Obs-Gyn-Conditions Flashcards
Epidemiology of fatty liver of pregnancy
AFLP affects 1 in 7000 to 1 in 16,000 deliveries.
There is a predilection for nulliparous women and women with multiple gestations.
What is the prognosis / complications of endometrial polyp
0.5% contain adenocarcinoma cells
Frequently re-occur
(NB cervical usually don’t)
Untreated small polyps may regress
Increase the risk of miscarriage in IVF
May cause infertility if near Fallopian tubes
What are the three categories of excessive menorrhagia?
Endocrine Structural Pregnancy complication Infectious Haematological Physiological Iatrogenic Systemic disease
Ix for UTI in pregnancy
Urine dip - +ve nitrites, leucocytes, +/- blood
Urine culture
USS if pyelonephritis / blood cultures
What is considered prolonged phase 3 of labour?
Traditionally 30 mins
BUT
90% of placentas are delivered within 10 minutes and the risk of postpartum hemorrhage almost doubles by the time the duration of third stage reaches twenty minutes.
Prognosis of obstetric cholestasis
Mild disease
Prognosis is excellent. Most patients can attain a term delivery and complete resolution occurs within 24 to 48 hours in many cases. If prolonged >1 week, the patient should be evaluated for a retained placenta. Recurrence is expected in future pregnancies or with the use of oral contraceptives. All patients should be evaluated for hepatitis C if not already done. Although morbidity can be seen with mild disease, it is rare and no strategy to prevent fetal adverse outcome has been identified.
Severe disease
Most patients will attain gestational age 37 to 38 weeks as fetal demise or compromise is rare prior to term. Less than 10% will require premature delivery.
Define miscarriage
Miscarriage is an involuntary, spontaneous loss of a pregnancy before 24 completed weeks. After 24, the loss would be defined as a stillbirth. Miscarriage is associated with unprovoked vaginal bleeding with or without suprapubic pain.
Recognise the presenting symptoms/signs of dysfunctional uterine bleeding
uterine bleeding use of hormone therapy menstrual irregularity anaemia premenstrual molimina - Breast fullness and tenderness, weight gain, and mild mood swings are associated with ovulation.
Absence of these symptoms is suggestive of anovulatory DUB.
hirsutism, acne, acanthosis nigricans
A 61-year-old woman presents with 3 months of progressively worsening abdominal bloating and early satiety. She sought medical evaluation 2 months ago and was told she might have irritable bowel syndrome. On examination, the patient is in no acute distress. Her abdomen is dull to percussion and distended with minimal tenderness. A fluid wave is present. On pelvic examination, the cervix appears normal but is slightly deviated to the right. On bi-manual and recto-vaginal examination, a mass is palpable in the left adnexa extending down into the cul-de-sac.
Ovarian cancer
What is the epidemiology of toxic shock syndrome
Invasive infection complicates about one third of group A streptococcal infections, and it is estimated that there are 3.5 cases per 100,000 people.
People of all ages are affected and most do not have underlying diseases. [25] About 85% of invasive infections occur sporadically in the community, 10% are hospital acquired, 4% occur in residents of long-term care facilities, and 1% occur after contact with an infected person.
Most cases of staphylococcal TSS are due to methicillin-sensitive (MSSA) Staphylococcus aureus.
Non-menstrual cases now account for about 55% of all staphylococcal TSS.
A 42-year-old smoker presented to labour and delivery at 28 weeks of gestation with worsening abdominal pain of a few hours’ duration. She had also had some vaginal bleeding within the past hour. She was found to have low-amplitude, high-frequency uterine contractions, and the fetal heart rate tracing showed recurrent late decelerations and reduced variability. Her uterus was tender and firm to palpation.
Placental abruption
Define dysfunctional uterine bleeding
Dysfunctional uterine bleeding (DUB) is a common disorder of excessive uterine bleeding affecting pre-menopausal women that is not due to pregnancy or any recognisable uterine or systemic diseases. The underlying pathophysiology is believed to be due to ovarian hormonal dysfunction. However, the exact mechanisms remain unknown. DUB usually presents as heavy, prolonged, or frequent bleeding of uterine origin.
Sx of vulval cancer
Vulval lump Pruritus / irritation Pain (some tumours ulcerating) PM bleed Asymptomatic "cauliflower type growths" Skin thickening Most commonly labiamajora / clitoris Inguinal-femoral LNs Can be multifocal
Rx of polyhydramnios
Most cases of polyhydramnios respond in the first week of treatment with indomethacin. This approach appears to be highly effective (90-100% in some studies), provided that the cause is not hydrocephalus or a neuromuscular disorder that alters fetal swallowing.
_________________
Reductive amniocentesis may be performed and has contributed to prolonged pregnancy in patients who are severely affected by hydramnios.
This procedure can reduce the risk of preterm labor, premature rupture of the membrane (PROM), umbilical cord prolapse, and placental abruption. However, if too much fluid is removed, placental abruption may occur. Other risks of the procedure include infection, bleeding, and trauma to the fetus.
Laser ablation of placental vessels may be effective in cases of twin-to-twin transfusion syndrome, performed at highly specialized centers.
Patients with polyhydramnios tend to have a higher incidence of preterm labor secondary to overdistention of the uterus. Schedule weekly or twice weekly perinatal visits and cervical examinations.
Explain the aetiology of ectopic pregnancy
Two broad categories of conditions lead to ectopic pregnancy: 1) conditions that hamper the transport of a fertilised oocyte to the uterine cavity, and 2) conditions that predispose the embryo to premature implantation. However, more than half of diagnosed ectopic pregnancies are not associated with any known risk factors. Pelvic infection can increase risk by distorting fallopian tube anatomy. Factors associated with increased risk of ectopic pregnancy include smoking, multiple sexual partners, use of IUD, prior fallopian tube surgery, in utero diethylstilbestrol (DES) exposure, infertility and in vitro fertilisation, age <18 at first sexual intercourse, black race, and age >35 at presentation.
Define gestational hypertension
Defined by BP ≥140/90 mmHg on 2 occasions during pregnancy after 20 weeks’ gestation in a previously normotensive patient, without the presence of proteinuria (<300 mg in 24 hours).
What are the signs/symptoms of Rh incompatibility
RFs only
Identify appropriate investigations for diabetes in pregnancy and interpret the results
ORAL GLUCOSE TOLERANCE TEST
one-step test option: 75-gram oral glucose tolerance test (OGTT)
- Glucose level: ≥5.1 mmol/L (≥92 mg/dL) fasting; or ≥10.0 mmol/L (≥180 mg/dL) at 1 hour; or ≥8.5 mmol/L (≥153 mg/dL) at 2 hours
two-step test option: 1-hour 50-gram glucose load test (GLT), followed by 3-hour 100-gram OGTT
- ≥5.8 mmol/L (≥105 mg/dL) fasting; ≥10.6 mmol/L (≥190 mg/dL) at 1 hour; ≥9.2 mmol/L (≥165 mg/dL) at 2 hours; ≥8.0 mmol/L (≥145 mg/dL) at 3 hours.
fasting blood (plasma) glucose >7.0mmol/L random blood (plasma) glucose >11.1mmol/L
Summarise the prognosis for patients with ectopic pregnancy
With proper patient selection, expectant, medical, and surgical treatments are 82%, 90%, and 92% successful, respectively.
The rate of recurrent ectopic pregnancy is 5% to 20%, but it rises to >30% in women with two consecutive ectopic pregnancies.
The future fertility and tubal patency rates in laparoscopically treated patients are similar to those in the medically managed group. In women with a normal contralateral tube, salpingostomy does not appear to improve fertility prospects compared with salpingectomy.
Neither methotrexate nor salpingectomy affect subsequent ovarian response and pregnancy with IVF in women treated for ectopic pregnancy resulting from IVF.
Define cutaneous warts
Genital warts are the most prevalent form of viral genital mucosal lesions and are caused by infection with several types of human papillomavirus (HPV).
The infection manifests as verrucous fleshy papules that may coalesce into plaques. Lesion size ranges from a few millimetres to several centimetres.
The warts may be located anywhere in the anogenital or genital area, including on mucosal surfaces.
The colour can vary from whitish to flesh-coloured to hyperpigmented to erythematous.
They are generally asymptomatic, but may be painful, friable, or pruritic.
Define placenta praevia
Placenta praevia (PP) is defined as the placenta overlying the cervical os. It can be complete, partial, marginal, or low-lying. Partial, marginal, and low-lying PP may resolve as pregnancy progresses. In women with a scarred uterus (most commonly from a prior caesarean section), PP may be associated with an abnormally adherent placenta, where the placenta attaches to the myometrial layer of the uterus. Vasa praevia, where the fetal vessels lie over the internal cervical os, is an associated condition.
Define PROM
Breakage of the amniotic sac prior to labor
< 37w = PPROM
Recognise the presenting signs and symptoms of atrophic vaginitis
thinning of the vaginal walls
shortening and tightening of the vaginal canal
lack of vaginal moisture (vaginal dryness)
vaginal burning (inflammation)
spotting after intercourse
discomfort or pain during intercourse
pain or burning with urination
more frequent urinary tract infections
urinary incontinence (involuntary leakage)
Ix for PCOS
Serum total + free testosterone - High
DHEAS - High
Serum 17-hydroxyprogesterone - NORMAL (performed to rule out adult onset adrenal hyperplasia)
Serum prolactin - NORMAL (rule out prolactinoma)
Serum TSH - NORMAL (if high think hypothyroidism)
Check glucose tolerance
Fasting lipid panel - Dyslipidaemia frequently seen in PCOS
LH/FSH ratio >3 suggests PCOS
Pelvic USS - ≥12 follicles in each ovary measuring 2 to 9 mm in diameter, and/or increased ovarian volume (>10 mL) in either or both ovaries; endometrial lining >5 to 7 mm in thickness indicates endometrial thickening
What Ix should be performed for PROM
Symptoms
Speculum
Testing of fluid
What are the signs and symptoms of urinary incontinence in women
COMMON
Involuntary incontinence on effort/sneezing etc - stress incontinence
Involuntary incontinence preceded by urgency
Frequency
Bladder diary
Vaginal bulge/pressure - prolapse - stress incontinence
Urogenital atrophy
UNCOMMON
Hx cognitive impairment
Back injury
Dysuria
Urethral discharge or tenderness
What are the relevant Ix for menopause
Preg test - neg
FSH - elevated >30 IU/L (>30 mIU/mL)
Serum estradiol <110 -picomol/L (<30 picograms/mL)
(low because estrone becomes principle oestrogen)
Explain aetiology of cervical cancer & intraepithelial neoplasia
Human papillomavirus (HPV) is the most important aetiological factor, with most (99.7%) tumours containing HPV DNA.
HPV-16 and 18 are the 2 most common high-risk types detected in more than 70% of malignancies.
Peak infection incidence is in the late teens and early 20s, but in 80% of patients, the infection resolves within 12 to 18 months with a median duration of infection of roughly 8 months
- Squamous (80%)
- Adenocarcinomas (15%)
- Adenosquamous (3% to 5%)
Aetiology of mastitis / breast abscess
Mastitis may occur with or without infection. Infectious mastitis and breast abscess are usually caused by bacteria colonising the skin. Cases due to Staphylococcus aureus are by far the most common, followed by those due to coagulase-negative staphylococci. Methicillin-resistant S aureus is a growing problem and has been increasingly found in cases of mastitis and breast abscesses.
Non-infectious mastitis may result from underlying duct ectasia (peri-ductal mastitis or plasma cell mastitis) and infrequently foreign material (e.g., nipple piercing, breast implant, or silicone).
In lactational mastitis, milk stasis or milk overproduction, coupled with infection from bacteria entering the breast via a traumatised nipple (e.g., cracked or fissured) and/or from the infant’s mouth, can lead to mastitis.
In duct ectasia (dilated ducts associated with inflammation), the mammary duct-associated inflammatory disease sequence involves squamous metaplasia of lactiferous ducts. This causes blockage (obstructive mastopathy) with peri-ductal inflammation and possible duct rupture.
Left untreated, mastitis may cause tissue destruction resulting in an abscess.
NB tubercular possible
RFs of multiple pregnancy
Increased age
IVF
?FHx
List the RFs for Rh incompatibility
STRONG
Maternal RhD negative status Maternal sensitisation to RhS Invasive fetal procedures Placental trauma Abortion Multiparity Previous Hydrops (Rh incompatibility)
WEAK
External cephalic version
Molar pregnancy
Ectopic pregnancy
What is the aetiology of menopause
Women are born with a set number of oocytes. As this supply of oocytes becomes depleted during their early 40s, ovarian production of progesterone, estradiol, and testosterone begins to decline. Fertility also significantly declines.
Before the menopause, estradiol is the predominant oestrogen. Serum estradiol levels vary throughout the menstrual cycle but average about 367 picomol/L (100 picograms/mL). After the menopause, oestrone, which is derived from estradiol metabolism in the liver and peripheral conversion of androstenedione in adipose tissue, becomes the dominant oestrogen. Serum oestrone levels average about 110 to 184 picomol/L (30-50 picograms/mL). Symptoms of the menopause, such as hot flushes and urogenital atrophy, are closely related to decreasing estradiol levels.
Epidemiology of cardiac disease in pregnancy
Between 1997-9 only 35 deaths in UK from heart disease
10 from congenital
25 from acquired
1/3 of congenital were PHTN
7/25 of acquired were from puerperal cardiomyopathy
Older motherhood and lifestyle habits -> increasing IHD in pregnancy
A 22-year-old woman presents with postcoital bleeding, but denies any other symptoms. She is currently in a monogamous relationship with a male sexual partner. She is concerned that her partner may have had other sexual contacts. She currently uses oral contraception and does not use condoms. Her last sexual contact with her boyfriend was 8 days ago. On examination, her external genitalia are normal. Speculum examination reveals a mucopurulent discharge from the cervical os. The cervix is friable when scraped with a Dacron swab. Manual pelvic examination reveals no cervical motion tenderness. She has no other abnormalities on physical examination.
Genital tract chlamydia infection
What is the epidemiology of breech presentation
Breech presentation is common in early pregnancy and decreases with advancing gestational age, as most babies turn spontaneously to a cephalic presentation before birth. The prevalence at term in singleton pregnancies is 3% to 4% of all births. The prevalence prior to term at various gestations is as follows:
33% of births less than 28 weeks' gestation 14% of births at 29 to 32 weeks' gestation 9% of births at 33 to 36 weeks' gestation 6% of births at 37 to 40 weeks' gestation.
A 28-year-old G2P1 woman with a dichorionic twin gestation at 11 weeks presents to the emergency department with severe vomiting. She reports that she has experienced severe nausea and vomiting for 24 hours, and that during her previous pregnancy she also experienced severe morning sickness. On examination, the patient is afebrile, with a respiratory rate of 15 breaths/minute, pulse of 101 bpm, and BP of 127/85 mmHg. Urinalysis is positive for ketones.
Hyperemesis Gravidarum
Identify appropriate investigations for cutaneous warts and interpret the results
Clinical
Investigations to consider:
biopsy
anoscopy
urethroscopy
What are the signs/symptoms of gestational hypertension
Previously normotensive
BP 140/90mmHG after 2 readings 6+hrs apart
Measurement of diastolic BP during pregnancy should include K5 or the disappearance of the Korotkoff sound as opposed to K4 or the muffling of this sound.
Rx of LGA
Induction of labour for women with a baby with suspected macrosomia leads to babies being born at a lower birth weight, with fewer bone fractures and less shoulder dystocia, but could increase the number of women with perineal tears.
Predicting a baby’s weight can be inaccurate and women could be worried unnecessarily, and request their labour to be induced for no reason.
Doctors disagree whether women should be induced for suspected macrosomia and more research is needed to find out what this is best for women and their babies.
Aetiology of thyroid disease in pregnancy
Graves most common hyper
Hashimotos = most common hypo
Define ovarian cancer
Epithelial ovarian cancer is a relatively uncommon gynaecological cancer occurring when there is malignant transformation of the ovarian capsule epithelium. [1] The epithelium covering the ovary consists of the same epithelial cells that line the peritoneal cavity. Thus, epithelial ovarian cancer and primary peritoneal cancer occur via the same pathophysiology and are treated with the same basic principles. Sub-types of ovarian cancer include epithelial, germ cell, and sex-cord stromal tumours. The primary focus of this monograph will be the epithelial ovarian sub-type.
Describe the signs/symptoms of endometrial cancer
PM bleeding - 5-10% will have endometrial cancer
Uterine mass / adnexal
Abnormal menstruation
Aetiology of obstetric cholestasis
The aetiology is most likely multi-factorial with mutations in the canalicular phospholipid export pump MDR3
A large number of hepatobiliary disorders have been linked to these mutations, including familial intrahepatic cholestasis, adult biliary cirrhosis, and familial cholelithiasis.
Intrahepatic cholestasis caused by MDR3 mutations is typically associated with elevated gamma-glutamyl transferase (GGT) levels, which are encountered in up to 30% of pregnancies complicated by the disorder.
What is succenturiate placenta?
Where the placenta has 1 or more accessory lobes
Epidemiology of FGM
over 125 million women and girls in the 29 countries in Africa and the Middle East where the procedure is mainly practiced
What are the complications of Rh incompatibility
Hyperbilirubinaemia and kernicterus
Transfusion related fetal bradycardia
Fetal / neonatal hydrops
Neonatal anaemia - when haemoglobin falls <8 g/dL
Recognise the presenting symptoms of Asherman’s syndrome (Intrauterine adhesions)
An ovulatory woman who develops secondary amenorrhea or hypomenorrhea after an intrauterine procedure, particularly if the procedure was performed on a gravid uterus.
Sx Uterine bleeding Infertility Cyclical pelvic pain / dysmenorrhoea Recurrent pregnancy loss Incidental finding
Summarise the epidemiology of bacterial vaginosis
Vaginitis is the most common gynaecological diagnosis in the primary care setting. [2] Women presenting with vaginal discharge account for approximately 10 million clinic visits each year. In approximately 90% of affected patients in the US, this condition develops secondary to bacterial vaginosis, candidiasis, or trichomoniasis, of which bacterial vaginosis is the most common. [3]
What are the signs and symptoms of placental abruption
PV bleed (bleeding associated with abdominal pain, as compared with the painless bleeding of placenta praevia)
Abdo pain
Uterine contractions
Uterine tenderness - may feel hard, with the consistency of wood.
UNCOMMON
Lower back pain
Fetal death - common if 50% has detached
Define fibroids
Uterine fibroids (leiomyomata) are benign tumours of the uterus primarily composed of smooth muscle and fibrous connective tissue. They range in size from seedlings to large uterine tumours. Grossly, these tumours are round, firm, and well-circumscribed nodules located just under the uterine serosa (subserosal), within the myometrium (intramural) or just below the endometrium (submucosal). There are often multiple tumours in a single uterine specimen. Microscopically, these nodules are made up of spindle-shaped cells with no mitotic activity or remarkable nuclear atypia.
Discuss the management of cervical polyps
Removal by ring forceps
Laser or cauterisation
Abx if infected
Define pregnancy of unknown location
Pregnancy of unknown location (PUL) is the term used for a pregnancy where there is a positive pregnancy test but no pregnancy has been visualized using transvaginal ultrasonography
The true nature of the pregnancy can be an ongoing viable intrauterine pregnancy, a failed pregnancy, an ectopic pregnancy or rarely a persisting PUL.
Identify appropriate investigations for Asherman’s syndrome and interpret the results (Intrauterine adhesions)
Direct visualization of IUAs with hysteroscopy is the gold standard for the diagnosis
USS - thin endometrium
Estrogen/progestin withdrawal test takes too long.
Physical examination may show difficulty passing dilator
What are the relevant Ix for hyperemesis gravidarum
FBC - N
Metabolic panel - may show hypernatraemia + hypochloraemia
LFTs - N
Serum urea and Creatinine - Increased in hyperemesis
Serum TSH - may be decreased with hyperemesis
Urinalysis - ketonuria
Fetal USS - multiple gestation
Consider: Urine culture - N - to exclude pyelonephritis Serum amylase and lipase - N RUQ USS - N exclude gallstones etc Renal USS - N
What are the physiological causes of menorrhagia?
DUB
What is secondary amenorrhoea?
Lack of menses in a non-pregnant female for at least 3 cycles of her previous interval, or lack of menses for 6 months in a patient who was previously menstruating.
Discuss the aetiology of breech presentation
Aetiology is largely unknown. Factors that predispose pregnancies to breech presentation include preterm delivery, small for gestational age fetus, primiparity, congenital anomalies in the fetus, abnormal amniotic fluid volume, placental and uterine anomalies, and previous breech delivery. All these factors are associated with increased infant morbidity and mortality.
Frank
Baby’s buttocks lead the way into the birth canal
Hips are flexed, knees are extended, and the feet are in close proximity to the
65% to 70% of breech babies are in this
Complete
Baby presents with buttocks
Both the hips and the knees are flexed; the baby may be sitting cross-legged.
Incomplete or footling
One or both of the baby’s feet lie below the breech so that the foot or knee is lowermost in the birth
This is rare at term but relatively common with premature fetuses.
Discuss the management plan for gestational hypertension
<37w
1) Lifestyle modification
2) Methyldopa 250mg BD Oral
3) Labetalol 100mg BD orally
4) Nifedipine 30-60mg orally OD
> 37w
- induce labour if mild/mod
- REDUCE BP if >160/110mmHg
Aetiology of urogenital prolapse
Connective tissue defects
Levator ani + intact nerve supply required for function
Damaged through: birth, aging,
Congenital weaknesses (ie 2% of nulliparous still get)
Hysterectomy - with VVault
Anything causing raised intra-abdominal pressure - IE coughing/constipation
Generate a management plan for chlamydia
1g single dose azithromycin
Doxycycline
Erythromycin
Rx of thrush
- topical anti fungal eg clotrimazole
- fluconazole: 150 mg/dose orally as a single dose
COMPLICATED thrush
Complicated candidiasis refers to: non-albicans candidiasis, more than 4 episodes a year, and women with uncontrolled diabetes, debilitation, or immunosuppression.
1) fluconazole: 150 mg orally every 3 days for a total of 3 doses
Identify appropriate investigations a for bacterial vaginosis and interpret the results
vaginal pH
amine ‘whiff’ test of vaginal secretions
wet mount microscopy of vaginal secretions
Gram stain of vaginal secretions - reduced lactobacilli
HIV test
nucleic acid amplification test (NAAT) = chlam/gonorrhoea
VDRL = syphilis
serum rapid plasma reagin (RPR) test = syphilis
culture of vaginal secretions = trichomoniasis 3 day growth
Summarise the epidemiology of molar pregnancies
1 in 1000 to 1200 pregnancies
Patients with a previous diagnosis of hydatidiform mole have a 1% to 2% chance of molar gestation in subsequent pregnancies.
Among women over 35 years of age, there is a significantly higher chance of GTD, which increases progressively as maternal age advances
Aetiology of PCOS
The aetiology of PCOS is unknown. It is a syndrome wherein multiple systems are affected and the site of the primary defect is unclear. Various lines of evidence have supported primary defects in the hypothalamic-pituitary axis, postulating increased amplitude and frequency of pulses of LH, or defects involving the ovaries through an intrinsic problem leading to androgen over-production. Some theories postulate defects in insulin sensitivity with insulin resistance leading to compensatory hyper-insulinaemia.
Define premature labour
There is no internationally recognised definition of premature labour. Preterm birth occurs between 24 and 37 weeks’ gestation. In two-thirds of cases it occurs following spontaneous onset of labour. Only a minority of women who present with preterm contractions known as threatened premature labour (TPTL) progress to actual labour and delivery. The remainder of preterm birth is due to iatrogenic delivery, most commonly because of pre-eclampsia and intrauterine growth restriction. Preterm premature rupture of membranes (PPROM) is defined as the rupture of membranes at <37 weeks’ gestation and prior to the onset of labour.
Epidemiology of urogenital prolapse
41-50% over 40
10% risk of needing an operation for prolapse
What is the epidemiology of epilepsy in pregnancy
1 in 200 women of childbearing age
Epidemiology of thromboembolism in pregnancy
Risk of DVT/PE highest during pregnancy (in healthy women).
1 in 1000 pregnancies DVT
1 in 7000 pregnancies PE
10% of maternal deaths = PE
Discuss the prognosis of syphilis infection
Natural course of infection
Treatment is curative once antibiotic treatment is completed. However, re-infection may occur if there is further exposure to syphilis.
The natural course of organ-specific involvement is determined by the stage of syphilis at diagnosis and whether appropriate treatment has been administered. Follow-up of organ-specific complications requires specialist opinion (e.g., cardiology assessment of aortic regurgitation; neurology assessment of tabes dorsalis).
What are the relevant Ix for placental abruption
Fetal CTG - abnormalities in the tracing that suggest an abruption: late decelerations, loss of variability, variable decelerations, a sinusoidal fetal heart rate tracing, and fetal bradycardia, defined as a persistent fetal heart rate below 110 beats per minute
Hb + Hct - N/L
Coag studies - abnormal
K-B test for Rh+
USS - retroplacental haematoma (hyperechoic, isoechoic, hypoechoic); pre-placental haematoma (jiggling appearance with a shimmering effect of the chorionic plate with fetal movement); increased placental thickness and echogenicity; sub-chorionic collection or marginal collection
A 32-year-old woman presents to the emergency department with complaints of fever, chills, headache, muscle aches, and shortness of breath over the past 48 hours. Two weeks before her symptoms, she had an uncomplicated vaginal delivery at term. She has no significant past medical history. No one else at home has been sick recently or travelled outside the country. On physical examination, she is toxic appearing with a temperature of 39.5°C (103.1°F). Her pulse rate is 132 bpm and her BP is 100/60 mmHg with a respiratory rate of 34 breaths/minute. A diffuse erythematous rash is noted on the upper and lower extremities. Breath sounds are diminished at the bases. The rest of the examination is non-contributory.
Toxic shock syndrome
Recognise the presenting symptoms of asthma in pregnancy
presence of risk factors recent upper respiratory tract infection dyspnoea cough expiratory wheezes nasal polyposis
RFs
FHx
allergens
atopic history
nasal polyposis
obesity
gastro-oesophageal reflux
Complications/prognosis of substance abuse in pregnancy
Neonatal withdrawal syndrome occurs in 60% of all fetuses exposed to drugs.
In particular, the incidence of premature delivery, abruptio placentae, breech presentation, and intrauterine growth retardation are significantly increased in mothers who are dependent on drugs.
In particular, cocaine use, with its vasoconstrictive properties, has been associated with an increase in vaginal bleeding, abruptio placentae, placenta previa, premature rupture of membranes, abortion, pneumothorax, pneumonia, malnutrition, and seizures.
Opioid use has been shown to increase the rate of premature labor, premature rupture of membranes, breech presentation, antepartum hemorrhage, toxemia, anemia, uterine irritability, and infection (eg, HIV, hepatitis, syphilis).
Alcohol use has been associated with an increased rate of abruptio placentae. Complications for mothers who drink alcohol heavily can include increased spontaneous abortions and premature placental separation.
Cognitive and developmental defects for most
Discuss the RFs of epilepsy in pregnancy
febrile seizure head trauma CNS infection stroke brain tumour mental retardation (MR) and/or cerebral palsy dementia FHx of seizures vascular malformations
A 32-year-old women presents with a chief complaint of difficulty becoming pregnant. She was prescribed oral contraceptives at the age of 17 years because of irregular periods (4 to 6 periods per year). She continued with oral contraception until 30 years of age, at which point she and her husband decided they wanted to have a baby. Since ceasing oral contraception, she has gained weight and has only 3 to 5 periods per year. She has actively been trying to conceive, with no results.
PCOS
Generate a management plan for epilepsy in pregnancy
Aim is to have the lowest possible dose of antiepileptic medication
Sodium valproate - PARTICULARLY teratogenic - therefore CAUTION (consider swapping another medication)
Lamotrigine - SAFEST
Carbamazepine
Lacosamide
A 58-year-old obese post-menopausal woman (gravida 4, para 3) presents to her annual gynaecological visit without initial complaint. During the interview, she denies post-menopausal bleeding but acknowledges increased abdominal bloating and early satiety. Over the past year, she has experienced pelvic and low back pain that is mildly bothersome but worsening. Her family history is notable for a sister with breast cancer and mother with an unknown female cancer. Abdominal examination is non-diagnostic due to her body habitus, and pelvic examination is limited. There is concern for a vague fullness that is appreciated on rectovaginal examination.
Ovarian Cyst
A 30-year-old woman, gravida 2 para 1, at 22 weeks’ gestation presents to the outpatient obstetrics clinic for a routine antenatal visit. She has no significant past medical history. Her first pregnancy was uncomplicated and her child (now 4 years of age) is doing well. On examination, she is afebrile with a respiratory rate of 16 breaths per minute, pulse of 91 bpm, and blood pressure (BP) of 132/102 mmHg. Her previous BP reading was 120/80 mmHg. Urinalysis is negative for glucose and protein. The patient is asked to return in 1 week for a BP check. On check-in at the clinic, the patient tells the nurse that she does not have any symptoms. However, on examination, her BP has risen to 142/106 mmHg. Urinalysis remains negative for glucose and protein.
gestational HTN
Prognosis / complications of FGM
Early post-procedure complications thus include hemorrhage, infection, oliguria, and sepsis
The most common long-term complications are dysmenorrhea, dyspareunia, and chronic vaginal infections. Other complications are related to voiding
Summarise the indications for external cephalic version
Breech presentation after 36/37 weeks.
What is the epidemiology of placental abruption
Placental abruption complicates about 0.3% to 1% of births.
The incidence has risen more in black women than in white women.
Discuss the prognosis of ovarian cancer
The majority of patients (70% to 80%) will achieve a complete clinical remission after first-line therapy for ovarian cancer (debulking surgery followed by chemotherapy). When patients relapse, the most important prognostic factor is the treatment-free interval or time from completion of first-line therapy to diagnosis of recurrence. For patients with platinum-resistant or refractory disease, the overall prognosis is grim, as the likelihood of responding to second-line agents is estimated between 15% to 20%. For patients who have recurrent disease that is platinum sensitive, response rates for second-line therapy improve as the treatment-free interval increases.
Rx of vulval cancer
Excision of primary sites + LNs
Clear margins of 1-2cm
Positive modes -> radiotherapy
+/- chemotherapy
May need radical vulvectomy
Sx of cardiac disease in pregnancy
LVF -> pulmonary oedema, leg oedema
RVF -> JVP, fluid retention, orthopnoea, coughing, wheezing
What is the epidemiology of premature labour
In the UK in 2014, the percentage of births before 37 weeks’ gestation ranged from 6.4% to 9.9% of live births, depending on ethnicity.
Only 1% of all births occur below 32 weeks’ gestation. Mortality and serious morbidity are uncommon above 32 weeks’ gestation, although more subtle long-term effects, such as behavioural problems during childhood, still occur with later gestations.
The economic and psychological burdens on society are considerable. The estimated cost to the US is $26.2 billion per year.
Describe the pain control management of labour?
Pain control
Agents given in intermittent doses for systemic pain control include the following [4] :
Meperidine, 25-50 mg IV every 1-2 hours or 50-100 mg IM every 2-4 hours
Fentanyl, 50-100 mcg IV every hour
Nalbuphine, 10 mg IV or IM every 3 hours
Butorphanol, 1-2 mg IV or IM every 4 hours
Morphine, 2-5 mg IV or 10 mg IM every 4 hours
As an alternative, regional anesthesia may be given. Anesthesia options include the following:
Epidural
Spinal
Combined spinal-epidural
List the Ix for fibroids
USS
Endometrial biopsy - N
Consider Sonohysterography Hysteroscopy MRI Laparoscopy
What are the RFs for syphilis infection
Sexual contact with infected MSM Drug use Commercial sex Multiple partners HIV/other STDs Syphillis during pregnancy
What are the RFs for toxic shock syndrome
STRONG DM Alcoholism Minor trauma/injuries with bruising Surgical procedures Single tampon use Highly absorbent tampons
WEAK
NSAID
Contraceptive sponges
Untreated strep throat
Define chlamydia
Urogenital chlamydia infection is a common STD worldwide. The causative organism is Chlamydia trachomatis. Infection is usually asymptomatic in both men and women.
