Obstetrics and Gynaecology Flashcards
Primary Amenorrhoea
When the patient has never developed periods. This can be due to:
-Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
-Abnormal functioning of the gonads pop(hypergonadotropic hypogonadism)
-Imperforate hymen or other structural pathology (may still have cyclical pain, but no menstruation)
NB- gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
Secondary Amenorrhoea
When the patient previously had periods that subsequently stopped. This can be due to:
-Pregnancy (the most common cause)
-Menopause
-Physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors (typically due to reduced GnRH from the hypothalamus)
-Polycystic ovarian syndrome
-Medications, such as hormonal contraceptives
-Premature ovarian insufficiency (menopause before 40 years)
-Thyroid hormone abnormalities (hyper or hypothyroid)
-Excessive prolactin, from a prolactinoma
-Pituitary failure eg. trauma, surgery, radiotherapy, Sheehan syndrome
-Cushing’s syndrome
-Asherman’s syndrome
NB- gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
Irregular Menstruation
Abnormal uterine bleeding refers to irregularities in the menstrual cycle, affecting frequency, duration, regularity of the cycle length and the volume of menses. It can be due to:
-Extremes of reproductive age (early periods or perimenopause)
-Polycystic ovarian syndrome
-Physiological stress (excessive exercise, low body weight, chronic disease and psychosocial factors)
-Medications, particularly progesterone only contraception, antidepressants and antipsychotics
-Hormonal imbalances, such as thyroid abnormalities, -Cushing’s syndrome and high prolactin
Intermenstrual Bleeding
Any bleeding that occurs in between menstrual periods. It is a red flag. Some causes are;
-Hormonal contraception
-Cervical ectropion, polyps or cancer
-Sexually transmitted infection
-Endometrial polyps or cancer
-Vaginal pathology, including cancers
-Pregnancy
-Ovulation can cause spotting in some women
-Medications, such as SSRIs and anticoagulants
Dysmenorrhoea
Painful periods. Some causes are;
-Primary dysmenorrhoea (no underlying pathology)
-Endometriosis or adenomyosis
-Fibroids
-Pelvic inflammatory disease
-Copper coil
-Cervical or ovarian cancer
Primary- no underlying pathology. Starts soon after menarche. Management- NSAIDs eg. mefenamic acid, then COCP second line
Secondary- many years after menarche, and is associated with pathology. Management- refer to gyane service
Menorrhagia
Heavy menstrual bleeding. The causes include;
-Dysfunctional uterine bleeding DUB (no identifiable cause)
-Extremes of reproductive age
-Fibroids
-Endometriosis and adenomyosis
-Pelvic inflammatory disease (infection)
-Contraceptives, particularly the copper coil (not the IUS (Mirena)- this is used to treat menorrhagia)
-Anticoagulant medications
-Bleeding disorders (e.g. Von Willebrand disease)
-Endocrine disorders (diabetes and hypothyroidism)
-Connective tissue disorders
-Endometrial hyperplasia or cancer
-Polycystic ovarian syndrome
Postcoital Bleeding
Bleeding after sexual intercourse. It is a red flag. Causes include;
-Cervical ectropion or infection
-Trauma
-Atrophic vaginitis
-Polyps
-Most important- Vaginal, Cervical, or Endometrial cancer
Pelvic pain
Causes include;
-Urinary tract infection
-Dysmenorrhoea (painful periods)
-Irritable bowel syndrome (IBS)
-Ovarian cysts
-Endometriosis
-Pelvic inflammatory disease (infection)
-Ectopic pregnancy
-Appendicitis
-Mittelschmerz (cyclical pain, occurs during ovulation)
-Pelvic adhesions
-Ovarian torsion
-Inflammatory bowel disease (IBD)
Vaginal Discharge
Vaginal discharge is a normal physiological finding. Excessive, discoloured or foul-smelling discharge may indicate:
-Bacterial vaginosis
-Candidiasis (thrush)
-Chlamydia
-Gonorrhoea
-Trichomonas vaginalis
-Foreign body
-Cervical ectropion
-Polyps
-Malignancy
-Pregnancy
-Ovulation (cyclical)
-Hormonal contraception
Pruritus Vulvae
Refers to itching of the vulva and vagina. There are a large number of causes:
-Irritants such as soaps, detergents and barrier contraception
-Atrophic vaginitis
-Infections such as candidiasis (thrush) and pubic lice
-Skin conditions such as eczema
-Vulval malignancy
-Pregnancy-related vaginal discharge
-Urinary or faecal incontinence
-Stress
Hypogonadism
Hypogonadism refers to a lack of the sex hormones, oestrogen and testosterone, that normally rise before and during puberty. A lack of these hormones causes a delay in puberty. The lack of sex hormones is fundamentally due to one of two reasons:
-Hypogonadotropic hypogonadism: a deficiency of LH and FSH
-Hypergonadotropic hypogonadism: a lack of response to LH and FSH by the gonads (the testes and ovaries)
Hypogonadotropic hypogonadism
Involves deficiency of LH and FSH, leading to deficiency of the sex hormones (oestrogen). LH and FSH are gonadotrophins produced by the anterior pituitary gland in response to gonadotropin releasing hormone (GnRH) from the hypothalamus. Since no gonadotrophins are simulating the ovaries, they do not respond by producing sex hormones (oestrogen).
A deficiency of LH and FSH is the result of abnormal functioning of the hypothalamus or pituitary gland. This could be due to:
-Hypopituitarism (under production of pituitary hormones)
-Damage to the hypothalamus or pituitary, for example, by radiotherapy or surgery for cancer
-Significant chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or inflammatory bowel disease)
-Excessive exercise or dieting can delay the onset of menstruation in girls
-Constitutional delay in growth and development is a temporary delay in growth and puberty without underlying physical pathology
-Endocrine disorders such as growth hormone deficiency, hypothyroidism, Cushing’s or hyperprolactinaemia
-Kallman syndrome
Congenital adrenal hyperplasia
Underproduction of cortisol and aldosterone, and overproduction of androgens from birth. It is a genetic condition inherited in an autosomal recessive pattern.
In severe cases, the neonate is unwell shortly after birth, with electrolyte disturbances and hypoglycaemia. In mild cases, female patients can present later in childhood or at puberty with typical features:
-Tall for their age
-Facial hair
-Absent periods (primary amenorrhoea)
-Deep voice
-Early puberty
NB- the most common cause of ambiguous genitalia
NB- ADRenal ANDrogens
Hypergonadotropic hypogonadism
Where the gonads fail to respond to stimulation from the gonadotrophins (LH and FSH). Without negative feedback from the sex hormones (oestrogen), the anterior pituitary produces increasing amounts of LH and FSH. Consequently, you get high gonadotrophins (“hypergonadotropic”) and low sex hormones (“hypogonadism”).
Hypergonadotropic hypogonadism is the result of abnormal functioning of the gonads. This could be due to:
-Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps)
-Congenital absence of the ovaries
-Turner’s syndrome (XO)
Androgen insensitivity syndrome
a condition where the tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop. It results in a female phenotype, other than the internal pelvic organs. Patients have normal female external genitalia and breast tissue. Internally there are testes in the abdomen or inguinal canal, and an absent uterus, upper vagina, fallopian tubes and ovaries. The testes can cause bilateral groin swellings/inguinal hernias
NB- investigation is with chromosomal analysis (46XY karyotype), and management is counselling (raise child as female), oestrogen therapy, and bilateral orchidectomy (increased risk of cancer)
Investigation and management of primary amenorrhoea
NB- The threshold for initiating investigations is no evidence of pubertal changes in a girl aged 13. Investigation can also be considered when there is some evidence of puberty but no progression after two years.
