Women's Health Flashcards
Define Pelvic Organ Prolapse?
Descent of the pelvic organs into the vagina.
What is the pathology of a Prolapse?
The result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.
What types of prolapse can result from a weakness in the Apical Vaginal Wall?
- Uterine prolapse
- Vaginal Vault Prolapse
what is a Uterine Prolapse?
Where the uterus itself descends into the vagina
What is a Vaginal Vault Prolapse?
Occurs in women that have had a hysterectomy and no longer have a uterus.
The top of the vagina (the vault) descends into the vaginal canal
What types of Prolapse can result from a weakness in the Posterior Vaginal Wall?
- Enterocele
- Rectocele
What is an Enterocele?
Defect in the posterior vaginal wall allowing the small intestine to prolapse forwards into the vagina
What is a Rectocele?
Defect in the posterior vaginal wall allowing the rectum to prolapse forwards into the vagina
What type of prolapse can result from a weakness in the Anterior Vaginal Wall?
- Cystocele
- Urethrocele
- Cystourethrocele
What is a Cysteocele?
Prolapse of the bladder backwards into the vagina due to a defect in the anterior vaginal wall
What is a Urethrocele?
Prolapse of the Urethra backwards into the vagina due to a defect in the anterior vaginal wall
What is a Cystourethrocele?
Prolapse of both the bladder and the urethra into the vagina through the anterior vaginal wall.
What is the Epidemiology of Pelvic Organ Prolapse?
- Common condition
- More common in Postmenopausal women
- More common in those who have undergone childbirth
- Prevalence increases with age
What are some risk factors for developing pelvic organ prolapse?
- Multiple vaginal deliveries
- Increasing age
- Instrumental, prolonged or traumatic delivery
- Hysterectomy
- Advanced age and postmenopausal status
- Obesity
- Chronic respiratory disease causing coughing
- Chronic constipation causing straining
- Heavy lifting
- Connective tissue disorders
What are the clinical features of a pelvic organ prolapse?
Depend on the type and severity
- Pelvic discomfort or Sensation of Heaviness or Sensation of something coming down
- Visible protrusion of tissue from the vagina
- Urinary Symptoms such as Incontinence, recurrent UTIs or voiding difficulties
- Defecatory symptoms such as Constipation or incomplete bowel emptying
- Sexual Dysfunction
- Women may notice a lump or mass that they will often push back up themselves.
What clinical features are Rectoceles particularly associated with?
Constipation
- Women can develop Faecal loading in the part of the rectum that ha prolapsed.
- This may lead to significant constipation and urinary retention
What are some differential diagnoses for pelvic organ prolapse?
- Gynaecologic malignancy: associated with abnormal vaginal bleeding, weight loss, and pelvic pain
- Cervicitis: characterized by vaginal discharge, bleeding, and pelvic pain
- Urethral diverticulum: presents with dysuria, recurrent UTIs, and a palpable anterior vaginal mass
What are the investigations for a Pelvic Wall Prolapse?
Detailed Pelvic Examination
- Left lateral or Dorsal position
- Sim’s Speculum
- Ask the woman to cough or bear down
Imaging Studies
- Ultrasound or MRI
Urodynamic Studies
What is used to examine the pelvis when investigating for Pelvic organ prolapse?
Sim’s Speculum
- U shaped speculum that is used to support the anterior or posterior vaginal wall whilst the other walls are examined.
- Women are asked to cough or bear down to assess the full decent of the prolapse.
- Dorsal and Left Lateral position are used.
How is a uterine prolapse graded?
Pelvic organ prolapse quantification system (POP-Q):
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
A prolapse extending beyond the introitus can be referred to as uterine procidentia.
What is the management for Pelvic Organ Prolapse?
If asymptomatic or Mild prolapse then Conservative only
- Conservative management:
- Physiotherapy (pelvic floor exercises)
- Weight loss
- Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
- Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
- Vaginal oestrogen cream
- Vaginal Pessaries: Inserted into the vagina to provide extra support to the pelvic organs.
- Surgery: Definitive option for treating Pelvic organ prolapse but must consider the risk and benefits of each individual.
What conservative management options are there for Pelvic Organ Prolapse?
- Physiotherapy (pelvic floor exercises)
- Weight loss
- Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
- Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
- Vaginal oestrogen cream
What are some options for Vaginal Pessaries?
- Ring pessaries are a ring shape, and sit around the cervix holding the uterus up
- Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
- Cube pessaries are a cube shape
- Donut pessaries consist of a thick ring, similar to a doughnut
- Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.
What is some key information about Vaginal Pessaries?
- Should be removed and cleaned or changed periodically (every 4 months)
- Can cause vaginal irritation and erosion over time
- Oestrogen cream helps protect the vaginal walls from irritation
What are some Surgical Options for Pelvic Organ Prolapse?
cystocele/cystourethrocele:
- anterior colporrhaphy,
- colposuspension
uterine prolapse:
- hysterectomy,
- sacrohysteropexy
rectocele:
- posterior colporrhaphy
What are some possible complications of Pelvic Organ Prolapse Surgery?
- Pain, bleeding, infection, DVT and risk of anaesthetic
- Damage to the bladder or bowel
- Recurrence of the prolapse
- Altered experience of sex
Define Urinary Incontinence?
Involuntary passage of urine
Define Overactive Bladder Syndrome?
A chronic condition that results rom hyperactivity of the detrusor muscle. This is primarily characterised by urinary urgency and urge incontinence
What are the clinical features of Overactive Bladder Syndrome?
- Urinary Urgency
- Urge Incontinence
- Frequency
- Nocturia
What is a typical presentation of Overactive Bladder syndrome and Urge incontinence?
- Typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs.
- Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access.
- This can have a significant impact on their quality of life, and stop them doing work and leisure activities.
What are some differential diagnoses for Overactive Bladder Syndrome?
- Urinary tract infections: Characterised by dysuria, urgency, frequency, suprapubic pain and haematuria.
- Bladder stones: Symptoms include lower abdominal pain, dysuria, intermittent stream, and blood in the urine.
- Interstitial cystitis: Presents with symptoms such as chronic pelvic pain, a persistent, urgent need to urinate, and frequent urination.
- Diabetic neuropathy: Can cause bladder dysfunction, resulting in symptoms like frequent urination and incontinence.
What are the investigations for Overactive Bladder Syndrome?
- Urinalysis and culture: To rule out infection
- Frequency/volume chart: To assess the severity of the condition
- Urodynamics: To evaluate bladder muscle function
What is the management for Overactive Bladder Syndrome?
First Line: For at least 6 weeks:
- Bladder retraining: Which aims to increase the interval between voids, and suppress the urinary urge
- Behavioural modifications: Such as reducing oral fluid intake, and avoiding caffeine and alcohol
Second Line:
- Anticholinergic drugs: Like oxybutynin, Tolterodine and solifenacin
- Mirabegron: An alternative to anticholinergics
- Vaginal oestrogens: Used if urogenital atrophy is a likely contributory factor
Invasive options when medical treatments fail
- Botulism toxin: Used specifically for refractory cases
Give some anticholinergic drugs used to treat an Overactive Bladder?
- Oxybutynin
- Tolterodine
- Solifenacin
What are some side effects of Anticholinergic Mediations?
- Dry mouth and eyes
- Urinary Retention
- Constipation
- Postural Hypotension
- Cognitive decline and memory problems
- Worsening of Dementia
What is Mirabegron?
A beta 3 agonist that stimulates the sympathetic nervous system causing relaxation of the bladder.
What is a contraindication of Mirabegron?
Uncontrolled Hypertension.
- Since it stimulates the sympathetic nervous system it can lead to a raised blood pressure and can result in a hypertensive crisis!
- Can also increase the risk of stroke and TIA
What are some examples of Invasive options to treat Overactive Bladder Syndrome when the bladder has failed to respond to medication?
- Botulinum toxin type A injection into the bladder wall
- Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves
- Augmentation cystoplasty involves using bowel tissue to enlarge the bladder
- Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen
Define Urinary Incontinence
The loss of control of urination leading to involuntary passage of urine
What is the Physiology of the Storage phase (filling) of Continence?
Bladder function:
- Detrusor muscle remains relaxed to allow the bladder to fill with urine.
- This relaxation is primarily mediated by the sympathetic nervous system (via the hypogastric nerve, which releases noradrenaline), acting on β-adrenergic receptors in the bladder wall.
Urethral function:
- The internal urethral sphincter (smooth muscle) remains contracted, and the external urethral sphincter (skeletal muscle) maintains voluntary closure, preventing urine leakage.
- The sympathetic system helps keep the internal sphincter closed
- The somatic nervous system (via the pudendal nerve) controls the external sphincter.
Nervous control:
- The pontine storage centre in the brainstem inhibits detrusor contraction during bladder filling
- while sensory signals from the bladder stretch receptors are sent to the brain, indicating fullness without triggering voiding.
What is the Physiology of the Voiding phase of Continence?
Bladder function:
- When the bladder reaches a certain level of fullness, signals from the brain initiate the voiding phase.
- The parasympathetic nervous system (via the pelvic nerve) stimulates the detrusor muscle to contract, increasing pressure in the bladder.
Urethral function:
- At the same time, the internal urethral sphincter relaxes, and the external urethral sphincter voluntarily relaxes to allow urine to flow through the urethra.
Nervous control:
- The pontine micturition centre coordinates this process,
- Bladder contraction and sphincter relaxation.
- Voiding occurs when detrusor pressure overcomes urethral resistance.
Give a summary of the neurology involved in continence?
Sympathetic - T10-L2 hypogastric - detrusor relaxation, IUS closing
- Parasympathetic - S2-4 pelvic splanchnic - detrusor contraction, IUS opening
- Somatic afferent - S2-4 pudendal - sensation of bladder fullness
- Somatic efferent - S2-3 pudendal - closes / opens EUS.
What are the continence mechanisms in response to a raised intra-abdominal pressure?
- Reflexive contraction of the pelvic floor muscles elevates the IUS.
- Augmentation of pelvic floor muscle closure by suspensory ligaments.
- Urethrovaginal sphincter and compressor urethrae muscle contraction assists with urethral closure
What are the different types of Urinary Incontinence?
- Stress incontinence
- Urge incontinence
- Overflow incontinence
- Functional incontinence
- Mixed incontinence
What is Urge incontinence?
Caused by Overactivity of the detrusor muscle.
This is also known as overactive bladder syndrome
What is Stress incontinence?
Leaking of urine when intra-abdominal pressure is raised that puts pressure on the bladder. The pressure overcomes the mechanisms to maintain continence.
This occurs due to weakness of the pelvic floor and sphincter muscles
What are some risk factors for Stress incontinence?
- Childbirth (Especially vaginal)
- Hysterectomy
What are some triggers for Stress incontinence?
Anything that can increase abdominal pressure sufficiently
- Coughing
- Laughing
- Sneezing
- Exercising
What is the management for Stress incontinence?
Lifestyle Advice:
- Avoid caffeine, fizzy and sugary drinks
- Avoid excessive fluid intake
- Pelvic floor exercises (8x contractions x3 per day)
Medical Management:
- Duloxetine (only recommended if conservative management fails and the patient is not a surgical candidate)
Surgical Management:
- Pessaries
- Bulking agents placed at the bladder neck
- Colposuspension and fascial slings
- Mid urethral slings
What is the gold standard treatment for Stress incontinence?
Mid-urethral slings is the gold standard surgical treatment of stress incontinence.
It compresses the urethra against a supportive layer and assists in closing the urethra.
What is Functional incontinence?
Individual has the urge to pass urine but for whatever reason they are unable to access the necessary facilities and are aw a result incontinent.
What are some potential causes of Functional Incontinence?
- Sedating Medications
- Alcohol
- Dementias
What is Overflow incontinence?
Occurs when small amounts of urine leak without warning.
This may happen when the pressure within the bladder overcomes the pressures of the outlet structure and thus urine leaks
What are some causes of Overflow incontinence?
- Underactivity of the detrusor muscle such as from neurological damage
- Urinary outlet pressures are too high Such as in constipation or prostatism
- Chronic urinary retention due to an obstruction.
- Anti-cholinergic medications.
What is Mixed incontinence?
A combination of urge incontinence and stress incontinence.
It is crucial to identify which of the 2 is having the more significant impact and address this first.
What are the investigations of Incontinence?
First Line:
- Medical history and Assessment
- Physical Examination
- Bladder Diary: tracking fluid intake, episodes of urination and incontinence over at least 3 days
- Urinalysis and Urine-Dip stick: To look for infection or other pathology
Second Line:
- Urinary Stress Tests: Cough stress test, empty supine stress test
- Cystometry and Cystogram: Bladder scan to assess for bladder pressures when voiding or fistulas
- Urodynamics
What information should be obtained from a Medical history assessment for Incontinence?
Differentiate between Stress or Urge:
- Urinary leakage with coughing, laughing or sneezing (Stress)
- Urinary leakage due to sudden urge to pass with loss of control (Urge)
Assess for Modifiable lifestyle factors:
- Caffeine consumption
- Alcohol consumption
- Medications (anticholinergics)
- BMI
Assess the Severity:
- Frequency of urination
- Frequency of incontinence
- night-time urination
- Use of pads and changes of clothing.
What should be done during a Physical examination to look for incontinence?
Assessment of Pelvic Tone:
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
Also examine for
- Pelvic organ prolapse
- Atrophic vaginitis
- Urethral diverticulum
- Pelvic masses
- urinary incontinence (asking the patient to cough)
What are the indications for Urodynamic testing?
- Patients with Urge incontinence not responding to first line medical treatments
- Difficulties urinating
- Urinary retention
- Previous surgery in and around the pelvis
- Unclear diagnosis
What is done in Urodynamic testing for incontinence?
- Patients should stop taking anticholinergic and bladder related medications for 5 days before testing.
- A catheter is inserted into the bladder and the rectum and they measure the pressures for comparison. The bladder is filled with liquid and different measurements are taken.
What are each of these measurements for?
- Cystometry
- Uroflowmetry
- Leak Point Pressure
- Poist-void residual bladder volume
- Video urodynamic testing
- Cystometry measures the detrusor muscle contraction and pressure
- Uroflowmetry measures the flow rate
- Leak Point Pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence.
- Poist-void residual bladder volume tests for incomplete emptying of the bladder
- Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.
Define Urolithiasis?
Urinary tract stones or Urolithiasis refer to solid concretions or crystal aggregations formed in the urinary system from substances present in the urine
Define Renal Colic?
A condition characterised by severe pain caused by the presence of a stone in the urinary tract
What is the epidemiology of Urinary tract stones?
- Common condition affecting 2-3% of western population
- More common in males
- More common in people younger than 65
What is the aetiology of renal stones?
Calcium oxalate stones:
- Represent 85% of stones. They are radiopaque, formed in variable urine pH, and majorly linked to hypercalciuria.
Calcium phosphate stones:
- Account for 10% of stones. They are radiopaque and linked to renal tubular acidosis type 1 & 3, leading to increased urine pH and supersaturation of calcium and phosphate in the urine.
Cystine stones:
- Make up 1% of stones. Characterised by a semi-opaque “ground glass” appearance, they result from inherited recessive inborn errors of metabolism causing disruption in cystine transport and decreased absorption from the renal tubule.
Uric acid stones:
- Comprise 5-10 of stones. They are radiolucent, formed due to acid produced from purine metabolism and precipitate when urinary pH is low. They can be linked to diseases causing extensive tissue breakdown.
Struvite stones:
- Account for 2-20% of stones. They are radiopaque and formed from magnesium, ammonium, and phosphate, often associated with chronic UTIs from urease producing bacteria like ureaplasma, proteus.
Indinavir stones:
- Associated with the antiretroviral protease inhibitor Indinavir used in HIV treatment. It can crystallize in renal tubules and result in renal stones. These stones are radiolucent on CTKUB.
What is the most common cause of Renal stones?
Hypercalcaemia/Hypercalciuria
Patients may present with symptoms of hypercalcaemia (renal stones, painful bones, abdominal groans and psychiatric moans)
3 Main causes of Hypercalcaemia:
- Calcium supplementation
- Hyperparathyroidism
- Cancer (Myeloma, Breast, Lung)
What are the risk factors for Nephrolithiasis?
Modifiable risk factors include:
- Obesity
- Dehydration
- Diet rich in oxalate-rich foods like fruits, nuts, and cocoa
Non-modifiable risk factors include:
- Previous stone disease
- Anatomical abnormalities of the collecting system
- Family history
Underlying medical conditions, such as:
- Hyperparathyroidism
- Renal tubular acidosis
- Myeloproliferative disorders
- All chronic diarrhoeal conditions
What is Staghorn Calculus?
Where the stone forms in the shape of the renal pelvis giving it a similar appearance to the antlers of a deer stag.
Often associated with Struvite stones
What are the clinical features of Renal Colic?
- Unilateral Colicky loin to groin pain that can be excruciating (“worse than childbirth”)
- Haematuria
- Nausea or vomiting
- Reduced urine output
- Symptoms of sepsis (Fever), if infection is present
cancerWhat are some differential diagnoses for Renal Colic?
- Pyelonephritis: Presents with fever, flank pain, and urinary symptoms such as frequency, urgency, and dysuria.
- Appendicitis: Presents with right lower quadrant pain, nausea, vomiting, and possibly fever.
- Diverticulitis: Presents with left lower quadrant pain, fever, nausea, vomiting, and changes in bowel habits.
- Ovarian torsion: Presents with acute lower abdominal pain, nausea, vomiting, and sometimes fever.
- Ectopic pregnancy: Presents with lower abdominal pain, vaginal bleeding, and a positive pregnancy test.
- Abdominal aortic aneurysm: Presents with central abdominal pain, pulsatile/expansile abdominal aorta and if ruptured, haemodynamic instability.
What are the investigations for Renal Colic?
Bedside investigations:
- Urinalysis to detect haematuria
- Urine MC+S as there may be a co-existing infection/precipitant.
- Observations to look for any signs of sepsis
Blood tests:
- Full Blood Count to detect any inflammatory response
- Urea and Electrolytes to assess any impairment in renal function.
- Calcium & Uric acid to identify underlying metabolic conditions predisposing to stone formation.
Radiological investigations:
- A non-contrast helical CT KUB, the gold standard for identifying renal calculi.
- An x-ray for managing renal colic if there’s a confirmed stone on CT KUB, necessary for the use of extracorporeal shockwave lithotripsy.
What is the initial and gold standard investigation for Renal Colic?
Non-contrast CT Kidney, Ureter and Bladder (CTKUB) is both the initial and Gold standard investigation
- NICE recommend a CT within 24 hours of presentation
- BAUS recommend a CT within 14 hours of admission
What is the management for Renal Colic?
- Analgesia: NSAIDs such as IM Diclofenac
- Anti-emetics: Metoclopramide, Cyclizine
- Antibiotics: If infection is present
- Medical Expulsive Therapy: Uses Tamsulosin to help passage of distal ureter stones < 5mm
- Watchful Waiting: If stones are less than 5mm
- Surgical Intervention: required in larger stones 10mm or more or ones that do not pass spontaneously. Also required if there is complete obstruction or infection.
What are some surgical options for Renal Colic?
Stones < 2cm
- Extracorporeal shockwave lithotripsy (ESWL): shock waves fragment the stone to then be passed
- Ureteroscopy: Treatment of choice for middle or distal ureteric stones and for Pregnant women
Stones > 2cm
- Percutaneous nephrolithotomy: for large stones or complex calculi like staghorn or cysteine.
- Open Stone surgery: when other options have failed.
What is a complication of renal stones?
- Significant risk of recurrent episodes
- Obstructive infection
- Sepsis
- Renal Failure
What advice can be given to reduce the risk of recurrent stones?
- Increase oral fluid intake (2.5 – 3 litres per day)
- Add fresh lemon juice to water (citric acid binds to urinary calcium reducing the formation of stones)
- Avoid carbonated drinks (cola drinks contain phosphoric acid, which promotes calcium oxalate formation)
- Reduce dietary salt intake (less than 6g per day)
- Maintain a normal calcium intake (low dietary calcium might increase the risk of kidney stones)
Define Oligomenorrhea?
Infrequent/irregular menstrual periods (fewer than 6-8 per year)
Define Amenorrhoea?
Primary
Secondary
Absence of a menstrual period
Primary: absence of a period at age 15 in the presence of normal secondary sexual characteristics or at age 13 with no secondary sexual characteristics
Secondary: Absence of a period for 3 consecutive cycles in a women with a previously established menstrual cycle
What are some causes of Primary Amenorrhoea?
