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Obstetrics&Gynaecology I

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André Almeida

on 6 July 2013

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Transcript of Obstetrics&Gynaecology I

Obstetrics & Gynaecology
Diagnosed in 16-year-old girls with secondary sex characteristics or 14-year-old girls without secondary sex characteristic who fail menstruate
Turner syndrome
Complete or partial absence of one X chromosome
Short stature
Ovarian dysgenesis
Dysmorphic features (+- lymphoedema)
webbed neck
widely spaced nipples
Sensorineural and conduction deafness
Renal anomalies
CVS disease (coarctation of aorta and atherosclerosis)
Low bone density
Endocrine dysfunction, e.g. autoimmune thyroid disease
Fragile X syndrome
Kallmann's syndrome
Expansion of CGG repeat
20% of women affected get fragile X-related primary ovarian insufficiency
Menopause before the age of 40
How it causes primary amenorrhoea (???)
Type of hypogonadotrophic hypogonadism
GnRH deficiency
Anosmia - agenesis or hypoplasia of the olfactory bulbs
Most common cause: constitutional delay
Androgen Insensitivity
Abnormality of androgen receptor - complete or partially unable to respond to androgen stimulation
46, XY - DSD
Puberty - normal breast development, pubic and axillary hair growth is minimal
*Presents with primary amenorrhoea*
Vagina - blind-ending and short
Mullerian duct anomalies
Imperforate hymen
Vaginal septum
Menstrual blood retained in vagina - haematocolpos
Cyclical lower abdominal pain (cryptomenorrhoea)
Medications - progestogens, GnRH analogues and typical antipsychotics
Chemo/radiotherapy for childhood cancers
Hypothalamic hypogonadism - excessive exercise, stress, anorexia
Cessation of established menstruation in the absence of pregnancy
Pregnancy should always be excluded
High prolactin during breast feeding - suppresses ovulation and gives rise to lactational amenorrhoea
'Hypogonadotrophin hypogonadism'
Associated with stress, excessive physical activity and anorexia nervosa
Low FSH and LH and low oestrogen and prolactin
No pregnancy desired - oestrogen replacement - OCP
Wanted pregnacy - pulsatile GnRH or exogenous gonadotrophins
Hyperprolactinaemia - pituitary adenoma
Galactorrhoea occurs in <50% of those with hyperprolactinaemia
Treatment: bromocriptine or carbegoline
Hypo and hyperthyroidism
**Late-onset congenital adrenal hyperplasia**
Primary hypopituitarism - hypoprolactinaemia
Sheehan's syndrome - postpartum blood loss and subsequent hypovolemic shock result in pituitary necrosis - hypopituitarism
Premature Ovarian Failure
Cessation of ovarian function before the age of 40
Pregnancy by IVF with donor oocytes may be possible
HRT - relieve postmenopausal symptoms and protect against osteoporosis
Most common form of anovulatory infertility (10%)
Rotterdam criteria (2/3)
1. Oligo/Anovulation
2. Large-volume ovaries and/or multiple small follicles (US)
3. Clinical and/or biochemical evidence of excess androgens (acne, hirsutism)
Menstrual irregularity - COCP
Hirsutism - COCP, cyproterone acetate (anti-androgen)
Anovulatory infertility - clomifene, gonadotrophin injections, laparoscopic laser or diathermy to the ovary
Weight Reduction (Very important)
Long term - increased risk of endometrial hyperplasia and carcinoma (unopposed oestrogen); increased risk of non-insulin dependent diabetes mellitus and cardiovascular disease
Asherman's syndrome
Excessive uterine curettage - at time of miscarriage, TOP or secondary postpartum haemorrhage - formation of uterine adhesions (synechiae)
Treatment - breaking down adhesions through a hysteroscope
Most common cancer in women in many developing countries
CIN develops in the transformation zone of the cervix - area sampled cytologically
Transformation zone - everted columnar epithelium undergoes metaplasia into squamous epithelium after puberty - changes in pH and other factors
Rate of progression of CIN is unknown (maybe 10 years) - 1/3 progress, 1/3 remain unchanged, 1/3 regress
Every 3 years - aged 25-49; every 5 year - aged 50-64
Results should be given in 14 days
- smear test, liquid based cytology
Indication - significant dyskaryosis
Colposcope - binocular microscope
Lithotomy position with speculum inserted
During colposcopy:
CIN cells - high protein; low glycogen
Acetic acid coagulates protein - abnormal cells appear white
Lugol's iodine - stains glycogen; normal cells - brown: abnormal cells - light brown
Pictures - http://www.bsccp.org.uk/index.asp?PageID=105
NOTE: CGIN - glandular CIN - precursor to invasive cervical adenocarcinoma; associated with COC use
