OBS & GYN Flashcards
What is normal menstrual bleeding?
Normal Menstrual Bleeding:
• Avg 30mL lost with each menstrual period
• Upper limit is 80mL
Definition of abnormal uterine bleeding
- Blood loss of more than 80mL (subjective by the patient)
- Cycle length of < 24 days or > 35 days
- Intermenstrual or postcoital bleeding
Definition of dysfunctional uterine bleeding
Excessive bleeding which is not due to pregnancy, pelvic pathology or systemic disease that can be cyclical (ovulatory) or non-cyclical (anovulatory). Anovulatory bleeding commonly occurs at the beginning and end of reproductive life
(adolescence and premenapause).
Diagnosis of exclusion
Definition of menorrhagia
- Excessive or prolonged menstrual bleeding occurring at regular intervals
- Note: both patient and doctor are unreliable at predicting amount of blood lost
Definition of inter-menstrual bleeding
Bleeding that occurs between regular menstrual cycles
Definition of post-coital bleeding
Bleeding up to 24 hours after intercourse
Definition of pre-menstrual spotting
Bleeding during the week prior to a period
Definition of Metrorrhagia
Bleeding of normal or less than normal volumes at irregular intervals
Definition of Menometrorrhagia
Prolonged or excessive bleeding at irregular intervals
Definition of Polymenorrhoea
Regular bleeding that occurs at intervals < 24 days
Aetiology of abnormal uterine bleeding
What History and Examination for abnormal uterine bleeding
Investigations for abnormal uterine bleeding
Investigation considerations according to patient group
Common to consider:
- BHCG
- Bloods: iron, FBC, folate, B12, coags ,TFTs, LFTs
- Imaging: Pelvic, abdominal or transvaginal US
- STI swab
- Pap smear
- Colposcopy
- Hysteroscopy
- biopsy
Management of abnormal uterine bleeding
Uterine blood flow
Causes of abnormal uterine bleeding
DDx of abnormal uterine bleeding
- Ectopic pregnancy
- Miscarriage
- Placental abruption, placenta previa
- Breakthrough bleeding
- Benign structural abnormalities (adenomyosis, fibroids, polyps)
- Gynaecological malignancies
- Chlamydia
- Hormonal changes – menopause/perimenopause
- Prolapse
- Trauma
Investigation for abnormal uterine bleeding (part 2)
Treatment for abnormal uterine bleeding
Definition of uterine fibroids (leiomyoma)
Benign tumours of the uterus composed of smooth muscle and fibrous connective tissue
Epidemiology of uterine fibroids
Epidemiology:
• Incidence increases with age
• Affects 20-50% of women > 30 years
• Prevalence may be as high as 80%
Aetiology and anatomical classification of uterine fibroids
Clinical features of uterine fibroids
- Asymptomatic – most common
- Menorrhagia (caused by submucosal fibroids)
- Dysmenorrhoea (painful periods)
- Pelvic pain/pressure
- Bloating
- Enlarged uterus – firm, asymmetric, non-tender
- Usually slow growing but can be accelerated growth in pregnancy due to high oestrogen
Investigations for uterine fibroids
- Pelvic U/S
- Endometrial biopsy (via hysteroscopy)
- DDx – clinically similar to adenomyosis and uterine polyps (require biopsy)
Treatment for uterine fibroids
Complications and prognosis of Uterine fibroids
Anatomy of uterus
Definition and epidemiology of Antepartum Haemorrhage
Definition:
• Uterine bleeding that occurs after 20 weeks gestation that is unrelated to labour and delivery
Epidemiology:
• 6% of all pregnancies experience PV (per vagina) bleeding in the 3rd trimester
Aetiology of antepartum haemorrhage
General management of antepartum haemorrhage
Definition and epidemiology of abruptio placenta (placenta abruption)
Definition:
• Premature separation of a normal implanted placenta from the decidual lining of the uterus after 20 weeks gestation
Epidemiology:
• Occurs in 1 in 200 pregnancies
• Black women > white women
Aetiology and risk factors for placenta abruption
Aetiology:
• Exact cause is unknown
Types of placenta abruption
Types:
• Apparent: Bleeding apparent
• Concealed: Bleeding is not-apparent
• Mixed: Bleeding with concealment
Pathophysiology of placenta abruption
Pathophysiology:
- Rupture of maternal vessels in the decidua basalis at the interface of the anchoring villi
- Accumulating blood splits the decidua, separating a thin layer of decidua with its placental attachment from the uterus
- The bleeding may be small and self-limited or it can continue to separate the decidua leading to complete or near complete placental separation
- The detached portion is no longer able to exchange gases and nutrients
- May lead to foetal compromise if the remaining foeto-placental unit is unable to compensate for this loss of function
Clinical features of antepartum haemorrhage
DDx for anterpartum haemorrhage
DDx:
- Preterm labour - can co-exist/caused by placental abruption
- Placenta praevia
- Chorioamnionitis - bleeding is uncommon
Diagnosis and complications of antepartum haemorrhage
Diagnosis:
• Diagnosis of exclusion, based on clinical Hx and U/S
Complications:
• Hypovolaemic shock (medium)
• DIC
• Intra-uterine growth restriction
• Preterm birth
• Perinatal death
Management of antepartum haemorrhage
Definition of Placenta Praevia
Definition:
- The presence of placental tissue that extends over or lies proximate to the internal cervical os
- Should be suspected in any woman > 20 weeks gestation that presents with painless vaginal bleeding
Epidemiology and risk factors of placenta praevia
Epidemiology:
- Uncommon in 1st pregnancies (0.2% in nulliparous)
- 0.5% in multiparous and a 4-8% recurrence
Risk Factors:
- Previous placenta praevia - 0.7% risk
- Infertility treatments (IVF) - 2% risk • Endometrial scarring, (previous LSCS) - 0.6%
- Impeded endometrial vascularisation e.g. HTN, diabetes, uterine tumour, drugs (cocaine) smoking and Advanced maternal age
- Increased placental mass: ⁃ Multiparity
Aetiology and classification of placenta praevia
Clinical features of Placenta Praevia
DDx for placenta praevia
DDx:
- Normal labour
- Placental abruption
- Placenta accreta
- Miscarriage (more common in early pregnancy)
Investigations for placenta praevia
Investigations:
- Transabdominal U/S - Assess placental position
- Transvaginal U/S - Preferred
- FBC - Assess Hb level in acute bleeds
- Type and crossmatch
Management of Placenta Praevia
Complications of placenta praevia
Complications:
- Anaemia (short-term high) - due to bleeding
- Complications of C-section
- Preterm birth
- Abnormally adherent placenta
Prognosis of placenta praevia
Definition of Placenta Accreta
Epidemiology and risk factors of Placenta Accreta
Epidemiology
- 5-10% risk in the presence of placenta praevia
- 10-20% risk with previous LSCS
Risk Factors:
- Placenta praevia
- Previous C-section or uterine surgery
- Maternal age > 35 years
- Multiparity - increases after each childbirth
- Uterine pathology like fibroids
Aetiology and pathophysiology of placenta accreta
Aetiology:
- Unknown
- Abnormality to the uterine lining
Pathophysiology:
- Defective decidualisation (thin, poorly formed or absent decidua) related to previous surgeries or anatomical pathologies or extra-villous trophoblastic invasion
- Allows for the placenta to attach directly to the myometrium
Clinical features, Investigations and Management of Placenta Accreta
For Vasa Previa what is the:
- Definition
- Epidemiology
- Aetiology and pathophysiology
- Clinical features
- Diagnosis
Assisted reprodutive tech cards to be filled - Gobi’s incomplete - might have to check in Jims
Common cancer of the vulva, epidemiology and symptoms
The female external genitalia is called the vulva. Made up of 3 main parts: labia majora, labia minora and clitoris
- Cancer of the vulva makes up around 4% of female genital tract cancers and is quite rare
- Most are SCCs
- Most commonly diagnosed in post-menopausal women, ~ 70 years
- Symptoms include ulcerative sores that do not heal, itching, unusual vaginal bleeding and/or discharge
Aetiology of cancer of the vulva
Sites of vulval cancer
Symptoms of vulval cancer
Risk factors of vulval cancer
Types of vulval cancer
Diagnosis and staging of vulval cancer
Treatment of vulval cancer