- Constitutional delay (Familial)
- Imperforate hymen
- Endocrinological: Hypo-hyperthyroidism, Hyperprolactinaemia, Cushing’s Syndrome
- Androgen Insensitivity Syndrome
- Turners syndrome
What are some causes of Secondary Amenorrhoea?
- Pregnancy (most common cause)
- Breastfeeding
- Menopause
- Intrauterine adhesions leading to outflow tract obstruction (Asherman’s syndrome)
- Polycystic ovary syndrome (PCOS)
- Drug-induced amenorrhoea (e.g. contraceptive use)
- Functional Hypothalamic Amenorrhoea: Physical stress, excess exercise, and weight loss
- Pituitary gland pathology: such as Sheehan syndrome or hyperprolactinaemia
- Hypothyroidism or hyperthyroidism
Define Androgen Insensitivity Syndrome?
An X-linked Recessive genetic condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors This results in Genetic Males with a Female Phenotype
What is the pathophysiology of Androgen Insensitivity Syndrome?
- Mutation in Androgen receptor gene on the X chromosome results in cells becoming unable to respond to androgens.
- Excess androgens are converted to Oestrogen resulting in female secondary sexual characteristics
(Previously known as Testicular feminisation syndrome) - Males are genetically XY with a female phenotype
What is the anatomy of a patient with Androgen Insensitivity Syndrome?
- Female External Genitalia and Breast Development
- Testes located within the abdomen or inguinal canal.
- Absence of Female internal organs (Uterus, upper vagina, cervix, fallopian tubes and ovaries) due to the testes producing anti-Mullerian hormone.
- Patients are taller than female average, with a lack of pubic hair, facial hair and male type muscle bulk.
What is a risk of patients with Androgen Insensitivity Syndrome?
High risk of Testicular cancer unless the testes are removed
What is the Presentation of Androgen Insensitivity Syndrome?
- Often presents in infancy with Inguinal hernias containing testes
- May present at puberty with Primary Amenorrhoea
What are the investigations for Primary Amenorrhoea?
Exclude pregnancy with urinary or serum bHCG
Full blood count - anaemia
Urea & electrolytes
Coeliac screen
Thyroid function tests
Gonadotrophins (LH/FSH):
- Low levels indicate a hypothalamic cause where as
- Raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
- Raised if gonadal dysgenesis (e.g. Turner’s syndrome)
Prolactin for Hyperprolactinaemia
Androgen levels
- Raised levels may be seen in PCOS
Oestradiol
Second Line:
- Genetic Testing: Identify chromosomal or genetic abnormalities
- Imaging: To identify structural abnormalities
What are the results of hormonal tests in Androgen Insensitivity Syndrome?
- Raised LH
- Normal or raised FSH
- Normal or Raised Testosterone levels (For a male)
- Raised Oestrogen levels (For a male)
What is the management of Primary Amenorrhoea?
Depends on the underlying cause
- Hormone replacement therapy: For hormonal imbalances
- Surgery: For structural abnormalities
- Psychological support: For conditions related to stress or eating disorders
- Lifestyle modifications: For issues related to excessive exercise or low body weight
- Monitoring and regular follow-ups: To assess effectiveness of treatment and adjust as necessary
What is the management of Androgen Insensitivity Syndrome?
MDT Specialist Coordination: Paediatrics, Gynaecology, Urology, Endocrinology, Clinical Psychology
- Bilateral Orchiectomy: To avoid testicular tumours
- Oestrogen Therapy
- Vaginal Dilators or Vaginal Surgery: To create and adequate length vagina
Generally patients are raised as female but this is tailored to the individual
What is responsible for the embryological development of the upper vagina, cervix, uterus and fallopian tubes?
They develop from the paramesonephric ducts (Mullerian ducts)
Why do males not develop female gentalia?
The testes in a male foetus produce Anti-Mullerian hormone which suppresses the growth of the paramesonephric ducts and so they do not form.
What ae some Congenital structural Abnormalities for the Female Reproductive Tract?
- Bicornuate Uterus
- Uterus Agenesis
- Imperforate Hymen
- Transverse vaginal Septae
- Vaginal Hypoplasia and Agenesis
What is a Bicornuate Uterus?
- Uterus has 2 horns giving it a heart shaped appearance.
- This can be associated with adverse pregnancy outcomes however successful pregnancies are generally expected.
What are some complications of a Bicornuate Uterus?
- Miscarriage
- Premature Birth
- Malpresentation
What is an Imperforate Hymen?
Where the hymen at the entrance of the vagina is fully formed without an opening.
How does an Imperforate Hymen Present?
- May be discovered when the girl starts to menstruate, and the menses are sealed in the vagina.
- This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding.
What is the management of an Imperforate Hymen?
- Diagnosed during a clinical examination
- Treatment is a Surgical incision to create an opening in the hymen.
What is a complication of an Imperforate Hymen?
- If not treated then retrograde menstruation could occur leading to endometriosis
- Amenorrhoea
What is a Transverse Vaginal Septae?
Caused by an error in development, where a septum (wall) forms transversely across the vagina.
This septum can either be perforate (with a hole) or imperforate (completely sealed).
What is the Presentation of a Transverse Vaginal Septae?
- Perforate Septae: Girls will menstruate but can have difficulty with intercourse or tampon use
- Imperforate Septae: Presents similarly to an Imperforate Hymen
What are some complications of a Transverse Vaginal Septae?
- Infertility
- Pregnancy related complications
- Vaginal Stenosis
- Recurrence of the Septae
What is the management of a Transverse Vaginal Septae?
- Diagnosis is by Examination, Ultrasound or MRI
- Treatment with with Surgical Correction
What is Vaginal Hypoplasia and Agenesis?
Hypoplasia: An Abnormally small vagina
Agenesis: An absent vagina
These occur due to failure of the Mullerian ducts to properly develop and are often associated with an absent uterus and cervix
What is the difference between Vaginal Hypoplasia and Agenesis and Androgen Insensitivity Syndrome?
The Mullerian Ducts fail to develop but not due to Anti-Mullerian Hormone.
Therefore patients do not have Testes (like in AIS) but do have Ovaries
What is the management of Vaginal Hypoplasia and Agenesis?
- Vaginal Dilator over a prolonged period of time to create and adequate vaginal size
- Vaginal Surgery may be necessary
Define Menarche?
The first occurrence of Menstruation
At what age does Menarche normally occur?
Mean age 13
11-15 usually.
Define Menopause?
This term describes the permanent cessation of menstruation, characterised by at least 12 months of amenorrhoea in otherwise healthy women over the age of 45 who are not using hormonal contraception.
When does Menopause typically occur?
Between the ages of 45-55 with the average age being around 51-52 years old.
Define Perimenopause?
- The time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods.
- Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards.
- This is typically in women older than 45 years.
Define Postmenopause?
The period from 12 months after the final menstrual period
Define Early Menopause?
Menopause between the ages of 40-45 years old.
Premature Menopause is the menopause occuring prior to the age of 40 and is due to ovarian insufficiency
What is the Aetiology of Menopause?
Caused by ovarian failure which leads to oestrogen deficiency
What is the physiology of Menopause?
- Primordial follicles mature into primary and secondary follicles independently of the menstrual cycle.
- FSH stimulates secondary follicle development at the start of the menstrual cycle, leading to increased oestrogen production (granulosa cells).
- At Menopause primordial follicle number is depleated leading to a decline in follicle development, reducing oestrogen production.
- As oestrogen declines, the lack of negative feedback causes increased LH and FSH levels from the pituitary gland.
- Reduced follicular development leads to anovulation, irregular cycles, amenorrhoea, and perimenopausal symptoms due to low oestrogen.
- Without Oestrogen the endometrium does not develop eventually leading to a lack of menstruation (amenorrhoea)
What is the cause of the perimenopausal symptoms?
Lower levels of Oestrogen
What are some perimenopausal symptoms?
Vasomotor Symptoms:
- Hot flushes
- Night sweats
- Irregular periods, Heavy or lighter periods
- Joint Pains
Sexual Dysfunction:
- Vaginal dryness and atrophy
- Reduced libido
- Problems with Orgasm
- Dyspareunia
Psychological Symptoms:
- Depression
- Anxiety
- Mood Swings, Low mood and emotional lability
- Lethargy
- Reduced Concentration
What are some risks of menoupause?
Reduced oestrogen increases the risk of certain conditions:
- Cardiovascular disease and stroke
- Osteoporosis due to increased bone turn over since normal oestrogen levels inhibit osteoclast activity
- Pelvic Organ Prolapse
- Urinary Incontinence
What are some differential diagnoses for Menopause?
- Thyroid disease: symptoms can include hot flushes, sweating, palpitations, and changes in menstrual cycle
- Depression: exhibits mood swings, lethargy, reduced concentration
- Premature ovarian insufficiency: can cause hot flushes, night sweats, vaginal dryness, and reduced libido
What are the investigations for Menopause?
Diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms without performing any investigations
NICE Guidelines (2015) recommend FSH Blood test to help with Diagnosis:
- Women under 40 years with suspected premature menopause
- Women aged 40-45 with menopausal symptoms or a change in menstrual cycle
- Elevated FSH level (>30 IU/L) may predict impending menopause after several months of amenorrhoea
How long after the last menstrual period before the menopause should women continue to use contraception?
Two years after the last menstrual period in women under 50
One year after the last menstrual period in women over 50
What is the relationship between hormonal contraceptives and menopause?
Hormonal contraceptives do not affect the menopause, when it occurs or how long it lasts, although they may suppress and mask the symptoms.
This can make diagnosing menopause in women on hormonal contraception more difficult.
What are some good contraceptive options for women approaching menopause?
Barrier methods
Mirena or copper coil
Progesterone only pill
Progesterone implant
Progesterone depot injection (under 45 years)
Sterilisation
What are 2 main side effects of the progesterone depot injection?
Weight Gain and Reduce bone mineral density (osteoporosis)
This is why this form of contraception is unsuitable for women Over 45 years old
What is the management of Perimenopausal Symptoms?
Vasomotor symptoms likely resolve after 2-5 years without treatment
Management of Symptoms depends on severity, personal circumstances and response to treatment
First Line: Lifestyle Measures
- Regular Exercise
- Weight Loss (as necessary)
- Avoidance of triggers (Smoking, alcohol, spicy food)
Second line: Hormone replacement therapy (HRT)
- Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
- Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors for flushing
- Cognitive behavioural therapy (CBT)
- SSRI antidepressants, such as fluoxetine or citalopram
- Testosterone can be used to treat reduced libido (usually as a gel or cream)
- Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)
- Vaginal moisturisers, such as Sylk, Replens and YES
What is the purpose of HRT?
Oestrogens: Overcome oestrogen deficiency
Progesterone’s: Required for endometrial protection from unopposed systemic oestrogens
- HRT can be given cyclically (for perimenopause) or continuously (for post menopause)
What are some benefits and risks of HRT?
Benefits
- Relief of Vasomotor symptoms
- Relief of urogenital symptoms
- Reduced risk of Osteoporosis
Risks
- Increased risk of Breast Cancer
- Increased risk of Endometrial Cancer (if given oestrogen alone)
- Increased risk of VTE
What are some Absolute Contraindications to HRT?
B – Breast cancer (current or history of)
R – Recent heart attack (myocardial infarction)
E – Endometrial cancer (current or untreated)
A – Active liver disease
S – Stroke (recent or history of)
T – Thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism)
C – Clotting disorder (e.g., thrombophilia, protein C/S deficiency)
L – Liver disease (severe or active)
O – Oestrogen-sensitive cancer (like ovarian cancer)
T – Thrombosis risk (high risk for clot formation)
Define Adenomyosis?
Refers to a condition where endometrial tissue is inside the myometrium (muscle layer of the uterus)
What is the Epidemiology of Adenomyosis?
- More common in later reproductive years
- More common in those who have had several pregnancies (Multiparous)
- Occurs in around 10% of women
- May occur alone or alongside endometriosis or fibroids
What is the Aetiology of Adenomyosis?
Not fully Understood
- Multiple factors involved including Sex hormones, trauma and inflammation
- Condition is hormone dependent
What are the clinical features of Adenomyosis?
- enlarged, boggy uterus
- Painful periods (dysmenorrhoea)
- Heavy periods (menorrhagia)
- Pain during intercourse (dyspareunia)
- Infertility or pregnancy related complications
- 1/3 of patients are asymptomatic
What are the investigations for Adenyomyosis?
First Line:
- Transvaginal Ultrasound of the pelvis
- MRI and Transabdominal ultrasound are alternatives if transvaginal is unsuitable
Gold Standard:
- Histological examination of the uterus after a hysterectomy
- Not usually a suitable way of establishing the diagnosis for obvious reasons
What is the management of Adenomyosis?
Depends on symptoms, age and plans for pregnancy
Women does NOT want contraception
- Tranexamic Acid when there is no pain associated (antifibrinolytic)
- Mefenamic Acid when there is pain associated (NSAID)
Women DOES want Contraception:
- Mirena coil - First Line
- Combined Oral Contraceptive Pill (COCP)
- Cyclical oral progestogens
Other options considered by specialist
- GnRH analogues to induce menopause like state
- Endometrial ablation
- Uterine artery embolisation
- Hysterectomy
What are some pregnancy complications associated with Adenomyosis?
- Infertility
- Miscarriage
- Preterm birth
- Small for gestational age
- Preterm premature rupture of membranes
- Malpresentation
- Need for caesarean section
- Postpartum haemorrhage
Define Asherman’s Syndrome?
Where adhesions form within the uterus (intrauterine adhesions) following damage to the uterus that lead to outflow tract obstruction.
What is the Aetiology of Asherman’s syndrome?
Anything that creates scar tissue within the uterus causing adhesions that are normally not connected
- Pregnancy related dilation and Curettage procedure
- Treatment of retained productions of conception (removing placental tissue left behind after birth)
- Uterine surgery (myomectomy)
- Pelvic infection (endometritis)
What is the pathophysiology of Asherman’s Syndrome?
- Damage to the uterus causing scar tissue formation and subsequent adhesions.
- Adhesions form Physical Obstructions and distort the pelvic organs
- Leads to menstruation abnormalities, infertility, recurrent miscarriages
What are the clinical features of Asherman’s Syndrome?
Presents following recent dilatation and curettage, uterine surgery or endometritis with:
- Secondary amenorrhoea
- Significantly lighter periods
- Dysmenorrhoea
- Infertility
Incidentally found adhesions that are asymptomatic are not classed as Asherman’s Syndrome
What are the investigations for Asherman’s Syndrome?
History of uterine surgery
Hysteroscopy is Gold Standard investigation and can involve dissection and treatment of adhesions.
Others:
- Hysterosalpingography when contrast is injected into the uterus and imaged with X-rays
- Sonohysterography uterus is filled with fluid and pelvic USS is performed
- MRI Scan
What is the management of Asherman’s Syndrome?
- Dissecting the adhesions during hysteroscopy.
- Reoccurrence of the adhesions after treatment is common
What are the clinical features of Secondary Amenorrhea?
The primary symptom of secondary amenorrhoea is the absence of menstrual periods for six months or longer.
Additional symptoms, depending on the underlying cause, may include:
- Pregnancy symptoms: nausea, breast tenderness, increased urination, food cravings or aversions
- Menopause symptoms: hot flashes, night sweats, sleep problems, mood changes
- Symptoms of PCOS: acne, weight gain, hirsutism (excessive body hair), thinning hair
- Symptoms of pituitary gland issues: headaches, vision problems, unexplained weight gain or loss
What are the investigations for Secondary Amenorrhoea?
- Pregnancy test
- Hormone level checks: including FSH, LH, TSH, prolactin, and testosterone
- Ultrasound or other imaging studies, to identify potential structural abnormalities
- Hysteroscopy, in cases where intrauterine adhesions are suspected
What is the management of Secondary Amenorrhoea?
Management of secondary amenorrhoea is determined by the underlying cause:
- Pregnancy: regular prenatal care
- Menopause: hormone replacement therapy (HRT) if symptoms are troublesome
- PCOS: lifestyle changes, hormonal contraceptives, and potentially metformin
- Asherman’s syndrome: surgical removal of adhesions and hormone therapy
- Drug-induced amenorrhoea: discontinuing the offending drug if possible and safe to do so
- Conditions related to physical stress, weight loss, or excessive exercise: lifestyle modifications and nutritional counselling.
Define Lichen Sclerosus?
A chronic inflammatory skin condition that presents with patches of Porcelain-white skin.
It typically affects the genital and anal regions of the body: labia, perineum, perianal skin, foreskin and glans penis
What is the epidemiology of Lichen Sclerosus?
- Typically affects women
- Can affect men
- Considered to be an autoimmune condition and therefore is associated with T1DM, Alopecia, hypothyroid and vitiligo
What is the Aetiology of Lichen Sclerosus?
The cause of lichen sclerosus is currently unknown, but it is likely multifactorial.
Potential contributing factors could include autoimmune condition, genetic predisposition, and hormonal factors.
Some studies suggest a possible link with previous skin damage or trauma.
What is Lichen in medicine?
Lichen refers to a flat eruption that spreads.
*It is important not to get lichen sclerosus confused with lichen simplex or lichen planus.
Define Lichen simplex
Chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.
Define Lichen planus
Autoimmune condition (All the P’s)
Purple planar polygonal papules on extensor surfaces of the hand and Wickham striae in the mouth
What is a typical presentation of Lichen Sclerosus?
Woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva
The condition may be asymptomatic, or present with several symptoms:
- Itching
- Soreness and pain possibly worse at night
- Skin tightness
- Painful sex (superficial dyspareunia)
- Erosions
- Fissures
What is the Koebner phenomenon?
The appearance of new skin lesions on areas of pre-existing dermatosis and cutaneous injury (skin trauma)
This occurs with Lichen Sclerosus
What is the appearance of Lichen Sclerosus?
Changes affect the labia, perianal and perineal skin. There can be associated fissures, cracks, erosions or haemorrhages under the skin.
The affected skin appears:
- “Porcelain-white” in colour
- Shiny
- Tight
- Thin
- Slightly raised
- There may be papules or plaques
What are some differential diagnoses for Lichen Sclerosus?
- Lichen planus: Characterized by purplish, itchy, flat-topped bumps, and white lacy patches in the mouth or on the skin.
- Psoriasis: Manifests as red patches with silver scales, typically on the scalp, elbows, knees, and lower back.
- Vitiligo: Presents as patchy loss of skin color, usually first on sun-exposed areas of the skin.
What are the investigations for Lichen Sclerosus?
Primarily Clinical Diagnosis based on characteristic appearance of skin lesions
- Skin biopsy may be performed to confirm diagnosis
- Blood tests may rule out other potential autoimmune conditions
What is the Management of Lichen Sclerosus?
Lichen Sclerosus cannot be cured but symptoms are controlled and should be followed up every 3-6 months
First Line
-
Potent Topical Steroids: Clobetasol propionate 0.05% (dermovate)
- Steroids used long term to control symptoms
- Once daily for 4 weeks. Then gradually reduce frequency every 4 weeks to alternate days then twice weekly.
- Daily steroids when condition flares
- Emollients should be used regularly both with steroids and as part of maintenance
- Avoidance of soaps in affected areas to prevent further irritation.
What are some complications of Lichen Sclerosus?
- 5% risk of developing squamous cell carcinoma of the vulva
- Pain and discomfort
- Sexual dysfunction
- Bleeding
- Narrowing of the vaginal or urethral openings
Define Atrophic Vaginitis?
vulvovaginal atrophy is inflammation and thinning of the genital tissues, dryness and atrophy of the vaginal mucosa due to reduced oestrogen levels
What is the Aetiology of Atrophic Vaginitis?
Decrease in oestrogen levels most commonly due to menopause
What are the clinical features of Atrophic Vaginitis?
Presents in post-menopausal women with:
- Itching and dryness
- Loss of pubic hair
- Dyspareunia (discomfort or pain during sex)
- Post coital Bleeding due to localised inflammation
- recurrent UTIs or Stress incontinence
- Pelvic organ prolapse may also occur.
What are some differential diagnoses for Atrophic Vaginitis?
- Postmenopausal bleeding: malignancy, endometrial hyperplasia
- For genital itching/discharge: sexually transmitted infection, vulvovaginal candidiasis, skin conditions such as lichen sclerosis, lichen planus, diabetes
- For narrowed introitus: female genital mutilation
- For urinary symptoms: urinary tract infection, bladder dysfunction, pelvic floor disfunction, cystitis
- For dyspareunia: malignancy, vaginismus
What are the investigations for Atrophic Vaginitis?