Bedside- detailed history of their general health, development, family history, diet and lifestyle, pregnancy test
Bloods- FBC and haemanitics (anaemia), TFT, IGF-1 (GH deficiency), prolactin, testosterone (PCOS, AIS, CAH), LH FSH (gonadotrophins- low levels= hypothalamic cause, high levels= gonadal dysgenesis)
Imaging and specialist- genetic test (Turners), X ray wrist (constitutional delay), pelvic USS (ovaries), MRI head (tumour)
Management;
-Treat underlying cause
-Hypogonadotropic hypogonadism- give GnRH analogue (or if pregnancy is unwanted, hormones in the form of the COCP)
Secondary Amenorrhoea
Defined as no menstruation for more than three months after previous regular menstrual periods. Consider assessment and investigation after three to six months. In women with previously infrequent irregular periods, consider investigating after six to twelve months.
Investigation;
Bedside- history, examination and observations, urine pregnancy test
Bloods- betaHCG, LH, FSH, prolactin, testosterone, TFT’s
Imaging- USS ovaries (PCOS), MRI head (prolactinoma)
Secondary Amenorrhoea
Defined as no menstruation for more than three months after previous regular menstrual periods. Consider assessment and investigation after three to six months. In women with previously infrequent irregular periods, consider investigating after six to twelve months.
Investigation;
Bedside- history, examination and observations, urine pregnancy test
Bloods- betaHCG, LH, FSH, prolactin, testosterone, TFT’s
NB- Gonadotrophins (LH/FSH)- low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
Imaging- USS ovaries (PCOS), MRI head (prolactinoma)
Management;
-Treat underlying cause
NB- Dopamine agonists such as bromocriptine or cabergoline can be used to reduce prolactin production
Osteoporosis;
Patients with amenorrhoea associated with low oestrogen levels are at risk increased risk of osteoporosis. Where the amenorrhoea lasts more than 12 months, treatment is indicated to reduce the risk of osteoporosis:
Ensure adequate vitamin D and calcium intake
Hormone replacement therapy or the combined oral contraceptive pill
Premenstrual syndrome (PMS)
Describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation
Features;
Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment
Clumsiness
Reduced libido
NB- These symptoms can occur in the absence of menstruation after a hysterectomy, endometrial ablation or on the Mirena coil, as the ovaries continue to function and the hormonal cycle continues. They can also occur in response to the combined contraceptive pill or cyclical hormone replacement therapy containing progesterone
Management;
-General healthy lifestyle changes, such as improving diet (regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates), exercise, alcohol, smoking, stress and sleep
-Combined contraceptive pill (COCP)
-SSRI antidepressants
-Cognitive behavioural therapy (CBT)
If severe, transdermal oestrogen, GnRH analogues, Hysterectomy and bilateral oophorectomy
Investigation and Management of Menorrhagia
Investigations;
Bedside- bimanual and speculum exam, vaginal swabs (infection)
Bloods- FBC and haemanitics (anaemia), coagulation screen, TFT’s (hypothyroidism)
Imaging- hysteroscopy, TV USS
Management;
If they don’t want contraception- TXA or Mefenamic acid (pain also)
If they do want contraception;
-Mirena coil (first line)
-Combined oral contraceptive pill
-Cyclical oral progestogens
NB- when medical management fails- endometrial ablation and hysterectomy
Fibroids
Benign tumours of the smooth muscle of the uterus. (AKA uterine leiomyomas). They are oestrogen sensitive
Fibroids are often asymptomatic. They can present in several ways:
-Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
-Prolonged menstruation, lasting more than 7 days
-Abdominal pain, worse during menstruation (dysmenorrhea)
-Bloating or feeling full in the abdomen
-Urinary or bowel symptoms due to pelvic pressure or fullness
-Deep dyspareunia (pain during intercourse)
-Reduced fertility
-polycythaemia
NB- may be palpable on bimanual examination
Investigations;
Bedside-
Bloods-
Imaging- hysteroscopy, TV USS, MRI (surgical considerations)
Management;
Less than 3cm- same management as menorrhagia (can also be resected/have endometrial ablation)
More than 3cm- refer to gynae, same medical management as menorrhagia (+NSAID) and then surgical options include uterine artery ablation, myomectomy, and hysterectomy
NB- GnRH agonists can shrink them prior to surgery (over time they reduce the amount of sex hormones eg. oestrogen which fibroids need to grow)
NB- if fertility is an issue, then surgery is the definitive management
Complications of fibroids
Heavy menstrual bleeding, often with iron deficiency anaemia
Reduced fertility
Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
Constipation
Urinary outflow obstruction and urinary tract infections
Red degeneration
Torsion of the fibroid
Malignant change to a leiomyosarcoma
Red Degeneration of Fibroids;
Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy. Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy.
Red degeneration presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia.
Endometriosis
A condition where there is ectopic endometrial tissue outside the uterus. A lump of endometrial tissue outside the uterus is described as an endometrioma.
Endometriosis can be asymptomatic in some cases, or present with a number of symptoms:
-Menorrhagia
-Cyclical abdominal or pelvic pain
-Deep dyspareunia (pain on deep sexual intercourse)
-Dysmenorrhoea (painful periods)
-Infertility
-Cyclical bleeding from other sites, such as haematuria
-Urinary symptoms
-Bowel symptoms
-Endometrial tissue may be visible in the vagina on speculum examination, particularly in the posterior fornix
-A fixed cervix on bimanual examination (+retroverted uterus)
-Tenderness in the vagina, cervix and adnexa
Investigations;
Bedside- bimanual and speculum exam
Bloods
Imaging- TV USS, laparoscopic surgery with biopsy (and potential removal at the same time, gold standard)
Management;
Supportive- NSAID/ paracetamol
Medical- COCP, oral progesterone-only pill, the progestin depot injection, the progestin implant (Nexplanon), Mirena coil (all stop ovulation and reduce endometrial thickening)
NB- if these don’t work, GnRH agonists (overtime, reduce the amount of sex hormones which will reduce the growth of endometrial tissue), then;
Surgical- laparoscopic surgery to remove endometrial tissue, adhesiolysis (remove adhesions), hysterectomy
NB- adhesions are a major complication
NB- nice explanation of treatment options on 0-finals
Adenomyosis
refers to endometrial tissue inside the myometrium (muscle layer of the uterus).
Menopause
Menopause- the point at which menstruation stops. The diagnosis is made made after a woman has had no periods for 12 months. The average age is 51
Postmenopausal- the period from 12 months after the final menstrual period onwards.
Perimenopause- includes the time leading up to the last menstrual period, and the 12 months afterwards.
Premature menopause- menopause before the age of 40 years. It is the result of premature ovarian insufficiency.