Definition of cervical cancer
- Cervical cancer is a HPV-related malignancy of the uterine cervical mucosa
- HPV is transmitted via sexual intercourse
Epidemiology of cervical cancer
Epidemiology:
- Cervical cancer is the 2nd most common malignancy in women worldwide
- Peak infection incidence is between 15-25 years, with the majority resolving in 12-18 months
- Prevalence of HPV at age 35 is 5%
- Effective screening programs have reduced mortality by 75% in the last 50 years
- 60% of diagnoses occur in women who have never had screening or have not been screened in the last 5 years
- Pap smears are a very successful cancer screening tool
Aetiology and risk factors of cervical cancer
Pathophysiology of cervical cancer
Clinical features and staging of cervical cancer
Investigations for cervical cancer
Pap smear results in cervical cancer screening
Classification and staging of cervical cancer
Management of cervical cancer
Screening for cervical cancer
- 25-74 years
- Every 5 years
- Test looks for HPV
Prognosis for cervical cancer
Histology of the transformation zone and types of smears
Histology of cervical cancer
Contraception cards - gobi’s incomplete - please insert
Epidemiology and factors enhancing risk of diabetes in pregnancy
Complications and maternal insulin requirements in T1DM and pregnancy
Management of T1DM in pregnancy and delivery
Considerations and management of T2DM in pregnancy
Definition and epidemiology of Gestational Diabetes Mellitus (GDM)
Definition:
- Any degree of glucose intolerance with onset or first recognition in pregnancy
- Includes women that develop T1DM/T2DM during the pregnancy, hence need for retrospective classification
Epidemiology:
- Accounts for 70% of diabetes in pregnancy
- Higher in asian and black populations
- Rates of GDM are on the rise
Aetiology of GDM
Pathophysiology of GDM
Clinical features of GDM
Investigations for GDM
Screening for GDM
Management for GDM
Complications of GDM
Prognosis for GDM
Role of prostaglandins in labour
Role of oxytocin in labour
Role of B2 agonists in labour
Role of tocolytics in labour
Induction of labour and myometrial contraction
Inhibition of labour and myometrial relaxation
Definition of ectopic pregnancy
Definition:
- A pregnancy resulting from the fertilised ovum implanting in a site other than the normal uterine cavity
- Obstetric Emergency: If undiagnosed it can lead to maternal death due to rupture of the implantation site and intraperitoneal haemorrhage
Epidemiology:
- Incidence rate of 1-2% and rising
- Recurrence rate is 15% after 1st and 25% after the 2nd
- Accounts for 80% of 1st trimester maternal deaths. Mortality rates are declining
Aetiology and risk factors of ectopic pregnancy
Classification of ectopic pregnancy
Pathophysiology of ectopic pregnancy
Clinical features of ectopic pregnancy
Investigations for ectopic pregnancy
Diagnosis of ectopic pregnancy
Diagnosis:
- Elevated β-hCG with no intrauterine gestation sac (> 5 weeks is visible on TVS)
- Detection of free-fluid in the peritoneal cavity
- Laparoscopy rarely required for diagnostic purposes
Differential diagnosis for ectopic pregnancy
DDx:
- Miscarriage
- Acute appendicitis
- Ovarian torsion
- Ruptured corpus luteal cyst or follicle
- Normal 1st trimester bleeding (20% of women have normal pregnancies)
- UTI/PID
Management of ectopic pregnancy
Complications and management of ectopic pregnancy
Normal B-Hcg and diagnosis of interuterine/normal pregnancy
Definition and epidemiology of endometrial cancer
Definition:
• Epithelial malignancy of the uterine corpus mucosa - usually adenocarcinoma
Epidemiology:
- Most common gynaecological malignancy in the developed world
- 7th most common cancer in women overall
- Incidence in western countries is 10x more than in developing
Aetiology of endometrial cancer
Risk factors for endometrial cancer
Risk Factors:
- Obesity
- Age > 50 years
- Endometrial hyperplasia
- Unopposed exogenous/endogenous oestrogen exposure
- FHx of endometrial cancer
- FHx of breast or ovarian cancer
- HNPCC
