical management to soften the cervix.
- Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage
What are some side effects for Misoprostol?
- Heavier bleeding
- Pain
- Vomiting
- Diarrhoea
What is the management for an Incomplete miscarriage?
An incomplete miscarriage occurs when retained products of conception (foetal or placental tissue) remain in the uterus after the miscarriage. Retained products create a risk of infection.
Options for an Incomplete Miscarriage:
- Medical management (misoprostol)
- Surgical management (evacuation of retained products of conception)
Define Recurrent Miscarriage?
Defined as the loss of 3 or more consecutive 1st trimester pregnancies.
Defined as one or more second trimester pregnancies
What are the investigations for Recurrent Miscarriage?
- Antiphospholipid antibodies
- Testing for hereditary thrombophilias
- Pelvic ultrasound
- Genetic testing of the products of conception from the third or future miscarriages
- Genetic testing on parents
What is the Management of Recurrent Miscarriage?
The management is tailored to the contributing pathology:
Genetic disorder - refer to a clinical geneticist for genetic counselling. Options include continuing pregnancy attempts with prenatal diagnosis or use of a donor egg/sperm
Uterine structural abnormality - may be treated surgically. For some congenital uterine malformations there is insufficient evidence to recommend surgical treatment
Cervical incompetence - regular ultrasound monitoring of the cervix. May use cervical cerclage
Polycystic ovary syndrome - difficult to manage as pathophysiology is not fully understood. There is no consensus on the most appropriate management. Suppression of the high LH has not been found to be effective
Antiphospholipid syndrome - heparin or low-dose aspirin
Thrombophilia - heparin may increase the live birth rate
Diabetes - improve glycaemic control
Define Abortion?
A termination of pregnancy (TOP) that is an elective procedure to end a pregnancy governed by the 1967 Abortion Act
What are the criteria for an Abortion to be performed prior to 24 weeks gestation?
- Pregnancy has not exceeded 24 weeks gestation
-
Continuing the pregnancy involves greater risk to the physical or mental health of:
- The woman
- Existing children of the family
The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners.
What are the criteria for an Abortion to be performed at anytime during the pregnancy?
- Continuing the pregnancy is likely to risk the life of the woman
- Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
- There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
What are the legal requirements for an Abortion?
- Two registered medical practitioners must sign to agree abortion is indicated
- It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
What is some Pre-Abortion Care that should be provided?
- Abortion services can be accessed by self-referral or by GP, GUM or family planning clinic referral.
- Doctors who object to abortions should pass on to another doctor able to make a referral
- Marie Stopes UK is a charity that provides abortion services
- Women should be offered counselling and information to help decision making from a trained practitioner
- Informed consent is essential
What are the Medical Options for Abortion?
What else does a women require?
A medical abortion is most appropriate earlier in pregnancy, but can be used at any gestation. It involves two treatments:
- Mifepristone (anti-progestogen)
- Misoprostol (prostaglandin analogue) 1 – 2 day later
Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis.
What are the Surgical Options for Abortion?
Surgical abortion can be performed, depending on preference and gestational age, under: Local anaesthetic (+/-plus sedation) or General anaesthetic
- Prior to surgical abortion, medications are used for cervical priming. This involves softening and dilating the cervix with misoprostol, mifepristone or osmotic dilators.
Surgical Options:
- Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
- Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
Rhesus negative women having a surgical TOP should have anti-D prophylaxis if 10 weeks gestation or more
What is some Post-Abortion Care?
- Inform women they may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks post procedure
- UPT is performed 3 weeks after abortion to confirm completion
- Support and counselling is offered
What are some complications of an Abortion?
- Bleeding
- Pain
- Infection
- Failure of the abortion (pregnancy continues)
- Damage to the cervix, uterus or other structures
- Psychological stress
Define Gestational Diabetes?
Diabetes that is triggered by pregnancy due to reduced insulin sensitivity during pregnancy and resolves after birth.
What is the Epidemiology of Gestational Diabetes?
- Approximately 5% of pregnancies are affected by GDM.
- Second most common complication of pregnancy
- Women diagnosed with GDM have an increased risk of developing T2DM
- Up to a 50% chance of developing T2DM within 5-10 years postpartum
What are some risk factors for Gestational Diabetes?
- BMI of > 30 kg/m²
- previous macrosomic baby weighing 4.5 kg or above
- previous gestational diabetes
- first-degree relative with diabetes
- family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
What is the pathophysiology of Gestational Diabetes?
Placental Hormones:
- human placental lactogen (hPL), progesterone, cortisol, and prolactin, have anti-insulin properties.
- These hormones increase as the pregnancy progresses
- Promote insulin resistance in the mother, ensuring that more glucose is available for the growing fetus.
- By the third trimester, insulin resistance peaks, which can overwhelm the body’s ability to regulate blood sugar
Pancreatic Dysfunction:
- Imapired Beta-cell function
- limits the ability to increase insulin production
- Therefore cannot overcome the insulin resistance
- leads to hyperglycaemia
What are the clinical features of Gestational Diabetes?
Often no noticeable symptoms
- Thirst
- Polyuria
- Fatigue
What are the differential diagnoses for Gestational Diabetes?
- Type 1 or Type 2 Diabetes Mellitus: Generally presents with symptoms outside of pregnancy, including potential weight loss
- Other forms of gestational hyperglycaemia: These can be identified through early pregnancy HbA1c testing
When should Investigations for Gestational Diabetes take place?
- Women with PMHx of GDM should have OGTT performed ASAP after booking and at 24-28 weeks if first test is normal
- Women with any other risk factors should be screened for GDM at 24-28 weeks gestation
- When there are features suggestive of GDM:
- Large for dates fetus
- Polyhydramnios (increased amniotic fluid)
- Glucose on urine dipstick
What are the investigations for Gestational Diabetes?
Oral Glucose Tolerance Test (OGTT):
Used in patients with risk factors for gestational diabetes or when there are features suggestive of GDM.
OGTT performed in the morning after fasting. Patient drinks 75g glucose drink and then blood sugar level is measured before and at 2 hours after.
Gestational Diabetes:
- Fasting: > 5.6 mmol/l
- At 2 hours: > 7.8 mmol/l
(remember for GDM cut off is 5-6-7-8)
What is the Management for Gestaional Diabetes?
What monitoring is performed?
Patients with GDM need careful explanation about the condition and learn how to monitor and tract blood sugar
First Line:
- Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin if targets are not met.
Second Line:
- Fasting glucose above 7 mmol/l: start insulin ± metformin
- Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
- Glibenclamide (a Sulfonylurea) Can be used if Insulin or Metformin are not tolerated
Postpartum management includes glucose testing to ensure resolution of GDM
Women with GDM must also have 4 weekly USS to tract foetal growth at 28, 32 and 36 weeks
When are the extra scans required if a patient has gestational diabetes?
4-weekly scans at: 28, 32 and 36 weeks to monitor foetal growth
What are the target blood sugar levels for women with Gestational Diabetes?
NICE 2015 Targets:
- Fasting: 5.3 mmol/l
- 1 hour post-meal: 7.8 mmol/l
- 2 hours post-meal: 6.4 mmol/l
- Avoiding levels of 4 mmol/l or below
What are some Maternal Complications of Gestational Diabetes?
- Pre-eclampsia
- Developing T2DM (50% increased risk)
- Increased risk of cardiovascular disease
What are some Foetal complications of Gestational Diabetes?
Key Complications:
- Macrosomia leading to shoulder dystocia
- Neonatal hypoglycaemia
Others:
- Childhood Obesity (2x background risk)
- Increased risk of Metabolic syndrome + associated complications
- Polycythaemia (raised haemoglobin)
- Jaundice (raised bilirubin)
- Congenital heart disease
- Cardiomyopathy
What is the management for Neonatal hypoglycaemia?
Babies born to mothers with GDM need close monitoring for neonatal hypoglycaemia with regular blood glucose checks and frequent feeds.
- Maintain blood glucose > 2mmol/l
- If it falls below this they may need IV Dextrose of nasogastric feeding
How should you manage women with pre-existing diabetes who are considering getting pregnant?
- Weight loss for women with BMI of > 27
- Stop oral hypoglycaemic agents, apart from metformin, and commence insulin
- Folic acid 5 mg/day from pre-conception to 12 weeks gestation
- Detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
Retinopathy screening performed at booking and at 28 weeks gestation
Planned delivery between 37 and 38+6
What are the target levels for glucose during pregnancy for women with Pre-existing Diabetes?
Both type I and type II diabetes should aim for the same target insulin levels as with gestational diabetes
NICE 2015 Targets:
- Fasting: 5.3 mmol/l
- 1 hour post-meal: 7.8 mmol/l
- 2 hours post-meal: 6.4 mmol/l
- Avoiding levels of 4 mmol/l or below
What medication should women with Pre-existing type 2 diabetes be on during pregnancy?
Metformin and Insulin.
Other oral diabetic medications should be stopped
What is an important complication to consider in women with Pre-existing diabetes who are pregnant?
Diabetic Retinopathy: referral to ophthalmologist for diabetic retinopathy screening
- Retinopathy Screening should be performed shortly after Dating/Booking scan (11 and 14 weeks) and at 28 weeks gestation
- Pre-existing diabetes and pregnancy carries a risk of rapid progression of retinopathy
What should the planned delivery times be for women with Pre-existing and Gestational diabetes?
Pre-existing Diabetes:
- Planned delivery between 37 and 38+6 weeks
Gestational Diabetes:
- Women can give birth up to 40+6 weeks
What insulin treatment should be used during labour for women with Type I diabetes?
Sliding-scale insulin regime considered during labour for women with T1DM.
May also be considered for women with poorly controlled blood sugars with GDM or T2DM.
Define Multiple Pregnancy?
Refers to a pregnancy with more than one foetus
Define monozygotic?
identical twins (from a single zygote)
Define Dizygotic?
non-identical (from two different zygotes)
Define Monoamniotic?
Single amniotic sac
Define Diamniotic?
Two separate amniotic sacs
Define Monochorionic?
Share a single placenta
Define Dichorionic?
Two separate placentas
What type of Multiple pregnancy has the best outcomes?
Diamniotic, Dichorionic
Twin pregnancies as each foetus has their own nutrient supply.
How is Multiple Pregnancy usually diagnosed?
Usually diagnosed on the “booking/dating” ultrasound scan
How can the type of twins be identified from an Ultrasound Scan?
- Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign
- Monochorionic diamniotic twins have a membrane between the twins, with a T sign
- Monochorionic monoamniotic twins have no membrane separating the twins
What are the risks to the mother in the case of Multiple Pregnancies?
- Anaemia
- Polyhydramnios
- Hypertension
- Malpresentation
- Spontaneous preterm birth
- Instrumental delivery or caesarean
- Postpartum haemorrhage
What are the risks to the Foetuses/neonates in the case of Multiple Pregnancies?
- Miscarriage
- Stillbirth
- Foetal growth restriction
- Prematurity
- Twin-twin transfusion syndrome
- Twin anaemia polycythaemia sequence
- Congenital abnormalities
What is Twin-Twin Transfusion Syndrome?
Twin-twin transfusion syndrome occurs when the foetuses share a placenta. It is called foeto-foetal transfusion syndrome in pregnancies with more than two foetuses.
When there is a connection between the blood supplies of the two foetuses, one foetus (the recipient) may receive the majority of the blood from the placenta, while the other foetus (the donor) is starved of blood.
- The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios.
- The donor has growth restriction, anaemia and oligohydramnios. There will be a discrepancy between the size of the foetuses.
Women with Twin-Twin transfusion syndrome need to be referred to a tertiary specialist foetal medicine centre
What is Twin Anaemia Polycythaemia Sequence?
Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute.
One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).
What additional monitoring is required for Women in the case of Multiple Pregnancy?
Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at:
- Booking clinic
- 20 weeks gestation
- 28 weeks gestation
Additional ultrasound scans are required in multiple pregnancy to monitor for foetal growth restriction, unequal growth and twin-twin transfusion syndrome:
- 2 weekly scans from 16 weeks for monochorionic twins
- 4 weekly scans from 20 weeks for dichorionic twins
When should Planned birth be offered for Uncomplicated monochorionic monoamniotic twins?
32 and 33+6 weeks
When should Planned birth be offered for Uncomplicated monochorionic diamniotic twins?
36 and 36+6 weeks
When should Planned birth be offered for Uncomplicated dichorionic diamniotic twins?
37 and 37 +6 weeks
When should Planned birth be offered for Triplets?
Before 35 +6 weeks
What is the mode of delivery for monoamniotic twins?
Require elective caesarean section between 32 and 33 +6 weeks
What are the options for Delivery in Diamniotic twins?
Aim to deliver between 37 and 37 +6 weeks
- Vaginal delivery is possible when the first baby has a cephalic presentation (head first)
- Caesarean section may be required for the second baby after successful birth of the first baby
- Elective caesarean is advised when the presenting twin is not cephalic presentation
Why is Anaemia in Pregnancy a common issue?
Anaemia is defined as a low concentration of haemoglobin.
In pregnancy, the plasma volume increases and thus there is a reduction in the concentration of haemoglobin leading to anaemia.
It is important to optimise the treatment of anaemia in pregnancy so that the woman has reasonable reserves in cases there is significant blood loss during delivery
What is the presentation of Anaemia in pregnancy?
Often asymptomatic
May present as:
- Shortness of breath
- Fatigue
- Dizziness
- Pallor
When is anaemia routinely screened for during pregnancy and what are the normal ranges?
Booking/dating Bloods: > 110 g/l
28 Weeks Gestation: > 105 g/l
Post-partum: > 100 g/l
Women are also offered Haemoglobinopathy screening at the booking clinic for Thalassaemia and Sickle Cell Disease
What are some potential causes of Anaemia in pregnancy?
Low MCV Indicates Iron Deficiency Anaemia
Normal MCV: Indicates a physiological anaemia due to increased plasma volume of pregnancy
Raised MCV: Indicates B12 or Folate Deficiency
What is the Management of Anaemia in Pregnancy?
Depends on the cause:
Iron:
- Women with anaemia in pregnancy are started on iron replacement: Ferrous sulphate 200mg 3x daily
- Women who are not anaemic but have low ferritin may also be started on supplementary iron.
- Treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished
B12:
- The increased plasma volume and B12 requirements often result in a low B12 in pregnancy. Women with low B12 should be tested for pernicious anaemia (checking for intrinsic factor antibodies).
- IM Hydroxocobalamin injections or Oral Cyanocobalamin Tables
Folate:
- All women should already be taking folic acid 400mcg OD
- Women with folate deficiency are started on folic acid 5mg daily
Define Spina Bifida?
Spina bifida is a neural tube defect characterised by incomplete development of the spinal column, resulting in herniation of the spinal cord.
What is Spina Bifida Occulta?
- Incomplete fusion of the vertebrae, but with no herniation of the spinal cord
- May be visible only as a small tuft of hair overlying the site
What is Meningocele?
- Incomplete fusion of the vertebrae, with herniation of a meningeal sac containing CSF
- Visible prominence at the site, but usually covered by skin
What is Myelomeningocele?
- Incomplete fusion of the vertebrae with herniation of herniation of a meningeal sac containing CSF and spinal cord.
- Usually accompanied by other defects such as hydrocephaly or Chiari malformation
- Visible prominence at the site, with exposed meninges
How can Spina Bifida be prevented?
All pregnant women, and those trying to conceive are recommended to take folic acid as this has been shown to decrease the risk of neural tube defects
- 400 ug/day from 3 months prior to conception, until 12 weeks gestation
- In women at higher risk (e.g. those with a child affected by a neural tube defect, or those on certain medications) are recommended a higher dose of 5mg/day
How is Spina Bifida Diagnosed?
Usually diagnosed on prenatal scans
What are the clinical features of Spina Bifida?
Neurological:
- Motor deficits
- Sensory deficits
- Neurogenic bladder or bowel
- Hydrocephalus
- Seizures
Musculoskeletal:
- Increased risk of hip subluxation
- Scoliosis
- Contractures
What is the Management of Spina Bifida?
- Primary neurosurgical repair
- Orthopaedic surgery
Define Chronic Hypertension/Pre-existing in terms of pregnancy?
High blood pressure that exists before pregnancy or is diagnosed before 20 weeks gestation and is longstanding. This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia.
Define Pregnancy Induced Hypertension (Gestational Hypertension)?
When there is an onset of high blood pressure that occurs after 20 weeks gestation without the presence of proteinuria
What is the Aetiology of Gestational Hypertension?
Multifactorial, often involving genetic predisposition, lifestyle factors, and physiological changes during pregnancy.
What is the Presentation of Gestational Hypertension?
Asymptomatic
- May have headaches and blurred vision
What are some differential diagnoses for Gestational Hypertesion?
- Preeclampsia: Characterized by high blood pressure and damage to another organ system, most often the liver and kidneys, after 20 weeks of gestation.
- Chronic Kidney Disease: Typically presents with proteinuria, haematuria, and a rise in serum creatinine.
How is Gestational Hypertension diagnosed?
Gestational Hypertension must be new onset after 20 weeks gestation WITHOUT proteinuria
- Blood pressure Monitoring
- Urinalysis: To exclude proteinuria and subsequently Pre-eclampsia
How is Gestational Hypertension Managed?
Monitoring
BP Control
Admission
2nd/3rd line/
- Discontinuation of some anti-hypertensive medications (ACEis and ARBs) to switch to pregnancy safe options.
- Regular Blood Pressure Monitoring
- Regular Urinalysis at least weekly
- Monitoring Foetal growth by serial growth scans
- PlGF testing on one occasion
Blood pressure control:
- Gestational Hypertension > 150/100mmHg: Oral Labetalol
- Treating to aim for BP < 135/85mmHg
- Admission for women with a BP above 160/110 mmHg
- Gestational Hypertension (mild) of: 140/90 to 149/99mmHg: No treatment other than regular monitoring
Alternatives if Labetalol is not tolerated:
- 2nd Line: Nifedipine.
- 3rd Line: Methyldopa
Define Pre-eclampsia
Pre-eclampsia refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine).
It occurs after 20 weeks gestation
Define Eclampsia?
When seizures occur as a result of Pre-eclampsia due to cerebral vasospasm
What is the Epidemiology of Pre-eclampsia?
- Significant cause of maternal and foetal morbidity and mortality
- Occurs after 20 weeks gestation
What are some risk factors for Pre-eclampsia?
High-risk factors are:
- Pre-existing hypertension
- Previous hypertension in pregnancy
- Existing autoimmune conditions (e.g. systemic lupus erythematosus)
- Diabetes
- Chronic kidney disease
Moderate-risk factors are:
- Older than 40
- BMI > 35
- More than 10 years since previous pregnancy
- Multiple pregnancy
- First pregnancy
- Family history of pre-eclampsia
Aspirin is given to women from 12 weeks until delivery for those with 1 Major or 2 moderate risk factors
What is the Pathophysiology of Pre-eclampsia?
In normal pregnancy, the trophoblast cells (cells that form the placenta) invade the uterine lining and remodel the spiral arteries to become low-resistance vessels that supply adequate blood flow to the growing fetus.
- In pre-eclampsia, defective trophoblast invasion leads to incomplete remodeling of the spiral arteries. As a result, these arteries remain narrow and high-resistance, limiting the blood supply to the placenta (a state called uteroplacental ischemia).
- Placental hyoxia leads to oxidative stress and pro-inflammatory cytokines release.
- This leads to systemic inflammation and impaired endothelial cell function resulting in the symptoms and complications of Pre-eclampsia
What are the clinical features of Pre-eclampsia?
What is the classic Triad?
What are some other symptoms?
Classical Triad:
- Hypertension
- Proteinuria
- Peripheral Oedema
Symptoms:
- Severe Headaches (potentially due to cerebral oedema)
- Visual Disturbance (due to retinal artery vasospasm)
- Epigastric pain (due to reduced blood flow to the liver causing injury and swelling of liver and capsule)
- Drowsiness
- Nausea and vomiting
- Hyperreflexia
Why do you get Hypertension, Proteinuria and Peripheral Oedema in Pre-eclampsia?
Hypertension
- Oxidative stress on the placenta causes the release of pro inflammatory cytokines
- These entre the mothers circulation and cause endothelial cell dysfunction
- This results in vasoconstriction and salt retention (at the kidneys) leading to hypertension
Proteinuria
- Local vasospasm and hypertension will result in reduced blood flow to the kidneys.
- The systemic inflammatory response may also lead to glomerular changes and disruption of the basement membrane and podocytes
- This results in the leakage of proteins out the kidneys causing proteinuria
Peripheral Oedema
- Endothelial injury increases vascular permeability enabling water to leak out of blood vessels and into the surrounding tissues
- Furthermore, the proteinuria leads to low protein concentrations within blood vessels reducing the oncotic pressure and hence leads to further water loss into tissues
- This results in generalised oedema that is commonly seen in the Legs, face and hands.
- Pulmonary oedema (causing cough and SOB) as well as cerebral oedema (causing headaches, confusion and seizures)
What are some maternal complications of Pre-eclampsia?
- Eclampsia (seizures due to cerebrovascular vasospasm)
- Organ failure
- Disseminated intravascular coagulation (DIC)
- HELLP syndrome (the presence of haemolysis (H), elevated liver enzymes (EL) and low platelets (LP))
What are some foetal complications of Pre-eclampsia?
- Intrauterine growth restriction (IUGR)
- Pre-term delivery
- Placental abruption
- Neonatal hypoxia
What are the investigations for Pre-eclampsia?
Blood Pressure Monitoring
- Systolic BP > 140mmHg
- Diastolic BP > 90mmHg
- Severe Pre-eclampsia: Systolic >160mmHg and Diastolic >110mmHg
Urinalysis:
- Proteinuria 1+ or more on urine dipstick
- Urine protein:creatinine ratio > 30mg/mmol is significant
- Urine albumin:creatinine ratio > 8mg/mmol is significant
Blood Tests:
- U&E, FBC, LFTs (To assess kidney function, liver function and clotting status)
How is Pre-eclampsia diagnosed?
NICE guidelines 2019 state diagnosis can be made with:
- Hypertension (systolic >140mmHg/Diastolic >90mmHg)
PLUS any of:
- Proteinuria (1+ or more on urine dipstick)
- Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
- Placental dysfunction (e.g. foetal growth restriction or abnormal Doppler studies)
What is the Management of Pre-eclampsia?
Prophylaxis?
Gestational HTN Monitoring?
Pre-eclampsia Dx monitoring?
Management of BP?
Management of Pre-eclampsia during Labour?
After Delivery?
Prophylaxis:
- Aspirin (75mg - 150mg) from 12 weeks till birth
- Women with 1 Major or 2 Minor RFs
Gestational HTN Monitoring:
- Treating to aim for a blood pressure below 135/85 mmHg
- Admission for women with a blood pressure above 160/110 mmHg
- Urine dipstick testing at least weekly
- Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
- Monitoring fetal growth by serial growth scans
- PlGF testing on one occasion (20-35 weeks)
Pre-eclampsia Dx Monitoring:
- Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
- Blood pressure is monitored closely (at least every 48 hours)
- Urine dipstick testing is not routinely necessary (the diagnosis is already made)
- Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
Management of BP:
- BP < 140/90: Rest, weight loss, exercise
- BP > 150/100: Oral Labetalol
- BP > 160/110: Admit Patient - Labetalol
- 2nd Line: Nifedipine (Modified Release)
- 3rd Line: Methyldopa
- Severe HTN or Eclampsia: IV Hydralazine
Management During Labour:
- Fluid restriction if severe pre-eclampsia or eclampsia
- BP Meds
- IV Magnesium Sulphate in Labour and 24 hours after
- Corticosteroids if premature birth planned
After Delivery
- Delivery is definitive Tx
- BP monitored until normal
- Switch to Enalapril
How does Pre-eclampsia or Eclampsia affect the planning of Delivery?
Consider early delivery at 37 weeks if blood pressure cannot be controlled or complications occur.
Corticosteroids should be given to the women having a premature birth to help the foetal lungs mature
What is the definitive cure for pre-eclampsia and Eclampsia?
Delivery of the foetus and placenta
What is the Management for Eclampsia?
Similar to Pre-eclampsia with additional IV Magnesium Sulphate to manage the seizures
Also treat the cause (HTN) too so Labetalol/nifedipine.
What is HELLP Syndrome?
Combination of features that occur as a complication of Pre-eclampsia and Eclampsia:
Haemolysis
Elevated Liver enzymes
Low Platelets
What is the Epidemiology of HELLP syndrome?
- HELLP syndrome is relatively rare, affecting approximately 0.5-0.9% of all pregnancies.
- Occurs in 10-20% of women with severe pre-eclampsia or eclampsia
- However, it is a significant cause of maternal and perinatal morbidity and mortality.
What is the Pathophysiology of HELLP Syndrome?
- Reduced perfusion of the placenta and thus oxidative stress releasing inflammatory cytokines.
- Hypertension and endothelial damage reduces blood flow to the liver causing injury and swelling. This results in elevation of liver enzymes and stretches the liver capsule causing RUQ and epigastric pain
- Endothelial cell injury leads to formation of thrombi in vasculature using up platelets making their numbers low
- Thrombi can act as blocks for RBCs which crash into them causing them to become damaged and haemolyse
What are the clinical features of HELLP Syndrome?
Headache
Nausea and/or vomiting
Epigastric pain
Right upper quadrant abdominal pain due to liver distension
Blurred vision
Peripheral Oedema
What are the investigations for HELLP Syndrome?
- Full blood count to assess for low platelet count and evidence of haemolysis
- Liver function tests to assess for elevated liver enzymes
- Coagulation studies to evaluate for disseminated intravascular coagulation
- Ultrasound scans to assess for liver abnormalities and placental abruption
What is the Management of HELLP Syndrome?
Delivery of the baby and placenta
- Mothers may also require blood transfusions to manage anaemia and thrombocytopenia
Define Obstetric Cholestasis?
Obstetric cholestasis, also known as intra-hepatic cholestasis of pregnancy, is a pregnancy-related hepatobiliary disorder that typically manifests after the 24th week of gestation.
The condition is characterised by impaired bile flow leading to the accumulation of bile acids.
When does Obstetric Cholestasis typically occur and who does it commonly affect?
- Relatively common complication of pregnancy occuring in 1%
- Develops later in pregnancy (Typically after 24-28 weeks)
- More common in South Asian Ethnicity
What is the Aetiology of Obstetric Cholestasis?
Multifactorial:
- Hormonal Factors such as Increased oestrogen and Progesterone thought to be main cause
- Genetic factors
- Environmental triggers
What is the Pathophysiology of Obstetric Cholestasis?
- Genetic and hormonal factors impair bile acid transport.
- Accumulation of bile acids in the liver due to defective bile transport.
- Increased serum bile acids cause pruritus and potential hepatocellular damage.
- Placental dysfunction due to toxic effects of high bile acid levels can lead to fetal complications like preterm labor or stillbirth.
Obstetric cholestasis is associated with an increased risk of stillbirth.
What are the clinical features of Obstetric Cholestasis?
Obstetric cholestasis typically present later in pregnancy, particularly in the third trimester.
Itching (pruritis) is the main symptom, particularly affecting the palms of the hands and soles of the feet.
Other symptoms are related to cholestasis and outflow obstruction in the bile ducts:
- Fatigue
- Dark urine
- Pale, greasy stools
- Jaundice
- Abdominal Pain
What alternative diagnoses should be considered if someone presents similarly to Obstetric Cholestasis however a rash is present?
- Polymorphic eruption of pregnancy
- Pemphigoid gestationis.
What are some differential diagnoses for Obstetric Cholestasis?
- Gallstones
- Acute fatty liver
- Autoimmune hepatitis
- Viral hepatitis
What are the investigations for Obstetric Cholestasis?
- Serum Bile Acids: Raised above 19 micromol/l
- LFTs: Mainly ALT, AST and GGT
ALP typically rises in pregnancy due to it being produced by the placenta.
What is the Management of Obstetric Cholestasis?
First Line:
- Emollients: soothe the skin
- Vitamin K Supplementation
- Antihistamines: Chlorphenamine to aid in sleeping (Not improve itching)
Second Line:
- Ursodeoxycholic acid: Improves LFTs, bile acids and symptoms and helps prevent premature birth
Induction of Labour at 37 weeks
Where is Bartholin’s Glands?
The Bartholin’s glands are a pair glands located either side of the posterior part of the vaginal introitus (the vaginal opening). They are usually pea-sized and not palpable. They produce mucus to help with vaginal lubrication.
What is a Bartholoin’s Gland Cyst
This occurs when the duct from the gland becomes blocked, resulting in palpable swelling and pain at the site of the Bartholin’s gland.
What is a Bartholin’s Gland Abscess?
This occurs when a cyst becomes infected, resulting in extreme pain, lymphadenopathy, erythema, and in rare cases, systemic upset.
What is the Aetiology of Bartholin’s Cysts and Abscesses?
The primary cause of Bartholin’s gland cysts and abscesses is the blockage of the gland’s duct.
This blockage can be due to thick mucus, inflammation, trauma, or in rare cases, malignancy.
Abscesses are typically caused by infection of a cyst, often with normal vaginal flora or sexually transmitted bacteria.
What are the clinical features of Bartholin’s Glands Cysts and Abscesses?
Bartholin’s gland cyst:
- Palpable swelling and without much pain at the site of the Bartholin’s gland.
Bartholin’s gland abscess:
- Extreme pain
- lymphadenopathy
- erythema,
- rare cases, systemic upset such as fever and malaise.
What are some differential diagnoses for Bartholin’s Cysts and Abscesses?
- Vaginal cysts: Typically asymptomatic but can cause discomfort during sex or when sitting.
- Skene’s duct cysts: Located on either side of the urethra, can cause discomfort during sex or urination.
- Vulvar cancer: Can present with a vulvar lump, itching, pain, or abnormal bleeding.
What are the investigations for a Bartholin’s Cyst or Abscess?
Clinical diagnosis with a physical examination
- Cyst is often painless
- Absess is often painful + lymphadenopathy
If postmenopausal then may require biopsy to exclude malignancy
What is the Management of Bartholin’s Cysts or Abscesses?
Cysts:
- Good hygiene and warm compresses
- Incision and Drainage is typically avoided due to likelihood of reoccurrence
Abscess:
- Antibiotics
-
Surgical intervention may be required:
- Word Catheter: requires local anaesthetic
- Marsupialisation: requires general anaesthetic
What is Sudden Infant Death Syndrome (SIDS)?
when does it most commonly occur?
Also known as Cot death is the sudden unexplained death of an infant.
It usually occurs within the first six months of life
What are some risk factors for SIDS?
- Putting the baby to sleep prone
- Parental smoking
- Co-sleeping in same bed
- Prematurity
- Hyperthermia (e.g. over-wrapping) or head covering (e.g. blanket accidentally moves)
What measures can be taken to minimise the risk of SIDS?
- Put the baby on their back when not directly supervised
- Breastfeeding
- Keep their head uncovered
- Place their feet at the foot of the bed to prevent them sliding down and under the blanket
- Keep the cot clear of lots of toys and blankets
- Maintain a comfortable room temperature (16 – 20 ºC)
- Avoid smoking. Avoid handling the baby after smoking (smoke stays on clothes).