Clinical Diagnosis
- Clinical examination, including speculum examination if tolerated, to look for vaginal signs of atrophy
Other tests:
- Transvaginal ultrasound and endometrial biopsy, if necessary, to exclude endometrial cancer
- An infection screen if itching or discharge is present
- A biopsy of any abnormal skin lesions, if needed
What would be seen on examination in Atrophic Vaginitis?
- Pale mucosa
- Thin skin
- Reduced skin folds
- Erythema and inflammation
- Dryness
- Sparse pubic hair
What is the management of Atrophic Vaginitis?
Hormonal treatment:
-
Topical oestrogen preparations:
- Estriol cream
- Estriol pessaries
- Estradiol Tablets
- Estradiol ring
Non-hormonal treatments:
- Lubricants such as Sylk, Replens, YES:, which provide short-term improvement to vaginal dryness, alleviating symptoms such as dyspareunia
- Moisturisers, which should be used regularly
What are some contraindications to Topical Oestrogens?
- Active or history of hormone-dependent cancers
- Undiagnosed vaginal bleeding.
- Known hypersensitivity.
- Severe liver disease
Define Vulval Cancer?
Malignant growth that primarily affects the skin of the vulva (the external part of the female genitalia).
It can be host to various types of Skin cancers however Squamous Cell Carcinoma is the most prevalent.
What is the Epidemiology of Vulval cancer?
- Rare gynaecological cancer accounting for 4%
- Most commonly found in older women >60 (but can occur at any age)
- 90% are Squamous Cell Carcinomas
What are some risk factors for Vulval Cancer?
- Advanced age (particularly over 75 years)
- Human papilloma virus (HPV) infection
- Vulval intraepithelial neoplasia (VIN)
- Immunosuppression
- Lichen sclerosus
What are the different types of Vulval Cancer?
- Squamous Cell Carcinoma (90%)
- Malignant Melanomas
- Basal Cell Carcinoma
What are the clinical features of Vulval Cancer?
- Vulval lump
- Lymphadenopathy in the groin
- Itching
- Ulceration
- Bleeding
- Pain
What region of the Vulva is most common affected in Vulval Cancer?
Labia Majora
What are some differential diagnoses for Vulval Cancer?
- Vulval intraepithelial neoplasia: This precancerous condition can cause itching, burning, skin changes, and discomfort.
- Lichen sclerosus: This condition can cause itching, pain, and white patches on the vulva.
- Bartholin’s cyst: This may present as a lump or swelling on the vulva, and can cause discomfort or pain.
What are the investigations for Vulval Cancer?
Physical Examination
Suspected vulval cancer should be referred on a 2-week-wait urgent cancer referral.
Establishing the diagnosis and staging involves:
- Biopsy of the lesion
- Sentinel node biopsy to demonstrate lymph node spread
- Further imaging for staging (e.g. CT abdomen and pelvis)
What is system is used to stage Vulval Cancer?
International Federation of Gynaecology and Obstetrics (FIGO)
Management of Vulval Cancer depends on the stage
What is the Management of Vulval Cancer?
Depends on the Stage
- Wide local excision to remove the cancer
- Groin lymph node dissection
- Chemotherapy
- Radiotherapy
What is Vulval Intraepithelial Neoplasia?
- VIN is a premalignant condition affecting the squamous epithelium of the skin.
- VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia)
What are the different types of Vulval Intraepithelial Neoplasia?
- High grade squamous intraepithelial lesion: A type of VIN associated with HPV infection that occurs in younger women aged 35-50 years.
- Differentiated VIN: Type of VIN associated with lichen Sclerosus and typically occurs in older women aged 50-60 years.
How is Vulval intraepithelial neoplasia diagnosed?
A biopsy
What are the management options for Vulval Intraepithelial Neoplasia?
- Watch and wait with close follow-up
- Wide local excision (surgery) to remove the lesion
- Imiquimod cream
- Laser ablation
Define Cervical Cancer?
Malignant proliferation of the cells of the Cervix (the lower part of the uterus that connects to the vagina)
What is the Epidemiology of Cervical Cancer?
- 3rd most common cancer worldwide and 4th biggest cause of cancer death
- Strongly associated with Human papilloma virus (HPV)
What are the different types of Cervical Cancer?
- Squamous Cell Carcinoma (80%)
- Adenocarcinoma (10-20%)
- Very rarely, Small cell Cancer
What are some risk factors for Cervical Cancer?
Increased risk of catching HPV occurs with:
- Early sexual activity
- Increased number of sexual partners
- Sexual partners who have had more partners
- Not using condoms
Non-engagement with cervical screening is a significant risk factor.
Other risk factors are:
- Smoking
- HIV (patients with HIV are offered yearly smear tests)
- Combined contraceptive pill use for more than five years
- Increased number of full-term pregnancies
- Family history
- Exposure to diethylstilbestrol
What is the Human Papilloma Virus?
- HPV is a Sexually Transmitted Infection of the virus that is associated with anal, vulval, vaginal, penile, mouth and throat cancers
- There are over 100 strains but theHPV 16 and 18 are responsible for 70% of cervical cancers
- HPV Infection spontaneously resolves within 2 years in 90% of women. At this point the risk returns to baseline.
Which strains of HPV are targeted in the HPV vaccine and when is the vaccine given?
Current NHS vaccine is Gardasil protecting against HPV 6, 11, 16, 18, 31, 33, 45, 52, 58
- HPV 6 and 11 cause Genital Warts
- HPV 16 and 18 cause Cervical Cancer (plus others)
- Girls and boys are given the HPV vaccine around age 12-13 years old
How does HPV promote cancer development?
- HPV 16 and 18 produces two proteins (E6 and E7) that inhibit tumour suppressor genes respectively
- HPV 16 - E6 inhibits p53
- HPV 18 - E7 inhibits pRb
- These cause dysregulated cell cycle regulation leading to the formation of a pre-malignant monoclonal cell population
- This cell population is cervical intraepithelial neoplasia (CIN) which subsequently mutates further to become an invasive carcinoma
What is Cervical Intraepithelial Neoplasia?
What is Cervical Intraepithelial Neoplasia (CIN) is a grading system for the level of dysplasia and premalignant change in the cells of the cervix
CIN is diagnosed at Colposcopy (not with cervical screening)
What are the grades of Cervical Intraepithelial Neoplasia?
- CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
- CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
- CIN III: severe dysplasia, very likely to progress to cancer if untreated
CIN III is sometimes called cervical carcinoma in situ.
What is the typical presentation of Cervical cancer?
Most cases are picked up asymptomatically during cervical screening or smears.
- Abnormal bleeding (post-coital/intermenstrual/post menopausal)
- Abnormal discharge
What are some clinical features of Cervical Cancer?
- Vaginal discharge
- Abnormal Vaginal Bleeding (e.g. postcoital or with micturition or defaecation)
- Dyspareunia
- Vaginal discomfort
- Urinary or bowel habit change
- Suprapubic pain
- Abnormal white/red patches on the cervix.
- Pelvic bulkiness on PV examination
- Mass felt on PR examination
What are some differential diagnoses for Cervical Cancer?
- Vaginitis: itching, burning, pain, and abnormal discharge
- Cervical Ectropion
- Nabothian cyst
- Cervicitis: abnormal discharge, pelvic pain, and postcoital bleeding
- Endometrial cancer: abnormal vaginal bleeding, pelvic pain, and unintentional weight loss
- Cervical polyps: abnormal vaginal bleeding, discharge, and pain during intercourse
What are the investigations for Cervical Cancer?
- Clinical History prompting Cervix examination with Speculum +/- Swabs to exclude infection
If there is an abnormal appearance of the cervix suggestive of cancer:
- First line investigation is an Urgent cancer referral for Colposcopy for visualisation and biopsy of the cervix.
- HPV testing
- CT Chest, Abdomen and Pelvis is used for Cancer Staging
What is Colposcopy?
- Involves inserting a speculum and using equipment (a colposcope) to magnify the cervix. This allows the epithelial lining of the cervix to be examined in detail.
- Stains such as Acetic acid and Iodine solution are used to identify abnormal areas
- A Punch biopsy or LLETZ Biopsy can be performed to get a tissue sample
What is seen on staining during Colposcopy?
Acetic Acid Stain:
- Abnormal cells appear white (Acetowhite)
Schiller’s Iodine Test:
- Stains healthy cells of the cervix a brown colour.
- Abnormal areas/cells will not stain
What may be seen on examination of the cervix that may suggest cervical cancer?
- Ulceration
- Bleeding
- Inflammation
- Visible tumour
What may be seen on Colposcopy that is suspicious of Cervical Cancer?
- Abnormal vascularity
- White change with Acetic Acid
- Exophytic Lesions
What are the Stages of Cervical Cancer?
FIGO system
Stage 1: Confined to cervix
Stage 2: Extending into the uterus or upper 2/3 of the vagina
Stage 3: Extending into lower third of the vagina or pelvic wall
Stage 4: Spread beyond true pelvis or bladder / rectum involvement
What is the management of Cervical Cancer?
Cervical intraepithelial neoplasia and early-stage 1A:
- LLETZ or cone biopsy
Stage 1B – 2A:
- Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B – 4A:
- Chemotherapy and radiotherapy
- Bevacizumab (VEG-F inhibitor)
Stage 4B:
- Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
What is the Prognosis for Cervical Cancer?
5 year survival drops significantly with an advanced stage.
- Stage 1a: 98% 5 year survival
- Stage 4: 15% 5 year survival
What is Bevacizumab (Avastin)?
- Monoclonal antibody used in combination with other chemotherapies in the treatment of Metastatic or Recurrent Cancers.
- It is a Vascular Endothelial Growth Factor A Inhibitor (VEGF-A) to reduce the development of new blood vessels from the cancer.
What is a Cone Biopsy?
- A cone biopsy is a treatment for cervical intraepithelial neoplasia (CIN) and very early-stage cervical cancer.
- It involves a general anaesthetic.
- The surgeon removes a cone-shaped piece of the cervix using a scalpel.
- This sample is sent for histology to assess for malignancy
What are the main risks of a Cone Biopsy?
- Pain
- Bleeding
- Infection
- Scar formation with stenosis of the cervix
- Increased risk of miscarriage and premature labour
What is a Large Loop Excision of the Transformation Zone (LLETZ)?
Also called a Loop Biopsy
- Involves a Local Anaesthetic
- Often performed during a Colposcopy procedure
- Involves a wire loop with electrical current (diathermy) to remove the abnormal epithelial tissue on the cervix.
- Electrical current cauterises the tissue and stops bleeding
What are the main risks of Large Loop Excision of the Transformation Zone (LLETZ)?
- Bleeding and Abnormal discharge can occur for several weeks following a LLETZ procedure
- Intercourse and tampon use after the procedure should be avoided to reduce infection
- May increase the risk of Preterm labour
Who is Eligible for the Cervical Screening Program?
- For all Women and People (Transmen) with a cervix between the age of 25-64 years
- Cervical sample is taken and tested for High -risk HPV viruses (hrHPV)
What are the normal intervals for Cervical Screening?
- 3 yearly for women aged 25-49
- 5 yearly for women aged 50-64
What is involved in the Cervical Screening tests?
Aims to pick up precancerous changes in epithelial cells of the cervix.
- Involves a smear test performed by a qualified practice nurse
- Test consists of a Speculum examination and collection of cells from the cervix using a small brush.
- The samples are initially tested for high-risk HPV before examination.
- The cells are then examined under a microscopy using liquid based cytology (LCB) for precancerous changes (dyskaryosis)
If the HPV is negative then the cells are not examined
What do the results of the Cervical Smear Test indicate?
Smear Test for hrHPV:
- Positive: further testing is indicated with LBC
- Negative: Return to normal recall (age based intervals)
1st Positive hrHPV:
- Use LBC to detect cellular atypia
- Cytology Positive: Colposcopy is indicated
-
Cytology Inadequate: Cytology is repeated in 3 months
- Repeat cytology inadequate - refer for colposcopy
- If Colposcopy is normal - test hrHPV in 12 months
- Cytology Negative: Perform 2nd hrHPV test in 12 months
2nd hrHPV:
- Negative: return to normal recall
- Positive: Offer 3rd hrHPV test in a further 12 months (24 months after first positive test)
3rd hr HPV:
- Negative: Return to normal Recall
- Positive: Refer to Colposcopy
What are some different Cytology results that may be seen following a smear test and liquid based cytology for cervical screening?
- Inadequate
- Normal
- Borderline changes
- Low-grade dyskaryosis
- High-grade dyskaryosis (moderate)
- High-grade dyskaryosis (severe)
- Possible invasive squamous cell carcinoma
- Possible glandular neoplasia
- Infections such as bacterial vaginosis, candidiasis, trichomoniasis
Which groups of people may have exceptions to the normal Cervical Screening Program?
- Women with HIV are screened annually
- Women over 65 may request a smear if they have not had one since aged 50
- Women with previous CIN may require additional tests (e.g. test of cure after treatment)
- Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
- Pregnant women due a routine smear should wait until 12 weeks post-partum
Define Menorrhagia?
Clinical condition defined as Heavy menstrual bleeding (excessive blood loss) during a menstrual period to the extent that it is affecting a woman’s quality of life
What level of blood loss is considered menorrhage?
It used to be 80ml.
Now it is based on the subjective opinion of the woman
What is the epidemiology of Menorrhagia?
- Common gynaecological complaint
- 50% of cases no underlying pathology is found and the condition is called Dysfunctional Uterine/endometrial bleeding
Define Dysfunctional Endometrial Bleeding?
Menorrhagia (heavy menstrual periods) where there is no underlying pathology identified
What is the Aetiology of Menorrhagia?
Local:
- Dysfunctional Uterine Bleeding
- Fibroids
- Adenomyosis
- Endometrial polyps
- Endometriosis
- Pelvic inflammatory disease
- PCOS
- Contraceptives such as copper coil
- Endometrial cancer (be highly suspicious of this if there is postmenopausal bleeding)
Systemic:
- Bleeding disorders
- Hypothyroidism
- Liver and kidney disease
- Obesity
What is the Clinical Presentation of Menorrhagia?
Heavy or prolonged menstrual bleeding
Other features: (Due to Iron deficiency Anaemia)
- Fatigue
- Weakness
- Shortness of Breath
What are some differential diagnoses for Menorrhagia?
Differentials that include abnormal uterine bleeding:
- Fibroids: Often asymptomatic, but can cause heavy or prolonged periods, pelvic pain or pressure, and frequent urination.
- Adenomyosis: Symptoms can include prolonged, heavy menstrual bleeding, severe menstrual cramps, and pain during intercourse.
- Endometrial polyps: Can cause irregular menstrual bleeding, bleeding between periods, excessively heavy periods, or postmenopausal bleeding.
- Endometrial cancer: Symptoms include abnormal vaginal bleeding, pelvic pain, and pain during intercourse.
What are the key things to ask in any presentation with a gynaecological problem?
- Age at menarche
- Cycle length, days menstruating and variation
- Intermenstrual bleeding and post coital bleeding
- Contraceptive history
- Sexual history
- Possibility of pregnancy
- Plans for future pregnancies
- Cervical screening history
- Migraines with or without aura (for the pill)
- Past medical history and past drug history
- Smoking and alcohol history
- Family history
What investigations should be performed in Menorrhagia?
Initial tests
Imagining
Additional
Comprehensive History about bleeding
- Laboratory investigations such as FBC
- Pelvic examination with a speculum: Should be performed unless there is a straightforward history without other risk factors or symptoms or they are young and not sexually active
Imaging Studies if Indicated:
- Hysteroscopy (outpatient)
- Pelvic and Transvaginal Ultrasound
Additional Tests based on features:
- Swabs if there is evidence of infection (e.g. abnormal discharge or suggestive sexual history)
- Coagulation screen if there is a family history of clotting disorders (e.g. Von Willebrand disease) or periods have been heavy since menarche
- Ferritin if they are clinically anaemic
- Thyroid function tests if there are additional features of hypothyroidism
What may indicate the need for an Outpatient Hysteroscopy in Menorrhagia?
- Suspected submucosal fibroids
- Suspected endometrial pathology, such as endometrial hyperplasia or cancer
- Persistent intermenstrual bleeding
What may indicate the need for Pelvic and Transvaginal Ultrasound in Menorrhagia?
- Possible large fibroids (palpable pelvic mass)
- Possible adenomyosis (associated pelvic pain or tenderness on examination)
- Examination is difficult to interpret (e.g. obesity)
- Hysteroscopy is declined
What is the Management of Menorrhagia?
Exclude underlying pathology/Treat pathology first
Women does NOT want Contraception:
- Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
- Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
Women DOES want Contraception:
- Mirena coil (first line)
- Combined oral contraceptive pill
- Progesterone only contraception can be tried
Medical management Failed:
- Hysterectomy
- Endometrial Ablation
Referral to Secondary Care:
- If treatment is unsuccessful
- Symptoms are Severe
- Large fibroids (>3cm)
Define Endometrial Cancer?
Malignant proliferation that originals from the endometrium (the inner lining of the uterus)
It is an Oestrogen Depending cancer meaning that oestrogen stimulates the growth of Endometrial cancer cells
What is the epidemiology of Endometrial Cancer?
- 6th Most commonly diagnosed cancer in women
- 15th most common cancer
- 80% of cases are adenocarcinoma
What is Endometrial Hyperplasia?
a precancerous condition that involves thickening of the endometrium
- The risk factors, presentation, investigations are similar to Endometrial cancer
- Most cases of Endometrial Hyperplasia will return to normal over time and <5% become endometrial cancer.
What are the types of Endometrial Hyperplasia?
- Hyperplasia without atypia
- Atypical Hyperplasia
How can Endometrial Hyperplasia be treated?
Without Atypical Cells:
- Reversal of risk factors: Weight loss, stopping HRT
- Intrauterine System (IUS/Mirena coil)
- Continuous Oral Progestogens (Medroxyprogesterone)
With Atypical Cells:
- Total Hysterectomy with Bilateral Salpingo-oophorectomy (TAH and BSO)
What are the risk factors for Endometrial Cancer?
Anything that causes increased Exposure to Unopposed Oestrogen (Oestrogen without progesterone):
- Increased Age
- Nulliparity (never given birth or carried child)
- Obesity
- Diabetes
- Early menarche
- Late menopause
- Polycystic ovary syndrome
- Oestrogen-only hormone replacement therapy
- Tamoxifen
How does PCOS increase your risk of Endometrial Cancer?
Polycystic ovarian syndrome leads to increased exposure to unopposed oestrogen due to a lack of ovulation.
Anovulation/oligoovulation means follicles don’t develop
No corpous luteum so no progesterone
Unopposed oestrogen acting on endometrium
What should be given to women with PCOS for Endometrial Protection?
Progestrogens
One of:
- Combined Contraceptive Pill
- Intrauterine System (Mirena coil)
- Cyclical Progestogens
How does Obesity increase the risk of Endometrial Cancer?
Obesity is a crucial risk factor because adipose tissue (fat) is a source of oestrogen.
Adipose tissue is the primary source of oestrogen in postmenopausal women.
Adipose tissue contains aromatase, which is an enzyme that converts androgens such as testosterone into oestrogen
This extra Oestrogen is unopposed in women that are not ovulating (PCOS/post-menopause)
How does Tamoxifen increase the risk of Endometrial Cancer?
Tamoxifen has an anti-oestrogenic effect on breast tissue however it has an oestrogenic effect on the endometrium increasing the risk of endometrial cancer.
What are some protective factors for Endometrial Cancer?
- Combined Contraceptive Pill
- Mirena Coil
- Increased Pregnancies
- Cigarette Smoking
What are the clinical features of Endometrial Cancer?
Features vary but commonly include:
- Postmenopausal Bleeding
- Postcoital bleeding
- Intermenstrual bleeding
- Unusually heavy menstrual bleeding
- Abnormal vaginal discharge
- Dyspareunia
- Abdominal discomfort or bloating
- Weight Loss
- Haematuria
- Anaemia
- Raised platelet count
What must you think about in women with postmenopausal bleeding?
This is endometrial cancer until proven otherwise
Other key risk factors include obesity and diabetes
What are some differential diagnoses for Endometrial Cancer?
- Uterine fibroids: Characterised by heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation.