- Tamoxifen use (oestrogen receptors antagonist) for Rx of breast Ca (7x)
- DM
- HTN
Classification of endometrial cancer
Classification:
- Adenocarcinoma (90%)
- SCC
- Transitional cell carcinoma
- Small cell
- Undifferentiated
Clinical features of endometrial cancer
Investigations for endometrial cancer
Differential diagnosis for endometrial cancer
DDx:
- Endometrial hyperplasia - commonly presents with abnormal uterine bleeding, irregular or heavy periods
- Endometrial polyp - usually asymptomatic, but if symptomatic presents similarly
- Endometriosis - More common in younger pre-menopausal women
- Cervical cancer - Typically younger women; PV bleeding usually provoked (post-coital)
Spread and management of endometrial cancer
Complications and prognosis of endometrial cancer
Definition and epidemiology of endometriosis
Definition:
• Ectopic endometrial glands and stroma growing outside the endometrial cavity and uterine musculature
Epidemiology:
- 3-10% of women aged 20-50 (women of reproductive age usually)
- Average age at diagnosis is 25-28 years
- Account for 25-35% of infertility
- Severity of symptoms increases with age and peaks at 40yrs • Prevalence higher in white women and women with Lower BMIs • Adolescent endometriosis exists
Aetiology + risk factors for endometriosis
Aetiology:
• Several theories exist + Genetic predisposition
Risk Factors:
- Reproductive Age
- Family Hx
- Nulliparity
- Mullerian anomolies
- Others: White, Low BMI, Autoimmune disease, Smoking
Pathogenesis of endometriosis
1. Retrograde menstruation theory: ⁃ Retrograde menstruation seeds in the abdominal cavity ⁃ Occurs in 70-90% of women
2. Coelomic metaplasia: ⁃ Peritoneal mesothelium undergoes metaplastic transformation into endometrial tissue
3. Induction theory: ⁃ Unknown biochemical substance induce undifferentiated peritoneal cells to form endometrial tissue
4. Immunological theory: ⁃ Alterations in cell-mediated immunity leads to abnormal clearance of endometrial cells
Pathophysiology of endometriosis
- Endometriosis and sub-fertility: Altered anatomy with tube/ovarian involvement and scarring and PG overproduction can also interfere with fertilisation
- Dysmenorrhoea occurs due to reactive hormonal-tissue in the abdomen
- Chronic pain may be due to fibrosis that occurs with chronic inflammation
Types of lesions in endometriosis
Three types of lesions in endometriosis:
- superficial peritoneal endometriosis – powder burn lesions on ovaries, serosa and peritoneum, may also appear as white plaques, scarring, red implants, serous vesicles
- ovarian cysts (endometrioma) – ‘chocolate cysts’ forming from menstrual bleeding in the ovaries
- deep infiltrative endometriosis – nodules extending more than 5mm beneath the peritoneum involving the uterosacral ligaments, vagina, bowel, bladder, or ureters
Signs and symptoms of endometriosis
Staging of endometriosis
Clinical presentation of endometriosis
Differential diagnosis of endometriosis
- Adenomyosis – hyperplasia leading to growth of endometrial tissue within the myometrium, symptoms may be identical, and endometriosis is often concurrent
- Pelvic inflammatory disease
- Malignancy – ovarian, uterine, endometrial
- Ovarian cyst
- Irritable bowel syndrome
Investigations and diagnosis of endometriosis
Investigations:
- TVS - may show ovarian endometrioma or deep pelvic endometriosis
- Diagnostic laparoscopy
Diagnosis:
- Laparoscopy - Gold Standard. Finding of extra-uterine endometrial tissue on visualization and biopsy (histopathology)
- Examination - Pouch of Douglas Pain with nodularity of the uterosacral ligament. Fixed in retroversion
- TVS: Especially for endometrioma
Management of endometriosis
Complications and prognosis of endometriosis
Definition of foetal malpresentation
Definitions:
- In normal pregnancies the foetus assumes a normal longitudinal (vertical) lie with a cephalic presentation and the head well flexed
- 5% of all term pregnancies have a deviation from this lie
Causative factors for foetal malpresentation