- Room sharing NOT BED SHARING
What support is available for families who have experienced SIDS?
- Lullaby Trust is a charity to help support families affected.
- Bereavement services and counselling should also be available.
- Care of Next Infant (CONI) Team supports parents with their next infant after SIDS including extra support and home visits and resuscitation training
What are the 2 stages of the Menstrual Cycle?
Follicular/Proliferative Phase Days 1-14
Luteal/Secretory Phase Days 15-28
What happens during the Follicular/Proliferative phase of the Menstrual Cycle?
- Increased frequency of pulsatile GnRH secretion leads to an increase in LH, and an initial increase in FSH.
- Oestrogen rises gradually as granulosa cells convert thecal androgens under the influence of FSH. Progesterone levels remain low after loss of corpus luteum. Moderate levels of oestrogen exert negative feedback on FSH secretion.
- Days 1-5: Progesterone withdrawal due to degeneration of corpus luteum leads to sloughing of the stratum functionalis (a menstrual bleed).
- Days 6-14: The endometrium undergoes its proliferative phase due to rising oestrogen levels.
- Meanwhile, 15-20 early antral (tertiary) follicles undergo development. At approximately day 7, a single dominant follicle is selected.
- It is thought that this occurs because rising oestrogen levels lower FSH levels through negative feedback - the dominant follicle is the one that can cope with lower FSH.
- Day 13 - Rising oestrogen levels reach a ‘tipping point’, at which their negative feedback on LH secretion is reversed - the LH surge occurs, stimulating the oocyte to complete meiosis I and form a single Graafian follicle.
- Day 14 - Ovulation - The secondary oocyte erupts from its follicle, carried by antral fluid.
What happens during the Luteal/Secretory phase of the Menstrual Cycle?
- Day 15 - the granulosa cells of the ruptured follicle become luteinised, forming the progesterone-secreting corpus luteum.
- The corpus luteum’s progesterone acts upon the endometrium to cause it to enter its secretory phase - amongst other things, it secretes glycogen and mucous.
- Progesterone levels peak 7 days before the next menstrual bleed - 7 days before CL completely degenerates.
- High levels of progesterone increase the volume and viscosity of cervical secretions; this begins the formation of the protective operculum.
-
After 10 days, if no conceptus has implanted, the corpus luteum spontaneously
regresses. This leads to diminishing progesterone levels:- Without progesterone’s negative feedback on the hypothalamus, GnRH release frequency increases and facilitates a rise in gonadotrophins.
- Progesterone withdrawal also stimulates the stratum functionalis of the secretory endometrium to be shed.
- As FSH and LH levels rise, and the menstrual bleed begins, the cycle restarts on Day 1.
What are some examples of Non-Hormonal Contraception?
- Copper intrauterine device (Cu-IUD)
- Barrier methods e.g. male condom, female condom, diaphragm/cervical cap
- Surgical methods e.g. tubal ligation, vasectomy
- Lactational amenorrhoea
- Fertility awareness methods (FAM)
What are some examples of Hormonal Contraception?
- Combined Hormonal Contraception (CHC)
- Combined Oral Contraceptive Pill (COCP)
- Progesterone Only Pill (POP/Mini-pill)
- Levonorgestrel Intrauterine System (LNG-IUS commonly known as Mirena)
- Contraceptive Injection (Depo-Provera)
- Contraceptive Implant
What are some examples of Emergency Contraception?
- Levonorgestrel Pill
- Ulipristal Acetate Pill (EllaOne)
- Copper Intrauterine Device (Cu-IUD)
What are the features of the Copper Intrauterine Device (Cu-IUD):
Mechanism:
Efficacy:
Advantages:
Absolute Contraindications:
Side Effects:
Other:
Mechanism: Decreases sperm motility and Survival. Makes the endometrium less accepting of implantation
Efficacy: 0.8% experience unintended pregnancy after 1 year
Advantages:
- Effective immediately on insertion (can be used in emergency).
- No hormonal side effects.
- High Efficacy
Absolute Contraindications:
- PID
- Gonorrhoea/Chlamydia
- Unexplained vaginal bleeding/endometrial cancer
- postpartum/postabortion septicaemia
- Gestational trophoblastic disease
- Purulent cervicitis, Pelvic TB
Side Effects:
- Breakthrough bleeding.
- Increased duration or heaviness of periods
Other:
- Classified as Long-acting reversible contraceptive (LARC)
- Left in situ for 5 years
- Most effective form of emergency contraception.
- The Cu-IUD is licensed for insertion 5 days post-ovulation.
What are the features of the Combined Oral Contraceptive Pill (COCP):
Mechanism:
Efficacy:
Advantages:
Absolute Contraindications:
Side Effects:
Other:
Mechanism: Inhibits ovulation
Efficacy: 0.03% failure rate if used perfectly but human error is important taking average unwanted pregnancy to 9%
Advantages:
- Rapidly reversible if unintended side effects
- Regulars and tends to lighten periods
Absolute Contraindications:
- <6 weeks postpartum in breastfeeding women
- Aged 35, smoking >15 cigarettes per day
- Stage 2 hypertension (160/100)
- History of VTE
- Disease: Breast cancer, inherited thrombophilia e.g. Factor V Leiden,
cardiomyopathy, cirrhosis, vascular disease, SLE, positive antiphospholipid
antibodies. - Migraine with aura
Side Effects:
- Headache
- Mood disturbance
- Breakthrough bleeding
What are the features of the Progesterone Only Pill (POP):
Mechanism:
Efficacy:
Advantages:
Absolute Contraindications:
Side Effects:
Other:
Mechanism: Thickens cervical Mucus
Efficacy: 9% experience unintended pregnancy after 1 year.
Advantages:
- Rapidly reversible
- Far fewer absolute contraindications than the combined pill
Absolute Contraindications:
- Breast Cancer
Side Effects:
- Breakthrough Bleeding
Other:
- Effective after 2 days of administration
What are the features of the Levonorgestrel Intrauterine System (LNG-IUS/Mirena)
Mechanism:
Efficacy:
Advantages:
Absolute Contraindications:
Side Effects:
Other:
Mechanism: Prevents endometrial proliferation and also thickens cervical mucus
Efficacy: 0.2% unintended pregnancy after 1 year
Advantages:
- Extremely high efficacy
- Can be left in situ for 3-5 years
- Lightens periods
- Systemic absorption is minimal, reducing systemic hormonal side effects
Absolute Contraindications:
- PID
- Gonorrhoea or chlamydia
- Unexplained vaginal bleeding / endometrial cancer
- Postpartum / post-abortion septicaemia
- Gestational trophoblastic disease
- Purulent cervicitis, pelvic TB
Side Effects:
- Irregular Menstrual Bleeding
What are the features of the Contraceptive Injection (Depo-Provera)
Mechanism:
Efficacy:
Advantages:
Absolute Contraindications:
Side Effects:
Other:
Mechanism: Inhibits Ovulation and also thickens cervical mucus (Medroxyprogesterone acetate)
Efficacy: 6% experience unintended pregnancy after 1 year.
Advantages:
- Long acting - Requires injection every 12 weeks
Absolute Contraindications:
- Breast Cancer
Side Effects:
- Amenorrhoea
- Weight gain
- Reduces BMD so cant be given to people beyond age 50
What are the features of the Contraceptive Implant:
Mechanism:
Efficacy:
Advantages:
Absolute Contraindications:
Side Effects:
Other:
Mechanism: Inhibit Ovulation and also thickens cervical mucus
Efficacy: 0.05% experience unintended pregnancy after 1 year
Advantages:
- Most effective contraception available.
- Active for 3 years before replacement is required.
Absolute Contraindications:
- Breast Cancer
Side Effects:
- Irregular Menstrual Bleeding
What are the features of the Levonorgestrel Pill (LNG)?
Mechanism:
Efficacy:
Mechanism:
- Inhibits ovulation
- Can delay ovulation by 5 days (the viable lifespan of ejaculated sperm).
- Not effective in the late luteal phase, in which case ulipristal acetate is required.
Efficacy:
- Effective up to 72 hours post UPSI
- Not effective if taken after ovulation has occurred
What are the features of the Ulipristal Acetate Pill (UPA EllaOne)
Mechanism:
Efficacy:
Mechanism: Inhibits ovulation
Efficacy:
- Effective up to 120 hours post UPSI
- Can delay ovulation even if LH surge has started
- Remains effective in late follicular phase
- Not effective if taken after ovulation
- Contraception with pill, patch or ring should be restarded after 5 days due to reduced effectiveness
What are the guidelines when offering emergency contraception?
- Offer most effective method (Cu-IUD) first line;
- Can be taken either within 120 hours of first UPSI or within 120 hours of
calculated date of ovulation; whichever is later.
- Can be taken either within 120 hours of first UPSI or within 120 hours of
- If Cu-IUD not acceptable / appropriate, offer oral emergency contraception;
- If within 72 hours of UPSI - offer LNG or UPA.
- If 72-120 hours post-UPSI - offer UPA.
Define Fertilisation
Fusion of haploid sperm and oocyte, typically occurring in the ampulla of the
fallopian tube.
What are the stages of Fertilisation?
1. Capacitation - final stage of sperm maturation - involves exposure of receptor sites involved in zona pellucida penetration.
2. Acrosome reaction - loss of the acrosome cap on the head of the sperm cell leads to release of lytic enzymes, which allows the sperm to penetrate the zona pellucida.
3. Adhesion and entry - cell membranes of sperm and egg fuse, and the head of the sperm if phagocytosed - it then breaks down to release the sperm nucleus.
4. Cortical reaction - modification of the zona pellucida to prevent polyspermy, induced by membrane fusion and mediated by cortical granules
5. Meiosis II - the oocyte completes meiosis II (which until this point is arrested in
metaphase II) to give the second polar body.
6. Syngamy - the male and female pronuclei replicate DNA and shed their nuclear
membranes as they move toward one another, before aligning at a common metaphase plate and undergoing mitosis
What are the key events in Embryonic Development?
- Day 6-7: implantation of blastocyst into endometrium
- Week 3: gastrulation - formation of trilaminar disc (endoderm, mesoderm, ectoderm) from the primitive streak
- Week 3-8: beginning of development of organ systems
- Week 4: neurulation - development of neural tube from the ectoderm
- Week 23: generally considered to be the threshold of viability.
What are the functions of the Placenta?
Exchange:
- gaseous: Oxygen moves readily from maternal to foetal haemoglobin (HbF) due to HbF’s higher affinity. CO2 diffuses from foetal to maternal blood down the concentration gradient
- Nutritional: Glucose moves from maternal to foetal circulation via facilitated diffusion; both amino acids and free fatty acids also cross from mother to foetus, the former through active transport.
Endocrine:
-
Human Chorionic Gonadotrophin (hCG) Produced by trophoblast cells -
maintains the corpus luteum to allow for sufficient progesterone production until
the placenta takes over -
Human Placental Lactogen (hPL): Increases maternal free fatty acid and insulin
levels, as well as inducing maternal insulin resistance. - Progesterone: Inhibits uterine contractility and thickens endometrium
- Oestrogen: Stimulates myometrial growth, oxytocin receptor synthesis and pregnancy related breast changes
Explain the phsyiological changes in pregnancy?
Mothers body prepares for new borns little life
Metabolic
- Increased metabolism: The hormone thyroxine (T4) increases, enhancing metabolic activity.
- Increased insulin resistance: Human placental lactogen (hPL), produced by the placenta, leads to insulin resistance to ensure more glucose is available for the fetus.
- Weight gain: Estrogen and progesterone contribute to fat storage, while hPL shifts energy metabolism toward fat utilization to save glucose for the baby.
Blood
- Increased blood volume: Driven by estrogen, which stimulates the production of blood plasma and increased fluid reabsorption at the kidneys
- Increased cardiac output: Progesterone relaxes smooth muscles, causing blood vessels to dilate, which reduces TPR increases blood flow, increases Venous reutrn, increased preload, SV and subsequently CO.
- Increased clotting factors: Estrogen increases clotting factors to prepare for childbirth and reduce blood loss causing hypercoagulability
- Hemodilution: Increased plasma volume (due to estrogen) results in a relative dilution of red blood cells, leading to physiological anemia.
Pulmonary (Lungs)
- Increased oxygen demand: Progesterone stimulates the respiratory centers in the brain, increasing the drive to breathe and ensuring more oxygen is available for both mother and baby.
- Increased tidal volume: Progesterone also leads to deeper breathing by expanding the lungs’ capacity.
- Decreased lung capacity: This is more of a mechanical effect due to the growing uterus pushing against the diaphragm, though hormonal factors also contribute.
Nervous (Neurological)
- Pregnancy brain: Often linked to fluctuating levels of progesterone and estrogen, which may impact memory and concentration.
- Increased risk of headaches and dizziness: Changes in blood pressure due to progesterone (vasodilation) and increased fluid retention from aldosterone can contribute to these symptoms.
Breasts:
- Ductal proliferation
- Prolactin stimulates milk production from alveolar cells
- Areola grow
Lower body (Renal, GI, Uterus)
- Kidneys: Increased blood flow to the kidneys is driven by progesterone and relaxin, which also cause dilation of the renal vessels, increasing the glomerular filtration rate (GFR).
- GI system: Progesterone relaxes smooth muscle, slowing down digestion and causing nausea, heartburn, and constipation. The hormone hCG (human chorionic gonadotropin) is responsible for early pregnancy nausea.
- Uterus growth: Estrogen promotes the growth of the uterine lining and stimulates the muscles of the uterus to expand during pregnancy.
Look (Skin)
- Hyperpigmentation: Melanocyte-stimulating hormone (MSH) increases, along with estrogen and progesterone, leading to darkening of the skin, especially on the face and abdomen (chloasma and linea nigra).
- Stretch marks: These are largely due to physical stretching, but cortisol (which increases during pregnancy) may weaken skin fibers, making stretch marks more likely.
- Increased oil production: Androgens (which rise slightly during pregnancy) stimulate the sebaceous glands, potentially causing acne.
- Spider veins and varicose veins: The increase in blood volume and the relaxing effects of progesterone on blood vessels cause veins to enlarge and become more visible.
- At 20 weeks, uterus can compress IVC in R. lateral position causing varicose veins and peripheral oedema.
How many routine appointments during Pregnancy?
8 routine for parous women and 11 for nulliparous women (Women who haven’t given birth to a live baby.) Also possibility of a 41 week appointment if women has not yet delivered
Nulliparous women have an additional 3 at: 25 weeks, 31 weeks and 40 weeks
What are the routine appointments during Pregnancy?
Before 10 weeks: Booking Clinic
Between 10 and 13+6: Dating Scan
16 weeks: Antenatal appointment
18-20+6: Anomaly Scan
Antenatal Appointments:
- 25 weeks (Nulliparous)
- 28 weeks
- 31 weeks (Nulliparous)
- 34 weeks
- 36 weeks
- 38 weeks
- 40 weeks (Nulliparous)
- 41 weeks
- 42 weeks
What are the Elements of Pregnancy screening in the UK?
All offered at the Booking visit
- Infectious Disease
- Sickle Cell and Thalassaemia
- Foetal Anomaly
What Infectious diseases are screened for in pregnancy?
- HIV: 25% risk of MTC transmission if untreated
- Syphilis: Risk of miscarriage, stillbirth, congenital syphilis
- Hepatitis B: 70-90% risk of MTC transmission if HBeAg positive
What Foetal Anomalies are screened for at the booking visit?
Trisomy’s 21 (Down’s), 18 (Edwards’) and 13 (Patau’s)
All Screened for between 11-14 weeks combined Test:
- b-HCG
- Pregnancy Associated Plasma Protein-A (PAPPA)
- Nuchal Translucency > 6mm
If the mother is late-booking (>14+0) then the quadruple test is used for T21:
- b-hCG
- AFP
- Inhibin A
- Serum Unconjugated Oestriol
If high Chance of Anomaly (> 1/150) there are 3 options:
- No further testing
- Non-invasive prenatal testing (NIPT) - Placental cell free DNA
- Prenatal diagnosis (PND) - Chorionic villus sampling (11-14 weeks), Amniocentesis (15+ weeks)
What are the results of the Combined test that are suggestive of Trisomy Anomaly?
Tests for Trisomy:
Trisomy 21 (Down’s): high b-hCG, Low PAPP-A, High NT
Edwards and Pataus are similar to Downs but HCG is lower
Trisomy 18 (Edwards’): Low b-hCG, Low PAPP-A, High NT
Trisomy 13 (Patau’s): Low b-hCG, Low PAPP-A, High NT
When does Labour and Delivery normally occur?
Normally occur between 37 and 42 weeks gestation
What are the 3 stages of labour?
- First stage – from the onset of labour (true contractions) until 10cm cervical dilatation
- Second stage – from 10cm cervical dilatation until delivery of the baby
- Third stage – from delivery of the baby until delivery of the placenta
What is classed as the first stage of labour?
How can this be split up?
The first stage of labour is defined as the period that starts with regular uterine contractions and ends when the cervix is fully dilated to 10cm. This stage can be further divided into:
Latent Phase:
- from 0 to 3cm dilation
- Progresses at around 0.5cm per hour.
- Irregular contractions.
Active Phase:
- from 3cm to 7cm dilation
- progresses at around 1cm per hour
- Regular contractions
Transition Phase:
- From 7cm to 10cm dilation
- Progresses at around 1cm per hour
- Strong and regular contractions.
What is the Physiology of the first stage of labour?
- Hormonal Mechanisms
- Uterine Contractions
- Cervical Changes
Hormonal Mechanisms
-
Oxytocin:
- Released by the posterior pituitary gland in response to uterine contractions.
- Stimulates stronger and more frequent uterine contractions, which push the baby down and cause cervical dilation.
- In a positive feedback loop, contractions stimulate the release of more oxytocin, which increases the strength and frequency of contractions.
-
Prostaglandins:
- Produced by the uterine tissue, prostaglandins help to soften and thin (efface) the cervix.
- They also assist in stimulating contractions and preparing the uterus for labor.
-
Relaxin:
- Relaxin, a hormone released during pregnancy, loosens the pelvic ligaments and softens the cervix, helping with dilation and allowing the baby to pass through the birth canal.
-
Estrogen and Progesterone:
- Towards the end of pregnancy, estrogen levels rise while progesterone levels drop.
- Estrogen enhances the sensitivity of the uterus to oxytocin, stimulating contractions,
- Progesterone (which maintained uterine relaxation during pregnancy) decreases, allowing labor to begin.
Uterine Contractions
- Contractions are the key driving force in the first stage of labor.
- They start as mild and irregular in the latent phase, gradually becoming more intense, regular, and rhythmic during the active phase.
- Each contraction pulls up the lower uterine segment and causes the cervix to thin (efface) and open (dilate).
Cervical Changes
-
Effacement:
- The cervix thins out from being thick and long to becoming soft and thin.
- Effacement is measured in percentages, with 100% indicating complete thinning.
-
Dilation:
- The cervix opens from 0 cm to 10 cm during the first stage of labor.
- Dilation progresses slowly in the latent phase (0–4 cm) and then speeds up significantly in the active phase (4–10 cm).
What are Braxton-Hicks Contractions?
- Occasional irregular contractions of the uterus.
- They are usually felt during the second and third trimester.
- Women can experience temporary and irregular tightening or mild cramping in the abdomen.
- These are not true contractions, and they do not indicate the onset of labour.
- They do not progress or become regular.
- Staying hydrated and relaxing can help reduce Braxton-Hicks contractions.
What are the Signs of the Onset of Labour?
- Signs of labour?
- Latent first stage?
- Established first stage?
Signs of Labour:
- Show (mucus plug from the cervix)
- Rupture of membranes
- Regular, painful contractions
- Dilating cervix on examination
Latent First stage: is when there are both
- Painful contractions
- Changes to the cervix with effacement and dilation up to 4cm
Established first stage of labour: is when there are both
- Regular painful contractions
- Dilation of the cervix from 4cm onwards
What is classed as the Second stage of labour?
What are the stages?
The second stage of labour is defined as the period beginning with complete cervical dilation and ending with the delivery of the foetus. There are 7 Stages:
- Descent:
- The baby’s head (providing it is in cephalic presentation) descends deeper into the pelvis until it is no longer palpable on abdominal examination.
- Flexion:
- The baby’s head flexes (chin to chest)
- This gives the narrowest (suboccipitobregmatic) diameter.
- Internal rotation:
- Baby’s occiput rotates anteriorly from the lateral position to give the normal occipito-anterior position.
- Extension:
- Baby’s occiput contacts the maternal pubic rami
- It then extends and crowns
- Restitution:
- Baby’s occiput re-aligns with its shoulders, which lie in between the anterior-posterior and lateral positions
- External rotation:
- Baby’s shoulders rotate into anterior-posterior position (i.e. perpendicular to mother’s).
- At this point, the baby’s head is delivered
- It is aligned with its shoulders, so the face looks laterally at the mother’s thigh.
- Delivery of shoulders:
- The anterior shoulder is delivered first from beneath the pubic ramus;
- The head is then gently lifted anteriorly to deliver the posterior shoulder.
- The rest of the baby’s body rapidly follows.
What is classed as the third stage of labour?
How is this managed?
The period beginning at the delivery of the foetus and ending with the delivery of the placenta and foetal membranes.
- This stage generally occurs within 30 minutes of delivery of the baby.
Physiological Management:
- Placenta is delivered bby maternal effort without medications or chord traction
- This stage generally lasts within 30 minutes to an hour when allowed to occur naturally
Active Management:
- Assisted by doctor or midwife
- Involves administration of IM oxytocin and Traction of the umbilical cord to guide placenta out of uterus.
When is Active management of the third stage of labour used?
Routinely offered to all women to reduce the risk of postpartum haemorrhage
Initiated if:
- Haemorrhage
- More than a 60 minute delay in the delivery of the placenta (Prolonged third stage)
What is Induction of Labour?
The medically initiated process of starting labour artificially.
It is performed under specific circumstances to ensure the safety of the mother and the child.
What are some indications for an Induction of Labour?
- Post-dates/Prolonged pregnancy (>41 weeks gestation)
- Prelabour rupture of membranes
- Fetal growth restriction
- Pre-eclampsia
- Obstetric cholestasis
- Existing diabetes
- Intrauterine fetal death
What are some contraindications for an Induction of Labour?
- Placenta praevia
- Malpresentations
- Severe foetal compromise
- Cord prolapse
- Vasa previa
- Previous classical/vertical incision during caesarean section
- Multiple lower uterine segment caesarean sections
- Transmissible infections e.g. herpes simplex
What system is used to determine whether to induce labour?
Bishop Scoring System: Score from 0-13
- Foetal station (scored 0 – 3)
- Cervical position (scored 0 – 2)
- Cervical dilatation (scored 0 – 3)
- Cervical effacement (scored 0 – 3)
- Cervical consistency (scored 0 – 2)
A score of 8 or more the cervix is ripe and there is a high chance of spontaneous labour or response to induction of labour
A score below 5 suggests that labour is unlikely to start without induction
What are some management options to induce labour?
Membrane Sweep
- Inserting a finger into the cervix to stimulate the cervix and begin the labour process
- Labour should follow within 48 hours if successful
- Is used from 40 weeks gestation to attempt to initiate labour in women over their EDD (estimated delivery date)
Vaginal Prostaglandin E2 (Dinoprostone)
- Insert a Gel, Tablet or Pessary into the vagina to slowly release local prostaglandins over 24 hours.
- Usually performed when there is a Bishop Score < 6
Cervical Ripening Balloon (CRB):
- Ballon inserted into the cervix to dilate it.
- Used when vaginal prostaglandins are not preferred (risk of UHS)
- Often done with prev caesarean section Hx or Para 3
Amniotomy (Artificial Rupture of Membranes)
- May be done with/without oxytocin infusion
- Only used where Vaginal Prostaglandins are not tolerated/successful
- Used when the Bishop Score > 6
What are some options to when there is slow or no progress following induction of labour?
- Further vaginal prostaglandins
- Artificial rupture of membranes and oxytocin infusion
- Cervical ripening balloon (CRB)
- Elective caesarean section
What is a key complication of Induced labour?
what is the criteria for it?
Uterine Hyperstimulation: This is where the contraction of the uterus is prolonged and frequent, causing foetal distress and compromise.
2 Criteria for Uterine Hyperstimulation:
- Individual uterine contractions lasting more than 2 minutes in duration
- More than five uterine contractions every 10 minutes
What can uterine Hyperstimulation lead to?
- Foetal compromise, with hypoxia and acidosis
- Emergency caesarean section
- Uterine rupture
What is the Management of Uterine Hyperstimulation?
- Removing the vaginal prostaglandins, or stopping the oxytocin infusion
- Tocolysis with terbutaline
What makes up the initial assessment of Labour?
- Take a history, Assess for risk factors and assess for pain
- Pules, BP, Resp Rate, Urinalysis
- Abdominal palpation to determine Lie, presentation, engagement and contraction strength
- Vaginal examination to determine station, position, cervical effacement and dilation, presence or absence of membranes and caput or cranial moulding.
How is the progression of the 1st stage of Labour monitored?
Partogram monitors first stage of labour
Progress:
- Cervical dilatation (measured by a 4-hourly vaginal examination)
- Descent of the fetal head (in relation to the ischial spines)
- Frequency and duration of contractions
Fetal Wellbeing:
- Fetal heart rate
- Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium
Maternal Wellbeing:
- Maternal pulse, blood pressure, temperature and urine output
- Drugs and fluids that have been given
How can Foetal Heart rate be measured?
Low risk deliveries: Intermittent Auscultation with a Doppler Probe
High risk Deliveries: Cardiotocograph (CTG)
What is Cardiotocography (CTG)?
Used to measure the foetal heart rate and the contractions of the uterus.
CTG Readouts are interpreted as:
Normal: No non-reassuring features
Suspicious: One non-reassuring feature
Pathological: Two non-reassuring features OR one abnormal feature
Need for urgent Intervention: Acute bradycardia or prolonged deceleration of more than 3 minutes
What is measured on a CTG?
- Contractions – the number of uterine contractions per 10 minutes
- Baseline rate – the baseline foetal heart rate
- Variability – how the foetal heart rate varies up and down around the baseline
- Accelerations – periods where the foetal heart rate spikes
- Decelerations – periods where the foetal heart rate drops
What are the Reassuring features of the CTG?
Baseline Heart Rate: 110-160bpm
Decelerations (Drops of 15 bpm for 15s): Absent
Accelerations (increases of 15 bpm for 15s): Present
Baseline variability: 5-25bpm
What are some Non-reassuring features of the CTG?
Baseline Rate: 100-109 / 160-179
Baseline Variability: <5 for 30-50 mins / >25 for <10mins
Decelerations:
- Repetitive Variable for < 30 mins
- Variable for < 30 mins
- Repetitive late for 30 mins
Accelerations: Absent
What are some Abnormal features of the CTG?
Baseline Rate: <100/ >180
Baseline Variability: <5 for 50 mins / >25for >10mins / sinusoidal pattern
Decelerations:
- Repetitive variable with concerning characteristics >30 mins
- Repetitive late > 30mins
- 3 minutes of Bradycardia
Accelerations: Absent
What does a Sinusoidal CTG suggest?
Severe Foetal Compromise
Usually associated with severe foetal anaemia caused by vasa praevia with foetal haemorrhage
What must be done in the case of Foetal Bradycardia?
Rule of 3s:
- 3 Minutes: Call for help
- 6 Minutes: Move to theatre
- 9 Minutes: Prepare for delivery
- 12 Minutes: Deliver the baby (by 15 Minutes)
DR C BRaVADO
What is the approach to assessing CTGs?
DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG)
C – Contractions
BRa – Baseline Rate
V– Variability
A – Accelerations
D – Decelerations
O – Overall impression (given an overall impression of the CTG and clinical picture)
What are some methods to improve symptoms such as pain in labour without medications?
- Understanding what to expect
- Having good support
- Being in a relaxed environment
- Changing position to stay comfortable
- Controlled breathing and relaxation techniques
- Water births may help some women
- TENS machines may be useful in the early stages of labour
What are some Non-regional analgesia that may be used in Labour?
Simple Analgesia: Paracetamol or Codeine (NSAIDS are avoided)
Gas and Air (Entonox): 50% nitrous oxide and 50% oxygen used during contractions for short term pain relief
IM Opiates (Pethidine, Diamorphine): Opioid medications given by IM injection
Patient Controlled Analgesia: PCA using IV remifentanil
What are some Regional Analgesia that may be used in Labour?
Epidural Local anaesthetic medications ((Levobupivacaine or bupivacaine combined with fentanyl injected into the epidural space at L3-4.
What are some adverse effects of an Epidural?
- Headache after insertion
- Hypotension
- Motor weakness in the legs
- Nerve damage
- Prolonged second stage
- Increased probability of instrumental delivery
Why do women need urgent anaesthetic review if they develop significant motor weakness following an Epidural?
Women unable to straight leg raise is concerning.
Suggests that the catheter for an epidural is incorrectly sited in the subarachnoid space (within the spinal cord)
What is the definition of a Venous Thromboembolism (VTE) in Pregnancy?
- A VTE involves blood clots (thrombosis) developing within the circulation.
- When they form within the venous system this is known as a Deep Vein Thrombosis (DVT).
- The thrombosis can mobilise (embolisation) from the deep veins and travel to the lungs, where it becomes lodged in the pulmonary arteries, resulting in a pulmonary embolism (PE).
- Thrombosis occurs as a result of stagnation of blood as well as in hyper-coagulable states, such as in pregnancy, making it much more likely.
What is the epidemiology of VTEs in pregnancy?
- Pulmonary embolism is a significant cause of death in obstetrics.
- The risk is significantly reduced with VTE prophylaxis.
- The risk is highest in the postpartum period.
What are the risk factors for VTEs in Pregnancy?
Women with a previous VTE Hx are automatically considered high risk
Thrombosis:
T – Thrombophilia: Inherited or acquired clotting disorders (antiphospholipid)
H – History: Previous VTE or family history of thrombosis.
R – Reduced mobility: Bed rest, hospitalization, or prolonged immobility.
O – Obesity: Body mass index (BMI) >30
M – Maternal age: Age >35 years
B – Birth (recent): Postpartum period, especially the first 6 weeks, is a high-risk period. and Parity > 3
O – Operative delivery: Cesarean section
S – Smoking
I – IVF
S – Severe preeclampsia/pre eclampsia
When does the RCOG advise starting VTE prophylaxis in pregnant women?
Immediately if women have prev Hx of VTE
- 28 weeks if there are three risk factors
- immediately if there are four or more of these risk factors
- It is stopped when the woman goes into labour but can be started again immediately after delivery (except with postpartum haemorrhage, spinal anaesthesia and epidurals)
- It is continued for 6 weeks postnatally.
What medications are used for VTE prophylaxis?
Low Molecular Weight Heparin (LMWH):
- Enoxaparin
- Dalteparin
- Tinzaparin.