- Endometrial polyps: Symptoms may include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual periods, and vaginal bleeding after menopause.
- Cervical cancer: Signs can include abnormal vaginal bleeding, postmenopausal bleeding, and pelvic pain.
What is the Referral Criteria for Endometrial Cancer?
Guidelines for a 2 week wait urgent Endometrial cancer referral:
- Postmenopausal Bleeding more than 12 months after the last menstrual period.
NICE also recommends referral for Transvaginal Ultrasound in women Over 55 years with:
- Unexplained vaginal discharge
- Visible haematuria Plus raised platelets, anaemia, or elevated glucose levels
What are the investigations for Endometrial Cancer?
1st line
Gold standard
- First Line: Transvaginal Ultrasound: for endometrial thickness (normal is less than 4mm post menopause)
- Second Line: Endometrial Biopsy
- Pipelle Biopsy: highly sensitive for endometrial cancer
- Hysteroscopy with endometrial biopsy
What are the stages of Endometrial Cancer?
FIGO System:
Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis
What is the Management for Endometrial Cancer?
- Progesterone: May be used as a hormonal treatment to slow the progression of the cancer
Stage 1 and 2 Endometrial Cancer:
- Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy (TAH and BSO): Removal of uterus, cervix and adnexa
Later stages spread outside of the uterus:
- Combination of Hysterectomy, Radiotherapy, Chemotherapy
Define Endometriosis?
A gynaecological condition where ectopic endometrium-like tissue (Glands and stroma) , which typically lines the uterus, proliferates outside the uterine cavity.
Endometrioma: A lump of endometrial tissue outside the uterus
Chocolate Cysts: Endometriomas in ovaries
Adenomyosis: Endometrial tissue within the myometrium of the uterus
What is the Epidemiology of Endometriosis?
*Approximately estimated to affect 10% of women in their reproductive years
What is the Aetiology of Endometriosis?
No clear cause but several theories:
- Genetic component: Though no specific genes are identified
- Retrograde menstruation
- Coelomic metaplasia: Cells outside of the uterus somehow change via metaplasia into endometrial cells
- Lymphatic or vascular dissemination of endometrial cells: Cells spread similarly to cancer
What are the clinical features of Endometriosis?
- Cyclical abdominal or pelvic pain
- Dysmenorrhoea
- Dyspareunia
- Sub/infertility
- Cyclical bleeding from other sites (eg. rectal bleeding o haematuria)
- Urinary and bowel symptoms
- Palpable mass on examination (endometriomas)
- Fixed retroverted uterus
What is the pathophysiology theories for the cause of endometriosis?
- Retrograde menses/Sampsons
- Metaplasia/Meyers
- Haematogenous spread
What are some differential diagnoses for endometriosis?
- Primary dysmenorrhoea: characterised by crampy pelvic pain at the onset of menses with no identifiable pelvic pathology.
- Uterine conditions (e.g. fibroids, adenomyosis): these can cause heavy menstrual bleeding and pelvic discomfort.
- Adhesions: pelvic pain and possible bowel obstruction.
- Pelvic inflammatory disease (PID): presents with lower abdominal pain, fever, abnormal vaginal discharge, and possible dyspareunia.
What are the investigations for Endometriosis?
Clinical Examination: May identify endometriomas or deep nodules.
Transvaginal/Pelvic Ultrasound scan: Often unremarkable however they may reveal large endometriomas or chocolate cysts
Referral to gynaecology for ultrasound or Laparoscopy: Patients with severe persistent or recurrent symptoms of endometriosis should be referred.
Laparoscopic Surgery (Gold Standard): Definitive diagnosis is established with a biopsy of lesion during Laparoscopy. Surgeons may also remove deposits of endometriosis to potentially improve symptoms.
What is the Gold Standard investigation for Endometriosis?
Laparoscopic Surgery
This however comes with risks of complications such as bowel perforation and therefore is not the first line initial investigation
What is the management of Endometriosis?
Initial management involves:
- Establishing a diagnosis
- Providing a clear explanation
- Listening to the patient, establishing their ideas, concerns and expectations and building a partnership
- First Line: Analgesia as required for pain (NSAIDs and paracetamol)
Hormonal management options can be tried before establishing a definitive diagnosis with laparoscopy:
- First line: Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
- Progesterone only pill
- Medroxyprogesterone acetate injection (e.g. Depo-Provera)
- Nexplanon implant
- Mirena coil
- Second Line: GnRH agonists (Goserelin (Zoladex) or Leuprorelin (prostap))
Surgical management options:
- Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
- Bilateral oophorectomy +/-Hysterectomy
Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.
Define Fibroids?
Benign smooth muscle tumours (uterine leiomyomas) originating from the myometrium of the uterus.
What is the Epidemiology of Fibroids?
- Most prevalent benign uterine tumour in women
- Leading cause for Hysterectomy
- Very common affecting 40-60% of women in later reproductive years
- More common in black women
What is the Aetiology of Fibroids?
Unknown but thought to be related to hormonal and environmental factors
Oestrogen sensitive meaning they grow in response to oestrogen
What are the different types of Fibroid?
- Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
- Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
- Submucosal means just below the lining of the uterus (the endometrium).
- Pedunculated means on a stalk.
What are the clinical features of Fibroids?
Often Asymptomatic
Symptoms:
- Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
- Prolonged menstruation, lasting more than 7 days
- Abdominal pain, worse during menstruation
- Bloating or feeling full in the abdomen
- Urinary or bowel symptoms due to pelvic pressure or fullness
- Deep dyspareunia (pain during intercourse)
- Reduced fertility
- Palpable mass on abdominal or pelvic exam
What are some differential diagnoses for Fibroids?
Other causes of Menorrhagia and Dysmenorrhoea:
- Endometrial polyps: Present with irregular menstrual bleeding and spotting
- Endometriosis: Characterized by dysmenorrhoea, deep dyspareunia, chronic pelvic pain, and infertility
What are the investigations for Fibroids?
First Line:
- Transvaginal/Pelvic/Abdominal Ultrasound scan
- Hysteroscopy is initial investigation for submucosal fibroids presenting with menorrhagia
Second Line:
- MRI scan if ultrasound does not provide enough detail before considering surgical options
What is the management of Fibroids?
Smaller Symptom
Smaller Surgical
Larger Symptom
Larger Surgical
Fibroids < 3cm:
- Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus
- Symptomatic management with NSAIDs and tranexamic acid
- Combined oral contraceptive
- Cyclical oral progestogens
Surgical options for managing smaller fibroids
- Endometrial ablation
- Resection of submucosal fibroids during hysteroscopy
- Hysterectomy
Fibroids > 3 cm
women need referral to gynaecology for investigation and management.
- Symptomatic management with NSAIDs and tranexamic acid
- Mirena coil – depending on the size and shape of the fibroids and uterus
- Combined oral contraceptive
- Cyclical oral progestogens
Surgical options for larger fibroids are:
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
What are some complications for Fibroids?
- Heavy menstrual bleeding, often with iron deficiency anaemia
- Reduced fertility
- Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
- Constipation
- Urinary outflow obstruction and urinary tract infections
- Red degeneration of the fibroid
- Torsion of the fibroid, usually affecting pedunculated fibroids
- Malignant change to a leiomyosarcoma is very rare (<1%)
What is Red Degeneration of Fibroids?
Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.
in pregnancy the fibroid outgrows blood supply causing Ischaemia and Infarction.
Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy.
How does Red Degeneration of Fibroids Present?
Look out for the pregnant woman (2nd/3rd trimester) with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.
- Severe abdominal pain
- Low grade fever
- Tachycardia
- Vomiting
What is the Management of Red Degeneration of Fibroids?
Supportive management
- Rest
- Fluids
- Analgesia
What is a Typical exam patient for Red Degeneration of Fibroids?
Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.
Define Hydatidiform Mole?
What spectrum is it a part of?
What are the features of this spectrum?
A type of tumour that grows like a pregnancy inside the uterus. This is known as a Molar Pregnancy
It forms part of a spectrum of disorders known as gestational trophoblastic disease
- Complete Hydatidiform Mole
- Partial Hydatidiform Mole
- Choriocarcinoma (cancer in the placenta)
What are the different Types of Hydatidiform Mole?
Complete Mole:
- Occurs when two sperm cells (or 1 which duplicates DNA) fertilise an ovum that contains no genetic material (an “empty ovum”).
- These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole (46YY)
- No foetal material will form.
Partial Mole:
- Occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time.
- The new cell now has three sets of chromosomes (triploidy (69 XXX or 69 XXY)
- The cell divides and multiplies into a tumour called a partial mole.
- In a partial mole, some foetal material may form.
What is the Epidemiology of a Molar Pregnancy?
Women at highest risk of developing a molar pregnancy are at the extreme ends of the fertility age range, specifically those under 16 years of age and over 45 years of age.
What are the clinical features of a Hydatidiform Mole?
Molar pregnancy behaves like a normal pregnancy. Periods will stop and the hormonal changes of pregnancy will occur. There are a few things that can indicate a molar pregnancy versus a normal pregnancy:
- More severe morning sickness
- Vaginal bleeding
- Increased enlargement of the uterus
- Abnormally high hCG
- Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
What are some differential diagnoses for a Hydatidiform Mole?
- Ectopic pregnancy: Symptoms include lower abdominal pain, vaginal bleeding, and amenorrhea.
- Miscarriage: Symptoms include vaginal bleeding, abdominal pain, and passage of tissue.
- Normal pregnancy: Typically characterized by a positive pregnancy test, absence of menstruation, and possible morning sickness.
What are the investigations for a Molar Pregnancy?
Initial Ix and findings?
Definitie Ix
Molar pregnancy behaves like a normal pregnancy However some indications include:
- B-hCG Levels are often significantly higher than normally expected
- Transvaginal Ultrasound: May show a snowstorm appearance of pregnancy, low resistance of blood vessel flow and absence of a foetus
- Histology may be used to confirm after mole evacuation
What is the management of a Molar Pregnancy?
Immediate referral to a specialist centre for treatment
- Evacuation of the uterus to remove the mole (using suction curettage) which is sent for histological examination
- Hysterectomy is a possibility if fertility preservation is not a concern
- Systemic Chemotherapy: may be required if the mole has metastasised
What surveillance should be done in a Molar Pregancy?
- Bimonthly serum and urine hCG testing until levels are normal.
- In the case of a partial mole, a repeat hCG test is done 4 weeks later - if normal, the patient is discharged from surveillance.
- In the case of a complete mole, monthly repeat hCG samples are sent for at least 6 months.
Define a Prolactinoma?
Pituitary tumours characterized by excessive production of prolactin (leading to hyperprolactinaemia), a hormone that plays a crucial role in lactation.
What is the epidemiology of prolactinomas?
- The most common hormone-secreting tumours originating in the pituitary gland.
- Can affect people of any age but more commonly diagnosed in adults
What genetic condition is associated with Prolactinomas?
Multiple Endocrine Neoplasia (MEN) Type I
What are the different types of Prolactinoma?
Microprolactinomas – smaller than 10 mm
Macroprolactinomas – larger than 10 mm
What are the clinical features of Prolactinomas?
Both Genders:
- Reduced Libido
- Headaches
- Visual Field Defects (bitemporal hemianopia)
Women:
- Oligomenorrhoea/Amenorrhoea
- Galactorrhoea (breast milk production outside of pregnancy or breastfeeding)
- Infertility
- Vaginal dryness
Men:
- Erectile dysfunction
- Reduced facial hair growth
- Gynaecomastia
What are the investigations for a Prolactinoma?
- Pregnancy Test: Essential in women with childbearing potential presenting with breast milk production
- Blood Tests: Serum Prolactin, U&Es, LFTs, TFTs
- MRI scan is investigation of choice for diagnosing pituitary tumours
What is the management of Prolactinomas?
Pharmacological:
- Dopamine Agonists (e.g. Cabergoline or Bromocriptine): These drugs reduce serum prolactin levels, alleviate galactorrhea, and restore gonadal function.
- Trans-sphenoidal Surgical Resection is indicated when medical treatment fails to manage the tumour effectively. Definitive treatment
- Radiotherapy: Reserved for cases where other treatments are unsuccessful.
What are some complications of Prolactinomas?
- Hormonal imbalances
- Recurrence of the tumour
- Risks associated with surgical and radiation interventions
Define Ovarian Cancer?
Malignant proliferation originating from various cell types within the ovary
* 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas
What are the different types of Ovarian Tumour?
- Epithelial Cell Tumours
- Germ Cell Tumours
- Sex Cord-Stromal tumour
- Malignant (Krukenberg Tumour)
What are Epithelial Cell Ovarian Tumours?
- Originate from the epithelium which lines the fimbria of the fallopian tubes or the ovaries
- Epithelial tumours are partially cystic, and the cysts can contain fluid
- The initial metastatic spread typically involves the peritoneal cavity, with seeding particularly affecting the bladder, paracolic gutters and the diaphragm
- Around 90% of ovarian cancers are epithelial ovarian tumours.
What are the subtypes of Epithelial Cell Ovarian Tumours?
- Serous tumours (the most common)
- Endometrioid carcinomas
- Clear cell tumours
- Mucinous tumours
- Undifferentiated tumours
What are Germ Cell Ovarian Tumours?
Also known as
Contents
Spread
Affect
Markers
- Originate from the germ cells in the embryonic gonad (Teratomas)
- May contain various tissue types such as Skin, teeth, bone and hair
- Spread predominantly via the lymphatic route
- Common in young women
- Tumour markers include alpha-fetoprotein and sometimes beta human chorionic gonadotrophin (B-HCG).
What are Sex Cord-Stromal Tumours?
- Originate Granulosa/Theca (in women) or Leydig/Sertoli cells (In males) or are Fibromas
- Make up less than 5% of tumours
Often produce Hormones:
- Granulosa: Oestrogen leading to precocious puberty
- Leydig: Androgens leading to masculinising features and associated with Peutz Jegher Syndrome
- Fibroma: Associated with Meigs Syndrome
What is a Krukenberg Tumour?
Characteristic cells?
Ovarian Tumours may be due to metastasis from a cancer elsewhere in the body
- A Krukenberg tumour refers to a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach.
- Krukenberg tumours have characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy.
Where do Ovarian Cancers typically metastasise to?
Occurs via Trans coelomic routes (Across a body cavity) and thus can spread to the liver, bowel and associated mesentery
What are some risk factors for Ovarian Cancer?
- Advanced age (peak age 60 years)
- Smoking
- Increased number of ovulations (early menarche, late menopause, no pregnancies)
- Genetic predisposition (BRCA 1 and 2 genes and family history)
- Obesity
- Hormone replacement therapy (HRT)
- Recurrent use of clomiphene (fertility drug)
What are some protective factors for Ovarian Cancer?
Factors that reduce lifetime ovulations
- Childbearing (parity)
- Breastfeeding
- Early Menopause
- Combined oral contraceptive pill
What are the clinical features of Ovarian Cancer?
Often present late in disease progression with Non-specific symptoms
- Abdominal bloating
- Early satiety (feeling full after eating)
- Loss of appetite
- Pelvic pain
- Urinary symptoms (frequency / urgency)
- Weight loss
- Abdominal or pelvic mass
- Ascites (due to VEGF increasing vessel permeability)
Why may a patient with Ovarian Cancer present with Hip or Groin Pain?
An Ovarian mass may press on the obturator nerve causing referred hip or groin pain.
What are some differential diagnoses for Ovarian Cancer?
- Gastrointestinal conditions (e.g., irritable bowel syndrome): Characterised by abdominal pain, bloating, and changes in bowel habits
- Fibroids: May cause heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation
- Ovarian cysts: Can cause pelvic pain, fullness or heaviness in the abdomen, and bloating
- Other cancers (e.g., bladder, endometrial): May present with symptoms such as abnormal bleeding, pelvic pain, and urinary symptoms
When should Suspected Ovarian Cancer prompt an Urgent 2 Week Wait Referral or Carry out further investigations before Referral
Direct Urgent 2-Week-Wait Referral
- Ascites
- Pelvic Mass
- Abdominal Mass
Carry out further Investigations before referral Starting with CA125 blood test
- New symptoms of IBS/change in bowel habit
- Abdominal Bloating
- Early Satiety
- Pelvic Pain
- Urinary frequency or urgency
- Weight loss
What are the investigations for Ovarian Cancer?
initial
Secondary care
What else should be calculated?
What should be done for women under 40 years?
Initial Investigations:
- CA125 Blood Test: (> 35IU/ml is significant)
Then
- Urgent Pelvic and Abdominal Ultrasound Scan
Secondary Care:
- CT scan to establish the diagnosis and stage the cancer
- Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy
- Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells
Diagnosis is difficult and often done with diagnostic Laparoscopy
Risk of Malignancy Index
Women Under 40 years with complex ovarian mass:
- AFP and hCG tumour markers for possible Germ cell tumour
What are some causes of a Raised CA125?
CA125 is a tumour marker for epithelial cell ovarian cancer.
It is not very specific, and there are many non-malignant causes of a raised CA125:
- Endometriosis
- Fibroids
- Adenomyosis
- Pelvic infection
- Liver disease
- Pregnancy
How is Ovarian Cancer Staged?
Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)
What is the management of Ovarian Cancer?
Managed by specialist gynaecology oncology MDT
Surgery: Radical Hysterectomy, BSO, Infracolic omentectomy are options if early stage
Chemotherapy: Used an adjuvant to surgery.
**Bevacizumab (anti-VEGF) may also be used
Define Ovarian Cysts
Fluid filled sac that develops within or on the surface of an ovary
They can range in size and occur as a normal part of the menstrual cycle or as a result of an underlying condition.
What is the Epidemiology of Ovarian Cysts?
- Very common in premenopausal women with most women experiencing at least one
- Cysts in postmenopausal women are more concerning for malignancy and need further investigation
- Majority of cysts in premenopausal women are benign
What is the Aetiology of Ovarian Cysts?
Can be caused by a variety of factors, including:
- Hormonal imbalances
- Endometriosis,
- Pregnancy
- Pelvic infection
What is a String of pearls appearance?
Patients with multiple ovarian cysts may have a String of pearls appearance to the ovaries
This is not PCOS unless they have other features of the condition
What are the clinical features of Ovarian Cysts?
Most ovarian cysts are Asymptomatic
May Cause:
- Pelvic pain (often acute unilateral pain)
- Bloating
- Fullness in the abdomen
- Palpable pelvic mass
- Intra-peritoneal haemorrhage with haemodynamic compromise
What are the different types of Ovarian Cyst?
Functional Cysts:
- Follicular Cysts: Most common and harmless. they form due to failure to the follicle failing to rupture and release an egg.
- Corpus Luteum Cysts: Occur when the corpus luteum fails to break down and fills with fluid. Often seen in early pregnancy
Non-Functional Cysts:
- Serous Cystadenoma: Benign tumours of the epithelial cells
- Mucinous Cystadenoma: Can become huge and cause psuedomyoxma peritoni
- Endometrioma: occurs with endometriosis
- Malignant cysts: Dermoid/ Sex cord/Stromal
What are some differential diagnoses for Ovarian Cysts?
- Ovarian torsion: Characterised by sudden, severe pain, often accompanied by nausea and vomiting.
- Ectopic pregnancy: Symptoms include abdominal pain, amenorrhea, and vaginal bleeding.
- Appendicitis: Presents with abdominal pain that begins near the navel and then moves lower and to the right, loss of appetite, nausea, and vomiting.
What are the investigations for Ovarian Cysts?
Detailed History and Examination: to establish for features that may suggest malignancy
Pregnancy test: Exclude ectopic pregnancy
Ultrasound Scan if less than 5cm in premenopausal women then no further investigation needed.
Tumour Markers: CA125, AFP, LDH, B-hCG
What are features from the history that may suggest malignancy?
- Abdominal bloating
- Reduce appetite
- Early satiety
- Weight loss
- Urinary symptoms
- Pain
- Ascites
- Lymphadenopathy
What is the Risk of Malignancy Index?
Estimates the risk of an ovarian mass being malignant, taking account of three things:
- Menopausal status
- Ultrasound findings
- CA125 level
What is the management of Ovarian Cysts?
Simple ovarian cysts in premenopausal women can be managed based on their size:
- Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.
- 5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.
- More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist
When there is a raised CA125, this should be a two-week wait suspected cancer referral
- Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.
What are some complications of Ovarian Cysts?
- Torsion
- Haemorrhage into the cyst
- Rupture, with bleeding into the peritoneum
What is Meig’s Syndrome?