Types of foetal malpresentations
Types of Malpresentations:
- Unstable lie
- Face presentation
- Brow presentation
- Compound presenation
- Breech presentation
Unstable or abnormal lie of foetal malpresentations
Face presentation of foetal malpresentation
Brow position of foetal malpresentation
Compound presentation of foetal malpresentation
Breech presentation of foetal malpresentation
Definition of gestational trophoblastic disease
Epidemiology and aetiology of gestational trophoblastic disease
Pathophysiology of gestational trophoblastic disease
Classification of gestational trophoblastic disease
Clinical features of gestational trophoblastic disease
Differential diagnosis of larger than stated uterus
DDx of larger than stated uterus:
- Wrong dates for LMP
- Multiple gestation (twins)
- Other intrauterine pathology (e.g. fibroids)
- GTD
Investigations for gestational trophoblastic disease
Differential diagnosis for gestational trophoblastic disease
DDx:
- Spontaneous abortion - can be differentiated on U/S
- Multiple gestation - larger than normal uterus and elevated hCG
- Pelvic tumour - may present with enlarged uterus, painless bleeding and adnexal mass
Management of gestational trophoblastic disease
Complications and prognosis of gestational trophoblastic disease
Gynae Hx Taking
Abdomen and vaginal exam
Antenal exam”
- BP
- void bladder and urine analysis
- general inspection
- Check for ankle oedema
- fundal height
- Foetal lie
- Foetal doppler
Vaginal examination
Definition of pre-eclampsia
Epidemiology, aetiology and risk factors for pre-eclampsia
Pathophysiology and types of pre-eclampsia
Clinical features of pre-eclampsia
Investigations for pre-eclampsia
Management of pre-eclampsia
Complications and prognosis of pre-eclampsia
Definition of eclampsia
Definition:
• Onset of convulsions during pregnancy or postpartum unrelated to other cerebral pathologies in women with pre-eclampsia
Epidemiology of eclampsia
Clinical features of eclampsia
Management of eclampsia
Definition of induction of labour
Definition:
- The planned initiation of labour prior to its spontaneous onset.
- It is an intervention designed to artificially initiate uterine contractions, resulting in progressive effacement and dilation of the cervix leading to birth of the baby
- It is performed when the benefits of delivery outweigh the risks of continuing the pregnancy
- Should be performed if the risk of the process to the mother and/or foetus is acceptable, otherwise proceed to a C-section
- Occurs in 1 in 5 deliveries
Aims for induction of labour
Aims:
- To stimulate regular uterine contractions
- To generate progressive cervical dilation
- To facilitate a subsequent vaginal delivery
Indication for Induction of Labour
Indication for IOL: “When the benefits of delivery outweigh the potential risks of continuing pregnancy”
- Prolonged pregnancy (post-date pregnancy) ** most common cause
- Foetal growth restriction
- Pre-eclampsia or other maternal HTN disorders
- Prelabour rupture of membranes
- Chorioamnionitis - inflammation of the foetal membranes
- Unexplained antepartum haemorrhage
- Maternal medical problems - diabetes or renal disease
- Logistics - distance from hospital
Contraindications for induction of labour
Contraindications:
- Placenta previa or Vasa previa (placental cord running close to the os)
- Transverse foetal lie
- Previous classical uterine incision
- Active genital herpes infection
- Pelvic structural abnormalities
Pre-induction of labour scoring system
Steps/Process involved in induction of labour
Complications and special cases in IOL
Questions
Definition of infertility
Epidemiology and risk factors for infertility
Epidemiology:
• Affects 1 in 12 couples
Risk Factors:
- Age > 35 years
- Hx of STIs
- Very high BMI
- Very low BMI
- Cigarette smoking ⁃ Related to accelerated menopause and decreased cilia function in uterine tubes
Aetiology of infertility
Pathophysiology of infertility
Fecundity to consider in infertility
History taking in infertility
Examination for infertility