If Heparin is contraindicated, Mechanical prophylaxis may be used:
- Intermittent pneumatic compression (with equipment that inflates and deflates to massage the legs)
- Anti-embolic compression stockings
What is the clinical presentation of a Deep Vein Thrombosis (DVT)?
- Calf or leg swelling
- Dilated superficial veins
- Tenderness to the calf (particularly over the deep veins)
- Oedema
- Colour changes to the leg
Deep vein thrombosis is almost always unilateral
What is the clinical presentation of Pulmonary Embolism (PE)?
- Shortness of breath
- Cough with or without blood (haemoptysis)
- Pleuritic chest pain
- Hypoxia
- Tachycardia (this can be difficult to distinguish from the normal physiological changes in pregnancy)
- Raised respiratory rate
- Low-grade fever
- Haemodynamic instability causing hypotension
How are VTEs investigated?
DVTs:
- Wells score 1 or less: D-dimer
- Wells Score 2 or more: Duplex Ultrasound
PEs:
- Wells score 4 or less: D-Dimer
- Wells Score >4: Immediate CT pulmonary angiogram (CTPA) or Ventilation-perfusion (VQ) scan.
Describe what CT pulmonary angiogram is
CT pulmonary angiogram involves a chest CT scan with an intravenous contrast that highlights the pulmonary arteries to demonstrate any blood clots.
This is usually the first choice for diagnostic of a PE (as opposed to a VQ Scan). This is the case because:
- It tends to be more readily available
- It provides a more definitive assessment
- It gives information about alternative diagnoses such as pneumonia or malignancy.
Describe what a Ventilation perfusion (VQ) scan is
- Ventilation-perfusion (VQ) scan involves using radioactive isotopes and a gamma camera, to compare the ventilation with the perfusion of the lungs.
- First, the isotopes are inhaled to fill the lungs, and a picture is taken to demonstrate ventilation. Next, a contrast containing isotopes is injected, and a picture is taken to demonstrate perfusion. The two images are compared.
- With a pulmonary embolism, there will be a deficit in perfusion, as the thrombus blocks blood flow to the lung tissue. This area of lung tissue will be ventilated but not perfused.
What are the possible complications of CTPAs and VQ Scans?
- CTPA carries a higher risk of breast cancer for the mother
- VQ scan carriers a higher risk of childhood cancer for the fetus
Why are D-Dimers not useful in pregnant women?
As pregnancy is a cause of a raised D-dimer. So it cannot be used to screen for DVTs and PEs.
What is the management of VTE in pregnancy?
Low molecular weight heparin (LMWH) (e.g. enoxaparin, dalteparin and tinzaparin).
- It should be started immediately, before confirming the diagnosis in patients where DVT or PE is suspected
- LMWH is continued for the remainder of pregnancy, plus six weeks postnatally, or three months in total (whichever is longer).
- After birth - swap to oral
Massive PEs are a medical emergency, and treatment can involve:
- Unfractionated heparin
- Thrombolysis
- Surgical embolectomy
What is the definition of Gonorrhoea?
Gonorrhoea is a sexually transmitted infection (STI) caused by the gram-negative diplococcus, Neisseria gonorrhoeae.
What is the epidemiology of Gonorrhoea?
- It’s most prevalent among young adults, specifically those aged 15–24 years.
- Increased prevalence in men who have sex with men
What is the clinical presentation of Gonorrhoea?
Women
- Odourless purulent discharge, possibly green or yellow
- Dysuria
- Pelvic pain
Male genital infections can present with:
- Odourless purulent discharge, possibly green or yellow
- Dysuria
- Testicular pain or swelling (epididymo-orchitis)
Extragenital complications can also be observed:
- Pharyngitis
- Rectal pain an discharge
- Disseminated infection.
What are some differentials for Gonorrhoea?
-
Chlamydia trachomatis infection
Presents with similar symptoms such as discharge and dysuria, often co-infected with gonorrhoea. -
Trichomonas vaginalis infection
May present with pruritus, dysuria, and malodorous discharge. -
Bacterial vaginosis
Characterised by a fishy-smelling discharge, increased vaginal pH and positive ‘whiff’ test. -
Candidiasis
Symptoms include pruritus, burning sensation and thick, white, ‘cottage cheese’ like discharge.
How is Gonorrhoea diagnosed?
To determine Presence of Gonorrhoea
- NAAT test from Endocervical, vulvovaginal or ureathral swaps Or First Catch Urine Sample
For MC&S to guide Abx
- Endocervical Charcoal Swab taken for MC&S is also vital
What is the management of Gonorrhoea?
What must be done after Treatment is administered?
If sensitivities are NOT known: Single dose 1g IM Ceftriaxone
If sensitivities ARE known: Single dose PO 500mg Ciprofloxacin
All patients should have a test of cure
NAAT if Asymptomatic and Culture if Symptomatic
- 72 hours after treatment for culture
- 7 days after treatment for RNA NAAT
- 14 days after treatment for DNA NAAT
What complications can Gonnorhoea cause during pregnancy?
- Increased risk of miscarriage and premature birth; due to pelvic inflammatory disease (PID).
- There can also be vertical transmission of gonorrhea between the mother and newborn baby during vaginal delivery.
- neonatal conjunctivitis (gonnorhoea ophthalmia neonatorum)
- It can also cause future infertility
What is the definition of Chlamydia?
A genital chlamydia infection sexually transmitted infection caused by the obligate intracellular bacterium Chlamydia trachomatis.
What is the epidemiology of Chlamydia?
- It is the most common bacterial STI in the UK.
- Highest prevalence among young sexually active adults, specifically those aged 15 to 24 years
- Having multiple partners also increases the risk of catching the infection.
What is the clinical presentation of Chlamydia?
What is found on examination?
Majority of cases are Asymptomatic
- Abnormal vaginal discharge
- Pelvic pain
- Abnormal vaginal bleeding (intermenstrual or postcoital)
- Painful sex (dyspareunia)
- Painful urination (dysuria)
Consider chlamydia in men that are sexually active and present with:
- Urethral discharge or discomfort
- Painful urination (dysuria)
- Epididymo-orchitis
- Reactive arthritis
On Examination:
- Pelvic or abdominal tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
What are the possible complications of Chlamydia during pregnancy?
- Preterm delivery
- Premature rupture of membranes
- Low birth weight
- Postpartum endometritis
- Ectopic pregnancy
- Neonatal infection (conjunctivitis and pneumonia)
What are some differentials for Chlamydia?
The differentials mainly incude other STIs such as:
-
Gonorrhoea
Often asymptomatic but may cause urethral discharge, dysuria, intermenstrual or postcoital bleeding, and lower abdominal pain. -
Trichomoniasis
May cause pruritus, dysuria, and discharge in both men and women. -
Genital herpes
Characterised by painful vesicular lesions, dysuria, and flu-like symptoms.
How is chlamydia diagnosed?
Nucleic acid amplification tests (NAAT). Which can involve a:
- Vulvovaginal swab
- Endocervical swab
- First-catch urine sample (in women or men)
- Rectal swab (after anal sex)
- Pharyngeal swab (after oral sex)
What is the management of uncomplicated Chlamydia (not in pregnancy)?
First Line - doxycycline 100mg twice a day for 7 days
What is the management of Chlamydia during pregancy?
Doxycycline is contraindicated in pregnancy and breastfeeding. Alternatives include:
- Azithromycin 1g stat then 500mg once a day for 2 days
- Erythromycin 500mg four times daily for 7 days
- Erythromycin 500mg twice daily for 14 days
- Amoxicillin 500mg three times daily for 7 days
Should a test of cure be done after Chlamydia treatment?
No
Apart from in cases of:
- Rectal Chlamydia
- Pregnancy
- when Symptoms persist
What are the possible non-pregnancy related complications of Chlamydia?
- Pelvic inflammatory disease
- Chronic pelvic pain
- Infertility
- Epididymo-orchitis
- Conjunctivitis - is usually as a result of sexual activity, when genital fluid comes in contact with the eye.
- Lymphogranuloma venereum
- Reactive arthritis
What is the presentation of chlamydial conjunctivitis?
Symptoms last for longer than 2 weeks:
- Chronic erythema
- Irritation
- Discharge
Most cases are unilateral
It occurs more frequently in young adults. It can also affect neonates with mothers infected with chlamydia.
What is Lymphogranuloma venereum?
What are the stages?
Caused by Chlamydia Serovars L1, 2 and 3
It is a condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men.
Stage 1:
- Small painless pustule which later forms an ulcer
stage 2:
- Painful inguinal lymphadenopathy
- may occasionally form fistulating buboes
stage 3:
- Proctocolitis
What is the management of Lymphogranuloma venereum?
1st Line - Doxycycline 100mg twice daily for 21 days
What is the definition of Syphilis?
Syphilis is a sexually transmitted infection caused by the spirochete bacterium Treponema pallidum.
What causes a Syphilis infection?
As stated, its caused by the bacterium Treponema pallidum. It can be transmitted by:
- Through direct contact with syphilis sores during sexual activity.
- Vertical transmission from an infected mother to her unborn child, resulting in congenital syphilis
- Intravenous drug use
- Blood transfusions and other transplants
What is the clinical presentation of Syphilis?
Primary
Secondary
Tertiary
Neuro
There are three stages of Syphilis:
Primary Syphilis
- A painless genital ulcer (chancre). That spontaneously recovers within 3 – 8 weeks. The lesion is round, with an indurated base.
- Local lymphadenopathy
Secondary Syphilis - Typically starts after the chancre has healed. (Or 4-10 weeks post-primary infection). Presents with:
- Symmetrical maculopapular rash, often involving the palms, soles, and face.
- Condylomata lata (grey wart-like lesions around the genitals and anus)
- Low-grade fever
- Lymphadenopathy
- Alopecia (localised hair loss)
- Oral lesions
Tertiary Syphilis - Can occur 20-40 years after the primary infection (in untreated patients). Presents with:
- Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
- Aortic aneurysms
- Neurosyphilis
Neurosyphilis - can occur at any stage if the infection reaches the central nervous system. Presents with:
- Headache
- Altered behaviour
- Dementia
- Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
- Ocular syphilis (affecting the eyes)
- Paralysis
- Argyll-Robertson pupil
What is the presentation of Syphilis in Neonates?
SYPHILIS
S – Saddle Nose and Snuffles
Y – Yellowish Skin (Jaundice)
P – Peg-shaped Teeth: Hutchinson’s teeth: Peg-shaped, notched central incisors are a classic sign seen in late congenital syphilis.
H – Hepatosplenomegaly
I – Interstitial Keratitis
L – Leg Bone Deformities: Saber shins: Bowing of the tibia (shin bone) due to abnormal bone development.
I – Intellectual Disability and deafness
S – Skin Rash and Scars (rhadages) at mouth
What is an Argyll-Robertson pupil?
- It is a specific finding in neurosyphilis.
- It is a constricted pupil that accommodates when focusing on a near object but does not react to light.
- They are often irregularly shaped.
- It is commonly called a “prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.
What are the investigations for Syphilis?
Initial Screening tests:
- Non-specific Treponemal tests
- Detect Antibodies produced against cardiolipid cholesteral lecithin antigens as a reslt of damage caused by T.pallidum
- VDRL (Venereal Disease Research Laboratory)
- RPR (Rapid Plasma Reagin)
Confirmatory Tests:
- Detect antibodies specific to the Bacterium
- TPPA (Treponema pallidum particle agglutination assay)
- FTA-ABS (Fluorescent Treponemal Antibody Absorption)
- EIA (Enzyme Immunoassay)
Direct Samples:
- Sample from chancre can be taken
- Darkfield Microscopy identifies T.pallidum from lesion
What is the management of Syphilis?
Primary, secondary, and early latent syphilis:
- A single dose of intramuscular penicillin G (benzathine benzylpenicillin) is the first-line therapy.
Tertiary and late latent syphilis or syphilis of unknown duration:
- Requires a longer course of intramuscular penicillin G for 2-3 weeks.
Neurosyphilis:
- Treated with intravenous penicillin G for 10-14 days
- Patients allergic to penicillin may be given doxycycline or tetracycline.
What is the definition of Bacterial Vaginosis?
Bacterial vaginosis is a bacterial imbalance of the vagina caused by an overgrowth of anaerobic bacteria and a loss of lactobacilli (the dominant bacterial species responsible for maintaining an acidic vaginal pH).
It is not a sexually transmitted infection but it increases the risk of developing an STI
What is the pathophysiology of Bacterial Vaginosis?
- Lactobacilli are the main component of the healthy vaginal bacterial flora. These bacteria produce lactic acid that keeps the vaginal pH low (under 4.5).
- The acidic environment prevents other bacteria from overgrowing.
- When there are reduced numbers of lactobacilli in the vagina, the pH rises. This more alkaline environment enables anaerobic bacteria to multiply.
What are the most common anaerobic bacteria associated with bacterial vaginosis?
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
Bacterial vaginosis can occur alongside STIs like candidiasis, chlamydia and gonorrhoea.
What is the epidemiology of Bacterial Vaginosis?
It is the most common cause of abnormal vaginal discharge in women of childbearing age.
What are the risk factors of Bacterial Vaginosis?
- Multiple sexual partners (although it is not sexually transmitted)
- Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
- Recent antibiotics
- Smoking
- Copper coil
- Pregnant women are at increased risk of bacterial vaginosis due to hormonal changes.
Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.
What is the presentation of Bacterial Vaginosis?
- fishy-smelling watery grey or white vaginal discharge (fishy smelling particularly after intercourse)
- Increased vaginal discharge
- Vaginal itching or irritation may be present but is less common
Half of women are asymptomatic
What are some differentials for Bacterial Vaginosis?
-
Vulvovaginal Candidiasis
Characterised by itching, burning, dyspareunia, and white, curd-like discharge. -
Trichomonas Vaginalis Infection
Presents with purulent, frothy, greenish discharge, pruritus, dyspareunia, and dysuria. -
Chlamydia or Gonorrhoea infection
May present with increased vaginal discharge and possibly lower abdominal pain, but are often asymptomatic. -
Atrophic Vaginitis
Most commonly seen in postmenopausal women, presenting with dryness, burning, dyspareunia, and thin, watery discharge.
How is Bacterial Vaginosis diagnosed?
Speculum Examination + High vaginal swab with Charcoal Swab
The Amsel Criteria - Three out of the following 4 features need to be present:
- Vaginal pH >4.5 (Vaginal swab with pH paper)
- Homogenous grey or milky discharge
- Positive whiff test (addition of 10% potassium hydroxide produces a fishy odour)
- Clue cells present on wet mount (Microsopy)
What is the management of Bacterial Vaginosis?
- First line treatement - Metronidazole is given either orally(5-7/7) or intravaginally.
- Second line management - Clindamycin
- Asymptomatic BV does not usually require treatment
You should also assess for the risk of STIs, as well as providing education about how to reduce the risk of recurrence.
What do patients on Metronidazole need to avoid?
Alcohol
This is because alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.
What are the possible complications of Bacterial Vaginosis?
Increase the risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV.
During Pregnancy:
- Miscarriage
- Preterm delivery
- Premature rupture of membranes
- Chorioamnionitis
- Low birth weight
- Postpartum endometritis
What is the definition of Trichomoniasis?
Trichomoniasis is a sexually transmitted infection (STI) caused by the flagellated protozoan parasite, Trichomonas vaginalis.
It primarily infects the urogenital tract, and has an incubation period of around 7 days.
What is the epidemiology of Trichomoniasis?
It is the most common non-viral STI globally.
What is the clinical presentation of Trichomoniasis?
What may be seen on examination?
Women:
- Profuse, frothy, yellow-green vaginal discharge
- intense Vulval irritation/itching
- Dyspareunia (painful sex)
- Asymptomatic presentation is also common (up to 50%)
- Strawberry Cervix sign may be seen on examination
- The vaginal pH will be raised (above 4.5) similar to bacterial vaginosis
Men
- Non-gonococcal urethritis
- Balanitis (inflammation to the glans penis)
- Also commonly asymptomatic
What can Trichomonas increase the risk of?
- Contracting HIV by damaging the vaginal mucosa
- Bacterial vaginosis
- Cervical cancer
- Pelvic inflammatory disease
- Pregnancy-related complications such as preterm delivery or low birth weight baby.
What investigations are done for Trichomonas?
- Diagnostic - Charcoal swab with microscopy
This should be taken from the posterior fornix of the vagina (behind the cervix) - Urethral swab or first catch urine is used in men
What are some differentials for Trichomonas?
-
Bacterial vaginosis
Characterized by a fishy-smelling, grayish-white vaginal discharge and vaginal pH > 4.5 -
Candidiasis
Presenting with a thick, white, “cottage cheese” like vaginal discharge and vulval itching -
Gonorrhea or Chlamydia
These STIs may present with mucopurulent cervical discharge, cervical motion tenderness, and may also be asymptomatic.
What is the management of Trichomonas?
Oral metronidazole
Either 400–500mg twice a day for 5–7 days, or a single dose of 2g orally.
Its advised to abstain from sexual activity for at least one week, or until the patient and all partners have completed treatment.
What is the definition of a Urinary Tract Infection?
Lower Urinary Tract Infection - Involves infection of the bladder, causing cystitis.
Upper Urinary Tract Infection - Involves infection up to the kidneys, called pyelonephritis.
What is the relationship between Pregancy and UTIs?
What do UTIs in pregnancy increase the risk of?
Pregnant women are at higher risk of developing both lower and upper UTIs
UTIs during pregnancy increase the risk of:
- Preterm delivery
- As well as other adverse pregnancy outcomes, like low birth weight and pre-eclampsia.
What is Asymptomatic Bacteriuria?
Why is it important to check for in pregnancy?
- Asymptomatic bacteriuria refers to bacteria present in the urine, without symptoms of infection.
- Pregnant women with asymptomatic bacteriuria are at a higher risk of developing UTIs, and subsequently at risk of preterm birth.
- As a result, pregnant women are tested at booking and routinely throughout pregnancy (urine sample testing for microscopy, culture & sensitivity).
- Urine testing of asymptomatic patients is not usually done (as it can lead to unescesary antibiotic use) but pregnant women are the exception due to the adverse outcomes associated with infection.
What is the presentation of a lower UTI?
- Dysuria (pain, stinging or burning when passing urine)
- Suprapubic pain or discomfort
- Increased frequency of urination
- Urgency
- Incontinence
- Haematuria
What is the presentation of an upper UTI (Pylonephritis)?
- Fever (more prominent than in lower urinary tract infections)
- Loin, suprapubic or back pain (this may be bilateral or unilateral)
- Looking and feeling generally unwell
- Vomiting
- Loss of appetite
- Haematuria
- Renal angle tenderness on examination
What investigation is routinely done in pregnant women to diagnose UTIs?
- Mid-stream urine samples are sent off for cultures and sensitivity testing.
What other investigations can be useful for investigating a UTI?
- Mid-stream urine (as stated above) - In children, men and pregnant women
- Urine Dipstick will be positive for nitrates and leukocytes (although this is unreliable in women older than 65 and those who are catheterised)
- Blood tests if there are signs of systemic upset (FBC, U+E, and CRP, etc…)
- Ultrasound scan of bladder/kidney (if there is concern about antecedents/complications (e.g.urinary retention/obstruction)
What are the most common causative organisms of UTIs?
- Escherichia coli (E. coli) (Most common)
- Klebsiella pneumoniae (gram-negative anaerobic rod)
- Enterococcus
- Pseudomonas aeruginosa
- Staphylococcus saprophyticus
- Candida albicans (fungal)
What is the management of UTIs in pregnancy?
Urinary tract infection in pregnancy requires 7 days of antibiotics
- First Line - Nitrofuratoin for 7 days (although this needs to be avoided in the 3rd trimester)
- Second Line - If nitrofuratoin is unsuitable then use Amoxicillin or Cefelexin for 7 days
Why does Nitrofuratoin need to be avoided during the 3rd trimester of pregnancy?
As it is associated with an increased a risk of neonatal haemolysis (destruction of the neonatal red blood cells).
Trimethoprim is a common alternative first line antibiotic for treatment of UTIs. Why can it not be given in pregnant women (especially in the first trimester)?
This is because it works as a folate antagonist. Folate is important in early pregnancy for the normal development of the fetus.
Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (i.e. spina bifida). It is not known to be harmful later in pregnancy, but is generally avoided unless necessary.
What can occur if a pregnant woman becomes infected with the Varicella zoster virus (VZV)?
If a non-immune woman contracts the varicella zoster virus (VZV) during the first trimester of her pregnancy, it can cause Congenital varicella syndrome in the foetus (as the virus can have teratogenic effects).
What is the management of confirmed VZV infection during pregnancy?
If maternal infection by VZV occurs, Acyclovir is the treatment of choice and should be administered within 24 hours of the onset of the rash
What is the definition of Premature ovarian insufficiency (POI)?
Premature ovarian insufficiency (POI) is a medical condition characterized by the onset of menopause in a woman aged below 40 years.
What can cause premature ovarian insufficiency?
- Idiopathic (the cause is unknown in more than 50% of cases)
- Iatrogenic, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy)
- Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease
- Genetic, with a positive family history or conditions such as Turner’s syndrome
- Infections such as mumps, tuberculosis or cytomegalovirus
What is the clinical presentation of Premature ovarian insufficiency?
Women with POI typically develop the same symptoms as those undergoing natural menopause, including:
-
Vasomotor symptoms:
Hot flushes, night sweats -
Sexual dysfunction:
Vaginal dryness, reduced libido, problems with orgasm, dyspareunia -
Psychological symptoms:
Depression, anxiety, mood swings, lethargy, reduced concentration
What are some differentials for Premature ovarian insufficiency?
-
Hypothyroidism:
Fatigue, weight gain, cold intolerance, depression, hair loss -
Hyperprolactinemia:
Irregular menstrual cycles, infertility, breast milk production not related to childbirth or nursing -
Polycystic Ovary Syndrome (PCOS):
Irregular periods, hirsutism, obesity, infertility
How is premature ovarian insufficiency diagnosed?
- Blood test for raised FSH levels; indicative of the menopause (repeated on at least 2 separate occasions)
What is the management of Premature ovarian insufficiency?
Hormone Replacement Therapy or COCP (HRT) until at least the age of normal menopause.
- HRT is done, unless the risks of HRT outweigh the benefits
- Psychological support should also be provided due to the potential mental health impacts of early menopause.
What is the definition of Oligohydramnios?
Oligohydramnios is defined as the presence of a lower than normal volume of amniotic fluid within the uterus.
What can cause Oligohydramnios?
Reduced production of amniotic fluid from either less placental production or less urine prodution from fetus
Fetal causes:
- Renal agenesis,
- polycystic kidney disease,
- urethral obstruction,
- IUGR,
- fetal demise.
Maternal causes:
- Dehydration,
- hypertensive disorders,
- diabetes,
- uteroplacental insufficiency.
Placental causes:
- Placental abruption,
- twin-to-twin transfusion syndrome (TTTS).
Post-term pregnancy (beyond 42 weeks)
Rupture of membranes (PPROM or amniotic fluid leakage).
Medications (ACE inhibitors, NSAIDs).
What is the presentation of Oligohydramnios in the neonate?
Potter Syndrome which includes:
- Bilateral Renal Agenesis
- Clubbed feet, facial deformity, congenital hip dysplasia (Due to foetal compression)
- Pulmonary hypoplasia (Due to lack of amniotic fluid)
Potter syndrome is largely the result of reduced ““space”” surrounding the fetus as well as the lack of amniotic fluid for fetal lung growth and development.
What is the main differential for Oligohydramnios?
Polyhydramnios - which is an overabundance of amniotic fluid.
How is Olighohydramnios diagnosed?
Diagnosis is made via ultrasound:
- This will show a reduced amniotic fluid index (AFI) or single deepest pocket (SDP)
- <500ml at 32-36 weeks
- AFI <5th percentile
What is the management of Oligohydramnios?
Management depends on the underlying aetiology; but options include:
-
Maternal rehydration
This may help to increase the amniotic fluid volume in mild cases of oligohydramnios. -
Amnioinfusion
This is the infusion of saline into the amniotic cavity to increase the volume of amniotic fluid. -
Delivery
In severe cases, or if the fetus is in distress, delivery may be the best option. This may be via induction of labour or caesarean section, depending on the clinical scenario.
What is the definition of Polyhydramnios?
Polyhydramnios is the presence of too much amniotic fluid within the uterus.
What is the aetiology of polyhydramnios?
The causes of polyhydramnios can be split into causes due to excessive production of amniotic fluid or insufficient removal of amniotic fluid:
Execessive production is caused by increased foetal urination which can be due to:
- Idiopathic
- Maternal diabetes mellitus
- Rhesus incompatibility
- Foetal anaemia
- Twin-to-twin transfusion syndrome
Insufficient removal is caused by reduced foetal swallowing which can be due to:
- Fetal GI disorders (oesophageal atresia)
- Fetal Neurological disorrders
- Chromosomal disorders
- Torch Infections
What is the clinical presentation of polyhydramnios?
- A uterus that feels tense or is large for the date of gestation
- Difficulty of feeling foetal parts upon palpation of the abdomen.
What possible maternal complications can polyhydramnios cause?
Maternal complications:
- respiratory compromise due to increased pressure on the diaphragm
- Increased risk of urinary tract infections
- Worsening of other symptoms: gastro-oesophageal reflux, constipation, peripheral oedema and stretch marks
- Increased risk of caesarean section delivery
- Increased risk of amniotic fluid embolism
What possible foetal complications can polyhydramnios cause?
Foetal complications:
- Pre-term labour and delivery
- Premature rupture of membranes
- Placental abruption
- Malpresentation of the foetus (the foetus has more space to “move” within the uterus)
- Umbilical cord prolapse (polyhydramnios can prevent the foetus from engaging with the pelvis, thus leaving room for the cord to prolapse out of the uterus before the presenting part)
What is the management of polyhydramnios?
- Management of the underlying cause (e.g. maternal diabetes)
- Amnio-reduction in severe cases of polyhydramnios
What is the definition of Malpresentation?
This is when the foetus is in a different orientation other than facing head-first down the pelvic inlet as birth approaches.
What is the definition of foetal presentation?
Fetal presentation is the orientation of the fetus in the womb that determines which part of the fetus presents first at the pelvic inlet during childbirth.
What is the most common (and safest) foetal presentation?
Cephalic Vertex presentation
Makes up 95% of pregnancies
What is the most common type of malpresentation?
Breech Presentation - Refers to the positioning of the fetus in a longitudinal lie with the buttocks or feet proximal to the cervix and the head near the fundus.
What is the epidemiology of malpresentations?
Around 20% of babies are in breech presentation at 28 weeks gestation. But the vast majority of these revert to a cephalic presentation spontaneously, and only 3% are breech at term.
Other types of malpresentation (e.g. shoulder) are much rarer than breech presentations.
What are the 3 different types of Breech presentation?
- Complete (flexed) breech – both legs are flexed at the hips and knees (fetus appears to be sitting ‘crossed-legged’).
- Frank (extended) breech – both legs are flexed at the hip and extended at the knee. This is the most common type of breech presentation.
- Footling breech – one or both legs extended at the hip, so that the foot is the presenting part.
What are the risk factors for a Breech presentation?
Uterine:
- Multiparity
- Uterine malformations (e.g. septate uterus)
- Fibroids
- Placenta praevia
Foetal:
- Prematurity
- Macrosomia
- Polyhydramnios (raised amniotic fluid index)
- Twin pregnancy (or higher order)
- Abnormality (e.g. anencephaly)
What is the clinical presentation of a Breech presentation?
It is usually identified upon clinical examination:
- Upon palpation of the abdomen the round fetal head will be felt in the upper part of the uterus, and an irregular mass (fetal buttocks and legs) in the pelvis.
- The foetal heart may be auscultated higher on the maternal abdomen than usual
- Sometimes it’s not diagnosed until labour, where it can present with signs of foetal distress such as meconium-stained liquor.
Diagnosis of Breech presentation is of limited clinical significance before 32-35 weeks gestation; as most likely the foetus will revert to cephalic presentation by birth.
How is Breech presentation diagnosed?
Ultrasound Scan
What are some differentials for a breech presentation?
-
Oblique lie
The fetus is positioned diagonally in the uterus, with the head or buttocks in one iliac fossa. -
Transverse lie
The fetus is positioned across the uterus, with the head on one side of the pelvis and the buttocks on the other. The shoulder is usually the presenting part. -
Unstable lie
This is where the presentation of the fetus changes from day-to-day.
What is the management of a breech presentation?
-
External Cephalic Version (ECV)
This is the is the manipulation of the fetus to a cephalic presentation through the maternal abdomen. It is offered to primiparous women at 36 weeks, and to multiparous women at 37 weeks. There is a 50% success rate (40% in primiparous, 60% in multiparous); and if successful, it can enable an attempt at vaginal delivery. -
Caesarean Section
If ECV is unsuccessful, contraindicated, or declined by the woman, current UK guidelines advise an elective Caesarean delivery. -
Vaginal Breech Birth
Some women may still choose to aim for a vaginal breech delivery. A footling breech is contraindicated however as the feet and legs can slip through a non-fully dilated cervix, and the shoulders or head can then become trapped.
What are the possible complications for an ECV?
- Transient fetal heart abnormalities (which revert to normal),
- Persistent heart rate abnormalities (e.g fetal bradycardia)
- Placental abruption.
What are the complications of a breech presentation?
- Cord prolapse - where the umbilical cord drops down below the presenting part of the baby, and becomes compressed. This occurs in 1% of breech presentations (Compared to 0.5% in cephalic presentations)
Less common:
- Fetal head entrapment
- Premature rupture of membranes
- Birth asphyxia – usually secondary to a delay in delivery.
- Intracranial haemorrhage – as a result of rapid compression of the head during delivery.
What is the definition of Cephalopelvic disproportion?
Cephalopelvic disproportion occurs when there is mismatch between the size of the fetal head and size of the maternal pelvis, resulting in “failure to progress” in labor for mechanical reasons.
This is a significant risk factor for post term pregnancies
What is the definition of a Uterine Rupture?
- Uterine rupture is a complication of labour, where the muscle layer of the uterus (myometrium) ruptures.
- Uterine rupture leads to significant bleeding. The baby may be released from the uterus into the peritoneal cavity. It has a high morbidity and mortality for both the baby and mother.
What are the types of Uterine Rupture?
There are two types:
- Incomplete (or uterine dehiscence) rupture - The uterine serosa (perimetrium) surrounding the uterus remains intact.
- Complete rupture - The serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.
What are the risk factors for uterine rupture?
- Previous Caesarean section (The most significant)
- Vaginal birth after caesarean (VBAC)
- Previous uterine surgery
- Increased BMI
- High parity
- Increased age
- Induction of labour
- Use of oxytocin to stimulate contractions
Why does a previous caesarian section increase the risk of a uterine rupture?
- The scar on the uterus becomes a point of weakness, and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin).
- It is extremely rare for uterine rupture to occur in a patient that is giving birth for the first time.
What is the clinical presentation of uterine rupture?