Summarise the epidemiology of dysfunctional uterine bleeding
Abnormal uterine bleeding (AUB) that is not related to pregnancy is believed to occur in more than half of all women at least once during their reproductive age period. DUB is a diagnosis of exclusion that is encountered in almost half of the occasions of AUB.
Ix for obesity in pregnancy
US scans are more difficult
Anaesthesia Spinal/epi challenges
Higher incidence of post-partum depression
Oralcontraception is more likely to fail
Sx of vasa praevia
Vasa previa is diagnosed prenatally with an average sensitivity of 93% and a specificity of 99%.
AT DELIVERY:
PV bleed
Sinusoidal fetal heart pattern, fetal bradycardia, or fetal heart rate decelerations during labor may all indicate a ruptured vasa previa
What are the complications of menopause?
Hormone-therapy related SEs: Vaginal bleeding Breast tenderness VTE Breast cancer Stroke
UTIs?
Complications of polyhydramnios
Polyhydramnios (amniotic fluid index [AFI] >24 cm) is associated with an increased rate of fetal malformations, genetic syndromes, neurologic disorders, and developmental delay, conditions that may only be diagnosed postnatally.
Other complications include premature rupture of the membranes (PROM), abruptio placenta, malpresentation, and postpartum hemorrhage
20% of cases of polyhydramnios involved associated fetal anomalies, including problems of the gastrointestinal system (40%), central nervous system (26%), cardiovascular system (22%), or genitourinary system (13%).
Risks and complications of amnioinfusion include amniotic fluid embolism, maternal respiratory distress, increased maternal uterine tone, and transient fetal respiratory distress. An increase in the risk of maternal or fetal infection is not substantiated.
Risks of amniocentesis include fetal loss (1-2%). Other complications are placental abruption, preterm labor, fetal-maternal hemorrhage, maternal Rh sensitization, and fetal pneumothorax. The risk of fetal infection is slightly increased.
Describe the signs/symptoms of hyperemesis gravidarum
RFs 1st trimester WL >5% Absence of thyroid enlargement Absence of CNS signs Dry Mucous Membranes Dizziness Tachycardia Hypotension Ketotic breath
What are the complications of placental abruption
Hypovolaemic shock DIC Surgical/anaesthetic risks IUGR Neurological infant impairment Preterm birth Perinatal death Acute RF
Epidemiology of oligohydramnios
11% pregnancies
What are the complications/prognosis of gestational hypertension
Pre-eclampsia
CVD for mother later in life
Fetal/neonatal complications - increases the risk of macrosomia, caesarean delivery, and admission of the neonate to the intensive care unit.
Mean gestational age and mean birth weight tend to be lower.
List RFs for molar pregnancy
STRONG
Extremes of maternal age
Prior GTD (10x risk)
WEAK
Summarise the prognosis for patients with fibroids
On cessation of medical therapy, regrowth of fibroids to pretreatment size occurs relatively quickly (within 12 weeks in the case of GnRH agonists, for example) and symptoms return.
Uterine-sparing surgeries such as myomectomy and uterine artery embolisation have been shown to be effective in treating fibroid-related symptoms such as menorrhagia and those related to uterine bulk. In a collection of 5 studies involving 285 patients undergoing myomectomy for menorrhagia, 81% showed reduction or complete resolution of heavy bleeding following surgery.
Unfortunately, there is some risk of recurrence of fibroids (up to 25%), which does not vary by type of surgery.
Describe management of the 3rd stage of labour?
The labor process has now entered the third stage, ie, delivery of the placenta. Three classic signs indicate that the placenta has separated from the uterus: (1) The uterus contracts and rises, (2) the cord suddenly lengthens, and (3) a gush of blood occurs.
Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus, but it is considered normal up to 30 minutes after delivery of the fetus. Excessive traction should not be applied to the cord to avoid inverting the uterus, which can cause severe postpartum hemorrhage and is an obstetric emergency. The placenta can also be manually separated by passing a hand between the placenta and uterine wall. After the placenta is delivered, inspect it for completeness and for the presence of 1 umbilical vein and 2 umbilical arteries. Oxytocin can be administered throughout the third stage to facilitate placental separation by inducing uterine contractions and to decrease bleeding.
Expectant management of the third stage involves allowing the placenta to deliver spontaneously, whereas active management involves administration of uterotonic agent (usually oxytocin, an ergot alkaloid, or prostaglandins) before the placenta is delivered. This is done with early clamping and cutting of the cord and with controlled traction on the cord while placental separation and delivery are awaited.
A review of 5 randomized trials comparing active versus expectant management of the third stage demonstrated that active management was associated with lowered risks of maternal blood loss, postpartum hemorrhage, and prolongation of the third stage, but it increased maternal nausea, vomiting, and blood pressure (when ergometrine was used).
After the placenta is delivered, the labor and delivery period is complete. Palpate the patient’s abdomen to confirm reduction in the size of the uterus and its firmness. Ongoing blood loss and a boggy uterus suggest uterine atony. A thorough examination of the birth canal, including the cervix and the vagina, the perineum, and the distal rectum, is warranted, and repair of episiotomy or perineal/vaginal lacerations should be carried out.
What systemic diseases could cause excessive menorrhagia?
Chronic renal and liver disease
Discuss the aetiology of cervical polyps
Believed to be due to inflammation of the cervix
May be due to raised oestrogen
or clogged cervical blood vessels
Epidemiology of PCOS
6-8% of women
PCOS accounts for 80% to 90% of cases of hyper-androgenism in women
Rx of multiple pregnancy
Multifetal reduction possible (postassium chloride injected into selected fetus) - Multifetal reduction in a monochorionic twin setting is typically not recommended due to unknown effects on the remaining twin.
Increased nutrition needed.
Monochorionic - US scans every 2w to detect TTTS
Dichorionic - 4-6weekly
Uncomplicated dichorionic, diamniotic twin gestation- 38 weeks
Uncomplicated monochorionic, diamniotic twin gestation- between 34-37 6/7 weeks
Uncomplicated monochorionic, monoamniotic twin gestations- 32-34 weeks
Trial labour allowed
Breeched second baby > ECV
Dependent on confidence of obstetrician
Recognise the presenting signs/symptoms of diabetes in pregnancy
presence of risk factors
elevated BMI
fetal macrosomia
polyuria
polydipsia
glycosuria
UTIs
Epidemiology of thyroid disease in pregnancy
Throtoxicosis / hyperthyroid = 2-17% of pregancies
Graves = most common.
Hashimotos = most common hypo
2-10 per 1000 pregnancies = hypothyroid
Define premenstrual syndrome
PMS is characterised by cyclical, physical, and behavioural symptoms occurring in the luteal phase of the normal menstrual cycle (the time between ovulation and onset of menstruation).
Symptoms must not be present at other times through the cycle, must also cause significant impairment, and must not represent an exacerbation of another disorder, and at least one symptom-free week must be present.
Define amniotic fluid embolism
Amniotic fluid embolism syndrome (AFES) is a rare but catastrophic condition that occurs when amniotic fluid enters the maternal circulation.
Acute pulmonary hypertension and rapid right ventricular failure ensue (usually lasting 15 to 30 minutes) followed by left ventricular dysfunction; hypoxemic respiratory failure and cardiovascular collapse quickly ensue and culminate in systemic inflammation and noncardiogenic pulmonary edema.
Discuss the Sx of endometrial polyps
Usually none Irregular MB IMB Menorrhagia PMB If polyp protrudes through cervix -> dispareunia/dysmenorrhoa
What is the epidemiology of PPH?
Incidence 5% deliveries in developed world
<38% in developing countries - maj cause maternal mortality
What position should the mother be in labour?
Supine with her knees bent (ie, dorsal lithotomy position; the usual choice)
Lateral (Sims) position
Partial sitting or squatting position
On her hands and knees
Spindle-shaped cells with no mitotic activity or remarkable nuclear atypia
Fibroid
Explain the aetiology of chlamydia
Infections are caused by the bacterium Chlamydia trachomatis , which is almost always transmitted by sexual contact, and it is one of the most commonly reported sexually transmitted infections. The bacterium may cause symptoms, but in most people the infection is asymptomatic.
Discuss the complications of toxic shock syndrome
Bacteraemia ARDS DIC RF Wound sequela Neuropsychiatric sequelae
What is the epidemiology of endometrial polyps
Pedunculated > sessile
40s-50s peak
10% of women
Present in 25% of women with abnormal bleeding
Aetiology of vulval cancer
Squamous cell cancers of skin
Femoral+inguinal LN involvement eventually -> before lung / liver
HPV related = young
Non- HPV = old - associated with VIN or lichen sclerosis
Summarise the prognosis for patients with endometriosis
Often long period before diagnosis
Positive association with 2+3rd trimester complications
Define molar pregnancy
Hydatidiform moles are chromosomally abnormal pregnancies that have the potential to become malignant (gestational trophoblastic neoplasia). Gestational trophoblastic disease includes tumours of fetal tissues, including hydatidiform moles, arising from placental trophoblasts. Syncytiotrophoblasts secrete human chorionic gonadotrophin and, therefore, this hormonal product is used as a tumour marker for the disease.
Sx of infertility in women
RFs Hx pelvic surgery Irregular cycles Hirsituism ACNE Palpable uterine abnormalities Adnexal abnormalities
UNCOMMON
Galactorrhoea
Dyspareunia - could indicate adhesions/endometriosis
Cul-de-sac abnormalities
Generate a management plan for placental abruption
Unstable fetus / mother
- Deliver
- Corticosteroids if <34w
- Post op uterotonic
- haemostatic preparations post op
Define hyperemesis gravidarum
Nausea and vomiting in pregnancy (NVP), commonly referred to as morning sickness, typically begins between the fourth and seventh week after the last menstrual period. It is characterised by nausea and vomiting that occur more frequently during the morning hours, and typically resolves in the second trimester. Hyperemesis gravidarum is the most severe form of NVP and is characterised by persistent vomiting, volume depletion, ketosis, electrolyte disturbances, and weight loss.
Assessment of vaginal bleeding
List causes of vaginal bleeding during reproductive ages?
Uterine fibroids Hypotheroidism Endometritis DUB - exclusion PCOS Cervical/endometrial carcinoma/polyp Leiomyomas (fibroid) Cervicitis Adenomyosis
POST COITAL
- Cancers / polyps / ectropion
SYSTEMIC
- liver disease
- RF
- Clotting disorders
Pharmacological/iatrogenic
Describe management of the 3rd stage of labour?
The labor process has now entered the third stage, ie, delivery of the placenta. Three classic signs indicate that the placenta has separated from the uterus: (1) The uterus contracts and rises, (2) the cord suddenly lengthens, and (3) a gush of blood occurs.
Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus, but it is considered normal up to 30 minutes after delivery of the fetus. Excessive traction should not be applied to the cord to avoid inverting the uterus, which can cause severe postpartum hemorrhage and is an obstetric emergency. The placenta can also be manually separated by passing a hand between the placenta and uterine wall. After the placenta is delivered, inspect it for completeness and for the presence of 1 umbilical vein and 2 umbilical arteries. Oxytocin can be administered throughout the third stage to facilitate placental separation by inducing uterine contractions and to decrease bleeding.
Expectant management of the third stage involves allowing the placenta to deliver spontaneously, whereas active management involves administration of uterotonic agent (usually oxytocin, an ergot alkaloid, or prostaglandins) before the placenta is delivered. This is done with early clamping and cutting of the cord and with controlled traction on the cord while placental separation and delivery are awaited.
A review of 5 randomized trials comparing active versus expectant management of the third stage demonstrated that active management was associated with lowered risks of maternal blood loss, postpartum hemorrhage, and prolongation of the third stage, but it increased maternal nausea, vomiting, and blood pressure (when ergometrine was used).
After the placenta is delivered, the labor and delivery period is complete. Palpate the patient’s abdomen to confirm reduction in the size of the uterus and its firmness. Ongoing blood loss and a boggy uterus suggest uterine atony. A thorough examination of the birth canal, including the cervix and the vagina, the perineum, and the distal rectum, is warranted, and repair of episiotomy or perineal/vaginal lacerations should be carried out.
What are the relevant Ix for epilepsy in pregnancy
Aim is to have the lowest possible dose of antiepileptic medication
Prognosis of PCOS
PCOS is a chronic condition. There is no cure. Thus, management options are targeted at alleviating the signs and symptoms to reduce morbidity. Another goal of treatment is to prevent the development of complications such as type 2 diabetes. There have been no clinical trials demonstrating the efficacy of any agent in terms of preventing complications. Many experts believe that weight loss and metformin may prevent diabetes and atherosclerosis.
In PCOS, therapy is generally continued throughout the reproductive years. If treatments are stopped during that time, symptoms generally recur. Once a women with PCOS reaches menopause, hyper-androgenic manifestations may improve as ovarian function declines, allowing withdrawal of therapies directed against hyper-androgenism.
Describe the RFs for pelvic inflammatory disease
STRONG Prev chalmidya / gonorrhoea Young age at onset of sexual activity Unprotected intercourse with multiple partners Hx PID IUD use
WEAK Smoking Low socioeconomic status Vaginal douching Intercourse during menstruation
Epidemiology of LGA
1 out of 10 women
1 in 3 Americans
Sx of obesity in pregnancy
BMI >30
Describe the prognosis of toxic shock syndrome
Mortality ranging from 30% to 85% has been reported for streptococcal toxic shock syndrome (TSS), despite prompt antibiotic therapy.
Shock is the most important predictor of death. Advanced age, hypotension, and multi-organ system failure are significantly associated with increased mortality.
Mortality for menstrual cases is now 1.8% compared with 6% mortality associated with non-menstrual cases.
Discuss the aetiology syphilis infection
Syphilis is caused by Treponema pallidum subspecies pallidum , a motile spirochaete bacterium. Although often described as spiral or coiled, high-resolution time-lapse microscopy has confirmed earlier reports that T pallidum has a flat-wave morphology. Humans are its only natural host. In-vitro culture is not possible. Entry of T pallidum probably occurs via the lesions of primary and secondary syphilis through areas of minor abrasion as a result of sexual intercourse at genital and mucous membrane sites. Oro-genital sex is an important route of transmission and, therefore, transmission can occur despite the use of condoms for penetrative sex. Other modes of transmission are blood transfusion and transplacental transmission from mother to fetus.
Describe the Sx of labour
Frequency and time of onset of contractions
Status of the amniotic membranes (whether spontaneous rupture of the membranes has occurred, and if so, whether the amniotic fluid is clear or meconium stained)
Fetal movements
Presence or absence of vaginal bleeding.
Braxton-Hicks contractions must be differentiated from true contractions. Typical features of Braxton-Hicks contractions are as follows:
Usually occur no more often than once or twice per hour, and often just a few times per day
Irregular and do not increase in frequency with increasing intensity
Resolve with ambulation or a change in activity
Contractions that lead to labor have the following characteristics:
May start as infrequently as every 10-15 minutes, but usually accelerate over time, increasing to contractions that occur every 2-3 minutes
Tend to last longer and are more intense than Braxton-Hicks contractions
Lead to cervical change
The physical examination should include documentation of the following:
Maternal vital signs
Fetal presentation
Assessment of fetal well-being
Frequency, duration, and intensity of uterine contractions
Abdominal examination with Leopold maneuvers
Pelvic examination with sterile gloves
Digital examination allows the clinician to determine the following aspects of the cervix:
Degree of dilatation, which ranges from 0 cm (closed or fingertip) to 10 cm (complete or fully dilated)
Effacement (assessment of the cervical length, which can be reported as a percentage of the normal 3- to 4-cm–long cervix or described as the actual cervical length)
Position (ie, anterior or posterior)
Consistency (ie, soft or firm)
Fatal heart rate assessed constantly via CTG
A 25-year-old pregnant woman presents for her routine antenatal visit. She is at 32 weeks’ gestation and reports no symptoms. On examination, her BP is 145/95 mmHg and urinalysis reveals proteinuria (2+). She is referred to the antenatal day unit where a quantitative protein measurement of 1.5 g/24 hours is confirmed. Further laboratory tests reveal elevated liver enzymes; however, platelets and all other tests are normal.
Pre-eclampsia
What are the Aetiology / RFs for gonorrhoea infection
STRONG Age 15-29 MSM Black ancestry Current prior Hx of STI Multiple recent sexual partners Inconsistent condom use RFs of partner Hx sexual/physical abuse
WEAK
Substance use
Past incarceration
Generate a management plan for dysfunctional uterine bleeding
Progestogens - medroxyprogesterone/norethisterone
Intrauterine progesterone device
A 62-year-old woman with poor access to health care presents with low energy, weight loss, and pelvic pain with an exophytic mass on pelvic exam and renal failure.
Cervical cancer
Summarise the epidemiology of atrophic vaginitis
An estimated 10 to 40 percent of postmenopausal women have symptoms of atrophic vaginitis
Define fatty liver of pregnancy
Acute fatty liver of pregnancy (AFLP) is a serious complication unique to pregnancy, characterized by microvesicular steatosis in the liver. The foremost cause of AFLP is thought to be due to a mitochondrial dysfunction in the oxidation of fatty acids leading to an accumulation in hepatocytes. The infiltration of fatty acids causes acute liver insufficiency, which leads to most of the symptoms that present in this condition. If not diagnosed and treated promptly, AFLP can result in high maternal and neonatal morbidity and mortality.
Rx of pregnancy of unknown location
Treatment should only be considered when a potentially viable intrauterine pregnancy has been definitively excluded
A treated persistent PUL is defined as one managed medically (generally with methotrexate) without confirmation of the location of the pregnancy such as by ultrasound, laparoscopy or uterine evacuation
A resolved persistent PUL is defined as serum hCG reaching a non-pregnant value (generally less than 5 IU/l) after expectant management, or after uterine evacuation without evidence of chorionic villi on histopathological examination
Identify appropriate investigations for ectopic pregnancy and interpret the results
Preg test - Positive
TVUS - determines location - “Donut” sign OR “Ring of fire” - increased blood flow with doppler
AbdoUSS - Less sensitivity that TVUS
Serum HCG - <53% increase in level over 48 hours or plateau of level
Uterine aspiration - intrauterine chorionic villi absent
What are the RFs for cervical polyps
Post-menarche
Pre-menopausal
Pregnancy
A 30-year-old woman with a history of mastitis presents with sharp shooting breast pain and an exquisitely tender, swollen, red, and warm fluctuant peri-areolar breast mass.
Breast abscess
What is the epidemiology of premenstrual syndrome
Clinically significant PMS is thought to affect 3% to 8% of women, with a point prevalence of 20% to 30% in some studies. Rates of PMDD are estimated to be between 1.2% and 10%.
W>B
Define epilepsy in pregnancy
A seizure is defined as “a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain”. Epilepsy is considered to be a disease of the brain defined by any of the following conditions:
At least 2 unprovoked (or reflex) seizures occurring more than 24 hours apart
One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after 2 unprovoked seizures, occurring over the next 10 years
Diagnosis of an epilepsy syndrome.
Epileptic seizures may be classified as focal, generalised, or unknown onset, with subcategories of motor, non-motor (absence), with retained or impaired awareness for focal seizures.
Discuss the aetiology of premenstrual syndrome
PMS and PMDD occur in women with ovulatory cycles, and they do not occur before puberty or after menopause. This association implies a role of gonadal steroid hormones. Absence of PMS/PMDD during pregnancy (in addition to supporting evidence) suggests that changing levels of gonadal steroid hormones play a role in PMS/PMDD.
Ix for mastitis / breast abscess
Breast US - if any pointer to abscess
Needle aspiration - purulent fluid indicates a breast abscess
Cytology of FNA
Milk, aspirate, discharge, or biopsy tissue for culture and sensitivity - +ve culture indicates infection
CAN DO PUNCH BIOPSY IF FEAR TB
If indication of systemic infection - perform blood cultures + FBC
Recognise the presenting symptoms/signs of cutaneous warts
presence of risk factors
female aged 19-22
male aged 22-26
sessile exophytic papillomas
asymptomatic
pruritus
bleeding
pain
Ix for vulval cancer
Biopsy
Staging
Describe the relevant Ix for Rh incompatibility
Maternal blood type - Rh -ve
Maternal serum AB Rh screen - +ve
Consider fetal/paternal blood typing
Consider USS - may show subcutaneous oedema, ascites, pleural effusion, or pericardial effusion if untreated
Doppler in MCA can predict anaemia in fetus if elevated ≥1.5 MoM
Aetiology of subfertilty in men
There is no formal classification of male infertility. It may be categorised according to aetiology:
Primary spermatic failure
Genetic disorders of infertility
Obstructive azoospermia
Varicocele
Hypogonadism
Cryptorchidism
Idiopathic
Male contraception
Male accessory gland infections
Germ cell malignancies and testicular microcalcifications
Disorders of ejaculation.
Factors that alter spermatogenesis through low testosterone levels include obesity, endocrinopathies, and exposure to medicine or environmental toxins.
Other factors that have a direct deleterious effect on spermatogenesis include varicocele, increased scrotal heat, systemic diseases, smoking, history of undescended testicles, and alcohol intake.
Generate a management pan for premature labour
Maternal evaluation + assessment of fetal viability
CORTICOSTEROIDS - beclametasone /dexamethasone sodium phosphate
IM
Consider induced delivery
ABx for group B strep -> clindamycin / benzylpenicillin sodium
Define ovarian cyst
Ovarian cyst is a surgical, imaging, or examination finding of an enlarged, fluid-filled ovary or portion of ovarian tissue. Ovarian cysts imply a pathophysiological process involving the ovary itself.
Sx of lichen sclerosis
Itchiness Soreness Splitting of skin (from itching) White parchment paper appearance Fissuring possible
Explain RFs fibroids
STRONG
Increased BMI
Increased age
Black ethnicity
WEAK HTN Dietary intake high in red meat Sex hormone exposure Nulliparous
What is the prognosis of breech presentation
No differences at 2 years postnatal were found between planned caesarean section and planned vaginal birth in maternal outcomes of breastfeeding; relationship with child or partner; pain; subsequent pregnancy; incontinence; depression; urinary, menstrual, or sexual problems; fatigue; or distressing memories of the birth experience. However, planned caesarean section was associated with a higher risk of constipation.
Adult intellectual performance at 18 years of age was not affected by mode of delivery. There was also no difference in the risk of death or neurodevelopmental delay.
Define termination of pregnancy
Elective termination of pregnancy
The law:
(a) that the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
(b) that the termination of the pregnancy is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
(c) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated
(d) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
Describe management of the second phase of labour?
When the woman enters the second stage of labor with complete cervical dilatation, the fetal heart rate should be monitored or auscultated at least every 5 minutes and after each contraction during the second stage.
Although the parturient may be encouraged to actively push in concordance with the contractions during the second stage, many women with epidural anesthesia who do not feel the urge to push may allow the fetus to descend passively, with a period of rest before active pushing begins.
When a prolonged second stage of labor is encountered, clinical assessment of the parturient, the fetus, and the expulsive forces is warranted.
Sx of polyhydramnios
LGA
Multiple pregnancy
Fetal abnormalities associated with polyhydramnios include neonatal macrosomia, fetal or neonatal hydrops with anasarca, ascites, pleural or pericardial effusions, and gastrointestinal tract obstruction (eg, duodenal atresia, tracheoesophageal fistula).
Skeletal malformations can also occur, including congenital hip dislocation, clubfoot, and limb reduction defect.
Abnormalities in fetal movement are suggestive of primary neurologic abnormalities or may be in association with a genetic syndrome, such as polyploidy.
Summarise the prognosis for patients with amniotic fluid embolism
Leading cause of maternal deaths in developed countries
85% have neurological injury.
RFs for urogenital prolapse
Birth, aging
Congenital weaknesses (ie 2% of nulliparous still get)
Hysterectomy - with VVault
Anything causing raised intra-abdominal pressure - IE coughing/constipation
Define PPH
Bloodloss >500-1L after delivery
RFs for trichomonas vaginalis
Multiple partners
Disuse of barrier contraceptives
Prognosis of infertility in women
Clomifene - 36% probability of pregnancy, 10% of pregnancies twins
GnRH - 20-22% probability of pregnancy, 30% of pregnancies twins
NB twins increase with age
IVF is the most successful treatment for infertility, regardless of diagnosis:
54.4% live births in women under 35 years of age. This declined with age: 42% for women aged 35 to 37 years; 26.6% for women aged 38 to 40 years; 13.3% for women aged 41 to 42 years; and only 3.9% in women aged over 42 years.
What are the relevant Ix for premenstrual syndrome
Symptom diary - predominance in luteal phase
TFTs - rule out - N
FSH - rule out Meno - N
Depression screen
Generate a management plan for anaemia in pregnancy
Supplemental plan for ALL WOMEN:
IRON - 30mg/day
OR 60mg/day guaranteed in FOOD
A 55 kg woman requires approximately 1 gram of additional iron from conception to delivery
BUT Rx of IDA:
Oral/IV iron
ORAL = Ferrous Sulphate 65mg-200mg daily (absorption increased with Vit C supplementation, avoidance of coffee)
IV = NOT used in 1st trimester, but low threshold in 2/3rd
Usually takes 3 weeks to correct.
Transfusion for SEVERE symptoms
OTHERS
- Folic acid supplementation
- Vit B12 supplementation
- Avoid oxidant meds if G-6PD
- SCD = transfusion
- Thal = transfusion
- A/I causes = transfusion
Continue post partum
A family attends a 12-week dating scan. The midwife sonographer appears concerned during the scan and obtains a second opinion. The second sonographer who undertakes the ultrasound examination confirms the absence of visible heart activity of the embryo.
Miscarriage
Sx of skin changes in pregnancy
Normally pigmented areas become more so - IE nipples, external genitalia, anal region
Fresh pigmentation on face = normal called CHLOASMA / MELASMA GRAVIDARUM
Fresh pigmentation also seen on linea alba line - called LINEA NIGRA
Thought to be due to excess melanin in pregnancy - Melanocyte-stimulating hormone is elevated early in pregnancy
NORMAL to see striae
- STRIAE GRAVIDARUM
Seen on thighs, abdomen, breast
Persistent striae are called STRIAE ALBICANTES
May be associated with increased ACTH
Increased glands in breasts - glands of Montgomery
Rectus abdominus may separate in middle - diastisis recti
Angiomas/vascular spiders also appear = normal
Palmar erythema also normal
RFs for vasa praevia
Vasa previa may be associated with low-lying placenta, placenta with accessory lobes, and with multiple pregnancies.
Summarise the possible complications of a molar pregnancy
The risk for recurrent gestational trophoblastic disease in a future pregnancy is 1% (or about 10 times the baseline risk). Patients should be followed closely in subsequent pregnancies.
Among patients with complete molar pregnancy, about 20% develop malignant gestational trophoblastic neoplasia (GTN).
About 5% of patients with partial molar pregnancies will develop malignant GTN. The rate of cure for these conditions exceeds 95%.
Discuss the management plan for gonorrhoea infection
Non-Pregnant
- DUAL ABx therapy
Ceftriaxone + azithromycin
Hx of sexual abuse - include metronidazole
Pregnancy = ceftriaxone + azithromycin
Neonate - just ceftriaxone
Summarise the epidemiology of chlamydia
Genital chlamydia is the most common bacterial STD in resource-rich countries.
A total of 202,546 chlamydia diagnoses were made in England in 2016, predominantly in departments of genitourinary medicine, where it accounts for 49% of all new STD diagnoses.
Generate a management plan for molar pregnancies
DESIRING FERTILITY
- Dilation and evacuation
- Contraception
= add antiemetic if hyper-E-Grav
= add Bblocker if thyrotoxicity
= add magnesium sulphate and anti-hypertensives with pre-eclampsia
= caution bleeding
NOT DESIRING FERTILITY
- hysterectomy
Aetiology of vasa praevia
Vasa previa occurs when the fetal vessels in the membrane are situated in front of the presenting part of the fetus. This may occur because of a velamentous insertion of the cord or with vessels running between the placenta and a succenturiate lobe. Vasa previa may also exist over the dividing membrane when a second twin has a velamentous insertion of the umbilical cord.
Discuss the aetiology of Rh incompatibility
Exposure of an RhD-negative mother to RhD-positive fetal RBCs results in the generation of B lymphocyte clones that recognise the foreign RBC antigen, and promote production of IgG. Memory B lymphocytes await the reappearance of RBCs containing the respective antigen in a subsequent pregnancy. When challenged by these antigenic erythrocytes, the lymphocytes differentiate into plasma cells and produce IgG. Maternal IgG crosses the placenta and attaches to fetal erythrocytes that have expressed the antigen. These RBCs are then sequestered by macrophages in the fetal spleen, where extravascular haemolysis occurs, producing fetal anaemia. The fetus attempts to compensate by increasing extramedullary haematopoiesis. This results in hepatosplenomegaly, portal hypertension, cardiac compromise, tissue hypoxia, hypoviscosity, and increased brain perfusion. Extreme fetal haemoglobin deficits of 70 g/L (7 g/dL) or greater can ultimately lead to hydrops fetalis (collection of fluid in serous compartments) and intrauterine fetal death, unless corrected by intrauterine fetal transfusion or neonatal exchange transfusion following delivery.
Aetiology of pregnancy of unknown location
The true nature of the pregnancy can be an ongoing viable intrauterine pregnancy, a failed pregnancy, an ectopic pregnancy or rarely a persisting PUL.
Definite ectopic pregnancy Extrauterine gestational sac with yolk sac or
embryo (with or without cardiac activity).
Pregnancy of unknown location – probable ectopic pregnancy Inhomogeneous adnexal mass or extrauterine sac-like structure.
“True” pregnancy of unknown location No signs of intrauterine nor extrauterine pregnancy on transvaginal ultrasonography.
Pregnancy of unknown location – probable intrauterine pregnancy Intrauterine gestational sac-like structure.
Definite intrauterine pregnancy Intrauterine gestational sac with yolk sac or embryo (with or without cardiac activity).
Define vulval cancer
Carcinoma of the vulva
HPV related = young
Non- HPV = old - associated with VIN or lichen sclerosis
85% squamous
5% melanoma
What is succenturiate placenta?
Where the placenta has 1 or more accessory lobes
A 28-year-old woman in her second post-partum week presents with recent-onset breast pain and a tender wedge-shaped area in one breast that feels firm, warm, and swollen, and appears erythematous. She has decreased milk output, flu-like symptoms, pyrexia of 38°C (100.4°F), and myalgia, in addition to feeling fatigued.
Infectious mastitis
A 32-year-old nulliparous woman presents with severe vulval pain and swelling. She has had increasing pain over the last day unrelieved by oral analgesics (paracetamol). She denies history of STDs, and her partner is asymptomatic. On exam, the patient is in severe discomfort and finding it difficult to sit down. She is mildly pyrexial. On vulval exam the left vulva is erythematous with swelling of the medial aspect and introitus, with the labium minus transecting a cystic swelling.
[Fig-2]
There is no involvement of the distal vagina and no palpable groin adenopathy. No lesions or excoriations are present. The cyst is very tender to palpation, and the patient is unable to tolerate speculum insertion for vaginal inspection.
Bartholin’s cyst
Summarise the indications for endometrial biopsy
Chronic anovulation -> eg PCOS -> increased risk for endometrial hyperplasia/neoplasia.
To rule out endometrial hyperplasia/neoplasia
Suspected uterine cancer (biopsy may discover cells in endometrium)
TVUS usually done BEFORE. If endometrial thickness <4cm then biopsy is RARELY performed
Pipelle used to obtain sample.