Females:
⁃ General Exam
⁃ Pelvic Exam
⁃ Cervical Smear
⁃ Swabs as appropriate
Male:
⁃ General Exam
⁃ Testes, vas, varicocele
⁃ Prostate
Investigations for infertility
Management of infertility
Prognosis for infertility
Notes on IVF
Infertility advice for couples
Definition of labour
Foetal and maternal anatomy in labour
The process of labour
Mechanism of labour
Factors affecting the outcome of labour
Factors affecting the duration of labour
Management of labour
Investigations prior to hospital booking for antenatal care
Schedule of routine visits for normal antenatal care
Schedule of Routine Visits:
- 11-12 weeks - booking Hx by hospital staff
- 12-14 weeks - appointment with specialist & allocated a model of AN care
- 16-24 weeks - 4 weekly appointments
- 28-36 weeks - 2 weekly appointments
- 36+ weeks - weekly appointments
Checks on each visit for normal antenatal care
Dietary advice for normal antenatal care
Additional investigations in normal antenatal care
Post delivery date women in antenatal care
Ovarian cancer epidemiology and introduction
- Ovarian cancer is the 2nd most common gynaecological malignancy and the major cause of death from gynaecological cancers
- Mean age of presentation is 63 years
- Patients with early-stage ovarian cancer are asymptomatic or have vague/non-specific symptoms
- In late disease, patients present with abdominal pain or swelling
- Survival rates for ovarian cancer remains poor due to late presentation of the disease
Aetiology and risk factors for ovarian cancer
Symptoms of Ovarian cancer
Metastatic spread of ovarian cancer
Metastatic Spread:
- Direct: Spread to surrounding structures
- Lymphatic: Spread to the pelvic and para-aortic nodes is common
- Haematoganous: Distant mets are uncommon
Types of ovarian cancer
Staging of ovarian cancer
Staging:
- Stage 1: Growth limited to the ovaries -
- Stage 2: Growth involving one or both ovaries with pelvic extension
- Stage 3: Growth involving one or both ovaries with peritoneal implants outside the pelvis or positive retroperitoneal or inguinal nodes
- Stage 4: Growth with distant metastases
Investigations for ovarian cancer
Blood tests and markers for ovarian cancer
Management of ovarian cancer
Definition of pelvic mass
Definition:
- A mass arising from a pelvic organ
- May originate from female reproductive organs (ovaries, uterus) or other pelvic organs (bladder, rectum, blood vessels)
Clinical features of pelvic mass
Definition of pelvic organ prolapse
Epidemiology, risk factors and aetiology of pelvic organ prolapse
Pelvic anatomy and support in pelvic organ prolapse
3 levels of pelvic support:
- Level I has long mesenteric attachments (cardinal and uterosacral ligaments),
- Level II has more direct connections to the pelvic walls (e.g. paravaginal attachments),
- Level III has a direct fusion of the vagina with the levator ani muscles, perineal membrane and body
Cystocele types, grading and treatment in pelvic organ prolapse
Rectocele and Enterocele description and treatment in pelvic organ prolapse
Uterine and vaginal wall description and treatment in pelvic organ prolapse
Staging and clinical features of pelvic organ prolapse
Investigations and complications of pelvic organ prolapse
Perineal tears description
Risk factors for 3rd and 4th degree perineal tears
Risk Factors for 3rd and 4th Degree Tears:
- Birth weight > 4kg
- Persistant occipitoposterior position
- Nulliparity
- Induction of labour
- Epidural anaesthesia
- 2nd stage labour > 1 hour
- Shoulder dystocia
- Midline episiotomy
- Forceps delivery
Anatomy of perineum and classification of perineal tears
Description of an episiotomy in perineal tears
Perineal repair and prognosis
Definition of Polycystic Ovarian Syndrome
According to the Rotterdam consensus,1 polycystic ovarian syndrome (PCOS) is defined by the presence of two of three of the following criteria:
- oligo‐anovulation,
- hyperandrogenism and
polycystic ovaries (≥ 12 follicles measuring 2‐9 mm in diameter and/or an ovarian volume > 10 mL in at least one ovary).