It presents with an acutely unwell mother. It may occur with induction or augmentation of labour with:
- Abdominal pain
- Vaginal bleeding
- Ceasing of uterine contractions
- Hypotension
- Tachycardia
- Collapse
What are some differentials of uterine rupture?
-
Placental abruption
Presents with abdominal pain +/- vaginal bleeding. The uterus is often described ‘woody’ and tense on palpation. -
Placenta praevia
Typically causes a painless vaginal bleeding. -
Vasa praevia
Characterised by a triad of ruptured membranes, painless vaginal bleeding, and fetal bradycardia.
What investigations are done to diagnose a uterine rupture?
- Intrapartum Cardiotocography (first line) - It is continuous recording of the fetal heart rate obtained via an ultrasound transducer placed on the mother’s abdomen. Changes in fetal heart rate pattern and prolonged fetal bradycardia are early indicators for uterine rupture.
- Ultrasound - Is diagnostic; features include abnormal fetal lie or presentation, haemoperitoneum and absent uterine wall.
What is the management of a uterine rupture?
- Uterine rupture is an obstetric emergency.
- Resuscitation and transfusion may be required.
- Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).
Define these terms:
SROM
Prelabour rupture of membranes
Preterm prelabour rupture of membranes
Prolonged Rupture of membranes
Rupture of membranes (ROM): The amniotic sac has ruptured.
Spontaneous rupture of membranes (SROM): The amniotic sac has ruptured spontaneously.
Prelabour rupture of membranes (PROM): The amniotic sac has ruptured before the onset of labour.
Preterm prelabour rupture of membranes (P‑PROM): The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).
Prolonged rupture of membranes (also PROM): The amniotic sac ruptures more than 18 hours before delivery.
What is the clinical presentation of Preterm labour?
Regular uterine contractions, changes in cervical effacement or dilation (before 37 weeks gestation)
What are some conditions associated with Preterm labour and delivery?
-
Overstretching of the uterus
Multiple pregnancy (commonly due to assisted conception) and polyhydramnios. -
Foetal risk conditions
Pre-eclampsia, intrauterine growth restriction, placental abruption. -
Uterus or cervical problems
Fibroids, congenital uterine malformation, short or weak cervix, previous uterine or cervical surgery. -
Infections
Chorioamnionitis, maternal or neonatal sepsis, bacterial vaginosis, trichomoniasis, Group B Streptococcus, sexually transmitted infections (e.g., Chlamydia), and recurrent urinary tract infections. -
Maternal co-morbidity
Hypertension, diabetes, renal failure, thyroid disease, etc.
What are some Prophylactic options for Preterm Labour?
Vaginal Progesterone
Cervical Cerclage
- A stitch put into the cervix to keep it closed which is removed when the woman goes into labour.
- Given to people with prev. premature birth or cervical trauma.
What investigations can be done when Preterm labour with intact membranes start?
Less than 30 weeks gestation
- Clinical assessment alone is enough to offer management of preterm labour.
More than 30 weeks gestation
- Transvaginal ultrasound can be used to assess the cervical length
- Alternative is Foetal fibronectin test (fFN test)
- A negative fFN test indicates a low risk of delivery occurring within the next 7-14 days.
When is Tocolysis used in Preterm Labour?
Why is it typically used?
Nifedipine is a CCB that stops uterine contractions.
Atosiban is an alternative (oxytoxin antagonist)
- Used between 24 and 33+6 weeks
- Used for a short time and may delay labour by 48 hours
Often done to give time to administer Corticosteroids or to transfer the patient to a more appropriate unit
What is the definition of Premature Rupture of the membranes (PROM)?
- PROM is a condition characterized by the rupture of the amniotic membranes (or sac) before the onset of labour.
- If this occurs after 37 weeks gestation, it is know as premature rupture of the membranes at term.
- If this occurs before 37 weeks however, it’s known as Preterm prelabour rupture of membranes (P‑PROM).
- Most women with PROM at term will spontaneously start labour within 24 hours.
What causes Premature Rupture of the membranes?
Exact cause isn’t well understood; but can be due to a combination of:
- Infection: Chorioamnionitis
- Inflammation
- Stress
- Mechanical forces.
What is the clinical presentation of Premature rupture of the membranes?
- Foul-smelling or greenish amniotic fluid
- Maternal fever
- Reduced foetal movements
A digital vaginal examination should be avoided in the absence of labour. But the foetal heart should be monitored.
What are some differentials for premature rupture of the membranes?
-
Urinary incontinence
This can be distinguished by the absence of amniotic fluid and the presence of urinary symptoms. -
Vaginal discharge or infection
This can be ruled out by the absence of foul-smelling or greenish discharge and the absence of other infection symptoms.
What investigations are done for premature rupture of the membranes?
Investigations for PROM should focus on assessing signs of infection and foetal distress, including:
- Monitoring maternal temperature
- Assessing foetal movements
- Monitoring foetal heart rate
- Observing vaginal discharge
Sterile Speculum Examination
- Fluid pooling in the posterior vaginal vault
Ultrasound
- reduced amniotic fluid index
What is the management of premature rupture of the membranes?
- If labour does not commence within 24 hours, induction of labour should be offered.
- If there are any signs of infection, immediate induction of labour should be commenced under consultant guidance and a broad spectrum antibiotic should be given.
- If there are any signs of foetal compromise, senior review is required to make a decision about whether immediate caesarean section is required.
- Following delivery, even if both baby and mother are asymptomatic, they should be closely observed in hospital for 12 hours post-birth.
What are some complications of premature rupture of the membranes?
- Chorioamnionitis - due to ascending infection
- Preterm birth - (and the associated complications) e.g. respiratory distress syndrome, necrotising enterocolitis, and foetal death
- Developmental problems - E.g. pulmonary hypoplasia, facial and limb deformities due to compression in the uterus, and cord prolapse due to low levels of amniotic fluid.
What is the definition of Umbilical cord prolapse?
- Cord prolapse is when the umbilical cord descends below the presenting part of the foetus and through the cervix into the vagina, after rupture of the fetal membranes.
- There is a significant danger of the presenting part compressing the umbilical cord, resulting in fetal hypoxia.
What are the risk factors of Cord Prolapse?
- Abnormal presentations e.g. Breech, transverse lie
- Prematurity
- Multiparity
- Polyhydramnios
- Twin pregnancy
- Cephalopelvic disproportion
- Low birth weight (SGA)
What is the clinical presentation of Cord Prolapse?
- Sudden change in the fetal heart rate pattern, particularly variable or prolonged decelerations.
- Feeling of the cord in the vagina or visible cord after rupture of membranes
- Abnormal fetal heart rate detected on cardiotocography
How is a Cord prolapse diagnosed?
- Cardiotocography - Umbilical cord prolapse should be suspected when there are signs of foetal distress on CTG.
- Vaginal examination - Can then be used to diagnose a prolapsed cord (by confirming the presence of the umbilical cord in the birth canal)
What is the management of a Cord prolapse?
When cord prolapse is diagnosed, swift action is vital to prevent fetal hypoxia and death:
- Emergency C-section
- Presenting part of the fetus may be pushed back into the uterus to avoid compression
- If the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm
- Patient goes onto all fours until C-section. Left lateral position may also be used.
- Tocolytics (Terbutaline) may be used to reduce uterine contractions
- Retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part
What is the definition of an Instrumental Delivery?
Instrumental delivery refers to a vaginal delivery assisted by either a ventouse suction cup or forceps.
These tools are used to help in the delivery of the baby’s head.
What percentage of births are done by Instrumental Delivery?
10% of UK Births
What are the indications to perform an instrumental delivery?
- Failure to progress
- Foetal distress
- Maternal exhaustion
- Control of the head in various fetal positions
- The use of an epidural for analgaesia, increases the risk that an instrumental delivery may be nescesary.
What are the maternal risks of an instrumental delivery?
- Postpartum haemorrhage
- Episiotomy
- Perineal tears
- Injury to the anal sphincter
- Incontinence of the bladder or bowel
- Nerve injury (obturator or femoral nerve)
What are the foetal risks of an instrumental delivery?
- Cephalohaematoma with ventouse
- Facial nerve palsy with forceps
Rarer (more serious complications):
- Subgaleal haemorrhage (most dangerous)
- Cerebral Palsy
- Intracranial haemorrhage
- Skull fracture
- Spinal cord injury
What is a Ventouse?
- It is essentially a suction cup on a cord.
- It goes on the baby’s head, and the doctor or midwife applies careful traction to the cord to help pull the baby out of the vagina.
- Its main complication is a cephalohaematoma - Which involves a collection of blood between the skull and the periosteum.
How are forceps used in an instrumental delivery?
- The forceps come as two pieces of curved metal that attach together, go either side of the baby’s head and grip the head in a way that allows the doctor or midwife to apply careful traction and pull the head from the vagina.
- Main complication is facial nerve palsy, with facial paralysis on one side.
- The forceps can also cause bruises on the baby’s face
What are the 2 nerves in the mother most commonly injured in an instrumental delivery?
- Femoral nerve
- Obturator nerve
The nerve injury tends to recover over 6 – 8 weeks.
How can the femoral nerve be injured during instrumental delivery?
The Femoral nerve can be compressed against the inguinal canal during a forceps delivery resulting in nerve injury.
What is the clinical presentation of a Femoral Nerve injury?
- Weakness of knee extension
- Loss of the patella reflex
- Numbness of the anterior thigh and medial lower leg.
How can the Obturator nerve be injured during instrumental delivery?
The obturator nerve may be compressed by forceps during instrumental delivery or by the fetal head during normal delivery.
What is the clinical presentation of a Obturator Nerve injury?
- Weakness of hip adduction and rotation
- Numbness of the medial thigh
What is the definition of Shoulder Dystocia?
- Shoulder dystocia is a specific type of obstructed labour where the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered.
- This is an obstectric emergency
What are the risk factors for Shoulder Dystocia?
- Maternal gestational diabetes
- Macrosomia
- Birthweight >4kg
- Advanced maternal age
- Maternal short stature or small pelvis
- Maternal obesity
- Post-dates pregnancy
What is the clinical presentation of Shoulder Dystocia?
- Difficult delivery of the foetal face or chin
- Retraction of the foetal head back into the vagina, after its been delivered (turtle-neck sign)
- Failure of restitution - where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head.
- Failure of descent of the foetal shoulders following delivery of the head.
What is the management of Shoulder Dystocia?
Its an Obstetric emergency that needs prompt intervention to deliver the baby. There are various manouvres to help with this:
- Call for Senior Help
- McRoberts manoeuvre
- Pubic Symphysis Pressure
An episiotomy can be used to enlarge the vaginal opening and reduce the risk of perineal tears. But this isn’t always nescesary.
Other Manouvres
- Rubins manoeuvre
- Wood’s screw manoeuvre
- Zavanelli manoeuver
What’s involved in a McRoberts manoeuvre?
It involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.
What’s involved in a Rubins manoeuvre?
It involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.
What’s involved in a Wood’s Screw Manouvre?
It is performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery.
What’s involved in a Zavanelli Manouvre?
It involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.
What is the definition of Placenta accreta?
- Placenta accreta refers to when the placenta implants deeper than usual onto the myometrium.
- It is referred to as placenta accreta spectrum, as there is a spectrum of severity in how deep and broad the abnormal implantation extends.
- it is due to defective decidua basalis
What are the 3 severities of the Placenta Accreta Spectrum?
- Superficial placenta accreta - is where the placenta implants in the surface of the myometrium, but not beyond
- Placenta increta - is where the placenta attaches deeply into the myometrium
- Placenta percreta - is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder.
What are the risk factors for the placenta accreta spectrum?
- Previous C-Section
- Previous placenta accreta
- Previous termination of pregnancy
- Dilatation and curettage
- Advanced maternal age
- Low lying placenta or placenta praevia
- Uterine structural defects
What is the pathophysiology of placenta accreta?
Defective Decidua Basalis
This deep implantation makes it very difficult for the placenta to separate during delivery, leading to extensive bleeding (postpartum haemorrhage).
What is the presentation of placenta accreta?
- It typically doesn’t cause any symptoms during pregnancy.
- It can present with bleeding (antepartum haemorrhage) in the third trimester.
- It may be diagnosed at birth, when it becomes difficult to deliver the placenta. It can cause significant postpartum haemorrhage.
How is placenta accreta diagnosed?
Ideally it is diagnosed before birth with an Antenatal Ultrasound
What are the possible complications of placenta accreta?
- Severe Postpartum Haemorrhage
- Preterm delivery
- Retained products of Conception
- Uterine rupture.
What is the management of placenta accreta?
Planned delivery between 35 and 36+6 weeks to prevent SROM
Antenatal Steroids to help fetal lung maturation
Delivery Options:
- Elective Ceesarian Section with hysterectomy is the safest management option.
If preserving the patient’s fertility is important to them, then the following can be attempted alongside the C-Section:
- Uterus preserving surgery, with resection of part of the myometrium along with the placenta
- Expectant management, leaving the placenta in place to be reabsorbed over time. But this comes with a significant risk of bleeding and infection.
What is the definition of Placenta Praevia?
- It’s defined as the placenta overlying the cervical os.
- This means that the placenta is attached in the lower portion of the uterus; lower than the presenting part of the fetus.
What is the difference between a Low lying placenta and Placenta Praevia?
- Low-lying placenta - Is used when the placenta is within 20mm of the internal cervical os
- Placenta praevia - Is used only when the placenta is over the internal cervical os
NOTE
A 4 stage grading system used to be used, but it’s now considered outdated.
What are the complications of Placenta Praevia?
It’s associated with increased morbidity and mortality for both the mother and fetus. Risks include:
- Antepartum haemorrhage
- Emergency caesarean section
- Emergency hysterectomy
- Maternal anaemia and transfusions
- Preterm birth and low birth weight
- Stillbirth
What are the 3 causes of Antepartum Haemorrhage?
- Placenta praevia
- Placental abruption
- Vasa praevia
What are the risk factors for Placenta Praevia?
- Previous caesarean sections
- Previous placenta praevia
- Older maternal age
- Multiparity
- Maternal smoking
- Structural uterine abnormalities (e.g. fibroids)
- Assisted reproduction (e.g. IVF)
What is the clinical presentation of Placenta Praevia?
- Bright red painless vaginal bleeding.
- shock in proportion to visible loss
- no pain
- uterus not tender
- lie and presentation may be abnormal
- fetal heart usually normal
- coagulation problems rare
- small bleeds before large
How is Placenta Praevia diagnosed?
What monitoring is done if you have low-lying/placenta praevia?
1st Line: Transvaginal Ultrasound scan
- placenta praevia is often picked up on the routine 20 week abdominal ultrasound
Digital vaginal examination should not be performed before an ultrasound as it may provoke a severe haemorrhage
Repeat TVUS for women with Low lying/ Placenta Praevia at 20 week scan
- At 32 weeks gestation
- At 36 weeks gesteation (if present on 32 week scan)
What is the management of Placenta Praevia?
- Repeat TVUS at 32 weeks and 36 weeks to guide delivery decisions
- Give Corticosteroids between 34-36 weeks of gestation (to mature the foetal lungs, given the increased risk of preterm labour)
- Planned cesarean section is adviced between 36 and 37 weeks gestation. (Its planned early to reduce the risk of spontaneous labour and bleeding).
- In cases were premature labour or where antenatal bleeding occurs; an emergency Cesarean section will be required.
What would the management of bleeding as a result of Placenta Praevia involve?
- Emergency caesarean section
- Blood transfusions
- Intrauterine balloon tamponade
- Uterine artery occlusion
- Emergency hysterectomy
What is the definition of Placental Abruption?
- Placental abruption is the premature separation of the placenta from the uterine wall during pregnancy.
- The site of attachment can bleed extensively after the placenta separates. Resulting in significant Maternal Antepartum Haemorrhage.
What are the risk factors for Placental Abruption?
ABRUPTION:
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gravida;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
What is the clinical presentation of Placental Abruption?
- Sudden onset severe abdominal pain that is continuous
- Vaginal bleeding (However in concealed abruptions; the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. So the severity of the bleeding would be largely underestimated.)
- Characteristic ‘Woody’ hard abdomen (Uterus) - suggests a large haemorrhage
- Hypovolaemic shock which is often disproportionate to the amount of vaginal bleeding visible
- Abnormalities on the CTG indicating foetal distress
How is the severity of Antepartum Haemorrhage graded?
- Spotting - spots of blood noticed on underwear
- Minor haemorrhage - less than 50ml blood loss
- Major haemorrhage - 50 – 1000ml blood loss
- Massive haemorrhage - more than 1000 ml blood loss, or signs of shock
What is the initial management of a major or massive haemorrhage?
- Urgent involvement of a senior obstetrician, midwife and anaesthetist
- 2 x grey cannula
- Bloods include FBC, UE, LFT and coagulation studies
- Crossmatch 4 units of blood
- Fluid and blood resuscitation as required
- CTG monitoring of the fetus
- Close monitoring of the mother
How is a Placental Abruption diagnosed?
- There are no reliable tests for diagnosing placental abruption.
- It is a clinical diagnosis based on the presentation
- Ultrasound can be useful in excluding placenta praevia as a cause for antepartum haemorrhage, but is not very good at diagnosing or assessing abruption.
What is the management of a Placental Abruption?
Fetus alive and < 36 weeks
- fetal distress: Emergency caesarean Section
- no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Fetus alive and > 36 weeks
- fetal distress: Emergency caesarean Section
- no fetal distress: deliver vaginally
Fetus dead Induce vaginal delivery
Antenatal Steroids: Offered between 24-34+6 weeks
Rhesus D Negative: Women require Anti-D prophylaxis using Kleihauer test to quantify dose required
Active management of third stage
What is the definition of Vasa Praevia?
- Vasa praevia is a condition seen in obstetrics where the foetal vessels, (unprotected by the umbilical cord or placental tissue), run dangerously close to or across the internal cervical os.
- These vessels are prone to rupture during the rupture of membranes, which can result in foetal haemorrhage and potentially foetal death.
What are the types of Vasa Praevia?
-
Velamentous umbilical cord (Type 1 Vasa Praevia)
Is where the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta. -
An accessory lobe of the placenta (Type 2 Vasa Praevia)
(Also known as a succenturiate lobe) is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes.
What are the risk factors for Vasa Praevia?
- Low lying placenta
- IVF pregnancy
- Multiple pregnancy
What is the clinical presentation of Vasa Praevia?
Often presents as antepartum haemorrhage in 2nd/3rd trimester or during labour
Classic Triad of:
- Rupture of membranes often followed by:
- Painless vaginal bleeding
- Foetal bradycardia (or resulting foetal death)
What are some differentials for Vasa Praevia?
-
Placenta praevia
Characterized by painless vaginal bleeding, but without the accompanying foetal bradycardia or death seen in vasa praevia. -
Abruptio placentae
Typically presents with painful vaginal bleeding, abdominal pain, and uterine tenderness and rigidity. Foetal distress is common.
How is Vasa Praevia diagnosed?
- Transabdominal or Transvaginal Ultrasound
- The majority of cases are diagnosed antenataly.
- Although, it may only be diagnosed during labour, when pulsating fetal vessels are seen in the membranes through the dilated cervix.
- The later this is diagnosed, the greater the risk of foetal mortality.
What is the management of Vasa Praevia?
- Corticosteroids, given from 32 weeks gestation to mature the fetal lungs
- Elective caesarean section, planned for 34 – 36 weeks gestation
When antepartum haemorrhage occurs:
- Emergency caesarean section is required to deliver the fetus before death occurs.
What is the definition of Postpartum Haemorrhage?
Postpartum haemorrhage (PPH) refers to bleeding after delivery of the baby and placenta (within 24 hours).
To be classed as a PPH, there need to be a loss of:
- 500ml after a vaginal delivery
- 1000ml after a caesarean section
What is the epidemiology of Postpartum Haemorrhage?
It is the most common cause of significant obstetric haemorrhage.
How can Postpartum Haemorrhage be Classified?
Vaginal > 500ml Blood loss
Caesarean > 1000ml Blood loss
Minor Vs Major:
- Minor PPH – under 1000ml blood loss
- Major PPH – over 1000ml blood loss
Major PPH further classification:
- Moderate PPH – 1000 – 2000ml blood loss
- Severe PPH – over 2000ml blood loss
Primary Vs Secondary:
- Primary PPH - bleeding within 24 hours of birth
-
Secondary PPH - from 24 hours to 12 weeks after birth
(Infection and RPOC)
What are the causes of Primary Postpartum Haemorrhage?
The 4 Ts:
Tone (Uterine Atony):
- Over-distension of the uterus: Multiple pregnancy, twin pregnancy, Polyhydramnios
- Prolonged delivery causing muscle fatigue
- Full bladder
- Medications: Nifedipine, terbutaline, MgSO4
Trauma
- C-Section
- Instrumental Delivery
- Episiotomy/perineal tears
- Haematoma
Tissue:
- Retained products of pregnancy (placenta)
- Placenta Accreta, increta, percreta
Thrombin:
- Coagulation disorders, Von willibrand, Placental abruption, Eclampsia/HELLP
What are the risk factors for Postpartum Haemorrhage?
- PPH in previous pregnancy
- BMI >35
- Multiple pregnancy
- Nulliparity
- Conditions such as placenta praevia or accreta, placental abruption, pre-eclampsia, gestational hypertension or anaemia
- Delivery via Caesarean section
- Induction of labour
- Instrumented delivery (forceps or ventouse) and episiotomy
- Prolonged labour (greater than 12 hours)
- Macrosomia (>4kg baby)
- Advanced maternal age
What investigations need to be done for a Postpartum Haemorrhage?
Primary
Secondary
In Primary PPH:
- Blood tests for Group/Save and Crossmatch
In Secondary PPH:
- Ultrasound looking for retained products
- Endocervical/high vaginal swabs looking for infection
What is the initial management to stabilise a Postpartum Haemorrage?
- Resuscitation with an ABCDE approach
- Lie the woman flat, keep her warm and communicate with her and the partner
- Insert two 14-gauge cannulas
- Bloods for G&S, FBC, U&E and clotting screen
- Group and cross match 4 units
- Warmed IV fluid and blood resuscitation as required
- Oxygen (regardless of saturations)
- Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion.
How can the bleeding be stopped in a Postpartum Haemorrhage?
Mechanical:
- Fundal Massage through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)
- Catheterisation (bladder distention prevents uterus contractions)
Medical:
- Oxytocin (slow injection followed by continuous infusion) - 40mg in 500mls
- Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)
- Carboprost(intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
- Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
- Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding
Surgical:
- Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
- B-Lynch suture – putting a suture around the uterus to compress it
- Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
- Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life
What is the management of a Secondary Postpartum Haemorrhage?
It depends on the cause:
- Surgical evaluation of retained products of conception
- Antibiotics for infection (endometritis)
How can a Rhesus Negative woman become sensitised to Rhesus-D antigens?
This can occur when a rhesus-D negative woman has a Rhesus-D positive baby. (Rhesus incompatability)
It is likely at some point in the pregnancy (i.e. childbirth) that the blood from the baby will find a way into the mother’s bloodstream. When this happens, the baby’s red blood cells display the rhesus-D antigen. The mother’s immune system will recognise this rhesus-D antigen as foreign, and produce antibodies to the rhesus-D antigen. The mother has then become sensitised to rhesus-D antigens.
What are some examples of sensitisation events where foetal and maternal blood may mix?
Examples of these sensitisation events include:
- Antepartum haemorrhage
- Placental abruption
- Abdominal trauma
- External cephalic version
- Invasive uterine procedures such as amniocentesis and chorionic villus sampling
- Rhesus positive blood transfusion to a rhesus negative woman
- Intrauterine death, miscarriage or termination
- Ectopic pregnancy
- Delivery (normal, instrumental or caesarean section)
What issues can maternal sensitisation to rhesus-D antigens cause in the foetus?
- Usually, the sensitisation process does not cause problems during the first pregnancy.
- During subsequent pregnancies, the mother’s anti-rhesus-D antibodies can cross the placenta into the fetus. If that fetus is rhesus-D positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack them, causing the destruction of the red blood cells (haemolysis).
- The red blood cell destruction caused by antibodies from the mother is called haemolytic disease of the newborn.
What is the management of Rhesus Incompatibility between the mother and foetus?
All mothers should be tested for rhesus status and anti-D antibodies at booking
Prevention of sensitisation - is the mainstay of management. This involves giving intramuscular anti-D injections to rhesus-D negative women.
Anti-D injections are given routinely on two occasions:
- 28 weeks gestation
- 34 weeks gestation
- Birth (if the baby’s blood group is found to be rhesus-positive)
Anti-D injections should also be given at any time where sensitisation may occur, such as:
- Antepartum haemorrhage
- Termination of pregnancy (ectopic, miscarriage, TOP)
- Amniocentesis procedures
- Abdominal trauma
- ECV
Anti-D is given within 72 hours of a sensitisation event..
What is the Kleihauer Test and when is it done?
- The Kleihauer test checks how much fetal blood has passed into the mother’s blood during a sensitisation event.
- This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required.
What is the definition of a Puerperal Infection?
A Puerperal infection is defined as an infection of the genital tract occurring at labour or within 42 days of the postpartum period.
What is the definition of Puerperal Pyrexia?
What are the main causes?
Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.
Causes:
- Endometritis: most common
- UTI
- Wound infections (perineal tears/c-section
- Mastitis
- VTE
What can increase the risk of postpartum endometritis?
- Cesarean section (especially emergency or after labor)
- Prolonged rupture of membranes (>18 hours)
- Prolonged labor (>24 hours)
- Multiple vaginal exams during labor
- Manual removal of the placenta
- Retained products of conception
- Preexisting infections (e.g., bacterial vaginosis)
What bacteria can cause Postpartum Endometritis?
- It can be caused by a large variety of gram-negative, gram-positive and anaerobic bacteria.
- It can also be caused by sexually transmitted infections such as chlamydia and gonorrhoea.
What is the presentation of Puerperal Pyrexia?
It can present from shortly after birth to several weeks postpartum, with:
- >38 degree fever in first 14 days
- Foul-smelling discharge or lochia
- Bleeding that gets heavier or does not improve with time
- Lower abdominal or pelvic pain
- Fever
- Sepsis
What investigations are done for Puerperal Pyrexia?
- Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
- Urine culture and sensitivities
- Ultrasound may be considered to rule out retained products of conception (although it is not used to diagnose endometritis).
What is the management of Puerperal Pyrexia?
Septic patients:
- SEPSIS SIX
Milder Infections:
- Referred to hospital for IV antibiotics
- Clindamycin and Gentamicin until afebrile for 24 hours.
What are some differentials of Breast Lumps?
- Breast Cancer
- Fibroadenoma
- Breast Cysts/Abscess
- Fibrocystic Breast Changes
- Fat necrosis
- Intraductal Papilloma
- Lipoma
- Duct Ectasia
- Implants
What is Fat Necrosis?
What are the common triggers for Fat necrosis?
Does it increase the risk of Breast Cancer?
Benign breast lump caused by localised degeneration and scarring of the Fat tissue in the breast
Triggers:
- Localised trauma
- Radiotherapy/surgery
- Inflammatory reaction
Does NOT increase the risk of breast cancer
What is the presentation of Fat Necrosis?
- Painless, Firm, Irregular lump
- Fixed in local structures
- There may be skin dimpling or nipple inversion
What investigations are performed for Breast Lumps?
Triple Assessment to rule out Breast CA
- Physical Examination
- Imaging: Mammography/Ultrasound
- Biopsy and Histology: Fine needle or core
What is the definition of Mastitis?
- Mastitis is the inflammation of the breast tissue, which can be with or without an infection.
- When associated with lactation in postpartum women, the condition is specified as puerperal mastitis.
What is the epidemiology of Mastitis?
Lactational Associated with Breast feeding
Non-lactational is mastitis caused not in the context of breast feeding
- Mastitis, (particularly puerperal mastitis), is a common condition among postpartum women
- It typically occurs within the first six weeks postpartum, particularly in the second and third weeks.
- It usually affects first-time mothers and those with a history of mastitis in previous pregnancies.
What causes Mastitis?
- Milk stasis from poor feeding or inadequate feeding
- Staph aureus is most common organism invading through the nipple
What are the risk factors for developing Mastitis?
- Poor breastfeeding technique
- Nipple damage
- Maternal stress
- Previous history of mastitis
- First time pregnancy
- Smoking
What is the clinical presentation of Mastitis?
What may Mastitis progress to?
- Breast pain and tenderness (unilateral)
- Erythema in a focal area of breast tissue
- Local warmth and inflammation
- Nipple discharge
- Fever
- The condition is usually unilateral and tends to present within the first week postpartum.
Mastitis may develop into a breast absces
- manifesting as a fluctuant, tender mass with overlying erythema.
What are some differentials for Mastitis?
-
Breast abscess
Fluctuant mass, tenderness, overlying erythema, systemic signs of infection. -
Inflammatory breast cancer
Swelling, skin changes resembling orange peel, nipple inversion, axillary lymphadenopathy. -
Breast engorgement
Typically bilateral and associated with milk stasis, painful, and tense breasts.
How is Mastitis investigated?
- Diagnosis of mastitis is primarily clinical
- An ultrasound may be useful in identifying an abcess if that is suspected
What is the management of Mastitis?
First Line:
- Continue breastfeeding. (even if infection present)
- Analgesia
- Regular expression of milk and breast massage
- A warm compresses
Second Line: if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection’
-
Antibiotics
- 1st Line is oral flucloxacillin
for 10-14 day - Erythromycin in pen-allergy
- 1st Line is oral flucloxacillin
What complications can arise as a result of Mastitis?
- Candida infection of the nipple (often after a course of antibiotics). This can lead to Recurrent mastitis
- Breast Abcess
What is the presentation of Candida of the nipple?
- Sore nipples bilaterally, particularly after feeding
- Nipple tenderness and itching
- Cracked, flaky or shiny areola
- May cause symptoms in the baby such as white patches in the mouth, tongue or nappy rash
Its associated with oral thrush and candidal nappy rash in the infant.
What is the management of Candida of the nipple?
Both the mother and baby need treatment, or it will reoccur. Treatment is with:
- Topical miconazole 2% after each breastfeed
- Treatment for the baby (e.g. miconazole gel or nystatin)
What is the definition of a breast abscess?
A breast abscess is a collection of pus within an area of the breast, usually caused by a bacterial infection. This may be a:
- Lactational abscess (associated with breastfeeding)
- Non-lactational abscess (unrelated to breastfeeding)
It often occurs as a result of infectious mastitis.
What are the most common causative organisms of Mastitis / Breast Abscesses?
- Staphylococcus aureus (the most common)
- Streptococcal species
- Enterococcal species
- Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)
What is the presentation of a Breast Abscess?
- Alongside the features of Mastitis (mastalgia, warmth, erythema, swelling)
- Purulent nipple discharge
- The key feature that suggests a breast abscess is a swollen, fluctuant, tender lump within the breast.
- As well as more generalised symptoms of infection like; Muscle aches, Fatigue, Fever, Signs of sepsis (e.g., tachycardia, raised respiratory rate and confusion).