Identify the possible complications of cutaneous warts and its management
Bleeding/scarring/infection from Rx
SCC / adenocarcinoma
Persistent hyperpigmentation
Rx related hypertrophic scarring
List the complications of ovarian cysts
Cyst spillage (may contain malignant cells( Cyst rupture Ovarian torsion Dyspareunia Ovarian cancer
List the complications of placenta praevia
Anaemia C-section complications Preterm birth Abnormally adherent placenta DIC IUGR Fetal death Sudden infant death syndrome
A 22-year-old nulliparous woman presents with vulval pain and swelling. She noted sudden onset
of swelling with increasing discomfort after sexual intercourse several days before. Her partner is asymptomatic. She denies any history of STDs. Her general exam is unremarkable and she is afebrile. On vulval exam, a swelling is noted at the medial aspect of the labia and introitus with the labium minus transecting the cystic mass.
[Fig-1]
There is no palpable groin adenopathy. No lesions or excoriations are present. The cyst is mildly tender to palpation. Vaginal speculum exam reveals normal-appearing mucosa without significant discharge.
Bartholins cyst
What are the signs/symptoms of ovarian cancer
COMMON
Pelvic mass (adnexal) GI - abdominal bloating, nausea, dyspepsia, early satiety, diarrhoea, and constipation Symptom duration 3 months Ascites Distention
UNCOMMON
Pleural effusion
A 37-year-old primigravid white female with a dichorionic twin gestation presents for a routine antenatal visit at 30 weeks. Her chief complaint is that of itching of the palms of her hands and the soles of her feet of several days’ duration. She states that the symptoms started at night but have now progressed to generalised pruritus sparing her face. She cannot sleep at night. She denies nausea, emesis, and abdominal pain and feels excellent fetal activity. She denies new exposures. She previously had her gall bladder removed for cholelithiasis. There is no evidence of jaundice and her liver is non-tender. The fundal height is 31 cm above the pubis and a fetal non-stress test is reactive. Urinalysis is negative for protein. She has excoriations on her arms, legs, and abdomen from scratching. There is no evidence of ulcers, papules, or urticaria.
obstetric cholestasis
Rx of oligohydramnios
The transabdominal instillation of indigo carmine may be used to evaluate for PROM.
The transcervical instillation of isotonic sodium chloride solution (ie, amnioinfusion) at the time of delivery reduces the risk of cord compression, fetal distress, and meconium dilution. It also reduces the potential need for cesarean delivery.
Maternal bed rest and hydration promote the production of amniotic fluid by increasing the maternal intravascular space. Bed rest may also help when pregnancy-induced hypertension (PIH) is present, allowing prolongation of the pregnancy.
Studies show that oral hydration, by having the women drink 2 liters of water, increases the AFI by 30%.
Explain the aetiology / risk factors of Bartholin’s cyst
Bartholin’s cysts arise in the duct system of the Bartholin’s gland and are typically the result of occlusion of the main duct into the vestibule.
The glands are believed to provide a lubricating function during sexual intercourse and a moisturising effect on the vulval surfaces. While ductal obstruction is an essential aetiological factor, the cause of obstruction is typically obscure. It may occur secondary to mucus or trauma, or from infection and oedema compressing the duct.
A Bartholin’s abscess more commonly results from polymicrobial non-gonorrhoeal infection of the cyst fluid rather than primary infection of the gland or duct.
Common isolates from Bartholin’s gland abscesses include:
Staphylococcus aureus Staphylococcus epidermidis Streptococcus faecalis Group B streptococci Enterococcus species Escherichia coli Pseudomonas aeruginosa Bacteroides fragilis Clostridium perfringens Peptostreptococcus species Fusobacterium species Coliforms Neisseria gonorrhoeae (no cases reported in most recent case series) Chlamydia trachomatis (no cases reported in most recent case series).
RFs: Reproductive age Hx Bartholins Sex Trauma/surgery
Define infertility in women
The diminished ability of a couple to conceive a child. This may result from a definable cause (e.g., ovulatory, tubal, or sperm problem), or may be unexplained failure to conceive over a 2-year period.
Can be due to ovulatory dysfunction, tubal or other anatomical disorders, endometriosis, or unknown causes.
Workup requires evaluation of reproductive anatomy and physiology; even in the absence of diagnosis, a couple is considered to be subfertile after 2 years of regular unprotected sexual intercourse without pregnancy.
Timing and type of treatment are diagnosis-dependent, but may include medical therapy, surgical therapy, or IVF.
Prognosis is dependent on patient age, infertility diagnosis, and treatment plan.
A 45-year-old G3, P3 black woman presents with several years of progressively heavier and prolonged menstrual periods. Over the past months she has also experienced lethargy and weakness. She recently visited her primary care physician for tiredness and was diagnosed with moderate anaemia (haemoglobin of 90 g/L [9 g/dL]). Family history is remarkable for a sister who underwent hysterectomy at age 49 for uterine fibroids. Bimanual examination discloses a 16-week enlarged, firm and irregular uterus. Adnexal and rectal examinations are normal and stool is haem negative. Pelvic ultrasound shows an enlarged uterus with irregular contour and multiple intramural masses consistent with uterine fibroids. Both ovaries are visualised and normal.
Fibroids
Assessment of vaginal bleeding
List the causes of PM bleeding?
Malignancies
Atrophic vaginitis = usually associated with intercourse
What are the relevant Ix for epilepsy in pregnancy
EEG - defines whether generalsed or focal
Blood Glucose - extreme hypo/hyper can cause provoked generalised tonic-clonic seizures
FBC - CNS/systemic infection can cause seizures
Electrolytes - hypo/hypernatraemia or uraemia can cause
Toxicology screen - drugs can cause
Prolactin - >2x baseline indicates a generalised tonic-clonic seizure
CK - >200mU/mL (questionable reliability but high levels 2hrs after insult can suggest tonic-clonic seizure)
MRI brain - structural lesion can cause
Rx of trichomonas vaginalis
Metronidazole 200mg TD for a week OR one dose of 2g (and avoidance of alcohol)
Short courses more likely to produce gastritis but may be good if non-adherent patient
Recheck smear after Rx
A 28-year-old woman first presents for antenatal care at 24 weeks of gestation. Past medical history is notable for irregular periods and class I obesity (BMI 30 kg/m²). The results of a 75-gram oral glucose tolerance test performed after an overnight fast are: fasting glucose 5.8 mmol/L (105 mg/dL); 1-hour glucose 11.1 mmol/L (200 mg/dL); and 2-hour glucose 8.9 mmol/L (160 mg/dL).
GDM
A 35-year-old woman presents at 37 weeks’ gestation with severe headache and acute abdominal pain. She had a routine antenatal visit 4 days previously with no signs or symptoms reported or observed. On examination, her BP is 165/110 mmHg and urinalysis reveals proteinuria (3+). She is admitted to hospital and is started on labetalol.
Pre-eclampsia
A 38-year-old woman, gravida 5, para 4, and an active smoker, is found to have an abnormal placenta on a routine dating ultrasound at 13 weeks. She returns with painless, bright red vaginal bleeding at 28 weeks. She is not in labour.
Placenta praevia
Summarise the epidemiology of Bartholin’s cyst
2-3%
Approximately 3% of women who underwent pelvic MRI (serving as controls as part of research studies) were noted to have Bartholin’s gland cysts identified.
Bartholin’s cysts typically occur in sexually active women of reproductive age.
Aetiology of fatty liver of pregnancy
The foremost cause of AFLP is thought to be due to a mitochondrial dysfunction in the oxidation of fatty acids leading to an accumulation in hepatocytes. The infiltration of fatty acids causes acute liver insufficiency, which leads to most of the symptoms that present in this condition. If not diagnosed and treated promptly, AFLP can result in high maternal and neonatal morbidity and mortality.
Explain the risk factors of ectopic pregnancy
STRONG previous ectopic pregnancy previous tubal sterilisation surgery in utero diethylstilbestrol exposure of the mother intrauterine device (IUD) use previous genital infections chronic salpingitis salpingitis isthmica nodosa infertility multiple sexual partners smoking
WEAK assisted reproductive technology (ART) first sexual encounter <18 years maternal age >35 years tubal reconstruction surgery
Rx of UTI in pregnancy
Asymptomatic - nitrofurantoin / trimethoprim (can do single dose/3 days/ten days)
Pyelonephritis:
Prompt antimicrobials:
Ampicillin + Gentamicin OR ceftriaxone (until afebrile for 24hr)
IV hydration = cornerstone of Rx
NB 30-40% of pyelos relapse -> consider longer Rx 7-10days nitrofurantoin
Recognise the presenting symptoms of bacterial vaginosis
presence of risk factors vaginal discharge dysuria discharge adherent to vaginal mucosa prior episodes pruritus vulvodynia vaginal dryness dyspareunia erythema pale epithelium shiny epithelium decreased elasticity friable epithelium fever vaginal bleeding abdominal pain strawberry cervix
Identify appropriate investigation for anaemia in pregnancy
RBC count
CBC count
Iron studies - serum ferritin (eg, <30 ng/mL [<30 mcg/L]),
TIBC, Transferrin Sat (<20%) - beware iron supplements can cause pseudo.
Extreme microcytosis (eg, mean corpuscular volume [MCV] <80 fL), suggestive of thalassemia
Macrocytosis (MCV >100 fL), suggestive of vitamin B12 or folate deficiency or reticulocytosis due to hemolysis
Other cytopenias such as thrombocytopenia or neutropenia
Abnormally high white blood cell (WBC) count or platelet count
Abnormal RBC or WBC morphologies
Failure of the anemia to correct with iron supplementation
Sx of termination of pregnancy/ discuss counselling
Most abortion counseling focuses on the decision-making process, the options for continuing the pregnancy, medical issues of the pregnancy, information regarding the pregnancy itself, full disclosure of the risks of continuing to term, information and options for the technique of the abortion procedure, and, finally, information regarding a contraceptive decision. The risks and benefits of both medical and surgical abortions should be reviewed.
The counseling process is aimed primarily at the woman herself but may also include other persons she chooses to be involved. Studies indicate that males are involved in more than 40% of the decisions, but only scant research has been performed on male involvement in the process. Some women can reach a decision quickly; others take longer to decide. The counseling process should include referrals for those who need ongoing support.
Of utmost importance is to ensure that the patient has had enough time to consider her options and that she is not being coerced into her decision. In actual US Supreme Court reference materials there are statements that women may experience “regret…depression…loss of esteem”; however, most research fails to substantiate this, and, in fact, postabortion mental health benefits have been shown. Some studies show significant negative mental health effects of bearing an unwanted child, which others argue should be placed into the counseling context, although it seldom is. Most women experiencing depression postabortion experienced significant preabortion depression. [18]
Many strategies can be used in the counseling session. Open-ended questions bring out issues that are pertinent to the woman and encourage meaningful exchange of dialogue. The patient’s emotions should be validated, and the counselor should encourage the client to explore her feelings in more depth. Health care providers and counselors may not have the time or expertise to devote themselves to lengthy sessions, and not all women are able to complete the process in a day if these issues need to be explored before the abortion procedure.
Define toxic shock syndrome
Toxic shock syndrome (TSS) is an exotoxin-mediated illness caused by bacterial infection. Organisms commonly responsible include group A streptococcus ( Streptococcus pyogenes ), or methicillin-sensitive (MSSA) or methicillin-resistant (MRSA) Staphylococcus aureus . Although the presenting signs and symptoms can be non-specific (e.g., fever, chills, myalgias, headache), the course of the disease is precipitous, and shock and multi-organ system failure occur early in the course of the disease.
Staphylococcal TSS can be split into 2 groups: menstrual TSS, which occurs in women during menstruation with extended use of a single tampon or, historically, with highly absorbable tampons; and non-menstrual TSS, which can result from a variety of staphylococcal post-partum vaginal and caesarean wound infections.
List the complications of urinary incontinence in women
Surgery related: Retention UTI Perforation of bladder Haemorrhage Bowel injury Voiding disorders Wound complications
What is the epidemiology of gestational hypertension
Hypertension is the most frequently identified medical problem during pregnancy. Hypertensive disorders are a common cause of morbidity and mortality during pregnancy, contributing to poor maternal and neonatal outcomes if not adequately managed. In the UK, gestational hypertension and pre-eclampsia complicate around 5% to 6% of pregnancies.
Healthy nulliparous women may experience higher rates of gestational hypertension (6% to 17%) compared with multiparous women (2% to 4%).
African-American women may be at greater risk than white women.
Gestational hypertension occurs more often in twin pregnancies than in singleton pregnancies.
What are the infectious causes of menorrhagia?
Endometritis
Salpingitis
PID
Recognise the presenting symptoms/signs of endometriosis
Dysmenorrhoea
Chronic/cyclic pelvic pain
Dyspareunia
Sub-fertility
Uterosacral ligament nodularity - rectovaginal palmpation reveals “guitar string” ligament + potential pain on palpation
Pelvic mass
Fixed retroverted uterus
Depression
Dysuria/flank pain/haematuria if bladders involved
Dyschezia/haematochezia if colon involved
Identify the possible complications of bacterial vaginosis and its management
Preterm birth
Preterm membranes rupture
Low birth weight
Inc STI risk
Define evacuation of retained products of conception (ERPC)
AKA dilation and evacuation OR surgical termination.
A method of abortion as well as a therapeutic procedure used after miscarriage to prevent infection by ensuring that the uterus is fully evacuated.
___________
The first step in the procedure itself is dilation of the cervix. The second step is insertion of a vacuum curette through the cervix. Under ultrasound, the tip of that curette is placed up against the fetal chest or abdomen. The suction is turned on. Amniotic fluid is removed and the fetus dies instantly due to removal of the fetal heart, lungs, and abdominal contents.
This leaves the fetal cranium and skeleton with soft tissue to be removed. The thorax, pelvis, cranium, and each arm and leg are removed separately using surgical instruments. The fetal cranium will usually have to be crushed in order to be extracted. Use of ultrasound greatly facilitates this part of the procedure although it may be done safely without ultrasound guidance. In the absence of ultrasound, the tissue will be carefully inspected to insure all fetal tissue is removed. It is important to recognize that this is the removal of dead tissue to protect the patient from bleeding and infection well after the fetus died instantly. Under no circumstances is the fetus being dismembered alive.
After removal of all fetal tissue, the uterine cavity is thoroughly curetted to insure that all placental tissue, blood, and membranes are removed. The uterus will then be massaged to insure it is firmly contracted to minimize post operative bleeding. The entire procedure usually takes less than 30 minutes and is well tolerated.
What are the signs/symptoms of pre-eclampsia
- Headache: usually frontal; occurs in around 40% of patients with severe disease, and is one the few symptoms that predict an increased risk of eclampsia.
- Upper abdominal pain: usually right upper quadrant pain; occurs in around 16% of patients with severe disease, and is a clinical symptom of HELLP syndrome. HELLP syndrome is a subtype of severe pre-eclampsia characterised by haemolysis (H), elevated liver enzymes (EL), and low platelets (LP).
- Visual disturbances: for example, photopsia (perceived flashing lights in the visual fields), scotomata, retinal vasospasm; are relatively rare but predict an increased risk of eclampsia. Cortical blindness should alert a clinician to underlying cerebral oedema.
- Breathlessness: due to pulmonary oedema and may complicate pre-eclampsia. If it occurs after delivery, it is one of the main causes of maternal mortality.
- Seizures: mandates admission to intensive care unit, stabilisation, and delivery.
- Oliguria.
HTN Reduced metal movement FGR Oedema Hyperreflexia
Summarise the prognosis for patients with cutaneous warts
There is no cure for genital warts, and recurrence is not uncommon. The goal of treatment is to eliminate visible lesions. There is no evidence showing that treatment affects the natural course of human papillomavirus infection.
If left untreated, 10% to 30% of genital warts will resolve spontaneously within 3 months.
Generate a management plan for urinary incontinence in women
STRESS
Lifestyle - pelvic muscle exercises, WL, fluid management, smoking cessation etc
STRESS with urethral sphincter insufficiency
- Pseudoephedrine
Imipramine
Duloxetine
Oestrogen -> estradiol or conjugated oestrogens IF PM
Urethral bulking injection
Surgery
URGE INCONTINENCE
Anticholinergics:
Oxybutynin
Mirabegron - (adrenergic)
Fesoterodine
Neuromodulation - implant in sacral spine, inhibits micturition reflex - 60-70% works
Botox Rx - makes bladder more compliant. Less firing of afferent, and less ability to contract. 6-12months.
MIXED = use aspects of both
What is amenorrhoea?
Transient or permanent absence of menstrual flow and may be subdivided into primary / secondary, relative to menarche.
A 27-year-old woman (gravida 2, para 2) presents to her general practitioner with a chief complaint of pelvic pain. The pain began about 3 weeks previously and is characterised as dull with a pressure-like fullness in the right pelvis. The pain is exacerbated by some movements and by sexual intercourse. She noted no change in intensity or character with her last menses 2 weeks previously. Her past gynaecological and medical histories are unremarkable. Previous surgeries include one caesarean delivery and an appendectomy. Review of symptoms reveals some increased frequency of urination but no other notable menstrual, haematological, GI, or genitourinary symptoms. Physical examination reveals a well-nourished female in no acute distress who demonstrates mild tenderness on deep palpation of the right lower quadrant of her abdomen. On pelvic examination, palpation of the right adnexa elicits moderate tenderness.
Ovarian cyst
Prognosis of termination of pregnancy
Safer to terminate than continue pregnancy
Contraindications to mifepristone include serious medical problems, such as cerebrovascular or cardiovascular disease, severe liver, kidney or pulmonary disease, preoperative anemia (< 10 mg/dL), undiagnosed ectopic pregnancy, allergies, contraindications to prostaglandin use, active uterine bleeding, or large uterine leiomyomata.
Of all methods of second trimester abortion, the safest procedure (using mortality surveillance data) is dilation and extraction. Labor induction with prostaglandins and passive dilators has a higher risk than dilation and extraction due to the risk of retained placenta.
Ix for cervical polyps
Pelvic examination + speculum
- Generally bright red, spongy texture, may be pedunculated (attached by a stalk)
Generally <1cm
Biopsy
Rx of cardiac disease in pregnancy
TOP:
- If eisenmenger
- Tetraology of fallot = 1% mortality risk
AFTER 12 weeks the risk of termination is as great as continuing the pregnancy
Minor lesions such as uncomplicated septal defects + PDA rarely justify surgical Rx during pregnancy
Any infections = Rx rigorously. Chest infection = admission to hospital + expert cardiology opinion
Anaemia should be avoided and Rx
Good dental care + dental surgery should be Rx with Abs (endocarditis)
Conversion to IV heparin may be considered if on warfarin
CS may be indicated as labour can be tumultuous
LABOUR Rx
Patient should be propped up. Lithotomy position should be avoided (increases venous return)
Analgesia must be OPTIMUM to reduce tachycardia. Epidurals are good -> provided hypotension is avoided
IM ampicillin and gentamicin given IF ANY evidence of structural lesions (to prevent endocarditis)
During stage 2 labour:
Patient should not be made to make substantial expulsive efforts
Vacuum/forceps should be used readily
Stage 3:
Allow time for circulatory adjustment. Do not rush.
The risk of atonic PPH must be balanced with the effects of oxytocin (tachycardia and hypotension)
IF ACUTE PULMONARY OEDEMA: Sit up Hang legs over bed O2 via face mask Morphine IM Frusemide 20-40mg Seek cardiology
Define cervical cancer & intraepithelial neoplasia
Cervical cancer is a human papillomavirus-related malignancy of the uterine cervical mucosa.
RFs for LGA
Poorly controlled GDM / T2DM (NB T1DM is associated with microsomia) Obesity Gestational age past 40w Male Multiparity Hydrops fetalis Congenital anomalies causing hydros fetalis Amoxicillin Some links to polyhydramnios
RFs for vulval cancer
Age HPV Lichen sclerosis Smoking Impaired immunity Hx of VIN
Epidemiology of failure to progress/abnormal delivery?
Of all cephalic deliveries, 8-11% are complicated by an abnormal first stage of labor. Dystocia occurs in 12% of deliveries in women without a history of prior cesarean delivery. Dystocia may account for as many as 60% of cesarean deliveries.
List complications of premenstrual syndrome
None
List the RFs for urinary incontinence in women
STRONG
Increasing age Pregnancy - parity, vag delivery, episiotomy Obesity LUTsymptoms Long term care facility residence Dementia Constipation - straining Faecal incontinence High impact physical activity Pelvic organ prolapse Stroke Parkinsons MS Diuretic use Caffeine
WEAK
White PM-Women Functional impairment FHx Childhood enuresis DM - neurogenic - overflow Depression Chronic heart failure Smoking Genitourinary and pelvic surgery Radiation exposure Alcohol Antihistamine use Sedative use Hypnotic use Anticholinergic use Antidepressants CCBs Alpha adrenergic agonist
Describe the management plan for PROM
If at term - induce labour.
34-36weeks - treat like term
24-34weeks - steroids, watchful waiting, tocolytics, magnesium sulphate,
ABx to prevent group B strep transmission in all
<24 weeks previable. Usually watchful waiting or induction of labor
What are the Rxs for breech presentation
<37w = specialist
> 37w
1) external cephalic version
- Contraindications include multiple pregnancy (except after delivery of a first twin), ruptured membranes, current or recent (<1 week) vaginal bleeding, rhesus isoimmunisation, other indications for caesarean section (e.g., placenta praevia or uterine malformation), or abnormal electronic fetal monitoring.
2) Tocolytic - salbutamol / terbutaline, ritodrine
+ Anti D
3) UNSUCCESSFUL = C section
4) No imminent delivery needed = vaginal breech delivery
Define endometrial cancer
An epithelial malignancy of the uterine corpus mucosa, usually an adenocarcinoma.
Define endometrial biopsy
The endometrial biopsy is a medical procedure that involves taking a tissue sample of the lining of the uterus.
Sent to histology.
Discuss the Ix for miscarriage
Urine PREG test
FBC - check Hb
RhD - must assess
Serum B-hCG titres - falling indicates failing pregnancy
TVUS - confirms viability
Serum progesterone - low titres = non-viable preg
Lupus anticoagulant/cardiolipin antibodies
Cytogenetic analysis of products of conception OR parental karyotyping - chromosomal abnormalities
Vaginal swab - bacterial vaginosis
Define diabetes in pregnancy
Gestational diabetes mellitus (GDM) has traditionally been defined as any degree of glucose intolerance with onset or first recognition during pregnancy. However, the criteria for diagnosis are controversial, and some authorities now define it as diabetes diagnosed in the second or third trimester of pregnancy that is clearly not overt diabetes.
It is usually recognised at 24 to 28 weeks of gestation on the basis of abnormal glucose tolerance testing.
Sx of urogenital prolapse
"Baring down" Lump Discomfort Backache Bleeding Dyspareunia Renal failure - if urethral kinking
SPECIFIC
Cysto-urthral - urinary freq/urgency/UTI/Stress incontinence
Rectocele - incomplete bowel emptying, digitation, splinting, anal incontinence
Describe the RFs for ovarian cancer
STRONG BRCA1 mutation (AD inheritance) BRCA2 mutation Increased Age FHx breast/ovarian Never used OCP Lynch II syndrome
WEAK
Nulliparity
Obesity
HRT
Epidemiology of polyhydramnios
1% pregnancies
In pregnancies affected by polyhydramnios, approximately 20% of neonates are born with a congenital anomaly of some type; therefore, the delivery of these newborns in a tertiary care setting is preferred.
An 18-year-old pregnant woman presents at 10 weeks’ gestation with vaginal bleeding. Vital signs indicate sinus tachycardia and hypertension. On pelvic examination the uterus is enlarged to 16 weeks’ gestational size with a palpable left adnexal cyst of about 9 cm diameter. Pelvic ultrasound reveals a mixed echogenic (snow-storm) pattern with no fetus and thin-walled cysts in the left ovary.
Molar pregnancy
Identify the possible complications of endometrial ablation
Perforation of the uterus
Burns to the uterus (beyond the endometrial lining)
Pulmonary edema or embolism
Bowel burn leading to death
Post-ablation tubal sterilization syndrome
Placenta accreta may occur if the patient becomes pregnant after endometrial ablation, so birth control is necessary.
Define obstetric cholestasis
Intrahepatic cholestasis of pregnancy (ICP) is a pruritic condition during pregnancy caused by impaired bile flow allowing bile salts to be deposited in the skin and the placenta. The cause is a combination of hormonal, genetic, and environmental factors. ICP may predispose mothers to vitamin K deficiency and the fetus to adverse pregnancy outcomes that may include prematurity, intra-uterine fetal demise, and respiratory distress syndrome.
May be associated with an increased risk of adverse pregnancy outcomes, including premature birth, intra-uterine fetal demise, and placental abruption in severe disease.
There is an increased risk of respiratory distress syndrome in neonates, owing to meconium aspiration syndrome, which is unpredictable by available methods of surveillance.
The only definitive cure is delivery of the baby.
The condition is associated with a history of hepatitis C and there may be an association with long-term liver disease.
Mild disease with bile acid levels <40 micromol/L or mild itching can be treated with bile-sequestering agents and antihistamines, such as colestyramine and hydroxyzine. However, if tolerated no treatment is necessary.
Severe disease with bile acid levels >40 micromol/L or severe pruritus remote from term can be treated effectively with ursodeoxycholic acid.
Close fetal surveillance with delivery near term can be expected with premature delivery reserved for those with severe, worsening disease despite treatment.
Epidemiology of vulval cancer
10 per 100k incidence
1000 per year in UK
Epidemiology of termination of pregnancy
1.7% of US women 15-44 per year
Half have had at least one prior abortion. 89% of abortions occur less than 12 weeks gestation
Globally, abortion mortality accounts for at least 13% of all maternal mortality. New estimates are that 50 million induced abortions are performed each year in developing countries, with approximately 20 million of these performed unsafely because of conditions or lack of provider training.
1 in 100k mortality with 1st trimester abortions BUT always safer for abortion than continuation
Women in their 20s account for more than half of all abortions.
What are the three groupings for primary amenorrhoea?
Group I: low oestrogen, low FSH, and no hypothalamic-pituitary pathology, leading to a diagnosis of hypogonadotrophic hypogonadism.
Group II: normal oestrogen, normal FSH, and normal prolactin, leading to a diagnosis of polycystic ovary syndrome.
Group III: low oestrogen and high FSH, leading to a diagnosis of gonadal failure.
Rx of thromboembolism in pregnancy
DVT: LMWH (better bioavailability than unfractionated). Converted to unfractionated during the last month of pregnancy. (less bleeding from epi/spinal)
Unfractionated heparin can be reversed with Protamine Sulfate.
PE:
If needing to undergo CS soon: Vena cava filter
Risk of death lower if given Alteplase BUT increased risk of fatal bleeding episode. Case-by-case decision.
WILL ALL NEED THROMBOPROPHYLAXIS POST CS UNLESS NO RISK FACTORS
6 week Rx
NB warfarin can be given as thromboprophylaxis postnatally.
Ix for fatty liver of pregnancy
LFTs - elevated AST ALT Blood glucose - decreased Serum ammonia - increased Coagulation assessment - prolongation of prothrombin time, low fibrinogen, and low antithrombin levels (decreased production by the damaged liver) Bilirubin - high
IF pancreatitis too - increased serum amylase/lipase
IF kidneys affected - creatinine + uric acid increased (met acidosis seen)
Imaging rarely needed
RFs for infertility in women
STRONG Age >35 Hx sexually transmitted disease Very high body fat Very low body fat Cigarette smoking
WEAK A/I disease Hx appendicitis Psychiatric disease Substance abuse Alcohol consumption Caffeine consumption Stress
Describe the second stage of labour
Second stage of labor
Begins with complete cervical dilatation and ends with the delivery of the fetus
In nulliparous women, the second stage should be considered prolonged if it exceeds 3 hours if regional anesthesia is administered or 2 hours in the absence of regional anesthesia
In multiparous women, the second stage should be considered prolonged if it exceeds 2 hours with regional anesthesia or 1 hour without it.
Rx of subfertilty in men
KALLMANS
- Give GnRH / HCG
HYPERPROLACTINOMA
Cabergoline/bromocriptine
VARICOCELE
varicocelectomy
UNEXPLAINED
- GnRH / HCG / CLOMIFENE / Tanoxifen
NB Clomifene = nonsteroidal SERM
ALL ELSE FAILS
Intrauterine insemination - better than timed sex if male factor infertility
IVF
Define labour?
Labor is a physiologic process during which the products of conception (ie, the fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus. Labor is achieved with changes in the biochemical connective tissue and with gradual effacement and dilatation of the uterine cervix as a result of rhythmic uterine contractions of sufficient frequency, intensity, and duration.
Labor is a clinical diagnosis. The onset of labor is defined as regular, painful uterine contractions resulting in progressive cervical effacement and dilatation. Cervical dilatation in the absence of uterine contraction suggests cervical insufficiency, whereas uterine contraction without cervical change does not meet the definition of labor.
RFs for thromboembolism in pregnancy
Stasis
Trauma
Hypercoagulability
Obstetrical: CS DM Haemorrhage/anaemia Hyperemesis Immobility Multiple gestation Multiparity Pre-eclampsia Puerperal infection
General: >35yo Cancer Connective tissue disease Dehydration Immobility Infection/inflammatory disease Nephrotic syndrome Obesity Oral contraceptivo use Orthopedic surgery Paraplegia Hx of VTE SCD Smoking Thrombophilia
Rx of thyroid disease in pregnancy
Thyrotoxicosis:
PTU - propylthiouracil is safest drug (least crosses placenta). Recommended to switch to Methimazole in 2nd trimester (PTU associated with hepatotoxicity)
THYROID ABLATION + RADIOACTIVE IODINE Rx IS CONTRAINDICATED IN PREGNANCY
Hypo:
Levothyroxine 1-2ug/kg/day. Survey 4-6 weekly, increase dose by 25ug until normal t4.
RFs of obesity in pregnancy
Increased risk of GDM, GHTN, Preclampsia
Explain the risk factors of endometriosis
STRONG Reproductive age group FHx Nulliparity Mullerian abnormalities
WEAK White Low BMI AI Disease Late 1st sequel encounters
Identify the possible complications of chlamydia and its management
Epididymitis Reactive Arthritis Opthalmia Neonatorium Chlamidya Pneumonia Ectopic Pregnancy Infertility Cervical cancer Pelvic Inflammatory Disease
Summarise the epidemiology of ectopic pregnancy
Global rates of ectopic pregnancy are 1.1% in the UK, 1.49% in Norway, and 1.62% in Australia.
Identify the possible complications of Bartholin’s cyst and its management
Bartholins abscess
Dyspareunia
Bartholin’s-rectal fistula
Generate a management plan for Rh incompatibility
Anti-D immunoglobulin
Specialist: intravascular intrauterine blood transfusions
Define urogenital prolapse
Herniation of the genital tract through the pelvic diaphragm
Caused by deficiency pelvic fascia, or weakness of the ligaments, muscles, blood or nerves that supply the pelvic organs.
ANTERIOR VAGINAL WALL
Urethrocele
Cystocele
Cystourethrocele
POSTERIOR VAGINAL WALL
Rectocele
Enterocele
APICAL WALL
Uterovaginal
Vaginal vault
Complications of obstetric cholestasis
Resp distress in pre-term
Vit K deficiency
Premature labour
Intrauterine fetal demise
RFs for lichen sclerosis
Other A/I conditions:
Thyroid disease
Pernicious anaemia
A 32-year-old single woman with no prior pregnancy presents for a routine examination. She reports recurrent symptoms of fatigue, abdominal bloating, breast tenderness, increased appetite, and irritability that have occurred for many years, predominantly 1 week before the start of menses. The symptoms improved when she was on oral contraceptives during her 20s but recently have become more troublesome, interfering with her interpersonal relationships and her ability to perform optimally at work as a research assistant. Her last menstrual period ended 1 week ago. Physical examination reveals normal findings with normal breast and pelvic examination. She does not meet clinical criteria for depression.