Perimenopausal symptoms
A lack of oestrogen in the perimenopausal period leads to symptoms of:
Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido
NB- vasomotor symptoms are likely to resolve after 2 – 5 years without any treatment
Risks
A lack of oestrogen increases the risk of certain conditions:
Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
Investigations;
Clinical diagnosis in over 45’s. FSH should be checked in women under 45
NB- contraception in women 40+ (they are still fertile), >50, 12 months from LMP, <50, 24 months from LMP
Management of symptoms;
-Supportive- No treatment/ CBT/ vaginal moisturisers
-Medical- Hormone replacement therapy (HRT), SSRI antidepressants, Testosterone (reduced libido) , Vaginal oestrogen (vaginal dryness and atrophy)
Premature ovarian insufficiency
Menopause before the age of 40 years
Characterised by hypergonadotropic hypogonadism. Hormonal analysis will show:
-Raised LH and FSH levels (gonadotropins)
-Low oestradiol levels
Causes;
Idiopathic (the cause is unknown in more than 50% of cases)
Iatrogenic, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy)
Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease
Genetic, with a positive family history or conditions such as Turner’s syndrome
Infections such as mumps, tuberculosis or cytomegalovirus
Management- HRT
HRT
Women with a uterus require endometrial protection with progesterone, whereas women without a uterus can have oestrogen-only HRT. Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds. Postmenopausal women with a uterus and more than 12 months without periods should go on continuous combined HRT.
Benefits;
-Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms)
-Improved quality of life
-Reduced the risk of osteoporosis and fractures
Risks;
-Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk)
-Increased risk of endometrial cancer (women with a womb need progesterone too, to oppose oestrogen)
-Increased risk of venous thromboembolism (use patches not pills)
-Increased risk of stroke and coronary artery disease with long term use in older women
-The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal
NB- no increased risk in women under 50 and oestrogen-only doesn’t increase risk of CVD
Contradictions to HRT;
-Undiagnosed abnormal bleeding
-Endometrial hyperplasia or cancer
-Breast cancer
-Uncontrolled hypertension
-Venous thromboembolism
-Liver disease
-Active angina or myocardial infarction
-Pregnancy
NB- too much, have a look at 0-finals before counselling
PCOS
a common condition causing metabolic and reproductive problems in women.
Presentation;
Oligomenorrhoea or amenorrhoea
Infertility
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne
Hair loss in a male pattern
Complications;
Insulin resistance and diabetes
Acanthosis nigricans
Cardiovascular disease
Hypercholesterolaemia
Endometrial hyperplasia and cancer
Obstructive sleep apnoea
Depression and anxiety
Sexual problems
Rotterdam Criteria
The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features:
-Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
-Hyperandrogenism, characterised by hirsutism and acne
-Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
Investigations;
Bedside- speculum and bimanual examination
Bloods- Testosterone, Sex hormone-binding globulin, LH, FSH, Prolactin, TSH
Imaging and specialist- TV USS, OGTT (insulin resistance)
NB- raised LH, and the raised LH:FSH ratio, and string of pearls appearance or ovarian volume of more than 10cm3 on USS
Management;
Supportive- weight loss, exercise, smoking cessation
Medical- (anti CVD medications), COCP (hirsutism and acne)
NB- if infertility is an issue, weight loss should help, but also referral to fertility service may be necessary (also involve specialist, clomiphene may help)
Ovarian cysts
The vast majority of ovarian cysts in premenopausal women are benign. Cysts in postmenopausal women are more concerning for malignancy and need further investigation.
Patients with multiple ovarian cysts or a “string of pearls” appearance to the ovaries cannot be diagnosed with polycystic ovarian syndrome unless they also have other features of the condition.
Features;
Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans. Occasionally, vague symptoms:
-Pelvic pain
-Bloating
-Fullness in the abdomen
-A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
-Pressure effects on bladder
-Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.
Investigations;
Bedside-
Bloods- Ca125 (LDH, aFP, bHCG if under 40)
Imaging and specialist- TV USS
Management;
-Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.
-5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.
-More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
Surgery- if large cyst or enlarging
NB- cysts in post menopausal women need referral to specialist
Complications (acute abdominal pain);
-Torsion
-Haemorrhage into the cyst
-Rupture, with bleeding into the peritoneum
Meig’s syndrome;
-Ovarian fibroma (a type of benign ovarian tumour)
-Pleural effusion
-Ascites
NB- cysts that are not simple on imaging always need further assessment
Ovarian cysts
The vast majority of ovarian cysts in premenopausal women are benign. Cysts in postmenopausal women are more concerning for malignancy and need further investigation (referral to gynaecology)
Patients with multiple ovarian cysts or a “string of pearls” appearance to the ovaries cannot be diagnosed with polycystic ovarian syndrome unless they also have other features of the condition.
Features;
Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans. Occasionally, vague symptoms:
-Pelvic pain
-Bloating
-Fullness in the abdomen
-A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
-Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.
Investigations;
Bedside-
Bloods- Ca125 (LDH, aFP, bHCG if under 40)
Imaging and specialist- TV USS
Management;
-Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.
-5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.
-More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
Surgery- if large cyst or enlarging
NB- cysts in post menopausal women need referral to specialist
Complications (acute abdominal pain);
-Torsion
-Haemorrhage into the cyst
-Rupture, with bleeding into the peritoneum
Meig’s syndrome;
-Ovarian fibroma (a type of benign ovarian tumour)
-Pleural effusion
-Ascites
Ovarian torsion
Sudden onset severe unilateral pelvic pain. The pain is constant, gets progressively worse and is associated with nausea and vomiting. May be a palpable mass and localised tenderness
Investigations;
Bedside- pregnancy test, obs
Bloods- other causes of acute abdomen
Imaging and s- TV USS (whirlpool sign), laparoscopy
Management- laparoscopic surgery to untwist/remove the ovary
NB- usually due to underlying structural abnormality eg. ovarian cyst. Always have ectopic pregnancy as a differential too
Asherman’s syndrome
Adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.
Features;
Secondary amenorrhoea
Significantly lighter periods
Dysmenorrhoea
Infertility.
Investigations;
-Hysteroscopy
-Hysterosalpingography
-MRI scan
NB- management is adhesiolysis performed during hysteroscopy
Cervical ectropion
When the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix).
Features;
-asymptomatic found incidentally during speculum examination)
-vaginal discharge
-vaginal bleeding
-dyspareunia
-postcoital bleeding
Management;
Asymptomatic ectropion require no treatment. Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. Having a cervical ectropion is not a contraindication to the combined contraceptive pill.
Problematic bleeding-cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy
NB- cervical ectropion is different to CIN
Nabothian cysts
fluid-filled cysts often seen on the surface of the cervix.
Asymptomatic and no treatment required
Rarely, use colposcopy and get a biopsy to exclude other diagnoses
Pelvic organ prolapse
Descent of the pelvic organs into the vagina
Features;
-A feeling of “something coming down” in the vagina
-A dragging or heavy sensation in the pelvis
-Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
-Bowel symptoms, such as constipation, incontinence and urgency
-Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
- a lump or mass in the vagina, some will already be pushing it back up themselves.
-prolapse will become worse on straining or bearing down.
Management;
Supportive- physiotherapy, weight loss, incontinence pads, vaginal pessaries (ie. ring)
Medical- vaginal oestrogen creams
Surgical- surgical repair (vaginal vault prolapse- sacroplexy)
Urge incontinence
Overactivity of the bladder. Sudden need to run to the toilet
Management;
Supportive- Bladder retraining (gradually increasing the time between voiding) for at least six weeks
Medical- Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin or mirabegron
Surgical- botox into bladder wall, urinary diversion, sacral nerve stimulation etc.
Stress Incontinence
Due to weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder. The typical description of stress incontinence is urinary leakage when laughing, coughing or surprised.
NB- can have mixed stress and urge incontinence
Management;
Supportive- Avoiding caffeine, diuretics and overfilling of the bladder, weight loss (if appropriate), supervised pelvic floor exercises
Medical- duloxetine
Surgical- eg. tension free vaginal tape, colposuspension etc.