Triad of:
- Ovarian fibroma (benign ovarian tumour)
- Pleura effusion
- Ascites
Treatment is removal of the tumour
Define Ovarian Torsion?
A condition where the ovary twists in relation to the surrounding connective tissue, the fallopian tube (Adnexa) and blood supply.
Adnexal torsion: when the fallopian tube is involved
What is the aetiology of Ovarian torsion?
- Usually due to an ovarian mass (often > 5cm) such as a cyst or tumour.
- Can occur with normal ovaries in girls before menarche when girls have a longer infundibulopelvic ligaments
What are some risk factors for Ovarian Torsion?
- Ovarian mass: present in around 90% of cases of torsion
- Being of a reproductive age
- Pregnancy
- Ovarian hyperstimulation syndrome
What is the pathophysiology of Ovarian Torsion?
- Ovary twists around the adnexa and blood supply
- Leads to ischaemia of the Ovary
- If torsion persists then necrosis will occur and the function of the ovary will be lost
- Ovarian torsion is an emergency where treatment delay can have significant consequences
What are the clinical features of Ovarian Torsion?
-
Sudden onset severe unilateral pelvic pain
- Constant getting progressively worse
- Associated with Nausea and Vomiting
- Localised tenderness
- May have a palpable mass
- Vaginal examination may show adnexial tightness
What are the investigations for Ovarian Torsion?
Pelvic Ultrasound initial investigation of choice
- Transvaginal is Ideal but Transabdominal can be used if transvaginal is not possible.
- May show “Whirlpool sign of free fluid” in the pelvis and Oedema of the ovary
Laparoscopic Surgery is definitive diagnostic investigation
What is the management of Ovarian Torsion?
- Patients need emergency admission under gynaecology for urgent investigation and management.
- Depending on the duration and severity of the illness they require laparoscopic surgery to either:
- Un-twist the ovary and fix it in place (detorsion)
- Remove the affected ovary (oophorectomy)
What are some complications of Ovarian Torsion?
- Delayed treatment can lead to loss of function of that ovary
- If necrotic ovary is not removed it may lead to infection, abscess formation and sepsis
Define Polycystic Ovarian Syndrome (PCOS)?
PCOS is the most common endocrine condition in women of reproductive age.
The disorder is characterised by failure of follicles to release eggs leading to anovulation, hyperandrognism features and enlarged/multicystic ovaries
Define these words:
Anovulation
Oligoovulation
Amenorrhoea
Oligomenorrhoea
Androgens
Hyperandrogenism
Hirsutism
Insulin Resistance
- Anovulation: refers to the absence of ovulation
- Oligoovulation: refers to irregular, infrequent ovulation
- Amenorrhoea: refers to the absence of menstrual periods
- Oligomenorrhoea: refers to irregular, infrequent menstrual periods
- Androgens: are male sex hormones, such as testosterone
- Hyperandrogenism: refers to the effects of high levels of androgens
- Hirsutism: refers to the growth of thick dark hair, often in a male pattern, for example, male pattern facial hair
- Insulin Resistance: refers to a lack of response to the hormone insulin, resulting in high blood sugar levels
What is the Epidemiology of PCOS?
- Prevalent condition affecting up to 1/3 of women during their reproductive years
What is the Aetiology of PCOS?
Complex and Multifactorial (still unclear)
- Hormone imbalances, low oestrogen, high androgens and high insulin (with insulin resistance) leads to increased circulating androgens
What criteria is used to make a diagnosis of PCOS?
Rotterdam Criteria: requires at least 2 out of 3 key features:
- Oligoovulation or Anovulation
- Biohemical evidence of Hyperandrogenism (hirsutism and acne)
- Polycystic Ovaries on Ultrasound (> 12 cysts on imaging or ovarian volume > 10 cm3)
Having only one feature such as multiple ovarian cysts does not qualify for diagnosis of PCOS
What are some key clinical features in PCOS?
- Oligomenorrhoea or amenorrhoea
- Sub/Infertility
- Obesity (in about 70% of patients with PCOS)
- Hirsutism
- Acne
- Acanthosis Nigricans
- Mood changes including Anxiety and depression
- Hair loss in a male pattern
What other features may women with PCOS experience?
- Insulin resistance and diabetes
- Acanthosis nigricans
- Cardiovascular disease
- Hypercholesterolaemia
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
What are some differential diagnoses for PCOS?
- Menopause: characterised by cessation of menstruation, hot flashes, vaginal dryness, mood changes, and sleep problems.
- Congenital adrenal hyperplasia (CAH): presenting with signs of androgen excess like hirsutism, acne, and irregular periods.
- Hyperprolactinaemia: symptoms include irregular periods, galactorrhoea, and infertility.
- Androgen-secreting tumours: may cause virilisation, amenorrhoea, and hirsutism.
- Cushing’s syndrome: characterised by weight gain, purple stretch marks, and easy bruising.
What are some differential diagnoses for Hirsutism?
- Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
- Ovarian or adrenal tumours that secrete androgens
- Cushing’s syndrome
- Congenital adrenal hyperplasia
What is the relationship between Insulin Resistance and PCOS?
When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body.
Insulin promotes the release of androgens from the ovaries and adrenal glands.
Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone).
Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver.
SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS.
The high insulin levels contribute to halting the development of the follicles in the ovaries
This leads to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan).
Diet, exercise and weight loss help reduce insulin resistance.
What are the investigations for PCOS?
Blood tests
Addition for DDx
Imaging
Blood Tests:
- LH: Raised
- LH:FSH Ratio increased >2 aids in differentiating from menopause (ratio is normal)
- SHBG is normal or low
- Total and Free Testosterone: Raised
Other Blood Tests for Exclusion of conditions
- Insulin resistance (Fasting and OGTT)
- Oestrogen Levels: Normal or Raised
- TFTs: Exclude thyroid dysfunction
- 17 Hydroxyprogesterone: Exclude CAH
- Prolactin levels: Exclude hyperprolactinaemia
- 24 Hour urinary cortisol: Exclude Cushing’s
Imaging: Pelvic Ultrasound
- Transvaginal Ultrasound is Gold Standard
- String of Pearls Appearance
- 12 or more developing follicles in one ovary
- Ovarian Volume > 10 cm3
What is PCOS a significant risk factor for?
Endometrial Cancer
Within the syndrome of PCOS it has multiple risk factors for Endometrial cancer including:
- Obesity
- Diabetes
- Insulin Resistance
- Amenorrhoea
What is the General Management of PCOS?
General advice
Endometrial risk
Infertility
Hirsuitism
Acne
General Advice:
- Education and reduction of increased risks of CVD, DM, Endometrial cancer, Obesity
- Weight Loss,
- Orlistat may be used in BMI >30
- Exercise,
- Smoking cessation,
- Antihypertensives (if required),
- Statins (if QRISK >10%)
Managing risk of Endometrial Cancer:
> 3 month gap between periods or abnormal bleeding - A withdrawal bleed required every 3-4 months
- Pelvic USS to measure endometrial thickness
- If Contraception wanted: Mirena coil/COCP
- If no Contraception wanted: Medroxyprogesterone Acetate 10mg OD for 14 days
Manage Infertility:
- 1st Line: Weight Loss
- 2nd line: Clomifene/Letrozole (Metformin may also help)
- 3rd line: IVF
Managing Hirsuitism:
- 1st Line: Shaving/hair removal
- 3rd Gen COCP (co-cyprindiol/Dianette)
- Topical Elfornithine
Managing Acne:
- 1st Line: COCP
- Topical Benzoyl Peroxide
- Oral Tetracycline
How is the Risk of Endometrial Cancer reduced in PCOS?
- Weight loss
- Mirena coil
-
Inducing a withdrawal bleed at least every 3-4 months using:
- Cyclical Progestogens (medroxyprogesterone acetate 10mg OD for 14 days)
- COCP
How can Infertility be managed in PCOS?
1st Line: Weight loss is the initial step for improving fertility
2nd Line:
- Letrozole
- Clomiphene - induces ovulation by inhibiting oestrogen feedback on hypothalamus so increase FSH
3rd Line:
- Laparoscopic Ovarian Drilling
- IVF
How can Hirsutism be managed in PCOS?
Weight loss may improve the symptoms of Hirsutism
- Co-cyprindiol (Dianette) is a COCP liscenced for hirsutism and acne with anti-androgenic effects
Others:
- Topical Eflornithine
- Electrolysis
- Laser hair removal
How can Acne be managed in PCOS?
Combined Oral Contraceptive Pill (COCP) is First line (Co-cprindiol).
Other treatments:
- Topical Adapalene (retinoid)
- Topical Antibiotics (clindamycin + Benzoyl peroxide)
- Topical Azelaic acid 20%
- Oral Tetracycline antibiotics (lymecycline)
What is a major side effect of Co-cyprindiol (Dianette)?
Significantly increased risk of Venous Thromboembolism
- This contraindicated in increased risk of clots
- Medication usually stopped after 3 months of use.
Define Pelvic Inflammatory Disease (PID)
Inflammation and infection of the organs of the pelvis, caused by infection spreading up the vagina through the cervix and into the upper genital tract.
It is a significant cause of tubular infertility and chronic pelvic pain
Define these words:
Endometritis
Salpingitis
Oophoritis
Parametritis
Peritonitis
- Endometritis: is inflammation of the endometrium
- Salpingitis: is inflammation of the fallopian tubes
- Oophoritis: is inflammation of the ovaries
- Parametritis: is inflammation of the parametrium, which is the connective tissue around the uterus
- Peritonitis: is inflammation of the peritoneal membrane
What is the Aetiology of PID?
Most commonly via Sexually Transmitted Pelvic Infections:
- Neisseria gonorrhoeae (produces more severe PID)
- Chlamydia trachomatis
- Mycoplasma genitalium
Less commonly via non-sexually transmitted infections:
- Gardnerella vaginalis (associated with bacterial vaginosis)
- Haemophilus influenzae
- Escherichia coli
What are the risk factors for PID?
- Not using barrier contraception
- Multiple sexual partners
- Younger age
- Existing sexually transmitted infections
- Previous pelvic inflammatory disease
- Intrauterine device (e.g. copper coil)
What are the clinical features of PID?
Women may present with symptoms of:
- Pelvic or lower abdominal pain
- Abnormal vaginal discharge
- Abnormal bleeding (intermenstrual or postcoital)
- Pain during sex (dyspareunia)
- Fever
- Dysuria
Examination findings may reveal:
- Pelvic tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
What are some differential diagnoses for PID?
- Appendicitis: Presents with right lower quadrant abdominal pain, fever, nausea, and vomiting.
- Ectopic Pregnancy: Symptoms may include unilateral lower abdominal pain and vaginal bleeding. A positive pregnancy test is a key distinguishing factor.
- Endometriosis: Chronic pelvic pain, dysmenorrhea, and dyspareunia are common. Pain typically worsens during menstruation.
- Ovarian Cyst: Symptoms can include unilateral lower abdominal pain, bloating, and a palpable mass on examination.
- Urinary Tract Infection: Symptoms usually include dysuria, frequency, urgency, suprapubic pain, and possible fever.
What are the investigations for PID?
Pelvic Examination
High vaginal Swabs for causative organisms:
- NAAT swabs for gonorrhoea and chlamydia
- NAAT swabs for Mycoplasma genitalium (if available)
- HIV Test
- Syphilis test
High vaginal swab for BV, trichomoniasis and Candidiasis
Microscopy for Pus cells
Blood Tests: Inflammatory markers (CRP/ESR) can help support diagnosis
Pregnancy test: To exclude ectopic pregnancy
Transvaginal Ultrasound May be used
What is the management of PID?
Combination Antibiotics
- Ceftriaxone IM 1g Single dose (Cover for gonorrhoea)
- Doxycycline 100mg BD for 2/52 (cover for chlamydia and Mycoplasma)
- Metronidazole 400mg BD for 2/52 ( Cover for Gardnerella)
Alternative regime is Ofloxacin + Metronidazole
Analgesia may be required
Contact Tracing
What are the complications of PID?
- Chronic pelvic pain (in around 40% of cases)
- Infertility (approximately 15%)
- Ectopic pregnancy (about 1%)
- Sepsis
- Abscess
- Fitz-Hugh-Curtis Syndrome (about 10%)
What is Fitz-Hugh-Curtis Syndrome?
Complication of PID, chlamydia and gonorrhoea where adhesions form between the liver capsule and the peritoneum causing inflammation and infection of the liver capsule (Glisson’s capsule)
This results in right upper quadrant pain in about 10% of patients
What is the management of Fitz-Hugh-Curtis Syndrome?
Investigations include abdominal ultrasound to exclude stones.
laparoscopy to diagnose, visualise and treat adhesions by Adhesiolysis
Define Baby Blues (Postpartum Blues)?
A transient mood disorder that typically manifests around three days after childbirth.
It is characterized by irritability, anxiety about parenting skills, and tearfulness.
The condition typically resolves within two weeks without medical intervention.
What is the Epidemiology of Baby Blues?
- Very common affecting up to 80% of women after childbirth
- More commonly affects first time mothers
- 10% of these women may develop a more severe form: Postnatal Depression
What is the Aetiology of Baby Blues?
not fully understood
- Likely due to hormonal changes that occur after childbirth including a rapid drop in oestrogen and progesterone.
- Fatigue/sleep deprivation, physical discomfort after delivery and stress/challenges of caring for a new baby likely also contribute
what are the clinical features of Baby Blues?
Presents within the first week after childbirth
- Mood swings
- Low mood
- Anxiety (about parenting)
- Irritability
- Tearfulness
What are some differential diagnoses for Baby Blues?
Postpartum blues should be differentiated from other postnatal mood disorders such as postnatal depression and postpartum psychosis. The primary distinguishing symptoms are:
- Postnatal depression: Persistent feelings of sadness, anxiety, or emptiness; difficulty bonding with the baby; severe mood swings; trouble eating, sleeping, or concentrating; and thoughts of harming oneself or the baby.
- Postpartum psychosis: Severe confusion and disorientation, hallucinations and delusions, paranoia, and attempts to harm oneself or the baby.
What are the investigations for Baby Blues?
Clinical Diagnosis
- Routine screening at medical appointments is recommended by NICE to identify the approximately 10% of women who may develop postnatal depression following postpartum blues.
- Use of tools such as the Edinburgh Postnatal Depression Scale
What is the management of Baby Blues?
Supportive measures and reassurance (that the condition is common)
- Symptoms are usually mild and only last a few days.
- Baby blues tend to resolve within two weeks of delivery without any treatment being required
- Mothers should be encouraged to seek help if they have symptoms persisting beyond 2 weeks
What is the definition of Postpartum depression?
It’s a significant mood disorder that can develop at any time up to one year after the birth of a baby.
This condition represents a considerable aspect of maternal mental health and extends beyond the common “baby blues”.
Typically presenting with persistent depressive symptoms that may interfere with daily functioning and parenting.
What is the Epidemiology of Postpartum Depression?
- Affects approximated 10-20% of mothers within 1 year of childbirth
- Rates vary depending on population, geographic location, socioeconomic status (low), History of mental health and lack of social support
- Typically women are affected around 3 months after birth
What causes Postpartum depression?
Development of postpartum depression is multifactorial with a combination of Biological, Psychological, and Social factors all contributing.
What biological factors contribute to the development of postpartum Depression?
- Hormonal fluctuations post-delivery, including sudden drops in progesterone, estrogen, and thyroid hormones.
- Alterations in melatonin and cortisol rhythms and immune-inflammatory processes
- Genetic predispositions
What Psychological factors contribute to the development of postpartum Depression?
- A history of mood or anxiety disorders
- Previous episodes of postpartum depression
- Certain personality traits such as neuroticism
- Psychological stress from the transition to parenthood
- Unrealistic expectations of motherhood
What Social Factors contribute to the development of postpartum depression?
- Lack of social support
- Relationship issues,
- Life stressors
- Low socioeconomic status
What are the signs and symptoms of postpartum depression?
Classic triad of:
- Low Mood
- Anhedonia: reduced enjoyment or interest in activities.
- Lowering of energy levels.
Others:
- Biological symptoms of depression like poor appetite and disturbed sleep patterns (not associated with normal disturbed sleep patterns with a baby)
- Concerns related to bonding with the baby, caring for the baby, and in extreme circumstances, thoughts about harming oneself or the baby.
What are some differentials for postpartum depression?
Baby blues
Characterised by mild mood swings, irritability, anxiety, and tearfulness. However, these symptoms usually present within the first two weeks after birth and resolve spontaneously.
Postpartum Psychosis
Adjustment disorders
These disorders may develop in response to a major life change or stressor, such as having a baby, but the emotional or behavioural symptoms are less severe than in depression.
Generalized Anxiety Disorder (GAD)
What is the main screening tool for Postpartum depression?
Edinburgh Postnatal Depression Scale (EPDS) assess how the mother has felt over the past week with 30 questions.
A cut-off score of over 10 is used as a positive result.
What is the management of postpartum depression?
First-line treatments:
- Self-help strategies and psychological therapies e.g. Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT).
Pharmacological treatments
- Antidepressants (SSRIs) considered in high risk cases
In severe cases admission to a mother and baby inpatient mental health unit might also be necessary.
What antidepressants are preferred to be used in Postpartum Depression?
SSRIs such as:
- Paroxetine
- Sertraline
Due to their safety profile in breastfeeding as they have a low milk:plasma ratio
Fluoxetine shouldn’t be used due to its long half life
What is the definition of Postpartum Psychosis?
Also known as Puerperal Psychosis
It’s a serious psychiatric disorder that typically develops within the first two weeks following childbirth.
It is characterised by a range of psychological symptoms, including paranoia, delusions, hallucinations, mania, depression, and confusion.
What is the Aetiology of Postpartum Psychosis?
unknown but thought to be a combination of:
- Genetic susceptibility
- Hormonal Changes
- Psychosocial stressors
- Prior history of severe mental illness significantly increases the risk
What are the risk factors for Postpartum Psychosis?
- Prior history of severe mental illnesses such as schizophrenia or bipolar affective disorder
- Family history of postpartum psychosis
- Previous episode of postpartum psychosis
What is the clinical presentation of Postpartum Psychosis?
Often between 2-3 weeks post partum
- Paranoia
- Delusions (including Capgras Delusions)
- Hallucinations
- Manic episodes
- Depressive episodes
- Confusion
What is the main differential for Postpartum Psychosis?
Postpartum depression with psychotic features
How is Postpartum depression diagnosed?
Diagnosis is predominantly clinical, based on the presenting signs and symptoms.
It requires a thorough psychiatric evaluation.
Consideration should be given to other medical conditions that may cause similar symptoms, such as thyroid disorders or sepsis.
How is Postpartum psychosis managed?
Women with Postpartum Psychosis need urgent assessment and input from specialist mental health services
- Admission to mother and baby unit
- Cognitive behavioural Therapy
- May require pharmacotherapy with:
- Antidepressant medications
- Antipsychotic medications
- Mood stabilisers in some instances
Potential referral to a specialist mother and baby inpatient mental health unit in very severe cases (when the mother experiences command hallucinations, thoughts of self-harm or suicide, or delusional beliefs regarding the baby’s role or identity).
What needs to be considered when prescribing medications for Postpartum Psychosis?
The mother’s breastfeeding status and the potential for the transfer of drugs to the nursing infant.
What is the Mother and Baby Unit?
The mother and baby unit is a specialist unit for pregnant women and women that have given birth in the past 12 months.
They are designed so that the mother and baby can remain together and continue to bond. Mothers are supported to continue caring for their baby while they get specialist treatment.
How can mothers prepare for Postnatal Depression/Psychosis?
Women with existing mental health concerns before or during pregnancy are referred to perinatal mental health services.
Advice and input from specialists can help manage decisions around ongoing medications such as SSRIs, antipsychotics and lithium during pregnancy.
They also ensure that mothers are closely followed up after giving birth so management can be put in place early should these conditions occur.
What is a risk of taking SSRIs during pregnancy?
Neonatal abstinence syndrome/neonatal adaptation syndrome
- Presents in first few days after birth
- Symptoms include irritability and poor feeding
- Neonates are monitored for this after delivery
- Treatment is supportive management
Define Ectopic Pregnancy?
Gynaecological Emergency
Where a fertilised egg or embryo implants and begins to grow Outside of the uterine cavity.
Most common site is the fallopian tube
What are the regions where an Ectopic Pregnancy may occur?