Premenstrual syndrome
Complications/prognosis of vasa praevia
Fetal mortality for cases not recognized before the onset of labor is reported to range between 22.5% and 100%.
Epidemiology of infertility in women
Infertility is a major disease worldwide. The primary cause of infertility worldwide is tubal disease due to infection, including gonorrhoea, chlamydia infection, and tuberculosis.
In their 2015 Assisted Reproductive Technology (ART) report, the Centers for Disease Control and Prevention identified female factors in 13% (tubal), 15% (ovulatory dysfunction), 31% (diminished ovarian reserve), 8% (endometriosis), and 6% (uterine) of ART cycles. Male factors were detected in 33% of cases and unknown factors in 13% of cases.
What is velamentous insertion?
Where the umbilical cord inserts upon the chorioamniotic fetal membranes instead of the placental mass
What is the epidemiology of PROM
8% pregnancies at term
30% of premature births
<24weeks 1%
PPROMs account for 5% of all PROMs
Describe the first stage of labour
First stage of labor
Divided into a latent phase and an active phase
Begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm
The latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix
Contractions become progressively more rhythmic and stronger
The active phase usually begins at about 3-4 cm of cervical dilation and is characterized by rapid cervical dilation and descent of the presenting fetal part
An 18-year-old female university student with a history of prior chlamydia infection presents with low-grade fever and non-specific lower abdominal pain. Examination reveals mild diffuse lower abdominal tenderness on deep palpation. She has cervical motion tenderness and a mucopurulent vaginal discharge on pelvic examination.
PID
Sx of UTI in pregnancy
Asymptomatic Suprapubic dyscomfort Fever Dysuria Freq urination + urgency Foul smelling urine
Haematuria, flank pain, shivering, anorexia, N+V
Pyelonephritis = unilateral and RS in 50%
- May cause ARDS NB
Describe the management of endometrial cancer
- Staging surgery +/- vaginal brachytherapy
- (stage 2+) +/- Pelvic radiation
- +/- Chemotherapy
IF ER/PR positive then add hormonal therapy plus aromatase inhibitor
Complications / prognosis of thromboembolism in pregnancy
Haemorrhage thrombocytopenia Osteoporosis Death RVH/F PHTN
Sx of pregnancy of unknown location
Sx of pregnancy
Bleeding
Generate a management plan for bacterial vaginosis
non-pregnant: isolated acute episode bacterial vaginosis 1st line – metronidazole bacterial vaginosis – 1st line – clindamycin: intravaginal cream bacterial vaginosis – 2nd line – clindamycin: oral preparations or intravaginal ovules bacterial vaginosis – 2nd line – tinidazole trichomoniasis – 1st line – nitroimidazole therapy uncomplicated vulvovaginal candidiasis – 1st line – antifungal therapy complicated vulvovaginal candidiasis
Assessment of vaginal bleeding
List causes of premenarchal bleeding?
Precocious puberty
STDs
Childhood genital malignancy of the vagina
DUB
What are the complications of syphilis infection
Jarisch-Herxheimer reaction - acute reaction to ABx therapy to treponemes
Allergic reaction to penicillin
Iatrogenic procaine reaction - occurs when IM benzylpenicillin is administered IV
HIV infection
Asymptomatic progression of disease
Discuss the signs/symptoms of premenstrual syndrome
COMMON
- ALL resolve post menstruation
Abdo bloat Fatigue Breast tenderness Headaches Labile mood Adverse effects on life Increased appetite Difficulty concentrating
UNCOMMON
Insomnia/hypersomnia
GI upset
Palpitations
Hot flushes
What is the prognosis of pre-eclampsia
Pre-eclampsia is a self-limiting condition of pregnancy that usually resolves once the placenta has been delivered, although it may persist for a few days post delivery. There are few long-term sequelae; however, there are some long-term disease associations.
Women with pre-eclampsia have an increased long-term risk of type 2 diabetes, cardiovascular disease, including hypertension and stroke.
Identify appropriate investigations for endometriosis and interpret the results
TVUS
Rectal US
Hysterosalpingography
MRI
Define endometrial ablation
Endometrial ablation is an outpatient medical procedure that is used to remove (ablate) or destroy the endometrial lining of the uterus in women who have heavy menstrual bleeding.
Endometrial ablation should never be performed on women who wish to have children.
Endometrial Ablation procedure is primarily performed while patients are under local and/or light sedative anesthesia, or if necessary, general or spinal anesthesia.
Ablation using cauterisation - minerva.
Pt usually leaves 1hr post procedure.
Progestogen Rx prior to therapy reduces endothelial thickness.
Recognise the presenting symptom/signs of Bartholin’s cyst
Vulval/perineal mass (common) • Classically a medially protruding cystic structure at the inferior aspect of the labia majora in the 5 or 7 o'clock position. Vulval pressure or fullness (common) Fever (common) Dyspareunia (common) Vulval erythema and induration (common) Spontaneous rupture (uncommon)
What is the prognosis of post-natal depression
Episodes of postnatal depression last 3 to 6 months on average, but a few women remain depressed at 1 year
Women with a first episode of postnatal depression have a higher risk of subsequent postnatal depression (41% versus 18%) but a lower risk of non-postnatal depression (38% versus 62%).
Approximately 14% of women with first-time psychiatric contacts during the first postnatal month converted to a bipolar diagnosis within the follow-up period, compared with only 4% of women with a first psychiatric contact unrelated to childbirth.
A 65-year-old obese woman with hypertension and diabetes presents with post-menopausal vaginal bleeding, 12 years after menopause. She has never been pregnant. She has a first-degree relative and a second-degree relative who have had endometrial cancer. Bleeding is scanty but has persisted for more than 1 month. She has not recently used HRT and she had a normal Pap smear 6 months previously. She is morbidly obese with a BMI of 41, and vaginal examination reveals evidence of recent bleeding.
Endometrial carcinoma
Complications of termination of pregnancy
Medical abortions can provide some measure of safety in that they eliminate the risk of cervical lacerations and uterine perforations.
Medical: can cause bleeding
A rare and serious infection of Clostridium sordellii is related to medical abortions.
Discuss the aetiology of placenta praevia
Advanced maternal age, [12] multiple pregnancies, and tobacco use increase the risk of placenta praevia (PP), but the mechanisms are uncertain. With the exception of the risk factor of previous uterine scarring, it is likely that multiple risk factors contribute together to the occurrence of the condition.
Define small for dates/IUGR
Intrauterine growth restriction (IUGR) refers to a condition in which a fetus is unable to achieve its genetically determined potential size. This functional definition seeks to identify a population of fetuses at risk for modifiable but otherwise poor outcomes. This definition intentionally excludes of fetuses that are small for gestational age (SGA) but are not pathologically small. SGA is defined as growth at the 10th or less percentile for weight of all fetuses at that gestational age. Not all fetuses that are SGA are pathologically growth restricted and, in fact, may be constitutionally small. Similarly, not all fetuses that have not met their genetic growth potential are in less than the 10th percentile for estimated fetal weight (EFW).
What are the complications of breech presentation
Compared with cephalic presentation, persistent breech presentation has increased frequency of cord prolapse, abruptio placentae, pre-labour rupture of membranes, perinatal mortality, fetal distress (heart rate <100 bpm), preterm delivery, lower fetal weight.
C section complications: PE Bleeding Infection Iatrogenic damage to bladder/bowel
LONG TERM
- repeat c section
Placenta praevia, uterine rupture, emergency hysterectomy etc…
Explain the aetiology / risk factors of bacterial vaginosis
An overgrowth of bacterial organisms such as Gardnerella vaginalis , Mobiluncus species, Mycoplasma hominis , Escherichia coli , group B streptococci, and Peptostreptococcus species are proven to be the main cause of bacterial vaginosis.
douching poor or excessive hygiene antibiotic use change in feminine hygiene products and/or soap HIV infection diabetes black women IUD oral contraceptive pill use latex condom/diaphragm reproductive age menopause multiple or new sex partners tobacco increased frequency of intercourse pregnancy
Discuss the aetiology of toxic shock syndrome
Menstrual TSS occurs in women during menstruation with extended use of a single tampon or, historically, with highly absorbable tampons.
Non-menstrual TSS can result from a variety of staphylococcal postpartum vaginal and caesarean wound infections, including mastitis, therapeutical abortions, episiotomy infections, endometritis, and infected abdominal wounds. Sinusitis, septorhinoplasty, osteomyelitis, arthritis, burns, cutaneous infections, soft-tissue infections, enterocolitis, endovascular infections, visceral abscesses, and post-influenza respiratory infections have also been implicated.
Most frequent cause of anaemia in pregnancy worldwide?
IDA
RFs for polyhydramnios
IDIOPATHIC
Twin/multiple gestation
TTTS
Oesophageal atresia (usually associated with a tracheoesophageal fistula), tracheal agenesis, duodenal atresia, and other intestinal atresias
CNS problems preventing swallowing
Hydrops associated
Chromosomal abnormalities, most commonly trisomy 21, followed by trisomy 18 and trisomy 13.
Complications /prognosis of pregnancy of unknown location
Between 6% and 20% have an ectopic pregnancy
Between 30% and 47% of women with pregnancy of unknown location are ultimately diagnosed with an ongoing intrauterine pregnancy, whereof the majority (50–70%) will be found to have failing pregnancies where the location is never confirmed
Persisting PUL is where the hCG level does not spontaneously decline and no intrauterine or ectopic pregnancy is identified on follow-up transvaginal ultrasonography
What are the Ix for premature labour
Cardiotocogram
Tocography - >1 in 10
TVUS
Cervico-vaginal swab for fetal fibronectin - +ve
FBC - check Hb + WCC
CRP - infection
Urine dip/microscropy
High vaginal/rectal swab - may be positive for group B strep
Define FGM
Female genital cutting, also known as female circumcision or genital mutilation, is a culturally determined practice, predominantly performed in parts of Africa and Asia and affecting more than 125 million women and girls worldwide
●Type I consists of excision of the prepuce, with or without excision of part or all of the clitoris.
●Type II involves clitoridectomy and partial or total excision of the labia minora.
●Type III, or infibulation, includes removing part or all of the external genitalia and reapproximation of the remnant labia majora, leaving a small neointroitus. Type IV involves other forms of injuries to the genital region including pricking, piercing, stretching, burning, scraping, or any other manipulation of external genitalia.
Identify the possible complications of asthma in pregnancy and its management
Possible gastrochisis, cardiac defects, autism with B agonists.
Several potential areas of concern have been raised with systemic glucocorticoids: congenital malformations (primarily cleft palate [12th week]), preeclampsia, gestational diabetes, low birth weight, and neonatal adrenal insufficiency.
Aetiology of oligohydramnios
Rupture of the membranes is the most common cause of oligohydramnios. However, because the amniotic fluid is primarily fetal urine in the latter half of the pregnancy, the absence of fetal urine production or a blockage in the fetus’s urinary tract can also result in oligohydramnios.
A near term fetus produces 500-1200 mL of urine and swallows between 210 and 790 mL of amniotic fluid per day.
Complications/prognosis of substance abuse in pregnancy
Neonatal withdrawal syndrome occurs in 60% of all fetuses exposed to drugs.
Summarise the prognosis for patients with chlamydia
Nearly all patients are cured with the current recommended antibiotic therapy. Potential complications in women for untreated or inadequately treated infections include PID and infertility. Men can develop prostatitis, epididymitis, and urethral strictures if not treated. Occasionally, a reactive arthritis may occur.
Ix for infertility in women
Semen analysis
Luteal phase progesterone - <9.5 = anovulatory
Urinary LH - a positive test kit result indicates imminent ovulation
Transvaginal USS - may demonstrate follicular development, polycystic appearance of ovaries, presence of significant cysts (including endometriomas), abnormal uterine structure (e.g., with congenital abnormalities), presence of fibroids, endometrial polyps, hydrosalpinges
Hysterosalpingogram - performed between cycle days 7 and 11 - fallopian tubes: patent or blocked, with free spill of dye and normal tubal pattern; uterus: normal or abnormal contour, presence or absence of filling defects
Consider basal FSH measurement - hypogonadotophism
Serum LH - hypogonadotophism
Check serum testosterone, prolactin, TSH
Can do 3d US
Karyotyping - may demonstrate chromosomal abnormality (e.g., with Turner’s syndrome)
A 38-year-old woman presents to her gynaecologist for her annual examination. She has no specific complaints. Her menstrual cycle is regular, occurring every 28 to 30 days and lasting about 5 days. She has, however, noticed that recently her periods have been heavier than usual. On pelvic examination, she has an enlarged uterus, about the size of an 8-week pregnant uterus. Urine pregnancy test is negative. Her full blood count is normal. A pelvic ultrasound shows 2 fibroids within the uterine wall measuring 2 cm each.
Fibroids
An 18-year-old pregnant woman presents at 10 weeks’ gestation with vaginal bleeding. Vital signs indicate sinus tachycardia and hypertension. On pelvic examination the uterus is enlarged to 16 weeks’ gestational size with a palpable left adnexal cyst of about 9 cm diameter. Pelvic ultrasound reveals a mixed echogenic (snow-storm) pattern with no fetus and thin-walled cysts in the left ovary.
Molar pregnancy
What are the endocrine causes of excessive menorrhagia?
PCOS Hyperprolactinaemia Hypothyroidism Dysfunction of the hypothalamo-pituitary-ovarian axis Dysfunctional corpus luteum
Ix for urogenital prolapse
Clinical
Potential UTI screen
Describe the complications of endometrial cancer
Bladder instability post surgery Vaginal stenosis, atrophy, fibrosis post radio Long term sexual dysfunction Local/distant spread Lymphoedema Chemo toxicity Bowel/bladder fistulae
Generate a management plan for ectopic pregnancy
Tubal
Low risk - Expectant management
Mod/high - methotrexate + surgery + anti-D immunoglobulin +/- post surgical methotrexate
Summarise the indications for evacuation of retained products of conception (ERPC)
Second trimester abortion
Post miscarriage
Summarise the prognosis for patients with diabetes in pregnancy
GDM recurs in 30% to 84% of subsequent pregnancies. Risk factors for GDM recurrence are older age, increased BMI, and higher weight gain between pregnancies.
Eventually the majority of women with GDM develop type 2 diabetes.
- metformin/exercise reduces
Ten-year risk approximates 50%
A 42-year-old smoker presented to labour and delivery at 28 weeks of gestation with worsening abdominal pain of a few hours’ duration. She had also had some vaginal bleeding within the past hour. She was found to have low-amplitude, high-frequency uterine contractions, and the fetal heart rate tracing showed recurrent late decelerations and reduced variability. Her uterus was tender and firm to palpation.
Placental abruption
A couple presents to a fertility clinic as they were unable to achieve pregnancy after 1 year of unprotected intercourse. The woman is 28 years old with regular and normal menses. A hysterosalpingogram shows normal uterine contour and patent tubes bilaterally. The male partner is 29 years old with negative medical history. Examination is unremarkable, with normal testicular volume and secondary sexual characteristics. Two semen analyses separated by 1 month show low sperm concentration (15 million/mL), decreased sperm motility (20%), and increased percentages of sperm with abnormal morphology.
Male factor infertility
Define Bartholin’s cyst
A Bartholin’s duct cyst is a non-infectious occlusion of the distal Bartholin’s duct, with resultant retention of secretions.
The paired Bartholin’s ducts are located at the posterior vestibule and provide a conduit for secretions from the Bartholin’s glands. A Bartholin’s duct cyst may be asymptomatic if the cyst is small. It typically presents as a medially protruding mass at the inferior aspect of the labia majora, in the posterior introitus, and is crossed by the labium minus. Duct cysts and gland cysts are indistinguishable, and the terms are used interchangeably. A Bartholin’s duct abscess may be primary (from bartholinitis) or secondary (from infection of Bartholin’s cyst).
Define bacterial vaginosis
Vaginitis is inflammation of the vagina due to changes in the composition of the vaginal micro-environment from infection, irritants, or from hormonal deficiency (e.g., atrophic vaginitis). Bacterial vaginosis, trichomoniasis, and candidiasis are types of infections that cause vaginitis.
Describe the prognosis for miscarriage
Recurrent miscarriage of pregnancies with the same partner affects 1% to 2% of otherwise healthy women. These patients will require a complete assessment to identify the cause.
Persistence of vaginal bleeding or spotting should raise the possibility of gestational trophoblastic disease
Psychological upset after a miscarriage event is not uncommon, but the severity varies.
RFs for fatty liver of pregnancy
There is a predilection for nulliparous women and women with multiple gestations.
Recognise the presenting symptoms/signs of ectopic pregnancy
abdominal pain
- Typically unilateral lower abdominal pain; however, patient may present with generalised or upper abdominal pain.
- Pain with vomiting may be indicative of tubal rupture.
amenorrhoea - 6-8 weeks
vaginal bleeding
abdominal tenderness
- Typically lower quadrant with voluntary guarding.
- If involuntary guarding, rebound, or other acute abdomen findings present, could be warning sign of rupture.
adnexal tenderness or mass
blood in vaginal vault
UNCOMMON
haemodynamic instability, orthostatic hypotension
cervical motion tenderness
urge to defecate
referred shoulder pain
- Bleeding from Fallopian tube -> irritates diaphragm
Sx of FGM
●Type I consists of excision of the prepuce, with or without excision of part or all of the clitoris.
●Type II involves clitoridectomy and partial or total excision of the labia minora.
●Type III, or infibulation, includes removing part or all of the external genitalia and reapproximation of the remnant labia majora, leaving a small neointroitus. Type IV involves other forms of injuries to the genital region including pricking, piercing, stretching, burning, scraping, or any other manipulation of external genitalia.
Women seek defibulation because they are pregnant or planning pregnancy, or because of apareunia/dyspareunia, dysmenorrhea, or difficulty urinating
Identify the possible complications of atrophic vaginitis and its management
Adverse effects — Adverse effects of vaginal estrogen therapy are uncommon. Women may complain of vaginal irritation, vaginal bleeding, or breast tenderness. Women who dislike the messiness of cream may use the insert or ring.
Complications / prognosis of cardiac disease in pregnancy
Severe HD:
Preterm labour, IUGR
Cyanosis of mother = severe risk
What is vasa praevia?
Whereby there is a vilamentous insertion of the cord. Vessels lie on the membranes that cover the internal os.
When the membranes rupture, vessels can be torn and PV bleeding/haemorrhage occurs. HOWEVER this is foetal blood - therefore delivery must be prompt
What are the complications of premature labour
Neonatal morbidity and mortality
Maternal adverse effects to Beta agonists
List Ix used to diagnose pelvic inflammatory disease
WCC - High
Vaginal secretion PMNs - High PMNs on smean (polymorphnucs)
ESR - elevated
N.Gonorrhoea/Ctracho in Vag secretions
CONSIDER TVUSS - increased tubal wall thickness/tubo-ovarian abscess/cogwheel tubal wall MRI/CT Laparoscopy Endometrial Biopsy
What are the signs/symptoms of pelvic inflammatory disease
MINIMUM CRITERIA FOR DIAGNOSIS:
A young, sexually active woman is presumed to have PID if she has pelvic or lower abdomen pain, no other cause for illness, and one or more of the following minimum criteria on pelvic examination:
- Adnexal tenderness
- Uterine tenderness
- Cervical motion tenderness.
OTHER: Lower abdominal pain - May be associated with dysuria, dyspareunia, or uterine bleeding. Abnormal discharge Fever N+V
Describe the management of endometrial polyps
Hysteroscopy + curettage / forceps
Histology
The most common presentations are hirsutism and infertility. Women typically present with oligo- or anovulation, manifesting as infrequent, irregular menstrual periods. PCOS may also more rarely present with menometrorrhagia. Some women present with regular menses and hirsutism, and on further investigation are found to have anovulatory cycles. There are no pathognomic features that suggest PCOS. It is largely a diagnosis of exclusion.
PCOS
Ix for subfertilty in men
Sperm concentration <15 million per ML
Sperm motility - <40% motile spermatozoa
Sperm morphology - <4% normal forms
Seminal fluid parameters - poor liquefaction; low ejaculate volume (<1.5 ml); decreased seminal pH; presence of fructose; increased leukocyte count
____________
Consider sperm viability testing - >42% sperm necrosis
Sperm membrane function - >40% reacted sperms
Measure FSH, LH, free and total testosterone, estradiol, sex hormone-binding globulin, and prolactin levels.
MRI - prolactinoma
Colour Flow doppler - varicocele
List the secondary causes of PPH?
24hrs-6weeks
Retained products
Endometritis
Persistent molar / choriocarcinoma
What are the complications of LETZ
Infection Haemorrhage Risk of infertility/sub Slight risk of miscarriage Increased risk of preterm births with multiple Rx
Prognosis of mastitis / breast abscess
When treated promptly and appropriately, most breast infections, including abscess, will resolve without serious complications. Resolution of mastitis after 2-3 days of appropriate antibiotic therapy is expected among most patients.
Lactational abscesses tend to be easier to treat than non-lactational abscesses because their aetiology and pathology is better understood. Non-lactational abscesses can be multifactorial and have a greater risk of becoming chronic.
HIV-infected mothers
To completely prevent HIV transmission via human milk, the US American Academy of Pediatrics recommends that HIV-infected mothers do not breastfeed their infants.
Mastitis may recur with delayed therapy, inappropriate therapy, uncorrected poor breastfeeding technique, nipple candidiasis, an underlying breast condition, and in Staphylococcus carriers. Recurrent mastitis or persistence of a mass after therapy may be due to a breast abscess or underlying breast lesion. Granulomatous mastitis has a high (up to 50%) recurrence rate.
Complications of small for dates/IUGR
Relative risks associated with IUGR using morbidity and mortality parameters, from the study by Bernstein et al, are as follows:
Relative risk of death, 2.77; 95% confidence interval (CI), 2.31-3.33
Relative risk of respiratory distress syndrome, 1.19; 95% CI, 1.03-1.29
Relative risk of intraventricular hemorrhage, 1.13; 95% CI, 0.99-1.29
Relative risk of severe intravascular hemorrhage, 1.27; 95% CI, 0.98-1.59
Relative risk of necrotizing enterocolitis, 1.27; 95% CI, 1.05-1.53
Generate a management plan for asthma in pregnancy
Normal Rx except:
- Caution with systemic glucocorticoids
- Methylxanthines, chromoglycates NOT USED
- Terbutaline = parenteral B agonist of choice
- Budesonide/salmeterol/albuterol used
- Immunoglobulins seem safe
Maternal positioning – In general, pregnant patients with acute asthma should rest in a seated or lateral position, rather than supine, particularly in the third trimester, to avoid aortocaval compression by the gravid uteru
Albuterol is recommended as the short-acting beta agonist of choice.
Budesonide has been the preferred inhaled glucocorticoid for use during pregnancy
Salmeterol/formoterol has been recommended as the inhaled long-acting beta agonist of choice
Montelukast or zafirlukast could be considered as alternative but NOT preferred therapy for mild persistent asthma or as add-on therapy to inhaled glucocorticoids
Identify appropriate investigations for asthma in pregnancy and interpret the results
FEV1/FVC ratio FEV1 peak expiratory flow rate (PEFR) CXR FBC
bronchial challenge test
immunoassay for allergen-specific IgE
skin prick allergy testing
Ix for lichen sclerosis
Biopsy can confirm but usually clinical
What is the aetiology of post-natal depression
The aetiology is poorly understood but is likely to involve an interaction between psychological, social, and biological factors.
Define UTI in pregnancy
Infection of the urinary tract.
Asymptomatic bacteria = most common
Ranges from cystitis -> pyelonephritis
Pyelonephritis is the most common serious medical complication of pregnancy
What is the aetiology of endometrial polyps
Appear to grow in response to oestrogen
RFs for obstetric cholestasis
STRONG Hx of prev Hx Hep C FHx Age >35
WEAK
Multiple pregnancy
What are the Ix for ovarian cancer
Pelvic USS - presence of solid, complex, septated, multi-loculated mass; high blood flow
CT scan - peritoneal thickening, enlarged lymph nodes, ascites, omental thickening, liver metastases
CA-125 - >35 units (>65 in PM = usually cancer)
Histopathology - infiltrative destructive growth best demonstrated by clusters of disorganised cells, usually with desmoplasia
CONSIDER PET
Define pelvic inflammatory disease
Pelvic inflammatory disease (PID) comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually transmitted organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis , are implicated in many cases; however, micro-organisms that comprise the vaginal flora (e.g., anaerobes, Gardnerella vaginalis , Haemophilus influenzae , enteric gram-negative rods, and Streptococcus agalactiae ) have also been associated with PID. In addition, cytomegalovirus (CMV), Mycoplasma hominis , Mycoplasma genitalium , and Ureaplasma urealyticum might be associated with some cases of PID. Symptoms include fever, vomiting, back pain, dyspareunia, and bilateral lower abdominal pain, as well as symptoms of lower genital tract infection such as abnormal vaginal odour, itching, bleeding, or discharge. In some instances, symptoms are mild or even absent.
Describe the relevant investigations for urinary incontinence in women
Empty supine stress test - urine leakage
Urinalysis - normal or may show WBCs, nitrites, RBCs with underlying infection, or malignancy
Post-void residual measurement - elevated if >100mL or >50% voided volume
Cough stress test - leakage
Urodynamic testing - The bladder is filled with sterile fluid. Changes such as first sensation, desire to void, and bladder capacity are recorded electronically during the filling and storage phase. Urinary loss from the urethra during provocative manoeuvres, such as coughing, is documented.
Cystourethroscopy - may reveal fistula, foreign body, tumour, or interstitial cystitis
Describe the RFs for ovarian cysts
STRONG Premenopausal Early Menarche 1st Trimester PHx infertility / PCOS (due to GnRH Rx) Tamoxifen Hx / FHx endometriosis
WEAK
Smoking
Sx of mastitis / breast abscess
COMMON Fever - mastitis or asbscess Flu-like symptoms, myalgia, malaise Breast pain (when breast feeding) Decreased milk outflow Breast warmth - Lactational mastitis tends to involve more peripheral wedge-shaped areas. Tenderness Breast firmness Breast swelling Erythema
UNCOMMON Mass - abscess Fistula - may be associated with abscess Discharge Lymphadenopathy (axillae) Extra-mammary lesions
Summarise the indications for cardiotocography
Labour
Problems in pregnancy
Monitoring in high risk.
Define ectopic pregnancy
A fertilised ovum implanting and maturing outside of the uterine endometrial cavity, with the most common site being the fallopian tube (97%), followed by the ovary (3.2%) and the abdomen (1.3%). [1] If undiagnosed or untreated, it may lead to maternal death due to rupture of the implantation site and intraperitoneal haemorrhage.
Describe the signs/symptoms for toxic shock syndrome
Severe diffuse/localised pain in an extremity (streptococcal) Fever Localised swelling/erythema Desquamating rash Hypotension
UNCOMMON Diffuse erythematous rash Influenza-like symptoms Muscle tenderness/weakness Abdominal pain/tenderness Myocarditis features Hypothermia (shock)
Generate a management plan for menopause
Lifestyle changes - diet, WL, reducing stress
HRT - Oestrogen + Progestin SERMs SSRIs - treat vasomotor symptoms Gabapentin Clonidine
Can give vag oestrogen-androgen combination in Vag symptoms only
What is the epidemiology of post-natal depression
The overall prevalence of clinically significant postnatal depressive symptoms is estimated to be 7% to 19%, although estimates vary.
What is the epidemiology of Rh incompatibility
About 15% of the white population has an RhD-negative blood type.
In the UK, about 16% of the white population is RhD negative. In 2005, it was estimated that about 65,000 RhD-positive babies were born in the UK to women who were RhD-negative (accounting for 10% of all births).
Identify appropriate investigations for amniotic fluid embolism and interpret the results
INC WCC
Anaemia
DIC - inc D-dimer, low fibrinogen (<200g/L), thrombocytopenia <150-400
ABG - hypoxaemia, pos met acidosis if cardiac arrest
Radiographic - pos bilateral oedema/haemorrhage
ECG - tachy / pos arrhythmia
FETAL signs:
- decelerations
- loss of variability
- bradycardia
Typical investigations include complete blood count, chemistries, renal and liver function tests, cardiac enzymes, brain natriuretic peptide levels, chest radiography, arterial blood gases, electrocardiography, and/or bedside ultrasonography (if available). The primary purpose of initial investigations is to narrow the differential since AFES is a diagnosis of exclusion.
Aetiology of lichen sclerosis
A/I
Inflammation in the subnormal layers resulting in hyalinisation of the skin
Define colposcopy +/- cervical punch biopsy
Medical procedure allowing visualisation of the cervix and tissues of the vulva and vagina using a camera.
Illuminated and magnified view.
3% Acetic acid solution and iodine solution (Lugol’s or Schiller’s) are applied to the surface to improve visualization of abnormal areas.
Areas of acetowhiteness correlate with higher nuclear density.
A cervical punch biopsy [punch forceps] is when a small piece of tissue is taken from the cervix.
Endocervical curettage to collect tissue.
Silver nitrate to coagulate blood.
Dorsal lithotomy position
Explain the aetiology of fibroids
The exact aetiology of uterine fibroids is not completely understood. There is good evidence that uterine fibroids grow from a single mutated uterine smooth muscle cell and are thereby monoclonal tumours. Initiation and promotion of abnormal growth of this single myometrial cell, however, is less well-understood. Chromosomal rearrangements including specific translocations have been identified in some specimens, which may be responsible for the initiation and proliferation of uterine fibroids. Multiple leiomyomas develop de novo rather than through a metastatic mechanism.
Describe management of the first phase of labour?
Most women experience onset of labor without premature rupture of the membranes (PROM); however, approximately 8% of term pregnancies is complicated by PROM. Spontaneous onset of labor usually follows PROM such that 50% of women with PROM who were expectantly managed delivered within 5 hours, and 95% gave birth within 28 hours of PROM.
Group B streptococcal prophylaxis be given based on prior culture results or risk factors of cultures not available.
On admission to the Labor and Delivery suite, a woman having normal labor should be encouraged to assume the position that she finds most comfortable. Possibilities including walking, lying supine, sitting, or resting in a left lateral decubitus position. Of note, ambulating during labor did not change the progression of labor in a large randomized controlled study of >1000 women in active labor.
The patient and her family or support team should be consulted regarding the risks and benefits of various interventions, such as the augmentation of labor using oxytocin, artificial rupture of the membranes, methods and pharmacologic agents for pain control, and operative vaginal delivery (including forceps or vacuum-assisted vaginal deliveries) or cesarean delivery. They should be actively involved, and their preferences should be considered in the management decisions made during labor and delivery.
The frequency and strength of uterine contractions and changes in cervix and in the fetus’ station and position should be assessed periodically to evaluate the progression of labor. Although progression must be monitored, vaginal examinations should be performed only when necessary to minimize the risk of chorioamnionitis, particularly in women whose amniotic membrane has ruptured. During the first stage of labor, fetal well-being can be assessed by monitoring the fetal heart rate at least every 15 minutes, particularly during and immediately after uterine contractions. In most labor and delivery units, the fetal heart rate is assessed continuously.
Two methods of augmenting labor have been established. The traditional method involves the use of low doses of oxytocin with long intervals between dose increments. For example, low-dose infusion of oxytocin is started at 1 mili IU/min and increased by 1-2 mili IU/min every 20-30 minutes until adequate uterine contraction is obtained.
The second method, or active management of labor, involves a protocol of clinical management that aims to optimize uterine contractions and shorten labor. This protocol includes strict criteria for admission to the labor and delivery unit, early amniotomy, hourly cervical examinations, early diagnosis of inefficient uterine activity (if the cervical dilation rate is < 1.0 cm/h), and high-dose oxytocin infusion if uterine activity is inefficient. Oxytocin infusion starts at 4 mili IU/min (or even 6 mili IU/min) and increases by 4 mili IU/min (or 6 mili IU/min) every 15 minutes until a rate of 7 contractions per 15 minutes is achieved or until the maximum infusion rate of 36 mili IU/min is reached.