What is the management of a Breast Abscess?
- Referral to the on-call surgical team in the hospital for management
- Antibiotics (Co-amoxicalv, Metronidazole)
- Ultrasound (confirm the diagnosis and exclude other pathology)
- Drainage (needle aspiration or surgical incision and drainage)
- Microscopy, culture and sensitivities of the drained fluid
Women are advised to continue breastfeeding. They should regularly express breast milk if feeding is too painful, then resume feeding when possible.
How is a Breast Abscess diagnosed?
Breast Ultrasound
What is the definition of a Fibroadenoma?
Do they increase the risk of breast CA?
- Fibroadenomas are common benign tumours of stromal and epithelial breast duct tissue.
- They originate from the lobules (the milk-producing glands of the breast)
Fibroadenomas are not usually associated with an increased risk of developing breast cancer.
- Complex fibroadenomas and a positive family history of breast cancer may indicate a higher risk.
What is the epidemiology of Fibroadenomas?
- More common in younger women (aged between 20 and 40)
- They’re particularly common in periods of reproductive hormonal change such as puberty, pregnancy, and perimenopause.
What causes a fibroadenoma?
- Exact cause is unclear
- They respond to the increased levels of female reproductive hormones (oestrogen and progesterone). As they often grow in size during pregnancy, and shrink during menopause.
What is the clinical presentation of a Fibroadenoma?
Painless, Smooth, Round and Well circumscribed (well-defined borders) breast lump.
- Firm
- Mobile (moves freely under the skin and above the chest wall)
- Usually up to 3cm diameter
Not directly influenced by menstrual cycle unlike benign fibrocystic breast changes
What are some differentials for a Fibroadenoma?
-
Breast cysts
These can be soft to firm, mobile, and round with distinct edges, similar to fibroadenomas. However, they may be tender and can fluctuate in size with the menstrual cycle. -
Invasive breast cancer
Typically presents with a hard, irregularly shaped, immobile mass. There may be associated nipple discharge, retraction or skin changes. -
Intraductal papilloma
Generally presents with nipple discharge, occasionally blood-stained, but may also have an associated palpable mass. -
Lipoma
Presents as a soft, mobile mass. Unlike fibroadenomas, lipomas can grow beyond 3cm and are typically painless.
What investigations are done for a fibroadenoma?
While fibroadenomas are benign, patients usually undergo a triple assessment to exclude more serious pathology. This includes:
- Clinical examination
- Imaging (usually ultrasound and/or mammogram)
- Needle biopsy (fine needle aspiration or core biopsy)
What is the management of a fibroadenoma?
-
Conservative management
Many fibroadenomas do not require treatment and will regress naturally after menopause. -
Surgical excision
This may be required if the fibroadenoma is large, growing, causing significant symptoms, or if there is diagnostic uncertainty after triple assessment.
Are fibroadenomas associated with an increased risk of breast cancer?
No
- They are not usually associated with an increased risk of developing breast cancer.
- Complex fibroadenomas and a positive family history of breast cancer may indicate a higher risk.
What is the definition of a Breast Cyst?
Breast cysts are benign, individual, fluid-filled lumps of the breast.
What is the epidemiology of breast cysts?
- They are the most common cause of breast lumps
- Occur most often between ages 30 and 50, more so in the perimenopausal period.
What is the clinical presentation of breast cysts?
The Lumps can be:
- Possibly painful
- Smooth
- Well-circumscribed
- Mobile
- Possibly fluctuant
They can also fluctuate in size over the menstrual cycle
How are breast cysts investigated?
All breast lumps should be investigated with Triple Assessment to exclude cancer):
- Clinical examination
- Imaging (usually ultrasound and/or mammogram)
- Needle biopsy (fine needle aspiration or core biopsy)
What is the management of breast cysts?
- Aspiration of the breast cyst is the recommended treatment in symptomatic cases.
- Repeat aspiration or excision may be required in cases of recurrent cysts
- Non-symptomatic (non-painful) breast cysts do not need to be drained unless they bother the patient or cause concerns.
Do breast cysts increase the risk of cancer?
Yes
Having a breast cyst may slightly increase someone’s cancer risk
What is the definition of Ductal Ectasia?
Mammary duct ectasia is a benign condition where there is dilation of the large ducts in the breasts. Ectasia means dilation. There is inflammation in the ducts, leading to intermittent discharge from the nipple. The discharge may be white, grey or green.
What is the definition of an Intraductal Papilloma?
- An intraductal papilloma is a warty lesion that grows within one of the ducts in the breast.
- It is the result of the proliferation of epithelial cells.
- They are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.
What is the epidemiology of an Intraductal Papilloma?
Most common between 35-55 years
What is the clinical presentation of an Intraductal Papilloma?
They may present with:
- Nipple discharge (clear or blood-stained)
- Breast tenderness or pain
- A palpable lump
They are often asymptomatic and can be picked up incidentally on mammograms or ultrasound.
How is an Intraductal Papilloma diagnosed?
Patients require triple assessment with:
- Clinical assessment (history and examination)
- Imaging (ultrasound, mammography and MRI)
- Histology (usually by core biopsy or vacuum-assisted biopsy)
Ductography may also be used. This involves injecting contrast into the abnormal duct and performing mammograms to visualise that duct. The papilloma will be seen as an area that does not fill with contrast (a “filling defect”).
What is the management of an Intraductal Papilloma?
- Intraductal papillomas require complete surgical excision.
- After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy.
What is the definition of Breast Cancer?
- Breast cancer or carcinoma refers to a malignant tumour originating from the cells of the breast tissue.
What is the epidemiology of Breast Cancer?
- Breast cancer is the most common form of cancer in the UK.
- It mostly affects women and is rare in men (about 1% of UK cases).
- Around 1 in 8 women will develop breast cancer in their lifetime.
What are the risk factors for Breast Cancer?
BREAST CARE
Females
B: BRCA1/BRCA2 gene mutations
R: Radiation exposure to the chest
E: Early menarche & late menopause (longer estrogen exposure)
A: Advanced age
S: Smoking and Supplemental Combined hormones (HRT)
T: Time of first pregnancy (1st Pregnancy > 30 years or nulliparity)
C: Contraceptive pills (long-term use)
A: Alcohol intake
R: Relatives with breast cancer (family history)
E: Excess weight (obesity) and Exercise (lack of)
What are BRCA genes?
- BRCA refers to the BReast CAncer gene. The BRCA genes are tumour suppressor genes.
- Mutations in these genes lead to an increased risk of breast cancer (as well as ovarian and other cancers).
What chromosomes are the genes BRCA 1 and 2 on?
What are the risks of developing Breast/Ovarian cancer due to the BRCA genes
BRCA1 gene is on chromosome 17
- 70% will develop breast cancer by aged 80
- 50% will develop ovarian cancer
- Also increased risk of bowel and prostate cancer
BRCA2 gene is on chromosome 13
- 60% will develop breast cancer by aged 80
- 20% will develop ovarian cancer
What are some other types of Breast cancer?
- Pagets disease of the Nipple
- Inflammatory Breast Cancer
- Medullary breast cancer
- Mucinous breast cancer
- Tubular breast cancer
- Multiple others
What is the typical presentation of Breast Cancer?
- Lumps that are hard, irregular, painless or fixed in place
- Lumps may be tethered to the skin or the chest wall
- Nipple retraction
- Skin dimpling or oedema (peau d’orange)
- Lymphadenopathy, particularly in the axilla
Describe the NHS Breast Cancer Screening program
Mammogram is offered every 3 years to women aged 50-70 years
The screening aims to detect breast cancer early, which improves outcomes.
Annual Mammogram Screening may be provided to women deemed high risk
What are some potential downsides to Breast Cancer Screening?
- Anxiety and stress
- Exposure to radiation during mammograms, with a very small risk of causing breast cancer
- Missing cancer, leading to false reassurance
- Unnecessary further tests or treatment where findings would not have otherwise caused harm
Who is classed as a high risk patient for Breast Cancer?
People who have:
- A first-degree relative with breast cancer under 40 years
- A first-degree male relative with breast cancer
- A first-degree relative with bilateral breast cancer, first diagnosed under 50 years
- Two first-degree relatives with breast cancer
Annual mammogram screening is offered to women with increased risk. Potentially starting from aged 30, if high risk.
How can high risk patients decrease their risk of developing Breast Cancer?
Chemoprevention may be offered:
- Tamoxifen if premenopausal
- Anastrozole if postmenopausal (except with severe osteoporosis)
Risk-reducing bilateral mastectomy or bilateral oophorectomy (removing the ovaries) is also an option for women at high risk; but this is only suitable for a small subset of women.
What is the NICE Referral criteria for Breast Cancer?
When would NICE suggest a non-urgent referral?
Two week wait referral for:
- An unexplained breast lump in patients aged 30 or above
- Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
- An unexplained lump in the axilla in patients aged 30 or above
- Skin changes suggestive of breast cancer
NICE recommend considering non-urgent referral for unexplained breast lumps in patients under 30 years
What are the differentials for Breast Cancer?
-
Fibroadenoma
Typically presents as a solitary, painless, and well-circumscribed breast lump in young women -
Cyst
Characterized by a round or oval, well-defined, and movable mass. It may be painful and size may vary with the menstrual cycle. -
Mastitis
Typically presents in breastfeeding women, characterized by a painful, warm, red breast often accompanied by systemic symptoms like fever. -
Lipoma
Presents as a soft, mobile, and painless lump.
What investigations are used when diagnosing suspected Breast Cancer?
What investigations should be done once breast cancer is diagnosed?
Initial Investigations are with a Triple Diagnostic Assessment:
- Clinical assessment (history and examination)
- Imaging (ultrasound or mammography)
- Biopsy (fine needle aspiration or core biopsy)
Then once the woman has been diagnosed with breast cancer, then an assessment of the Lymph nodes is required:
- Ultrasound of the axilla (armpit)
- Ultrasound-guided biopsy of any abnormal nodes
- A sentinel lymph node biopsy may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.
What are the advantages of different imaging modalities when investigating Breast Cancer?
Ultrasound scans:
- Are used to assess lumps in younger women (e.g., under 30 years).
- They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps.
Mammograms:
- Are generally more effective in older women due to less density in breast tissue
- They can pick up calcifications missed by ultrasound.
MRI Scans may be used:
- For screening in women at higher risk of developing breast cancer (e.g., strong family history)
- To further assess the size and features of a tumour
How is Breast Cancer prognosis assessed?
Nottingham Prognostic Index (NPI)
- Uses Tumour Size, Lymph node score and Grade Score
- Higher the grade the worse the prognosis
NPI Prognostic indicator
- NPI <2.4 = Excellent prognosis (Normal Population survival)
- NPI <3.4 = Good prognosis (80% 10 year survival)
- NPI <5.4 = Intermediate prognosis (50% 10 year survival)
- NPI >5.4 = Poor prognosis (<20% 10 year survival)
Where does Breast Cancer tend to metastasis to?
Breast cancer can spread to anywhere in the body, whoever the most common locations are:
2Ls and 2Bs
- L – Lungs
- L – Liver
- B – Bones
- B – Brain
What are the 3 types of receptor that may be present on breast cancer?
- Oestrogen receptors (ER)
- Progesterone receptors (PR)
- Human epidermal growth factor (HER2)
These receptors can be targeted with breast cancer treatments
What is a triple negative breast cancer?
Triple-negative breast cancer is where the breast cancer cells do not express any of the three typical receptors. (ER, PR or HER2)
This carries a worse prognosis, as it limits the treatment options for targeting the cancer.
What is Gene Expression Profiling and when is it done?
- Gene expression profiling involves assessing which genes are present within the breast cancer on a histology sample.
- This helps predict the probability that the breast cancer will reoccur as a distal metastasis (away from the original cancer site) within 10 years.
The NICE guidelines recommend this for women with early breast cancers that are:
- ER positive but HER2 and lymph node negative
- It helps guide whether to give additional chemotherapy.
What does the management of Breast Cancer Involve?
Management will depend on the type of cancer and the patients preference but may involve:
- surgery
- radiotherapy
- hormone therapy
- biological therapy
- chemotherapy
What are the side effects of Radiotherapy?
- General fatigue from the radiation
- Local skin and tissue irritation and swelling
- Fibrosis of breast tissue
- Shrinking of breast tissue
- Long term skin colour changes (usually darker)
What are the side effects of Chemotherapy?
- Fatigue
- Hair loss
- Easy bruising and bleeding
- Infection
- Anaemia
- Nausea and vomiting
- Appetite changes
- Problems with concentration or memory.
What are the side effects of Hormone therapy drugs?
What are the major risk factors of Tamoxifen?
- Hot flashes
- Vaginal dryness or discharge
- Menstrual changes
- Fatigue
- Mood changes
- Osteoporosis.
Tamoxifen RFs
- Increased risk of endometrial cancer
- VTE
- Menopausal symptoms.
What is the mechanism of action of Tamoxifen?
- Tamoxifen is a selective oestrogen receptor modulator (SERM).
- It either blocks or stimulates oestrogen receptors, depending on the site of action.
- It blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones.
- This means it helps prevent osteoporosis, but it does increase the risk of endometrial cancer.
What is the mechanism of Aromatase Inhibitors?
- Aromatase is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen.
- After menopause, the action of aromatase in fat tissue is the primary source of oestrogen.
- Aromatase inhibitors work by blocking the creation of oestrogen in fat tissue.
- Examples include: letrozole, anastrozole or exemestane
When is Breast Reconstruction done?
Breast reconstructive surgery is offered to all patients having a mastectomy. There are two options:
- Immediate reconstruction - done at the time of the mastectomy
- Delayed reconstruction - which can be delayed for months or years after the initial mastectomy
What are the 2 options of Breast Reconstruction after Breast conserving surgery?
After breast-conserving surgery, reconstruction may not be required. The standard options, if needed, are:
- Partial reconstruction (using a flap or fat tissue to fill the gap)
- Reduction and reshaping (removing tissue and reshaping both breasts to match.
What are the 2 options of Breast Reconstruction after a Mastectomy?
- Breast implants (inserting a synthetic implant)
- Flap reconstruction (using tissue from another part of the body to reconstruct the breast)
What are the advantages/disadvantages of implants instead of Flap Reconstruction?
Advantages
- Inserting an implant is a relatively simple procedure (compared with a flap) with minimal scarring.
- It gives an acceptable appearance
Disadvantages
- Implants can feel less natural (e.g., cold, less mobile and static size and shape).
- There can also be long-term problems, such as hardening, leakage and shape change.
What are the 3 different types of Flap reconstruction?
- Latissimus Dorsi Flap
- Transverse Rectus Abdominis Flap (TRAM Flap)
- Deep Inferior Epigastric Perforator Flap (DIEP Flap)
What is Chronic Lymphoedema?
- Lymphoedema is a chronic condition caused by impaired lymphatic drainage of an area.
- Lymphoedema can occur in an entire arm after breast cancer surgery on that side, with removal of the axillary lymph nodes in the armpit.
- lymphatic system is responsible for draining excess fluid from the tissues. The tissues in areas affected by an impaired lymphatic system become swollen with excess, protein-rich fluid (lymphoedema).
- Areas of lymphoedema are prone to infection
What are the treatment options for Chronic Lymphoedema?
- Massage techniques to manually drain the lymphatic system (manual lymphatic drainage)
- Compression bandages
- Specific lymphoedema exercises to improve lymph drainage
- Weight loss if overweight
- Good skin care
What are the possible surgical complications of Breast surgery?
- Pain: Persistent or worsening pain at the surgical site.
- Bleeding: Increased wound drainage, decreased blood pressure, increased heart rate.
- Infection: Wound redness, swelling, pain, pus discharge, and fever.
- Seroma: Swelling at the surgical site, fluid-filled lump.
- Displeasure with cosmetic outcome: Patient dissatisfaction with the appearance of the breast after surgery.
What are the possible anaesthetic complications of Breast Surgery?
- Stroke: Sudden onset of neurological deficits such as weakness, speech impairment, visual changes.
- Venous thromboembolism: Swelling, pain, and redness in the leg (deep vein thrombosis); shortness of breath, chest pain, and rapid heart rate (pulmonary embolism).
- Myocardial infarction: Chest pain, shortness of breath, sweating, nausea, and lightheadedness.
- Aspiration: Sudden onset of coughing, wheezing, and difficulty breathing.
What are the possible Axillary node clearance related complications of Breast Surgery?
- Lymphoedema: Swelling of the arm, feeling of heaviness or tightness, restricted range of motion.
- Damage to brachial plexus: Numbness, tingling, or weakness in the arm.
- Axillary artery/vein injury: Swelling, pain, pallor, and decreased pulse in the arm.
What is the definition of Paget’s disease of the nipple?
Paget’s disease of the nipple, also known as Paget’s disease of the breast, is a rare condition characterised by the presence of cancer cells in the skin of the nipple.
- This disease often suggests an underlying ductal carcinoma in situ (DCIS) or invasive breast cancer.
What is the epidemiology of Paget’s Disease of the nipple?
- Most common in Postmenopausal women
- Only accounts for around 5% of breast cancers
What are the 2 theories for how Paget’s disease of the nipple occurs?
- Epidermotropic theory - suggests that cancer cells from an underlying breast tumour migrate to the nipple.
- Intraepidermal origin theory - which proposes the disease originates in the nipple itself.
What is the clinical presentation of Paget’s disease of the nipple?
- Eczema-like rash on the skin of the nipple and areola that is often itchy, red, crusty, and inflamed
- Bloody nipple discharge
- Burning sensation, increased sensitivity, or pain in the nipple
- Changes to the nipple, such as retraction or inversion
- Palpable breast lump (in some cases)
- Non-healing skin ulcer (in some cases)
What are the differentials for Paget’s disease of the Nipple?
-
Atopic dermatitis (eczema)
Characterised by itchy, red, and inflamed skin, usually occurring in patches -
Contact dermatitis
Caused by irritants or allergens, presents with a red rash, itching, and possibly blisters -
Intraductal papilloma
Produces bloody nipple discharge but typically does not involve skin changes -
Mastitis or breast abscess
Presents with breast redness, swelling, pain, and possible fever; often related to breastfeeding -
Psoriasis
Presents with silvery scales on red, raised patches, often with itching or burning
How is Paget’s disease of the nipple diagnosed?
- Physical examination of the breasts and lymph nodes
- Mammography or breast ultrasound
- Punch Biopsy of the affected skin and nipple discharge cytology
- MRI may be used in certain circumstances to better assess the extent of disease
What does management of Paget’s disease of the nipple involve?
Management of Paget’s disease of the nipple primarily involves surgical intervention. Approaches can include:
- Simple mastectomy: Removal of the entire breast, including the nipple and areola
- Modified radical mastectomy: Removal of the entire breast along with some of the axillary (underarm) lymph nodes
- Breast-conserving surgery (lumpectomy): If the underlying cancer is small and limited
Additionally, adjunctive treatments such as radiation therapy, chemotherapy, or hormonal therapy may be used depending on the characteristics of the underlying breast cancer.
What is the definition of Vulvovaginal Candidiasis?
- Vulvovaginal candidiasis, often referred to as a yeast infection, is an inflammation of the vagina and the vulva due to an overgrowth of the yeast fungus, primarily Candida Albicans.
- Recurrent vulvovaginal candidiasis is defined as four or more symptomatic episodes in one year, with at least two episodes confirmed by microscopy or culture when symptomatic.
What causes Vulvovaginal Candidiasis?
- Candida Albicans is the main causative organism (causing 85-90% of cases)
- Transmission is usually non-sexual
What are the risk factors for developing vulvovaginal candidiasis?
- diabetes mellitus
- drugs: antibiotics, steroids
- pregnancy
- immunosuppression: HIV
What is the clinical presentation of Vulvovaginal Candidiasis?
- cottage cheese’, non-offensive discharge
- vulvitis: superficial dyspareunia, dysuria
- itch
- vulval erythema, fissuring, satellite lesions may be seen
What are some differentials for Vulvovaginal Candidiasis?
-
Bacterial vaginosis
Characterised by greyish-white discharge, fishy odour, and absence of significant inflammation. -
Trichomoniasis
Presents with yellow-green, frothy discharge, dysuria, and itching. -
Chlamydia or Gonorrhoea
These sexually transmitted infections can cause similar symptoms such as discharge, but often also present with pelvic pain or bleeding. -
Genital herpes
Characterised by painful blisters or open sores in the genital area.
What investigations are done for vulvovaginal candidiasis?
Routine investigations are not typically required for acute, uncomplicated vulvovaginal candidiasis cases.
However, in instances where the clinical presentation is unclear or recurrent episodes occur, the following investigations may be necessary:
- Microscopy - Detection of blastospores, pseudohyphae and neutrophils suggests Candida infection.
- Culture - Recommended for recurrent vulvovaginal candidiasis cases to identify the Candida species.
What is the management of Vulvovaginal Candidiasis?
First Line:
- Oral fluconazole 150 mg as a single dose
Second line:
- clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
- If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
What is the management of Recurrent vulvovaginal candidiasis?
4 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
An induction-maintenance regime
- Induction: oral fluconazole every 3 days for 3 doses
- Maintenance: oral fluconazole weekly for 6 months
What is the definition of Balanitis?
- Balanitis is inflammation of the glans penis.
- If the foreskin is also inflamed, the correct term is balanoposthitis, although balanitis is commonly used to refer to both.
What is the epidemiology of Balanitis?
- More common in Men than boys
- It’s uncommon in circumcised boys and men (circumcision reduces the risk of inflammatory skin conditions which may cause balanitis).
What are the risk factors for Balanitis?
- Diabetes mellitus.
- Use of oral antibiotics.
- Poor hygiene in uncircumcised males.
- Immunosuppression.
- Chemical or physical irritation of glans.
What are the possible causes of Balanitis?
Infectious Causes:
- Candida infection
- Staph Aureus
- Anaerobic Bacteria
Dermatological Causes
- Circinate balanitis (Associated with reactive arthritis)
- Psoriasis
- Fixed drug eruption (especially with sulfonamides and tetracycline)
Other causes
- Intertrigo (alot of cases)
- Irritation or contact dermatitis: wet nappies, poor hygiene, smegma, soap, condoms.
- Trauma
- Severe oedema due to right heart failure.
- Morbid obesity
What is the clinical presentation of Balanitis?
- Sore, inflamed and swollen glans/foreskin
- Non-retractile foreskin (phimosis).
- itchy
- Penile ulceration.
- Penile plaques.
- Satellite lesions.
- May be purulent and/or foul-smelling discharge (most common with streptococcal/anaerobic infection).
- Dysuria.
- Interference with urinary flow in severe cases.
- Obscuration of glans/external urethral meatus.
- Impotence or pain during coitus.
- Regional lymphadenopathy.
ts
What is Intertrigo?
Intertrigo is a common inflammatory skin condition that is caused by skin-to-skin friction (rubbing) that is intensified by heat and moisture.
What investigations are done for Balanitis?
- Blood/urine testing for glucose if diabetes mellitus is possible.
- Swab of discharge for microscopy, Gram staining, culture and sensitivity.
What is the management of Balanitis?
Caused by contact dermatitis:
- Avoid Triggers
- Topical hydrocortisone 1% once daily (consider adding an imidazole cream), for up to 14 days.
Caused by Candidal infection
- Clotrimazole cream 1% or miconazole cream 2%; apply twice daily until symptoms have settled.
- Alternative regimens: fluconazole 150 mg stat orally
- Topical imidazole with 1% hydrocortisone if there is marked inflammation
Caused by Bacterial infection
- Common bacterial infection - flucloxacillin (or erythromycin in penicillin-allergic patients).
- Anaerobic infection - metronidazole 400 mg twice-daily for one week
Surgery
- Is not often done, but surgical referral for consideration of circumcision if balanitis is recurrent or pathological phimosis is present.
What is the definition of Chancroid?
- Chancroid is a sexually transmitted infection (STI) of the genital skin.
- It is primarily caused by the gram-negative bacillus Haemophilus ducreyi.
What is the epidemiology of Chancroid?
- Most common in tropical and subtropical regions as well as Greenland
- Sexual behaviour, poor living conditions, and a lack of public health infrastructure contribute to the increased incidence in these areas
What causes Chancroid?
- Chancroid is caused by an infection with the gram-negative bacillus Haemophilus ducreyi.
- The bacterium is sexually transmitted and can cause a genital ulcer and inflammation of the inguinal lymph nodes.
- Given its higher prevalence in other parts of the world, its important to ask patients about recent travel.
What is the clinical presentation of Chancroid?
- Presents as a painful, potentially necrotic genital lesion; that may bleed on contact.
- Painful lymphadenopathy, commonly known as “bubo,” which may rupture and discharge pus.
Symptoms often develop within 4-10 days after exposure to the bacterium.
What are some differentials for Chancroid?
-
Herpes Simplex Virus (HSV)
Presents with multiple, small, vesicular lesions that become ulcers, accompanied by systemic symptoms such as fever and malaise. -
Syphilis
Presents with a painless ulcer (chancre) and generalized non-tender lymphadenopathy. -
Lymphogranuloma Venereum (LGV)
Presents with a small painless ulcer or papule that often goes unnoticed, followed by painful inguinal lymphadenopathy (“bubo”) similar to chancroid.
What investigations are done for Chancroid?
Diagnosis is usually based upon the clinical picture. But the following can confirm the diagnosis:
- Culture - H. ducreyi is a fastidious organism and culture is often difficult and time-consuming.
- PCR (Polymerase Chain Reaction) - PCR for H. ducreyi can be performed on genital ulcer specimens, providing a more rapid diagnosis.
What is the management of Chancroid?
- Single dose 500mg Ciprofloxacin or Single dose 250mg IM Ceftriaxone
Adjunctive therapy can include:
- Analgesics for pain control
- Incision and drainage of buboes
What is the definition of Lymphogranuloma venereum (LGV)?
- Lymphogranuloma venereum (LGV) is a sexually transmitted infection.
- Predominantly caused by the L1, L2, or L3 serovars of Chlamydia trachomatis.
What is the epidemiology of LGV?
More common in Men who have sex with Men
What causes LGV?
Its caused by infection with the L1, L2, or L3 serovars of Chlamydia trachomatis, typically through sexual contact.
What is the clinical presentation LGV?
- Painless genital ulcer - Typically appears 3-12 days after infection. It might go unnoticed, particularly if it occurs inside the vagina
- Inguinal lymphadenopathy, often noticeable
- Proctitis, associated with rectal pain and discharge (in case of rectal infections)
- Systemic symptoms can include fever and malaise
What are the differentials of LGV?
-
Primary syphilis
Presents with a solitary, painless genital ulcer (chancre) and regional lymphadenopathy -
Herpes simplex virus infection
Characterised by multiple painful vesicles or ulcers, systemic symptoms, and occasional inguinal lymphadenopathy -
Chancroid
Caused by Haemophilus ducreyi, it presents with painful genital ulcers and painful inguinal lymphadenopathy
How is LGV diagnosed?
Polymerase chain reaction (PCR), are employed to detect C. trachomatis from a swab of the genital ulcer.
What is the management of LGV?
Its managed by anitibiotics. Common regimes include:
- Oral doxycycline - 100 mg administered twice daily for 21 days
- Oral tetracycline - 2 g administered daily for 21 days
- Oral erythromycin - 500 mg given four times daily for 21 days
What is the definition of Genital Herpes?
- Genital herpes is an infectious disease characterized by the appearance of painful sores or ulcers on the genitals.
- It is caused by infection with the herpes simplex viruses, either HSV-1 or HSV-2.
What is the epidemiology Genital Herpes?
More common in 15 - 24 year olds
What is the cause of Genital Herpes?
- HSV-1 - Is traditionally associated with oral herpes, but it is now the most common cause of genital herpes in the UK.
- HSV-2 - Was reviously the most common cause of genital herpes in the UK, it is more likely to cause recurrent anogenital symptoms.
What is the clinical presentation of Genital Herpes?
- Asymptomatic presentation in some individuals
- multiple painful Ulcers or blistering lesions affecting the genital area
- Neuropathic type pain (tingling, burning or shooting)
- Flu-like symptoms (e.g. fatigue and headaches)
- Dysuria (painful urination)
- Inguinal lymphadenopathy
Initial presentation is worst, Symptoms can last three weeks in a primary infection. Recurrent episodes are usually milder and resolve more quickly.
How is Genital Herpes Diagnosed?
- Clinical history and examination
- Swab from the base of the ulcer analysed using nucleic acid amplification tests (NAATs), the most effective method
What is the management of Genital Herpes?
General advice and measures?
Medications?
What additional aspects are considered in pregnancy?
General measures include:
- Saline bathing
- Analgesia
- Topical anaesthetic agents e.g. lidocaine
Medication:
- Oral Aciclovir (400mg for 5 days)
some patients with frequent exacerbations may benefit from longer-term aciclovir
Pregnancy:
- Elective caesarean section at 37 weeks if infected post 28 weeks.
- Women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low
What is the definition of Genital Warts?
- Genital warts, or anogenital warts, are a type of sexually transmitted infection characterised by small, skin-colored or grey growths in the genital area.
- They are typically painless and present in regions traumatised during sexual intercourse.
What are some risk factors for Genital Warts?
- Unprotected sex
- Multiple sexual partners
- Immunosuppression
- Starting sexual activity at a young age.
What causes Genital Warts?
- They are caused by the human papillomavirus (HPV)
- 90% of cases are attributed to attributed to serotypes 6 and 11
- Transmission primarily occurs through direct skin-to-skin contact during sexual activity.
What is the clinical presentation of Genital Warts?
- Painless lumps on the genitals or anal area
- The lumps are either skin coloured or grey
- Lumps that are either keratinised (hard) or non-keratinised (soft)
- Areas of the body that are traumatised during sexual intercourse are commonly affected
What are some differentials of Genital Warts?
-
Molluscum contagiosum
Characterised by small, firm, round bumps with a central indentation. -
Condyloma lata (secondary syphilis)
Presents as large, flat, grey-white lesions, often with a moist surface. -
Genital herpes
Presents with painful blisters or open sores in the genital area. -
Skin tags
Small, soft, skin-colored growths that hang off the skin and can appear anywhere.
How is Genital Warts Diagnosed?
- Diagnosis is primarily clinical made through a detailed history and visual inspection of the warts.
- But in uncertain cases the diagnosis can be confirmed through biopsy and histopathological investigation.
What does the management of Genital Warts involve?
Self Administered
Reassurance partner may not have cheated due to long latency of virus
- Podophyllotoxin - a plant-based antiviral that can destroy wart tissue
- Imiquimod -may weaken condoms
Specialist Treatments
- Cryotherapy (a process that freezes the wart using liquid nitrogen) or ablative therapy can be used to treat keratinised warts
- Trichloroacetic acid - a chemical treatment that burns off warts.
There is a high chance of reccurrence regardless of treatment.
What is the definition of a Primary HIV Infection?
- Primary HIV infection, or acute retroviral syndrome, is the phase that commences immediately after the initial exposure to the Human Immunodeficiency Virus (HIV).