Definition:
• Complex endocrine disorder characterised by hyper-androgenism, symptoms of hyper-androgenism, oligo/ anovulation, and polycycstic ovarian morphology on U/S
Epidemiology, risk factors and aetiology of polycystic ovarian syndrome
Pathophysiology of polycystic ovarian syndrome
Clinical features of polycystic ovarian syndrome
Investigations for polycystic ovarian syndrome
Differential diagnosis for polycystic ovarian syndrome
DDx:
- 21-hydroxylase deficiency - Leads to accumulation of androgen precursors
- Thyroid dysfunction - May lead to irregular menstruation but hyper-androgenism is absent
- Hyperprolactinaemia - May lead to infrequent or absent menses. Galactorrhoea is usually present
- Cushingʼs syndrome - Cortisol excess leading to obesity, HTN, hirsutism, acne and menstrual irregularities
- Androgen secreting neoplasms - Of the adrenal gland or ovaries
Diagnosis of polycystic ovarian syndrome
Diagnosis:
- Clinical features, elevated androgens and polycystic ovarian morphology on U/S
- NOTE: Up to 25% of women have polycystic ovarian morphology, but do not have PCOS without symptoms
Management of polycystic ovarian syndrome
Complications and prognosis of polycystic ovarian syndrome
Definition of post partum haemorrhage
Epidemiology of post partum haemorrhage
Aetiology of post partum haemorrhage
Antepartum risk factors for post partum haemorrhage
Intrapartum and post partum risk factors for post partum haemorrhage
Management of post partum haemorrhage
Reasons for foetal HR monitoring
CTG interpretations in foetal HR monitoring
Deceleration in detail on CTG for foetal HR monitoring
Management of Foetal HR in context of CTG readings
Interpret CTG
Interpret CTG
Interpret CTG
Interpret CTG
Interpret CTG
Interpret CTG
Interpret CTG
Interpret CTG
Interpret CTG
Definition of pre-term labour
Definition:
- Pre-term Labour = Labour that occurs between 20 weeks and 36 + 6 weeks
- Term Labour = Labour that occurs between 37 weeks and 41 + 6 weeks
Epidemiology of pre-term labour
Epidemiology:
- Leading cause of perinatal morbidity/mortality in developed countries
- Morbidity/mortality inversely proportional to gestational age
- Morbidity/mortality is uncommon > 32 weeks getation
- Incidence of 5-25%
- 12.7% in Australia with < 2% below 32 weeks
- Increasing incidence (IVF, multiple pregnancies, elective)
Aetiology of pre-term labour
Multifactorial:
⁃ 50% - Spontaneous
⁃ 30% - PPROM (Pre-term prelabour rupture of membranes) = Rupture of membranes < 37 weeks
⁃ 20% - Iatrogenic
⁃ < 1% - Cervical incompetence
Pathophysiology and classification of pre-term labour
- inflammation (infection or autoimmune)
- uterine stretch + cervical incompetence
- antepartum hemorrhage
- premature desidual activation
- social stress
- Genetics
Risk factors of pre-term labour
Clinical features of pre-term labour
Management of pre-term labour
Definition of rhesus haemolytic disease
Causes of foetal anaemia
Causes of Foetal Anaemia:
- Rhesus disease
- Transplacental viral infection (Parvovirus B16)
- Placental foetal vessel rupture
- Twin-twin transfusion
Epidemiology of Rhesus Haemolytic Disease
Aetiology of foetal haemolytic disease
Pathophysiology of foetal haemolytic disease
Signs of foetal aneamia
Signs of Foetal Anaemia:
- Polyhydramnios
- Enlarged foetal heart
- Ascites and pericardial effusion
- Hyperdynamic foetal circulation (detected on MCA flow doppler)
- Reduced foetal movements
- Abnormal CTG with reduced variability, eventually leading to a sinusoidal trace
Investigations for foetal haemolytic disease
Management of Foetal Haemolytic Disease