At least 30% of patients with CIN III, if left untreated will probably develop invasive cancer over a period of 5-20 years
Sexual behaviour - more sexual partners, young age at first intercourse, less use of barrier methods, lack of circumcision in male partner
HPV - DNA virus, >130 types; low risk - 6, 11; high risk - 16, 18 , 45, 56
COCP - long term use, 4x increased risk in women with HPV infection
Vaccination program in the UK for girls 12-13 years old
Before - Cervarix (bivalent) - HPV 16, 18
Now- Gerdasil (quadrivalent) - HPV 6, 11, 16, 18
PCB, intermenstrual bleeding, menorrhagia or an offensive vaginal discharge
Most common - squamous cell carcinomas (keratinizing - the commmonest, large cell, non-keratinizing and small cell); adenocarcinomas - 10-25%
Spread - direct, lymphatics
Mostly arising from the endometrium
Majority - adenocarcinomas (glandular tissue); rarer - sarcomas (myometrium)
Associated with relatively high levels of oestrogen (or maybe oestrogen to progestogen ratio)
Risk factors
Obesity - aromatisation of androgens to oestrogens
Late menopause
Unopposed HRT - four-fold increased risk
Oestrogen-secreting tumours - thecoma
Tamoxifen - oestrogen antogonist in breast tissue, has agonist effect on the postmenopausal uterus (Mirena - reduces effect)
COCP and smoking - PROTECTIVE
Post-menopausal bleeding - malignancy until proven otherwise (5-10% will have a malignancy)
Less common - vaginal discharge
Direct, lymphatic and haematogenous spread can happen
US - TVUS used to measure endometrial thickness; if less 4 mm, cancer is unlikely; fluid associated with cancer in 25%
Endometrial biopsy - Pipelle (plastic tube attached to suction pump); only for those with low risk carcinoma (high false positive rates)
Dilatation and curettage - under GA, used alone will miss 10% of endometrial cancers
Hysteroscopy - with or without GA, biopsy and curettage can be done at the same time. Hysteroscopy with biopsy - gold standard
Most common gynaecological malignancy in affluent countries
Nulliparous women have a higher risk
(number of ovulation events is the main risk factor)
COCP - protective; HRT - no significant effect
Pregnacy - protective
Genetic factors - BRCA1 and BRCA2 - 10-50% lifetime risk of developing ovarian carcinoma; HNPCC or Lynch syndrome (also associated with bowel and endometrial carcinoma)
Germ cell
Sex cord/stromal
Account for 50% of ovarian cancers
Serous cystoadenomas - benign, cysts with straw-coloured fluid; bilateral in 20%
Serous cystoadenocarcinomas - bilateral in 50%; cystic and solid components
Psammoma bodies - calcified concretions
Account for 10-20% of all tumours
Less than 10% are malignant
Multioculated and contain mucinous fluid of variable viscosity
(5% concomitant pseudomyxoma peritonei)
Clear Cell
Virtually all malignant
Poor prognosis
Association with ovarian endometriosis
Clear cytoplasmt (contains glycogen) and hobnail cells
Usually malignant
Mimic endometrial cancer in histological appearance
Rare, comprise 5-10% of all ovarian tumours
Granulosa cell
Functional low-grade tumours
3/4s secrete oestrogen - precocious pseudopuberty, irregular menstrual bleeding
Cells contain Call-Exner bodies - pathognomonic
Cause endometrial hyperplasia
Unilateral, rarely malignant
Thecomas are oestrogenic
Fibromas may present with non-malignant ascites, right sided pleural effusion and ovarian mass - Meigs' syndrome
Affects children and young women - 20-25% of all ovarian tumours
1/3 is malignant
Aka ovarian dermoid cysts; usually benign
Contain elements of all three embryonic germ cell layers
Commonest in women in their 20s
75% occur in females aged 10-30
Commonly malignant
Secondary tumours in the ovaries are surprisingly common
Breast and endometrial cancer can metastasize to the ovary - examine the breasts
GI tumours also metastasise to the ovary; in the case of gastric cancer - Krukenberg tumour - contain mucin-producing signet ring adenocarcinoma cells; may cause hormone production - patients may complain of virilisation
Spread - tumour is seeded onto the surfaces of the intraperitoneal structures and organs
Tends to present at a late stage
Diverse and non-specific symptoms
Most common complaint - abdominal distension (ascites or masses)
Other symptoms - pain, anorexia, nausea and vomitting, weight loss
Risk of malignancy index (RMI) = U(US score) x M(menopausal score) x Ca125
US score - 1 point for each of the following: multilocular cysts, solid areas, metastases, ascites, bilateral lesions U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score of 1), U = 3 (for an ultrasound score of 2–5).
