Contents

Obstetrics & Obstetrics

History & Examination 1

Gynaecology Notes
Different Modalities of Delivery
2
Normal vaginal delivery, Assisted delivery, Caesarean section (C/S)
Malposition & Malpresentation 3
Management of common problems in pregnancy
4
Diabetes Mellitus, Hypertension, Multiple pregnancy
Integration & Summarization of important Common disorders in obstetrics
5
topics Cardiovascular disorders, Anaemia, Malaria
Perinatal infection (TORCH) 6
By: Drugs in Obstetrics 7
Gynaecology
Dr. Mohamed Ataelmanan Abdalla Mohamed Early antepartum haemorrhage 8
Late antepartum haemorrhage 9
University of Khartoum Postpartum haemorrhage 9
Menstrual disorders 10
Menorrhagia, Dysmenorrhoea, Amenorrhoea
Faculty of Medicine Contraception
11
Hormonal, Progesterone only contraception, IUCD
Infertility 12
Common disorders in gynaecology
13
PCOS, Fibroid, Endometriosis, Prolapse, Menopause
Ovarian tumour 14
Malignant Gynaecological tumour
15
Cervical, Endometrial, & Ovarian tumours
Infection in gynaecology 16
Appendix
Obstetrics & gynaecology Instruments 17
References 18