NB- continuous dribbling suggests a vesicovaginal fistula and necessitates urological dye studies
Overflow incontinence
Can occur when there is chronic urinary retention due to an obstruction to the outflow of urine. It can occur with anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries
Investigation for urinary incontinence
Bedside- bladder diary, tracking fluid intake and episodes of urination and incontinence over at least three days, urine dipstick (infection, microscopic haematuria etc.)
Imaging and specialist- bladder scan for post-void residual bladder volume, urodynamic testing eg. Cystometry (stop anticholinergics 5 days before)
Atrophic vaginitis
Dryness and atrophy of the vaginal mucosa related to a lack of oestrogen (typically during the menopause)
Features;
-Itching
-Dryness
-Dyspareunia (discomfort or pain during sex)
-Bleeding due to localised inflammation
Examination of the labia and vagina will demonstrate:
-Pale mucosa
-Thin skin
-Reduced skin folds
-Erythema and inflammation
-Dryness
-Sparse pubic hair
Management;
Supportive- vaginal lubricants
Medical- topical oestrogens (contraindications- breast cancer, angina and VTE)
Bartholin cysts
When ducts supplying the Bartholin glands become blocked
Features;
-Swelling is typically unilateral and forms a fluid-filled cyst between 1 – 4 cm.
-Cysts can become infected, forming a Bartholin’s abscess (hot, tender, red and potentially draining pus)
Management;
Supportive- good hygiene, analgesia and warm compresses
Medical- ABX for an abscess
Surgical- surgical drainage (marsupialisation or a word catheter)
Lichen sclerosus
A chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin.
The condition may be asymptomatic, or present with several symptoms:
Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures
NB- the Koebner phenomenon refers to when the signs and symptoms are made worse by friction to the skin eg. tight underwear that rubs the skin, urinary incontinence and scratching.
Areas commonly affected- labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men (foreskin and glans of the penis)
Investigations;
Clinical diagnosis, but may want to do a biopsy to exclude malignancy
Management;
Supportive- emollients, regular review by dermatologist/ gynaecologist (risk of SCC of vulva)
Medical- topical steroids eg. Clobetasol propionate 0.05% (dermovate).
NB- cannot be cured, but can be treated
Cervical Cancer
Most commonly SCC (then adenocarcinoma). Associated with HPV
Risk factors;
-HPV (16,18,33) (unvaccinated)
-Smoking
-HIV (patients with HIV are offered yearly smear tests)
-Combined contraceptive pill use for more than five years
-Increased number of full-term pregnancies
-Family history
-Exposure to diethylstilbestrol during fetal development
-Non engagement with screening
-Early first intercourse, many sexual partners
Features;
Asymptomatic (picked up on screening)
Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
Vaginal discharge
Pelvic pain
Dyspareunia (pain or discomfort with sex)
Investigations;
2 WEEK WAIT PATHWAY
Bedside- obs, speculum and bimanual examination
Bloods- usual pannel
Specialist- colposcopy with LLETZ (biopsy)
Management (MDT)
Supportive-
Medical- chemo and radio
Surgical- LLETZ/cone biopsy (if stage 1 and wishing to maintain fertility)/complete cervical removal
HPV
Cause cervical, anal, vulval, vaginal, penis, mouth and throat cancers. HPV is primarily a sexually transmitted infection.
The important ones to remember are type 16 and 18
Increased risk of catching HPV occurs with:
Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms
HPV Vaccine
The HPV vaccine is ideally given to girls and boys before they become sexually active. The intention is to prevent them contracting and spreading HPV once they become sexually active. The current NHS vaccine is Gardasil, which protects against strains 6, 11, 16 and 18:
Strains 6 and 11 cause genital warts
Strains 16 and 18 cause cervical cancer
Cervical Screening
The samples are initially tested for high-risk HPV before the cells are examined. If the HPV test is negative (the person does not have HPV), the cells are not examined, the smear is considered negative, and the woman is returned to the routine screening program. If cells are examined, they are observed for dyskaryosis (precancerous changes)
The cervical screening program involves performing a smear for women (and transgender men that still have a cervix):
Every three years aged 25 – 49
Every five years aged 50 – 64
There are some notable exceptions to the program:
-Women with HIV are screened annually
-Women over 65 may request a smear if they have not had one since aged 50
-Women with previous CIN may require additional tests (e.g. test of cure after treatment)
-Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
-Pregnant women due a routine smear should wait until 12 weeks post-partum
Management following a smear result;
-Inadequate sample – repeat the smear after at least three months (2x inadequate samples, then colposcopy)
-HPV negative – continue routine screening
-HPV positive with normal cytology – repeat the HPV test after 12 months;
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
-HPV positive with abnormal cytology – refer for colposcopy
NB- always test HPV first, then cytology if needed
Colposcopy
During colposcopy, stains such as acetic acid and iodine solution can be used to differentiate abnormal areas.
Cervical intraepithelial neoplasia (CIN) is a grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at colposcopy (not with cervical screening). The grades are:
CIN I: mild dysplasia
CIN II: moderate dysplasia
CIN III: severe dysplasia (cervical carcinoma in situ)
NB- try not to get mixed up between dysplasia found during colposcopy and dyskaryosis on smear results.
Large Loop Excision of the Transformation Zone (LLETZ) (loop biopsy)- to remove abnormal epithelial tissue on the cervix.
Cone biopsy- a treatment for cervical intraepithelial neoplasia (CIN) and very early-stage cervical cancer.
Endometrial Cancer
An oestrogen-dependent cancer, meaning that oestrogen stimulates the growth of endometrial cancer cells. Typically adenocarcinoma
Risk Factors (all about unopposed oestrogen aka. without progesterone);
-Increased age
-Earlier onset of menstruation
-Late menopause
-Oestrogen only hormone replacement therapy
-No or fewer pregnancies
-Obesity
-Polycystic ovarian syndrome
-Tamoxifen
-2 factors not related to unopposed oestrogen include T2DM and HNPCC/Lynch syndrome
Features;
-Postmenopausal bleeding (endometrial cancer until proven otherwise)
-Postcoital bleeding
-Intermenstrual bleeding
-Unusually heavy menstrual bleeding
-Abnormal vaginal discharge
-Haematuria
-Anaemia
-Raised platelet count
Investigations;
2 WEEK WAIT PATHWAY
Bedside- speculum and bimanual examination
Bloods- routine panel
Imaging- TV USS (endometrial thickness), Pipelle biopsy, hysteroscopy with biopsy
Management;
Supportive-
Medical- progesterone (may slow progression), chemo and radio
Surgical- total abdominal hysterectomy with bilateral salpingo-oophorectomy
Protective factors against endometrial cancer include:
-Combined contraceptive pill
-Mirena coil
-Increased pregnancies
-Cigarette smoking
Ovarian cancer
Risk Factors
-Age (peaks age 60)
-BRCA1 and BRCA2 genes (consider the family history)
-Increased number of ovulations
-Obesity
-Smoking
-Recurrent use of clomifene
Factors that increase the number of ovulations, increase the risk of ovarian cancer. These include:
-Early-onset of periods
-Late menopause
-No pregnancies
Protective Factors (reduced number of ovulations)
-Combined contraceptive pill
-Breastfeeding
-Pregnancy
Features;
Ovarian cancer can present with non-specific symptoms. In older women, keep the possibility of ovarian cancer in mind and have a low threshold for considering further investigations. Symptoms that may indicate ovarian cancer include:
Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites
Hip or groin pain (if pressing on obturator nerve)
Investigations;
Bedside- speculum and bimanual investigations, obs etc.