- This phase is characterised by a surge in viral replication and often coincides with the onset of clinical symptoms.
What causes a HIV infection?
- HIV, specifically HIV-1 and HIV-2, are RNA retroviruses that cause primary HIV infection.
- The virus enters and destroys the CD4 T-helper cells of the immune system.
They are transmitted through:
- Unprotected anal, vaginal or oral sexual activity
- Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission)
- Mucous membrane, blood or open wound exposure to infected blood or bodily fluids (e.g., sharing needles, needle-stick injuries or blood splashed in an eye)
What is the clinical presentation of a primary HIV infection?
Typically presents experience as a mild flu-like illness 2-6 weeks post-exposure. But it can widely range in the serverity of symptoms. Classic presentation includes:
- Fever
- Lymphadenopathy
- Maculopapular rash (commonly found on the upper chest)
- Mucosal ulcers
- Myalgia
- Arthralgia
- Fatigue
- Some people can remain asymptomatic
After this initial flu-like illness within the first few weeks of infection. The infection is then asymptomatic until the condition progresses to immunodeficiency. Disease progression may occur years after the initial infection.
What are the indications in a primary HIV infection, that the patient may rapidly progress to AIDS?
- Symptom onset within 3 weeks of infection
- Symptoms lasting longer than 2 weeks
- Symptoms involving the central nervous system (CNS)
What are some differentials for Primary HIV?
-
Influenza
Characterised by sudden onset fever, cough, headache, muscle and joint pain, severe malaise, sore throat, and a runny nose. -
Mononucleosis (Epstein-Barr virus or cytomegalovirus)
Typically presents with fever, pharyngitis, lymphadenopathy, and fatigue. -
Acute streptococcal pharyngitis
Symptoms include sore throat, fever, headache, abdominal pain, nausea, and vomiting. -
Viral hepatitis
May present with jaundice, fatigue, nausea, fever, and muscle aches.
How is a primary HIV infection diagnosed?
Serum HIV enzyme-linked immunosorbent assay (ELISA)
A positive result must be confirmed using a second test.
What additional tests can be done when investigating a primary HIV infection?
- HIV viral load
- Full blood count
- Lymphocyte subset panel (including CD4 count)
- Screening for other sexually transmitted infections such as chlamydia, gonorrhoea, and syphilis
- Screening for viral hepatitis
- Kidney function tests
- Liver function tests
- Glucose
- Lipids
What is the management of a HIV infection?
Every patient is offered Combination Antiretroviral Therapy regardless of their viral load or CD4 count.
There are several classes of ART drugs:
- Protease inhibitors (PI)
- Integrase inhibitors (II)
- Nucleoside reverse transcriptase inhibitors (NRTI)
- Non-nucleoside reverse transcriptase inhibitors (NNRTI)
- Entry inhibitors (EI)
The usual starting regime is:
- Two NRTIs (e.g. tenofovir plus emtricitabine)
- Plus a third agent (e.g. bictegravir).
The aim of treatement achieve a normal CD4 count and undetectable viral load.
What are the 2 types of HIV Screening test?
Fourth-generation laboratory test for HIV
- Checks antibodies to HIV and the p24 antigen
- It has a window period of 45 days, meaning it can take up to 45 days after exposure to the virus for the test to turn positive.
- A negative result within 45 days of exposure is therefore unreliable
Point of care tests for HIV
- Only checks for HIV antibodies
- Has a window period of 90 days
How is a HIV infection monitored?
CD4 Count - gives the number of CD4 cells in the blood. These are the cells destroyed by the virus. The lower the count, the higher the risk of opportunistic infection (and the development of an AIDs defining illness).
* 500-1200 cells/mm3 is the normal range
* Under 200 cells/mm3 puts the patient at high risk of opportunistic infections
HIV RNA per ml of blood indicates the viral load. And is another way to monitor how well controlled a HIV infection is. An undetectable viral load means the level is below the recordable range (usually 20 copies/ml)
What treatment should be given to all HIV patients with a CD4 count below 200/mm3?
Prophylactic co-trimoxazole is given to protect against pneumocystis jirovecii pneumonia (PCP)
What is the definition of AIDS (Acquired immunodeficiency syndrome)?
- AIDS is the terminal stage of HIV infection where combination antiretroviral therapy (cART) has not halted the spread of the virus.
- It is defined by the presence of an AIDS-defining illness alongside a CD4 count of less than 200 cells/mm³.
What is the epidemiology of AIDs?
Most common in Sub-Saharan Africa
What are some examples of AIDS defining illnesses?
- Kaposi’s sarcoma
- Pneumocystis jirovecii pneumonia (PCP)
- Cytomegalovirus infection
- Candidiasis (oesophageal or bronchial)
- Lymphomas
- Tuberculosis
What is the clinical presentation of AIDS?
It depends on the specific AIDS defining illness that is present, which can include:
* Gastrointestinal symptoms
Such as dysphagia or odynophagia in oesophageal candidiasis
* Respiratory symptoms
In cases of Pneumocystis pneumonia or recurrent pneumonia
* Neurological symptoms
In cases of HIV encephalopathy, toxoplasmosis, or progressive multifocal leukoencephalopathy
* Skin lesions
In cases of Kaposi’s sarcoma or lymphoma
* Visual symptoms
In cases of cytomegalovirus (CMV) retinitis.
What investigations are done for AIDS?
- HIV testing: Primary diagnosis of HIV infection
- CD4 cell count: To determine the progression of the disease
- Tests specific to AIDS-defining illnesses: For example, bronchoscopy for suspected Pneumocystis pneumonia or biopsy for Kaposi’s sarcoma
What does the management of AIDS involve?
-
Combination antiretroviral therapy (cART)
To suppress HIV replication and slow disease progression -
Prophylaxis against opportunistic infections
Including Pneumocystis pneumonia and toxoplasmosis -
Treatment of AIDS-defining illnesses
Specific to the illness, for example, antifungal therapy for candidiasis or chemotherapy for lymphoma
How can the spread of HIV be prevented (or the risk reduced)?
- Correct use of condoms
- Effective treatment combined with an undetectable viral load appears to prevent the spread of HIV, even during unprotected sex.
- Post-Exposure Prophylaxis (PEP) - Can be used after exposure to reduce the risk of transmission. Its not 100% effective however and must be commenced within a short window of opportunity (less than 72 hours).
- Pre-exposure prophylaxis (PrEP) is also available to take before exposure to reduce the risk of transmission.
What is the most common form of PrEP?
Emtricitabine or tenofovir (Truvada).
What is the recommended regime for PEP?
- It involves a combination of Anti-retroviral therapy
- emtricitabine/tenofovir (Truvada) and raltegravir for 28 days.
- The sooner PEP is started after exposure, the greater the chance it will work.
How can a HIV infection affect a pregnancy?
The HIV virus can transfer from mother to child at any stage of the pregnancy; however the greatest risk is during delivery (particularly a vaginal delivery)
The mother’s viral load affects what delivery type is reccomended:
- Under 50 copies/ml - Normal vaginal delivery
- Over 50 copies/ml - Pre-labour Cesaerean section is recommended
IV zidovudine is given as an infusion during labour and delivery if the viral load is unknown or above 1000 copies/ml.
After birth, what prophlaxis can be given to the baby with a HIV positive mother?
Post Exposure Prophylaxis
- Low-risk babies (mother’s viral load is under 50 copies per ml) are given zidovudine for 2-4 weeks
- High-risk babies are given zidovudine, lamivudine and nevirapine for four weeks
Can HIV positive mothers breastfeed?
- HIV can be transmitted during breastfeeding.
- Therefore the safest option is to avoid breastfeeding alltogether and to use formula milk (even if the mother’s viral load is undetectable).
What is the definition of Erectile Dysfunction?
Erectile dysfunction (ED) is defined as the consistent or recurrent inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance.
What is the epidemiology of Erectile Dysfunction?
- It is more common in older men
- It affects more than 50% of men aged over 60
What causes erectile dysfunction?
-
Vascular disease
Atherosclerosis can lead to impaired blood flow to the penis, leading to ED. -
Autonomic neuropathy
This can cause penile denervation, most commonly seen in conditions like diabetes or with excessive alcohol intake. -
Medications
Certain drugs, such as antihypertensive agents, can cause ED. -
Psychogenic
Anxiety, depression, and other psychological factors can contribute to ED. -
Endocrine causes
Conditions like prolactinoma and hypogonadism can cause hormonal imbalances leading to ED. -
Pelvic surgery
Procedures involving the bladder, prostate, or other pelvic structures can damage nerves and blood vessels, leading to ED. -
Anatomical abnormalities
Conditions like Peyronie’s disease, characterized by fibrous scar tissue inside the penis, can cause ED.
What is the clinical presentation of Erectile Dysfunction?
What are some signs that suggest an:
Organic cause
Psychogenic cause
Primary symptom of erectile dysfunction is the inability to achieve or maintain an erection sufficient for sexual intercourse. This can also lead to:
- Reduced sexual desire
- Difficulty in ejaculation
- Anxiety or depression related to sexual performance
Signs which suggest an organic cause:
- lack tumescence
- slow-onset
- normal libido.
Signs which suggest a psychogenic cause
- If situational
- Acute onset
- High levels of stress
- Still having early morning erections.
What are some differentials for Erectile Dysfunction?
-
Premature ejaculation
Characterized by uncontrolled ejaculation either before or shortly after sexual penetration. -
Hypogonadism
Characterized by low testosterone levels, resulting in low sex drive, fatigue, and mood changes. -
Peyronie’s disease
Presents with a significant bend in the penis during erection, which can interfere with sexual function.
How is Erectile Dysfunction investigated?
- Detailed sexual and psychological history to identify potential contributing factors.
- Blood tests - Full blood count, urea and electrolytes, thyroid function tests, lipid profile, testosterone, and prolactin to evaluate overall health and hormonal status.
- QRISK is also required to be calculated
What is the management of Erectile Dysfunction?
-
Psychosexual therapy
To address any underlying psychological factors. -
Oral phosphodiesterase inhibitors (e.g. Sildenafil)
To enhance the effect of nitric oxide, increasing blood flow to the penis. -
Vacuum erection devices
To draw blood into the penis by applying negative pressure. -
Intra-cavernosal injections
To directly increase blood flow. -
Penile prostheses
For cases resistant to other treatments.
What are the side effects of Phosphodiesterase inhibitors (Sildenafil)?
- Priapism
- Headache
- Flushing
- Hypotension
- Blue tinge to vision (little blue pill).
In what patients is Sildenafil contraindicated in?
- Individuals taking nitrates
- Hypertension/hypotension
- Arrhythmias
- Unstable angina
- Stroke
- Recent myocardial infarction.
What are the investigations to confirm Preterm Prelabour Rupture of Membranes (PPROM)?
Sterile Speculum Examination: look for pooling of amniotic fluid in posterior vaginal vault.
Digital examination Should be avoided due to risk of infection
Second Line: Fluid testing for:
- Insulin Like Growth Factor Binding Protein (IGFBP-1)
- Placental alpha microglobulin-1 protein (PAMG-1)
Ultrasound scan may show oligohydramnios
What is the management for PPROM?
Prophylactic Antibiotics: TDS 250mg Erythromycin for 10 days or until labour established
Induction of labour may be offered from 34 weeks but try to get to 37 weeks.
What are the main complications of Shoulder Dystocia?
Maternal
- Postpartum haemorrhage
- Perineal tears
Fetal
- Brachial plexus injury
- Erbs Palsy Where damage to C5/6 leads to Internally rotated shoulder, Extended elbow, Flexed wrist facing backwards (pronated), Lack of movement in the affected arm
- Neonatal death
What are the complications of Placental Abruption?
Maternal
- Shock
- DIC
- Renal failure
- PPH
Fetal
- IUGR
- Hypoxia
- Death
What are the indications for Mastectomy vs Wide local Excision?
Wide Local Excision:
- Solitary Lesion
- Small lesion in large breast
- Peripheral Tumour
- DCIS < 4cm
Mastectomy:
- Multifocal Tumour
- Central Tumour
- Large lesion in small breast
- DCIS > 4cm
When is Axillary Node clearance indicated in breast cancer?
What are some side effects of lymph node clearance?
Women with no palpable axillary lymphadenopathy pre-operatively should have an Ultrasound. If negative then a Sentinel node biopsy should be done
Women With palpable lymphadenopathy should have axillary node clearance at primary surgery.
Side effects include: Lymphoedema, functional arm impairment
What are the features of Locally Advanced breast cancer?
- Ulceration
- Peau d’orange
- Inflammatory Breast Cancer
- Fixed to chest wall
- Fixed and matted to axillary lymph nodes
This type of breast cancer is surgically incurable
What is Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum?
The term ‘nausea and vomiting of pregnancy’ (NVP) to describe troublesome symptoms, with hyperemesis gravidarum being the extreme form of this condition.
When is Hyperemesis Gravidarum typically experienced?
Most common between 8-12 weeks but may persist up until 20 weeks
What are the risk factors for Hyperemesis Gravidarum?
Increased levels of beta-hCG
- Multiple pregnancies
- Trophoblastic disease
Other:
- Nulliparity
- Obesity
- Thyrotoxicosis (mimic of TSH as bHCG)
- Family or personal history of NVP
Smoking is associated with a decreased incidence of hyperemesis.
What is the criteria for Hyperemesis Gravidarum?
Triad of:
- 5% pre-pregnancy weight loss
- Dehydration
- Electrolyte imbalance
What scoring system is used to classify the severity of nausea and vomiting in pregnancy?
pregnancy-Unique Quantification of Emesis (PUQE) Score
When should admission be considered for patients with nausea and vomiting in pregnancy?
- Unable to tolerate oral antiemetics or keep down any fluids
- More than 5 % weight loss compared with pre-pregnancy
- Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
- Other medical conditions need treating that required admission
What is the Management for Hyperemesis Gravidarum?
Non-pharacological
Pharamcological 1st line
2nd line
When to admit
Admission treatment
Simple Measures:
- Rest and avoid triggers
- Ginger
- Acupressure on the wrist at the PC6 point (inner wrist)
- Bland plain food
First Line Medications:
- Antihistamines: Cyclizine or Promethazine
- Phenothiazines: Prochlorperazine or chlorpromazine
Second Line Medications:
- Oral Ondansetron
- Oral Metoclopramide or Domperidone (only used for no more than 5 days)
Moderate/Severe to Admission:
- Maybe required for IV/IM anti-emetics
- Normal saline with added potassium is used to rehydrate.
- Thiamine Supplementation to prevent Wernicke’s Korsakoff
- VTE prophylaxis
What is the concern with using Ondansetron in pregnancy?
Use in first trimester is associated with a small increased risk of Cleft lip/palate
What is the concern with using Metoclopramide?
May cause extrapyramidal effects so shouldnt be used for more than 5 days.
What are the Most common complications of Hyperemesis Gravidarum?
What are some other potential complications?
Most Common:
- Dehydration
- Weight loss
- Electrolyte imbalances - notably hypokalaemia
Other Complications:
- AKI
- Wernicke’s encephalopathy
- Mallory-weiss tear
- VTE
Define Premenstrual Syndrome?
Emotional and physical symptoms that women may experience in the luteal phase or a normal menstrual cycle
What is the Management for Premenstrual Syndrome?
Lifestyle advice
- Sleep
- Exercise
- Smoking and alcohol cessation
- Small balanced meals with rich complex carbs
Moderate Symptoms
- 3rd Generation COCP
Severe Symptoms
- SSRIs such as fluoxetine taken during the luteal phase
- Cognitive Behavioural Therapy
What is the Management for Fat Necrosis?
Exclude Breast Cancer as it is a close mimic
- Do Triple Assessment to rule out
Once diagnosis is made
- Conservative management
- May resolve spontaneously
- May require surgery to remove if troublesome
Who does Mammary Ductal Ectasia affect?
SMOKERS and perimenopausal women
What is the presentation of Mammary Ductal Ectasia?
- Nipple discharge - white, grey, green
- Tenderness or pain
- Nipple retraction or inversion
- A breast lump (pressure on the lump may produce nipple discharge)
What is the Management for Mammary Ductal Ectasia?
- Reassurance after excluding cancer may be all that is required
- Symptomatic management of mastalgia (supportive bra and warm compresses)
- Antibiotics if infection is suspected or present
- Surgical excision of the affected duct (microdochectomy) may be required in problematic cases
What are the investigations for Ductal Ectasia?
What is a key finding?
What additional investigations may be performed?
Triple Assessment first
- Microcalcifications are a key finding to remember on a mammogram
Other Investigations:
- Ductography - contrast injected into abnormal duct and mammograms used to visualise
- Nipple Discharge Cytology
What are the different types of Breast Implants?
Give some advantages and disadvantages of both
Silicon:
- Advantages: Less likely to fold or rupture. Feel more natural
- Disadvantages: May cause lumps
Saline:
- Advantages: if they rupture, can be absorbed into the body safely
- Disadvantage: More likely to go down/rupture
Both types of implants last about 10 years
What are the short term complications of Breast Implants?
- Bleeding
- Blood clots
- Infection
- Allergic reaction
What are the long term complications of Breast implants?
- Obvious Scarring
- Capsular contracture
- Ruptured implant
- Produce less breast milk when feeding
- BIA-ALCL (Breast implant associated, anaplastic large cell lymphoma)
- Breast Implant Illness
What is Fibrocystic Breast changes?
generalised lumpiness to the breast (Not a disease).
The anatomy of the breast may become fibrous and cystic with changes in hormones and this can fluctuate with the menstrual cycle.
What are the features of fibrocystic breast changes?
Common in women of menstruating age
Symptoms occur prior to menstruation and resolve as menstruation begins
Will fluctuate with menstrual cycle
Does not tend to affect post-menopausal women
Can affect different areas of the breast or both breasts with:
- Lumpiness
- Breast pain or tenderness (mastalgia)
- Fluctuation of breast size
What is the management of fibrocystic breast changes?
Exclude Breast CA with Triple Assessment:
Manage Symptoms of myalgia:
- Wearing a supportive bra
- NSAIDs for pain
- Avoiding caffeine is commonly recommended
- Applying heat to the area
- Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
What is defined as small for gestational age?
Fetus measuring < 10th centile for gestational age based on:
Estimated fetal weight (EFW)
Fetal abdominal circumference
What is severe SGA?
Fetus is below the 3rd centile for gestational age
What defines Low birth weight?
Birth weight less than 2500g
What are the cause of SGA?
- Constitutionally small
- Fetal growth restriction/Intrauterine Growth Restriction (IUGR)
Define IUGR?
How does this differ from constitutionally small?
When the fetus is small or not growing as expected dur to pathology reducing the amount of nutrients and oxygen delivered to the fetus through the placenta
constitutionally small means the baby is growing appropriately and matching the mother or others in the family. There is no pathological cause
What are the two categories of causes for IGUR?
Placental mediated growth Restriction
Non-placental mediated growth restriction
What are some placenta mediated growth restriction causes?
Conditions that affect the transfer of nutrients across the placenta
- Idiopathic
- Pre-eclampsia
- Maternal smoking
- Maternal alcohol
- Anaemia
- Malnutrition
- Infection
- Maternal health conditions
What are some Non-placenta mediated growth restriction causes?
Pathology of the fetus
- Genetic abnormalities
- Structural abnormalities
- Fetal infection
- Errors of metabolism
What are some short term complications of IUGR?
- Fetal death or still birth
- Birth asphyxia
- Neonatal hypothermia
- Neonatal hypoglycaemia
What are some long term complications of IUGR?
- CVD particularly Hypertension
- T2DM
- Obesity
- Mood and behavioural problems
What are some risk factors for SGA?
Previous SGA baby
Obesity
Smoking
Diabetes
Existing hypertension
Pre-eclampsia
Older mother (over 35 years)
Multiple pregnancy
Low pregnancy‑associated plasma protein‑A (PAPPA)
Antepartum haemorrhage
Antiphospholipid syndrome
What monitoring should be done in women with a fetus that is SGA?
low risk women have SFH measured at every antenatal appointment from 24 weeks onwards.
Women with 1 major or 3 minor risk factors will have serial growth scans and umbilical artery dopplers every 4 weeks from 28 weeks/
What is measured during a serial growth scan for fetuses of SGA?
- Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity
- Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery
- Amniotic fluid volume
What management steps should be taken if a child is at risk of SGA?
- Identifying those at risk of SGA
- Aspirin is given to those at risk of pre-eclampsia
- Treating modifiable risk factors (e.g. stop smoking)
- Serial growth scans to monitor growth (eg. 4 weekly at 28 weeks)
- Early delivery where growth is static, or there are other concerns
What investigations may be done to identify the underlying cause of SGA?
- Blood pressure and urine dipstick for pre-eclampsia
- Uterine artery doppler scanning
- Detailed fetal anatomy scan by fetal medicine
- Karyotyping for chromosomal abnormalities
- Testing for infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria)
What is the management for a child with IUGR or where growth is static?
Planned early delivery
- Corticosteroids are given to help fetal lungs mature
- Magnesium sulphate may be given for neuroprotection for gestations between 24-32 weeks
Define Large for Gestational Age (LGA)?
Macrosomia where the weight of the newborn is >4.5kg at birth.
EFW above the 90th centile is considered LGA
What are some causes for Macrosomia?
- Constitutional
- Maternal diabetes
- Previous macrosomia
- Maternal obesity or rapid weight gain
- Overdue
- Male baby
What are the risks to the mother if a fetus is macrosomic?
- Shoulder dystocia
- Failure to progress
- Perineal tears
- Instrumental delivery or caesarean
- Postpartum haemorrhage
- Uterine rupture (rare)
What are the risks to the baby if the fetus is Macrosomic?
- Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
- Neonatal hypoglycaemia
- Obesity in childhood and later life
- Type 2 diabetes in adulthood
What are the investigations if a baby is found to be LGA?
- Ultrasound to exclude polyhydramnios and estimate the fetal weight
- Oral glucose tolerance test for gestational diabetes
What are some pregnancy related rashes?
- polymorphic eruption of pregnancy
- Melasma
- Pemphigoid Gestations
What timeline defines 1st, 2nd and 3rd Trimester?
First Trimester Start - 12 weeks
Second Trimester 13 weeks - 26 weeks
Third Trimester 27 weeks - birth
When are Fetal movements typically felt?
From around 20 weeks gestation until birth
What Vaccines are offered to all pregnant women?
- Influenza (Flu) at any time during pregnancy
- Pertussis from 16 weeks gestation
Live vaccines such as MMR are avoided
When is Aspirin given in pregnancy?
Women are offered 75-150mg Aspirin daily from 12 weeks gestation until birth if they have:
- One high-risk factor
- More than one moderate-risk factors.
What is Polymorphic Eruption of Pregnancy?
An itchy rash that tends to start in the Third trimester that usually begins on the abdomen
What are the characteristic features of Polymorphic Eruption of Pregnancy
- Urticarial papules
- Wheals (Raised itchy areas of skin)
- Plaques
What is the management of Polymorphic Eruption of Pregnancy?
Topical emollients, oral antihistamines and topical steroids
Condition gets better towards the end of pregnancy and after delivery
What is Melasma?
Increased pigmentation to patches of the skin on the face.
Typically doesn’t require treatment
What are pemphigoid gestations?
Autoimmune skin condition occurring in pregnancy.
Auto Abs damage connections between epidermis and dermis produced in response to placental tissue.
What is the cause of Congenital Rubella Syndrome?
Maternal infection with the rubella virus during the first 20 weeks of pregnancy. The risk is highest before ten weeks gestation.
What vaccine should women planning to become pregnant ensure they have had?
MMR vaccine to prevent congenital rubella syndrome
When in doubt rubella immunity should be tested.
If they do not have antibodies then they can be vaccinated with 2 doses of MMR 3 months apart.
What are the clinical features of congenital rubella syndrome?
A Blind deaf neurotic duck
- Blind - congenital cateracts
- Deaf - congenital deafness
- Neurotic - learning disability
- Duck - PDA and pulmonary stenosis
Why is chicken pox dangerous in pregnancy/what can it cause in the mother and the infant?
Mother: Varicella pneumonitis, Hepatitis or encephalitis
Fetal Varicella syndrome
Severe neonatal varicella infection if infected around delivery
What should the mother do if they come into contact with someone with chickenpox whilst pregnant?
- When the pregnant woman has previously had chickenpox, they are safe
- When they are not sure about their immunity, test the VZV IgG levels. If positive, they are safe.
- When they are not immune, they can be treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox. This should be given within ten days of exposure.
When may congenital varicella syndrome occur?
occurs in around 1% of cases of chickenpox in pregnancy.
It occurs when infection occurs in the first 28 weeks of gestation.
What are the clinical features of Congenital Varicella Syndrome?
LIMBE
L: Limb Hypoplasia
I: Intrauterine Growth Restriction (IUGR)
M: Microcephaly (brain underdevelopment, hydrocephalus and LD)
B: Blistering Skin Lesions
E: Eye defects (cataracts and chorioretinitis)
What is Listeria and Listeriosis?
Listeria is a gram positive bacteria that can easily lead to listeriosis in pregnant women
What are the complications of Listeriosis in pregnancy?
High rate of Miscarriage or fetal death
Can cause severe neonatal infection
How is Listeria typically transmitted?
unpasteurised dairy products
Processed meats
Women are advised to avoid high risk foods such as blue cheese, camembert and brie
What is the management for Listeriosis?
Primary treatment involves a combination of the antibiotics ampicillin and an aminoglycoside
What are the features of congenital cytomegalovirus infection (CMV)
Janice, Peri and Cory are pure deaf
- Jaundice
- Periventricular Calcifications and Microcephaly (and FGR)
- Chorioretintis
- Purpuric skin (and Thrombocytopenia)
- Sensorineural deafness
How is Toxoplasmosis spread?
Toxoplasma gondii parasite is usually asymptomatic
Spread via contamination with faeces from a cat
What is the classical triad of congenital Toxoplasmosis?
- Intracranial Calcification
- Hydrocephalus
- Chorioretinitis
What are the features of Congenital Toxoplasmosis?
Cory with the big head likes stiff calcium jerky
Cory (chorioretinitis)
Big head (hydrocephalus)
Stiff (spasticity)
Calcium (cerebral calcifications)
Jerky (seizures)
What are the complications of Parovirus B19 infection during pregnancy?
Which trimesters are most important?
Affects first and second trimesters
- Miscarriage or fetal death
- Severe fetal anaemia
- Hydrops Fetalis (fetal heart failure)
- Mirror Syndrome
What is Mirror Syndrome?
Maternal pre-eclampsia like syndrome: A rare complication of hydrops fetalis characterised by the triad:
- Hydrops Fetalis
- Placental Oedema
- Oedema in the mother
PLUS features of hypertension and proteinuria mirroring Pre-eclampsia
What should be done for women suspected for Parvovirus B19 infection during pregnancy?
What treatment may be required?
- IgM to parvovirus, which tests for acute infection within the past four weeks
- IgG to parvovirus, which tests for long term immunity to the virus after a previous infection
- Rubella antibodies (as a differential diagnosis)
Treatment is supportive. Women with parvovirus B19 infection need a referral to fetal medicine to monitor for complications and malformations.
How is the Zika Virus spread?
Host Aedes Mosquitos.
It can be spread by sex with someone infected with the virus
What are the features of Congenital Zika Syndrome?
- Microcephaly
- Fetal Growth Restriction
- Intracranial abnormalities: Ventriculomegaly and cerebellar atrophy
What are the classifications of Caesarean Section?
Category 1:
- Within30 mins of decision
- Immediate threat to life of women or fetus
Category 2:
- Within 75 mins of decision
- Maternal/fetal compromise but not immediately life threatening
Category 3:
- No compromise but early birth is indicated
Category 4:
- Elective - maternal choice
What are the indications for Caesarean Section?
- Previous caesarean
- Symptomatic after a previous significant perineal tear
- Placenta praevia
- Placenta accreta spectrum
- Vasa praevia
- Breech presentation
- Multiple pregnancy
- Uncontrolled HIV infection
- Cervical cancer
What are the indications for Emergency C-Section?
- Fetal Bradycardia
- Abruption
- Uterine rupture
- Cord Prolapse
- Fetal pH < 7.2
- Failure of instrumental delivery
What are some complications of Caesarean Section?
Maternal
Fetal
Maternal Complications
- General surgical risks (bleeding, infection, pain ,VTE)
- Post partum Complications (haemorrhage, infeection, endometritis)
- Damage to local Structures (Ureter, bladder, bowel, Blood vessels)
- Effects on abdo organs (Ileus, adhesions, hernias)
- Effects on future pregnancies ( Repeat c-section, uterine rupture, placenta praevia, still birth)
Effects on Baby:
- Risk of lacerations
- Increased risk of Transient Tachypnoea of the Newborn
What are some Surgical Options for Pelvic Organ Prolapse?
cystocele/cystourethrocele:
- anterior colporrhaphy,
- colposuspension
uterine prolapse:
- hysterectomy,
- sacrohysteropexy
rectocele:
- posterior colporrhaphy
What is Mifepristone?
Mifepristone is an anti-progesterone that sensitises the myometrium to prostaglandins and induces breakdown of decidua basalis
What is Misoprostol?
Misoprostol is a prostaglandin analogue that soften the cervix and stimulates uterine contractions.
What are some causes of recurrent miscarriages?
- Idiopathic (particularly in older women)
- Antiphospholipid syndrome
- Hereditary thrombophilias
- Uterine abnormalities
- Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
- Chronic histiocytic intervillositis
- Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)
What is Antiphospholipid Syndrome?
How is it managed?
Antiphospholipid syndrome is a disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting.
The patient is in a hyper-coagulable state. The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage.
APLs Abx
- Anti-cardiolipin
- Lupus anticoagulant
- Anti-b2 Glycoprotein I
The risk of miscarriage in patients with antiphospholipid syndrome is reduced by using both:
- Low dose aspirin
- Low molecular weight heparin (LMWH)
What are some Uterine abnormalities that can lead to recurrent miscarriage?
- Uterine septum (a partition through the uterus)
- Unicornuate uterus (single-horned uterus)
- Bicornuate uterus (heart-shaped uterus)
- Didelphic uterus (double uterus)
- Cervical insufficiency
- Fibroids
What is Chronic Histiocytic Intervillositis?
What other pregnancy related problems can it cause?
What is the pathophysiology?
What are the diagnostic findings?
Chronic histiocytic intervillositis is a rare cause of recurrent miscarriage, particularly in the second trimester. It can also lead to intrauterine growth restriction (IUGR) and intrauterine death.
The condition is poorly understood. Histiocytes and macrophages build up in the placenta, causing inflammation and adverse outcomes.
It is diagnosed by placental histology showing infiltrates of mononuclear cells in the intervillous spaces.
What are the NICE recommended situations where Medical or Surgical management is better than Expectant for miscarriage treatment?
Increased risk of haemorrhage
- she is in the late first trimester
- if she has coagulopathies or is unable to have a blood transfusion
Previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
Evidence of infection
What is the role of Placental Growth Factor?
NICE Guidelines 2019 and Placental Growth Factor (PlGF):
Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low.