Swate3
mohattta@hotmail.com 2010 .
 History & Examination
History Examination
My patient name is , ..years old (date of birth .../../...), The patient lying ..........., ... on her bed, (mention any connecting device
originally from .. & live in . the patients tribe is .. if present, like canula, catheter..). of weight & height (BMI).
education: ...., occupation: ....., duration of marriage: .... The patient is anaemic, jaundice, cyanosed.
o
her husband name is .., ..years old, education/occupation:.. Vital signs: pulse: .. beat/min (mention the 6 characteristics), BP: -------, temp.: .. C
consanguinity: , patient blood group is ... NOTE: measurement of BP when women seated or on semi-recumbent position only (why?)
the patient admitted ... days ago. Oral cavity: .. oral hygiene, dental caries,. denture, . artificial teeth.
C/O:a pregnant woman, who is GA week, presented with Thyroid....., JVP...., Cervical LNs ....., Trachea ......
... Breast: 1) Inspection: - normal symmetrically developed breasts with normal nipple & areola
Gynecological history: menarche: ... year (normal at 13), .. regular, .. character - there is . scar, fissure, or area of hypo/hyperpigmentation
Kata = ---------- , ... intermenstural bleeding, ... dysmenorrhoea - there is . Montgomery tubercle (dilated sebaceous gland areola)
.. vaginal discharge (colour, amount, odour, itching, consistency) . contraceptive - there is . discharge (colostrum, milk, blood, pus)
user (type, duration) colostrum = normal from 16 wk onward, milk = IUFD or lactation, blood = cancer, pus = infection
.... history of gynecological operation, ....... infertility, ... prolapse 2) Palpation:- using the palm of the hand palpate the 6 areas including the axillary tail
NOTE:- Importance of COCP: post-pill amenorrhoea may contribute to wrong date - examine the axillary lymph nodes any palpable mass/tenderness
- Importance of gyn. operation: scar uterus Abdomen: 1) Inspection: a) abdomen is distended (symmetrical or not ?????)
Obstetric history: G . P ...+.... b) comment on the umbilicus (flat, everted or inverted)
G = (all pregnancies) / P = (delivered fetuses & stillbirth) + (spontaneous abortion) c) comment on linea nigra (due to ACTH)
History of previous pregnancy: ....... d) comment on striae gravidarum (stretch of smooth muscle)
Mention: number of previous birth, type -vaginal delivery or C/S-, at home -attended or not- e) comment on any scar(s) / visible pulsation / dilated vein
or at hospital, term or not, outcome -male or female-, any complications, alive & well or not f) comment on fetal movement if visible, hirsutism if present
History of current pregnancy: LMP: ..../..../20.. g) comment on hernial orifices
EDD: .../../20..... GA:... weeks 2) Superficial palpation: the abdomen is:
NOTE: Naegeles rule; add 1 year, add 7 days, & subtract 3 months in a regular cycle of 28 a) soft (normal) or tense (due to excessive liquor) or rigid (extravasation of blood)
days length. if the cycle is more than 28 days, add the difference to the expected date b) comment on any tenderness / superficial mass / (temperature examiner policy? better avoided)
The patient is ... on regular antenatal care (DD of tenderness: chorioamnionitis, abrupto placentae, red degeneration of fibroid, scar dehiscence)
First trimester: .. vaginal bleeding, .. infection, .... radiation, .... drugs, .. trauma c) describe amount of liquor (average: if abdomen is not tense & fetal part is not easily palpable)
(confirm her pregnancy by HCG raise after 1 wk of missed cycle &/or U/S +ve at 5-6 wk) 3) Deep palpation: for organomegally (liver, spleen & kidney)
Second trimester: .. quickening, . symptoms of UTI, . symptoms of anaemia, Obstetric examination:
vaccination: , (mention if she is on haematinics oral iron) 1) Fundal level: with the palm of your hand, palpte to determine the dome. then with the
NOTE: ulnar side of your hand determine the upper limit and calculate accordingly..(1finger = 2wks)
- Quickening occur at about 18-20 wk in primagravidae & earlier 16-18 wk in multiparous (Tape method: zero point at symphysis pubis, centimeter marks face down, measure up to top of the
- Predisposing factor for UTI: progesterone relaxation of smooth muscle, & gravid uterus fundus, then turn the tap to the other side & read the result in centimeter)
st
- Tetanus vaccine taken twice in the 1 pregnancy, & once in the following two pregnancies 2) Fundal grip: determine which part of the fetus occupy it. 96.5% breech
Third trimester: appreciate the fetal movement. (& if she is still on haematinics) (Characteristic of breech: soft, not palatable, broad than the head, irregular)
Systemic review: CVS, RS, GIT, GU, CNS ... 3) Lateral grip: to determine the lie, position & where the back of the fetus is right or left
... (Characteristic of back: hard, broad, continuous) 60% left occipitolateral
Past medical history: ... DM, .... HTN, .... hospitalization, ... surgical operation, 4) First pelvic grip: with one hand, thumb against 3 fingers: fix one side & move the other and
.... blood transfusion, . radiation. vice versa (if not cephalic presentation, it will be empty)
Family history: ... HTN, ... DM, ....... other inherited diseases, (Characteristic of the head: small, smooth, hard, round, palatable)
................... congenital anomalies, .. multiple pregnancy on maternal side. 5) Second pelvic grip: with your two hands, determine the head engagement
Drug history: ..... HSR,.... on long term medication, current medication Engagement occur at about 37 wk in nulliparous, & until onset of labour in multiparous
Social history: socioeconomic status. (live in their house or renting house, water Fetal heart sound: if cephalic; below the umbilicus, if breech: above it (DD: uterine souffl)
& electricity supply, number of members per room, animals in the house, smoking, alcohol...) Lower limb oedema: 1 finger, 1 inch, 1 minute. Lower limb varicosity pt standing..............
Summary: ...years old, G .. P .+.., GA ., complain of .. Summary: fundal level ... which is ... equivalent to date, .. presentation,
(mention any known medical condition, or +ve PMH), admitted for .... ..... lie, .... position, head is . engaged, .........amount of liquor, .. fetal heart.
 Different modalities of Delivery
Normal Vaginal Delivery Assisted Vaginal Delivery Caesarean Section (S/C)
Def.: Spontaneous delivery of single, term, vertex well flexed, alive & Def.: Delivery of a baby vaginally using an instrument for assistance. Def.: an operation performed to deliver a baby via transabdominal
viable, not complicated, in not less than 4 hr & not more than 24 hr. Forceps (traction, rotation, protection) route. (Incidence: should be less than 25%)
IF less than 4hr: precipitant & more than 24hr: obstructed labour Indication Contraindication Indications
Symptoms:1- true labour pain, due to: - face presentation Maternal Fetal
a) increase in steroid due to lung maturity - gestation less than 34 wk - head not fully engaged - repeat C/S (two or more) - malpresentation
b) increase in oxytocin which cause uterine contraction - active fetal bleeding - cervix not fully dilated - CPD (major degree) - dystocia
2- show: bloodstained plug of mucous that close the - after coming head of breech Pipers - pelvic tumours - multiple gestation
cervix, & drop down when the cervix dilated Design: - consists of two blades: each blade consists of handle, shank, - placenta praevia (major) - macrosomia
Signs: 1- dilatation of the cervix 2- fore water drop lock, fenestrated blade with pelvic curve & cephalic curve. - medical disorder (e.g. HTN) - fetal distress
Stages of labour: Types: - Outlet: scalp visible at introitus, without separating the labia - successful repair of vesico- - congenital anomalies
First stage: (in primagravidae 12-16 hr, in multiparous 6-8 hr): vaginal fistula - maternal infections & HIV
- Low forceps: leading edge of skull below +2 station. (e.g.Wrigleys)
= from diagnosis of labour to full dilatation of cervix (10 cm) - previous upper segment - post mortem C/S (within 10
- divided into latent (up to 4cm dilatation) & active phase - Mid-cavity: leading edge of skull above +2 station & it should be uterine incision min to deliver viable baby)
Second stage: (in primagravidae 2 hr, in multiparous 1 hr): engaged. (e.g. Simpsons) Contraindication
= from full dilatation of cervix to delivery of fetus or fetuses - High forceps: used for rotation of the head, & asynclitism. it has no a) dead fetus (except in severe pelvic contracture, severe accidental
- divided into passive & active phase (maternal urge to push) pelvic curve. know, abandoned in favour of C/S (e.g. Kjellands) haemorrhage, & neglected shoulder)
Third stage: (it take about 30 min): Ventouse (Vacuum extractor) b) DIC c) extensive scar or pyogenic infection
From delivery of fetus or fetuses to delivery of placenta(s) Indication Contraindication Types
Mechanism of labour: - delay in the second stage - face presentation - According to time: elective or selective (emergency)
1) Preparation in uterus & head: - fetal distress in second stage - gestation less than 34 wk - According to site: upper segment (classical) or lower segment
* uterus: - contraction & relaxation - maternal condition requiring - active fetal bleeding Pre-operative care
- differentiation between upper & lower segment short second stage - counseling, consent - urine analysis
- cervix: become short, soft, dilated Design: - suction cup: silastic, plastic or metal connected via tube to - fasting for 6-8 hours - shaving suprapubic hair
* fetal head: moulding (to reduce the diameter of the skull) vacuum source - CBC, blood grouping & X - urinary catheter (after
2) Engagement: widest diameter of presenting part pass successfully Types:- Electric vacuum - Manual vacuum - Kiwi hand held pump matching anaesthesia) advantage???
through the inlet (less than 2/5 of it palpable abdominally). * Pressure is 0.6-0.8 kg/cm, & NOT used for more than 3 times Note: fasting is due to delayed gastric empty in pregnancy, & fear of
o
- angle of inclination is 130 & should not be more than that. Application (of Forceps or Ventouse) Mendelsons syndrome (aspiration of gastric acid), if not fasting
- engagement of head occur in right oblique diameter (why?)... A: Address, Ask for help, and G: Gentle traction should be treated with antacid or suction.
3) Descent: due to uterine action & Valsalva manoeuvre. Anaesthesia (e.g. pudendal) H: Handle elevated to follow Post-operative care
4) Flexion: passive movement due to surrounding structure. B: Bladder empty - observation of vital - IV Fluids in form of Dextrose 5% in
the J shaped pelvic curve
- important in minimizing the diameter of presenting part signs: PR, RR, BP. water around 3 liters/24 hrs
C: Cervix must be fully dilated I: Incision, possible need for
5) Internal rotation: from OP to OA position. - continue fasting until - analgesia
D: Determine position of the episiotomy
6) Extension: crowning of the head to distend the vulva bowel sounds heard - thromboprophylaxis, antibiotics ??
7) Restitution: rotation of occiput through 1/8 of a circle fetal head J: remove forceps when Jaw is Anaesthesia
8) External rotation: occiput rotate through further 1/8 of a circle (so, E: Equipment ready reachable - Regional anaesthesia (spinal, epidural)
the shoulder rotate to direct AP plane). F: Forceps ready After end: DOCUMENTATION - General anaesthesia - Local anaesthesia ??
Anasthesia:- pudendal: best for preineal anasthesia (most frequent) Complications of Instrumental delivery Note: - spinal anaesthesia complication: hypotension, headache
- epidural: best for active phase of labour & delivery Maternal Fetal - general anaesthesia complication: aspiration of vomitus
Conduction of labour: using Partogram. - failure - cerebral haemorrhage Complications: 1- Intra-operative
- 3 contractions per 10 min (each last about 45 sec)... a) maternal mortality: 2-4 times that of C/S (e.g. due to shock...)
- cervical tears - cephalhaematoma
- auscultate for fetal heart rate every 15 min during active labour b) injury to fetus c) injury to bladder & uretur
After delivery: - catch the baby from the leg to remove any secretion - vaginal lacerations - retinal haemorrhage
rd d) injury to the bowel e) complications of anasthesia
& to increase the brain blood supply. - perineal tears: 3 degree and - skull bone fracture
2- Post-operative
- milk the cord (in diabetic mother should be away from the baby due extended episiotomy - low Apgar score Early Intermediate Late
to polycythaemia). - uterine rupture - need for phototherapy - pulmonary embolism
- cut the cord away from the baby (hernia, vessels for exchange uses). - ventouse is less likely to injure the mother, but has high failure rate - DVT (third day) - scar rupture
- PPH
-PV to confirm delivery of placenta, & observe for missing cotyledons. Note: dont use both instrument at the same time, if one fail; C/S - sepsis & infection - incisional hernia
- paralytic ileus
Signs of placental separation: gush of blood, lengthening of umbilical Note: epidural block increase the length of second stage of labour, so - bursed abdomen - depression
- post spinal headache
cord, uterus rises in abdomen & become globular in shape increase the need for augmentation & instrumental delivery.
 MALPOSITION
Type Incidence Aetiology Diagnosis Management
Definition: where the fetus is lying longitudinally and the vertex is presenting, but it is not in the OA position.
Common in - Anteriorly situated placenta - Abdominal palpation, shape - Epidural anaesthesia
Occipitoposterior primagravidae - Anthropoid pelvis - Flat sacrum - Vaginal examination - Transverse arrest may require operative intervention
causes of - Pendulous abdomen - Early caput formation - Lack of progress may warrant C/S
nonengagement - By chance - PROM - Vacuum preferable to Forceps