Discuss the signs and symptoms of post-natal depression
Depressed mood Anhedonia Decreased energy Decreased concentration Appetite change Feelings of guilt Loss of confidence Sleep disturbance Obsessive thoughts Suicidal ideation
OTHER
Self harm
FHx
Psychotic symptoms
Rx of obesity in pregnancy
Behavioural, pharmacological and surgical methods
Very difficult
Weight reduction not advisable during pregnancy
Should LIMIT weight gain to 5-9kg (lifestyle interventions and physical activity)
Be diligent at picking up GHTN / Pre-Eclampsia
Define pre-eclampsia
A hypertensive syndrome that occurs in pregnant women after 20 weeks’ gestation, consisting of new-onset, persistent hypertension (defined as a BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic, based on at least 2 measurements taken at least 4 hours apart) with one or more of the following: 1) proteinuria (defined as urinary excretion of ≥0.3 g/24 hours of protein); 2) evidence of systemic involvement, such as renal insufficiency (elevated creatinine), liver involvement (elevated transaminases and/or right upper quadrant pain), neurological complications, haematological complications; 3) fetal growth restriction.
Summarise the indications for colposcopy +/- cervical punch biopsy
Normally for abnormal Pap smear
Other indications:
- Immunosuppression
- HIV
- Sexual assault forensic examination
Summarise the prognosis of molar pregnancies
Preeclampsia - usually asymptomatic
Invasive gestational trophoblastic neoplasia - ie invasion of hydatidiform mole - CHECK HCG has gone down
Choriocarcinoma
Trophoblastic tumours in placenta / epithelioid
Post-evacuation resp distress
Ashermans syndrome
Metastases
Define cardiotocography
Cardiotocography (CTG) is a technical means of recording the fetal heartbeat and the uterine contractions during pregnancy.
Continuous or intermittent.
Heart rate (A) is calculated from fetal heart motion determined by ultrasound, and uterine contractions are measured by a tocodynamometer (B)
Abnormal baseline is termed bradycardia when the baseline FHR is less than 110 bpm; it is termed tachycardia when the baseline FHR is greater than 160 bpm.
Contractions:
Normal- less than or equal to 5 contractions in 10 minutes, averaged over a 30-minute window
Tachysystole- more than 5 contractions in 10 minutes, averaged over a 30-minute window
Using this definition, the baseline FHR variability is categorized by the quantitated amplitude as:
Absent- undetectable
Minimal- greater than undetectable, but less than or equal to 5 beats per minute
Moderate- 6-25 beats per minute
Marked- greater than 25 beats per minute
Moderate = low chance of academia / hypoxic injury.
An abrupt increase is defined as an increase from the onset of acceleration to the peak in less than or equal to 30 seconds. To be called an acceleration, the peak must be greater than or equal to 15 bpm, and the acceleration must last greater than or equal to 15 seconds from the onset to return to baseline.[12] A prolonged acceleration is greater than or equal to 2 minutes but less than 10 minutes in duration.
Early Decelerations are a result of increased vagal tone due to compression of the fetal head during contractions. Early decelerations begin and end at approximately the same time as contractions, and the low point of the fetal heart rate occurs at the peak of the contraction.
Late Decelerations are a result of placental insufficiency, which can result in fetal distress. In contrast to early deceleration, the low point of fetal heart rate occurs after the peak of the contraction, and returns to baseline after the contraction is complete.
Variable Decelerations are generally a result of umbilical cord compression, and contractions may further compress a cord when it is trapped around the neck or under the shoulder of the fetus. When variable decelerations are associated with uterine contractions, their onset, depth, and duration commonly vary with successive uterine contractions.
Prolonged Deceleration: Decrease in FHR from baseline greater than or equal to 15 bpm, lasting greater than or equal to 2 minutes, but less than 10 minutes. A deceleration greater than or equal to 10 minutes is a baseline change.
Internal cardiotocography uses an electronic transducer connected directly to the fetal scalp
Define syphilis infection
Syphilis is a sexually transmitted infection caused by the spirochaetal bacterium Treponema pallidum , subspecies pallidum . It is found only in human hosts. Acquired infection is transmitted through direct person-to-person sexual contact with an individual with early syphilis. Vertical transmission from mother to baby causes a congenital infection. Most sexual transmission of syphilis probably occurs from the genital and mucous membrane lesions of primary and secondary syphilis. Syphilis has often been described as the great imitator because many of the symptoms and signs are difficult to distinguish from other diseases.
What is the prognosis of placenta praevia
About 85% of placentas that are praevia at about 15 to 20 weeks and about one third that are praevia at 20 to 23 weeks will no longer be praevia at the onset of labour.
Prognosis may be worse in complete versus partial placenta praevia.
Prognosis/complications of urogenital prolapse
Stress incontinence
Dyspareunia
Recurrence
Rx of mastitis / breast abscess
In an early stage, when signs and symptoms of mastitis have not been present for more than 12-24 hours, it may be possible to manage the condition without antibiotics. However, antibiotics are required if the pain becomes severe or lasts more than 12-24 hours, if milk or blood culture is positive, or if there are any signs of systemic infection.
Breastfeeding should continue frequently (e.g., breastfeeding 8-12 times per day) to promote effective milk removal.
Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used.
The patient should be advised to increase her fluid intake, try warm and/or cold compresses, and have bed rest.
_________________
Antibiotics are indicated for patients with acute pain, severe symptoms, or symptoms lasting more than 12-24 hours; fever or any other signs of systemic infection; or positive microbiology studies.
Flucloxacillin / cefalexin / clindamycin 10-14 days
NB NO IMPROVEMENT IN 24 HRS = give vancomycin IV
_________________
Needle aspiration (18- to 19-gauge needle) with local anaesthesia, with or without ultrasound guidance, can be used to drain an abscess.
Discuss the signs and symptoms of premature labour
COMMON
Uterine contractions
PROM
Advanced cervical dilation
Cervical length <2cm
UNCOMMON
Increased maternal/fetal HR
Non-specific lower abdominal or back pain
Fever
Vaginal bleeding
Explain the aetiology of molar pregnancy
Not fully understood.
An important component is the presence of excess paternal chromosomes. There is a greater risk for malignant transformation in the presence of a Y chromosome, suggesting a genetic component for the more aggressive form of the disease.
Classified as:
Benign trophoblastic tumours
Hydatidiform moles
Gestational trophoblastic neoplasia = malignant possibilities
Complications / prognosis of vulval cancer
5yr survival 75%
Prognosis poor if >4cm, sphincter involvement, groin mets
Wound breakdown/infection Thromboemolic disease Secondary haemorrhage Chronic leg oedema Parasthesia over leg Impaired sexual function
Discuss the signs/symptoms of menopause
Amenorrhoea Irregular cycle in 40s marks perimenopause Hot flushes + night sweats (7.4y duration) Vag dryness, itching Dyspareunia Pale/dry looking Decreased vag rugae Irritability + mood swings Sleep disturbance Mild memory impairment Sleep disturbance Mild memory impairment
Complications of PCOS
Infertility Spontaneous pregnancy loss T2DM NAFLD CVD Endometrial hyperplasia/cancer Metabolic syndrome Dyslipidaemia Psychological complications OSA
What are the RFs for pre-eclampsia
Primiparity Hx FHx BMI >30 Maternal age > 35 Twin pregnancy Sub-fertility Gestational HT PCOS A/I disease Renal disease Chronic HTN
WEAK
Interval of 10ys since last pregnancy
High altitude
Aetiology of FGM
Cultural
Ix for thyroid disease in pregnancy
HYPER:
Markedly depressed TSH, elevated t4, sometime t3.
Graves: anti-TSH receptor antibodies
May be associated with GTD/Hyperemesis G
HYPO:
High TSH, Low t4
Anti-TPO antibodies
Discuss the management of PPH?
Basic ABC + resus
IV access
Replace blood / factors etc as needed / u+e
Atony - give syntocinon, IM/PR prostaglandins (carboprost), SURGERY - bilateral uterine artery embolisation
Genital tract trauma - repair
Retained placenta - controlled cord traction delivery + ABx
Accrete
What are the signs/symptoms of cervical polyps
Irregular menstrual bleeding IMB PMB PC bleed Thick white/yellow discharge Asymptomatic
Prognosis/complications of fatty liver of pregnancy
The prognosis for women who develop AFLP is excellent, assuming they survive the acute event. However, a case of chronic pancreatitis has been described, occurring about 3 months after recovery and discharge from the hospital.
List aetiology of pruritus vulvae
Candida Lichen sclerosis Eczema VIN Contact dermatitis
Vulva irritation can be caused by any moisture left on the skin. This moisture may be perspiration, urine, vaginal discharge or small amounts of stool. It may be caused by vaginal infections, vulvitis, HPV (human papilloma virus) infection, anal incontinence, Bowen’s disease, or dietary irritants (caffeine, potatoes, chilli, capsicum, tomatoes, and peanuts).
Patch testing may be useful for diagnosis
What are the RFs for miscarriage
STRONG Older age Uterine malformation Bacterial vaginosis (2nd trimester) Thrombophilia [hyperhomocysteinaemia//antiphosp] Parental chromosomal anomaly
WEAK Hx Infertility NSAIDs Caffeine Alcohol Smoking BMI high DM Thyroid dysfunction
Define the 3 stages of labour
First stage of labor
Divided into a latent phase and an active phase
Begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm
The latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix
Contractions become progressively more rhythmic and stronger
The active phase usually begins at about 3-4 cm of cervical dilation and is characterized by rapid cervical dilation and descent of the presenting fetal part
Second stage of labor
Begins with complete cervical dilatation and ends with the delivery of the fetus
In nulliparous women, the second stage should be considered prolonged if it exceeds 3 hours if regional anesthesia is administered or 2 hours in the absence of regional anesthesia
In multiparous women, the second stage should be considered prolonged if it exceeds 2 hours with regional anesthesia or 1 hour without it.
Third stage of labor
The period between the delivery of the fetus and the delivery of the placenta and fetal membranes
Delivery of the placenta often takes less than 10 minutes, but the third stage may last as long as 30 minutes
Expectant management involves spontaneous delivery of the placenta
The third stage of labor is considered prolonged after 30 minutes, and active intervention is commonly considered.
Active management often involves prophylactic administration of oxytocin or other uterotonics (prostaglandins or ergot alkaloids), cord clamping/cutting, and controlled traction of the umbilical cord
Ix for pregnancy of unknown location
USS:
Definite ectopic pregnancy Extrauterine gestational sac with yolk sac or
embryo (with or without cardiac activity).
Pregnancy of unknown location – probable ectopic pregnancy Inhomogeneous adnexal mass or extrauterine sac-like structure.
“True” pregnancy of unknown location No signs of intrauterine nor extrauterine pregnancy on transvaginal ultrasonography.
Pregnancy of unknown location – probable intrauterine pregnancy Intrauterine gestational sac-like structure.
Definite intrauterine pregnancy Intrauterine gestational sac with yolk sac or embryo (with or without cardiac activity).
Define substance abuse in pregnancy
The use and abuse of illicit or harmful drugs during pregnancy
Rx of vasa praevia
Cesarean delivery is the preferred mode of delivery for known vasa previa and is mandatory if significant vaginal bleeding occurs.
Sx of subfertilty in men
Inability to conceive Vasectomy Palpable and dilated testicular veins ED Dec libido TEstis atrophy Body habitus, abnormal hair distribution, and gynaecomastia - KLEINFELTERS Absent vasa/epididymus
OTHER UNCOMMON
Headaches/galactorrhoea/visual disturbance -> prolactinoma
Anosmia - kallmans
Frequent resp infections - immotile cilia syndrome - PCD
Pain, blood or pus with ejaculation - prostatitis or epididymitis
Define menopause
Onset of the menopause is heralded by the cessation of menses for at least 12 consecutive months, without some other reason for amenorrhoea (such as pregnancy, hormone therapy, or other medical condition).
Permanent cessation of ovarian function may occur surgically by removal of both ovaries (surgical menopause) or medically, usually due to chemotherapy or radiotherapy (treatment-induced menopause)
The perimenopause includes the years before and after the cessation of menses in an ovulating woman and is marked by irregular menses and menopausal symptoms. Management of menopause symptoms requires individualisation based on each woman’s clinical circumstance.
Ix for vasa praevia
Vasa previa is diagnosed prenatally with an average sensitivity of 93% and a specificity of 99%.
US scan
Consider endovaginal color flow Doppler ultrasonography to rule out vasa previa for patients with a known succenturiate lobe or velamentous insertion of the cord.
Explain the risk factors of diabetes in pregnancy
advanced maternal age (>40 years) elevated BMI polycystic ovarian syndrome (PCOS) non-white ancestry Hx Smoking Dec exercise FH Low fibre/high glycemic index
Define placental abruption
The premature separation of a normally located placenta from the uterine wall that occurs before delivery of the fetus. Abruption may be revealed, when blood escapes through the vagina, or concealed, when the bleeding occurs behind the placenta, with no evidence of bleeding from the vagina. [1] Abruption may be partial, affecting only part of the placenta, or total, involving the entire placenta.
Abnormal uterine artery Doppler velocimetry at 23 to 24 weeks of gestation may carry an increased risk of abruption later in pregnancy
Aetiology of multiple pregnancy
The etiology of monozygotic twinning is unknown. Dizygotic twins are thought to result from the ovulation of multiple follicles caused by elevations in serum gonadotropin levels. Hence, advanced maternal age is associated with an increased prevalence of twin birth.
The availability of assisted reproductive technology has contributed to the increase in multiple gestations seen over the past 20 years. During ovulation induction treatment, the ovaries are stimulated to produce several follicles, thus increasing the risk of multiple eggs being released and subsequently fertilized. The risk of multiple gestations during in-vitro fertilization is directly related to maternal age and number of embryos transferred.
A 41-year-old white female presents to her gynaecologist for a routine healthcare visit. She has no complaints except for some mild lower abdominal bloating. Her past medical and surgical history is unremarkable. Her sister has recently been diagnosed with endometriosis. She and her husband have been trying to conceive for the past 2 years and have been unsuccessful. She is requesting a referral to an infertility consultant. On examination, she is thin and in no distress. Pelvic examination reveals 10 cm bilateral adnexal masses indistinguishable from the uterus. Transvaginal ultrasound performed in the clinic is significant for ovarian masses with homogeneous, low-level internal echoes.
Endometriosis
Rx of fatty liver of pregnancy
Monitor fetal wellbeing closely and counsel mother on emergency deliveries
5% dextrose - prevent + Rx hypoglycaemia
Monitor fluid balance closely
Plasmapheresis/plasma exchange has improved outcomes if - severe encephalopathy, on ventilator support, or with severe liver or renal insufficiency who failed to respond to conventional management
Consult anaesthetist regarding the anaesthetics that can be used
Generate a management plan for post-natal depression
Facilitated self help.
Lifestyle
Antidepressants - Sertraline / paroxetine
What are the iatrogenic causes of menorrhagia?
IUD
Anticoagulant therapies
Tamoxifen
Herbal supplements - ginseng
Ix for substance abuse in pregnancy
The following studies are indicated when assessing perinatal drug abuse and neonatal drug withdrawal:
Obtain a serum glucose level.
Obtain a serum calcium level.
Perform a CBC count with differential and platelets.
Consider blood culture and other cultures to rule out newborn sepsis.
Confirm maternal hepatitis status and treat accordingly.
Confirm human immunodeficiency virus (HIV) status.
A urine toxicological screen may be helpful in determining drug use. A urine screen only signifies recent use or heavy use of drugs. In general, the length of time that a drug is present in urine after use is as follows:
Marijuana: 7 days to 1 month in an adult, perhaps even longer in an infant
Cocaine: 24-28 hours in an adult, 72-96 hours in an infant
Heroin: 24 hours in an adult, 24-48 hours in an infant
Methadone: Up to 10 days in an infant
A 38-year-old primigravida woman presents for routine antenatal care. Her blood type is known to be Rh-negative with a negative indirect Coombs test, and her sexual partner is Rh-positive. She has been counselled regarding the need for Rh immunoprophylaxis at 28 weeks of pregnancy and postnatally if her newborn is found to be Rh-positive.
Rh incompatibility
Rx of lichen sclerosis
Good skin care - cleaning and moisturising afterwards
Steroid cream eg dermovate
A 30-year-old woman, gravida 2 para 1, at 22 weeks’ gestation presents to the outpatient obstetrics clinic for a routine antenatal visit. She has no significant past medical history. Her first pregnancy was uncomplicated and her child (now 4 years of age) is doing well. On examination, she is afebrile with a respiratory rate of 16 breaths per minute, pulse of 91 bpm, and blood pressure (BP) of 132/102 mmHg. Her previous BP reading was 120/80 mmHg. Urinalysis is negative for glucose and protein. The patient is asked to return in 1 week for a BP check. On check-in at the clinic, the patient tells the nurse that she does not have any symptoms. However, on examination, her BP has risen to 142/106 mmHg. Urinalysis remains negative for glucose and protein.
gestational HTN
What are the RFs for premature labour
STRONG
Hx premature labour Hx cervical trauma Hx induced abortion Maternal infections Multifetal pregnancies (av 3w before) Short cervical length Positive fetal fibronectin (1/3-1/2 of women have a +ve FFN at 23 weeks deliver before 30weeks) PROM
WEAK
Fetal abnormalities Smoking BMI <19 Social factors and ethnicity Polyhydramnios Domestic violence Poor dental hygeine
Define multiple pregnancy
The term multifetal gestation includes twins, triplets, and higher-order multiples.
Twins can be classified as monozygotic, originating from the fertilization and subsequent division of one egg, or dizygotic, originating from the fertilization and development of two eggs.
Twins can be further classified by their chorionicity. Dizygotic twins are almost always dichorionic, diamniotic. The chronicity of monozygotic twins depends on the timing of division of the fertilized egg. Dichorionic, diamniotic twins result if the fertilized egg splits 0-3 days after fertilization. This is thought to occur in approximately 20-30% of monozygotic twins. Monochorionic, diamniotic twins occur at days 4-8 after fertilization and account for approximately 70% of monozygotic twins. Monochorionic, monoamniotic twins are rare (1-5% of monozygotic twins) and result secondary to division 8-12 days postfertilization. Conjoined twins occur with division 13 days or later; this is extremely rare.
Identify the possible complications of anaemia in pregnancy and its management
Intrauterine growth restriction, death in utero, infection, preterm delivery and neurodevelopmental damage, which may be irreversible.
Maternal death (most common cause)
Explain risk factors of cervical cancer & intraepithelial neoplasia
STRONG Human papillomavirus (HPV) infection Age group HIV Multiple sexual partners Cigarette smoking Immunosuppression WEAK STDs Oral Contraceptive High Parity Uncircumcised male partner Micronutrient malnutrition Low folate Low Vit C Alcohol abuse Low socioeconomic
Summarise the epidemiology of Asherman’s syndrome (Intrauterine adhesions)
- 5 percent = incidental finding at hysterosalpingogram
21. 5 percent with a hx of postpartum uterine curettage
Explain the aetiology of diabetes in pregnancy
Women who develop GDM have deficits in beta-cell response leading to insufficient insulin secretion to compensate for the increased insulin demands. Risk is increased by:
Age: due to age-related decreased pancreatic beta-cell reserve
Obesity: leads to increased insulin resistance, which is further compounded by pregnancy
Smoking: increases insulin resistance and decreases insulin secretion
Polycystic ovarian syndrome: associated with insulin resistance and obesity
Non-white ancestry
Family history of type 2 diabetes
Low-fibre and high-glycaemic index diet
Weight gain as a young adult: correlates with risk
Lack of physical activity: exercise increases insulin sensitivity and may impact body weight
Prior GDM: GDM recurs in as many as 80% of subsequent pregnancies.
Ix for cardiac disease in pregnancy
Pre-pregnancy counselling:
- assessment of cardiac status
- eisenmenger = contraindication to pregnancy
Booking:
Haemic systolic murmurs are common in pregnancy
Assessment by cardiologist should be performed
Patients with known lesions should be supervised jointly by a cardiologist and obstetrician
List RFs for uterine atony (a cause of PPH)?
Multiple pregnancy Grand multiparity Fetal macrosomia Polyhydramnios Fibroid uterus Prolonged labour Previous PPH Antepartum haemorrhage
Describe the third stage of labour
Third stage of labor
The period between the delivery of the fetus and the delivery of the placenta and fetal membranes
Delivery of the placenta often takes less than 10 minutes, but the third stage may last as long as 30 minutes
Expectant management involves spontaneous delivery of the placenta
The third stage of labor is considered prolonged after 30 minutes, and active intervention is commonly considered.
Active management often involves prophylactic administration of oxytocin or other uterotonics (prostaglandins or ergot alkaloids), cord clamping/cutting, and controlled traction of the umbilical cord
RFs for PCOS
STRONG
FHx
Premature adrenarche
WEAK LBW Fetal androgen exposure Obesity Environmental endocrine disruptors
Describe the signs/symptoms of miscarriage
RFs PV bleed +/- clots Suprapubic pain/crampy Low-back pain Recent post-coital bleed Uterine structural abnormality eg fibroids
What is the epidemiology of vasa praevia?
1 in 2000-6000 pregnancies
Explain the aetiology / risk factors of atrophic vaginitis
An estimated 40% of woman post-menopause
Chemotherapy and radiotherapy
Prescription drugs and medicines that have anti-estrogen effects
Disorders/conditions affecting the function of ovaries, surgical removal of ovarian cysts
The period after childbirth; mothers who are lactating
Reduced incidence of sexual activity (intercourse) in adult women
Deficient production of the hormone estrogen due to cigarette smoking, physiological factors, vaginal changes, depression or intensive stress
Generate a management plan for pre-eclampsia
ALL WOMEN ADMITTED UNTIL BIRTH unless v low risk.
DEFINITIVE Rx = Delivery
<32 weeks - prolonging gestation is beneficial for fetes
34-37 weeks = early delivery increases risk of fetal respiratory distress syndrome BUT earlier delivery safer for mother
GIVE antenatal corticosteroids before 34 weeks if early delivery to mature fetal lungs
Delivery >36 weeks = optimum
ANTI-HTN
- Labetalol
- Nifedipine
- Methyldopa
- Hydralazine
SEIZURE COVER
- Magnesium sulfate
ASPIRIN
Rx of obstetric cholestasis
TREATMENT DEPENDS ON SEVERITY
MILD: <40micromol bile acids
Anti-Histamines - eg dipenhydramine
Ursodeoxycholic acid
Colestyramine
Phytomenadione (vit k)
SEVERE: >40micromol bile acids
Ursodeoxycholic acid
Phenobarbital (induces microsomal enzymes)
FETAL SURVEILLANCE IS REQUIRED
Steroids - systemic reduce itchiness, IM gven to mature metal lung
Colestyramine
Phytomenadione (vit k)
Anti-Histamines - eg dipenhydramine
NB do not give phenobarbital if used within 2 hours of colestyramine.
Pathological CTG - DELIVER
There is increased risk of pre-term delivery and intra-uterine fetal demise in those with intrahepatic cholestasis of pregnancy. Almost half will have meconium and up to 25% will develop non-reassuring fetal status in labour. The overall perinatal mortality is between 3% and 20%.
What are the complications of miscarriage
Incomplete evacuation of the uterus Post evacuation uterine bleeding Sepsis Uterine/cervix perforation Recurrence Ashermans syndrome Psychological dysfunction PV bleeding
What is considered prolonged active phase 1 of labour?
> 6cm dilation with ruptured membranes and one of the following: 4 hours or more of adequate contractions (>200 MVU) or 6 hours or more of inadequate contractions and no cervical change.
What is the prognosis for hyperemesis gravidarum
Uncomplicated = resolves by 20w
Furthermore, women who experience NVP have been shown to have improved pregnancy outcomes. These include a decrease in miscarriages, pre-term deliveries, and stillbirths. In addition, there is a lower prevalence for reduced fetal birth weight, fetal growth restriction, and fetal mortality.
Hyperemesis:
In contrast with uncomplicated NVP, hyperemesis gravidarum is associated with an increase in maternal morbidity, and also increased fetal morbidity and mortality.
Generate a management plan for endometriosis
- COCP
- NSAID throughout - +ve feedback of PG synthesis - Progestogen
- GnRH agonist
- Androgen
- Hysterectomy with bilateral salpingooophorectomy + excision of pelvic disease
- Will need HRT
Generate a management plan for cutaneous warts
Cryotherapy Trichloroacetic acid Podophyllotoxin topical Surgical removal CO2 laser ablation
Epidemiology of pregnancy of unknown location
8% and 10% of women attending for an ultrasound assessment in early pregnancy will be classified as having a PUL
Define urinary incontinence in women
Urinary incontinence is a complaint of involuntary loss of urine. It can have devastating effects on the patient, detrimentally affecting her level of activity and psychosocial state, leading to depression and withdrawal from social settings. Characterisation of the type of incontinence can help to elucidate the underlying aetiology and help to guide management.
Ix for small for dates/IUGR
SFH
US estimated gestation:
Measures FL, AC, HC
Hadlock 1 used FL, AC
Often uterine + umbilical arteries measured.
MCA doppler performed - abnormal MCA study results had earlier deliveries, lower birth weights, fewer vaginal deliveries, and increased admissions to neonatal ICUs
3D US can be performed in some places
Define vasa praevia
Vasa previa is an uncommon obstetrical complication that poses a high risk of fetal demise if not recognized before rupture of membranes. It is vital that providers recognize risk factors for vasa previa and diagnose this condition before the onset of labor so that fetal shock or demise is prevented. Neither the umbilical cord nor the placenta supports the vessels. Vasa previa presents with painless vaginal bleeding at the time of spontaneous rupture of membranes or amniotomy (AROM). Fetal shock or demise can occur rapidly. Fetal mortality for cases not recognized before the onset of labor is reported to range between 22.5% and 100%.
Ix for oligohydramnios
Oligohydramnios is ultrasonographically defined as an AFI less than 7 cm or the absence of a fluid pocket 2-3 cm in depth.
Premature rupture of membrane (PROM) is the most common cause of oligohydramnios; therefore, obtain available tests to confirm or exclude this condition. Maternal substance abuse and certain medications (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], angiotensin-converting enzyme inhibitors [ACEI]) can also cause oligohydramnios.
Test for systemic lupus erythematosus (SLE), which causes immune-mediated infarcts in the placenta as well as placental insufficiency.
Evaluate for pregnancy-induced hypertension (PIH) and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Test for elevated blood pressure, proteinuria, elevated uric acid levels, increased liver function test results, and low platelet count.
Generate a management plan for atrophic vaginitis
Vaginial moisturisers / lubricants
Inc sex reduces symptoms
Vaginal dilators
VAGINAL ESTROGEN THERAPY — Estrogen is the most effective treatment for moderate to severe symptoms of vaginal atrophy. (EDependent tumour = contra) vaginal > systemic - dec risk of thrombosis/breast cancer
Ring — A silastic ring impregnated with estradiol
Estradiol cream
Use of an opposing progestin — A progestin is probably not necessary to protect against endometrial hyperplasia or cancer in women treated for vaginal atrophy with low-dose preparations
OSPEMIFENE — Ospemifene (SERM)
Discuss the RFs for menopause
Age 40-60
Cancer Rx (chemo/radio destroy ovarian follicles)
Smoking
Ovarian surgery
Mothers age - not a strong predictor but weak
What is the epidemiology of placenta praevia?
Occurs in 0.3% to 0.5% of pregnancies worldwide.
The condition is uncommon in first pregnancies.
One caesarean section increases the incidence in the next pregnancy to about 0.6%. Subsequent caesarean sections increase the risk only slightly compared with one procedure.
Epidemiology of substance abuse in pregnancy
Neonatal withdrawal = 1-40 per 10k
The prevalence of prenatally exposed newborns to one or more illicit drugs averages approximately 5.5%, with a range of 1.3-50%
14.8% of pregnant women consumed alcohol
Identify the possible complications of cervical cancer & intraepithelial neoplasia and its management
Bleeding Bladder instability Radiation comps: vaginal stenosis/atrophy/fibrosis Long term Sex Dys Post radio lyphoedema Preterm birth Bowel/bladder fistula
Sx of thyroid disease in pregnancy
Hyper:
Often difficult to detect due to normal t4 excess in pregnancy:
SX
Tachycardia, thryomegaly, exophthalmos, failure to gain weight
Hypo:
Fatigue, constipation, cold intolerance, muscle cramps, weight gain.
Oedema, dry skin, hair loss, def deep tendon reflexes
Define endometrial polyp
Mass in the inner lining of the uterus
May be sessile or pedunculated
List the prognosis of ovarian cysts
The majority of ovarian cysts resolve spontaneously in all patient groups. Without strong supporting evidence for malignancy, management hinges on determining the likelihood of natural resolution. Surgery provides an immediate solution, but each patient group heralds different risks for recurrence.
Pregnancy related: 70-100% regress
A 34-year-old nulligravid woman presents to her gynaecologist with a complaint of inability to conceive. She has been married for 2 years and stopped using contraception 1 year ago. Her menstrual cycles occur regularly every 28 days and are associated with moliminal symptoms (breast tenderness, bloating, and mood changes). She denies dysmenorrhoea or dyspareunia. She has no significant medical history, has never had a sexually transmitted disease, and has never had surgery. Her husband is 34 years old and has never fathered a child. He has a history of hypertension controlled by beta-blockers.
Infertility in women
Generate a management plan for cervical cancer & intraepithelial neoplasia
Stage 1a - Local excision+LN dissection +/- hysterectomy
Stage 1a-b - radical hysterectomy + lymphadenectomy +/- chemoradiation
Stage 2b-4a - chemoradiation
Metastatic - combined chemo +/- local ablative therapy
Key questions in history taking for primary amenorrhoea?
Galactorrhoea: Hyperprolactinaemia is more commonly associated with secondary amenorrhoea.
History of a traumatic head injury or infection: a remote history may be elicited from the patient or parents.
Headache/visual field changes: suggest a CNS tumour (e.g., craniopharyngioma).
Anosmia: suggests Kallman syndrome or a complete congenital gonadotrophin-releasing hormone (GnRH) deficiency.
Poor nutritional status due to systemic illness, an eating disorder, and/or low body fat: may result in hypothalamic dysfunction. Extreme athleticism, especially with low BMI, may result in a similar phenomenon. An inquiry into a patient’s health status, eating habits, and body image is necessary.
Emotional stress: can impair hypothalamic function, resulting in hypogonadotrophic hypogonadism.
Chronic systemic illness: may present with fatigue, malaise, anorexia, and weight loss.
Family history: height should be documented and compared with that of other family members. Short stature is suggestive of Turner syndrome or hypothalamic-pituitary disease. A history of familial delayed puberty, in addition to onset of menarche in the patient’s mother and female siblings, should be elicited.
Define anaemia in pregnancy?
First trimester – Hemoglobin <110 g/L (approximately equivalent to a hematocrit <33 percent)
Second trimester – Hemoglobin <105 g/L (approximate hematocrit <31 or 32 percent)
Third trimester – Hemoglobin level <110 g/L (approximate hematocrit <33 percent)
Some individuals may have a significant decrease from baseline without crossing these thresholds, and clinical judgment is required to determine the reason(s) for the decrease and the need for (and aggressiveness of) further evaluation. As an example, in an individual with a baseline hemoglobin of 14 g/dL that decreases to 11 g/dL associated with macrocytosis, checking a reticulocyte count and testing for vitamin B12 and folate deficiencies is reasonable.
Anaemia is normally <120g/L FEMALE
<140g/L MALE
PREGNANCY = RF for anaemia
Other RFs include: extremes of age, female gender, lactation, and pregnancy.