- NICE recommend testing on one occasion during pregnancy in women suspected to have Pre-eclampsia between 20 and 35 weeks gestation to rule out pre-eclampsia
- sFLT:PlGF ratio >85 is diagnostic
What is the mechanism of action for the Combined Oral Contraceptive Pill (COCP)?
It prevents ovulation, thickens cervical mucus, and inhibits endometrial proliferation, reducing the chance of implantation.
What are the side effects of the COCP?
Unscheduled bleeding, breast pain, mood changes, headaches, and an increased risk of venous thromboembolism (VTE), breast and cervical cancer.
What are the contraindications for using the COCP?
My CUPLETS”
M: Migraines with aura - Increased risk of stroke.
C: Cardiovascular disease - Includes ischemic heart disease, uncontrolled hypertension, or history of stroke.
U: Undiagnosed vaginal bleeding and Uncontrolled Hypertension - Needs to be investigated before starting COCP.
P: Pregnancy - COCP should not be used during pregnancy.
L: Liver disease - Severe liver disease, cirrhosis, or liver tumors can be worsened by the COCP.
E: Estrogen-dependent cancers - History or risk of breast cancer or endometrial cancer.
T: Thromboembolism - History of deep vein thrombosis (DVT) or pulmonary embolism (PE).
S: Smoking (especially over the age of 35) - Increases the risk of cardiovascular complications.
When should the COCP be started, and is additional contraception needed?
Start on the first day of the menstrual cycle for immediate protection. If started after day 5, use additional contraception for 7 days.
What is the mechanism of action for the Progesterone-Only Pill (POP)?
It thickens cervical mucus and inhibits endometrial proliferatoin.
Desogestrel POP can inhibit ovulation
What are the side effects of the POP?
Irregular bleeding, breast tenderness, and mood changes.
What are the contraindications for using the POP?
Breast cancer, severe liver disease, and undiagnosed vaginal bleeding.
When should the POP be started, and is additional contraception needed?
Start on the first day of the menstrual cycle for immediate protection. If started later, use additional contraception for 2 days.
What is the mechanism of action for the Intrauterine Device (IUD)?
The IUD prevents fertilization by creating an environment toxic to sperm and preventing implantation.
What are the side effects of the IUD?
Heavier periods, cramping, and increased risk of infection and ectopic pregnancies
What are the contraindications for using the IUD?
Current pelvic infection, unexplained vaginal bleeding, wilsons disease, and uterine abnormalities
When should the IUD be inserted, and is additional contraception needed?
Can be inserted at any time during the cycle if pregnancy is ruled out. No additional contraception is needed after insertion.
What is the mechanism of action for the Intrauterine System (IUS)?
It releases progesterone, thickening cervical mucus, thinning the endometrium, and inhibiting sperm movement.
What are the side effects of the IUS?
Irregular bleeding, headaches, breast tenderness, and mood changes.
What are the contraindications for using the IUS?
Current pelvic infection, breast cancer, and uterine abnormalities.
When should the IUS be inserted, and is additional contraception needed?
Insert during the first 7 days of the cycle for immediate protection. If inserted later, use additional contraception for 7 days.
What is the mechanism of action for the Contraceptive Implant?
It releases progesterone, preventing ovulation, thickening cervical mucus, and thinning the endometrium.
What are the side effects of the Contraceptive Implant?
Worsen bleeding, cause acne, weight gain, mood changes, and headaches.
What are the contraindications for using the Contraceptive Implant?
Breast cancer, severe liver disease, and unexplained vaginal bleeding.
When should the Contraceptive Implant be inserted, and is additional contraception needed?
Insert during the first 5 days of the cycle for immediate protection. If inserted later, use additional contraception for 7 days.
What is the mechanism of action for the Contraceptive Injection?
It releases progesterone, preventing ovulation, thickening cervical mucus, and thinning the endometrium.
What are the side effects of the Contraceptive Injection?
Irregular bleeding, weight gain, osteoporosis, mood changes, and delayed return of fertility.
What are the contraindications for using the Contraceptive Injection?
Breast cancer, severe liver disease, and unexplained vaginal bleeding.
When should the Contraceptive Injection be given, and is additional contraception needed?
Given during the first 5 days of the cycle for immediate protection. If given later, use additional contraception for 7 days.
What is the mechanism of action for the Contraceptive Patch?
It releases oestrogen and progesterone, preventing ovulation, thickening cervical mucus, and thinning the endometrium.
What are the side effects of the Contraceptive Patch?
Skin irritation, breast tenderness, mood changes, and headaches.
What are the contraindications for using the Contraceptive Patch?
Uncontrolled hypertension, migraines with aura, history of VTE, smokers over 35, and heart disease.
When should the Contraceptive Patch be applied, and is additional contraception needed?
Apply on the first day of the menstrual cycle for immediate protection. If started later, use additional contraception for 7 days.
What is the mechanism of action for the Vaginal Ring?
It releases oestrogen and progesterone, preventing ovulation, thickening cervical mucus, and thinning the endometrium.
What are the side effects of the Vaginal Ring?
Vaginal irritation, breast tenderness, mood changes, and headaches.
What are the contraindications for using the Vaginal Ring?
Uncontrolled hypertension, migraines with aura, history of VTE, smokers over 35, and heart disease.
When should the Vaginal Ring be inserted, and is additional contraception needed?
Insert on the first day of the menstrual cycle for immediate protection. If started later, use additional contraception for 7 days.
What is the mechanism of action for Emergency Contraception?
It delays ovulation and may prevent implantation if taken before ovulation.
What are the side effects of Emergency Contraception?
Nausea, vomiting, fatigue, and irregular bleeding.
What are the contraindications for using Emergency Contraception?
Known pregnancy (though not harmful if taken in early pregnancy).
When should Emergency Contraception be taken, and is additional contraception needed?
Take within 72 hours of unprotected sex for the best effectiveness. No additional contraception is needed for the emergency method itself but use ongoing contraception afterward.
What are the Absolute Contraindications for the COCP
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura (risk of stroke)
History of VTE
Aged over 35 and smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus (SLE) and antiphospholipid syndrome
What takes place at the booking clinic?
BRAVE MUm
Booking Bloods:
- Blood group, antibodies and rhesus D status
- Full blood count for anaemia
- Screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
- Infection Screen (HIV, Hep B, Syphilis)
Risk Assessment:
- Rhesus negative (book anti-D prophylaxis)
- Gestational diabetes (book oral glucose tolerance test)
- Fetal growth restriction (book additional growth scans)
- Venous thromboembolism (provide prophylactic LMWH if high risk)
- Pre-eclampsia (provide aspirin if high risk)
Advice:
- Lifestyle advice in pregnancy (e.g. not smoking)
- Supplements (e.g. folic acid and vitamin D)
- Antenatal classes
- Breastfeeding classes
- Discuss mental health
Vitals:
- Blood pressure
- Weight, Height, BMI
Early Screening:
- Offer Early screening tests such as Downs and Arrange Dating Scan
Medical History:
- Past pregnancies
- Prev. Mental health problems
- Prev. GIH, GDM,
- Pre-existing HTN or DM.
Urine Tests:
- Protein
- Bacteruria
- Glucose
What occurs at a routine Antenatal Appointment?
Weeks 16, 25, 28, 31, 34, 36, 38, 40, 41,42
- Discuss plans for the remainder of the pregnancy and delivery
- Symphysis–fundal height measurement from 24 weeks onwards
- Fetal presentation assessment from 36 weeks onwards
- Urine dipstick for protein for pre-eclampsia
- Blood pressure for pre-eclampsia
- Urine for microscopy and culture for asymptomatic bacteriuria
What are some additional appointments/milestones to consider in some women?
- Additional appointments for higher risk or complicated pregnancies
- Oral glucose tolerance test in women at risk of gestational diabetes (between 24 – 28 weeks)
- Anti-D injections in rhesus negative women (at 28 and 34 weeks)
- Ultrasound scan at 32 weeks for women with placenta praevia on the anomaly scan
- Serial growth scans are offered to women at increased risk of fetal growth restriction
What is some general lifestyle advice for Pregnant Women?
- Take folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects)
- Take vitamin D supplement (10 mcg or 400 IU daily)
- Avoid vitamin A supplements and eating liver or pate (vitamin A is teratogenic at high doses)
- Don’t drink alcohol when pregnant (risk of fetal alcohol syndrome)
- Don’t smoke (smoking has a long list of complications, see below)
- Avoid unpasteurised dairy or blue cheese (risk of listeriosis)
- Avoid undercooked or raw poultry (risk of salmonella)
- Continue moderate exercise but avoid contact sports
- Sex is safe
- Flying increases the risk of venous thromboembolism (VTE)
- Place car seatbelts above and below the bump (not across it)
What is the advice regarding Alcohol in pregnancy?
- Alcohol can cross the placenta, enter the fetus, and disrupt fetal development.
- There is no safe level of alcohol in pregnancy.
- Pregnant women are encouraged not to drink alcohol at all.
- Small amounts are less likely to result in lasting effects.
- The effects are greatest in the first 3 months of pregnancy.
What are the risks of drinking alcohol during pregnancy? (Especially early)
Miscarriage
Small for dates
Preterm delivery
Fetal alcohol syndrome
What are the characteristics of Fetal Alcohol Syndrome?
- Microcephaly (small head)
- Thin upper lip
- Smooth flat philtrum (the groove between the nose and upper lip)
- Short palpebral fissure (short horizontal distance from one side of the eye to the other)
- Learning disability
- Behavioural difficulties
- Hearing and vision problems
- Cerebral palsy
What are the risks of Smoking in pregnancy?
Smoking increases the risk of:
- Fetal growth restriction (FGR)
- Miscarriage
- Stillbirth
- Preterm labour and delivery
- Placental abruption
- Cleft lip or palate
- Sudden infant death syndrome (SIDS)
Smoking seems to reduce the risk of pre-eclampsia (although the risks of smoking in pregnancy very far outweigh any benefits)
What does the RCOG say about flying in pregnancy?
The RCOG advises flying is generally ok in uncomplicated healthy pregnancies up to:
37 weeks in a single pregnancy
32 weeks in a twin pregnancy
What are two methods of monitoring during the induction of labour?
- Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour
- Bishop score before and during induction of labour to monitor the progress
How is Progress in Labour influenced?
- Power (uterine contractions)
- Passenger (size, presentation and position of the baby)
- Passage (the shape and size of the pelvis and soft tissues)
When is it classified as a delay in the First stage and Second stage of labour?
Delay of First stage of Labour
- Less than 2cm of cervical dilation in 4 hours
- Slowing of progress in a multiparous woman
When the active second stage (pushing) lasts over:
- 2 hours in a nulliparous woman
- 1 hour in a multiparous woman
What factors are responsible for the success of the second stage of labour?
3Ps:
Power:
- Strength of uterine contractions
- If they are weak, oxytocin can be used to stimulate the uterus
Passenger: (SALP)
- Size: eg. macrosomic
- Attitude: posture of fetus
- Lie: Longitudinal, Transverse, Oblique
- Presentation: Cephalic, Shoulder, Breech
Passage:
- Size and shape of the passageway (pelvis)
What are some interventions that may be used during delayed second stage of labour?
Changing positions
Encouragement
Analgesia
Oxytocin
Episiotomy
Instrumental delivery
Caesarean section
What Classifies a delay in the third stage of labour and what is the management?
Defined as:
- More than 30 minutes with active management
- More than 60 minutes with physiological management
Active management involves intramuscular oxytocin and controlled cord traction.
What are some management options for Failure to progress in labour?
- Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes
- Oxytocin infusion
- Instrumental delivery
- Caesarean section
What is done if a Pregnant women is Exposed to Chicken Pox During Pregnancy?
Always advice avoiding chicken pox in pregnancy especially in first trimester due to risk of congenital varicella syndrome
When the pregnant woman has previously had chickenpox
- They are safe
When they are not sure about their immunity
- test the VZV IgG levels.
- If positive, they are safe.
- If not immune, treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox.
- This should be given within ten days of exposure.
If Infected
- Treat with Aciclovir within 24 hours
What is Prematurity?
When are babies considered non-viable
What are the WHO Classifications for Prematurity?
Birth before 37 weeks gestation.
Babies are considered non-viable below 23 weeks gestation.
- Under 28 weeks: extreme preterm
- 28 – 32 weeks: very preterm
- 32 – 37 weeks: moderate to late preterm
What is Preterm Prelabour Rupture of Membranes?
PPROM is where the amniotic sac ruptures, releasing amniotic fluid, before the onset of labour and in a preterm pregnancy (under 37 weeks gestation).
How is Preterm Prelabour Rupture of Membranes Diagnosed?
What tests are done if there is doubt of the diagnosis?
Speculum Examination: Shows pooling of amniotic fluid in the posterior vaginal vault.
Digital examination Should be avoided due to risk of infection
If in doubt:
- Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes
- Placental alpha-microglobin-1 (PAMG-1) is a similar alternative to IGFBP-1
What is the Management for Preterm Prelabour Rupture of Membranes?
Prophylactic antibiotics should be given to prevent the development of chorioamnionitis.
- NICE Recommend erythromycin 250mg QDS for ten days, or until labour is established if within ten days.
- Induction of labour may be offered from 34 weeks to initiate the onset of labour.
What is Preterm Labour with Intact Membranes?
Preterm labour with intact membranes involves regular painful contraction and cervical dilatation, without rupture of the amniotic sac.
When are Antenatal Steroids and Magnesium Sulphate used in the management of Preterm Labour?
Antenatal Steroids:
- Given to women <36 weeks gestation
- Help fetal lung maturation and prevent RDS
- 2 doses IM Betamethasone 24 hours apart
Magnesium Sulphate:
- Helps protect fetal brain and reduce incidence of CP
- Given within 24 hours of delivery for Pre-terms < 34 weeks gestation
What are the management options for improving outcomes in Preterm Labour?
- Fetal Monitoring: CTG or intermittent Auscultation
- Tocolysis with Nifedipine
- Maternal Corticosteroids (offered before 35 weeks)
- IV Magnesium Sulphate (offered before 34 weeks)
- Delayed cord clamping/cord milking
What is Fetal Fibronectin?
What is the test used for?
Fetal fibronectin is the “glue” between the chorion and the uterus, and is found in the vagina during labour.
Can be used as a screening test used to assess the risk of preterm delivery after the onset of pre-term labour
A result of less than 50 ng/ml is considered negative, and indicates that preterm labour is unlikely.
What needs to be monitored when giving IV Magnesium Sulphate for Preterm Labour?
Magnesium toxicity at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex).
Key signs of toxicity are:
- Reduced respiratory rate
- Reduced blood pressure
- Absent reflexes
What are the common causes of Secondary Post Partum Haemorrhage?
Often retained Products of Conception or Infection (such as endometritis)
What are some measures to reduce the risks and consequences of Postpartum Haemorrhage?
- Treat Anaemia (as haemorrhage if the patient is anaemic will have more severe consequences)
- Give birth with an empty bladder (bladder distension prevents uterine contraction)
- Active 3rd stage management
- IV TXA during caesarean section
How can Breast Cancer be classified?
Which type is the most common form of breast cancer?
Affects the Ductal tissue or the Lobular tissue (Ductal or Lobular)
Spread beyond the local tissue or not (in situ/Invasive)
- Ductal Carcinoma In Situ (DCIS)
- Lobular Carcinoma In Situ (LCIS)
- Invasive Ductal Carcinoma (Also called Non-special Type (NST))
- Invasive Lobular Carcinoma
Invasive Ductal Carcinoma (NST) is the most common type of Breast Cancer
What is the presentation of Inflammatory Breast Cancer?
- Presents similarly to a breast abscess or mastitis
- Swollen, warm, tender breast with pitting skin (peau d’orange)
- Does not respond to antibiotics
- Worse prognosis than other breast cancers
What is a Sentinel Node Biopsy?
Sentinel node biopsy is performed during breast surgery for cancer.
An isotope contrast and a blue dye are injected into the tumour area.
The contrast and dye travel through the lymphatics to the first lymph node (the sentinel node).
The first node in the drainage of the tumour area shows up blue and on the isotope scanner.
A biopsy can be performed on this node, and if cancer cells are found, the lymph nodes can be removed.
How is Breast Cancer Staged?
what are some investigations used to help stage Breast Cancer?
TNM Staging:
Investigations used:
- Lymph node assessment and biopsy
- MRI of the breast and axilla
- Liver ultrasound for liver metastasis
- CT of the thorax, abdomen and pelvis for lung, abdominal or pelvic metastasis
- Isotope bone scan for bony metastasis
What are some surgical options for breast cancer?
Breast Conserving Surgery:
- Wide local excision
- often coupled with radiotherapy
Mastectomy:
- May have immediate or delayed breast reconstruction
Axillary Node Clearance:
- Depends on Criteria
- Increased risk of lymphoedema
What are the indications for Radiotherapy in Breast Cancer?
Often used in patients with Breast Conserving Surgery
It can reduce the risks of reoccurrence
Patients will have a course after surgery (eg. every day for 3 weeks)
When is Chemotherapy used in the management of Breast Cancer?
Neoadjuvant therapy – intended to shrink the tumour before surgery
Adjuvant chemotherapy – given after surgery to reduce recurrence
Treatment of metastatic or recurrent breast cancer
What are some Hormonal/Targeted Breast Cancer Treatments?
What is the big risk of one of the biologic therapies?
Oestrogen Positive (ER)
- Pre-menopausal women: Tamoxifen
- Post-Menopausal Women: Aromatase inhibitors (anastrozole)
Biologic Therapy:
- Trastuzumab (Herceptin) used for HER2 positive tumours
- Pertuzumab (another monoclonal Ab against HER2
- Neratinib (tyrosine kinase inhibitor to reduce growth in HER2 positive cases)
Trastuzumab cannot be used in patients with a history of heart disorders
Why are aromatase inhibitors used instead of Tamoxifen in post-menopausal women with breast CA?
Aromatisation accounts for the majority of oestrogen production in post-menopausal women from adipose tissue.
Furthermore Tamoxifen increases the risk of Endometrial cancer due to the oestrogenic effects on the uterus and the lack of progesterone from the menstrual cycle
What Follow-up is recommended after Breast cancer treatment?
All patients treated for breast cancer have surveillance mammograms yearly for 5 years (or longer if not yet reached the age for National Breast CA Screening)
What are the 2 types of Mastalgia?
Cyclical Related to the menstrual cycle
Non-Cyclical
What are the features of Cyclical Mastalgia?
Symptoms typically occur 2 weeks before menstruation
Features:
- Bilateral and generalised
- Heaviness
- Aching
What are the features of Non-Cyclical Mastalgia?
What are the causes?
Common in women aged 40-50
Often no cause is found
May be caused by:
- Medications (e.g., hormonal contraceptive medications)
- Infection (e.g., mastitis)
- Pregnancy
The pain may not originate in the breast but instead come from:
- The chest wall (e.g., costochondritis)
- The skin (e.g., shingles or post-herpetic neuralgia)
What are the investigations for Mastalgia?
A breast pain diary can help diagnose cyclical breast pain.
The three main things to exclude when someone presents with breast pain are:
- Cancer (perform a thorough history and examination)
- Infection (mastitis)
- Pregnancy (perform a pregnancy test)
What is the management of Cyclical Mastalgia?
- Wearing a supportive bra
- NSAIDs
- Avoiding caffeine is commonly recommended
- Applying heat to the area
- Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
What is a Galactocele?
When do they occur?
How do they present?
What is the management?
They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk.
Galactoceles occur in women that are lactating (producing breast milk), often after stopping breastfeeding.
They present with a firm, mobile, painless lump, usually beneath the areola.
They are benign and usually resolve without any treatment.
It is possible to drain them with a needle. Rarely, they can become infected and require antibiotics.
What is Phyllodes Tumour?
What age do they typically affect?
What is the management of a Phyllode Tumour?
Rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50.
They are large and fast-growing. They can be benign (~50%), borderline (~25%) or malignant (~25%).
Malignant phyllodes tumours can metastasise.
Treatment involves surgical removal of the tumour and the surrounding tissue (“wide excision”). They can reoccur after removal.
Chemotherapy may be used in malignant or metastatic tumours.
What is Mycoplasma Genitalium?
Mycoplasma genitalium (MG) is a bacteria that causes non-gonococcal urethritis. It is a sexually transmitted infection.
What are the clinical features of Mycoplasma Genitalium?
Often Asymptomatic and presents similarly to Chlamydia
- Urethritis is a key feature
May present with:
- Epididymitis
- Cervicitis
- Endometritis
- Pelvic inflammatory disease
- Reactive arthritis
- Preterm delivery in pregnancy
- Tubal infertility
What are the investigations for Mycoplasma Genitalium?
What needs to be done to the positive samples of MG?
NAAT testing for DNA/RNA
- First Urine sample for men
- Vaginal Swabs for women
Checking every positive sample for macrolide resistance, and performing a “test of cure” after treatment in every positive patient.
What is the management for Mycoplasma Genitalium?
Guidelines recommend a course of doxycycline followed by azithromycin for uncomplicated genital infections:
- Doxycycline 100mg twice daily for 7 days then;
- Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)
Moxifloxacin is used as an alternative or in complicated infections. Azithromycin alone is used in pregnancy and breastfeeding (remember doxycycline is contraindicated).
What are the symptoms of Premenstrual Syndrome?
When do symptoms not occur?
Symptoms occur in the days prior to menstruation and improve once menstruation begins.
Emotional symptoms include:
- Anxiety
- stress
- fatigue
- mood swings
Physical symptoms
- bloating
- breast pain
Symptoms are not present before menarche, during pregnancy or after menopause. These are key things to note when you take a history.
How is Premenstrual Syndrome Diagnosed?
Initial Ix
Definitive IX
Symptom diary spanning two menstrual cycles.
- The symptom diary should demonstrate cyclical symptoms that occur just before, and resolve after, the onset of menstruation.
Definitive diagnosis by administering a GnRH analogues to halt the menstrual cycle
- temporarily induce menopause, to see if the symptoms resolve.
What is cervical Ectropion?
What are the consequences of cervical ectropion?
Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix).
Also called cervical erosion
The cells of the endocervix (columnar epithelial cells) are more fragile and prone to trauma. They are more likely to bleed with sexual intercourse. This means cervical ectropion often presents with postcoital bleeding.
What are the associations of Cervical Ectropion?
Higher Oestrogen Levels
- Younger women
- Combined Contraceptive Pill Use
- Pregnancy
What is the Transformation Zone in the Cervix?
The transformation zone is the border between the columnar epithelium of the endocervix (the canal), and the stratified squamous epithelium of the ectocervix (the outer area of the cervix visible on speculum examination).
When the transformation zone is located on the ectocervix, it is visible during speculum examination as a border between the two epithelial types.
How does Cervical Ectropion Present?
Many cervical ectropion are asymptomatic, and they are found incidentally during speculum examination for other reasons, for example, smear tests.
May present with:
- Postcoital bleeding. (Intercourse is a common cause of minor trauma to the ectropion)
- Vaginal discharge
- Vaginal bleeding
- Dyspareunia
What is the management of Cervical Ectropion?
Asymptomatic ectropion require no treatment
Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant.
Problematic bleeding is an indication for the treatment of cervical ectropion
- Cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy.
What does female genital mutilation (FGM) involve?
FGM involves surgically changing the genitals of a female for non-medical reasons.
When does FGM usually occur?
FGM usually occurs in girls before puberty.
How is FGM classified in terms of child protection?
FGM is considered a form of child abuse and a safeguarding issue.
What law makes FGM illegal in the UK?
FGM is illegal under the Female Genital Mutilation Act 2003.
What is the legal requirement for healthcare professionals regarding FGM?
Healthcare professionals are legally required to report cases of FGM to the police.
Which organization provides information on the epidemiology of FGM?
UNICEF provides information on the epidemiology of FGM.
Where is FGM most commonly practiced?
FGM is most common in many African countries, including Somalia, Ethiopia, Sudan, and Eritrea.
Which country has the highest levels of FGM?
Somalia has the highest levels of FGM.
Name some countries outside Africa where FGM is practiced.
FGM is practiced in Yemen, Kurdistan, Indonesia, and parts of South and Western Asia.
How many types of FGM are there?
There are four types of FGM.
What is Type 1 FGM?
Type 1 FGM involves the removal of part or all of the clitoris.
What is Type 2 FGM?
Type 2 FGM involves the removal of part or all of the clitoris and labia minora. The labia majora may also be removed.
What is Type 3 FGM?
Type 3 FGM involves narrowing or closing the vaginal orifice (infibulation).
What is Type 4 FGM?
Type 4 FGM includes all other unnecessary procedures to the female genitalia.
What are two key risk factors for FGM?
Coming from a community that practices FGM and having relatives affected by FGM are key risk factors.
What scenarios suggest a risk of FGM?
- Pregnant women with FGM and a possible female child,
- siblings or daughters of affected women,
- extended trips to areas where FGM is practiced,
- refusal of examination or cervical screening,
- new patients from communities that practice FGM.
What are some immediate complications of FGM?
Pain, bleeding, infection, swelling, urinary retention, urethral damage, and incontinence.
What are some long-term complications of FGM?
Vaginal infections, pelvic infections, urinary tract infections, dysmenorrhea, sexual dysfunction, infertility, pregnancy-related complications, psychological issues, and reduced engagement with healthcare.
Why is it important to educate patients and relatives about FGM?
It is important to educate them because FGM is illegal in the UK and has serious health consequences.
What is mandatory for healthcare professionals regarding cases of FGM in patients under 18?
It is mandatory to report all cases of FGM in patients under 18 to the police.
Which other services should be contacted when managing FGM cases?
Social services, safeguarding, paediatrics, specialist gynaecology or FGM services, and counselling.
How should cases of FGM in patients over 18 be handled?
Cases should be handled with careful consideration, possibly involving a risk assessment tool to decide on reporting to the police or social services.
What action should be taken if the unborn child of a pregnant woman affected by FGM is at risk?
A referral should be made.
What is a de-infibulation procedure?
It is a surgical procedure to correct narrowing or closure of the vaginal orifice in Type 3 FGM cases.
Is performing re-infibulation after childbirth legal?
No, performing re-infibulation is illegal.
What is ovarian hyperstimulation syndrome (OHSS)?
OHSS is a complication of ovarian stimulation during IVF infertility treatment, associated with the use of hCG to mature follicles during the final steps of ovarian stimulation.
What hormone is associated with the maturation of follicles in OHSS?
Human chorionic gonadotropin (hCG) is associated with the maturation of follicles in OHSS.
What is the primary mechanism for OHSS?
The primary mechanism for OHSS is an increase in vascular endothelial growth factor (VEGF) released by the granulosa cells of the follicles, which increases vascular permeability.
What does VEGF do in the context of OHSS?
VEGF increases vascular permeability, causing fluid to leak from capillaries, resulting in oedema, ascites, and hypovolaemia.
What triggers OHSS during IVF treatment?
OHSS is triggered by the “trigger injection” of hCG 36 hours before oocyte collection.
What role does the renin-angiotensin system play in OHSS?
The renin-angiotensin system is activated in OHSS, with raised renin levels correlating with the severity of the condition.
What are some risk factors for developing OHSS?
Risk factors include younger age, lower BMI, raised anti-Müllerian hormone, higher antral follicle count, polycystic ovarian syndrome, and raised oestrogen levels during ovarian stimulation.
How are women monitored during stimulation to assess their risk of OHSS?
They are monitored with serum oestrogen levels and ultrasound to monitor the number and size of follicles.
What are some strategies to reduce the risk of OHSS in high-risk women?
Strategies include using the GnRH antagonist protocol, lower doses of gonadotrophins and hCG, and alternatives to hCG injections like a GnRH agonist or LH.
When does early OHSS present?
Early OHSS presents within 7 days of the hCG injection.
When does late OHSS present?
Late OHSS presents from 10 days onwards.
What are some features of OHSS?
Features include abdominal pain and bloating, nausea, vomiting, diarrhoea, hypotension, hypovolaemia, ascites, pleural effusions, renal failure, peritonitis, and a prothrombotic state.
How is the severity of OHSS determined?
Severity is determined based on clinical features like abdominal pain, bloating, ascites, urine output, serum albumin levels, potassium, and haematocrit.
What are the characteristics of mild OHSS?
Mild OHSS is characterized by abdominal pain and bloating.
What are the characteristics of moderate OHSS?
Moderate OHSS includes nausea, vomiting, and ascites seen on ultrasound.
What are the characteristics of severe OHSS?
Severe OHSS features ascites, low urine output (oliguria), low serum albumin, high potassium, and raised haematocrit (>45%).
What are the characteristics of critical OHSS?
Critical OHSS includes tense ascites, no urine output (anuria), thromboembolism, and acute respiratory distress syndrome (ARDS).
How is OHSS managed?
Management is supportive, including oral fluids, monitoring urine output, low molecular weight heparin, ascitic fluid removal, and IV colloids.
How are mild to moderate cases of OHSS usually managed?
Mild to moderate cases are often managed as outpatients.
What is required for managing severe OHSS cases?
Severe cases require hospital admission, while critical cases may require ICU admission.
What does a raised haematocrit level indicate in OHSS?
Raised haematocrit indicates less fluid in the intravascular space, which can be a sign of dehydration.
What percentage of couples will conceive within a year of regular unprotected sex?
85% of couples will conceive within a year of regular unprotected sex.
How many couples will struggle to conceive naturally?
1 in 7 couples will struggle to conceive naturally.
When should investigation and referral for infertility begin?
Investigation and referral should start after 12 months of trying to conceive without success, or 6 months if the woman is older than 35.
What are the main causes of infertility?
Sperm problems (30%), ovulation problems (25%), tubal problems (15%), uterine problems (10%), and unexplained causes (20%).
What percentage of infertile couples have a mix of male and female causes?
40% of infertile couples have a mix of male and female causes.
What general lifestyle advice is recommended for couples trying to get pregnant?
Take 400mcg folic acid daily, aim for a healthy BMI, avoid smoking and excessive alcohol, reduce stress, aim for intercourse every 2-3 days, and avoid timing intercourse.
Why is timed intercourse not recommended?
Timed intercourse can lead to increased stress and pressure in the relationship.
What are initial investigations for infertility?
Initial investigations include BMI measurement, chlamydia screening, semen analysis, female hormonal testing, and rubella immunity check.
What does female hormonal testing involve?
Serum LH and FSH on days 2-5, serum progesterone on day 21, anti-Mullerian hormone, thyroid function tests, and prolactin levels when indicated.
What does high FSH suggest in female hormonal testing?
High FSH suggests poor ovarian reserve.
What condition may high LH indicate?
High LH may suggest polycystic ovarian syndrome (PCOS).
What does a rise in serum progesterone on day 21 indicate?
A rise in progesterone indicates ovulation has occurred.
What does anti-Mullerian hormone indicate?
Anti-Mullerian hormone indicates ovarian reserve, with high levels suggesting a good reserve.
What further investigations are often performed in secondary care for infertility?
Ultrasound pelvis, hysterosalpingogram, and laparoscopy with dye test.