M - premenopausal (1); postmenopausal (3)
All women with RMI>200 refer to MDM
Tumour Markers
80% of epithelial ovarian cancers are associated with high CA125
Suggestive, but not diagnostic - also high in endometriosis, peritoneal trauma
50% of stage 1 ovarian cancers will have a normal CA125
65% of germ cell tumours have high levels of AFP and/or hCG
Prognosis - Due to the late presentation, lack of effective screening methods the overall 5-year survival is 35%
Treatment - debulking surgery + chemotherapy (carboplatin and taxane)
Ectopic pregnancy
Majority of extra-uterine pregnancies are tubal - ampulla (can be ovarian, cervical or intra-abdominal)
1:200 (major cause of maternal mortality)
With positive pregnancy test and absence of shock perform a TVUS - distinguish between ectopic, miscarriage or viable intrauterine pregnancy
If B-hCG does not increase by over 66% in 48 - likely to be an ectopic
Risk Factors
Fertility treatment
Clinical features
Hx of amenorrhoea
Abdominal pain
Dark vaginal bleeding
Shoulder tip pain
Signs of haemodynamic instability
Abdominal tenderness +- rebound
Cervical excitation
Tender adnexae
Closed cervical os
If shocked on admission - urgent pregnancy test, if positive consider urgent laparotomy; also resuscitation and transfusion
All women who are rhesus negative with a confirmed or suspected ecotpic pregnancy should receive anti-D Ig
Laparoscopic salpingectomy or salpingotomy
Done if preferred by the patient, unable to return for follow-up, significant pain, adnexal mass>35mm, fetal heart beat visible on US and serum hCG>5000IU/L
Complications: of the anaesthesia, laparoscopic entry, risk of transfusion, conversion to laparotomy
In the presence of a healthy contralateral tube, no evidence that salpingotomy should be performed over salpingectomy
With salpingotomy - check hCG after
Systemic methotrexate + monitor hCG on day 4 and 7; weekly until negative
Possible in women with minimal symptoms
Adnexal mass<35mm; no visible heartbeat
Serum hCG<3000IU/L
No intrauterine pregnancy
Complication: chance of requiring further treatment
Monitor patient and hCG levels (should be falling)
Done in willing, stable and asymptomatic women with US diagnosis of ectopic
Decreasing hCG level, initially <1500IU/L
Ectopic mass <3cm
No foetal heartbeat or pregnancy location unclear
Antenatal care
Booking visit (10w)
History (detailed obstetric)
US scan (11-13W) - gestation, viability, detect multiple pregnancies, NT
BP and Urine
Booking bloods (FBC, ABO and rhesus, rubella status, Hb electrophoresis - sickle cell and thalassaemia, Hep B status, Syphilis test and HIV)
Importance of vitamin D intake during pregnancy
Avoid vitamin A supplementation and liver products (risk of birth defects)
Avoid food at risk of Salmonella, Listeria i.e. raw meat, seafood , unpasteurised products
Discuss smoking cessation, recreational drug use and alcohol consumption
Folic acid
Low risk - 400 ug (1-3 months preconception and up to 1st trimester)
High risk - 5 mg
High risk - FHx of NTD, previous baby with NTD, diabetes or epilepsy
Rhesus-negative women without sensitisation - recommended two doses of anti-D Ig at 28 and 34 weeks (and at delivery)
Antenatal complaints
Backache - ligaments relax, support brace may help
Pelvic girdle pain (14-22%) - dysfunction of symphysis pubis
Carpal tunnel syndrome
Constipation, haemorrhoids, heartburn, leg cramps, itching
Nausea and vomiting - 6w until 16w - hyperemesis gravidarum (hospital admission)
Prenatal diagnosis
Approximately 2% of newborn babies have a serious abnormality detectable at, or soon after, birth.
Ultrasound scan screening
1. 11-13 weeks: date pregnancy, single or multiple pregnancy and NT
2. 20-22 weeks: anomaly scan
Combined test*
Nuchal translucency
Maternal age
*Done up to 13+6 weeks gestation; high, high, low, high in Down's
Quadruple test*
*Done if combined test is not possible; high, low, low, high in Down's; also gives risk of NTD
Nuchal translucency is also a marker for structural defects, particularly cardiac, renal, abdominal wall and diaphragmatic herniae
Invasive diagnosis
Chorionic villus sampling
Any time after 10 weeks (10-14w)
Results available in 72 h
Full karyotype available in 3 weeks
Flexible cannula through the cervix
Or, transabdominal needle with US guidance
Risk of miscarriage - 1%
Early CVS associated with limb abnormalities
Bleeding, infection
If calculated risk is >1:150
Performed after 15 weeks
Needle is inserted with US guidance
10-15 ml of fluid are colleceted
Rhesus negative women are given anti-D
Risk of miscarriage 1%
Results in 72h, full karyotype in 3 weeks
Placental abruption, intra-amniotic bleeding, infection, rupture of membranes
Read paeds section for structural anomalies and infections
Maternal disorders in pregnancy
Diabetes mellitus
Not uncommon for type 2 diabetes to be diagnosed during pregnancy
Women with pre-existing diabetes - hyperglycaemia in the first trimester - increased rate of congenital abnormalities:
Cardiac defects
Renal Anomalies
Pre-pregnancy and early pregnancy glucose control - reduces the risk
Maternal insulin does not cross the placenta - fetus produces its own insulin from 10 weeks
Fetal hyperinsulinaemia often results in macrosomia, organomegaly, increased erythropoiesis and neonatal polycythaemia
Labour and delivery - shoulder dystocia
Neonates - hypoglycaemia, hypocalcaemia, hypomagnesaemia and polycythaemia
Pregnancy may exacerbate diabetic retinopathy
(retinal screening at booking, 16-20w, 28w)
Increased incidence of:
Polyhydramnios - from fetal polyuria - results in unstable lie, malpresentation and preterm labour
Screening (IGT and GDM)
At 24-28 weeks, 75g GTT to women with risk factors - FHx, raised BMI (>30), previous macrosomic baby, previous GDM.