Identify appropriate investigations for dysfunctional uterine bleeding and interpret the results
Pregnancy test, neg FBC - anaemia Coag profile - N Low progesterone Prolactin - hyperprolactinaemia TSH (hypo/hyperthyroid) Androgen levels - PCOS 17a hydroxyprogesterone - high in congenital adrenal hyperplasia Endometrial thickness - N NSAIDS Ovulation induction agents GnRH analogue
Generate a management plan for ovarian cancer
Grade 1/2 - comprehensive surgical staging
Grade 3 - chemotherapy (carboplatin + docetaxel)
Stage 2/3/4 - just chemotherapy
Define obesity in pregnancy
Pregnancy in an obese patient
AKA BMI >30
What Rx can be given for failure to progress?
Syntocinon
Dinoprostone and misoprostol are prostaglandin analogs used to stimulate cervical dilation and uterine contractions; they are pharmacologic alternatives to using laminaria or placing a Foley bulb in the cervix. Using prostaglandin analogs with a scarred uterus (eg, from prior cesarean or myomectomy) for labor induction is absolutely contraindicated due to the significant risk for uterine rupture.
Propranolol can be given
Identify the possible complications of dysfunctional uterine bleeding and its management
Endometrial hyperplasia/carcinoma possible
ID anaemia
Identify the possible complications of diabetes in pregnancy and its management
Maternal HTN C-Section Fetal macrosomia Neonatal hypoglycaemia Neonatal polycythaemia Neonatal jaundice Neonatal hypocalcaemia Birth injuries - shoulder dystocia Neonatal death Hypoglycaemia (insulin) Recurrent GDM T2DM
Define Asherman’s syndrome
Intrauterine adhesions
IUAs, or intrauterine synechiae, is a condition in which scar tissue develops within the uterine cavity. Intrauterine adhesions that are accompanied by symptoms (eg, infertility, amenorrhea) are referred to as Asherman syndrome. The degree of adhesion formation and the impact of the adhesions on the contour of uterine cavity vary greatly. Minimal disease is characterized by thin strands of tissue stretched across the uterine cavity while severe disease is characterized by complete obliteration of the cavity, with the anterior wall of the uterus densely adherent to the posterior wall.
Define subfertilty in men
The clinical definition of male factor infertility is the presence of abnormal semen parameters in the male partner of a couple unable to achieve conception after 1 year of unprotected intercourse. The World Health Organization defines male factor infertility as the presence of ≥1 abnormalities in the semen analysis or the presence of inadequate sexual or ejaculatory function.
Presence of abnormal semen parameters in the male partner of a couple unable to achieve conception after 1 year of unprotected intercourse.
Male factor alone contributes to 20% of cases of infertile couples and to an additional 30% to 40% in combination with other factors.
Most cases are of unknown aetiology.
Diagnosed if abnormal semen parameters in 2 semen analyses separated by 1 month.
Sperm functional assays, endocrine tests, genetic testing, and imaging can be helpful.
Treatment should be targeted to the aetiological factors whenever possible.
Assisted reproductive techniques are often the fastest and most effective method to achieve pregnancy regardless of the aetiology
Explain the aetiology / risk factors of dysfunctional uterine bleeding
age (years after puberty and before menopause) - women at both ends of their reproductive age period
polycystic ovary syndrome (PCOS)
other anovulatory disorders
endocrine disorders - hypothyroidism and hyperprolactinaemia, are frequently associated with DUB.
obesity
Summarise the RFs for endometrial cancer
STRONG Obesity - BMI over 30 triples risk Age >50 Endometrial Hyperplasia Unopposed exogenous oestrogen Tamoxifen FHx endometrial/breast/ovarian Fix PTEN syndromes PCOS Radiotherapy
WEAK Inactivity Insulin resistance (DM 3x risk) Nulliparity / Infertility White ethnicity
The condition can present in primigravidas or multi-gravidas, in the young and in those of advanced age. It can present as early as 20 weeks’ gestation but usually presents in the third trimester. A small number of women will have jaundice and significant liver dysfunction, and rarely coagulopathy from vitamin K deficiency. In some women the condition can present with signs of non-reassuring fetal status (abnormal fetal heart rate pattern or biophysical profile with score of ≤4) with severe pruritus, jaundice, elevated transferases, and premature labour or intra-uterine fetal demise. In a small number of patients the condition is confused with plaques, urticaria, and papules of pregnancy (PUPPS) as the pruritus leads to scratching, which can cause a rash-like appearance if not severe enough to cause excoriations. Pruritus without rash or other exposures is enough for the presumptive diagnosis.
obstetric cholestasis
Complications of infertility in women
Clomifene induced hypo-oestrogenism
Multiple gestation
Ovarian cancer
Ovarian hyper-stimulation syndrome:
Symptoms range from mild to severe. Mild OHSS manifests as bloating and abdominal discomfort. As the abdominal fluid collection continues it restricts diaphragmatic activity with resultant shortness of breath. Increased abdominal pressure can also restrict the inferior vena cava and reduce pre-load. A reduced intravascular volume decreases glomerular filtration rate and may result in renal failure. As intravascular depletion continues, the rising haematocrit can increase the risk of blood clotting. This risk is further increased by the high level of estradiol. Third spacing can occur in other tissues including the lungs and the brain.
Treatment is supportive. Paracentesis can improve respiratory effort and cardiac output. OHSS occurs in approximately 20% of all IVF cases but is only severe in <5%. Symptoms last approximately 1 week, but will continue longer when conception occurs.
Describe the examination of a PPH?
ABC Blood loss quantification Pulse BP Urine output Uterine contraction - if fully contracted it makes trauma/retained placenta likely cause Fundal height Placenta/membranes complete Genital tract trauma
Complications of subfertilty in men
Testicular cancer
Discuss the aetiology of placental abruption
Direct abdominal trauma may cause separation of the placenta.
Indirect trauma may shear the placenta off the uterine wall.
Cocaine use causes vasospasm that may lead to placental separation.
Define atrophic vaginitis
Vulvovaginal atrophy (also referred to as vaginal atrophy, urogenital atrophy, or atrophic vaginitis) results from estrogen loss and is often associated with vulvovaginal complaints (eg, dryness, burning, dyspareunia) in menopausal women [1]. Urinary frequency and recurrent bladder infections may also occur.
Summarise the epidemiology of amniotic fluid embolism
AFES is rare. Most studies indicate that the incidence is between 1 and 12 cases per 100,000 deliveries
90% occur during labour/immediately postpartum
RFs for termination of pregnancy
20s
Identify appropriate investigations for Bartholin’s cyst and interpret the results
Microscopy and culture of abscess material - Polymicrobial growth
Biopsy of vulval lesion - non-malignant cells
Atypical presentations may include mastitis and/or abscesses involving both breasts; the development of multiple breast abscesses; associated nipple inversion and/or retraction; and septicaemia and/or toxic shock syndrome. Inflammation of the male breast may occur but is unusual. Epidemic (hospital-acquired) puerperal mastitis is also infrequent. Uncommon causes of breast inflammation include myiasis (maggot infestation) and self-inflicted mastitis (mastitis factitia).
mastitis
The patient may present with an existing medical condition that is known to affect male fertility, including cystic fibrosis, prior chemotherapy or radiotherapy, hypospadias, cryptorchidism, and Klinefelter’s syndrome. Patients may also present with erectile dysfunction and signs of endocrinopathy.
Male factor infertility
Assessment of vaginal bleeding
List the causes of bleeding during pregnancy?
Ectopic
Miscarriage (before 22w)
2/3rd TRIMESTER
Placenta praevia (placenta overlying the cervical os)
Placental abruption - (premature separation of the placenta from the uterus)
Complications/prognosis of multiple pregnancy
FOETAL Preterm delivery (increases with number of gestations) TTTS (monochorionic) 3x risk cerebral palsy Stillbirth 7x risk of neonatal death Congenital anomalies IUGR
MATERNAL Preterm leabour PROM Pre-eclampsia GHTN GDM Placental abruption PE PPH Polyhydramnios VTE AFLP Malpresentation
What are the pregnancy related causes of menorrhagia?
Miscarriage
GTD (choriocarcinoma)
Ectopic
Aetiology of polyhydramnios
Fetal swallowing, which occurs physiologically, reduces the amount of fluid, and an absence of swallowing or a blockage of the fetus’s gastrointestinal tract can lead to polyhydramnios.
A near term fetus produces 500-1200 mL of urine and swallows between 210 and 790 mL of amniotic fluid per day.
IDIOPATHIC
Twin/multiple gestation
TTTS
Oesophageal atresia (usually associated with a tracheoesophageal fistula), tracheal agenesis, duodenal atresia, and other intestinal atresias
CNS problems preventing swallowing
Hydrops associated
Chromosomal abnormalities, most commonly trisomy 21, followed by trisomy 18 and trisomy 13.
Define asthma in pregnancy
Asthma is a chronic inflammatory airway disease characterised by intermittent airway obstruction and hyper-reactivity. Many cellular components are involved in the asthmatic pathway, including mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells. On insult, in susceptible people, inflammation causes increased bronchial hyper-responsiveness and recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, which are usually associated with widespread but variable airway obstruction that is reversible either spontaneously or with treatment.
What is the prognosis of pelvic inflammatory disease
Prognosis for complete recovery is good in patients treated within 3 days of symptom onset and who are able to complete the full course of therapy. Clinical and microbiological cure rates of 88% to 100% have been reported after oral antibiotic treatment. The risks of tubal occlusion and infertility depend on severity of infection before treatment. Clinical improvement may not translate into improved fertility. Patients who have co-existent conditions (HIV infection, pregnancy, IUD, prior PID or tubo-ovarian abscess) require close observation and may require hospitalisation.
Discuss the RFs for PROM
Infection of amniotic fluid PROM Hx Bleeding PV in pregnancy Smoking Low BMI Polyhydramnios Multiple gestation Invasive procedures Cervical insufficiency
Recognise the presenting symptoms of cervical cancer & intraepithelial neoplasia
Vaginal bleeding Postcoital bleeding Pelvic pain, dyspareunia Cervical Mass Cervical bleeding Mucoid/purulent discharge Bladder / renal / bowel OB Bone pain
What is the aetiology of ovarian cysts
Physiological: cyst development as an exaggerated response to normal physiological processes; includes follicular, endometriotic, corpus luteum, and theca lutein cysts
Infectious: an abscess or cystic collection of cellular debris
Benign neoplastic: excessive growth of normal ovarian tissue types without dysplasia; includes serous cystadenoma, mucinous cystadenoma, adenofibroma, fibroma, thecoma, mature cystic teratoma (dermoid cyst), and Brenner’s tumour
Malignant neoplastic: includes serous cystadenocarcinoma, mucinous cystadenocarcinoma, endometrioid carcinoma, and immature teratoma
Metastatic: invasion and growth of neoplastic tissue from another malignant source, most commonly ovarian, endometrial, colonic, or gastric cancers.
Discuss the investigations of PPH?
Establish IV access Send blood haemoglobin, platelets, clotting factors Cross-match blood Check U+Es Full blood count - secondary USS - check if retained products/molar B-HCG - if molar round - CxR + LFTs
Generate a management plan for placenta praevia
- If needing to deliver <34 weeks -> CORTICOSTEROIDS
- Potential tocolytics if preterm labour
- Labour desirable -> C section
Identify the possible complications of external cephalic version
Typical risks include umbilical cord entanglement, abruption of placenta, preterm labor, premature rupture of the membranes (PROM) and severe maternal discomfort.
Identify appropriate investigations for chlamydia and interpret the results
nucleic acid amplification test (NAAT)
direct immunofluorescence
enzyme immunoassay
nucleic acid hybridisation tests
cell culture
RFs for cardiac disease in pregnancy
Aggregating factors: Anaemia Respiratory infection Febrile illness Excessive exercise Emotional upset -> all cause tachycardias
What are the complications of gonorrhoea
Ectopic - PID Infertility in women - PID Infertility in men Blindness PID Fitz-hugh-curtis syndrome
What are the indications for LETZ
High grade cervical dysplasia CIN2/3
Recognise the presenting symptoms/signs of amniotic fluid embolism
Aura – 1/3 = sense of sudden doom, chills, nausea and vomiting, agitation, anxiety, or change in mental status
Cardiorespiratory failure and/or arrest – Patients suddenly develop hypoxemic respiratory failure, hypotension from cardiogenic shock, and/or cardiovascular collapse/cardiac arrest.
Typical clinical findings include oxygen desaturation, dyspnea, tachypnea, cyanosis, crackles, and occasionally, wheeze.
Hypoventilation is unusual unless in the setting of respiratory arrest. Those with cardiac arrest can present with bradycardia, tachycardia, ventricular fibrillation, pulseless electrical activity (PEA) and/or asystole. If patients survive the initial cardiorespiratory event, noncardiogenic pulmonary edema often develops (worsening dyspnea and tachypnea, crackles) as left ventricular failure resolves.
Hemorrhage from disseminated intravascular coagulation (DIC) typically occurs shortly after the development of cardiorespiratory compromise but may be the initial presentation [1,2,5,43].
Prolonged bleeding from sites of invasive interventions and bruising are the most common manifestations of DIC.
Neurologic manifestations – Tonic-clonic seizures (30 percent) and stroke (rare) .
Levels of zinc coproporphyrin-1 and sialyl Tn antigen increased in some
RFs for substance abuse in pregnancy
FHx Closer relatives = higher risk Hx sexual abuse Psychiatric comorbidity Teenage years + other RFs
Prognosis of subfertilty in men
The patient’s prognosis depends on the initial diagnosis. Some reversible causes of male infertility are curable. However, for most conditions, the value of medical and surgical care remains controversial. Artificial reproductive technologies remain an effective option for the infertile man.
Chromosomal defects may be passed on to offspring if intracytoplasmic sperm injection is used. Men with severe oligospermia should be offered karyotypic evaluation and advised of this risk.
Define abnormal labour
To define abnormal labor, a definition of normal labor must be understood and accepted. Normal labor is defined as uterine contractions that result in progressive dilation and effacement of the cervix. By following thousands of labors resulting in uncomplicated vaginal deliveries, time limits and progress milestones have been identified that define normal labor. Failure to meet these milestones defines abnormal labor, which suggests an increased risk of an unfavorable outcome. Thus, abnormal labor alerts the obstetrician to consider alternative methods for a successful delivery that minimize risks to both the mother and the infant.
Dystocia of labor is defined as difficult labor or abnormally slow progress of labor. Other terms that are often used interchangeably with dystocia are dysfunctional labor, failure to progress (lack of progressive cervical dilatation or lack of descent), and cephalopelvic disproportion (CPD).
Abnormal labor constitutes any findings that fall outside the accepted normal labor curve.
Identify the possible complications of evacuation of retained products of conception (ERPC)
Rare: damage to uterine lining or cervix, perforation of the uterus, infection, and blood clots
List the investigations for molar pregnancies
Serum HCG - ABNORMALLY high for gestational age
FBC - anaemia
TSH - N
- DO blood typing
Pelvic USS - MASS
CxR - high output cardiac failure (kerley B lines, fluid, alveolar infiltrates, interstitial markings)
Whatare the relevant Ix for gonorrhoea infection
urethral/urine/cervical/vaginal NAAT - +VE
Culture - +ve chocolate agar culture
- can culture Urethral, endocervical, rectal, pharyngeal, blood, synovial fluid, CSF, or conjunctival specimen
Urinalysis - +ve leukocyte esterase
Gram-stain urine/discharge
DO HIV / SYPHILIS TEST TOO
Define Rh incompatibility
Rh incompatibility is caused by destruction of fetal erythrocytes from transplacental passage of maternally derived IgG antibodies. IgG antibodies are produced by the maternal immune system, usually against the rhesus D (RhD) antigen. These antibodies can freely cross the placenta, binding to and destroying RBCs. More than 50 known RBC antibodies potentially cause Rh incompatibility. The consequence is progressive fetal anaemia, which, untreated, may ultimately lead to hydrops fetalis (collection of fluid in serous compartments) and death.
What is the prognosis of endometrial cancer?
The 5-year survival rate for all types and grades of endometrial adenocarcinoma, following treatment, is:[163]
• 75%to95%forstageI • 70% for stage II
• 50% to 60% for stage III • 5% to 15% for stage IV.
Because endometrial cancer is usually diagnosed in the early stages (70% to 75% of cases are in stage I at diagnosis; 10% to 15% in stage II; 10% to 15% in stage III or IV), there is a better probable outcome from endometrial cancer than from other types of gynaecological cancers such as cervical or ovarian cancer.
Of cases that recur, 85% of cases of endometrial adenocarcinoma recur within the first 2 years. Recurrences for early stage disease occur at the vaginal cuff and pelvis.
Prognosis of oligohydramnios
Perinatal Mortality Rate = 4.12 deaths per 1000 patients with polyhydramnios and 56.5 deaths per 1000 patients with oligohydramnios.
The mortality rate in oligohydramnios is high. The lack of amniotic fluid allows compression of the fetal abdomen, which limits movement of its diaphragm. In addition to chest wall fixation, the lack of amniotic fluid flowing in and out of the fetal lung leads to pulmonary hypoplasia.
Oligohydramnios is also associated with meconium staining of the amniotic fluid, fetal heart conduction abnormalities, umbilical cord compression, poor tolerance of labor, lower Apgar scores, and fetal acidosis. In cases of intrauterine growth restriction (IUGR), the degree of oligohydramnios is often proportional to growth restriction, is frequently reflective of the extent of placental dysfunction, and is associated with a corresponding increase in the PMR.
Complications of UTI in pregnancy
The majority of long-term sequelae are due to complications associated with septic shock, respiratory failure, and hypotensive hypoxia (ie, extremity gangrene).
ARDS
Untreated upper UTIs are associated with low birth weight, prematurity, premature labor, hypertension, preeclampsia, maternal anemia, and amnionitis
Ix for thromboembolism in pregnancy
Compression US with doppler
D dimer often raised anyway in pregnancy BUT a negative d dimer is reassuring.
MRI if pelvic/iliofemoral suspected..often not seen on US doppler
PE:
CTPA is most sensitive but increased radio dose so:
Ventilation -perfusion scan = preferable
Can do MR-angiography
Summarise the indications for endometrial ablation
Heavy menstrual bleeding IN THE CONTEXT OF NOT WANTING CHILDREN.
IE DUB / Adenomyosis
Alternative to hysterectomy.
List the complications of ovarian cancer
Chemotherapy SEs Blood loss/infection from surgery Neutropaenic sepsis/fever Bowel obstruction BM suppression
Summarise the epidemiology of asthma in pregnancy
Asthma is one of the most common medical conditions encountered during pregnancy, occurring in 3 to 8 percent of pregnant women
Ix for termination of pregnancy
Pregnancy test
FBC + haematinics
Rhesus typing
STI screen
May perform
Coagulation studies, RFTs, LFTs
Post operative HCG may be performed - Titer resolution is different between surgical and medical abortions. The titer should decrease to approximately 64% of its preabortion value within 24 hours of misoprostol being administered in medical abortion protocols. By 2 weeks, the titers should have dropped 99%.
US scan may be performed - establish gestation
List the common causes of primary amenorrhoea?
COMMON Eating disorders / athlete Emotional/physical stress Post contraception with depot medroxyprogesterone Hyperprolactinaemia PCOS Idiopathic premature ovarian failure Post chemoradiation ovarian failure Fragile X carrier Turner's syndrome mosaic (fewer manifestations than turners) Non-classic congenital adrenal hyperplasia (presents later) Hypothyroidism
UNCOMMON
Malnutrition / chronic disease
Empty sella syndrome
Sheehans syndrome (postPart pituitary necrosis(
Post-encephalitis
Androgen producing ovarian/adrenal tumour
A/I prem ovarian failure
Cushing’s syndrome
Ashermans syndrome
Drug induced - ie antipsychotics cause galactorrhea
Define cardiac disease in pregnancy
The obstetric population is generally fit and healthy, with a small proportion having pre-existing cardiac disease.
Pre-existing: ensure patient is counselled prior to pregnancy
Either way the job of the obstetrician is to involve the MDT
Discuss the prognosis of Rh incompatibility
RhD alloimmunisation is a disease that will usually progress during the pregnancy and in future pregnancies. Therefore, follow-up of these patients is required through antibody titres and fetal middle cerebral artery Doppler ultrasound during subsequent pregnancies.
Summarise the epidemiology of endometriosis
Low-end estimates of prevalence are 1% to 7% for women undergoing gynaecological surgery, including tubal sterilisation.
The prevalence is thought to be higher in white women and in those with a lower body mass index.
RFs for FGM
Africa and the Middle East
Describe the signs/symptoms of ovarian cysts
Pelvic pain
Bloating / early satiety
Palpable adnexal mass
Mass features consistent with malignancy include irregularity, solid consistency, fixed mobility, nodularity, and presence of ascites.
Summarise the aetiology of endometrial cancer
Endometrial hyperplasia
• Endometrial hyperplasia commonly results from chronic oestrogen stimulation unopposed by the counterbalancing effects of progesterone.
• Complex hyperplasia with cytological atypia has been termed ‘intra-epithelial endometrial neoplasia’ (IEN).
Unopposed endogenous oestrogenic stimulation of the endometrium
• Seen in chronic anovulation, which is a feature of polycystic ovary syndrome.
• In post-menopausal women, continued ovarian secretion of estradiol or conversion of the androgens
androstenedione and testosterone to oestrone and estradiol occurs, by aromatase in adipocytes.
• In obese women, high levels of endogenous oestrogen are due to the conversion of androstenedione
to oestrone and the aromatisation of androgens to estradiol in adipose tissue.
• Sex cord stromal tumours of the ovary, such as granulosa cell tumours, are also a source of
endogenous estradiol.
Unopposed exogenous oestrogenic stimulation of the endometrium
• Exogenous oestrogen therapy (e.g., HRT) in pre-menopausal and post-menopausal women is associated with endometrial hyperplasia.
Familial cancer syndromes
• Family history of endometrial, ovarian, breast, or colon cancer.
• Hereditary non-polyposis colon cancer (HNPCC) or Lynch syndrome.
• Cowden’s syndrome, related to mutation in the PTEN (phosphatase and tensin homologue protein
gene) tumour suppressor gene. Carriers have an increased risk for endometrial, breast, thyroid, colorectal, and renal cancer.
What is the prognosis of urinary incontinence in women
This disorder has a significant impact on a patient’s quality of life, including loss of self-esteem and decreased ability to exercise, socialise, and maintain independence. As the condition worsens, dependence on carers increases, leading to restriction on social interaction. Treatment is directed at improving quality of life and should be individualised according to impact severity. No treatment is fully curative, and combination therapy may be beneficial.
A 19-year-old man presents with dysuria. He denies any penile discharge. He does not use condoms and had recent unprotected vaginal intercourse with a new female sexual partner about 7 days ago. He denies any prior sexually transmitted infections. On examination, there is no apparent discharge on initial inspection. There is a slight whitish discharge after applying pressure along the penile shaft. No other physical abnormalities are noted.
Genital tract chlamydia infection
Recognise the presenting symptoms/signs of anaemia in pregnancy
Palpitations Dizziness SOB Fatigue Pallor Fainting
Maternal consequences: maternal cardiovascular strain, reduced physical and mental performance, reduced peripartum blood reserves, increased risk for peripartum blood product transfusion, and increased risk for maternal mortality
A 32-year-old G1P0 (gravida 1 para 0) woman, at 10 weeks estimated gestational age, presents with a 3- week history of nausea and vomiting. She reports that the episodes are gradually worsening in frequency and severity, although they typically resolve by early afternoon. She has no dizziness or light-headedness and reports no diarrhoea. She has had a weight loss of around 1 kg in recent weeks. The patient reports that symptoms are somewhat resolved by eating salty foods. She has not tried any over-the-counter or prescription medicines. The patient’s vital signs are normal except for a pulse of 105 bpm. Otherwise, the physical examination is unremarkable except for the finding of dry mucous membranes.
Hyperemesis G / morning
Epidemiology of UTI in pregnancy
Asymptomatic bacteria = 5-6% non-pregnant women, more common in diabetics. Usually detected at antenatal clinics. Must be Rx. 25% will develop Sx in pregnancy.
Pyelonephritis is the most common serious medical complication of pregnancy. 15-20% have bacteraemia.
3.5% antepartum admissions for UTIs
Explain the management for hyperemesis gravidarum
Euvolaemic = conservative - Ginger is good FAILED - Pyridoxine (B6) OR Antiemetics eg: Meclozine Metoclopramide Chlorpromazine Prochlorperazine Promethazine Domperidone
HYPEREMESIS
- Corticosteroids eg prednisolone
Summarise the prognosis for patients with dysfunctional uterine bleeding
In younger patients suffering from DUB due to anovulation during the first few years following menarche, the prognosis is usually excellent once regular ovulatory menstrual cycles are attained. In peri-menopausal women, DUB has also excellent prognosis after medical treatment. The problem disappears upon reaching the menopause.
Generate a management plan for diabetes in pregnancy
PREGNANT:
Diet, exercise, metformin, glucose monitoring
Add insulin if uncontrolled
32-34 weeks = fetal monitoring
LABOUR
Best to avoid hyperglycaemia in pregnancy: INSULIN
Rx of substance abuse in pregnancy
Opiates - naloxone
Other drugs - no specific Rx yet determined
Non-opiate withdrawal - can be Rx with barbiturates:
(phenobarbital)
1. The newborn with a nonopiate withdrawal
2. The newborn with a known polydrug withdrawal
3. The newborn with abstinence-related seizures
4. The newborn who has already received the maximum safe level of deodorized tincture of opium (DTO)
All medically treated newborns should constantly be monitored for cardiovascular, respiratory, and oxygen saturation changes (see Medication).
Increased caloric intake
The child’s comfort is paramount. Being a newborn is extremely stressful in the first few weeks of life because every external stimulus is entirely new to the infant. Add the stress of the internal stimuli from drug withdrawal, and the usefulness of environmental control can be understood. With this in mind, consider that 40% of all withdrawing newborns can be treated symptomatically (without medication).
Involve general paeds follow up
Early intervention and developmental pediatrics
Social services
A 46-year-old woman presents for a routine gynaecological examination. She has a history of unprotected intercourse with multiple sexual partners and is a smoker. Pap smear is abnormal.
Cervical cancer
RFs for oligohydramnios
Foetal urinary abnormalities - renal genesis, PKD, obstructive lesion
PROM
Chorioamnionitis
Placental insufficiency (T1DM, maternal Gest-HTN)
Maternal use of prostaglandin synthase inhibitors or angiotensin-converting enzyme
Epidemiology of lichen sclerosis
1 in 300
15% have involvement elsewhere on body
Describe the relevant investigations for endometrial cancer
Pelvic TVUSS - Thickening >5mm
Endometrial biopsy + histopathology - show adenocarcinoma
Hysteroscopy + histopathology
Pap smear - NOT a screening test - but can identify abnormalities further up the genital tract in 50%
FBC - anaemia
Serum CA-125 <35 units
Consider: LFTs - ALP increased if liver involvement CT for initial staging CxR MRI PET scan
Define external cephalic version
External cephalic version (ECV) is a process by which a breech baby can sometimes be turned from buttocks or foot first to head first.
Practitioner experience, maternal weight, obstetric factors such as uterine relaxation, a palpable fetal head, a non-engaged breech, non-anterior placenta, and an amniotic fluid index above 7–10 cm, are all factors which can be associated with higher success rates.
Contraindications: antepartum haemorrhage, placenta praevia, abnormal fetal monitoring, ruptured membranes, multiple pregnancy, pre-eclampsia, reduced amniotic fluid and some other abnormalities of the uterus or baby
Identify the possible complications of endometrial biopsy
Cramps / pelvic pain
RARE uterine perforation/infection
What are the complications of pre-eclampsia
IUGR Eclampsia Pulmonary Oedema Pregnancy-related stroke Placental Abruption Renal Failure Still-birth
RFs for UTI in pregnancy
Urinary stasis
DM/GDM
Vesicouteric reflux
Puerperal RFs:
Bladder sensitivity reduced post surgery
Discomfort from haematomas / episiotomy lines
Cathetisation to relieve retention
What are the Sx of PROM
Painless gush PV Steady leakage PV Absence of contractions More palpable baby Decreased uterine size Meconium
Examination: Pooling of amniotic fluid in fornixes Leakage on valsalva Nitrazine test - HIGHER pH (7.1-7.3) than acidic vaginal fluid. (turns nitrazine paper from orange to blue) Fibronectin + AFP blood tests
Identify the possible complications of ectopic pregnancy and its management
Methotrexate SEs - hepato/nephrotoxicity, myelosuppression
Persistent trophoblast - 4% to 15%
Iatrogenic damage
Generate a management plan for syphilis infection
1) IM benzathine benzylpenicillin
+ Prednisolone
PENICILLIN ALLERGY = Oral Doxycyclone
What is the epidemiology of urinary incontinence in women
Prevalence increases with age
1 in 4 seek consultation
Women in long term institutions - 43-65%
Discuss the relevant Ix for pre-eclampsia
Urinalysis - 1+ protein OR >0.3g/24hrs OR PCR >30mg/mmol
Fetal USS
Fetal CTG
Umbilical doppler - absence of end-diastolic flow is a sign that delivery needs to occur soon.
Amniotic fluid assessment - deepest vertical pocket <2cm = bad
FBC - may reveal low platelets
LFTs may be up
Serum creatinine - may be elevated
Ix for multiple pregnancy
USS (establish chorionicity)
A 32-year-old woman has just been confirmed by ultrasound scan as pregnant with twins at a gestational age of 10 weeks. She had been trying for a pregnancy for the past 5 years, but has had no sub-fertility treatment. On her way home, she notices bright red vaginal bleeding. She is not in any pain. She has no postural dizziness.
Miscarriage
Generate a management plan for amniotic fluid embolism
- Prompt delivery of child if viable
- Supportive
- Examination
- Small fluid boluses 250-500ml, inotrope, vasopressor therapy, etc etc
Potential transfusion with DIC, replacement of blood, fresh frozen plasma, platelets, and cryoprecipitate should be available in the operating room.
A 32-year-old woman presents at 25 weeks’ gestation in her third pregnancy with a positive antibody screen. She is known to be Rh-negative with an Rh-positive sexual partner. Two previous children were born overseas: the first child was carried to term and is healthy. The second child, also born at term, underwent phototherapy in the immediate neonatal period due to jaundice. The patient did not have anti-D prophylaxis given antenatally or postnatally in the previous pregnancies. Physical examination is normal.
Rh incompatibility
Identify appropriate investigations for cervical cancer & intraepithelial neoplasia and interpret the results
Vaginal or speculum examination
Colposcopy - white change/+vascular
Biopsy
HPV testing
CONSIDER FBC LFT RFT CxR Renal USS CT/PET +/- contrast
Discuss the aetiology of urinary incontinence in women
Stress incontinence - involuntary leakage on effort, exertion, sneezing, or coughing
Urge incontinence - involuntary leakage accompanied by or immediately preceded by urgency
Overactive bladder (detrusor overactivity) - urgency with or without urge incontinence; usually with frequency and nocturia in the absence of an underlying metabolic or pathological condition
Mixed incontinence - combination of stress and urge incontinence symptoms
Nocturnal enuresis - involuntary loss of urine occurring during sleep
Continuous incontinence - continuous loss of urine
Overflow incontinence - urinary leakage from an over-distended bladder; terminology is no longer widely used
Other - involuntary leakage during situations not encompassed by other classifications (i.e., during sexual activity or change in body position).
What is the epidemiology of pelvic inflammatory disease
Pelvic inflammatory disease (PID) is most often seen in young, single, sexually active women with a history of sexually transmitted diseases.
The exact incidence is unknown because it is difficult to diagnose definitively based on clinical signs and symptoms.
PID peaks in women aged 20 to 24 years.