MALPRESENTATION
Types Incidence Aetiology Diagnosis Management
Definition: where the fetal buttocks or lower extremities present into the maternal pelvis.
(1)
1) External Cephalic Version (ECV) , contraindication:
- Fetal: premature, multiple, fetal
Breech - Abdominal shape, palpation - placenta praevia - ROM, oligohydraminous
anomalies (e.g. hydrocephalus)
a) Frank (65%) - 40% at 26 wk - Vaginal examination in labour: - uterine anomalies - multiple gestation
- Liqour: oligo or polyhydraminous
b) Complete (25%) - 20% at 30 wk * anus has sphincter tone - pre-eclampsia - indication for C/S or vaginal
- Uterine: anomalies
c) Footling (10%) - 3% at term * anus is in line with the ischial 2) Elective C/S, indication: failed ECV, hyperextended head,
- Placenta: praevia
tuberosities footling breech, contraindication for ECV see above
- Pelvis: contraction, tumour... (2)
3) Vaginal breech delivery (only for frank or complete)
Definition: extreme extension of the fetal head so the face (rather than the skull) presents to the birth canal. Presenting diameter: submentobregmatic (9.5cm)
- Vaginal examination in labour: - Internal rotation to MA, 60-80% will deliver spontaneously
- Fetal goitre, Cystic hygroma,
Face * mouth has no sphincter tone - If MP or MT not convert to MA: C/S indicated
1:500 Anencephaly
* mouth forms a triangle with the malar - Oxytocin should not be used
- High maternal parity
prominences - Forceps may be used on MA face presentation
Definition: head is extended such that attitude is halfway between flexion (vertex) and hyperextension (face) -usually transitional-
On vaginal examination, palpate: - 50-75% convert to vertex or face presentation: delivered
when the head is in the process of
Brow - Anterior fontanelle vaginally
1:2000 converting from a vertex to a face or
- Supra-orbital ridges - persistent brow: delivered by C/S (because mentovertical
vice versa
- Nose diameter is presenting 13.5cm non delivered vaginally)
Definition: long axis of the fetus is perpendicular to long axis of the mother (i.e. occurs in transverse lie). other presentation: hand & arm, cord, nil i.e. unstable lie
- Abdominal palpation; no fetal pole
- Vaginal examination; may palpate ribs, - If diagnosed before labour: ECV
Shoulder - As breech presentation (FLUPP)
1:300 scapula, clavicle - If diagnosed in labour: C/S (classical type, or by low
- High maternal parity
- In advanced labour; fetal hand and arm vertical incision)
may prolapse into the vagina
Definition: when a fetal extremity prolapses alongside the presenting part, and both enter the maternal pelvis at the same time.
- Exclude cord prolapse (occurs in 20%)
Compound - Abdominal palpation
- Fetal: multiple, premature - Mostly doesnt interfere with normal delivery
1:1000 - Vaginal examination
- Maternal: multiparity - Vertex-foot: gently reposition the lower extremity
- During labour
- Vertex-hand convert to shoulder: C/S
(1) Risks of the ECV: placental abruption, PROM, cord accident, transplacental haemorrhage, & fetal bradycardia
(2) Breech vaginal delivery: - Factors that increase the likelihood of a successful: normal size baby, flexed neck, multiparous, breech deeply engaged, & positive mental attitude of women
- Prerequisites: presentation should be either flexed or extended, no evidence of CPD, estimated fetal weight < 3500g, no evidence of fetal abnormalities...
- Management of labour: fetal wellbeing, if non-reassuring fetal buttocks blood sample./ progress of labour & possible need for induction or augmentation...
- Complications: cord prolapse, abnormal CTG, damage to visceral organ or brachial plexus, asphyxia for large fetus, intracerebral haemorrhage for small fetus...
- Manoeuvres: Pinards for extended leg, Lovesets for extended arm, Mauriceau - Smellie - Veit manoeuvre for aftercoming head if difficulty; Pipers forceps...
 Management of common problems in Pregnancy
Antepartum Intrapartum
Postpartum
Maternal Fetal Time & Mode of Delivery During Delivery
- tight glycaemic control precoceptual One day before induction: - half the rate of infusion in
- Early dating U/S scan:
- patient on insulin should continue on it normal diet, normal insulin, no need for type 1 & 2 diabetes
is important to confirm GA
- patient on oral hypoglycemic should overnight fasting - maintain serum glucose
- At 18-22wks:
convert to insulin TIME: controversial On the day of induction: between 4-9 m.mole
detailed anomaly scan with
- insulin requirement fluctuates during Induction at 38-39 wks - half the morning dose of insulin before - continue insulin infusion until
Diabetes Mellitus (1)