Bloods- Ca125, usual panel, aFP, HCG (if under 40)
Imaging- TV USS, biopsy (laparoscopy), staging CT, paracentesis with cytology (if ascites present)
NB- carry out physical exam first, if there is ascites or a mass, refer urgently to gynae (2ww). If no ascites/mass, do Ca125 first, if raised, then do a scan: if scan suggests cancer, refer to gynae on a 2ww pathway
Management;
Ovarian cancer will be managed by a specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.
Causes of a raised Ca125;
-Endometriosis
-Fibroids
-Adenomyosis
-Pelvic infection
-Liver disease
-Pregnancy
-Ovarian cancer
The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things:
-Menopausal status
-Ultrasound findings
-CA125 level
Vulval cancer
Typically SCC
Risk Factors;
-Advanced age (particularly over 75 years)
-Immunosuppression
-Human papillomavirus (HPV) infection
-Lichen sclerosus
Features;
-Vulval lump
-Ulceration
-Bleeding
-Pain
-Itching
-Lymphadenopathy in the groin
Vulval cancer most frequently affects the labia majora, giving an appearance of:
-Irregular mass
-Fungating lesion
-Ulceration
-Bleeding
Investigation;
2 WEEK WAIT PATHWAY
Bedside- obs, exam etc.
Bloods- usual panel
Specialist- biopsy of lesion, sentinel node biopsy (spread), staging CT
Management (MDT);
-Wide local excision to remove the cancer
-Groin lymph node dissection
-Chemotherapy
-Radiotherapy
Vulval intraepithelial neoplasia (VIN)
a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer. VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia).
A biopsy is required to diagnose VIN. A specialist will coordinate management. Treatment options include:
Watch and wait with close followup
Wide local excision (surgery) to remove the lesion
Imiquimod cream
Laser ablation
Infertility
Investigation and referral for infertility should be initiated after the couple has been trying to conceive without success for 12 months. This can be reduced to 6 months if the woman is older than 35
General pre-conception advice;
-The woman should be taking 400mcg folic acid daily
-Aim for a healthy BMI
-Avoid smoking and drinking excessive alcohol (both)
-Reduce stress as this may negatively affect libido and the relationship
-Aim for intercourse every 2 – 3 days
-Avoid timing intercourse
Investigations;
Bedside- BMI, observations, physical exam, chlamydia screen
Bloods- rubella immunity in mother, female hormone testing (FSH, LH, progesterone, TFT, anti-mullerian, prolactin)
Specialist- semen analysis, TV USS (ovaries), Hysterosalpingogram (patency of the fallopian tubes), laparoscopy and dye (adhesions)
General management for anovulation (apart from treating underlying cause);
Supportive- weight loss, smoking cessation
Medical- clomifene, letrozole, gonadotrophin analogues
Specialist- surgery to restore normal anatomy eg. adhesions
NB- consider things like IVF
Management of Sperm Problems;
-Surgical sperm retrieval
-Surgical correction of an obstruction
-Intra-uterine insemination
-Intracytoplasmic sperm injection (ICSI)
-Donor insemination with sperm from a donor
NB- measure serum progesterone 7 days prior to expected next period (day 21 if 28 day cycle)
Male Factor infertility
Factors affecting sperm quality;
Hot baths
Tight underwear
Smoking
Alcohol
Raised BMI
Caffeine
Pre-testicular causes;
-Pathology of the pituitary gland or hypothalamus
-Suppression due to stress, chronic conditions or hyperprolactinaemia
-Kallman syndrome
Testicular causes;
Mumps
Undescended testes
Trauma
Radiotherapy
Chemotherapy
Cancer
Klinefelter syndrome
Y chromosome deletions
Sertoli cell-only syndrome
Anorchia (absent testes)
Post-testicular causes;
Damage to the testicle or vas deferens from trauma, surgery or cancer
Ejaculatory duct obstruction
Retrograde ejaculation
Scarring from epididymitis, for example, caused by chlamydia
Absence of the vas deferens
Investigations;
USS testicles
Hormonal analysis with LH, FSH and testosterone levels
Genetic testing
Further imaging, such as transrectal ultrasound or MRI
Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction
Testicular biopsy
IVF
could be a counselling station (NHS)
Ovarian hyperstimulation syndrome (OHSS)
a complication of ovarian stimulation during IVF infertility treatment. It is associated with the use of human chorionic gonadotropin (hCG)
Features;
Abdominal pain and bloating
Nausea and vomiting
Diarrhoea
Hypotension
Hypovolaemia
Ascites
Pleural effusions
Renal failure
Peritonitis from rupturing follicles releasing blood
Prothrombotic state (risk of DVT and PE)
Management;
Oral fluids
Monitoring of urine output
Low molecular weight heparin (to prevent thromboembolism)
Ascitic fluid removal (paracentesis) if required
IV colloids (e.g. human albumin solution)
NB- Haematocrit may be monitored to assess the volume of fluid in the intravascular space. Haematocrit is the concentration of red blood cells in the blood. When the haematocrit goes up, this indicates less fluid in the intravascular space, as the blood is becoming more concentrated. Raised haematocrit can indicate dehydration.
Bacterial vaginosis
An overgrowth of bacteria in the vagina, specifically anaerobic bacteria. It is not a sexually transmitted infection. It is caused by a loss of the lactobacilli “friendly bacteria” in the vagina.
Risk Factors;
-Multiple sexual partners (although it is not sexually transmitted)
-Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
-Recent antibiotics
-Smoking
-Copper coil
Features;
-fishy-smelling watery grey or white vaginal discharge
Investigations;
Bedside- speculum examination, vaginal pH (>4.5), high vaginal charcoal swab for MCS (clue cells on microscopy), exclude STI’s eg. chlamydia and gonorrhoea
Management- asymptomatic, none required, symptomatic, metronidazole (avoid alcohol)
Complications;
Increased risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV.
It is also associated with several complications in pregnant women:
Miscarriage
Preterm delivery
Premature rupture of membranes
Chorioamnionitis
Low birth weight
Postpartum endometritis
Candidiasis (thrush)
Bacterial infection by yeast candida
Risk Factors;
-Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
-Poorly controlled diabetes
-Immunosuppression (e.g. using corticosteroids)
-Broad-spectrum antibiotics
Presentation;
-Thick, white discharge that does not typically smell
-Vulval and vaginal itching, irritation or discomfort
More severe infection can lead to:
-Erythema
-Fissures
-Oedema
-Pain during sex (dyspareunia)
-Dysuria
-Excoriation
Investigations (typically clinical);
-Bedside- speculum exam, vaginal pH (<4.5), high vaginal charcoal swab for MCS
Management (antifungals);
-Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
-Antifungal pessary (i.e. clotrimazole)
-Oral antifungal tablets (i.e. fluconazole) (no oral medication if pregnant, use a pessary)
NB- warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.
NB- Canesten duo is an OTC remedy
Recurrent Disease;
-Blood glucose test to exclude DM
-Induction-maintenance regimen
Chlamydia
The majority of cases of chlamydia in women are asymptomatic. Consider chlamydia in women that are sexually active and present with:
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding (intermenstrual or postcoital)
Painful sex (dyspareunia)
Painful urination (dysuria)
Consider chlamydia in men that are sexually active and present with:
Urethral discharge or discomfort
Painful urination (dysuria)
Epididymo-orchitis
Reactive arthritis
It is worth considering rectal chlamydia and lymphogranuloma venereum in patients presenting with anorectal symptoms, such as discomfort, discharge, bleeding and change in bowel habits.