- Fallopian tube (most common (97%))
- Ovary
- Cervix
- Abdomen
What are some risk factors for an Ectopic Pregnancy?
- Previous ectopic pregnancy
- Previous pelvic inflammatory disease, STIs or Salpingitis (tubal inflammation)
- Previous surgery to the pelvis (Especially the fallopian tubes)
- Intrauterine devices in situ (coils)
- Endometriosis
- Older age
- Smoking
What is the pathophysiology of an Ectopic Pregnancy?
- Fertilisation of the oocyte typically takes place in the ampulla of the fallopian tube; the conceptus must then travel into the endometrial cavity.
- This occurs due to tubal peristalsis alongside ciliary motion and tubal fluid flow.
- Any dysfunction in the tubal peristalsis above due to e.g. tubal surgery, salpingitis, PID can prevent the conceptus from implanting in the correct place.
- A pregnancy that implants in the fallopian tube will grow and eventually lead to rupture and catastrophic bleeding.
- Most tubal ectopics implant in the ampulla (widest point).
When do Ectopic pregnancies typically present?
Around 6-8 weeks gestation
What are the clinical features of an Ectopic Pregnancy?
- Pelvic or abdominal pain Often unilateral to the side of the ectopic (RIF/LIF)
- Abnormal vaginal bleeding: missed period or intermenstrual bleeding
- Cervical motion tenderness (Chandeller sign) where pain occurs when moving the cervix during a bimanual examination
- Haemodynamic instability caused by blood loss if the ectopic ruptures
- Dizziness or Syncope (due to blood loss)
- Shoulder tip pain (blood irritating the diaphragm causing referred pain)
What are some differential diagnoses for Ectopic Pregnancies?
- Miscarriage
- Appendicitis
- Ovarian Torsion
What are the investigations for an Ectopic Pregnancy?
Any female of childbearing age presenting with abdominal pain should be offered a UPT (urine pregnancy test) to exclude ectopic pregnancy
- Urine Pregnancy Test (First Line)
- Transvaginal Ultrasound Scan is investigation of choice to locate the pregnancy
- Serial serum B-hCG if no pregnancy found of USS.
What are the ultrasound findings in an ectopic pregnancy?
- A mass representing a tubal ectopic pregnancy moves separately to the ovary.
- It may appear similar to the corpus luteum however this will move with the ovary
Other features indicative:
- An empty uterus
- Fluid in the uterus (may be mistaken as a gestational sac)
What is the Management of an Ectopic Pregnancy?
women with pelvic pain/tenderness and a positive pregnancy test need to be referred to an Early Pregnancy Assessment Unit (EPAU)
All ectopic pregnancies need to be terminated (they are not viable)
Options for terminating an Ectopic Pregnancy:
- Expectant management (awaiting natural termination)
- Medical Management (methotrexate)
- Surgical management (Salpingectomy or Salpingotomy)
What is the Expectant Management for an Ectopic Pregnancy?
Criteria:
- Follow up needs to be possible to ensure successful termination
- The ectopic needs to be unruptured
- Adnexal mass < 35mm
- No visible heartbeat
- No significant pain
- HCG level < 1000 IU / l
Women with Expectant management need careful follow up with close monitoring of hCG levels and quick/easy access to services if their condition changes
What is the Medical Management for an Ectopic Pregnancy?
Criteria: Injection of Methotrexate
- Follow up needs to be possible to ensure successful termination
- The ectopic needs to be unruptured
- Adnexal mass < 35mm
- No visible heartbeat
- No significant pain
- HCG level < 5000 IU / l
- Confirmed absence of intrauterine pregnancy on ultrasound
Methotrexate is highly teratogenic and is given as an IM Injection to halt the progress of pregnancy and results in spontaneous termination
Women treated with Methotrexate are advised to not get pregnant for 3 months following treatment as the harmful effects of methotrexate may last this long
What are the monitoring criteria for Expectant or Medical management of Ectopic Pregnancies?
- Measure beta-hCG on days 0, 2, 4, and 7
- If drop of more than 15% from previous measurement, repeat weekly until beta-hCG is less than 20IU/L.
- If not, refer for further management.
What are some common side effects of using Methotrexate as medical management for an ectopic pregnancy?
- Vaginal Bleeding
- Nausea and Vomiting
- Abdominal Pain
- Stomatitis (inflammation of the mouth)
What is the Surgical Management for an Ectopic Pregnancy?
Anyone that does not meet the criteria for expectant or medical management requires surgical
Criteria for Surgical:
- Patient is haemodynamically unstable
- Pain
- Adnexal mass > 35mm
- Visible heartbeat
- HCG Levels > 5000 IU/l
Surgical Options:
- Laparoscopic salpingectomy (first line treatment for ectopic pregnancy)
- Laparoscopic salpingotomy (used in women at increased risk of infertility due to damage to other fallopian tube)
Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy
What is the problem with Laparoscopic salpingotomy as a treatment for ectopic pregnancies?
Increased risk of failure to remove the ectopic pregnancy with salpingotomy compared to salpingectomy.
- 1 in 5 women having salpingotomy may need further treatment with methotrexate or salpingectomy
Define Pregnancy of Unknown Origin/location?
Diagnosed when a woman has a positive pregnancy test, but there are no signs of an intrauterine or extrauterine pregnancy on transvaginal ultrasound.
What is the Aetiology of Pregnancy of Unknown Origin/Location?
- An early viable or failing intrauterine pregnancy
- A complete miscarriage
- An ectopic pregnancy
What are the differentials for a Pregnancy of Unknown Origin/Location?
Early viable or failing intrauterine pregnancy
- Signs and symptoms: Mild cramping, spotting or delayed menstruation.
Complete miscarriage
- Signs and symptoms: Severe abdominal pain, heavy bleeding, passage of tissue or clot-like material.
Ectopic pregnancy
- Signs and symptoms: Sharp or stabbing pain in the abdomen, light vaginal bleeding, dizziness or fainting.
What are the Investigations for Pregnancy of Unknown Origin/Location?
Serum hCG is tracked over time to monitor Pregnancy of Unknown Origin/Location
Serum hCG level is repeated after 48 hours to measure change from baseline
Monitoring the clinical signs and symptoms is more important than tracking the hCG level, and any change in symptoms needs careful assessment.
The developing syncytiotrophoblast of the pregnancy produces hCG. In an intrauterine pregnancy, the hCG will roughly double every 48 hours. This will not be the case in a miscarriage or ectopic pregnancy.
Rise of more than 63%:
- After 48 hours likely indicates an Intrauterine pregnancy.
- Repeat Ultrasound scan after 1-2 weeks to confirm intrauterine pregnancy
- Pregnancy should be visible on USS once hCG > 1500 IU/ L
Rise of Less than 63%
- May indicate an Ectopic pregnancy. This patient needs close monitoring and review
Fall of More than 50%
- Likely to indicate a miscarriage
- Urine pregnancy test should be performed after 2 weeks (confirms miscarriage is complete)
Define Miscarriage?
Miscarriage is defined as the spontaneous loss/termination of a pregnancy prior to 24 weeks gestation.
Early Miscarriage: Before 12 weeks gestation
Later Miscarriage: Between 12 and 24 weeks gestation
What is the Epidemiology of Miscarriage?
- 10% of recognised pregnancies end in miscarriage.
- Number is likely higher as many occur without the women realising she in pregnant
What are the different types of Miscarriage and how can you easily distinguish them?
Internal Os Open:
- Incomplete or Inevitable
- If there is still a full fetus then it is inevitable, if there are only retained products then it is incomplete
Internal Os Closed:
- Threatened, Missed, Completed
- Completed then symptoms have occurred and there is no fetus or tissue within the uterus
- Threatened, vaginal bleeding and pain and the fetus still has a heart beat
- Missed is when the fetus is dead, the mother may not have experienced symptoms and it requires evacuation.
What is a missed miscarriage?
thT foetus is no longer alive, but no symptoms have occurred and thus the miscarriage is often missed as the mother did not know that something was wrong.
- a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
- mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
- cervical os is closed
- when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
What is a threatened miscarriage?
vaginal bleeding with a closed cervix and a foetus that is alive
What is an Inevitable miscarriage?
vaginal bleeding with an open cervix. Due to the cervix being open the miscarriage is inevitable.
What is an Incomplete miscarriage?
retained products of conception remain in the uterus after the miscarriage
- not all products of conception have been expelled
- pain and vaginal bleeding
- cervical os is open
What is a complete miscarriage?
A full miscarriage has occurred, and there are no products of conception left in the uterus
What is an Anembryonic pregnancy?
a gestational sac is present but contains no embryo
What are the various causes of Miscarriage?
Often Idiopathic
Foetal Pathology:
- Genetic disorder
- Abnormal development
- Placental failure
Maternal Pathology:
- Uterine abnormality (Bicornuate uterus, Cervical insufficiency)
- Cervical incompetence
- Polycystic ovary syndrome
- Poorly controlled diabetes
- Poorly controlled thyroid disease
- Anti-phospholipid syndrome, Factor V Leiden
- Infections: Toxoplasmosis, Syphilis
What are some risk factors for a miscarriage?
- advanced maternal age, with women over 35 having a significantly higher risk
- a history of previous miscarriages
- previous large cervical cone biopsy
lifestyle factors:
- smoking
- alcohol consumption
- obesity
Medical conditions:
- uncontrolled diabetes
- thyroid disorders,
What are the clinical features of a miscarriage?
May be Asymptomatic
- Vaginal Bleeding
- Pelvic Pain - Often reported to be worse than the pain of a usual period
- Vaginal tissue loss
What is the main differential for a miscarriage?
Main other differential for vaginal bleeding before 24 weeks gestation is an Ectopic Pregnancy
- Both can present with pain and vaginal bleeding
- Pain is often the first symptom in an ectopic
- Vaginal bleeding is usually larger in miscarriage
What are the investigations for a Miscarriage?
What parameters are you looking for?
Transvaginal Ultrasound Scan: Investigation of choice
Viability of Pregnancy features:
- Mean Gestational Sac Diameter
- Foetal pole and crown-rump length
- Foetal Heart Beat
When does a foetal pole develop?
- A foetal pole is expected once the mean gestational sac diameter is 25mm or more.
- When there is a mean gestational sac diameter of 25mm or more, without a foetal pole, the scan is repeated after one week before confirming an anembryonic pregnancy.
When does the foetal heart beat become visible?
- A foetal heartbeat is expected once the crown-rump length is 7mm or more.
- When the crown-rump length is less than 7mm, without a foetal heartbeat, the scan is repeated after at least one week to ensure a heartbeat develops
- When there is a crown-rump length of 7mm or more, without a foetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.
Pregnancy is considered viable when there is a foetal heart beat
What is the Management of a possible miscarriage at less than 6 weeks gestation
Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be managed expectantly
- Provided they have no pain and no other complications or risk factors (e.g. previous ectopic).
What is the Expectant Management option in a miscarriage in women less than 6 weeks gestation?
Expectant management before 6 weeks gestation involves:
- Awaiting the miscarriage without investigations or treatment.
- An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen.
- A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed.
- When bleeding continues, or pain occurs, referral and further investigation is indicated.
What are the NICE recommended situations where Medical or Surgical management is better than Expectant for miscarriage treatment?
Increased risk of haemorrhage
- she is in the late first trimester
- if she has coagulopathies or is unable to have a blood transfusion
Previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
Evidence of infection
What is the Management of a Miscarriage at More than 6 weeks gestation?
When do you need to perform monitoring?
What determines if you do expectant, medical or surgical management
NICE 2019 suggests referral to an early pregnancy assessment service (EPAU) for women with a positive pregnancy test (more than 6 weeks’ gestation) and bleeding.
Expectant Management: Watch and Wait
- First line for women without risk factors for heavy bleeding or infection
- 1-2 weeks are given to allow the miscarriage to occur spontaneously
- repeat UPT preformed 3 weeks after bleeding and pain settle to confirm miscarriage is complete
- Persistent or worsening bleeding require further assessment
Medical Management: 200mg Mifepristone followed by 800ug Misoprostol 48 hours later
- Used for a Missed Miscarriage
- Can be a vaginal suppository or Oral dose
Surgical Management: Third line:
- Surgical Options Include:
- Manual Vacuum aspiration: under local anaesthetic as outpatient
- Electric vacuum aspiration: under general anaesthetic
- Prostaglandins (misoprostol) are given before surgical management to soften the cervix.
- Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage
What is Mifepristone?
Mifepristone is an anti-progesterone that sensitises the myometrium to prostaglandins and induces breakdown of decidua basalis
What is Misoprostol?
Misoprostol is a prostaglandin analogue that soften the cervix and stimulates uterine contractions.
What are some side effects for Misoprostol?
- Heavier bleeding
- Pain
- Vomiting
- Diarrhoea
What is the management for an Incomplete miscarriage?
An incomplete miscarriage occurs when retained products of conception (foetal or placental tissue) remain in the uterus after the miscarriage. Retained products create a risk of infection.
Options for an Incomplete Miscarriage:
- Medical management (misoprostol)
- Surgical management (evacuation of retained products of conception)
Define Recurrent Miscarriage?
Defined as the loss of 3 or more consecutive 1st trimester pregnancies.
Defined as one or more second trimester pregnancies
What are some causes of recurrent miscarriages?
- Idiopathic (particularly in older women)
- Antiphospholipid syndrome
- Hereditary thrombophilias
- Uterine abnormalities
- Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
- Chronic histiocytic intervillositis
- Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)
What is Antiphospholipid Syndrome?
How is it managed?
Antiphospholipid syndrome is a disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting.
The patient is in a hyper-coagulable state. The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage.
APLs Abx
- Anti-cardiolipin
- Lupus anticoagulant
- Anti-b2 Glycoprotein I
The risk of miscarriage in patients with antiphospholipid syndrome is reduced by using both:
- Low dose aspirin
- Low molecular weight heparin (LMWH)
What are some Uterine abnormalities that can lead to recurrent miscarriage?
- Uterine septum (a partition through the uterus)
- Unicornuate uterus (single-horned uterus)
- Bicornuate uterus (heart-shaped uterus)
- Didelphic uterus (double uterus)
- Cervical insufficiency
- Fibroids
What is Chronic Histiocytic Intervillositis?
What other pregnancy related problems can it cause?
What is the pathophysiology?
What are the diagnostic findings?
Chronic histiocytic intervillositis is a rare cause of recurrent miscarriage, particularly in the second trimester. It can also lead to intrauterine growth restriction (IUGR) and intrauterine death.
The condition is poorly understood. Histiocytes and macrophages build up in the placenta, causing inflammation and adverse outcomes.
It is diagnosed by placental histology showing infiltrates of mononuclear cells in the intervillous spaces.
What are the investigations for Recurrent Miscarriage?
- Antiphospholipid antibodies
- Testing for hereditary thrombophilias
- Pelvic ultrasound
- Genetic testing of the products of conception from the third or future miscarriages
- Genetic testing on parents
What is the Management of Recurrent Miscarriage?
The management is tailored to the contributing pathology:
Genetic disorder - refer to a clinical geneticist for genetic counselling. Options include continuing pregnancy attempts with prenatal diagnosis or use of a donor egg/sperm
Uterine structural abnormality - may be treated surgically. For some congenital uterine malformations there is insufficient evidence to recommend surgical treatment
Cervical incompetence - regular ultrasound monitoring of the cervix. May use cervical cerclage
Polycystic ovary syndrome - difficult to manage as pathophysiology is not fully understood. There is no consensus on the most appropriate management. Suppression of the high LH has not been found to be effective
Antiphospholipid syndrome - heparin or low-dose aspirin
Thrombophilia - heparin may increase the live birth rate
Diabetes - improve glycaemic control
Define Abortion?
A termination of pregnancy (TOP) that is an elective procedure to end a pregnancy governed by the 1967 Abortion Act
What are the criteria for an Abortion to be performed prior to 24 weeks gestation?
- Pregnancy has not exceeded 24 weeks gestation
-
Continuing the pregnancy involves greater risk to the physical or mental health of:
- The woman
- Existing children of the family
The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners.
What are the criteria for an Abortion to be performed at anytime during the pregnancy?
- Continuing the pregnancy is likely to risk the life of the woman
- Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
- There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
What are the legal requirements for an Abortion?
- Two registered medical practitioners must sign to agree abortion is indicated
- It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
What is some Pre-Abortion Care that should be provided?
- Abortion services can be accessed by self-referral or by GP, GUM or family planning clinic referral.
- Doctors who object to abortions should pass on to another doctor able to make a referral
- Marie Stopes UK is a charity that provides abortion services
- Women should be offered counselling and information to help decision making from a trained practitioner
- Informed consent is essential
What are the Medical Options for Abortion?
What else does a women require?
A medical abortion is most appropriate earlier in pregnancy, but can be used at any gestation. It involves two treatments:
- Mifepristone (anti-progestogen)
- Misoprostol (prostaglandin analogue) 1 – 2 day later
Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis.
What are the Surgical Options for Abortion?
Surgical abortion can be performed, depending on preference and gestational age, under: Local anaesthetic (+/-plus sedation) or General anaesthetic
- Prior to surgical abortion, medications are used for cervical priming. This involves softening and dilating the cervix with misoprostol, mifepristone or osmotic dilators.
Surgical Options:
- Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
- Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
Rhesus negative women having a surgical TOP should have anti-D prophylaxis if 10 weeks gestation or more
What is some Post-Abortion Care?
- Inform women they may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks post procedure
- UPT is performed 3 weeks after abortion to confirm completion
- Support and counselling is offered
What are some complications of an Abortion?
- Bleeding
- Pain
- Infection
- Failure of the abortion (pregnancy continues)
- Damage to the cervix, uterus or other structures
- Psychological stress
Define Gestational Diabetes?
Diabetes that is triggered by pregnancy due to reduced insulin sensitivity during pregnancy and resolves after birth.
What is the Epidemiology of Gestational Diabetes?
- Approximately 5% of pregnancies are affected by GDM.
- Second most common complication of pregnancy
- Women diagnosed with GDM have an increased risk of developing T2DM
- Up to a 50% chance of developing T2DM within 5-10 years postpartum
What are some risk factors for Gestational Diabetes?
- BMI of > 30 kg/m²
- previous macrosomic baby weighing 4.5 kg or above
- previous gestational diabetes
- first-degree relative with diabetes
- family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
What is the pathophysiology of Gestational Diabetes?
Placental Hormones:
- human placental lactogen (hPL), progesterone, cortisol, and prolactin, have anti-insulin properties.
- These hormones increase as the pregnancy progresses
- Promote insulin resistance in the mother, ensuring that more glucose is available for the growing fetus.
- By the third trimester, insulin resistance peaks, which can overwhelm the body’s ability to regulate blood sugar
Pancreatic Dysfunction:
- Imapired Beta-cell function
- limits the ability to increase insulin production
- Therefore cannot overcome the insulin resistance
- leads to hyperglycaemia
What are the clinical features of Gestational Diabetes?
Often no noticeable symptoms
- Thirst
- Polyuria
- Fatigue
What are the differential diagnoses for Gestational Diabetes?
- Type 1 or Type 2 Diabetes Mellitus: Generally presents with symptoms outside of pregnancy, including potential weight loss
- Other forms of gestational hyperglycaemia: These can be identified through early pregnancy HbA1c testing
When should Investigations for Gestational Diabetes take place?
- Women with PMHx of GDM should have OGTT performed ASAP after booking and at 24-28 weeks if first test is normal
- Women with any other risk factors should be screened for GDM at 24-28 weeks gestation
- When there are features suggestive of GDM:
- Large for dates fetus
- Polyhydramnios (increased amniotic fluid)
- Glucose on urine dipstick
What are the investigations for Gestational Diabetes?
Oral Glucose Tolerance Test (OGTT):
Used in patients with risk factors for gestational diabetes or when there are features suggestive of GDM.
OGTT performed in the morning after fasting. Patient drinks 75g glucose drink and then blood sugar level is measured before and at 2 hours after.
Gestational Diabetes:
- Fasting: > 5.6 mmol/l
- At 2 hours: > 7.8 mmol/l
(remember for GDM cut off is 5-6-7-8)
What is the Management for Gestaional Diabetes?
What monitoring is performed?
Patients with GDM need careful explanation about the condition and learn how to monitor and tract blood sugar
First Line:
- Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin if targets are not met.