Complications and prognosis of foetal haemolytic disease
Red cell Antigens
Definition of twin gestation
Definition:
- Multiple Gestation: Consists of two or more foetuses (twins make up 99% of this)
- Monozygotic Twins: Arising from a single fertilised egg that divides
- Dizygotic Twins: Arising from two separately fertilised eggs
Epidemiology of twin gestation
Epidemiology:
- 1-2% of pregnancies have more than one foetus
- The chance of miscarriage, foetal abnormalities, poor growth, preterm delivery and intrauterine or neonatal death are considerably higher in twin than singleton pregnancies
- 2/3rds of twins are dizygotic (non-identical) & 1/3rd are monozygotic (identical)
- Incidence is on the rise
Risk factors of multiple gestations
Risk Factors for Multiple Gestations:
- Assisted reproduction techniques (ovulation induction and IVF)
- ↑Maternal Age (35-39 years)
- High parity
- Black race
- Maternal family Hx
Aetiology of twin gestation
Classification of multiple gestations
Types of twin gestation
Maternal physiological changes of twin gestation
Complications of twin gestation
Medical management of twin gestation
Twin to twin transfusion syndrome:
- Pathophysiology
- Management
- Complications
- Prognosis
Twin Reversed Arterial Perfusion sequence:
- Description
- Management
- Prognosis
Multifoetal reduction
Description/definition of vaginal cancer
The vagina is a muscular canal ~7.5cm long that extends from the vulva to the cervix
- Primary cancer of the vagina is one of the rarest gynaecological cancers (makes up around 2%)
- Most commonly diagnosed in women > 50 years who were exposed to the drug Diethylstilbestrol (DES) in the womb
- Symptoms include abnormal vaginal bleeding, postcoital bleeding, vaginal discharge & pelvic pain
- Most cases are detected in advanced stages and require radiation therapy or chemoradiation for treatment
Aetiology of vaginal cancer
Symptoms of vaginal cancer
Symptoms of Vaginal Cancer:
- Early stages are asymptomatic
- Painless vaginal bleeding not associated with menstruation
- Postcoital bleeding
- Smelly discharge
- Pain on urinating or passing bowel motions (may indicate local spread) • Constant pelvic pain
Metastatic spread of vaginal cancer
Risk factors for vaginal cancer
Risk Factors:
- Age - usually occurs in women > 50 years
- Previous Hx of gynaecological cancers
- Previous treatment of dysplastic cells
- HPV infection
- Smoking
- Prenatal exposure to DES
- Vaginal adenosis (almost all DES daughters have vaginal adenosis)
Types of vaginal cancers
Types of Vulval Cancers:
- Vaginal SCC - Accounts for 95%
- Vaginal Adenocarcinoma - most are clear-cell carcinomas arising from DES daughters
- Vaginal Melanoma - rare
- Vaginal Sarcoma - arising from connective tissue or muscle cells of the vagina (rare)
DES-related vaginal cancers
DES-related Vaginal Cancers:
- Diethylstilbestrol was used from 1938-1971 as a synthetic hormone that was mistakenly used to prevent miscarriage
- DES exposure in utero alters the shape of the cervix and uterus and up to 30% have vaginal adenosis
- There is a small risk (1 in 1000) of vaginal adenosis in DES-exposed women to develop into a clear-cell carcinoma of the vagina
- Mean age of diagnosis is 19 years
Investigations for vaginal cancer
Investigations:
- Colposcopy
- Biopsy and staging
- CXR, CT abdomen and pelvis or MRI/PET for mets
Treatment for vaginal cancer
Other complications of vaginal cancer
Other complications:
• Rectovaginal or vesicovaginal fistula formation, which can be hard to treat palliatively
Shoulder dystocia