fetal CTG and serum

first trimester (due to hormonal changes) provided that diabetes is light breakfast patient is eating
screening to exclude
& increase in the second & third trimester controlled & there is no - prostaglandin inserted early - return to pre-pregnancy dose
congenital malformation
- insulin administers as short acting complication. - 500 ml of 10% dextrose and 20 m.mole of insulin after patient start to
- After 28wks:
(Actarapid) pre-meals and medium acting of KCL at rate of 100 ml/hr take orally
regular U/S scanning for C/S indications:
(Insulatard) pre-bedtime - insulin given through infusion pump - breast feeding reduce insulin
fetal growth & amniotic a) fetal macrosomia & fear
- glycaemic control should be monitored (50 units Actarapid in 49.5ml NS) requirement by 25 %
fluid index to identify of shoulder dystocia
by serial capillary glucose measurement - blood glucose should be between 4-7 - contraception (>6wk):
macrosomia and (i.e. EFW > 4.5 kg)
(at least 4 times/day), aim: m.mole (stop infusion if <4) POP & IUCD can be used.
polyhydraminous b) failed induction of labor - monitor blood glucose every 15 min in
(1) fasting blood glucose < 5.5 m.mole COC & injectable progesterone
- After 36wks:
(2) post-prandial glucose < 7 m.mole second stage increases insulin resistance.
close fetal surveillance for
(3) HBA1c < 7 %. - continuous fetal monitoring (why??) - GTT 6 wks & 3 month after
unexplained IUFD
(4) to avoid hypo and hyper-glycaemia - epidural anesthesia (why??) delivery
- Clinical: - Symptoms; relive it TIME: await spontaneous
- delivery is the definitive management - careful observation as BP tend
Hypertension (2)

- Blood Pressure; control it with: labour, or induction of

- Growth scan every 2 weeks - steroid before delivery if preterm to to decrease, & start to increase
Hydralazine, Labetalol, Methyldopa or vaginal delivery at 38wk
- Amount of liquor enhance lung maturation after 48 hours
Nifedipine (ACEI is contraindicated) - If develop pre-eclampsia:
- Biophysical profile score - correct platelet if very low - breastfeeding is encouraged,
- Fluid management delivery at 37 wk
- Doppler flow studies for - general anesthesia if platelet is low, or & safe with these drugs
- Biochemical: urine analysis & 24 hour - If develop eclampsia:
umbilical vessels HELLP syndrome (pre-eclampsia) - non of antihypertensive is
protein, RFTs, serum uric acid abort the fit, control PB,
- spinal anesthesia if platelet is normal contraindicated
- Haematological: CBC, LFTs aim of immediate delivery
1) determine chorionicity: TIME: try to reach After delivery of the first clamp the cord.
st
- diet: Increase in energy sources, iron U/S in late 1 trimester reasonable maturity If the second is longitudinal:
Multiple Pregnancy (Twin)