Second Line:
- Fasting glucose above 7 mmol/l: start insulin ± metformin
- Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
- Glibenclamide (a Sulfonylurea) Can be used if Insulin or Metformin are not tolerated
Postpartum management includes glucose testing to ensure resolution of GDM
Women with GDM must also have 4 weekly USS to tract foetal growth at 28, 32 and 36 weeks
When are the extra scans required if a patient has gestational diabetes?
4-weekly scans at: 28, 32 and 36 weeks to monitor foetal growth
What are the target blood sugar levels for women with Gestational Diabetes?
NICE 2015 Targets:
- Fasting: 5.3 mmol/l
- 1 hour post-meal: 7.8 mmol/l
- 2 hours post-meal: 6.4 mmol/l
- Avoiding levels of 4 mmol/l or below
What are some Maternal Complications of Gestational Diabetes?
- Pre-eclampsia
- Developing T2DM (50% increased risk)
- Increased risk of cardiovascular disease
What are some Foetal complications of Gestational Diabetes?
Key Complications:
- Macrosomia leading to shoulder dystocia
- Neonatal hypoglycaemia
Others:
- Childhood Obesity (2x background risk)
- Increased risk of Metabolic syndrome + associated complications
- Polycythaemia (raised haemoglobin)
- Jaundice (raised bilirubin)
- Congenital heart disease
- Cardiomyopathy
What is the management for Neonatal hypoglycaemia?
Babies born to mothers with GDM need close monitoring for neonatal hypoglycaemia with regular blood glucose checks and frequent feeds.
- Maintain blood glucose > 2mmol/l
- If it falls below this they may need IV Dextrose of nasogastric feeding
How should you manage women with pre-existing diabetes who are considering getting pregnant?
- Weight loss for women with BMI of > 27
- Stop oral hypoglycaemic agents, apart from metformin, and commence insulin
- Folic acid 5 mg/day from pre-conception to 12 weeks gestation
- Detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
Retinopathy screening performed at booking and at 28 weeks gestation
Planned delivery between 37 and 38+6
What are the target levels for glucose during pregnancy for women with Pre-existing Diabetes?
Both type I and type II diabetes should aim for the same target insulin levels as with gestational diabetes
NICE 2015 Targets:
- Fasting: 5.3 mmol/l
- 1 hour post-meal: 7.8 mmol/l
- 2 hours post-meal: 6.4 mmol/l
- Avoiding levels of 4 mmol/l or below
What medication should women with Pre-existing type 2 diabetes be on during pregnancy?
Metformin and Insulin.
Other oral diabetic medications should be stopped
What is an important complication to consider in women with Pre-existing diabetes who are pregnant?
Diabetic Retinopathy: referral to ophthalmologist for diabetic retinopathy screening
- Retinopathy Screening should be performed shortly after Dating/Booking scan (11 and 14 weeks) and at 28 weeks gestation
- Pre-existing diabetes and pregnancy carries a risk of rapid progression of retinopathy
What should the planned delivery times be for women with Pre-existing and Gestational diabetes?
Pre-existing Diabetes:
- Planned delivery between 37 and 38+6 weeks
Gestational Diabetes:
- Women can give birth up to 40+6 weeks
What insulin treatment should be used during labour for women with Type I diabetes?
Sliding-scale insulin regime considered during labour for women with T1DM.
May also be considered for women with poorly controlled blood sugars with GDM or T2DM.
Define Multiple Pregnancy?
Refers to a pregnancy with more than one foetus
Define monozygotic?
identical twins (from a single zygote)
Define Dizygotic?
non-identical (from two different zygotes)
Define Monoamniotic?
Single amniotic sac
Define Diamniotic?
Two separate amniotic sacs
Define Monochorionic?
Share a single placenta
Define Dichorionic?
Two separate placentas
What type of Multiple pregnancy has the best outcomes?
Diamniotic, Dichorionic
Twin pregnancies as each foetus has their own nutrient supply.
How is Multiple Pregnancy usually diagnosed?
Usually diagnosed on the “booking/dating” ultrasound scan
How can the type of twins be identified from an Ultrasound Scan?
- Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign
- Monochorionic diamniotic twins have a membrane between the twins, with a T sign
- Monochorionic monoamniotic twins have no membrane separating the twins
What are the risks to the mother in the case of Multiple Pregnancies?
- Anaemia
- Polyhydramnios
- Hypertension
- Malpresentation
- Spontaneous preterm birth
- Instrumental delivery or caesarean
- Postpartum haemorrhage
What are the risks to the Foetuses/neonates in the case of Multiple Pregnancies?
- Miscarriage
- Stillbirth
- Foetal growth restriction
- Prematurity
- Twin-twin transfusion syndrome
- Twin anaemia polycythaemia sequence
- Congenital abnormalities
What is Twin-Twin Transfusion Syndrome?
Twin-twin transfusion syndrome occurs when the foetuses share a placenta. It is called foeto-foetal transfusion syndrome in pregnancies with more than two foetuses.
When there is a connection between the blood supplies of the two foetuses, one foetus (the recipient) may receive the majority of the blood from the placenta, while the other foetus (the donor) is starved of blood.
- The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios.
- The donor has growth restriction, anaemia and oligohydramnios. There will be a discrepancy between the size of the foetuses.
Women with Twin-Twin transfusion syndrome need to be referred to a tertiary specialist foetal medicine centre
What is Twin Anaemia Polycythaemia Sequence?
Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute.
One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).
What additional monitoring is required for Women in the case of Multiple Pregnancy?
Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at:
- Booking clinic
- 20 weeks gestation
- 28 weeks gestation
Additional ultrasound scans are required in multiple pregnancy to monitor for foetal growth restriction, unequal growth and twin-twin transfusion syndrome:
- 2 weekly scans from 16 weeks for monochorionic twins
- 4 weekly scans from 20 weeks for dichorionic twins
When should Planned birth be offered for Uncomplicated monochorionic monoamniotic twins?
32 and 33+6 weeks
When should Planned birth be offered for Uncomplicated monochorionic diamniotic twins?
36 and 36+6 weeks
When should Planned birth be offered for Uncomplicated dichorionic diamniotic twins?
37 and 37 +6 weeks
When should Planned birth be offered for Triplets?
Before 35 +6 weeks
What is the mode of delivery for monoamniotic twins?
Require elective caesarean section between 32 and 33 +6 weeks
What are the options for Delivery in Diamniotic twins?
Aim to deliver between 37 and 37 +6 weeks
- Vaginal delivery is possible when the first baby has a cephalic presentation (head first)
- Caesarean section may be required for the second baby after successful birth of the first baby
- Elective caesarean is advised when the presenting twin is not cephalic presentation
Why is Anaemia in Pregnancy a common issue?
Anaemia is defined as a low concentration of haemoglobin.
In pregnancy, the plasma volume increases and thus there is a reduction in the concentration of haemoglobin leading to anaemia.
It is important to optimise the treatment of anaemia in pregnancy so that the woman has reasonable reserves in cases there is significant blood loss during delivery
What is the presentation of Anaemia in pregnancy?
Often asymptomatic
May present as:
- Shortness of breath
- Fatigue
- Dizziness
- Pallor
When is anaemia routinely screened for during pregnancy and what are the normal ranges?
Booking/dating Bloods: > 110 g/l
28 Weeks Gestation: > 105 g/l
Post-partum: > 100 g/l
Women are also offered Haemoglobinopathy screening at the booking clinic for Thalassaemia and Sickle Cell Disease
What are some potential causes of Anaemia in pregnancy?
Low MCV Indicates Iron Deficiency Anaemia
Normal MCV: Indicates a physiological anaemia due to increased plasma volume of pregnancy
Raised MCV: Indicates B12 or Folate Deficiency
What is the Management of Anaemia in Pregnancy?
Depends on the cause:
Iron:
- Women with anaemia in pregnancy are started on iron replacement: Ferrous sulphate 200mg 3x daily
- Women who are not anaemic but have low ferritin may also be started on supplementary iron.
- Treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished
B12:
- The increased plasma volume and B12 requirements often result in a low B12 in pregnancy. Women with low B12 should be tested for pernicious anaemia (checking for intrinsic factor antibodies).
- IM Hydroxocobalamin injections or Oral Cyanocobalamin Tables
Folate:
- All women should already be taking folic acid 400mcg OD
- Women with folate deficiency are started on folic acid 5mg daily
Define Spina Bifida?
Spina bifida is a neural tube defect characterised by incomplete development of the spinal column, resulting in herniation of the spinal cord.
What is Spina Bifida Occulta?
- Incomplete fusion of the vertebrae, but with no herniation of the spinal cord
- May be visible only as a small tuft of hair overlying the site
What is Meningocele?
- Incomplete fusion of the vertebrae, with herniation of a meningeal sac containing CSF
- Visible prominence at the site, but usually covered by skin
What is Myelomeningocele?
- Incomplete fusion of the vertebrae with herniation of herniation of a meningeal sac containing CSF and spinal cord.
- Usually accompanied by other defects such as hydrocephaly or Chiari malformation
- Visible prominence at the site, with exposed meninges
How can Spina Bifida be prevented?
All pregnant women, and those trying to conceive are recommended to take folic acid as this has been shown to decrease the risk of neural tube defects
- 400 micrograms/day from 3 months prior to conception, until 12 weeks gestation
- In women at higher risk (e.g. those with a child affected by a neural tube defect, or those on certain medications) are recommended a higher dose of 5mg/day
How is Spina Bifida Diagnosed?
Usually diagnosed on prenatal scans
What are the clinical features of Spina Bifida?
Neurological:
- Motor deficits
- Sensory deficits
- Neurogenic bladder or bowel
- Hydrocephalus
- Seizures
Musculoskeletal:
- Increased risk of hip subluxation
- Scoliosis
- Contractures
What is the Management of Spina Bifida?
- Primary neurosurgical repair
- Orthopaedic surgery
Define Chronic Hypertension/Pre-existing in terms of pregnancy?
High blood pressure that exists before pregnancy or is diagnosed before 20 weeks gestation and is longstanding. This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia.
Define Pregnancy Induced Hypertension (Gestational Hypertension)?
When there is an onset of high blood pressure that occurs after 20 weeks gestation without the presence of proteinuria
What is the Aetiology of Gestational Hypertension?
Multifactorial, often involving genetic predisposition, lifestyle factors, and physiological changes during pregnancy.
What is the Presentation of Gestational Hypertension?
Asymptomatic
- May have headaches and blurred vision
What are some differential diagnoses for Gestational Hypertesion?
- Preeclampsia: Characterized by high blood pressure and damage to another organ system, most often the liver and kidneys, after 20 weeks of gestation.
- Chronic Kidney Disease: Typically presents with proteinuria, haematuria, and a rise in serum creatinine.
How is Gestational Hypertension diagnosed?
Gestational Hypertension must be new onset after 20 weeks gestation WITHOUT proteinuria
- Blood pressure Monitoring
- Urinalysis: To exclude proteinuria and subsequently Pre-eclampsia
How is Gestational Hypertension Managed?
Monitoring
BP Control
Admission
2nd/3rd line/
- Discontinuation of some anti-hypertensive medications (ACEis and ARBs) to switch to pregnancy safe options.
- Regular Blood Pressure Monitoring
- Regular Urinalysis at least weekly
- Monitoring Foetal growth by serial growth scans
- PlGF testing on one occasion
Blood pressure control:
- Gestational Hypertension > 140/100mmHg: Oral Labetalol
- Treating to aim for BP < 135/85mmHg
- Admission for women with a BP above 160/110 mmHg
- Gestational Hypertension (mild) of: 140/90 to 149/99mmHg: No treatment other than regular monitoring
Alternatives if Labetalol is not tolerated:
- 2nd Line: Nifedipine.
- 3rd Line: Methyldopa
Define Pre-eclampsia
Pre-eclampsia refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine).
It occurs after 20 weeks gestation
Define Eclampsia?
When seizures occur as a result of Pre-eclampsia due to cerebral vasospasm
What is the Epidemiology of Pre-eclampsia?
- Significant cause of maternal and foetal morbidity and mortality
- Occurs after 20 weeks gestation
What are some risk factors for Pre-eclampsia?
High-risk factors are:
- Pre-existing hypertension
- Previous hypertension in pregnancy
- Existing autoimmune conditions (e.g. systemic lupus erythematosus)
- Diabetes
- Chronic kidney disease
Moderate-risk factors are:
- Older than 40
- BMI > 35
- More than 10 years since previous pregnancy
- Multiple pregnancy
- First pregnancy
- Family history of pre-eclampsia
Aspirin is given to women from 12 weeks until delivery for those with 1 Major or 2 moderate risk factors
What is the Pathophysiology of Pre-eclampsia?
In normal pregnancy, the trophoblast cells (cells that form the placenta) invade the uterine lining and remodel the spiral arteries to become low-resistance vessels that supply adequate blood flow to the growing fetus.
- In pre-eclampsia, defective trophoblast invasion leads to incomplete remodeling of the spiral arteries. As a result, these arteries remain narrow and high-resistance, limiting the blood supply to the placenta (a state called uteroplacental ischemia).
- Placental hyoxia leads to oxidative stress and pro-inflammatory cytokines release.
- This leads to systemic inflammation and impaired endothelial cell function resulting in the symptoms and complications of Pre-eclampsia
What are the clinical features of Pre-eclampsia?
What is the classic Triad?
What are some other symptoms?
Classical Triad:
- Hypertension
- Proteinuria
- Peripheral Oedema
Symptoms:
- Severe Headaches (potentially due to cerebral oedema)
- Visual Disturbance (due to retinal artery vasospasm)
- Epigastric pain (due to reduced blood flow to the liver causing injury and swelling of liver and capsule)
- Drowsiness
- Nausea and vomiting
- Hyperreflexia
Why do you get Hypertension, Proteinuria and Peripheral Oedema in Pre-eclampsia?
Hypertension
- Oxidative stress on the placenta causes the release of pro inflammatory cytokines
- These entre the mothers circulation and cause endothelial cell dysfunction
- This results in vasoconstriction and salt retention (at the kidneys) leading to hypertension
Proteinuria
- Local vasospasm and hypertension will result in reduced blood flow to the kidneys.
- The systemic inflammatory response may also lead to glomerular changes and disruption of the basement membrane and podocytes
- This results in the leakage of proteins out the kidneys causing proteinuria
Peripheral Oedema
- Endothelial injury increases vascular permeability enabling water to leak out of blood vessels and into the surrounding tissues
- Furthermore, the proteinuria leads to low protein concentrations within blood vessels reducing the oncotic pressure and hence leads to further water loss into tissues
- This results in generalised oedema that is commonly seen in the Legs, face and hands.
- Pulmonary oedema (causing cough and SOB) as well as cerebral oedema (causing headaches, confusion and seizures)
What are some maternal complications of Pre-eclampsia?
- Eclampsia (seizures due to cerebrovascular vasospasm)
- Organ failure
- Disseminated intravascular coagulation (DIC)
- HELLP syndrome (the presence of haemolysis (H), elevated liver enzymes (EL) and low platelets (LP))
What are some foetal complications of Pre-eclampsia?
- Intrauterine growth restriction (IUGR)
- Pre-term delivery
- Placental abruption
- Neonatal hypoxia
What are the investigations for Pre-eclampsia?
Blood Pressure Monitoring
- Systolic BP > 140mmHg
- Diastolic BP > 90mmHg
- Severe Pre-eclampsia: Systolic >160mmHg and Diastolic >110mmHg
Urinalysis:
- Proteinuria 1+ or more on urine dipstick
- Urine protein:creatinine ratio > 30mg/mmol is significant
- Urine albumin:creatinine ratio > 8mg/mmol is significant
Blood Tests:
- U&E, FBC, LFTs (To assess kidney function, liver function and clotting status)
How is Pre-eclampsia diagnosed?
NICE guidelines 2019 state diagnosis can be made with:
- Hypertension (systolic >140mmHg/Diastolic >90mmHg)
PLUS any of:
- Proteinuria (1+ or more on urine dipstick)
- Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
- Placental dysfunction (e.g. foetal growth restriction or abnormal Doppler studies)
What is the role of Placental Growth Factor?
NICE Guidelines 2019 and Placental Growth Factor (PlGF):
Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low.
- NICE recommend testing on one occasion during pregnancy in women suspected to have Pre-eclampsia between 20 and 35 weeks gestation to rule out pre-eclampsia
- sFLT:PlGF ratio >85 is diagnostic
When is Aspirin given in pregnancy?
Women are offered 75-150mg Aspirin daily from 12 weeks gestation until birth if they have:
- One high-risk factor
- More than one moderate-risk factors.
What is the Management of Pre-eclampsia?
Prophylaxis?
Gestational HTN Monitoring?
Pre-eclampsia Dx monitoring?
Management of BP?
Management of Pre-eclampsia during Labour?
After Delivery?
Prophylaxis:
- Aspirin (75mg - 150mg) from 12 weeks till birth
- Women with 1 Major or 2 Minor RFs
Gestational HTN Monitoring:
- Treating to aim for a blood pressure below 135/85 mmHg
- Admission for women with a blood pressure above 160/110 mmHg
- Urine dipstick testing at least weekly
- Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
- Monitoring fetal growth by serial growth scans
- PlGF testing on one occasion (20-35 weeks)
Pre-eclampsia Dx Monitoring:
- Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
- Blood pressure is monitored closely (at least every 48 hours)
- Urine dipstick testing is not routinely necessary (the diagnosis is already made)
- Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
Management of BP:
- BP < 140/90: Rest, weight loss, exercise
- BP > 140/100: Oral Labetalol
- BP > 160/110: Admit Patient - Labetalol
- 2nd Line: Nifedipine (Modified Release)
- 3rd Line: Methyldopa
- Severe HTN or Eclampsia: IV Hydralazine
Management During Labour:
- Fluid restriction if severe pre-eclampsia or eclampsia
- BP Meds
- IV Magnesium Sulphate in Labour and 24 hours after
- Corticosteroids if premature birth planned
After Delivery
- Delivery is definitive Tx
- BP monitored until normal
- Switch to Enalapril
How does Pre-eclampsia or Eclampsia affect the planning of Delivery?
Consider early delivery at 37 weeks if blood pressure cannot be controlled or complications occur.
Corticosteroids should be given to the women having a premature birth to help the foetal lungs mature
What is the definitive cure for pre-eclampsia and Eclampsia?
Delivery of the foetus and placenta
What is the Management for Eclampsia?
Similar to Pre-eclampsia with additional IV Magnesium Sulphate to manage the seizures
Also treat the cause (HTN) too so Labetalol/nifedipine.
What is HELLP Syndrome?
Combination of features that occur as a complication of Pre-eclampsia and Eclampsia:
Haemolysis
Elevated Liver enzymes
Low Platelets
What is the Epidemiology of HELLP syndrome?
- HELLP syndrome is relatively rare, affecting approximately 0.5-0.9% of all pregnancies.
- Occurs in 10-20% of women with severe pre-eclampsia or eclampsia
- However, it is a significant cause of maternal and perinatal morbidity and mortality.
What is the Pathophysiology of HELLP Syndrome?
- Reduced perfusion of the placenta and thus oxidative stress releasing inflammatory cytokines.
- Hypertension and endothelial damage reduces blood flow to the liver causing injury and swelling. This results in elevation of liver enzymes and stretches the liver capsule causing RUQ and epigastric pain
- Endothelial cell injury leads to formation of thrombi in vasculature using up platelets making their numbers low
- Thrombi can act as blocks for RBCs which crash into them causing them to become damaged and haemolyse
What are the clinical features of HELLP Syndrome?
Headache
Nausea and/or vomiting
Epigastric pain
Right upper quadrant abdominal pain due to liver distension
Blurred vision
Peripheral Oedema
What are the investigations for HELLP Syndrome?
- Full blood count to assess for low platelet count and evidence of haemolysis
- Liver function tests to assess for elevated liver enzymes
- Coagulation studies to evaluate for disseminated intravascular coagulation
- Ultrasound scans to assess for liver abnormalities and placental abruption
What is the Management of HELLP Syndrome?
Delivery of the baby and placenta
- Mothers may also require blood transfusions to manage anaemia and thrombocytopenia
Define Obstetric Cholestasis?
Obstetric cholestasis, also known as intra-hepatic cholestasis of pregnancy, is a pregnancy-related hepatobiliary disorder that typically manifests after the 24th week of gestation.
The condition is characterised by impaired bile flow leading to the accumulation of bile acids.
When does Obstetric Cholestasis typically occur and who does it commonly affect?
- Relatively common complication of pregnancy occuring in 1%
- Develops later in pregnancy (Typically after 24-28 weeks)
- More common in South Asian Ethnicity
What is the Aetiology of Obstetric Cholestasis?