List the complications of hyperemesis gravidarum
Mallory Weisss Pre-eclampsia Splenic avulsion Oesophageal rupture FGR Fetal mortality Wernickes Encephalopathy
Explain the aetiology / risk factors of Asherman’s syndrome (Intrauterine adhesions)
IUAs appear to result from trauma to the basalis layer of the endometrium
Pregnancy
Intrauterine procedures - curettage / fibroid removal / myomectomy
Infection: Endometritis, Genital TB,
Uterine compression sutures (used to treat postpartum haemorrhages)
Aetiology of LGA
Poorly controlled GDM / T2DM (NB T1DM is associated with microsomia) Obesity Gestational age past 40w Male Multiparity Hydrops fetalis Congenital anomalies causing hydros fetalis Amoxicillin Some links to polyhydramnios
What is the epidemiology of ovarian cancer
In the UK there are approximately 7100 new cases of ovarian cancer per year and 4300 deaths from the disease each year.
The median age of patients with ovarian cancer is 60 years, with an estimated lifetime risk of 1 in 70.
Although the overall 5-year survival rate is relatively low (46%), it varies by age: women younger than 45 years of age are far more likely to survive (77%) than women aged 75 years and older (20%).
W>B
Ix for FGM
Clinical
Generate a management plan for pelvic inflammatory disease
- Parenteral cephalosporin + doxycycline +/- metronidazole
+/- IUD removal - Fluoroquinolone
IF severe: IV
What is considered prolonged latent phase 1 of labour?
According to Friedman et al., latent stage considered to be prolonged if takes >20 hours for nulliparous women and >14 hours for multiparous women. However, prolonged latent phase does not usually lead to any clinically significant adverse events for mother or the infant. Therefore, diagnosis of abnormal labor during the latent phase is uncommon and is not relevant for clinical practice.
Define cervical polyp
A common benign polyp or tumour of the surface of the cervical canal
Sx of LGA
Common risks in LGA babies include shoulder dystocia, hypoglycemia, metatarsus adductus, hip subluxation and talipes calcaneovalgus due to intrauterine deformation.
Poorly controlled GDM / T2DM (NB T1DM is associated with microsomia) Obesity Gestational age past 40w Male Multiparity Hydrops fetalis Congenital anomalies causing hydros fetalis Amoxicillin Some links to polyhydramnios
What are the S+S of gonorrhoea?
COMMON Urethral discharge in men Pelvic pain in women Tenderness/swelling of epididymus Micropurulent exudate at endocervix
OTHER
Urethral irriation
Dysuria
UNCOMMON Orchitis Swollen prostate Anal pruritus Micropurulent discharge from anus Rectal pain Tenesmus Vaginal discharge Cervical friability Uterine/adnexal/cervical motion tenderness - PID Uterine mass - PID
OTHERS Conjunctivitis - gonococcal infection Fever - disseminated infection Cutaneous lesions - due to disseminated infection Polyarthritis
Meningitis signs: Purpuric rash - gonococcal meningitis Positive brudzinski / kernig Seizures Focal cerebral
Murmur - gonococcal endocarditis
Opthalma neonatorum - Preg complication to neonate = neonatal conjunctivitis
Infantile Rhinitis
Infantile urethritis
Describe the RFs for post-natal depression
STRONG
Hx depression, anxiety Stress Poor social support Discontinuation of anti-depressants Sleep deprivation Genetic susceptibility Domestic violence
WEAK
Postnatal hypomania Personality disorder Birth complications Poor socioeconomic status Age <16
What is the prognosis of menopause?
The endocrine changes are permanent, but hot flushes usually resolve in most women within 5 to 10 years. Urogenital atrophy may stay the same or worsen.
Sx of trichomonas vaginalisq
Acute phase: Vaginal pain + tenderness acutely Irritant discharge Inflamed vaginal walls Strawberry vaginitis Copious frothy, offensive discharge Burning sensation Pruritus Dysuria Dyspareunia Latet-dormant phase - no symptoms
What is the epidemiology of gonorrhoea infection
2nd most common WW
Global rate 9/1000 F
24/1000 M
M>F
A 27-year-old man notes a painless penile ulcer. He has recently started a new relationship. He is otherwise asymptomatic, as is his partner. On examination, the ulcer is indurated and the inguinal lymph nodes are rubbery and moderately enlarged.
Syphilis
What are the complications of pelvic inflammatory disease
Tuboovarian abscess Infertility Chronic pelvic pain Ectopic Fitz-Hugh-Curtis syndrome - Comprises right upper quadrant abdominal pain associated with perihepatitis. Characterised by 'violin string' perihepatic adhesions seen at laparoscopy. Treatment is the same as for PID.
Ix for polyhydramnios
US measured AFI >24
or SINGLE pocket of 8cm depth containing >2000ml
Chromosome testing, testing for evidence of congenital infection, ultrasonography of the genitourinary tract, and appropriate radiologic evaluation of the gastrointestinal tract. Electrocardiography and echocardiography may also be indicated.
Histologic examination of the placenta may be helpful in determining the cause of the polyhydramnios or oligohydramnios.
If premature delivery is anticipated with either oligohydramnios or polyhydramnios, the amniotic fluid lamellar body count, lecithin-sphingomyelin (L:S) ratio, and phosphatidylglycerol (PG) concentration are helpful in determining the maturity of the fetal lungs and, therefore, in assessing the likelihood of respiratory distress syndrome.
If fetal hydrops is present, immunologic and fetal infection need to be investigated. This should include screening for maternal antibodies to D, C, Kell, Duffy, and Kidd antigens to determine maternal antibody production against the fetal red blood cells. Infections of the fetus include cytomegalovirus (CMV), toxoplasmosis, syphilis, and parvovirus B19. The investigation should include the following studies:
Venereal Disease Research Laboratories (VDRL) test to screen for syphilis
Immunoglobulin G (IgG) and IgM titers to evaluate for exposure to rubella, CMV, toxoplasmosis, and parvovirus
A test for congenital viruses in the amniotic fluid using polymerase chain reaction (PCR)
Kleihauer-Betke test to evaluate fetal-maternal hemorrhage
Hemoglobin Bart in patients of Asian descent (who may be heterozygous for alpha-thalassemia)
Fetal karyotyping for trisomy 21, 13, and 18
Identify the possible complications of amniotic fluid embolism and its management
Leading cause of maternal deaths in developed countries
Cardiogenic shock / cardiac arrest
Potential neurological injury.
20-50% neonates die.
Generate a management plan for ovarian cysts
Non-malignant = serial USS
Suspicious: Laparoscopy + histopathology
Gynae oncology referral
Acutely unwell:
Laparoscopy / otomy
+ resus/haemodynamic support/ABx
Recognise the presenting symptoms/signs of chlamydia
presence of risk factors
asymptomatic
cervical discharge
friable cervix
abnormal vaginal bleeding
penile discharge
Describe the aetiology of hyperemesis gravidarum
Progesterone has been shown to decrease gastric motility and cause nausea and vomiting in non-pregnant women. Some studies have shown that NVP is associated with elevated human chorionic gonadotrophin (hCG) levels. Other studies have shown that NVP is more common in women with high oestrogen levels and less common in those with lower oestrogen levels. Finally, a recent systematic review demonstrated an association between the presence of Helicobacter pylori and hyperemesis gravidarum.
Summaries the epidemiology of fibroids
Incidence increases with age during the reproductive years such that cases occur in 20% to 50% of women older than 30 years.
In another study, the estimated cumulative incidence by age 50 was >80% for black women and approaching 70% for white women. Uterine fibroids represent the most common solid tumours of the female pelvis and are the leading cause for hysterectomy.
What are the signs/symptoms of placenta praevia
Painless PV bleeding 2/3 trimester - {{{Digital vaginal examination should not be performed on women with active vaginal bleeding until the position of the placenta is known with certainty.}}}
Absence of cervical/vaginal causes of bleeding on speculum
Lack of uterine tenderness
Low BP / tachycardia - haemorrhage
Identify the possible complications of endometriosis and its management
Ovarian failure post surgery
Adhesion formation post surgery
Describe the aetiology if pelvic inflammatory disease
PID is a polymicrobial infection. Sexually transmitted organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis , are implicated in many cases; however, micro-organisms that comprise the vaginal flora (e.g., anaerobes, Gardnerella vaginalis , Haemophilus influenzae , enteric gram-negative rods, and Streptococcus agalactiae ) also have been associated with PID. In addition, cytomegalovirus (CMV), Mycoplasma hominis , Mycoplasma genitalium , and Ureaplasma urealyticum might be the aetiological agents in some cases of PID.
A 24-year-old woman presents 8 weeks after her last menstrual period. She reports one episode of vaginal spotting during the past week. Urine pregnancy screen is positive, and serum beta human chorionic gonadotrophin is elevated. Ultrasound of the pelvis reveals an apparent missed abortion, with no identifiable fetal pole.
Molar pregnancy
Epidemiology of mastitis / breast abscess
1-10% of lactating women
Duct ectasia occurs in 5-9% of non-lactating women
Breast abscess 3-11% of women with mastitis, and
0.1-3% of breastfeeding women
Approximately 50% of infants with neonatal mastitis will develop a breast abscess
Mammary fistula occurs in 1% to 2% of women
Define polyhydramnios
Amniotic fluid index [AFI] >24 cm
It cushions the fetus from physical trauma, permits fetal lung growth, and provides a barrier against infection. Normal amniotic fluid volume varies. The average volume increases with gestational age, peaking at 800-1000 mL, which coincides with 36-37 weeks’ gestation. An abnormally high level of amniotic fluid, polyhydramnios, alerts the clinician to possible fetal anomalies. An inadequate volume of amniotic fluid, oligohydramnios , results in poor development of the lung tissue and can lead to fetal death.
What is the epidemiology of ovarian cysts
Worldwide, about 7% of women have an ovarian cyst at some point in their lives.
A large European screening trial revealed a 21.2% incidence of ovarian cysts among healthy post-menopausal women.
Identify the possible complications of Asherman’s syndrome and its management
Infertility
Menstrual abnormalities
Recurrence 1/3-2/3
Obstetric outcomes
Describe the aetiology / pathophysiology of failure of progression?
Passenger (infant size, fetal presentation [occiput anterior, posterior, or transverse])
- Macrosomia most common
Pelvis or passage (size, shape, and adequacy of the pelvis)
- mechanical dystocia
Power (uterine contractility)
- Surgical scars
- Fibroids
- Atony
Prognosis / complications of LGA
Common risks in LGA babies include shoulder dystocia, hypoglycemia, metatarsus adductus, hip subluxation and talipes calcaneovalgus due to intrauterine deformation.
Big babies are at higher risk of hypoglycemia in the neonatal period, independent of whether the mother has diabetes.
Complications were most often due to C-sections and included bleeding (hemorrhage), wound infection, wound separation, fever, and need for antibiotics.
What is the prognosis of premature labour
Risk of recurrence of spontaneous premature labour and birth are well defined, and remarkably consistent in spite of the varied aetiology. Only if women have recurrent preterm births at early gestations do they tend to have a future risk of >50%. Even in women who have major risk factors, such as extensive cervical surgery, it is rare not to achieve a viable pregnancy with appropriate management. These cases may be more amenable to intervention such as cervical cerclage.
Define LGA
LGA is often defined as a weight, length, or head circumference that lies above the 90th percentile for that gestational age.
Generate a management plan for premenstrual syndrome
MILD Lifestyle mod CBT NSAID B6/12 + calcium carbonate COC
SEVERE COC SSRI GnRH agonist Surgical oophorectomy
List the primary causes of PPH?
<24hrs after pregnancy
Uterine atony Trauma Retained placenta / placenta accrete Coagulation disorders Uterine inversion Uterine rupture
Complications/prognosis of thyroid disease in pregnancy
HYPER RELATED
Pre-eclampsia, HF, IUGR, preterm delivery, stillbirth, thyrotoxocosis, goitre
HYPER RELATED DRUGs:
Hepatotoxicity
Fetal malformations if methimazole is used in 1st trimester
transient leukopenia
HYPO RELATED COMPLICATIONS: Pre-eclampsia Placental abruption Cardiac dysfunction LBW Stillbirth Fetal hypothyroidism HTN possible Congenital hypothyroidism Cretinism
Complications of oligohydramnios
In the setting of oligohydramnios with renal agenesis, mortality is 100%. Milder forms of renal dysplasia or obstructive uropathy can be associated with a mild to severe degree of pulmonary hypoplasia and long-term renal failure. In cases of pulmonary hypoplasia, the effectiveness of many treatments such as the administration of surfactant, high-frequency ventilation, and nitric oxide has not been established. The prognosis in these cases is related to the volume of amniotic fluid and the gestational age at which oligohydramnios develops.
The mortality rate in oligohydramnios is high. The lack of amniotic fluid allows compression of the fetal abdomen, which limits movement of its diaphragm. In addition to chest wall fixation, the lack of amniotic fluid flowing in and out of the fetal lung leads to pulmonary hypoplasia.
Oligohydramnios is also associated with meconium staining of the amniotic fluid, fetal heart conduction abnormalities, umbilical cord compression, poor tolerance of labor, lower Apgar scores, and fetal acidosis. In cases of intrauterine growth restriction (IUGR), the degree of oligohydramnios is often proportional to growth restriction, is frequently reflective of the extent of placental dysfunction, and is associated with a corresponding increase in the PMR
The primary complications of oligohydramnios are those related to fetal distress before or during labor. The risk of fetal infection is increased in the presence of prolonged rupture of the membranes.
Describe the aetiology of pre-eclampsia
Pre-eclampsia is associated with a failure of normal invasion of trophoblast cells leading to maladaptation of maternal spiral arterioles, and is associated with hyperplacentation disorders such as diabetes, hydatidiform mole, and multiple pregnancy.
The systemic maternal response results in vasoconstriction and capillary leaking, leading to hypertension and complications such as:
• cerebral vascular dysregulation and oedema;
• liver vascular dysregulation and oedema; and
• pulmonary oedema.
A 23-year-old nulligravida presents with a 2-day history of sharp intermittent RLQ abdominal pain, non- radiating, without any alleviating factors, exacerbated with movement, progressively worsening, and not associated with any gastrointestinal symptoms. Her last menstrual period was 7 weeks ago. She denies medical problems. Her gynaecological history is significant for a prior chlamydial infection as a teenager, but is otherwise negative.
Ectopic
Ix for trichomonas vaginalis
Smear + microscopy - observation of trichomonas
Culture of smear
What are the complications / prognosis of PROM
Premature birth Cord compression Infection Placental abruption PP endometritis Chorioamnionitis
Fetus: <37w: Necrotising enterocolitis Resp distress Brain injury Death
<24w:
Fetal deformity
Contractures
Pulmonary hypoplasia
Prognosis of small for dates/IUGR
Increasingly, data support the idea that long-term consequences of IUGR last well into adulthood. Several authors have noted that these individuals have a greater predisposition to develop a metabolic syndrome later in life, manifesting as obesity, hypertension, hypercholesterolemia, cardiovascular disease, and type 2 diabetes.
Discuss the relevant Ix for toxic shock syndrome
Microscopy and culture - blood, wound, fluid, tissue - +ve for group A strep / staph A
FBC - Inc WCC, thrombocytopenia, left shift, anaemia
PT/APTT - increased if DIC + staphylococcal infection
Serum urea + creatinine - increased
Urinalysis - haemoglobinuria precedes hypotension with streptococcal disease
LFTs - increased transaminases + bilirubin
CK - increased in new fasciitis
Calcium + albumin - low in streptococcal
Lactic acid - increased in sepsis
Generate a management plan for miscarriage
Manual evacuation Misoprostol 800mcg IVag AntiD immunoglobulin OR conservative (follow up 2w) Suction evacuation of the uterus + ABx Counselling
Define gonorrhoea infection
Neisseria gonorrhoeae is a gram-negative diplococcus bacterium that is closely related to other human Neisseria species. Gonorrhoea is any manifestation of infection by N gonorrhoeae . Aside from causing infection in the lower genital tract, it can also cause conjunctivitis and severe disseminated infections, especially if acquired congenitally. The pathogen is almost exclusively sexually transmitted and can be found in the genital tract, pharynx, and rectum.
What is the aetiology of PROM
Infection
Weakness of membranes - poor collagenation, cell death, breakdown by MMPs
Lower levels of TIMPs
Recognise the presenting signs/symptoms of fibroids
Menorrhagia Irregular firm pelvic mass Pelvic pain Pelvic pressure Dysmenorrhoea Bloating Infertility Urinary complaints Constipation Enlarged uterus (more commonly adenomysosis than fibroids)
What is primary amenorrhoea?
Lack of menses by age 15 years in a patient with appropriate development of secondary sexual characteristics, or absent menses by age 13 years and no other pubertal maturation.
Explain the aetiology / risk factors of anaemia in pregnancy
Physiological/Dilutional - plasma volumes increase to a greater proportion than RBC volume
IDA
OTHER:
Haemoglobinopathies
- Thalassaemia
- Sickle Cell
RBC membrane disorders:
- hereditary sphere/ellipto
Acquired:
- Folate
- B12 (don’t forget crohns)
- Vit A deficiency
- A/I ie SLE / acute viral infection causing anaemia
- Hypothyroidism / CKD
Ix for vaginal thrush
Normally clinical
PH - normal in candidiasis
Swab + microscopy - Candidiasis: hyphae and budding yeast are better seen with the KOH preparation microscopy.
Sx of multiple pregnancy
Women carrying multiple gestations may be initially asymptomatic or may have normal signs and symptoms of pregnancy (eg, breast tenderness, fatigue, nausea, vomiting). Multiple gestations may be suspected in the setting of hyperemesis gravidarum or in a patient who has undergone assisted reproductive technology. A complete history, including a family history, should be taken in every woman suspected to have multiples.
Large for dates
Aetiology of termination of pregnancy
Few absolute conrtaindications for pregnancy.
Cardiac conditions that still carry maternal mortality rates of 5-15% include severe mitral stenosis, coarctation of the aorta, uncorrected tetralogy of Fallot, aortic stenosis, history of myocardial infarction, and the presence of artificial heart valves. Higher mortality rates have been reported in women with coarctation of the aorta with vascular involvement, pulmonary hypertension, Marfan syndrome with aortic involvement, and myocardial infarction in pregnancy.
The most common fetal anomalies encountered in abortion counseling include most fetal cardiac anomalies; trisomy 21; open and closed neural tube defects; limb, face, or cleft abnormalities; esophageal or duodenal atresia; chest and abdominal wall defects; cystic kidneys or hydronephrosis; intracranial calcifications suggestive of viral disease; or diaphragmatic defects.
Fetal conditions that are incompatible with life include anencephaly, trisomy 13, trisomy 18, renal agenesis, thanatophoric dysplasia, alobar holoprosencephaly, and some hydrocephalic cases.
Medical abortion is contraindicated in patients with clotting disorders, severe liver disease, renal disease, cardiac disease, and chronic steroid use.
Medical abortion is also contraindicated in women with no access to emergency services and no partners or family to be with the patient during the heaviest bleeding times.
Surgical abortion is contraindicated in patients with hemodynamic instability, profound anemia, and/or profound thrombocytopenia. The conditions should be managed and the context of pregnancy continuation must be considered.
The rare instance of placenta accreta and percreta in the second trimester may necessitate laparotomy with hysterotomy or hysterectomy.
What does it mean if heavy bleeding BUT irregular cycles?
Anovulatory bleeding
Rx of FGM
Defibulation
We suggest defibulation prior to coitus to prevent dyspareunia or prior to pregnancy to prevent problems with vaginal delivery
Explain the aetiology / risk factors of asthma in pregnancy
Asthma is a complex disease with underlying multi-gene association interacting with environmental exposure.
The genes associated with the disease include, but are not limited to, ADAM 33, dipeptidyl peptidase 10, PHD finger protein 11, prostanoid DP1 receptor, chromosome 12q, and polymorphisms in tumour necrosis factor (TNF).
Patients’ genetic make-up may predispose them to hyper-responsiveness to environmental aetiological triggers. Those triggers include viral infections (e.g., rhinovirus, respiratory syncytial virus, human metapneumovirus, and influenza virus), bacterial infections ( Mycoplasma pneumoniae or Chlamydia pneumoniae ), allergen exposure (e.g., tree, grass, or weed pollen; fungi; or indoor allergens), occupational exposures (e.g., animal or chemical), food additives and chemicals (e.g., metabisulfites), irritants, or aspirin in predisposed people.
What is the epidemiology of endometrial cancer
Endometrial cancer is the most common gynaecological tumour in the developed world, with approximately 320,000 new cases each year. It is the sixth most common cancer overall in women. The incidence
in Western countries is 10 times higher than in the developing world because of the increasing obesity epidemic.
RFs for mastitis / breast abscess
STRONG Female >30yo Poor breastfeeding technique Lactation Milk stasis Nippleinjury Hx Hx abscess Nipple piercing Shaving nipples Anatomical breast defect Breast cancer Foreign body Skin infection Staph A carrier Immunosuppression
WEAK Hx admission Trauma to breast Primiparity Overabundant milk supply Post maturity Complications of delivery Maternal fatigue Tight clothing Antifungal nipple cream Fibrocystic breast disease Smoking Poor nutrition Anti-retroviral therapy
Aetiology of UTI in pregnancy
E coli Kelbsiella Enterobacter Proteus GBS Staph A
Epidemiology of multiple pregnancy
1 in 80 = spontaneous
Summarise the prognosis for patients with bacterial vaginosis
Overall, with the proper treatment, the prognosis is very good for all types of vaginitis.
Sx of PCOS
COMMON Reproductive age female Irregular menstruation (oligo/an) <21 >35 days Infertility Hirsituism Hirsutism is the presence of terminal hairs (thick, pigmented) in androgen-dependent areas (upper lip, chin, chest, back, upper arm, shoulders, linea alba, peri-umbilical region, thigh, buttocks). Acne Overweight/obese HTN
UNCOMMON
Scalp hairloss
Oily skin / excessive sweating
Acanthosis nigricans
Sx of thromboembolism in pregnancy
DVT:
70% iliofemoral
Pain, oedema, swelling, pain on dorsiflexion, erythema.
NB 30-60% of women with lower extremity DVT have an asymptomatic PE
PE: Dyspnoea Pleuritic chest pain Cough Syncope Haemoptysis
Tachypnoea
Tachycardia
Apprehension
RAD, S1q3t3
May be atelectasis
Haemodynamic instability - saddle emboli
Describe the sepsis 6
- Oxygen
- Blood cultures
- IV ABx
- IV Fluids
- Serial lactates (>4 = critical care)
- Measure UO
POST SEPSIS SIX IF PT HAS: SystBP <90 Reduced consciousness despite resus RR >25 Lactate not reducing
CRITICAL CARE OUTREACH
What are the haematological causes of menorrhagia?
Coagulation disorders
Explain the aetiology / risk factors of amniotic fluid embolism
Cesarean or instrumental vaginal delivery
Precipitous or tumultuous labor
Advanced maternal age (eg, ≥35 years)
Placenta previa, placenta accrete/percreta/increta, or placental abruption
Grand multiparity (≥5 live births or stillbirths)
Cervical lacerations
Fetal distress
Eclampsia
Pharmacologic induction of labor
Uterine rupture
Polyhydramnios
Miscarriage, abortion, amniocentesis
Rx of small for dates/IUGR
This should include steroid administration when at all feasible, based on the monitoring and delivery strategies
Case by case. Some need immediate delivery, some benefit from delayed:
Situation 1
See the list below:
Test results – AC less than fifth percentile, low AC growth rate, high ratio of head circumference to AC; BPS greater than or equal to 8 and AFV normal; abnormal UV and/or cerebroplacental ratio; normal MCA
Interpretation – IUGR diagnosed, asphyxia extremely rare, increased risk for intrapartum distress
Recommended management – Intervention for obstetric or maternal factors only, weekly BPS, multivessel Doppler every 2 weeks
Situation 2
See the list below:
Test results – IUGR criteria met, BPS greater than or equal to 8, AFV normal, UA with absent or reversed end-diastolic velocities, decreased MCA
Interpretation – IUGR with brain sparing, hypoxemia possible and asphyxia rare, at risk for intrapartum distress
Recommended management – Intervention for obstetric or maternal factors only; BPS 3 times a week; weekly UA, MCA, and venous Doppler
Situation 3
See the list below:
Test results – IUGR with low MCA PI; oligohydramnios; BPS greater than or equal to 6; normal IVC, DV, and UV flow
Interpretation – IUGR with significant brain sparing, onset of fetal compromise, hypoxemia common, acidemia/asphyxia possible
Recommended management – If at more than 34 weeks’ gestation, deliver (route determined by obstetric factors). If at less than 34 weeks’ gestation, administer steroids to achieve lung maturity and repeat all testing in 24 hours.
Situation 4
See the list below:
Test results – IUGR with brain sparing, oligohydramnios, BPS greater than or equal to 6, increased IVC and DV indices, UV flow normal
Interpretation – IUGR with brain sparing, proven fetal compromise, hypoxemia common, acidemia/asphyxia likely
Recommended management – If at more than 34 weeks’ gestation, deliver (route determined by obstetric factors and oxytocin challenge test [OCT] results). If at less than 34 weeks’ gestation, individualize treatment with admission, continuous cardiotocography, steroids, maternal oxygen, and/or amnioinfusion and then repeat all testing up to 3 times a day depending on status.
Situation 5
See the list below:
Test results – IUGR with accelerating compromise, BPS less than or equal to 6, abnormal IVC and DV indices, pulsatile UV flow
Interpretation – IUGR with decompensation, cardiovascular instability, hypoxemia certain, acidemia/asphyxia common, high perinatal mortality, death imminent
Recommended management – If fetus is considered viable by size, deliver as soon as possible at tertiary center. Route determined by obstetric factors and OCT results. Fetus requires highest level of natal ICU care.
Complications / prognosis of obesity in pregnancy
Early pregnancy loss
Subfertility (increased insulin resistance + loss of gonadotrophin pulses)
Recurrent loss
Preterm delivery
Baby will have:
Increased rates of mortality, morbidity and obesity
General obesity: T2DM HTN CAD Cardiomyopathy Sleep apnoea Gallbladder disease NAFLD/NASH Osteoarthritis Subfertility Cancers (endometrium, breast, colon) DVT Poor wound healing Carpal Tunnel
What are the Ix for endometrial polyp
Vag USS - may be difficult
Hysteroscopy
Dilation + curettage
1mm-3cm usually
Same red/brown of the endometrium
Larger = darker red
Sessile or Pedunculated
Define post-natal depression
Postnatal depression refers to the development of a depressive illness following childbirth and may form part of a bipolar or, more usually, a unipolar illness. Postnatal depression is not recognised by current classification systems as a condition in its own right, but the onset of a depressive episode within 4 weeks of childbirth can be recorded via the perinatal-onset specifier in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Sx of obstetric cholestasis
COMMON
RF presence
Pruritus, sparing face
Excoriations BUT NO RASH
OTHER
Mild jaundice
Define menorrhagia
Blood loss >80mls per month during menses
What are the signs/symptoms of breech presentation
COMMON
Buttocks or feet presenting part
Fetal head under costal margin
Fetal HR above maternal umbilicus
UNCOMMON
Subcostal tenderness
Pelvic/bladder pain
Define mastitis / breast abscess
Mastitis is inflammation of the breast with or without infection. Mastitis with infection may be lactational (puerperal) or non-lactational (e.g., duct ectasia). Non-infectious mastitis includes idiopathic granulomatous inflammation and other inflammatory conditions (e.g., foreign body reaction). A breast abscess is a localised area of infection with a walled-off collection of pus. It may or may not be associated with mastitis.
Breast infection (including infectious mastitis and breast abscess) more commonly affects women aged 15-45 years, especially those who are lactating. Mastitis and breast abscess can occur at any age.
Staphylococcus aureus is the most frequent pathogen isolated.
Prompt and appropriate management of mastitis usually leads to a timely resolution and prevents complications, such as a breast abscess.
Treatment of infectious and non-infectious mastitis includes antibiotic therapy and effective milk removal if lactating.
Breast abscess requires removal of pus and antibiotic therapy. Surgical interventions can include aspiration and incision and drainage.
It is imperative to identify and treat any underlying co-existent causes of infection and to exclude breast carcinoma.
An 18-year-old woman presents with a chief complaint of hirsutism. She needs to wax her upper lip and chin twice a week. This has been a problem for 4 years. She also has excess hairs on her upper back and lower abdomen. Her periods are irregular, occurring every 2 to 3 months. Embarrassment about the facial hirsutism has affected her social life, and she is finding she feels depressed much of the time.
PCOS
Describe the aetiology of ovarian cancer
The aetiology of ovarian cancer is poorly understood at present, and further studies are warranted. There are promising data implicating genetic causes in specific populations, such as breast ovarian cancer gene 1 (BRCA1) and breast ovarian cancer gene 2 (BRCA2). Also, in patients with hereditary non-polyposis colon cancer, mutations MSH2 and MLH1 can be associated with ovarian cancer.
Discuss the Ix relevant for post-natal depression
Depression screen questions
TFTs - rule out hypothyroid
FBC - anaemia exclusion
Urine drug screen - N
Brain CT/MRI - in case structural abnormality
Aetiology of small for dates/IUGR
Maternal causes of IUGR include the following:
Chronic hypertension Pregnancy-associated hypertension Cyanotic heart disease Class F or higher diabetes Hemoglobinopathies Autoimmune disease Protein-calorie malnutrition Smoking Substance abuse Uterine malformations Thrombophilias Prolonged high-altitude exposure
Placental or umbilical cord causes of IUGR include the following:
Twin-to-twin transfusion syndrome Placental abnormalities Chronic abruption Placenta previa Abnormal cord insertion Cord anomalies Multiple gestations
Epidemiology for obstetric cholestasis
0.7% prevalence
1-1.5% of Indian-Asian and Pakistani-Asian
Scandinavian (2%) or Chilean descent (14%), with 4.7% of Chilean singletons and 20.9% of Chilean twin gestations affected.
Describe the mechanism of labour/fetal steps?
Baby engages....then Do Frogs In Canada Ride In A Pink Limo Descent Flexion Internal rotation of head Crowning Restitution Internal rotation of shoulders Anterior shoulder Posterior shoulder Lateral flexion
What are the structural causes of excessive menorrhagia?
Fibroids
Polyps
Adenomyosis (endometrial gland growth into myometrium)
What is the prognosis / complications of endometrial polyp
0.5% contain adenocarcinoma cells
Frequently re-occur
(NB cervical usually don’t)
Untreated small polyps may regress
Increase the risk of miscarriage in IVF
May cause infertility if near Fallopian tubes
Describe the epidemiology of hyperemesis gravidarum
Nausea and vomiting in pregnancy (NVP) occurs in up to 75% of pregnant women.
Hyperemesis gravidarum occurs in 1 in 200 pregnancies and is a severe form of NVP.[5] Its incidence is increased with multiple gestation, gestational trophoblastic disease, triploidy, trisomy 21, and hydrops fetalis.[1]
What are the RFs for hyperemesis gravidarum
STRONG FHx Hx Multiple gestation / increased placental size GTD Trisomy 21/18
WEAK
Female fetus
Hx motion sickness
Hx migraine
Rx of PCOS
Fertility
Weight loss
Metformin if insulin resistance
1) Clomifene - Clomifene is a non-steroidal anti-oestrogen that inhibits oestrogen negative feedback on the hypothalamus/pituitary, which in turn leads to an increase in follicle-stimulating hormone secretion that may allow follicular maturation and ovulation.