What is a hysterosalpingogram?
A scan to assess the shape of the uterus and patency of the fallopian tubes, with both diagnostic and therapeutic benefits.
What are the risks of a hysterosalpingogram?
There is a risk of infection, and antibiotics are often given prophylactically.
What does a laparoscopy and dye test involve?
Dye is injected into the uterus to see if it enters the fallopian tubes; it can also assess for endometriosis or adhesions.
What are management options for anovulation?
Options include weight loss, clomifene, letrozole, gonadotropins, ovarian drilling, and metformin.
What is clomifene and how is it used?
Clomifene is an anti-oestrogen that stimulates ovulation and is taken on days 2-6 of the menstrual cycle.
What does ovarian drilling involve?
Ovarian drilling is a laparoscopic procedure that improves hormonal balance to restore ovulation.
What are options for managing tubal factors in infertility?
Options include tubal cannulation, laparoscopy, and in vitro fertilisation (IVF).
How are uterine factors managed in infertility?
Surgery may be used to correct polyps, adhesions, or structural abnormalities.
What is surgical sperm retrieval?
It is used when there is a blockage in the vas deferens and involves collecting sperm directly from the epididymis.
What is intracytoplasmic sperm injection (ICSI)?
ICSI involves injecting sperm directly into the cytoplasm of an egg, which is then implanted into the uterus.
What is donor insemination?
Donor insemination involves using sperm from a donor as an option for male factor infertility.
Why might women with existing health conditions require additional management during pregnancy?
They may need management of both the existing health condition and the pregnancy, typically by the obstetric team and a specialist.
What are the risks of untreated hypothyroidism in pregnancy?
Untreated hypothyroidism can lead to miscarriage, anaemia, small for gestational age, and pre-eclampsia.
How is hypothyroidism treated during pregnancy?
With levothyroxine (T4), and the dose often needs to be increased by 25-50 mcg (30-50%). Treatment is adjusted based on TSH levels.
Which medications for hypertension should be stopped during pregnancy due to risk of congenital abnormalities?
ACE inhibitors (e.g., ramipril), angiotensin receptor blockers (e.g., losartan), and thiazide diuretics (e.g., indapamide).
Which medications are safer for managing hypertension in pregnancy?
Labetalol, calcium channel blockers (e.g., nifedipine), and alpha-blockers (e.g., doxazosin).
Why should women with epilepsy take folic acid 5mg daily before conception?
To reduce the risk of neural tube defects.
How can pregnancy affect epilepsy?
Pregnancy may worsen seizure control due to stress, hormonal changes, and altered medication regimens.
Which anti-epileptic drugs are considered safer during pregnancy?
Levetiracetam, lamotrigine, and carbamazepine.
Why is sodium valproate avoided in pregnancy?
It causes neural tube defects and developmental delays.
What specific program is used for women taking sodium valproate to prevent pregnancy?
The Prevent (valproate pregnancy prevention programme).
What is rheumatoid arthritis?
It is an autoimmune condition that causes chronic inflammation of the synovial lining of joints, tendon sheaths, and bursa.
How should rheumatoid arthritis be managed before pregnancy?
It should be well controlled for at least three months before pregnancy.
How does rheumatoid arthritis often change during pregnancy?
Symptoms often improve during pregnancy and may flare up after delivery.
Which rheumatoid arthritis medication is considered safe during pregnancy?
Hydroxychloroquine and sulfasalazine are considered safe.
Which medication is contraindicated in pregnancy due to risks in rheumatoid arthritis?
Methotrexate is contraindicated as it is teratogenic and can cause miscarriage and congenital abnormalities.
What can be used during flare-ups of rheumatoid arthritis in pregnancy?
Corticosteroids may be used during flare-ups.
What is the definition of stillbirth?
Stillbirth is defined as the birth of a dead fetus after 24 weeks gestation. It results from intrauterine fetal death (IUFD) and occurs in approximately 1 in 200 pregnancies.
What are the main causes of stillbirth?
Causes include unexplained (around 50%), pre-eclampsia, placental abruption, vasa praevia, cord prolapse or wrapped around the fetal neck, obstetric cholestasis, diabetes, thyroid disease, infections like rubella, parvovirus, and listeria, and genetic abnormalities or congenital malformations.
What factors increase the risk of stillbirth?
Risk factors include fetal growth restriction, smoking, alcohol, increased maternal age, maternal obesity, twins, and sleeping on the back (as opposed to either side).
How is the risk of a small for gestational age (SGA) baby assessed?
A risk assessment for having a baby that is SGA or with fetal growth restriction (FGR) is performed on all pregnant women, with serial growth scans for those at risk.
What are the three key symptoms to always ask about during pregnancy?
The three key symptoms are reduced fetal movements, abdominal pain, and vaginal bleeding.
What is the first-line investigation for diagnosing IUFD?
Ultrasound scan is the investigation of choice for diagnosing IUFD, used to visualize the fetal heartbeat.
What is the purpose of a repeat ultrasound scan in cases of suspected IUFD?
A repeat scan is offered to confirm the situation since passive fetal movements are possible after IUFD.
What is the management for Rhesus-D negative women after IUFD?
Rhesus-D negative women require anti-D prophylaxis when IUFD is diagnosed, with a Kleihauer test used to determine the dose required.
What is the preferred method of delivery after IUFD?
Vaginal birth is first-line unless there are reasons for a caesarean section. Women can choose between induction of labour or expectant management.
What medications are used for induction of labour after IUFD?
Induction of labour involves using oral mifepristone (anti-progesterone) and vaginal or oral misoprostol (prostaglandin analogue).
What is the role of dopamine agonists after stillbirth?
Dopamine agonists like cabergoline are used to suppress lactation after stillbirth.
What tests are done after stillbirth with parental consent?
Testing includes genetic testing of the fetus and placenta, postmortem examination of the fetus (including xrays), testing for maternal and fetal infection, and testing the mother for conditions like diabetes, thyroid disease, and thrombophilia.
Why is testing done after stillbirth?
Identifying the cause of stillbirth can help reduce the risk in future pregnancies, and pregnancies are closely monitored in women with previous stillbirth.
What support is provided to parents after a stillbirth?
Sensitive breaking of bad news, emotional support, counselling for women, partners, and family members, support with individual wishes (such as seeing or naming the baby), and assistance with funeral arrangements and services.
Question
Answer
What is defined as a perineal tear?
A perineal tear occurs when the external vaginal opening is too narrow to accommodate the baby, leading to tearing of skin and tissues as the baby’s head passes.
What are the ranges of perineal tears?
Perineal tears can range from a graze to large tears involving the anal sphincter (third-degree) and rectal mucosa (fourth-degree).
What are the risk factors associated with perineal tears?
Risk factors include first births (nulliparity), large babies (over 4kg), shoulder dystocia, Asian ethnicity, occipito-posterior position, and instrumental deliveries.
What is the first degree of perineal tear?
First-degree perineal tear involves injury limited to the frenulum of the labia minora and superficial skin.
What does a second-degree perineal tear involve?
Second-degree perineal tear includes the perineal muscles but does not affect the anal sphincter.
What is a third-degree perineal tear?
Third-degree perineal tear includes the anal sphincter but does not affect the rectal mucosa.
How is a fourth-degree perineal tear defined?
Fourth-degree perineal tear includes the rectal mucosa.
How can third-degree tears be subcategorized?
Third-degree tears can be subcategorized as: 3A (less than 50% of external anal sphincter affected), 3B (more than 50% of external anal sphincter affected), 3C (both external and internal anal sphincter affected).
What is the management for first-degree perineal tears?
First-degree tears usually do not require any sutures.
What is the management for perineal tears larger than first-degree?
Tears larger than first-degree typically require sutures, while third or fourth-degree tears may need repairing in theatre.
What are the additional measures taken after perineal tear repair?
Additional measures include broad-spectrum antibiotics, laxatives, physiotherapy, and follow-up monitoring for complications.
What option is available for women with third or fourth-degree tears in subsequent pregnancies?
Women symptomatic after third or fourth-degree tears are offered an elective caesarean section in future pregnancies.
What are some short-term complications after perineal tear repair?
Short-term complications include pain, infection, bleeding, and wound dehiscence or breakdown.
What are some lasting complications of perineal tears?
Lasting complications can include urinary incontinence, anal incontinence, fistulas, sexual dysfunction, and psychological issues.
What is an episiotomy?
An episiotomy is a surgical cut made in the perineum before delivery to provide additional room for the baby.
How is an episiotomy performed?
An episiotomy is performed under local anaesthetic, with a cut made at around 45 degrees diagonally, avoiding damage to the anal sphincter.
What is done after an episiotomy is performed?
The cut is sutured after delivery.
What is perineal massage and its purpose?
Perineal massage involves massaging the skin and tissues between the vagina and anus from 34 weeks onwards to reduce the risk of perineal tears.
What should you do when prescribing medications to pregnant women?
Always check the BNF, guidelines, and consult with seniors when in doubt.
What are examples of non-steroidal anti-inflammatory drugs (NSAIDs)?
Examples include ibuprofen and naproxen.
How do NSAIDs work?
NSAIDs work by blocking prostaglandins, which are important for maintaining the ductus arteriosus and stimulating uterine contractions.
Why are NSAIDs generally avoided in pregnancy?
They are avoided because they can cause premature closure of the ductus arteriosus in the fetus and delay labor.
What are the risks of using NSAIDs in the third trimester?
NSAIDs can cause premature closure of the ductus arteriosus and delay labor.
What are beta-blockers commonly used for in pregnancy?
They are used for hypertension, cardiac conditions, and migraine.
What is the most commonly used beta-blocker in pregnancy?
Labetalol is the most frequently used beta-blocker in pregnancy.
What are potential side effects of beta-blockers in neonates?
They can cause fetal growth restriction, hypoglycemia, and bradycardia in the neonate.
How do ACE inhibitors and ARBs affect the fetus?
They can cross the placenta and mainly affect the kidneys, reducing urine production, and may cause hypocalvaria.(fetal development issues)
What conditions can ACE inhibitors and ARBs cause during pregnancy?
They can cause oligohydramnios, miscarriage or fetal death, hypocalvaria, renal failure in the neonate, and neonatal hypotension.
What is neonatal abstinence syndrome (NAS)?
It is a withdrawal syndrome in neonates caused by maternal opiate use, presenting 3-72 hours after birth with irritability, tachypnea, high temperatures, and poor feeding.
Why is warfarin avoided during pregnancy?
It is teratogenic, crosses the placenta, and can cause fetal loss, congenital malformations, and bleeding complications.
What are the risks of sodium valproate in pregnancy?
It can cause neural tube defects and developmental delays.
What program is used to prevent pregnancy in women taking sodium valproate?
The Prevent (valproate pregnancy prevention programme) ensures strict criteria are met to avoid pregnancy.
What is lithium used for?
Lithium is used as a mood stabilizer for patients with bipolar disorder, mania, and recurrent depression.
Why is lithium avoided in pregnancy, particularly the first trimester?
It is linked with congenital cardiac abnormalities, especially Ebstein’s anomaly.
What is Ebstein’s anomaly?
It is a congenital cardiac defect where the tricuspid valve is positioned lower, causing an enlarged right atrium and a smaller right ventricle.
How often should lithium levels be monitored during pregnancy?
Levels should be monitored every four weeks, then weekly from 36 weeks.
Why should lithium be avoided in breastfeeding?
It enters breast milk and is toxic to the infant.
What are the most commonly used antidepressants in pregnancy?
Selective serotonin reuptake inhibitors (SSRIs) are most commonly used.
What are potential risks of SSRI use during pregnancy?
They are linked with congenital heart defects when used in the first trimester and persistent pulmonary hypertension in the neonate with third-trimester use.
What risks are associated with first-trimester use of paroxetine?
There is a stronger link with congenital malformations.
What symptoms might neonates experience if exposed to SSRIs in utero?
Neonates may experience withdrawal symptoms, usually mild and not requiring medical management.
What is isotretinoin (Roaccutane) used for?
It is used to treat severe acne.
Why is isotretinoin highly teratogenic?
It can cause miscarriage and congenital defects.
What precaution must be taken when a woman is prescribed isotretinoin?
Women need to use very reliable contraception before, during, and for one month after taking isotretinoin.
What is sepsis?
Sepsis is a condition where the body launches a large immune response to an infection, causing systemic inflammation and affecting organ function.
What is severe sepsis?
Severe sepsis occurs when sepsis results in organ dysfunction, such as hypoxia, oliguria, or raised lactate.
How is septic shock defined?
Septic shock is defined as when arterial blood pressure drops, resulting in organ hypo-perfusion.
Why is sepsis in pregnancy a medical emergency?
Sepsis in pregnancy is a medical emergency that requires prompt recognition and management to reduce maternal and fetal morbidity and mortality.
What are two key causes of sepsis in pregnancy?
The two key causes of sepsis in pregnancy are chorioamnionitis and urinary tract infections.
What is chorioamnionitis?
Chorioamnionitis is an infection of the chorioamniotic membranes and amniotic fluid, often occurring in later pregnancy and during labor.
What are the bacteria that can cause chorioamnionitis?
Chorioamnionitis can be caused by various bacteria, including gram-positive, gram-negative, and anaerobes.
What monitoring system is used for patients in maternity units?
Patients are monitored on a MEOWS chart (maternity early obstetric warning system) to identify signs of sepsis.
What are the non-specific signs of sepsis?
Non-specific signs include fever, tachycardia, raised respiratory rate, reduced oxygen saturations, low blood pressure, altered consciousness, reduced urine output, raised white blood cells, and evidence of fetal compromise on a CTG.
What additional signs are associated with chorioamnionitis?
Additional signs include abdominal pain, uterine tenderness, and vaginal discharge.
What additional signs indicate a urinary tract infection?
Signs include dysuria, urinary frequency, suprapubic pain or discomfort, renal angle pain, and vomiting (with pyelonephritis).
What blood tests should be arranged for suspected sepsis?
Tests include full blood count, U&Es, LFTs, CRP, clotting studies, blood cultures, and blood gas analysis.
What additional investigations may be helpful based on the suspected source of infection for maternal sepsis?
Additional investigations include urine dipstick and culture, high vaginal swab, throat swab, sputum culture, wound swab, and lumbar puncture.
Who should be involved in the care of women with suspected chorioamnionitis or sepsis?
Senior obstetricians and midwives should be involved early in the care of these women.
What is essential for managing maternal sepsis?
Early recognition and management, including continuous maternal and fetal monitoring, is essential.
When might emergency caesarean section be indicated?
Emergency caesarean section may be indicated when there is fetal distress, guided by a senior obstetrician.
What type of anesthesia is usually required for women with sepsis undergoing surgery?
General anesthesia is usually required, as spinal anesthesia is avoided.
What should be considered when choosing antibiotics for sepsis management?
Local guidelines for antibiotic choices should be followed, with heavy-hitting antibiotics needed to cover gram-positive, gram-negative, and anaerobes.
What are examples of antibiotic regimens for maternal sepsis?
Examples include piperacillin and tazobactam plus gentamicin, or amoxicillin, clindamycin, and gentamicin.
What are the components of the septic six?
The septic six includes three tests: blood lactate level, blood cultures, and urine output, along with three treatments: oxygen to maintain saturations, empirical broad-spectrum antibiotics, and IV fluids.
What type of care do most women receive in the postnatal period?
Most women receive routine midwife-led care.
Where may women be transferred after delivery for monitoring?
They may be transferred to the postnatal ward for a short period.
What post-natal routine care occurs in the days after delivery?
Analgesia as required
Help establishing breast or bottle-feeding
Venous thromboembolism risk assessment
Monitoring for postpartum haemorrhage
Monitoring for sepsis
Monitoring blood pressure (after pre-eclampsia)
Monitoring recovery after a caesarean or perineal tear
Full blood count check (after bleeding, caesarean or antenatal anaemia)
Anti-D for rhesus D negative women (depending on the baby’s blood group)
Routine baby check
What support is given for feeding after delivery?
Help is provided to establish breast or bottle-feeding.
What risk assessment is performed post-delivery?
Venous thromboembolism risk assessment is conducted.
What complications are monitored in the postnatal period?
Monitoring for postpartum haemorrhage and sepsis is performed.
What vital sign is monitored after pre-eclampsia?
Blood pressure is monitored.
What is monitored after a caesarean or perineal tear?
Recovery is monitored.
When is a full blood count check performed?
It is checked after bleeding, caesarean, or antenatal anaemia.
What treatment is given to rhesus D negative women?
Anti-D may be administered depending on the baby’s blood group.
What routine check is performed on the baby?
A routine baby check is conducted.
What topics are discussed during follow-up with a midwife after the initial postnatal period?
General wellbeing
Mood and depression
Bleeding and menstruation
Urinary incontinence and pelvic floor exercises
Scar healing after episiotomy or caesarean
Contraception
Breastfeeding
Vaccines (e.g. MMR)
What is the purpose of the six-week postnatal check?
To assess the mother’s recovery and wellbeing, usually done alongside the newborn baby check.
What topics are covered at the six-week check?
Topics include general wellbeing, mood, bleeding, scar healing, contraception, breastfeeding, fasting blood glucose, and blood pressure.
What is lochia?
Lochia is the vaginal bleeding that occurs after birth, consisting of blood, endometrial tissue, and mucus.
What color is lochia initially?
Initially, lochia is dark red.
What should be avoided during the lochia period?
Tampons should be avoided due to the risk of infection.
How long should bleeding settle after delivery?
Bleeding should settle within six weeks.
What effect does breastfeeding have on uterine contractions?
Breastfeeding releases oxytocin, which causes the uterus to contract, possibly leading to more bleeding.
What effect can breastfeeding have on the menstrual cycle?
They may not have regular periods for six months or longer, unless they stop breastfeeding.
Lactational Amenorrhoea
When will bottle-feeding women start having menstrual periods?
Bottle-feeding women may begin having periods from three weeks onwards.
How long after giving birth is fertility considered to return?
Fertility is considered to return after 21 days postpartum.
What contraception is recommended for women after 21 days?
After 21 days, women are considered fertile and need contraception.
How effective is lactational amenorrhea as contraception?
Lactational amenorrhea is over 98% effective for up to 6 months after birth.
What type of contraception can be started after delivery and when?
The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.
The combined contraceptive pill should be avoided in breastfeeding until 6 weeks after childbirth
A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than four weeks after birth (UKMEC 1), but not inserted between 48 hours and four weeks of delivery (UKMEC 3).
What does “retained products of conception” refer to?
It refers to pregnancy-related tissue remaining in the uterus after delivery, miscarriage, or termination.
What is a significant risk factor for retained products of conception?
Placenta accreta is a significant risk factor.
Can retained products of conception occur without symptoms?
Yes, it may be present without any suggestive symptoms.
What symptoms may indicate retained products of conception?
- Vaginal bleeding that gets heavier or does not improve with time
- Abnormal vaginal discharge
- Lower abdominal or pelvic pain
- Fever (if infection occurs)
What is another symptom of retained products of conception?
Abnormal vaginal discharge.
What abdominal symptom may occur with retained products of conception?
Lower abdominal or pelvic pain.
What systemic symptom may occur if infection develops?
Fever may occur if infection develops.
What is the investigation of choice for diagnosis of RPOC?
Ultrasound is the investigation of choice.
What is the standard management for postpartum retained products of conception?
Surgical removal is the standard management.
What does ERPC stand for?
Evacuation of retained products of conception.
What is involved in the ERPC procedure?
The cervix is gradually widened, and retained products are removed using vacuum aspiration and curettage.
What type of anaesthetic is used for ERPC?
General anaesthetic is used for the procedure.
What is another name for the procedure involving curettage?
It may be referred to as “dilatation and curettage.”
What are two key complications of ERPC?
Endometritis and Asherman’s syndrome.
What is Ashermans syndrome?
It is a condition where adhesions form within the uterus after curettage.
How can endometrial curettage lead to Asherman?s syndrome?
It can damage the basal layer of the endometrium, causing abnormal healing and scar tissue formation.
What complications can adhesions from Asherman?s syndrome cause?
They can lead to infertility.
Where may adhesions form in Asherman?s syndrome?
They can form binding the uterine walls together or within the endocervix, sealing it shut.
What is Sheehan’s syndrome?
A rare complication of postpartum hemorrhage leading to avascular necrosis of the pituitary gland.
What causes Sheehan’s syndrome?
A drop in circulating blood volume results in low blood pressure and reduced perfusion of the pituitary gland, causing ischaemia and cell death.
Which part of the pituitary gland is affected by Sheehan’s syndrome?
Only the anterior pituitary gland is affected.
Are hormones produced by the posterior pituitary gland affected in Sheehan’s syndrome?
No, hormones produced by the posterior pituitary are spared.
What is the blood supply system for the anterior pituitary?
The anterior pituitary receives blood from the hypothalamo-hypophyseal portal system, which is susceptible to rapid drops in blood pressure.
How does the blood supply of the posterior pituitary differ from the anterior pituitary?
The posterior pituitary has a better blood supply from various arteries and is not susceptible to ischaemia during blood pressure drops.
Name the hormones released by the anterior pituitary.
Thyroid-stimulating hormone (TSH)
Adrenocorticotropic hormone (ACTH)
Follicle-stimulating hormone (FSH)
Luteinising hormone (LH)
Growth hormone (GH)
Prolactin
What hormones are released by the posterior pituitary?
Oxytocin and antidiuretic hormone (ADH).
What are the symptoms of Sheehan’s syndrome?
Symptoms caused by lack of Anterior pituitary hormones
Reduced lactation (lack of prolactin)
Amenorrhea (lack of LH and FSH)
Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH)
Hypothyroidism with low thyroid hormones (lack of TSH)
How is Sheehan’s syndrome managed?
Management is under the guidance of a specialist endocrinologist and involves hormone replacement therapy.
What hormone replacements are used for Sheehan’s syndrome?
Oestrogen and progesterone as hormone replacement therapy for the female sex hormones (until menopause)
Hydrocortisone for adrenal insufficiency
Levothyroxine for hypothyroidism
Growth hormone
What is postpartum thyroiditis?
A condition with changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease.
What type of antibodies are associated with postpartum thyroiditis?
Thyroid peroxidase antibodies.
What are the three typical stages of postpartum thyroiditis?
- Thyrotoxicosis (first three months)
- Hypothyroid (3-6 months)
- Return to normal thyroid function (within one year)
When should thyroid function tests be performed after delivery?
6-8 weeks after delivery for women with suggestive symptoms.
What is the typical management for thyrotoxicosis?
What is the typical treatment for hypothyroidism?
Symptomatic control, such as propranolol (a non-selective beta-blocker).
Levothyroxine.
How often should women with postpartum thyroiditis be monitored for thyroid function tests?
Annual monitoring is required, even after the condition resolves, to identify long-term hypothyroidism.
How are symptoms and thyroid function tests managed in postpartum thyroiditis?
They are monitored, and treatment is altered or stopped as the condition changes
What is the purpose of a semen analysis?
Semen analysis is used to examine the quantity and quality of semen and sperm and assess for male factor infertility.
What are the instructions for men providing a semen sample?
- Abstain from ejaculation for at least 3 days and at most 7 days
- Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
- Attempt to catch the full sample
- Deliver the sample to the lab within 1 hour of ejaculation
- Keep the sample warm (e.g. in underwear) before delivery
What lifestyle factors can affect semen analysis and sperm quality?
- Hot baths
- Tight underwear
- Smoking
- Alcohol
- Raised BMI
- Caffeine
When should a repeat semen sample be taken?
A repeat sample is indicated after 3 months for borderline results or earlier (2-4 weeks) with very abnormal results.
What are the normal results for semen analysis according to the World Health Organisation?
- Semen volume (more than 1.5ml)
- Semen pH (greater than 7.2)
- Concentration of sperm (more than 15 million per ml)
- Total number of sperm (more than 39 million per sample)
- Motility of sperm (more than 40% of sperm are mobile)
- Vitality of sperm (more than 58% of sperm are active)
- Percentage of normal sperm (more than 4%)
What does polyspermia refer to?
Polyspermia (or polyzoospermia) refers to a high number of sperm in the semen sample (more than 250 million per ml).
What is normospermia?
Normospermia (or normozoospermia) refers to normal characteristics of the sperm in the semen sample.
What is oligospermia, and how is it classified?
Oligospermia (or oligozoospermia) is a reduced number of sperm in the semen sample, classified as:
- Mild oligospermia (10 to 15 million / ml)
- Moderate oligospermia (5 to 10 million / ml)
- Severe oligospermia (less than 5 million / ml)
What does cryptozoospermia indicate?
Cryptozoospermia refers to very few sperm in the semen sample (less than 1 million/ml).
What is azoospermia?
Azoospermia is the absence of sperm in the semen.
What are some pre-testicular causes of male infertility?
Hypogonadotrophic Hypogonadism:
- Pathology of the pituitary gland or hypothalamus
- Suppression due to stress, chronic conditions or hyperprolactinaemia
- Kallman syndrome
What are some testicular causes of male infertility?
Testicular causes include:
- Mumps
- Undescended testes
- Trauma
- Radiotherapy
- Chemotherapy
- Cancer
What are some post-testicular causes of male infertility?
Post-testicular causes include:
- Damage to the testicle or vas deferens from trauma, surgery or cancer
- Ejaculatory duct obstruction
- Retrograde ejaculation
- Scarring from epididymitis, for example, caused by chlamydia
- Absence of the vas deferens (may be associated with cystic fibrosis)
- Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)
What are the initial steps for investigating abnormal semen analysis?
The initial steps include taking a history, conducting a physical examination, repeating the sample, and performing an ultrasound of the testes.
When are patients with abnormal semen results referred?
Patients with abnormal semen results are referred to a urologist for further investigations.
What further investigations may be considered for abnormal semen analysis?
- Hormonal analysis with LH, FSH and testosterone levels
- Genetic testing
- Further imaging, such as transrectal ultrasound or MRI
- Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction
- Testicular biopsy
What management options are available for male infertility?
Management options depend on the underlying cause and may include:
- Surgical sperm retrieval where there is obstruction
- Surgical correction of an obstruction in the vas deferens
- Intra-uterine insemination involves separating high-quality sperm, then injecting them into the uterus
- Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg
- Donor insemination involves sperm from a donor
What is in vitro fertilization (IVF)?
IVF involves fertilizing an egg with sperm in a lab, then injecting the resulting embryo into the uterus. It is a complicated and expensive process with strict funding criteria that vary by area. Couples are limited to a set number of cycles funded by the NHS.
What is the success rate of each IVF attempt at producing a live birth?
Each IVF attempt has a success rate of approximately 25-30% at producing a live birth.
How does intrauterine insemination (IUI) differ from IVF?
IUI is a more straightforward process that involves injecting sperm directly into the uterus, avoiding intercourse. It is used in cases such as donor sperm for same-sex couples, HIV (to avoid unprotected sex), and practical issues with vaginal sex.
What does a cycle of IVF involve?
A cycle of IVF involves a single episode of ovarian stimulation and collection of oocytes (eggs). Multiple embryos may be produced and transferred separately during one cycle. Any unused embryos can be frozen for later use.
What are the steps involved in the IVF process?
- Suppressing the natural menstrual cycle
- Ovarian stimulation
- Oocyte collection
- Insemination / intracytoplasmic sperm injection (ICSI)
- Embryo culture
- Embryo transfer
*
How is the natural menstrual cycle suppressed during IVF?
The natural menstrual cycle is suppressed using GnRH agonists or antagonists to prevent ovulation and ensure proper ovarian response. The choice of protocol depends on individual factors.
What is the GnRH agonist protocol?
The GnRH agonist protocol involves an injection of a GnRH agonist (e.g., goserelin) around 7 days before the expected menstrual period. It initially stimulates the pituitary gland, causing an increase in FSH and LH, but later suppresses GnRH production, preventing ovulation.
What is the GnRH antagonist protocol?
The GnRH antagonist protocol involves daily subcutaneous injections of a GnRH antagonist (e.g., cetrorelix) starting from day 5-6 of ovarian stimulation. This prevents the release of LH and avoids ovulation.
What is involved in ovarian stimulation during IVF?
Ovarian stimulation uses medications (usually FSH) to promote the development of multiple follicles. This starts on day 2 of the menstrual cycle and continues for 10-14 days, monitored by transvaginal ultrasound. An hCG injection is given 36 hours before egg collection to trigger final maturation.
How are oocytes collected during IVF?
Oocytes are collected under transvaginal ultrasound guidance, where a needle is inserted through the vaginal wall into the ovaries to aspirate fluid containing mature oocytes. This procedure is typically done under sedation.
What happens during oocyte insemination?
The male provides a semen sample around the time of oocyte collection, or frozen sperm may be used. The sperm is mixed with the egg in a culture medium to facilitate fertilization.
What is intracytoplasmic sperm injection (ICSI)?
ICSI is a technique used primarily for male factor infertility, where a single high-quality sperm is injected directly into the cytoplasm of the egg after oocyte collection.
What occurs during embryo culture?
Fertilized eggs are incubated and observed for 2?5 days to monitor their development, typically until they reach the blastocyst stage around day 5.
How is the embryo transferred into the uterus?
After 2?5 days, the highest quality embryos are selected, and a catheter is inserted under ultrasound guidance through the cervix into the uterus, injecting a single embryo. Generally, only one embryo is transferred, but two may be transferred for women over 35. Any remaining embryos can be frozen.
When is a pregnancy test performed after IVF, and what does it indicate?
A pregnancy test is performed around day 16 after egg collection. A positive result indicates successful implantation, while a negative result means implantation has failed.
What hormonal treatment is used after oocyte collection?
Progesterone is used from oocyte collection until 8-10 weeks of gestation, typically as vaginal suppositories, to mimic the natural progesterone produced during a typical pregnancy. After 8-10 weeks, the placenta takes over production, and the suppositories are stopped.
What complications can arise from the IVF process?
- Failure
- Multiple pregnancy
- Ectopic pregnancy
- Ovarian hyperstimulation syndrome
What are some risks associated with the egg collection procedure?
- Pain
- Bleeding
- Pelvic infection
- Damage to the bladder or bowel
What are the different types of Miscarriage and how can you easily distinguish them?
Internal Os Open:
- Incomplete or Inevitable
- If there is still a full fetus then it is inevitable, if there are only retained products then it is incomplete
Internal Os Closed:
- Threatened, Missed, Completed
- Completed then symptoms have occurred and there is no fetus or tissue within the uterus
- Threatened, vaginal bleeding and pain and the fetus still has a heart beat
- Missed is when the fetus is dead, the mother may not have experienced symptoms and it requires evacuation.
Which of these risks are caused by what hormonal drug that may be used in cancer?
- Risk of Alopecia areata
- Risk of Hot flushes and VTE
- Risk of cardiotoxicity
- Risk of peripheral neuropathy
- Risk of Osteoporosis
- Risk of Alopecia areata - General chemotherapy
- Risk of Hot flushes and VTE - Tamoxifen
- Risk of cardiotoxicity - Trastuzumab
- Risk of peripheral neuropathy - Vincristine
- Risk of Osteoporosis - Aromatase inhibitors