Previous GDM - self-monitoring or GTT at 16-18 weeks, if negative, repeat at 28 weeks
Diabetes: fasting ≥ 7mmol/l and/or 2-hour ≥ 11mmol/l
IGT: fasting < 7mmol/l and/or 2-hour= 7.8-11mmol/l
First Step - dietary advice and adjustment
Aim: pre-prandial glucose < 6mmol/l
Insulin treatment if this is not achieved with diet
Metformin might also be of benefit
70% of women with IGT develop DM in the subsequent 25 years
Recurrence of GDM in future pregnancies is 75% - especially if insulin was needed
Antenatal established DM
Tight control - pre-prandial = 3.5-5.9 mmol/l and 1-hour<7.8 mmol/l
Check HbA1c before and in early pregnancy (levels<6.1%)
In pregnancy - increased levels of fibrinogen, prothrombin and reduced levels of endogenous antiocoagulants
Gravid uterus causes mechanical obstruction of the venous system - venous stasis in lower limbs
Calf tenderness
Chest pain
(or asymptomatic)
Also abdo or groin pain
D-dimers NOT helpful!
Duplex doppler US - useful
Treatment - iv or sc heparin continued into labour
LMWH (enoxaparin) is appropriate in most cases - lower risk of thrombocytopenia and of osteoporosis
Cardiac disease
Serious consideration of pregnancy termination is advisable in women with Eisenmenger's syndrome, primary pulmonary hypertension or pulmonary veno-occlusive disease
With AF - anticoagulation is required
MI - commonest cause of maternal mortality
Peripartum cardiomyopathy (<1:5000) - 5% mortality - associated with HTN in pregnancy, multiple pregnancy, high multiparity and increased maternal age
A seizure in pregnancy should be assumed to be eclampsia until proven otherwise
1/3 of pregnant women with epilepsy have an increase in seizure frequency
Single drug regimens are less teratogenic than multidrug therapy - sodium valproate carries the highest risk of teratogenesis
Fits associated with poor compliance, increased plasma volume, hyperemesis and excessive tiredness
Fetus not affected by fits
Remember 5 mg folic acid + 10 mg of vit k daily from 36 weeks
Carbamazepine and lamotrigine are the safest
HTN, Pre-eclampsia & Eclampsia
PIH and pre-eclampsia are the second highest cause of direct maternal deaths in the UK
Essential HTN - <20 weeks
Pregnancy-induced HTN (PIH) - HTN only, no proteinuria
Pre-eclampsia (PET) - HTN, proteinuria +- multisystem involvement
HTN in pregnancy
≥140/90 mmHg on 2 occasions more than 4h apart
≥110mmHg diastolic, ≥160mmHg systolic
≥30mmHg above booking systolic, ≥15-25mmHg above booking diastolic
Urine protein concentration of >300mg/l or protein excretion >300mg in 24h - equivalent to 1+ or more on dipstick
Treatment of essential HTN during pregnancy: methyldopa, labetalol or nifedipine
Risk factors for PIH/PET
1st pregnancy
Extremes of maternal age
FHx - mother or sister
Medical - HTN, renal disease, DM, SLE, antiphospholipid syndrome
Obstetric - multiple pregnancy, previous PET, hydatiform mole, triploidy, inter-pregnancy interval >10 years
Impending Eclampsia
1. Unusual headaches, frontal
2. Visual disturbances
3. Restlessness or agitation
4. Epigastric pain, nausea and vomiting
5. Sudden severe HTN and proteinuria
6. Fluid retention and reduced urine output
7. Hyperreflexia or ankle clonus
8. Retinal oedema, haemorrhages or papilloedema
Management of PET
Indication for admission
BP >170/110mmHg or 140/90 with 2+ of proteinuria
Significant symptoms (headaches, visual disturbance, epigastric pain, oedema)
Abnormal biochemistry or hematology results
Significant proteinuria
Need to start anti-HTN medication
Signs of fetal compromise
1. Reduce diastolic to <100 mmHg using labetalol, nifedipine, hydralazine or methyldopa
2. Monitor fluid input and output
3. In severe PET, magnesium sulphate halves the risk of subsequent eclampsia
4. To consider delivery (aim for after 34 weeks)
Eclampsia - tonic-clonic seizure in association with PET
Management of eclampsia
1. Patient turned onto left side - avoid aortocaval compression
2. Airway secured - high flow oxygen
3. IV magnesium sulphate + infusion to prevent further seizures (if signs of toxicity - decreased patellar reflex - give calcium gluconate)
4. Urgent delivery - if antenatal or intrapartum seizure
5. Paralysis and ventilation if recurrent
Give 75mg aspirin daily (15% reduction)
Calcium supplementation
Haemoloysis, elevated liver enzymes, low platelets
12% of those with PET/eclampsia
More common in multiparous women with PET
Epigastric pain
Nausea and vomiting
RUQ tenderness
High AST and LDH
Associated with
Acute renal failure
Risk of recurrence 20 %
Stabilise mother
Correct coagulation disorder
Assess fetal well-being
Assess need for delivery
Smoking is protective!!