2) Dexamethasone can be given if Clomifene. fails - surpasses androgen production
3) follitropin alfa/beta - Gonadotrophins (human menopausal gonadotrophins [hMG]: luteinising hormone + follicle-stimulating hormone [FSH]) directly act on the ovary, stimulating follicular recruitment and maturation. (risk of multiple gestation / ovarian hyper stimulation syndrome)
4) IVF
5) Ovarian drilling
NOT REQUIRING FERTILITY
1) COCP
2) Spironolactone / finasteride
3) long acting GnRH
4) Cyclic progesterone
Define thyroid disease in pregnancy
Increased TBG, increase t3/t4,
Serum TSH decreases in early pregnancy (-ve feedback from weak stimulation by BHCG). Thus TRH also reduced (typically undetectable).
Maternal thyroxine important for normal fatal development.
Fetal thyroid begins producing thyroxine from 12 weeks.
Maternal sources still contribute to 30% at term.
15% of pregnant women have TPO antibodies
RFs for subfertilty in men
STRONG Varicocele Cryptochidism Prior chemo/radio Current medications - sulfsalazine/antifungals CF Congenital absence of the vas deferens Y chromosome abnormalities - Kleinfelters - 47XXY Hyperprolactinaemia Kallmanns Hx infertility
WEAK Genital tract infection Erectile dysfunction Retrograde ejaculation - Prostatic surgery, diabetes, and some medications, such as psychiatric agents (thioridazine, chlorpromazine, and amitriptyline) Obesity Testicular torsion Smoking Alcohol Age >55 (affects sperm motility sometimes) Environmental toxin exposure CAD DM Hot tub use Hx STD
Aetiology od trichomonas vaginalis
Colonisation + infection of the vagina by trichomonas vaginalis, a protozoan organism.
Infests the vagina and urethra
Single celled organism with 4 flagella and an undulating membrane
Acquired via sexual intercourse
Discuss RFs for endometrial polyp
Obesity High BP Hx cervical polyps HRT Tamoxifen Mirena REDUCES incidence in women on tamoxifen
Discuss the RFs for premenstrual syndrome
STRONG
Post-pubescant/Premenopausal
WEAK FHx Mood disorders Cigarette smoking White women Sexual abuse/trauma
What is a resolved praevia?
Low-lying placenta seen in early pregnancy that has migrated away from the cervical os
A 28-year-old woman presents to her gynaecologist with a complaint of inability to conceive for 1 year. She has 1 child. It took her 1 year to conceive that child. Her antenatal course was uncomplicated, although she required a caesarean section for failure to progress and chorioamnionitis. There were no post-operative complications and the child is healthy. She has heavy menstrual cycles every 35 to 42 days without significant dysmenorrhoea or dyspareunia. Her husband is 38 years old and is the father of her first child. He is healthy, takes no medication, and has no other children.
Infertility in women
Rx of infertility in women
Manage any underlying medical conditions
All women need to be counselled. The process cam be stressful and evidence is emerging that stress can be associated with treatment failure.
ANOVULATORY
- Gonadotrophin stimulation - menotrophin / follitrophin
- HCG
- IVF
PCOS
- WL
- Metformin
- Clomifene / GnRH stimulation
- Ovarian drilling
- IVF
TUBAL
- IVF
- Can do tubal reconstruction
ENDOMETRIOSIS
- Clomifene / GnRH stimulation
- IVF
- Surgical ablation of endometriosis
AGE RELATED
- Oocyte donation
- Can try ovarian stimulation -> Clomifene / GnRH
UNEXPLAINED
- Try ovarian stimulation
- Intra-uterine insemination possible (evidence suggests no more successful than timed intercourse)
- IVF
DAMAGED UTERUS
- Surrogacy
Explain the aetiology / risk factors of cutaneous warts
intercourse at an early age
increasing number of lifetime sexual partners
increasing number of partner’s lifetime sexual partners
immunocompromise
Define oligohydramnios
The amniotic fluid that bathes the fetus is necessary for its proper growth and development. It cushions the fetus from physical trauma, permits fetal lung growth, and provides a barrier against infection. Normal amniotic fluid volume varies. The average volume increases with gestational age, peaking at 800-1000 mL, which coincides with 36-37 weeks’ gestation. An abnormally high level of amniotic fluid, polyhydramnios, alerts the clinician to possible fetal anomalies. An inadequate volume of amniotic fluid, oligohydramnios , results in poor development of the lung tissue and can lead to fetal death.
Discuss prophylaxis for PPH?
Use of an oxytotic drug (reduces incidence by 30-40%)
IE Syntometrine
Contolled cord traction to deliver placenta (Brandt-andrews)
Clamping and cutting the cord
Aetiology of cardiac disease in pregnancy
Sharp rise in CO during 1st trimester, followed by gradual 40% increase above normal by 2nd trimester
CO rises even more during labour during contractions, and delivery of placentae
Can cause myocardial compromise
Cardiac failure can occur gradually in the pregnancy as the heart fails to meet the demand on the circulation.
LHF presents early in pregnancy if mod-severe disease
More commonly acute HF occurs as tachycardia >110 due to reduced ventricular filling
In mitral valve disease -> 2nd trimester + birth are dangerous -> increases in circulatory volumes
EISENMENGER = CONTRAINDICATION TO PREGNANCY
Define trichomonas vaginalis
Colonisation + infection of the vagina by trichomonas vaginalis, a protozoan organism.
Infests the vagina and urethra
Single celled organism with 4 flagella and an undulating membrane
Acquired via sexual intercourse
What is the prognosis of premenstrual syndrome
There are no reports documenting spontaneous remission before the menopause. It is difficult to define spontaneous remission, because women could remit during pregnancy only for symptoms to return subsequent to pregnancy. Women with PMS/PMDD tend to suffer throughout their reproductive life.
Summarise the epidemiology of diabetes in pregnancy
NICE suggests that the prevalence of GDM in England and Wales is approximately 3.5% of all pregnancies.
A 50-year-old white schoolteacher presents complaining of night sweats and difficulty sleeping. She has also noticed a decrease in her libido and discomfort during intercourse. Her family complains that she is more irritable. She is worried about a 3 kg weight gain since her last visit 1 year ago. She has not had a period for 12 months; immediately prior to that her periods were lighter and shorter. On pelvic examination, the labia minora appear thin and the vaginal mucosa is slightly pale, but the rest of the physical examination is unremarkable.
Menopause
Summarise the prognosis for patients with cervical cancer & intraepithelial neoplasia
Most recurrence happens within 2 years. The tumour may spread locally; to the lymphatics (pelvic or paraaortic 11%, supraclavicular 7%); haematogenously (lungs 21%, bone 16%, liver, adrenals, brain); or transcelomically to the ovary or bowel (more common in adenocarcinomas but still very rare, <2%).
The 5- year survival depends on the stage of the tumour:
• Stage IA1: 100%
• Stage IB2-IIB: 50% to 70% • Stage III: 30% to 50%
• Stage IV: 5% to 15%.
Discuss the RFs for placental abruption
STRONG
Chronic HTN Pre-eclampsia Smoking Cocaine use Trauma Chorioamnionitis Uterine malformations Hx Oligohydramnios
WEAK
Prev C-S Preterm ROM Multiparity Inc age Polyhydramnios Multiple pregnancy Uterine Fibroids Thrombophilias
Identify the possible complications of colposcopy +/- cervical punch biopsy
Bleeding
Infection
What investigations should be performed for primary amenorrhoea?
Follicle-stimulating hormone (FSH): in concert with estradiol levels, gonadotrophins help determine if amenorrhoea is due to gonadal failure, hypothalamic dysfunction, or systemic or functional causes.
Serum estradiol: low levels are suggestive of either primary ovarian failure (along with elevated FSH) or suppressed hypothalamic function (low FSH).
Serum prolactin: elevated levels of circulating prolactin (hyperprolactinaemia), whether idiopathic or due to a pituitary adenoma, result in hypogonadotrophic hypogonadism. For persistently elevated levels, neuroimaging is indicated to rule out intracranial neoplasm. [12]
Thyroid-stimulating hormone (TSH): is indicated to rule out (primary) hypothyroidism, more commonly associated with secondary amenorrhoea. Mild or sub-clinical hypothyroidism is unlikely to result in menstrual irregularities. [17] It is proposed that elevated thyrotrophin-releasing hormone (TRH) stimulates prolactin secretion from the pituitary, suppressing FSH production. [18]
Serum androgens: done for signs of hyperandrogenism. Levels such as dehydroepiandrosterone sulphate (DHEAS) and free testosterone will be elevated in patients with polycystic ovary syndrome, [19] but might be significantly higher in patients with androgen-producing tumours.
Karyotype: helps to identify patients at risk for gonadal tumours, such as those with premature ovarian failure (usually secondary amenorrhoea) younger than 30 years, androgen insensitivity syndrome, or gonadal dysgenesis. [5]
Cranial MRI - prolactinoma
TVUSS - tumours / endometrial thickness
Define PCOS
Polycystic ovary syndrome (PCOS) includes symptoms of hyper-androgenism, presence of hyper-androgenaemia, oligo-/anovulation, and polycystic ovarian morphology on ultrasound.
RFs for small for dates/IUGR
Maternal causes of IUGR include the following:
Chronic hypertension Pregnancy-associated hypertension Cyanotic heart disease Class F or higher diabetes Hemoglobinopathies Autoimmune disease Protein-calorie malnutrition Smoking Substance abuse Uterine malformations Thrombophilias Prolonged high-altitude exposure
Placental or umbilical cord causes of IUGR include the following:
Twin-to-twin transfusion syndrome Placental abnormalities Chronic abruption Placenta previa Abnormal cord insertion Cord anomalies Multiple gestations
List the signs and symptoms of syphilis infection
COMMON
Genital ulcer - initially a macule, then develops into a papule, then ulcerates. Usually indurated, solitary, and painless 14-21 days after exposure.
Lymphadenopathy
Diffuse rash - Symmetrical macular, papular, or maculopapular rash in secondary syphilis. Usually non-itchy, over the trunk, palms, soles, and scalp.
Constitutional symptoms Mouth ulcer Asymptomatic (latent syphilis) Tremor Headache Meningismus Eye pain Hearing loss Seizures Peripheral oedema Jaundice Peripheral neuropathy Areflexia Angina Dyspnoea Organomegaly
UNCOMMON
Patchy alopecia Condylomata lata - Oval papules in genitalia (2ndary syphilis) Memory impairment/dementia Visual disturbance Argyll-robertson pupils (small irregular pupils non-constricting to light, but do to accommodation) Loss of vibration sense Ataxia Loss of anal/bladder sphincter control \+ve rombergs sign Diastolic murmur
CONGENITAL Sx Rhinitis (can be bloody) Hepatosplenomegaly Miscarriage/stillbirth Premature labour/IUGR Neonatal skin rash Tibial bowling Craniofacial malformation (frontal bossing) Tooth abnormalities Necrotising funisitis
Summarise the epidemiology of anaemia in pregnancy
Estimated 30% WW women of reproductive age = anaemic
WHO WW = 40% preg women
Many individuals = iron deficient but not yet ANAEMIC
Discuss the Ix for breech presentation
Transabdo USS
TVUSS
List the RFs for breech presentation
STRONG Premature fetus (can turn easily) LBW Nulliparity Fetal congenital abnormalities Hx Breech Uterine abnormalities Female (54%)
WEAK
Abnormal amniotic fluid volume (oligo/poly)
Placental abnormalities (praevia)
Describe the epidemiology of miscarriage
The main symptom of miscarriage is vaginal bleeding, and up to 30% of all pregnancies may end in miscarriage.
The majority of miscarriages occur in the first trimester and <3% occur in the second trimester.
What are some causes of primary amenorrhoea?
Primary ovarian failure (dysfunctional/agenesis)
PCOS
Mullerian anomalies
HP dysfunction
Ix for LGA
USS to assess liquor volume and fetal size using haddock formulas (AC/HC/FL)
Define endometriosis
Endometriosis is defined as the presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature. Surgical appearance varies significantly from superficial blebs to infiltrating fibrosis. Direct visualisation confirmed by histological examination remains essential for diagnosis.
Epidemiology of trichomonas vaginalis
18% of female population
Explain the risk factors of chlamydia
age under 25 years, sexually active
new sex partner or multiple sex partners
sexual activity with infected partner
condoms not used
What are the complications of epilepsy in pregnancy
Rx can cause: Orofacial clefts Neural tube defects Congenital heart disease Haemorrhage disease of the newborn
Normal anaemia parameters?
Anaemia is normally <120g/L FEMALE
<140g/L MALE
PREGNANCY = RF for anaemia
Other RFs include: extremes of age, female gender, lactation, and pregnancy.
A 33-year-old gravida 3 para 2 presents with 4-day history of vaginal bleeding along with lower abdominal discomfort and nausea. She states that her symptoms have worsened over the previous 24 hours. Her last menstrual period was 6 weeks ago. She denies medical, gynaecological, or social problems and her review of systems is negative except for the above complaints. Her obstetrical history includes an abortion and two uncomplicated vaginal deliveries followed by an interval tubal ligation 1 year ago.
Ectopic
Summarise the prognosis for patients with Asherman’s syndrome
Recurrence 1/3-2/3
Prognosis / complications of lichen sclerosis
Associated with vulval cancer, but not a cause
Many presenting with vulval cancer have lichen sclerosis
Thought 3-5% of lichen sclerosis sufferers will develop vulval cancer
What is ovarian hyper-stimulation syndrome
Ovarian hyper-stimulation syndrome:
Symptoms range from mild to severe. Mild OHSS manifests as bloating and abdominal discomfort. As the abdominal fluid collection continues it restricts diaphragmatic activity with resultant shortness of breath. Increased abdominal pressure can also restrict the inferior vena cava and reduce pre-load. A reduced intravascular volume decreases glomerular filtration rate and may result in renal failure. As intravascular depletion continues, the rising haematocrit can increase the risk of blood clotting. This risk is further increased by the high level of estradiol. Third spacing can occur in other tissues including the lungs and the brain.
Treatment is supportive. Paracentesis can improve respiratory effort and cardiac output. OHSS occurs in approximately 20% of all IVF cases but is only severe in <5%. Symptoms last approximately 1 week, but will continue longer when conception occurs.
List Ix for ovarian cysts
TVUS - enlarged ovary or portion of ovarian tissue; may be cystic, solid, or mixed
Serum CA-125 - elevated in malignancy (Levels >35 U/mL in PM women, or >200 U/mL in pre-menopausal)
Doppler - penetrating vessels into solid, papillary, or central areas of malignant tumour
MRI/CT
Laparoscopy + histology
What is the prognosis of placental abruption
The maternal prognosis is linked primarily to the severity of the abruption, particularly to the amount of blood lost and to the presence or absence of associated coagulopathy.
For the fetus, the prognosis depends primarily on the gestational age at which the abruption occurs, and on the degree of the abruption.
Abruption is also an important cause of indicated preterm birth and is associated with an increased risk of perinatal asphyxia and long-term neurodevelopmental handicap.
Summarise the epidemiology of cutaneous warts
In the UK, the estimated prevalence of detected human papillomavirus (HPV) among women aged 16 to 25 years undergoing routine cervical screening is 42%. [8] This rate decreases with increasing age. [8]
Summarise the prognosis for patients with asthma in pregnancy
Acute asthma exacerbations are common during pregnancy and increase the risk of pre-eclampsia, gestational diabetes, placental abruption and placenta previa
What is the aetiology of gestational hypertension
The exact aetiology of gestational hypertension remains unknown. It is thought that insulin resistance may mediate the clinical onset of hypertension in pregnancy.
Aetiology of thromboembolism in pregnancy
Uterus compresses pelvic veins + inferior vena cava. Increases stasis.
Stasis
Trauma
Hypercoagulability
Obstetrical: CS DM Haemorrhage/anaemia Hyperemesis Immobility Multiple gestation Multiparity Pre-eclampsia Puerperal infection
General: >35yo Cancer Connective tissue disease Dehydration Immobility Infection/inflammatory disease Nephrotic syndrome Obesity Oral contraceptivo use Orthopedic surgery Paraplegia Hx of VTE SCD Smoking Thrombophilia
Generate a management plan for Bartholin’s cyst
Asymptomatic <40 = leave alone Symptomatic: Marsupialisation Catheter Drainage Excision - not preferred due to recurrence/infection/loss of function Aspiration Silver nitrate cauterisation Alcohol sclerotherapy \+BS ABx
What are the relevant Ix for syphilis infection
Dark field microscopy of lesion swab - coiled spirochaete bacterium viewed
Serum treponemal enzyme immune assay (EIA) - +ve
serum T pallidum particle agglutination (TPPA) - +ve
serum T pallidum haemagglutination (TPHA) - +ve
serum Venereal Disease Research Laboratory (VDRL) test - +ve
Lumbar puncture - WCC >10, Protein >50mg/dL, VDRL +ve, TPHA/TPPA/FTA-ABS +ve
CxR Echo MRI/CT brain HIV test Fetal USS FBC LFTs Audiometry
Ix for obstetric cholestasis
Bile acids - >11 micromol/L and <40 micromol/L (mild); >40 micromol/L (severe)
LFTs - transaminases elevated up to 300 units/L in more severe disease; alk phos 5- to 10-fold normal; direct bilirubin elevated in some, not usually >85.5 micromol/L (>5 mg/dL)
Coagulation - prothrombin time may be prolonged in rare cases when vitamin K has been depleted from liver dysfunction
Fasting serum cholesterol - total cholesterol and triglycerides are elevated above the 2- to 3-fold increase usually seen in pregnancy
Hep C serology - positive in hepatitis C infection
Generate a management plan for fibroids
FERTILITY DESIRED
Myomectomy + anti-progestogen ie leuprorelin/mifepristone
OR mirena OR naproxen 500mg orally
FERTILITY NOT DESIRED Uterine artery embolisation Myomectomy (same medical Rx post surgery) IF uterine preservation not desired = hysterectomy
What are the complications / prognosis of cervical polyps
1% progress to cancer
Unlikely to regrow
Define lichen sclerosis
Destructive inflammatory condition affecting the anogenital area in women
Rx of termination of pregnancy
MEDICAL:
Mifepristone + Buccal misoprostone - <9weeks
- Mifepristone administered there + then, misoprostal administered at home 24-48hrs after misoprostol.
- Most women deliver 2-24hr post misoprostol.
The package inserts for the medical regimen are critical to review with the patient and send home with her. They cover side effects, expected progress, and symptoms very completely.
Follow up appointment - 7-14 days later.
OR
Methrotrexate injection, misoprostol on days 6-7
SURGICAL: Manual vacuum aspiration - 4-10w Suction curettage - 6-14w Dilation and evacuation - 14-24w Hysterotomy - 12-24w (if large fibroids)
Surgical:
Often sedation only used.
Laminaria japonicas are small sticks of presterilized seaweed that can be inserted preoperatively to dilate the cervix.
May give vag/oral misoprotol to prepare cervix
May give local lidocaine to cervix
Agents useful to control bleeding include oxytocin, methylergonovine, or prostaglandins.
A surgical abortion is usually performed under local anesthesia. For those modestly tolerant of pain, either intravenous sedation or a preoperative antianxiolytic agent can be administered. Nonsteroidal anti-inflammatory drugs (NSAIDs) have also been used for preoperative preparation. Narcotics can be used for pain control but are usually not necessary.
Most antibiotics are used prophylactically to prevent postoperative endometritis. Some institutions have used dosages that would cover chlamydia and gonorrhea because patients often cannot be contacted after an abortion.
Sx of substance abuse in pregnancy
Alcohol withdrawal: Signs of alcohol withdrawal may include hyperactivity, crying, irritability, poor sucking, tremors, seizures, poor sleeping patterns, hyperphagia, and diaphoresis. Signs usually appear at birth and may continue until age 18 months. Withdrawal typically appears within 3-12 hours after delivery.
Barbiturate withdrawal: Signs may include irritability, severe tremors, hyperacusis, excessive crying, vasomotor instability, diarrhea, restlessness, increased tone, hyperphagia, vomiting, and disturbed sleep.
Marijuana withdrawal: For marijuana, a mild opiatelike withdrawal syndrome has been observed. Signs may include fine tremors, hyperacusis, and a prominent Moro reflex; however, these symptoms rarely require treatment.
Nicotine withdrawal: Mild signs are observed, including fine tremors and variations in tone; recent data have shown that maternal smoking was associated with subtle neonatal behaviors, such as poor self-regulation and an increased need for handling.
Methadone withdrawal: Symptoms typically appear within 48-72 hours but may not start until the infant is aged 3 weeks. This is particularly true for infants whose mothers took excessively higher doses.
Opiate withdrawal: Signs of NAS include hyperirritability, gastrointestinal dysfunction, respiratory distress, and vague autonomic symptoms (eg, yawning, sneezing, mottling, fever). Tremors and jittery movements, high-pitched cries, increased muscle tone, and irritability are common. Normal reflexes may be exaggerated. Loose stools are common, leading to possible electrolyte imbalances and diaper dermatitis.
Long-term symptoms have been difficult to study, but evidence supports that these children show hyperphagia, increased oral drive, sweating, hyperacusis, irregular sleep patterns, poor tolerance to environmental changes, and continued loose stools.
NAS appears to be less severe if the mother has used opiates longer than one week prior to delivery.
Cocaine: Acute signs such as tremors, high-pitched cry, irritability, excess suck, hyperalertness, apnea, and tachycardia can be seen with the first 72 hours of life.
Sx of fatty liver of pregnancy
Malaise
Nausea and vomiting (70%); this may present for the first time in the third trimester
Right upper-quadrant and epigastric pain (50-80%)
Upper gastrointestinal hemorrhage
Acute renal failure
Infection
Pancreatitis
Hypoglycemia
Fulminant liver failure with hepatic encephalopathy
Hypertension
Bleeding
Confusion and altered mental status
Jaundice: Hyperbilirubinemia resulting in jaundice is rarely encountered in patients with severe preeclampsia. When jaundice is present in pregnancy, AFLP should be high on the differential.
What is considered prolonged phase 2 of labour?
NULLIPAROUS
- 8 hours w/o regional anaesthesia
- 6 hours with
MULTIP
2hours w/o regional
1 hour with
One study found that if nulliparous women delivered after prolonged second stage, they were twice as likely to have operative vaginal delivery, three times as likely to develop chorioamnionitis, have higher odds of having episiotomy and 3rd or 4th degree lacerations, and one day longer median hospital stay.
Summarise the epidemiology of cervical cancer & intraepithelial neoplasia
Cervical cancer is the fourth most common malignancy in women worldwide with an estimated 530,000 new cases and 270,000 deaths in 2012.
Effective screening with the Pap smear in developed countries has reduced the incidence and mortality by 75% in the last 50 years.
Human papillomavirus is the most important aetiological factor. Incidence of cervical cancer correlates with early onset of sexual activity, multiple sexual partners, cigarette smoking, low socioeconomic status, poor nutrition, oral contraceptive use, and immunosuppression.
What is the aetiology of miscarriage
Embryonic factors:
- Primary embryonic disease/disorder/damage
- 80% chromosomally abnormal
- Particularly CNS malformation
Maternal factors:
- 2nd trimester Ms due to ascending infection from genital tract
- Exposure to chemo/irradiation/toxicity
- Asymptomatic Bacterial vaginosis (2nd T)
- Large submucosal fibroids
- Antiphospholipid syndrome
- Cervical incompetence, insufficiency, or weakness account for most recurrent second-trimester miscarriages.
- Ovulation induction, fetuses with high nuchal translucency, and in women with pre-existing diabetes mellitus
In practice, the most common causes of second-trimester miscarriage are cervical incompetence, weakness, or insufficiency following invasive fetal diagnostic procedures; trans-placental fetal viral infection; trans- placental fetal bacterial infection; severe rhesus isoimmunisation
Epidemiology of vasa praevia
1 in 2500
What is the epidemiology of syphilis infection
Syphilis is a common, worldwide STD, with approximately 10.6 million new cases reported in 2005 and 2008, according to the World Health Organization (WHO).
In 2014, 61% of cases of primary and secondary syphilis occurred in MSM.
Complications of mastitis / breast abscess
Cessation of breast feeding Abscess Sepsis Scarring Functional mastectomy Nec-fasc Extramammary skin infection Fistula
What is the prognosis of gonorrhoea
Appropriate treatment with recommended antibiotics should resolve gonorrhoeal infections. The key related morbidity in women is infertility, ectopic pregnancy, and chronic pelvic pain secondary to pelvic inflammatory disease. In men, treatment will help prevent ascending infection to the prostate, epididymis, and testis. Death is rare but can be the result of disseminated infection.
What are the RFs for gestational hypertension
STRONG
Nulligravity
WEAK
Black/hispanic Multiparity Obesity Small mother at gestation T1DM Migraine
Define breech presentation
Breech presentation in pregnancy occurs when a baby presents with the buttocks or feet rather than the head first (cephalic presentation) and is associated with increased morbidity and mortality for both the mother and the baby. There is good current evidence regarding effective management of breech presentation in late pregnancy using external cephalic version and/or planned caesarean section.
Describe the epidemiology of pre-eclampsia
While the exact incidence is unknown, pre-eclampsia has been reported to occur in about 4% of all pregnancies in the US. When figures include patients who develop pre-eclampsia postpartum, the incidence is between 2% and 8% of all pregnancies worldwide.
Define LETZ and describe the procedure
Excision of lesion using electrocautical loop
Cervical transformation zone and lesion excised 4-5mm beyond lesion
Usually histological specimens taken.
Rx of urogenital prolapse
MILD SYMPTOMS:
Pelvic floor physio
Silicon rubber pessaries
Severe: SURGERY - Colporrhaphy UTERINE PRESERVING: Hysterosacropexy Manchester repair Mesh repair
NON PRESERVING
Vaginal hysterectomy
Total abdominal hysterectomy + sacrocolplexy
Subtotal abdominal hysterectomy + sacrocervicoplexy
Discuss relevant Ix for placenta praevia
Uterine USS + doppler - position of placenta
FBC - potential anaemia
G+S + crossmatch
CONSIDER
MRI placenta
INR/PTT fibrinogen - possible DIC
Kleihauer-Betke test - if Rh+
A 38-year-old woman, gravida 5, para 4, and an active smoker, is found to have an abnormal placenta on a routine dating ultrasound at 13 weeks. She returns with painless, bright red vaginal bleeding at 28 weeks. She is not in labour.
Placenta praevia
Generate a management plan for toxic shock syndrome
SUSPECTED
Supportive - fluids, vasopressor, source control, etc
Empirical therapy - clindamycin + vancomycin
CONFIRMED STREP
Clindamycin + benzylpenicillin or vancomycin
Potential IVIG
CONFIRMED STAPHY
Clindamycin + oxacillin or vancomycin
What are the RFs of placenta praevia
STRONG
Uterine scarring (prior C) - do mid trimester USS Infertility Rxs (2% risk) Hx
WEAK
Increased age Multiparity Smoking Induced abortion Placental abnormalities Short interpregnancy intervals Illicit drug use
Summarise the prognosis for patients with Bartholin’s cyst
85% Rx success
May get vaginal dryness/dyspareunia
Discuss signs/symptoms of molar pregnancies
COMMON Presentation in 1st trimester. Missed period Vaginal bleeding Unusually large uterus for gestational age
UNCOMMON Headache / photophobia - exacerbated pre-eclampsia symptoms - due to high HcG SOB - anaemia Nausea / emesis - high HCG Thyrotoxicosis signs - HCG can cross react with TSH HTN Uterine bleeding Pelvic pain
Generate a management plan for Asherman’s syndrome
HYSTEROSCOPIC RESECTION — The standard treatment of symptomatic intrauterine adhesions is lysis under direct hysteroscopic visualization
Estrogen therapy — The rationale for postoperative estrogen therapy is that the hormone will promote regrowth of the endometrium over the denuded surface.
Intra-uterine catheter — Catheters (eg, size 8 pediatric bladder catheter with a 5 cc balloon or Malecot catheter) can be inserted into the uterine cavity immediately after adhesion lysis.
Intrauterine gel — Both hyaluronic acid gel and polyethylene oxide-sodium carboxymethylcellulose gel have appeared to reduce the reformation of IUAs,
Prevention: Surgical techniques - cold loop adhesion rather than cautery.
Semisolid (gel) adhesion barriers
A 30-year-old man presents with difficulty hearing conversations while in a crowded room. Following referral for audiometry, bilateral high-frequency hearing loss is diagnosed. On further questioning he reports a past history of an anal fissure about 10 weeks previously that healed spontaneously. He also describes a mild transient skin rash 2 weeks before his auditory symptoms appeared. He says that he has been feeling unusually tired.
Syphilis
Aetiology of infertility in women
Female infertility aetiologies include cervical/uterine abnormalities, tubal disease, ovulatory dysfunction, and unexplained infertility. The most common aetiology is ovarian dysfunction.
Polycystic ovarian syndrome, which is estimated to affect 5% of women, is also a major contributor to ovulatory infertility.
The primary cause of infertility worldwide is tubal disease due to infection, including gonorrhoea, chlamydia infection, and tuberculosis.
Cigarette smoking
High/low body fat
Decreased body mass
Endometriosis
Uterine - bicornuate, fibroids, ashermans, uterine septum
Discuss the epidemiology of menopause
Av age: 51
Hot flushes (vasomotor symptoms [VMS]) are the most common menopausal symptom: moderate to severe hot flushes were reported by 24% of women aged 50 to 54 years.
Prevalence decreased rapidly with age, from 15% in women aged 55 to 59 years to 6% in the 60- to 69-year age group, and to only 3% in women aged >70 years.
Aetiology of heavy menorrhagia?
Thinning of the vascular smooth muscle cell layer of the spiral arterioles, shifts in prostaglandin secretion towards vasodilatory prostaglandins, and disturbances in the endometrial coagulation mechanisms are often found in women with heavy menstrual bleeding.
Discuss the complications of post-natal depression
Impaired bonding with baby
Neglect of baby
Suicide
Bipolar Disorder
Epidemiology of subfertilty in men
It is estimated that 1 in 6 couples will have difficulty conceiving. Male factor alone is responsible for 20% of those cases. In an additional 30% to 40% of couples, male factor is present in combination with other factors including anovulation, tubal factor, increased maternal age, and endometriosis.
Sx of small for dates/IUGR
For most purposes, an EFW at or below the 10th percentile is used to identify fetuses at risk. Importantly, however, understand that this is not a definitive cutoff for uteroplacental insufficiency. A certain number of fetuses at or below the 10th percentile may be constitutionally small. In these cases, short maternal or paternal height, the neonate’s ability to maintain growth along a standardized curve, and a lack of other signs of uteroplacental insufficiency (eg, oligohydramnios, abnormal Doppler findings) can be reassuring to the clinician and parents. Customized growth curves for ethnicity, parental size, and gender are in development so as to improve sensitivity and specificity of diagnosing IUGR.
Epidemiology of hysterectomy in UK?
In the UK, 20% of women have a hysterectomy by the age of 60, mainly for heavy bleeding, despite the fact that 40% have a normal uterus on histological examination.
Sx of oligohydramnios
Marked deformation of foetus if real agenesis
Oligohydramnios adversely affects fetal lung development, resulting in pulmonary hypoplasia that typically leads to death from severe respiratory insufficiency. Other fetal deformations include bowed legs, clubbed feet, a single umbilical artery, gastrointestinal atresias, and a narrow chest secondary to external compression. Infants are typically small for their stated gestational age (SGA)
What are the complications of fibroids
Recurrence Labour + delivery complications: - Inc risk breach, dysfunctional labour, bleeding, inc CS risk Acute torsion Haemorrhage / anaemia Severe infection Infertility "Degenerative fibroid changes" Pregnancy loss
Prognosis of polyhydramnios
If polyhydramnios is not associated with any other findings, the prognosis is usually good.
Polyhydramnios (amniotic fluid index [AFI] >24 cm) is associated with an increased rate of fetal malformations, genetic syndromes, neurologic disorders, and developmental delay, conditions that may only be diagnosed postnatally.
Perinatal Mortality Rate = 4.12 deaths per 1000 patients with polyhydramnios and 56.5 deaths per 1000 patients with oligohydramnios.