Examination Findings;
Pelvic or abdominal tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge
Investigation;
Bedside- speculum exam, vaginal pH, high vaginal charcoal swab for MCS, vulvovaginal swab (or cervical/urinary/urethral) with NAAT
Management;
Supportive- abstain from sex for a week, refer to GUM for contact tracing, test and treat for other STI’s, provide advice on how to avoid future infections, safeguarding if children
Medical- doxycycline 100mg twice a day for 7 days (Doxycycline is contraindicated in pregnancy and breastfeeding- use azithromycin)
Complications;
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis
Pregnancy-related complications include:
Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis and pneumonia)
Contact tracing;
for men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms
for women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted
contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)
Lymphogranuloma Venereum
Lymphogranuloma venereum (LGV) is a condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men (MSM). LGV occurs in three stages:
The primary stage involves a painless ulcer (primary lesion). This typically occurs on the penis in men, vaginal wall in women or rectum after anal sex.
The secondary stage involves lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria. The inguinal or femoral lymph nodes may be affected.
The tertiary stage involves inflammation of the rectum (proctitis) and anus. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge. Tenesmus is a feeling of needing to empty the bowels, even after completing a bowel motion.
Doxycycline 100mg twice daily for 21 days is the first-line treatment for LGV recommended by BASHH. Erythromycin, azithromycin and ofloxacin are alternatives.
Chlamydial Conjunctivitis
Chlamydia can infect the conjunctiva of the eye. Conjunctival infection is usually as a result of sexual activity, when genital fluid comes in contact with the eye, for example, through hand-to-eye spread. It presents with chronic erythema, irritation and discharge lasting more than two weeks. Most cases are unilateral.
Chlamydial conjunctivitis occurs more frequently in young adults. It can also affect neonates with mothers infected with chlamydia. Gonococcal conjunctivitis is a crucial differential diagnosis and should be tested.
Gonorrhoea
Features;
Female genital infections can present with:
Odourless purulent discharge, possibly green or yellow
Dysuria
Pelvic pain
Male genital infections can present with:
Odourless purulent discharge, possibly green or yellow
Dysuria
Testicular pain or swelling (epididymo-orchitis)
NB- Rectal infection may cause anal or rectal discomfort and discharge, but is often asymptomatic. Pharyngeal infection may cause a sore throat, but is often asymptomatic. Prostatitis causes perineal pain, urinary symptoms and prostate tenderness on examination. Conjunctivitis causes erythema and a purulent discharge
Investigations;
Bedside- speculum exam, vaginal pH, high vaginal charcoal swab for MCS, vulvovaginal swab (or cervical/urinary/urethral) with NAAT
Management;
Patients should be referred to GUM clinics (or local equivalent) to coordinate testing, treatment and contact tracing. Management depends on whether antibiotic sensitivities are known (local guidelines). For uncomplicated gonococcal infections:
-A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
-A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known
NB- if ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose) should be used
NB- all patients should have a follow up “test of cure” given the high antibiotic resistance.
NB- Supportive- abstain from sex for a week, refer to GUM for contact tracing, test and treat for other STI’s, provide advice on how to avoid future infections, safeguarding if children
Complications;
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Epididymo-orchitis (men)
Prostatitis (men)
Conjunctivitis
Urethral strictures
Disseminated gonococcal infection
Skin lesions
Fitz-Hugh-Curtis syndrome
Septic arthritis
Endocarditis
Disseminated Gonococcal Infection
Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes:
Various non-specific skin lesions
Polyarthralgia (joint aches and pains)
Migratory polyarthritis (arthritis that moves between joints)
Tenosynovitis
Systemic symptoms such as fever and fatigue
Mycoplasma Genitalium
A bacteria that causes non-gonococcal urethritis. It is a sexually transmitted infection
Features;
Most cases of MG do not cause symptoms. But it can cause;
Urethritis
Epididymitis
Cervicitis
Endometritis
Pelvic inflammatory disease
Reactive arthritis
Preterm delivery in pregnancy
Tubal infertility
Investigations (nucleic acid amplification tests (NAAT));
-First urine sample in the morning for men
-Vaginal swabs (can be self-taken) for women
Management (need both);
-Doxycycline 100mg twice daily for 7 days then (not pregnancy/breastfeeding)
-Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)
Pelvic Inflammatory Disease
inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix.
Most cases of pelvic inflammatory disease are caused by one of the sexually transmitted pelvic infections:
Neisseria gonorrhoeae (more severe PID)
Chlamydia trachomatis (most common)
Mycoplasma genitalium
Presentation
Women may present with symptoms of:
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria
Examination findings may reveal:
Pelvic tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge
Patients may have a fever and other signs of sepsis.
Investigations;
Bedside- pregnancy test to rule out ectopic, speculum exam, vaginal pH, high vaginal charcoal swab for MCS (rule out BV, candidiasis, trichomonas- often negative), vulvovaginal swab (or cervical/urinary/urethral) with NAAT (rule out chlamydia/gonorrhoea)
Management;
GUM specialist- local guidelines (below), contact tracing etc. 2 medical options;
1) oral ofloxacin + oral metronidazole
2) intramuscular ceftriaxone + oral doxycycline + oral metronidazole
NB- severe cases may require admission to hospital
omplications
Sepsis
Abscess
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome
Fitz-Hugh-Curtis Syndrome
Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
Fitz-Hugh-Curtis syndrome results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.
Trichomoniasis
a type of parasite spread through sexual intercourse
Trichomonas can increase the risk of:
Contracting HIV by damaging the vaginal mucosa
Bacterial vaginosis
Cervical cancer
Pelvic inflammatory disease
Pregnancy-related complications such as preterm delivery.
Features
Asymptomatic
Vaginal discharge (frothy, yellow-green, fishy smell)
Itching
Dysuria (painful urination)
Dyspareunia (painful sex)
Balanitis (inflammation to the glans penis)
On examination;
Strawberry cervix (colpitis macularis)
Investigations
-Bedside: speculum exam, vaginal pH (>4.5), high vaginal charcoal swab for MCS
Management
Supportive- GUM: contact tracing
Medical- Metronidazole
Genital herpes
The herpes simplex virus (HSV) is commonly responsible for both cold sores (herpes labialis) and genital herpes.