Contains ethinylestradiol and a prosgestogen
Mainly by inhibiting ovulation, also acts on the cervical mucus and on the endometrium (causes atrophy)
CAD - very small increase
Ischemic stroke - 2x increase
VTE - 5x increase for 3rd generation progestogen (very small absolute risk) - 3x for 2nd generation
Breast Ca - Very small - no risk after stoping for 10 years
Cervical Ca - small increase after 5 years; 2x after 10 years
Ovarian Ca - Having of risk, lasting for >15 years
Endometrial Ca - Having of risk, lasting for >15 years
Colorectal Ca - reduction
If >35 years old and smokes <15 cigarettes per day SHOULD use alternative; if >15 cigarettes per day - absolute contraindication; other: CVS disease, liver disease, migraine with aura or migraine without aura (if >35)
COC should be started up to and including day 5 of the menstrual cycle and provide immediate contraceptive protection - if started after this time, condoms or abstinence is advised for the next 7 days
21 active pills - followed by 7-days pill free period - withdrawal bleed
In general, one pill can be missed at any time without need for barrier method
Antiepileptics e.g. carbamazepine; rifampicin and St John's Wort accelerate the hepatic breakdown of contraceptive steroids - potentially reduce the efficacy of COCP
COC should be stopped 6 weeks before any planned major elective surgery where immobilisation is expected
Can come in patch form - applied to abdomen, buttock or thigh on the same day each week for three consecutive weeks, followed by a patch free week
Ring form - 1 ring used for 21 days
All progestogen-only methods avoid the SE of oestrogen
Associated with disturbances in the bleeding patterns
Other SE: bloating, weight changes, acne, headaches and mood changes
Often used by women for whom a COCP is contraindicated
Thickens mucus, thins endometrium and stops ovulation (only Cerazette)
Should be taken at or around the same time every day without a pill free interval
POP can be started up to and including day 5 of the menstrual cycle (within 7 days of TOP or up to day 21 postpartum) to provide immediate contraception
If started at other times, condoms are required for the first 48 hours
Traditional POP is late if taken 27 hours after the previous one (i.e. 3 hours late)
Cezarette has a 12 hour window
If 1 pill is missed for longer than the window period (3h or 12h), condoms are needed for 48h
Tradiotional POP - levonorgestrel, norethisterone or etynodial diacetate
New POP (Cerazette) - desogestrel
Depot injection
Most widely used - depot medroxyprogesterone acetate - IM injection every 12 weeks
Mechanism: inhibition of ovulation
Bleeding is common in the first moths but usually settles - 70% of women are amenorrhoeic after 1 year of use
Delay in return of fertility - BUT no reduction in fertility
Reversible loss of mineral bone density
Weight gain can also occur
Progestogen-only injectable contraception
Subdermal etonogestrel implant
Licensed for contraception for up to 3 years
Changes in bleeding patterns are common and discontinuation due bledding in common (up to 43% within 3 years)
20% of users will have no bleeding but almost 50% with have infrequent, frequent or prolonged bleeding
Stops ovulation, thickens mucus, thins the endometrium
Weight change, mood change, loss of libido or headache (no evidence of a causal associated between these and progestogen-only implants)
Levonorgestrel-releasing intrauterine system (LNG-IUS)
Highly effective and reversible contraceptive
5 years use as contraception or as treatment of menorrhagia; 4 years use as the progestogenic component of HRT
Main effect: thickens mucus; in 25% of women ovulation is inhibited
Irregular bleeding is common in the first few months; intermenstrual bleeding is also frequent - resolve by 5-6 months
Menstrual loss is reduced by 90% at 12 months, 20% of women experience amenorrhoea
Complications with insertion
(as for the copper device)
Copper is toxic to ova and sperm and Cu-IUD works primarily by inhibiting fertilization; also causes endometrial inflammatory reaction - anti-implantation effect; changes in mucus
Most last 5 years, some last 10 years
No delay in return to fertility after removal
Spotting, light bleeding or heavier or prolonged bleeding is common in the first 3 to 6 months - but this may settle!
Pregnancy, septic abortion
Initiation with unexplained vag bleeding
Initiation in women with cervical ca or endometrial ca
Pelvic TB
Increased risk of ectopic
Expulsion and perforation - risk of expulsion is 1 in 20 in the first year of use, particularly in the first 3 months; risk of perforation - 2 in 1000 insertions - most occur at time of insertion
Pelvic infection - increased risk in the first 20 days;
If a pregnancy occurs whilst on IUD - the chance of having an ectopic is higher than in those without an device; however the overall risk is lower in those with an IUD than in those without!!