Multifactorial:
- Hormonal Factors such as Increased oestrogen and Progesterone thought to be main cause
- Genetic factors
- Environmental triggers
What is the Pathophysiology of Obstetric Cholestasis?
- Genetic and hormonal factors impair bile acid transport.
- Accumulation of bile acids in the liver due to defective bile transport.
- Increased serum bile acids cause pruritus and potential hepatocellular damage.
- Placental dysfunction due to toxic effects of high bile acid levels can lead to fetal complications like preterm labor or stillbirth.
Obstetric cholestasis is associated with an increased risk of stillbirth.
What are the clinical features of Obstetric Cholestasis?
Obstetric cholestasis typically present later in pregnancy, particularly in the third trimester.
Itching (pruritis) is the main symptom, particularly affecting the palms of the hands and soles of the feet.
Other symptoms are related to cholestasis and outflow obstruction in the bile ducts:
- Fatigue
- Dark urine
- Pale, greasy stools
- Jaundice
- Abdominal Pain
What alternative diagnoses should be considered if someone presents similarly to Obstetric Cholestasis however a rash is present?
- Polymorphic eruption of pregnancy
- Pemphigoid gestationis.
What are some differential diagnoses for Obstetric Cholestasis?
- Gallstones
- Acute fatty liver
- Autoimmune hepatitis
- Viral hepatitis
What are the investigations for Obstetric Cholestasis?
- Serum Bile Acids: Raised above 19 micromol/l
- LFTs: Mainly ALT, AST and GGT
ALP typically rises in pregnancy due to it being produced by the placenta.
What is the Management of Obstetric Cholestasis?
First Line:
- Emollients: soothe the skin
- Vitamin K Supplementation
- Antihistamines: Chlorphenamine to aid in sleeping (Not improve itching)
Second Line:
- Ursodeoxycholic acid: Improves LFTs, bile acids and symptoms and helps prevent premature birth
Induction of Labour at 37 weeks
Where is Bartholin’s Glands?
The Bartholin’s glands are a pair glands located either side of the posterior part of the vaginal introitus (the vaginal opening). They are usually pea-sized and not palpable. They produce mucus to help with vaginal lubrication.
What is a Bartholoin’s Gland Cyst
This occurs when the duct from the gland becomes blocked, resulting in palpable swelling and pain at the site of the Bartholin’s gland.
What is a Bartholin’s Gland Abscess?
This occurs when a cyst becomes infected, resulting in extreme pain, lymphadenopathy, erythema, and in rare cases, systemic upset.
What is the Aetiology of Bartholin’s Cysts and Abscesses?
The primary cause of Bartholin’s gland cysts and abscesses is the blockage of the gland’s duct.
This blockage can be due to thick mucus, inflammation, trauma, or in rare cases, malignancy.
Abscesses are typically caused by infection of a cyst, often with normal vaginal flora or sexually transmitted bacteria.
What are the clinical features of Bartholin’s Glands Cysts and Abscesses?
Bartholin’s gland cyst:
- Palpable swelling and without much pain at the site of the Bartholin’s gland.
Bartholin’s gland abscess:
- Extreme pain
- lymphadenopathy
- erythema,
- rare cases, systemic upset such as fever and malaise.
What are some differential diagnoses for Bartholin’s Cysts and Abscesses?
- Vaginal cysts: Typically asymptomatic but can cause discomfort during sex or when sitting.
- Skene’s duct cysts: Located on either side of the urethra, can cause discomfort during sex or urination.
- Vulvar cancer: Can present with a vulvar lump, itching, pain, or abnormal bleeding.
What are the investigations for a Bartholin’s Cyst or Abscess?
Clinical diagnosis with a physical examination
- Cyst is often painless
- Absess is often painful + lymphadenopathy
If postmenopausal then may require biopsy to exclude malignancy
What is the Management of Bartholin’s Cysts or Abscesses?
Cysts:
- Good hygiene and warm compresses
- Incision and Drainage is typically avoided due to likelihood of reoccurrence
Abscess:
- Antibiotics
-
Surgical intervention may be required:
- Word Catheter: requires local anaesthetic
- Marsupialisation: requires general anaesthetic
What is Sudden Infant Death Syndrome (SIDS)?
when does it most commonly occur?
Also known as Cot death is the sudden unexplained death of an infant.
It usually occurs within the first six months of life
What are some risk factors for SIDS?
- Putting the baby to sleep prone
- Parental smoking
- Co-sleeping in same bed
- Prematurity
- Hyperthermia (e.g. over-wrapping) or head covering (e.g. blanket accidentally moves)
What measures can be taken to minimise the risk of SIDS?
- Put the baby on their back when not directly supervised
- Breastfeeding
- Keep their head uncovered
- Place their feet at the foot of the bed to prevent them sliding down and under the blanket
- Keep the cot clear of lots of toys and blankets
- Maintain a comfortable room temperature (16 – 20 ºC)
- Avoid smoking. Avoid handling the baby after smoking (smoke stays on clothes).
- Room sharing NOT BED SHARING
What support is available for families who have experienced SIDS?
- Lullaby Trust is a charity to help support families affected.
- Bereavement services and counselling should also be available.
- Care of Next Infant (CONI) Team supports parents with their next infant after SIDS including extra support and home visits and resuscitation training
What are the 2 stages of the Menstrual Cycle?
Follicular/Proliferative Phase Days 1-14
Luteal/Secretory Phase Days 15-28
What happens during the Follicular/Proliferative phase of the Menstrual Cycle?
- Increased frequency of pulsatile GnRH secretion leads to an increase in LH, and an initial increase in FSH.
- Oestrogen rises gradually as granulosa cells convert thecal androgens under the influence of FSH. Progesterone levels remain low after loss of corpus luteum. Moderate levels of oestrogen exert negative feedback on FSH secretion.
- Days 1-5: Progesterone withdrawal due to degeneration of corpus luteum leads to sloughing of the stratum functionalis (a menstrual bleed).
- Days 6-14: The endometrium undergoes its proliferative phase due to rising oestrogen levels.
- Meanwhile, 15-20 early antral (tertiary) follicles undergo development. At approximately day 7, a single dominant follicle is selected.
- It is thought that this occurs because rising oestrogen levels lower FSH levels through negative feedback - the dominant follicle is the one that can cope with lower FSH.
- Day 13 - Rising oestrogen levels reach a ‘tipping point’, at which their negative feedback on LH secretion is reversed - the LH surge occurs, stimulating the oocyte to complete meiosis I and form a single Graafian follicle.
- Day 14 - Ovulation - The secondary oocyte erupts from its follicle, carried by antral fluid.
What happens during the Luteal/Secretory phase of the Menstrual Cycle?
- Day 15 - the granulosa cells of the ruptured follicle become luteinised, forming the progesterone-secreting corpus luteum.
- The corpus luteum’s progesterone acts upon the endometrium to cause it to enter its secretory phase - amongst other things, it secretes glycogen and mucous.
- Progesterone levels peak 7 days before the next menstrual bleed - 7 days before CL completely degenerates.
- High levels of progesterone increase the volume and viscosity of cervical secretions; this begins the formation of the protective operculum.
-
After 10 days, if no conceptus has implanted, the corpus luteum spontaneously
regresses. This leads to diminishing progesterone levels:- Without progesterone’s negative feedback on the hypothalamus, GnRH release frequency increases and facilitates a rise in gonadotrophins.
- Progesterone withdrawal also stimulates the stratum functionalis of the secretory endometrium to be shed.
- As FSH and LH levels rise, and the menstrual bleed begins, the cycle restarts on Day 1.
What are some examples of Non-Hormonal Contraception?
- Copper intrauterine device (Cu-IUD)
- Barrier methods e.g. male condom, female condom, diaphragm/cervical cap
- Surgical methods e.g. tubal ligation, vasectomy
- Lactational amenorrhoea
- Fertility awareness methods (FAM)
What are some examples of Hormonal Contraception?
- Combined Hormonal Contraception (CHC)
- Combined Oral Contraceptive Pill (COCP)
- Progesterone Only Pill (POP/Mini-pill)
- Levonorgestrel Intrauterine System (LNG-IUS commonly known as Mirena)
- Contraceptive Injection (Depo-Provera)
- Contraceptive Implant
What are some examples of Emergency Contraception?
- Levonorgestrel Pill
- Ulipristal Acetate Pill (EllaOne)
- Copper Intrauterine Device (Cu-IUD)
What are the features of the Copper Intrauterine Device (Cu-IUD):
Mechanism:
Efficacy:
Advantages:
Absolute Contraindications:
Side Effects:
Other:
Mechanism: Decreases sperm motility and Survival. Makes the endometrium less accepting of implantation
Efficacy: 0.8% experience unintended pregnancy after 1 year
Advantages:
- Effective immediately on insertion (can be used in emergency).
- No hormonal side effects.
- High Efficacy
Absolute Contraindications:
- PID
- Gonorrhoea/Chlamydia
- Unexplained vaginal bleeding/endometrial cancer
- postpartum/postabortion septicaemia
- Gestational trophoblastic disease
- Purulent cervicitis, Pelvic TB
Side Effects:
- Breakthrough bleeding.
- Increased duration or heaviness of periods
Other:
- Classified as Long-acting reversible contraceptive (LARC)
- Left in situ for 5 years
- Most effective form of emergency contraception.
- The Cu-IUD is licensed for insertion 5 days post-ovulation.
What are the features of the Combined Oral Contraceptive Pill (COCP):
Mechanism:
Efficacy:
Advantages:
Absolute Contraindications:
Side Effects:
Other:
Mechanism: Inhibits ovulation
Efficacy: 0.03% failure rate if used perfectly but human error is important taking average unwanted pregnancy to 9%
Advantages:
- Rapidly reversible if unintended side effects
- Regulars and tends to lighten periods
Absolute Contraindications:
- <6 weeks postpartum in breastfeeding women
- Aged 35, smoking >15 cigarettes per day
- Stage 2 hypertension (160/100)
- History of VTE
- Disease: Breast cancer, inherited thrombophilia e.g. Factor V Leiden,
cardiomyopathy, cirrhosis, vascular disease, SLE, positive antiphospholipid
antibodies. - Migraine with aura
Side Effects:
- Headache
- Mood disturbance
- Breakthrough bleeding
What are the features of the Progesterone Only Pill (POP):
Mechanism:
Efficacy:
Advantages:
Absolute Contraindications:
Side Effects:
Other:
Mechanism: Thickens cervical Mucus
Efficacy: 9% experience unintended pregnancy after 1 year.
Advantages:
- Rapidly reversible
- Far fewer absolute contraindications than the combined pill
Absolute Contraindications:
- Breast Cancer
Side Effects:
- Breakthrough Bleeding
Other:
- Effective after 2 days of administration
What are the features of the Levonorgestrel Intrauterine System (LNG-IUS/Mirena)
Mechanism:
Efficacy:
Advantages:
Absolute Contraindications:
Side Effects:
Other:
Mechanism: Prevents endometrial proliferation and also thickens cervical mucus
Efficacy: 0.2% unintended pregnancy after 1 year
Advantages:
- Extremely high efficacy
- Can be left in situ for 3-5 years
- Lightens periods
- Systemic absorption is minimal, reducing systemic hormonal side effects
Absolute Contraindications:
- PID
- Gonorrhoea or chlamydia
- Unexplained vaginal bleeding / endometrial cancer
- Postpartum / post-abortion septicaemia
- Gestational trophoblastic disease
- Purulent cervicitis, pelvic TB
Side Effects:
- Irregular Menstrual Bleeding
What are the features of the Contraceptive Injection (Depo-Provera)
Mechanism:
Efficacy:
Advantages:
Absolute Contraindications:
Side Effects:
Other:
Mechanism: Inhibits Ovulation and also thickens cervical mucus (Medroxyprogesterone acetate)
Efficacy: 6% experience unintended pregnancy after 1 year.
Advantages:
- Long acting - Requires injection every 12 weeks
Absolute Contraindications:
- Breast Cancer
Side Effects:
- Amenorrhoea
- Weight gain
- Reduces BMD so cant be given to people beyond age 50
What are the features of the Contraceptive Implant:
Mechanism:
Efficacy:
Advantages:
Absolute Contraindications:
Side Effects:
Other:
Mechanism: Inhibit Ovulation and also thickens cervical mucus
Efficacy: 0.05% experience unintended pregnancy after 1 year
Advantages:
- Most effective contraception available.
- Active for 3 years before replacement is required.
Absolute Contraindications:
- Breast Cancer
Side Effects:
- Irregular Menstrual Bleeding
What are the features of the Levonorgestrel Pill (LNG)?
Mechanism:
Efficacy:
Mechanism:
- Inhibits ovulation
- Can delay ovulation by 5 days (the viable lifespan of ejaculated sperm).
- Not effective in the late luteal phase, in which case ulipristal acetate is required.
Efficacy:
- Effective up to 72 hours post UPSI
- Not effective if taken after ovulation has occurred
What are the features of the Ulipristal Acetate Pill (UPA EllaOne)
Mechanism:
Efficacy:
Mechanism: Inhibits ovulation
Efficacy:
- Effective up to 120 hours post UPSI
- Can delay ovulation even if LH surge has started
- Remains effective in late follicular phase
- Not effective if taken after ovulation
- Contraception with pill, patch or ring should be restarded after 5 days due to reduced effectiveness
What are the guidelines when offering emergency contraception?
- Offer most effective method (Cu-IUD) first line;
- Can be taken either within 120 hours of first UPSI or within 120 hours of
calculated date of ovulation; whichever is later.
- Can be taken either within 120 hours of first UPSI or within 120 hours of
- If Cu-IUD not acceptable / appropriate, offer oral emergency contraception;
- If within 72 hours of UPSI - offer LNG or UPA.
- If 72-120 hours post-UPSI - offer UPA.
Define Fertilisation
Fusion of haploid sperm and oocyte, typically occurring in the ampulla of the
fallopian tube.
What are the stages of Fertilisation?
1. Capacitation - final stage of sperm maturation - involves exposure of receptor sites involved in zona pellucida penetration.
2. Acrosome reaction - loss of the acrosome cap on the head of the sperm cell leads to release of lytic enzymes, which allows the sperm to penetrate the zona pellucida.
3. Adhesion and entry - cell membranes of sperm and egg fuse, and the head of the sperm if phagocytosed - it then breaks down to release the sperm nucleus.
4. Cortical reaction - modification of the zona pellucida to prevent polyspermy, induced by membrane fusion and mediated by cortical granules
5. Meiosis II - the oocyte completes meiosis II (which until this point is arrested in
metaphase II) to give the second polar body.
6. Syngamy - the male and female pronuclei replicate DNA and shed their nuclear
membranes as they move toward one another, before aligning at a common metaphase plate and undergoing mitosis
What are the key events in Embryonic Development?
- Day 6-7: implantation of blastocyst into endometrium
- Week 3: gastrulation - formation of trilaminar disc (endoderm, mesoderm, ectoderm) from the primitive streak
- Week 3-8: beginning of development of organ systems
- Week 4: neurulation - development of neural tube from the ectoderm
- Week 23: generally considered to be the threshold of viability.
What are the functions of the Placenta?
Exchange:
- gaseous: Oxygen moves readily from maternal to foetal haemoglobin (HbF) due to HbF’s higher affinity. CO2 diffuses from foetal to maternal blood down the concentration gradient
- Nutritional: Glucose moves from maternal to foetal circulation via facilitated diffusion; both amino acids and free fatty acids also cross from mother to foetus, the former through active transport.
Endocrine:
-
Human Chorionic Gonadotrophin (hCG) Produced by trophoblast cells -
maintains the corpus luteum to allow for sufficient progesterone production until
the placenta takes over -
Human Placental Lactogen (hPL): Increases maternal free fatty acid and insulin
levels, as well as inducing maternal insulin resistance. - Progesterone: Inhibits uterine contractility and thickens endometrium
- Oestrogen: Stimulates myometrial growth, oxytocin receptor synthesis and pregnancy related breast changes
Explain the phsyiological changes in pregnancy?
Mothers body prepares for new borns little life
Metabolic
- Increased metabolism: The hormone thyroxine (T4) increases, enhancing metabolic activity.
- Increased insulin resistance: Human placental lactogen (hPL), produced by the placenta, leads to insulin resistance to ensure more glucose is available for the fetus.
- Weight gain: Estrogen and progesterone contribute to fat storage, while hPL shifts energy metabolism toward fat utilization to save glucose for the baby.
Blood
- Increased blood volume: Driven by estrogen, which stimulates the production of blood plasma and increased fluid reabsorption at the kidneys
- Increased cardiac output: Progesterone relaxes smooth muscles, causing blood vessels to dilate, which reduces TPR increases blood flow, increases Venous reutrn, increased preload, SV and subsequently CO.
- Increased clotting factors: Estrogen increases clotting factors to prepare for childbirth and reduce blood loss causing hypercoagulability
- Hemodilution: Increased plasma volume (due to estrogen) results in a relative dilution of red blood cells, leading to physiological anemia.
Pulmonary (Lungs)
- Increased oxygen demand: Progesterone stimulates the respiratory centers in the brain, increasing the drive to breathe and ensuring more oxygen is available for both mother and baby.
- Increased tidal volume: Progesterone also leads to deeper breathing by expanding the lungs’ capacity.
- Decreased lung capacity: This is more of a mechanical effect due to the growing uterus pushing against the diaphragm, though hormonal factors also contribute.
Nervous (Neurological)
- Pregnancy brain: Often linked to fluctuating levels of progesterone and estrogen, which may impact memory and concentration.
- Increased risk of headaches and dizziness: Changes in blood pressure due to progesterone (vasodilation) and increased fluid retention from aldosterone can contribute to these symptoms.
Breasts:
- Ductal proliferation
- Prolactin stimulates milk production from alveolar cells
- Areola grow
Lower body (Renal, GI, Uterus)
- Kidneys: Increased blood flow to the kidneys is driven by progesterone and relaxin, which also cause dilation of the renal vessels, increasing the glomerular filtration rate (GFR).
- GI system: Progesterone relaxes smooth muscle, slowing down digestion and causing nausea, heartburn, and constipation. The hormone hCG (human chorionic gonadotropin) is responsible for early pregnancy nausea.
- Uterus growth: Estrogen promotes the growth of the uterine lining and stimulates the muscles of the uterus to expand during pregnancy.
Look (Skin)
- Hyperpigmentation: Melanocyte-stimulating hormone (MSH) increases, along with estrogen and progesterone, leading to darkening of the skin, especially on the face and abdomen (chloasma and linea nigra).
- Stretch marks: These are largely due to physical stretching, but cortisol (which increases during pregnancy) may weaken skin fibers, making stretch marks more likely.
- Increased oil production: Androgens (which rise slightly during pregnancy) stimulate the sebaceous glands, potentially causing acne.
- Spider veins and varicose veins: The increase in blood volume and the relaxing effects of progesterone on blood vessels cause veins to enlarge and become more visible.
- At 20 weeks, uterus can compress IVC in R. lateral position causing varicose veins and peripheral oedema.
What is the most common (and safest) foetal presentation?
Cephalic Vertex presentation
Makes up 95% of pregnancies
What is the most common type of malpresentation?
Breech Presentation - Refers to the positioning of the fetus in a longitudinal lie with the buttocks or feet proximal to the cervix and the head near the fundus.
What are the 3 different types of Breech presentation?
- Complete (flexed) breech – both legs are flexed at the hips and knees (fetus appears to be sitting ‘crossed-legged’).
- Frank (extended) breech – both legs are flexed at the hip and extended at the knee. This is the most common type of breech presentation.
- Footling breech – one or both legs extended at the hip, so that the foot is the presenting part.
What is the management of a breech presentation?
-
External Cephalic Version (ECV)
This is the is the manipulation of the fetus to a cephalic presentation through the maternal abdomen. It is offered to primiparous women at 36 weeks, and to multiparous women at 37 weeks. There is a 50% success rate (40% in primiparous, 60% in multiparous); and if successful, it can enable an attempt at vaginal delivery. -
Caesarean Section
If ECV is unsuccessful, contraindicated, or declined by the woman, current UK guidelines advise an elective Caesarean delivery. -
Vaginal Breech Birth
Some women may still choose to aim for a vaginal breech delivery. A footling breech is contraindicated however as the feet and legs can slip through a non-fully dilated cervix, and the shoulders or head can then become trapped.