HSV-1- cold sores
HSV-2- genital herpes
Features;
-Ulcers or blistering lesions affecting the genital area
-Neuropathic type pain (tingling, burning or shooting)
-Flu-like symptoms (e.g. fatigue and headaches)
-Dysuria (painful urination)
-Inguinal lymphadenopathy
Investigations;
-Bedside- speculum exam, viral swab
Management;
Supportive- GUM clinic (contact tracing), clean area with warm water, analgesia, wear loose clothing, avoid intercourse whilst symptomatic
Medical- acyclovir (virus)
Pregnancy;
If after 28 weeks- acyclovir and C section
If before 28 weeks- acyclovir (vaginal delivery if at least 6 weeks between delivery and infection)
Syphilis
Caused by bacterium Treponema pallidum
Transmission;
Oral, vaginal or anal sex involving direct contact with an infected area
Vertical transmission from mother to baby during pregnancy
Intravenous drug use
Blood transfusions and other transplants (although this is rare due to screening of blood products)
5 stages- 1/2/latent/3/neuro
Features;
1- painless genital ulcer/local lymphadenopathy
2- Maculopapular rash, wart-like lesions around the genitals and anus, fever, lymphadenopathy, alopecia, oral lesions, buccal ‘snail track’ ulcers (30%)
condylomata lata (painless, warty lesions on the genitalia )
3- gummatous lesions (granulomas), aortic dissection, neurosyphilis
Neuro- Headache, altered behaviour, dementia, tabes dorsalis, ocular syphilis, paralysis, sensory impairment, Argyll-Robertson pupil (accommodates (distance) but doesn’t react to light)
Investigations;
non-treponemal tests and treponemal tests
Positive non-treponemal test + positive treponemal test
consistent with active syphilis infection
Positive non-treponemal test + negative treponemal test
consistent with a false-positive syphilis result e.g. due to pregnancy or SLE (see list above)
Negative non-treponemal test + positive treponemal test :
consistent with successfully treated syphilis
Management;
Supportive- GUM eg;
-Full screening for other STIs
-Advice about avoiding sexual activity until treated
-Contact tracing
-Prevention of future infections
Medical- one dose of IM benzathine benzylpenicillin
the Jarisch-Herxheimer reaction is sometimes seen following treatment
-fever, rash, tachycardia after the first dose of antibiotic
-in contrast to anaphylaxis, there is no wheeze or hypotension
-only antipyretics if needed
Ectopic Pregnancy
When a pregnancy is implanted outside the uterus. The most common site is a fallopian tube (ampulla, dangerous if isthmus). Typically presents around 6 – 8 weeks gestation.
Risk Factors;
Previous ectopic pregnancy
Previous PID
Previous surgery to the fallopian tubes
Intrauterine devices (coils)
Older age
Smoking
Endometriosis
IVF
Features;
Missed period
Constant lower abdominal pain in the right or left iliac fossa
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
Dizziness
Shoulder tip pain (peritonitis)
Diarrhoea/rectal pain- blood can irritate the pouch of Douglas
NB- always ask about the possibility of pregnancy, missed periods and recent unprotected sex in women presenting with lower abdominal pain.
NB- never feel for an adnexal mass (risk of rupture)
Investigations;
Bedside- pregnancy test, observations, physical exam etc.
Bloods- ABG, FBC, UE, bHCG etc.
Imaging- TV USS ( “blob sign”, “bagel sign” or “tubal ring sign” or pseudogestational sac in uterus)
HCG
hCG will roughly double every 48 hours
If pregnancy of unknown location;
-A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy (above 1500, pregnancy should be visible on the scan)
-A rise of less than 63% after 48 hours may indicate an ectopic pregnancy.
-A fall of more than 50% is likely to indicate a miscarriage
Management;
-Refer to gynae/ early pregnancy assessment unit
-Expectant management (awaiting natural termination)
-Medical management (IM methotrexate, no pregnancy for 3 months afterwards)
-Surgical management (salpingectomy or salpingotomy)
Criteria for expectant management:
Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l
Criteria for methotrexate are the same as expectant management, except:
HCG level must be < 5000 IU / l
Confirmed absence of intrauterine pregnancy on ultrasound
Criteria for surgical management;
Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l
NB- Anti-rhesus D prophylaxis is given to rhesus negative women
Either salpingectomy (first line), or salpingotomy (if other tube looks damaged)
Miscarriage
The spontaneous termination of a pregnancy. Early miscarriage is before 12 weeks gestation. Late miscarriage is between 12 and 24 weeks gestation.
Definitions;
Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred
Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive
Inevitable miscarriage – vaginal bleeding with an open cervix
Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage
Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus
Anembryonic pregnancy – a gestational sac is present but contains no embryo
Investigations;
TV USS (if recurrent- refer to recurrent miscarriage clinic for tests eg. antiphospholipid syndrome)
Management;
Early pregnancy assessment unit (they will need to come back to confirm the pregnancy has ended)
1) Expectant- wait 7-14 days
Situations where expectant wouldn’t be appropriate;
-Increased risk of haemorrhage (coagulopathy, late first trimester)
-Previous adverse pregnancy outcome
-Evidence of infection
2) Medical- vaginal misoprostol (contact if no bleeding within 24 hours)
3) Surgical- vacuum aspiration under local anaesthetic as an outpatient (or surgical management in theatre)
More than 6 weeks;
-Expectant
-Medical (misoprostol)
-Surgical (manual or electric vacuum aspiration)- Anti-rhesus D prophylaxis is given to rhesus negative women
Misoprostol
The key side effects of misoprostol are:
Heavier bleeding
Pain
Vomiting
Diarrhoea
Incomplete miscarriage
When retained products of conception (fetal or placental tissue) remain in the uterus after the miscarriage- risk of infection.
Management;
Medical management (misoprostol)
Surgical management (evacuation of retained products of conception)
NB- endometriosis is a complication
Recurrent miscarriage
Three or more consecutive miscarriages.
Investigations are initiated after:
-Three or more first-trimester miscarriages
-One or more second-trimester miscarriages
Causes;
Idiopathic (particularly in older women)
Antiphospholipid syndrome
Hereditary thrombophilias (eg. factor V leiden)
Uterine abnormalities (eg. fibroids)
Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
Chronic histiocytic intervillositis
Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)
Investigations;
Antiphospholipid antibodies
Testing for hereditary thrombophilias
Pelvic ultrasound
Genetic testing of the products of conception from the third or future miscarriages
Genetic testing on parents
Termination Of Pregnancy
An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of:
-The woman
-Existing children of the family
An abortion can be performed at any time during the pregnancy if:
-Continuing the pregnancy is likely to risk the life of the woman
-Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
-There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
The legal requirements for an abortion are:
-Two registered medical practitioners must sign to agree abortion is indicated
-It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
Medical Abortion;
It involves two treatments:
-Mifepristone (anti-progestogen)
-Misoprostol (prostaglandin analogue) 1 – 2 day later
Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.
NB- from 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion.
NB- Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis (or having a surgical TOP)
Surgical abortion;
-cervical dilation with suction/vacuum aspiration (<14 weeks) or evacuation with forceps/cutterage (>14 weeks)
NB- need to check pregnancy has ended in 4 weeks (may still have positive pregnancy tests until then)
Complications;
Bleeding
Pain
Infection
Failure of the abortion (pregnancy continues)
Damage to the cervix, uterus or other structures
Hyperemesis Gravidarum
Protracted nausea and vomiting of pregnancy
More than 5 % weight loss compared with before pregnancy
Dehydration
Electrolyte imbalance
Investigations;
Bedside- urinalysis (ketonuria and elevated specific gravity), H. pylori breath test
Bloods- FBC (normal), UE’s (hyponatraemia, elevated urea and creatinine), LFT (normal), serum ketones (elevated)
Further imaging if necessary eg. Abdominal ultrasound
Management;
Supportive- Assess severity with the Pregnancy-Unique Quantification of Emesis Score (PUQE), fluids, oral antiemetics at home (antihistamine eg. cyclizine, not severe)
Medical- admission considered if- can’t keep fluids down/ ketones 2+/ electrolyte imbalances/ other medical conditions (may need IV fluids and antiemetics/ VTE prophylaxis)
NB- ondansetron and metoclopramide are used 2nd line (metoclopramide- not more than 5 days due to EPSE’s)\
Associations;
multiple pregnancies
trophoblastic disease
hyperthyroidism
nulliparity
obesity
NB- smoking is associated with a reduced incidence
NB- if severe or prolonged it can also result in vitamin and mineral deficiencies. In this case, the patient has presented with diplopia and ataxia suggestive of Wernicke’s encephalopathy. Therefore, supplementation of thiamine (Vitamin B1) with a vitamin B and C complex (e.g. Pabrinex) is indicated.