Billing's method - restriction of intercourse to those days of the menstrual cycle on which conception is least likely to occur
Assess cervical mucus - prior to ovulation (fertile period) cervical mucus is clear, watery and is easily stretched into strands
After ovulation the mucus is thick and sticky
Progestogen-only method (levonorgestrel) can be used up to 72 hours after unprotected intercourse
Inhibit or delay ovulation and prevent up to 84% of expected pregnancies
Levonorgestrel 1.5 mg PO stat
Women who experience vomiting within 2 hours of administration should be advised to have a repeat dose
Can be inserted up to 5 days after the first episode of unprotected sex or up to 5 days after the predicted date of ovulation
Almost 99% of expected pregnancies can be prevented
Investigations before TOP
Fbc, ABO, rhesus status - rehsus negative women required anti-D after the abortion
Estimation of gestation - done mostly by US
Prevention of infections - either prophylactic antibiotics (metronidazole and azithromycin) or test for STI and treat positive women and partner
Cervical citology - if due a smear test, can be offered too
1. Mifepristone - progesterone receptor antagonist given by doctor or nurse - women can go home
2. 24-72h later - misoprostol (prostaglandin) is usually administered vaginally - bleeding starts within a few hours (plus expulsion of placenta and fetus) - bleeding continues for 10 days
Early (up to 9weeks)
Medical termination is the most effective type, compared to early surgical
1. Mifepristone 200 mg PO
2. Misoprostol 800 ug PV (36-48h later)
Late 1st Trimester (9-13w)
1. Mifepristone 200 mg PO
2. Misoprostol 800 ug PV - 36-48h later
3. Misoprostol 400 ug PV or PO -up to 4 doses
2nd Trimester (13-24w)
1. Mifepristone 200 mg PO
2. Misoprostol 800 ug PV - 36-48h later
3. Misoprostol 400 ug PV or PO -up to 4 doses
Below 7w
High failure rates than surgical abortion later and medical abortion at this stage
Usually TOP delayed until 7w
Manual aspiration still done
Under local paracervical block
Verify complete abortion - identifying POC or hCG follow-up
7-14 weeks
Performed by suction of vaccum aspiration (flexion suction curette and a mechanical or electrical pump)
Usually carried out under GA (LA also possible)
Misoprostol 400 ug PV, 3h prior to surgery - reduced risk of cervical trauma and uterine perforation
Late (15-24w)
Cervical dilatation and evacuation (D&E)
Women is unaware of the procedure
Some doctors and nurses find it disturbing
Retained products of conception - 5% of women, more common in medical, very early or late TOPs
Failure of abortion - 2.3 in 1000 (surgical); 1-14 in 1000 (medical); importance of follow-up
Post-abortion infection - pelvic infection can happen in 10% of women after abortion; can be halved if STI screening is done and antibiotics are given
Haemorrhage - 1 in 1000 cases (significant)
Perforation - 1 in 1000 surgical cases;
Fertility - no established association between TOP and future infertility, ectopic pregnancy or placenta praevia
Contraception - can be used straight after surgical TOP and after prostaglandin of medical TOP (inc. IUD, COCP, POP, implant, depo)
Common - occurring in 25% of pregnancies
1. Make sure it is non viable before uterine evacuation
2. Low threshold for ectopic - even without US evidence
WHO 'the expulsion from its mother of an embryo or fetus weighing 500 g or less'
UK - miscarriage <24 weeks; stillbirth >24 weeks
Vaginal bleeding +- pain
Cervical os closed
Ongoing viable pregnancy
(live intrauterine foetus)
No passage of products
Bleeding + pain
Cervical os open
Products still in cavity +- foetal heart
Passage of some, but not all, of the products of conception
Bleeding and pain
Cervical os open +- products in the cervical canal
Some products in cavity; absent foetal heart
Passage of all products
Pain and bleeding resolved
Cervical os closed
Empty cavity
Missed (silent)
Foetus has died but has not been expelled
Bleeding +- pain
Cervical os closed
Pregnancy in cavity, absent foetal heart
Usually a complication of incomplete miscarriage
Uterus tenderness
Bleeding + pain
Any possible US results
Risk increases with maternal age
Chromosomal abnormalities - 50% of 1st trimester miscarriages have a chromosomal abnormality; trisomies - 50-60%; 45XO monosomy - 7-20%; 2nd trimester only 20%
PCOS, poorly controlled diabetes
Autoimmune disease - 15% of women with recurrent miscarriages are positive for lupus anticoagulant, antiphospholipid antibodies or both; treatment - low-dose aspiring and LMWH
Uterine anomalies
Infection - CMV, rubella in early pregancy (also malaria, chlamydia, mycoplasma, listeria, syphilis)
50% are unexplained
Threatened miscarriage: if bleeding gets worse or persists beyond 14 days, return for treatment; if it stops continue with antenatal care
Wait until natural miscarriage occurs