and folic acid supplements 2) scan for fetal anomalies: provided that mother & - rupture membranes
- treatment of hypertension, gestational U/S at 20 wk, karyotyping, fetus are well (37 wk) - oxytocin infusion The risk of postpartum
diabbetes if developed amniocentesis & chorion - exclude cord prolapse (if occur; emreg. haemorrhage increase due to
- antepartum surveillance: more frequent villus sampling (CVS) TYPE: Depend on lie and LSCS) and monitor fetal heart rate large placental site, uterine
visits & serial U/S. 3) scan for fetal well-being: presentation of the first - hasten labour if bleeding or non- over-distension, so prepare:
- prevention of preterm labour: by U/S every 3-4 wk (for twin: reassuring heart rate * IV line & saved blood group
screening & treatment of other risk factor growth & amniotic fluid - Vaginal: If the second is oblique or transverse: * high dose oxytocin
like bacterial vaginosis & GBS. also; volume), Doppler, & CTG if the first is cephalic - try external cephalic version
transvaginal U/S cervical length at 20-24 For TTTS: - C/S: - if failed try internal podalic version Management of any fetal
wk - amniocentesis every 1-2 wk if the first is breech (fear - if failed or cervix contract: C/S complications
- maternal education, planning for intra- - fetoscopic laser of locked twin) After delivery of second twin:
partum care. coagulation of placental - Elective C/S: clamp the cord, active management of
vessels for other presentations third stage of labour
(1) DM Defined by WHO as: raised fasting blood glucose level of > 7.8 m.mol/L or a level of > 11.1 m.mol/L 2 hours following a 75 g oral glucose load
(2) HTN Defined as change of blood pressure on at least two occasions of either diastolic PB > 90 mmHg or systolic > 140 mmHg OR raise in diastolic at least 15 mmHg or of systolic at least 30 mmHg
 Common Disorders in Obstetrics
Cardiovascular Diseases Anaemia (Iron deficiency anaemia) Malaria
Rare (1%) BUT potentially serious Def.: haemoglobin concentration < 11 g/dl (or Hct less than 30%) Differential diagnosis:
Physiology during Pregnancy: Physiology during Pregnancy: meningitis (stiff neck), viral hepatitis (jaundice)
- blood volume & cardiac output increase by 40% - plasma volume increase by 40% - red cell mass increase by 20% For unconscious patient;
Maternal risks (mortality): physiological dilution with decrease Hb & haematocrit (Hct) ABCs, estimate the body weight for drugs, IV canula
- pulmonary hypertension & Eisenmengers syndrome (40-50 %) Iron: - only 10-30% of Fe available is absorbed Through examination:
- Marfans syndrome (up to 50%) - amount absorbed depend on Hb level; lower Hb, greater absorption - Glasgow coma scale - exclude bacterial meningitis
- Fallots tetralogy (5%) - in plasma, it links with transferrin (ferritin, hemosidrin) - plasma HCO 3 \venous lactate - arterial\capillary pH & gases
- others: cardiomyopathy, dissection of aorta (15%), IHD Diagnosis: low MCV & MCHC, low ferritin, high iron binding capacity - X-match, clotting studies - blood culture (septicaemia)
Fetal risks: Methods of correction in iron deficiency anaemia: Risk factors for traveler: no pre-immunization (prophylaxis)
- growth restriction, preterm delivery, fetal death a) blood transfusion b) total dose iron infusion (cosmofer) Cycle: (infection & reinfection of RBCs)
- fetus with congenital heart disease (5%) c) injectable iron d) oral iron + folic acid sporozoite (infectious form, develop in liver) merozoite (cause
Management: - Pre-pregnancy: Counseling about: cosmofer + folic acid 5 mg\day + vitamin C tablet or in food RBC destruction) ring form trophozoite (development in RBC)
- risk of maternal death S/E (iron dextracomplex): anaphylaxis multinucleated schizon (rupture) merozoite
- reduction in maternal life expectancy injectable iron ferrum ambole (2 ambole\ week up to 10-15 inj.) Defensive mechanism of malaria:
- risk of fetus with congenital heart disease S/E (iron sorbitol complex): abscess, painful - cytoadhesion: membrane of red cells attach to the endothelium,
- risk of preterm labour, IUGR Follow up: raise in reticulocyte count after 1 wk preventing RBCs from reaching the spleen
- need for frequent hospital attendance, intensive monitoring Complications: - rozitting: RBCs tend to become together
- Antenatal: - preterm labour - intercurrent infection Characteristics of severe malaria:
- continuity of care with obstetric/cardiac clinic - IUGR (asymmetrical) - PPH - impaired consciousness: coma - pul. oedema: tachypnoea
- symptoms of heart failure: a) breathlessness particularly at night -postpartum depression - DVT & thromboembolism - repeated seizure (>2 per day) - shock: low PB
b) change in heart rate or rhythm - lactate infertility (i.e. low amount of milk) - jaundice - acute renal failure
c) increase tiredness or reduction in exercise tolerance Management at time of labour: - abnormal bleeding: retinal haemorrhage
- admission according to patient condition (not as policy) i: blood transfusion is better than ferrus sulphate tab Lab finding in severe malaria:
- anticoagulation: a) warfarin throughout pregnancy, replaced by ii: oxytocin, oxygen by mask (if preterm labour) - severe anaemia (HCT<15%) - hypoglycaemia (B glu<40mg/dl)
heparin only for delivery (e.g. pul. HTN, artificial valve replacement) iii: continuous fetal heart monitoring - metabolic acidosis - renal insufficiency
b) replacing warfarin with heparin in 1sr trimester iv: when cervix is fully dilated; shorten the second stage of labour by -hyperparasitaemia (>5-10%) - high aminotransferrase
c) heparin throughout pregnancy using the forceps or the ventouse - high bilirubin - DIC
- heart failure treatment: admission, confirm diagnosis, diuretics, v: IV ergometrine when the shoulder appear
Causes of fetal death:
vasodilator, digoxin, oxygen & morphine. Fetal U/S & CTG vi: deliver the placenta by cord traction o
fever (1 C 2 beat\min), hypoxia, hypoglycaemia
- Labour & Delivery: vii: episiotomy when the head is crowning
Treatment of severe malaria:
- await onset of spontaneous labour (induction of labour for obstetric viii: if bleeding occur: misopristol (3 tabs per rectum) or
- clinical assessment - specific antimalarial ttt
indication only) prostaglandin F2alpha intramyometrium
- supportive care - adjuvant therapy
- epidural anaethesia (decrease demand on cardiac function) ix: observe the patient for any sign of depression & look for milk
- for fever: spondage, rectal supporities
- prophylactic antibiotics (reduce risk of bacterial endocarditis) - mature women have a total of 3500-4500 mg of iron (75% in RBCs & - for fluid: * balance between input & output
- monitoring: oxygen saturation, continuous arterial PB monitoring 20% as body store) * if fluid given with ARF: haemodialysis
- echocardiography is very important in monitoring -dead RBC release 27 mg of iron, also 1 mg is lost daily without return Drugs:
- keep second stage of labour short (by forceps or ventouse) - minimum need per day is 1 mg, increase in pregnancy (to 10 mg in - Quinine: IV:- loading dose 20 mg/kg over 4 hr
NOTE: early pregnancy & 20 mg in late pregnancy) - then, 10 mg/kg/8 hr for 7 days
* C/S less tolerated by cardiac patient (only for obstetric indication) non- pregnant pregnant oral:- after recover consciousness; Quinine 10 mg/kg &
* ergometrine is contraindicated (cause hypotension & heart failure) Hb (g\dl) 12 15 11 15 clindamycin 5 mg/kg 3 times per day for 7 days
* third stage of labour managed with oxytocin alone, given slowly MCV (fl) 75 99 more S/E: hypomagnesaemia & hypoglycaemia (that kill the fetus)

NOTE: RBC (mmol\l) 45 72 increase - overdose; headache, dizziness, severe CNS disturbance & delirium
- cardiac output increase in: i) early pregnancy Se. Fe (mmol\l) 13 27 13 27 - rapid IV administration can precipitate hypotension & fatal
ii) immediately after delivery (why??) Fe (mmol\l) 15 300 15 300 cardiovascular toxicity
- mitral stenosis is the commonest acquired cardiac disease (90%) - despite increase demand for iron; Se. Fe & Fe remain at normal - Artesunate: IV:- 2.4 mg/kg at hr 0, 12, 24, & then every 24 hr
- surgical valvotomy for mitral stenosis can be done during pregnancy nd rd
- iron screening in pregnant women; at booking, 2 & 3 trimester oral: 2 mg/kg for 7 days + clindamycin as above
but better if done before that. - if it low; correct complications, then give iron as injection at 30 wk At time of delivery: avoid thrombocytopenia by active management
- termination of pregnancy in Eisenmengers syndrome ??? or as blood transfusion at labour. of third stage of labour.
 Perinatal Infection (TORCH)
Infection Transmission Clinical features Fetal complications Diagnosis Treatment Notes
Primary Secondary Tertiary

3) TPHA (specific)
2) FTA (specific & 1 to be +ve) &
If +ve (DD: SLE, APS), then:
1) VDRL (non-specific): titre > 1/64

- Penicillin IM; 1.2 MU daily for:

- other option: Erythromycin IV
contraindicated in pregnancy
- second line: Tetracycline BUT
-Early: rash, hepatitis splenomegaly