Molar pregnancy
A type of tumour that grows like a pregnancy inside the uterus.
A complete mole- when two sperm cells fertilise an ovum that contains no genetic material. These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form.
A partial mole- when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.
Features;
More severe morning sickness
Vaginal bleeding
Uterus size greater than expected for gestational age
Abnormally high hCG
Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
Investigations;
USS- snowstorm appearance of the pregnancy (with biopsy when pregnancy has passed)
NB- TVUSS or abdominal USS?
Management;
-Surgical evacuation of uterus (send mole for histology)
-Monitor hCG levels
-Refer to the gestational trophoblastic disease centre for follow up
-contraception for the next 12 months?
Pregnancy Timeline
Last menstrual period (LMP) refers to the date of the first day of the most recent menstrual period
Gestational age (GA) refers to the duration of the pregnancy starting from the date of the last menstrual period
The first trimester start of pregnancy until 12 weeks gestation.
The second trimester is from 13 weeks until 26 weeks gestation.
The third trimester is from 27 weeks gestation until birth.
NB- fetal movements start from around 20 weeks
Key Milestones (see 0-finals)
Additional Milestones;
Additional appointments for higher risk or complicated pregnancies
Oral glucose tolerance test in women at risk of gestational diabetes (between 24 – 28 weeks)
Anti-D injections in rhesus negative women (at 28 and 34 weeks)
Ultrasound scan at 32 weeks for women with placenta praevia on the anomaly scan
Serial growth scans are offered to women at increased risk of fetal growth restriction
Routine Antenatal Appointments
Discuss plans for the remainder of the pregnancy and delivery
Symphysis–fundal height measurement from 24 weeks onwards
Fetal presentation assessment from 36 weeks onwards
Urine dipstick for protein for pre-eclampsia
Blood pressure for pre-eclampsia
Urine for microscopy and culture for asymptomatic bacteriuria
Vaccines;
-Whooping cough (pertussis) from 16 weeks gestation
-Influenza (flu) when available in autumn or winter
Live vaccines, such as the MMR vaccine, are avoided in pregnancy.
Pregnancy Lifestyle Advice
Take folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects)
Take vitamin D supplement (10 mcg or 400 IU daily)
Avoid vitamin A supplements and eating liver or pate (vitamin A is teratogenic at high doses)
Don’t drink alcohol when pregnant (risk of fetal alcohol syndrome)
Don’t smoke (smoking has a long list of complications, see below)
Avoid unpasteurised dairy or blue cheese (risk of listeriosis)
Avoid undercooked or raw poultry (risk of salmonella)
Continue moderate exercise but avoid contact sports
Sex is safe
Flying increases the risk of venous thromboembolism (VTE)
Place car seatbelts above and below the bump (not across it)
Foetal Alcohol Syndrome;
Microcephaly (small head)
Thin upper lip
Smooth flat philtrum (the groove between the nose and upper lip)
Short palpebral fissure (short horizontal distance from one side of the eye to the other)
Learning disability
Behavioural difficulties
Hearing and vision problems
Cerebral palsy
Flying in Pregnancy;
-37 weeks in a single pregnancy
-32 weeks in a twin pregnancy
After 28 weeks gestation, most airlines need a note from a midwife, GP or obstetrician to state the pregnancy is going well and there are no additional risks.
Smoking in Pregnancy;
Fetal growth restriction (FGR)
Miscarriage
Stillbirth
Preterm labour and delivery
Placental abruption
Pre-eclampsia
Cleft lip or palate
Sudden infant death syndrome (SIDS)
Booking Clinic
Education
What to expect at different stages of pregnancy
Lifestyle advice in pregnancy (e.g. not smoking)
Supplements (e.g. folic acid and vitamin D)
Plans for birth
Screening tests (e.g. Downs screening)
Antenatal classes
Breastfeeding classes
Discuss mental health
Booking Bloods
-Blood group, antibodies and rhesus D status
-Full blood count for anaemia
-Screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
Patients are also offered screening for infectious diseases, by testing antibodies for:
-HIV
-Hepatitis B
-Syphilis
Other Measures
Weight, height and BMI
Urine for protein and bacteria
Blood pressure
Discuss female genital mutilation
Discuss domestic violence
NB- risk assessment is completed (for VTE, diabetes etc.)
Down’s Syndrome Screening
Combined Test
-First line and the most accurate screening test. It is performed between 11 and 14 weeks
-USS (nuchal translucency- greater than 6mm)
-Maternal blood tests:
Beta‑human chorionic gonadotrophin (beta-HCG) – a higher result indicates a greater risk
Pregnancy‑associated plasma protein‑A (PAPPA) – a lower result indicates a greater risk
Triple Test
-Between 14 and 20 weeks gestation.
-Beta-HCG
-Alpha-fetoprotein (AFP)
-Serum oestriol– lower result indicates a greater risk
NB- quadruple test: also measures inhibin-A (higher=greater risk)
The screening tests provide a risk score for the fetus having Down’s syndrome. When the risk of Down’s is greater than 1 in 150 (occurs in around 5% of tested women), the woman is offered amniocentesis or chorionic villus sampling.
NB- maternal age is also factored into the risk tool
NB- Edwards: everything low, normal inhibin . NTD’s: isolated raised AFP
Pre-existing HTN in pregnancy
Medications that should be stopped as they may cause congenital abnormalities:
ACE inhibitors (e.g. ramipril)
Angiotensin receptor blockers (e.g. losartan)
Thiazide and thiazide-like diuretics (e.g. indapamide)
Medications that are not known to be harmful:
Labetalol (a beta-blocker – although other beta-blockers may have adverse effects)
Calcium channel blockers (e.g. nifedipine)
Alpha-blockers (e.g. doxazosin)
Epilepsy in Pregnancy
Levetiracetam, lamotrigine and carbamazepine are the safer anti-epileptic medication in pregnancy
Sodium valproate and phenytoin are avoided
Rheumatoid arthritis in pregnancy
Methotrexate is avoided
sulfalazine hydroxychloroquine and steroids are safe
Medications and Pregnancy
Avoid;
-NSAID
-ACE-i/ARB
-Opiates
-Warfarin
-Lithium, phenytoin
-Valproate
-Isotretinoin
-Methotrexate
-DOACs’ (use LMWH)
NB- be careful with Beta blockers (FGR- use labetolol) and SSRI’s (cardiac malformation)
Chickenpox and pregnancy
In pregnancy, there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome
Mothers that have previously had chickenpox are immune and safe. When in doubt, IgG levels for VZV can be tested (this is first line). A positive IgG for VZV indicates immunity. Women that are not immune to varicella may be offered the varicella vaccine before or after pregnancy.
Exposure to chickenpox in pregnancy:
-if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible (up to 10 days)
-if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
Chickenpox infection in pregnancy;
-oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
-if the woman is < 20 weeks the aciclovir should be ‘considered with caution’
Listeria
Listeria is typically transmitted by unpasteurised dairy products, processed meats and contaminated foods. Pregnant women are advised to avoid high-risk foods (e.g. blue cheese) and practice good food hygiene.