Use for 7-14 days with confirmed miscarriage; women is stable and willing
Complications: heavy and painful bleeding, need for unplanned surgery, infection
Vaginal misoprostol +- oral mifepristone
Women is stable and prefers this option
Up to 20% unsuccessful
Bleeding may continue for up to 3 weeks
Surgery may still be required
Surgical (ERCP)
Manual vaccum aspiration -LA
Surgical management under GA
Women's preference, heavy bleeding, sign of infection, increased haemorrhage
Cervical trauma (incompetence); perforation, infection, Ashermarn's syndrome
Rhesus (anti-D Ig)
1. Confirmed miscarriage: give anti-D to all rhesus negative women if it is after 12 weeks (complete or incomplete) OR women has undergone medical/surgical evacuation
2. Threatened miscarriage: give anti-D if is after 12 weeks
Chromosomal abnormality - 3-5%, usually a balanced translocation - karyotype both parents
Check maternal blood for lupus anticoagulant and anticardiolipin antibodies - antiphospholipid syndrome is diagnosed if the assays are positive more than once 6 weeks apart - Treat with LMWH and low-dose aspirin
Thrombophilia screen - e.g. activated protein C resistance, antithrombin III deficiency, protein C deficiency and protein S deficiency
Pelvic ultrasound scan to look for uterine abnormalities
Mid-trimester loss - think cervical incompetence (cervical suture)
Menorrhagia & Dysmenorrhoea
Bleeding that has impact on the quality of life
Common cause of iron-deficiency anaemia in the affluent world
Uterine pathology
Benign - fibroids, endometrial polyps, adenomyosis, pelvic infection
Malignant (rare) - endometrial cancer
Endometrial polyps
Common benign overgrowths of the endometrium
Intrauterine more likely to cause HMB than small endocervical polyps (malignant change is rare)
Benign tumours of the myometrium (20% of women in reproductive age)
More common in women of Afro-Caribbean origin
Types: subserosal, intramural, submucosal and cervical
Symptoms: menstrual dysfunction, infertility, miscarriage, dyspareunia and pelvic discomfort
Pressure effects: frequency of micturition and hydronephrosis (ureteric compression)
Growth mediated by sex hormones, esp oestrogen
Grow during pregnancy, shrink after the menopause
During pregnancy RED DEGENERATION
Dysfunctional uterine bleeding (DUB)
Menorrhagia in the absence of recognisable pelvic pathology or systemic disease
Diagnosis of exclusion
Hepatic disease
Renal disease
von Willebrand's disease
(Iatrogenic - Copper IUD)
Red light symptoms: irregular bleeding, dyspareunia pelvic pain or intermenstrual or postcoital bleeding
Require investigation
Symptoms: tiredness and fatigue
Risk factors for endometrial cancer
Unopposed oestrogen
Tamoxifen use
Family history of endometrial or colon cancer
Biopsy or hysteroscopy - endometrial assesment
Age > 45
Young women - failed medical treatment
'Red light' symptoms
Endometrial cancer risk factors
Polyps - polypectomy using hysteroscopic techniques
GnRH analogues - fibroid shrinkage
Side effects: hot flushes, bone loss (hypooestrogenism)
Short term use <6months
Myomectomy - conserves fertility (pregnancies after myomectomy are delivered by planned C-section)
Small submucous fibroid - hysteroscopic resection or microwave endometrial ablation
Uterine artery embolisation (UAE) - stops blood supply to the fibroid by blocking the uterine arteries; severe pain after occlusion of vessels (opiate analgesia) - preserves fertility
Chilbearing is complete - consider hysterectomy
Intrauterine progestogens
Levonorgestrel intrauterine system (LNG-IUS) - provides contraception (MIRENA)
First line treatment for HMB
Stays in place for 5 years
Many women are amenorrhoeic
Irregular bleeding (first 3-6 months)
Expulsion rate 5%
Inhibit synthesis of prostaglandins
Reduced menstrual blood loss by 25%
SE: GI complaints, dizziness and headache
TRANEXAMIC ACID - inhibits plasminogen activator (increases clot formation)
Reduced menstrual blood loss by 50%
SE: GI problems, nausea, tinnitus
Contraindication: predisposition to thromboembolism
Reduces blood loss by 50%
Oral progestogens
Unproven reduction in blood loss
Regulate periods
Long-term depot injections - amenorrhea
Unpredictable heavy bleeding (initial months)
SE: nausea, bloating, headache, breast tenderness, weight gain and acne
GnRH analogues
Endometrial ablation
Safer symptom control, shorter hospital stay and shorter recovery period than hysterectomy
Newer non-hysteroscopic procedures: heated balloon, microwave endometrial ablation (MEA), bilpolar radiofrequency impedance-controlled ablation
Satisfaction rate - 70-80%; Amenorrhoea rate of 20% (balloon) 50% (others)
Pregnancy is contraindicated
Only treatment that guarantees amenorrhoea - high satisfaction
Complications: haemorrhage, damage to bowel and urinary tract, infection, vaginal prolapse years later
Discuss: bilateral salpingo-oophorectomy if >45; or ovarian conservation in women <45