VDRL fall after 2y after ttt (depend

-Late: Hutchinsons signs

- Jarish-Herxheimer reaction: pro-

-Active disease: general paresis of

organism. Treated by IV Penicillin

lymphadenopathy, anaemia, and

- Syphilis cant be transmitted to

inflammatory cytokines to dying

- severe intrauterine infection &

FTA & TPHA remain +ve after ttt

21 days in late latent syphilis

12 days in early syphilis
Early Latent:
- 10%: neurosyphilis
- 20%: cardiovascular syphilis
- cant transmitted sexually
Late Latent:

(1.2 MU daily in divided dose)

the fetus in the first trimester
- 6 wk to 6 month after infection
regress after 2-4 wks without ttt
- painless genital ulcer (chancre)

- alopecia, uveitis, sensorineural

- non itchy maculopapular rash

- occur after 2years following

untreated secondary syphilis
(Treponema pallidum)

Sexually Transmitted

& local lymphadenopathy

bone abnormalities..
- 3-6 wk after infection
Disease (STD)

insane, gummata
- highly contagious

- condylomata lata

miscarriage
Syphilis

on IgM)
deafness

st
Prevalence:
10 %

hydrocephalus or microcephaly

- 3 trimester (75-90%):
Severe fetal damage
chorioretinitis, convulsion,

- Classical tetrad:
Less fetal damage

- 1 trimester (10-25%):

Course: 3wk of 2-3 g per day

- Sulphadiazine + Spiramycin

treated with Pyrimethamine

Pyrimethamine (teratogenic)
LNs or CSF (most accurate)
- demonstrate parasite on

in 1 trimester. After that

congenital toxoplasmosis
- Sabin-Feldman dye test

replace Spiramycin with

rd

st
(Toxoplasma gondii)

& cerebral calcification

- cat faces

st
- primary infection usually asymptomatic OR:

- ELISA & IgM Ab

+ Sulphonamide
- uncooked meat
Toxoplasmosis

- glandular fever like illness with atypical lymphocytes

-rarely: fulminating pneumonitis, fatal encephalomyelitis,
chorioretinitis.
Prevalence: - association with AIDS: recurrent toxoplasmosis and
Vary according to multiple brain abscess
eating habit

- respiratory tract - Triad: microcephaly, - isolating the virus in

antiviral for
Cytomegalovirus

- genitourinary tract blindness & deafness cell culture from

(herpes virus)

- primary infection is asymptomatic CMV:

- blood transfusion - also: pneumonitis, throat swab, urine, Herpes virus has
- virus excreted for wks or months by adult & for years by Ganciclovir &
- transplantation chorioretinitis, cerebral blood, CSF ability to
infant Foscarnet
Incidence: calcification, - rising titre of IgG Ab establish latency
- the virus persist in lymphocyte for life (not used in
0.5 % developmental delay - specific CMV IgM Ab
pregnancy)
(40% fetal infection) -infant: jaundice, purpura - amniocentesis/PCR
- Greggs triad: - no specific - if diagnosed in
- incubation period: 2-3 wk - detecting the virus in
cardiovascular defect, eye treatment first trimester:
(togavirus)

- mild fever, sore throat, enlarged cervical gland, rash, throat, urine, faeces
Rubella

Common in spring & defect, & deafness. available abortion

painful joint for 3-7 days - IgG Ab after 6 month
early summer - also: hepatitis, mental ret. - no vaccination - MMR vaccine
- abortion, stillbirth, & preterm birth can occur - rubella specific IgM
thrombocytopenia, bone during reduce the
- infection pass unnoticed in children found for 3-9 months
involvement, microcephaly pregnancy incidence
- incubation period: 2 wk Congenital - IV Aciclovir
Varicella zoster
(herpes virus)

- in children: mild disease, handful of lesion only varicella Neonatal - intensive care Other exanthems
From adult with syndrome: - electron microscopy support
- in adult: headache, general aches, pain, & malaise chickenpox: - smallpox
chickenpox or shingles hypoplastic - culture of scraping - for the fetus:
- cluster of vesicle emerge at different stages Mortality - eczema
through droplet spread limb, scar, & from vesicles * VZIG
- pregnant are more vulnerable to chickenpox & may rate: 30% herpeticum
CNS * IV Aciclovir
develop pneumonitis (fatal) anomalies
 Drugs IN Obstetrics
Drug Action Indication Contraindication Complication/Side effect Route of adm. Note
- rapid onset of action (tonic - induction of labour - CPD - uterine hyperstimulation - for induction:
(1) contraction) - augmentation of labour - hypertonic uterine - uterine rupture continuous infusion in high dose can
Oxytocin
- act on uterus mainly - prevention/treatment of PPH dysfunction - fetal compromise NS or 5% dextrose cause neonatal
(Syntocinon) (increase prostaglandin level) (safe in nulliparous, & less safe in - uterine scar - excessive fluid retention & (titration method) jaundice
- best action after ARM multiparous) - fetal distress - dilutional hyponatraemia - for PPH: IM
- dyspnoea, bradycardia not used for
Utrotonic Drugs

- delayed, but sustained - HTN, eclampsia

Ergometrine - transient HTN - tablets induction due to
contraction - prevention/treatment of PPH - cardiovascular disease
(Methergin) - vasoconstriction - injection sustained
- act on cervix & uterus - delivery of second twin
- stroke, MI, pul. oedema contraction
- nausea & vomiting
(2) - increase sensitivity & relative contraindication in - expensive
Prostaglandin - induction of labour - diarrhoea vaginal best route
receptors of oxytocin (act patient with concurrent - need optimum
(PGE2) - treatment of PPH - bronchoconstriction as tablet or gel form
through normal physiology) asthma temperature
- maternal pyrexia
- termination of pregnancy (high dose) - fever
synthetic prostaglandin used with caution in patient - oral, vaginal for - cheap
Misopristol - induction of labour (low dose) - diarrhoea
(adjust dose according to with previous uterine scar induction - kept in room
(Cytotec) - prevention/treatment of PPH - vomiting
uterine size) (VBAC) - vaginal for PPH temperature
- anti- peptic ulcer - convulsion (rare)
(1) Augmentation with oxytocin should only be commenced if CTG (or FBS) is normal. failure of progress in the next 4 to 6 hr is an indication for caesarean section.
(2) For induction: CTG should be performed 30 min before & after prostaglandin given, vaginal exam after 6 hr, if cervix not favourable; another dose given. oxytocin should not be used within less than 6 hr.
Drug Action Indication Contraindication Complication Signs of toxicity Route of adm. Antidote
- cerebral vasodilator - severe pre-eclampsia to - neuromuscular disease - respiratory depression - BP below 110/70
- 5g over 20 min via
Magnesium - membrane stabilizer prevent occurance of fit - Myasthenia Gravis - cardiac arrest - RR below 16/min calcium
an infusion pump
sulphate (displace intracellular Ca by Mg so, - abort fit in eclampsia - renal failure (therapeutic range in the - oliguria (<30 mL/h)
- continue with 2 g/h
gluconate
inhibition of contraction) - used as tocolytics - cardiac disease serum: 2-3 mmol/L) - absent knee jerk reflex

