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