Cramping lower abdominal pain
Affects 30-50% of menstruating women
Within first 2 years of menarche
Higher concentrations of PGE2 and PGF2a
Most severe on the day of menstruation (or day before)
Family Hx
Note: PGF2a increases contractility of the myometrium - pain
NSAIDS - Mefenamic acid and ibuprofen (preferred)
COCP - suppression of ovulation; highly effective in reducing severity
Depot prosgestogens
Levonorgestrel intrauterine system (LNG-IUS)
Associated with pelvic pathology
Onset many years after menarche
PID or infection
May be associated with IUD
Pain, 3-4 days prior to menses, last whole cycle and may increase in severity
Associated with deep dyspareunia, non-menstrual pain, urinary and GI symptoms, infertility
Tissue resembling the endometrium lying outside the endometrial cavity
Commonly in the pelvis - uterosacral ligaments behind the uterus
Responds to cyclical hormonal changes - bleeds at menstruation
Commonest cause of secondary dysmenorrhoea
Continuous non-spasmodic pain, before and throughout menstruation
Can be association with HMB and passage of clots
Plus: dyspareunia - endometriosis in POD or ovarian endometriomas
Note: lack of correlation between severity of symptoms and extent of the disease
LAPAROSCOPY is usually necessary to make diagnosis (gold standard)
Mechanism of interrelationship is uncertain
TVUS - gross endometriosis in ovaries (endometrioma or chocolate cyst)
MRI - lesions >1 cm
Medical treatment is founded upon the observation that endometriosis improves during pregnancy and menopause
COCP and GnRH analogues
Continuous progestogen therapy
Danazol (infrequently used - androgenic side effects)
Preserve fertility - laparoscopic diathermy destruction, laser vaporisation or excision of endometriosis deposits (recurrence as high as 30%)
TAH BSO - usually curative (hormone replacement required)
Theory: retrograde menstruation, metaplasia and venous or lymphatic spread
Perimenopause or climacteric - period of months and years before the last menstrual period
Anti-Mullerian hormone - better marker of follicular reserve than FSH - used in clinical practice
Irregular periods before the menopause (anovulatory menstrual cycles);
if persistent - endometrial assessment - exclude endometrial carcinoma
After 1 year of amenorrhoea - bleeding is postmenopausal - endometrial assessment!!
Vaginal Bleeding
Hot flushes (vasomotor)
NOTE: 10% of those with PMB have a gynae malignancy
Accompanied by nausea, palpitation and sweating
HRT (oestrogen) - relieves symptoms in 90% of cases
Genitourinary atrophy
Atrophic vaginitis - thinning of vaginal skin - dyspareunia and bleeding
Rise in pH - local infection
Urgency of micturition
Respond well to a short course of local and systemic oestrogen
Other symptoms
Loss of libido
Irritability, lethargy, depression
Breast Cancer
Early menopausal women - low risk
Late menopausal women - high risk
CVS disease
Increased risk (loss of protective effect of oestrogen)
Unconclusive evidence on the benefits of HRT
Bone resorption by osteoclasts is accelerated
Increased rate of fractures
distal radius, vertebral body, upper femur
Afro-Caribbean women lower risk than white or Asian
HRT very significant benefit in reducing the incidence of osteoporosis and osteoporotic fractures
Most of symptom relief from oestrogen supplementation
Prosgestogen added to protect the endometrium and reduce hyperplasia
NO HYSTERECTOMY = oestrogen and progestogen
HYSTERECTOMY - only oestrogen
Better lipid profile, more thrombotic
Cyclical - perimenopause (withdrawal bleeds)
Monthly - oestrogen daily & progestogen for last 14 days - women with regular periods
3-monthly - oestrogen daily & progestogen for last 14 days, every 13 weeks - women with irregular periods
Continuous - no period HRT - 2 years after LMP
Tibolone - steroid receptor agonist, instead of HRT
Raloxifene - used for osteoporosis
ALSO - transdermal patches, subcutaneous implants, vaginal preparations
Risk and side-effects
Nausea and breast tenderness
Unopposed oestrogen increases incidence of endometrial cancer 4x (Mirena+HRT is protective)
Small increased risk of breast cancer with combined HRT after 5 years of use
Increased risk of VTE in the first year of HRT (no risk beyond a year)
Increased risk of stroke in all age groups!!!!!
Pregnancy, thromboembolic disease, undiagnosed vaginal bleeding and liver disease
Previous breast carcinoma, advanced endometrial carcinoma (?ovarian cancer)
HRT for vasomotor symptoms is stopped after 2-3 (max 10 year)
HRT only recommended for treatment of vasomotor symptoms - NOT for prevention of osteoporosis
(first line treatment for osteoporosis is now bisphosphonate; in elderly - calcium, calcitonin and vit D reduce risk of hip fracture)
Risk of 10% of another in the future
Risk Factors
Age (35 to 45)
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