Drug Indication Action Side effect Drug Indication Action Side effect
Ritodrine increase cAMP in cell, which hypotension, tachycardia, Methyl-dopa false neurotransmission, CNS postural hypotension,
suitable area (<48 hr)

aiming of diastolic PB
(Beta-agonist) decrease free calcium anxiety, chest pain, ECG change effect (dopamine antagonist) depression, insomnia
2) give steroid to the

(orally)

- lower BP gradually
1) transfer the pt to

Antihypertensive

- prevention of CVA
mother (fetal lung)

90-100 mmHg
Hydralazine relaxation of arteriolar smooth flushing, headache,
Tocolytics

Atosiban oxytocin antagonist less S/E, but expensive

(IV) muscle (peripheral vasodilator) tachycardia, lupuslike synd.
calcium channel blocker orthostatic hypotension, severe calcium channel blocker orthostatic hypotension,
Nifedipine Nifedipine
(prevent Ca entry to cell) headache (prevent Ca entry to cell) severe headache
premature closure of ductus
Indomethacin prostaglandin synthetase Labetalol alpha- & beta- adrenergic
arteriosus (>34wks), gastritis, contraindicated in asthma
(Indocid) inhibitor (NSAID) proctitis, oligohydraminous.. (orally or IV) blocker
- Magnesium sulphate can also be used as tocolytics first agent due to high safety - all above antihypertensive are rapidly acting except methyl-dopa which may take up to 24 hr to act
- tocolytics drugs delay the onset of labour for not more than 48 hrs - Hydralazine (drug of choice in pre-eclampsia) if given without volume expansion: fetal tachycardia
)

Steroid single course of maternal steroids (two injections IM 12-24 hrs apart) given between 28 & 34 wks gestation & received within 7 days of delivery (for fetal lung maturation) dexamethasone

Action Indication Contraindication Side effect Dose

Lignocaine local - preineal & dental anasthesia - hypovolaemia - CNS effect (confusion, convulsion) Infiltration by injection. maximum dose 200 mg (or 500 mg if
(Lidocaine) anaesthetics - ventricular arrhythmia - complete heart block - respiratory depression, hypotension, bradycardia given in solution contain adrenaline)

Heparin cause prolongation of APTT (low molecular weight, assessed by factor X assay). complication: 1) osteoporosis if used for > 6 months 2) idiosyncratic thrombocytopenia rare
Anticoagulant st nd rd
Warfarin given orally & prolong prothrombin time (PT). Complication: 1 trimester; limb & facial defects / 2 & 3 trimester; fetal intracerebral haemorrhage so, used in high risk pt only

FOR Antimalarial drugs, see; Common Disorders in Obstetrics, Malaria in pregnancy

 Antepartum haemorrhage
Bleeding in Early pregnancy Fate:
1- Miscarriage (Abortion) a) Acute rupture ectopic: abdominal pain, vaginal bleeding & shock
Types History Examination Treatment b) No complete rupture (chronic ectopic): colic abdominal pain (for about 10 days)
stable manifestation: pale, tenderness, mass. empty uterine cavity on U/S
1- Threaten - small bleeding external os closed Conservative c) Acute on chronic: no complete rupture, then haematoma covered by omentum
10% incomplete - no pain fit, no tenderness, (weekly U/S) d) Missed ectopic: very rare
normal fundal level e) Tubal abortion: after fertilization goes by peristalsis outside the uterus (e.g.
stable - admission, inv., omentum, placenta)------- if there is no blood supply: death
- more bleeding FL less than date evacuate: ------- if there is blood supply: secondary abdominal pregnancy
2- Incomplete Note: in primary abdominal pregnancy, both ovum & sperm fall in the pouch, patient
- colicky abd. pain Passage of < 12wk: surgery
clots/tissue > 12wk: medical(1) complains of acute abdominal pain (not severe)... U/S show empty gestational sac
- less bleeding stable Treatment:
3- Complete antibiotic - Medically: follow the patient with methotrexate (small, early ectopic)
- less abd. pain external os closed
not stable, pale, - restore volume - Laparoscopy (in stable patient)
4- Invetible - severe bleeding - Laprotomy: final option in acute rupture
external os opened - digital evacuation
Between 1 & 2 - severe pain Salpingotomy (if less than 2 cm in diameter, not in peritoneum)
FL less than date - proper evacuation
vaginal discharge, - admission, inv., Salpengectomy (if rupture in peritoneum, not stable patient)
cessation of -------------------------------------------------------
FL less than date evacuate:
5- Missed symptoms of 3- Molar pregnancy (Hydatidiform mole)
If no FH: early preg. < 12wk: D&C
pregnancy Definition: Abnormal fertilization of sperm and ovum.
or blighted ovum >12wk:prostaglandin
vary from mild to - antibiotic, correct Types Complete Partial
think of: Fetus no fetus there is fetus
septic shock renal problem, DIC
6- Septic - criminal abortion
(gram ve - fresh blood 46 XX 69 XXY or 69 XXX
- perforation Karyotype
septicemia) -evacuation(4 hr later) 2 spem & no ovum 2 sperm & 1 ovum
Three or more in cervical circulage or Symptoms: exaggerated symptoms of pregnancy (e.g. morning sickness), passage of
DD: PCOS, cervical
similar manner suture internal os vesicles, vaginal bleeding (not always)
7- Habitual incompetence, D&C,
consecutive before time of Complications: 1- Thyrotoxicosis (alpha subunit of HCG) 2- Pre-eclampsia
operation in cervix
abortion abortion 3- Lutein cyst in ovary 4- Infection 5- Choriocarcinoma
8- Legal Investigations: - Serum HCG - Transvaginal U/S (show snow-storm appearance)
(1) prostaglandin (before or after 12 week) or oxytocin (only after 12 week) Treatment: - Removal by suction & evacuation
FL: Fundal Level, FH: Fetal Heart, DD: Differential Diagnosis, Preg.: Pregnancy, Abd.: Abdomen
NOTE: use of U/S is controversial, it differentiate between types of miscarriage, & can reassure the
- Methotrexate (antifolate): affect DNA replication (for invasive mole)
patient that the fetus is alive rising HCG is the most important single indication for chemotherapy
NOTE: dont forget the use of Anti-D if > 12 weeks miscarriage or heavy bleeding - Follow up: by HCG. by 2 month, if HCG not decreases: hysterectomy
------------------------------------------------------- Note:- PIH in molar pregnancy occur characteristically before 20 wk gestation
2- Ectopic pregnancy - metastasis to lung, liver, & CSF can occur very rarely
Definition: Implantation of fertilized ovum outside the normal site in the uterus - positive HCG for long time following delivery: think of choriocarcinoma
Commonest side: Fallobian tube (mainly in the ampulla) usually Rt side, why? - up to 90% of pt with metastatic choriocarcinoma can achieve normal life
Risk factors: - Uterine tube anomalies/surgery - PIDs Note: - HCG decrease after 1 month to 6 weeks in normal pregnancy
- Oral Contraceptive Pill - IUCD - HCG decrease after 15 days to 3 weeks in abortion
- Abnormal fertilized ovum - Assisted reproduction - HCG decrease after up to 2 months in molar pregnancy
 Antepartum haemorrhage Postpartum haemorrhage
Bleeding in Late pregnancy
Definition: any vaginal bleeding excess of 500 ml after delivery
Abrupto Placenta Rupture Local Vasa
Causes Types: a) Primary: occur in the first 24 hours after delivery
placentae(1) praevia(2) uterus causes previa(3)
b) Secondary: occur after the first 24 hours up to 6 weeks
Vaginal Bright
Dark Bright Bright red Dark
bleeding red Causes of primary postpartum haemorrhage:
Pain in Local (4Ts: Tone, Tissue, Trauma, Thrombus)
Pain Painful Painless Painful
labour only pain
1- Uterine atonia: due to over-distended uterus (i.e. polyhydraminous or multiple
Not Not Not
Pulse/BP Comparable Comparable pregnancy), placenta previa this is the most common cause of PPH
Comparable Comparable Affected
Fetus Affected Normal Affected Normal Affected (atonia: uterus will be hard, floppy, above the umbilicus & full of blood)
Usually in Usually not in Usually in Not in Usually 2- Tissue: due to retained placenta, accessory lobe, cotyledon
Time
labour labour labour (silent) labour in labour 3- Trauma: tear of vagina, cervix, perineum, rupture uterus
Diagnosis Clinical Ultrasound Clinical Speculum Clinical 4- Thrombus: DIC, IUFD, massive APH, eclampsia
If placenta in; think of retained tissues, If placenta out; think of other 3 causes...
- Anaemia
- Polyhydraminous
-Smoking -drug abuse
- ECV or ICV
- PIH

- Increase age
- Assisted conception
- Uterine anomalies
- Multiple pregnancy

- Constrictive surgery
- Obstructed labour
- Grand multiparity
- Previous scar

- Multiple pregnancy
- Placenta previa
- Scar (e.g. repeat C/S)
Risk factors

Causes of secondary postpartum haemorrhage:

1- Retained tissue (product of conception)
- Trauma

2- Uterine infection
other causes: endometritis, hormonal contraception, bleeding disorders, and
choriocarcinoma..
PPH, DIC, PPH, IPH, Circulatory Fetal
Complication Management:
ARF, shock shock collapse death
General: 1- ABCs according to the patient condition, IV line
3) hysterectomy
- C/S if fetal heart is +ve or cervix is closed
- Libral blood transfusion

shut down)
- ARM (decrease uterine tension & uterorenal

- No bleeding: conservative (till maturity)

- Heavy bleeding: C/S

Depend on: a) gestational age

1) repair
of rupture, condition of patient, then:
- Laprotomy, & according to parity, age, site
- Blood as twice as needed (> 4pint)
- Oxytocin
(after putting 2 IV lines, sending sample for

leaked to maternal circulation): fetal blood

grouping & cross matching, CBC & clotting
normal saline, blood & putting a catheter)

2- stop bleeding

- Kleihauer test (how many fetal blood

resist denaturation by acid or alcohol
profile, & start infusing expander like

Treatment according to the cause:

3- remove tissues
Cervix, vagina, perineum.

- Ultimate treatment is C/S

Specific: 1- rub uterine contraction by massage the uterus

b) amount of bleeding
c) if pt in labour (do C/S) or not
Specific Treatment

2- IV line (simultaneously with uterine massage)

3- give ergometrine or high dose IV oxytocin syntocinon (utrotonic drug
2) repair + tubal ligation

irrespective of the cause of bleeding, to protect against atonia)

- Pethidine

4- bladder should be empty

5- when Placenta out; look at it for missing cotyledon

Note: Prostaglandin F2-alpha injection; systemic or into myometrium can be used

Note: - If bleeding persists despite uterine contraction; think of genital tract trauma
- If haemodynamic status not improved; think of hidden bleeding (sites??)
Note: Surgery: intrauterine ballon, bilateral internal artery ligation, hysterectomy
(1) Uterine bleeding following premature separation of normally sited placenta (maternal & fetal blood lost) Note: - PPH is a part of post partum collapse
(2) Placenta covering or encroaching on the cervical os (maternal blood that is lost)
- other causes of post partum collapse: DIC, pulmonary embolism, amniotic
(3) Rupture of vessels on the fetal side of the placenta (fetal blood that is lost)
fluid embolism, rupture uterus, uterine inversion, gram ve septicaemia
 Other physiology: von Willebrands disease,
Other causes: IUCD,
Notes

other bleeding disorders, fibroid, endometrial Amenorrhoea can be normal in pregnancy,

submucous fibroid,
polyp, thyroid disease, drugs or IUCDs, lactation or prior to puberty
bleeding in pregnancy polyps
b) without visualization:

(single procedure that take

Endometrial ablation

thermal uterine balloon

then pregnancy contraind.
laser, diathermy, trans-

- abdominal, vaginal or
therapy, microwave or

nerve pathway from

a) with visualization:

cervical endometrial
Reduce MBL by 90%

Interrupting the
- total or subtotal
resection (TCRE)

Hysterectomy
about 30-45 min)
heated saline

laparoscopic

the uterus

Treatment depend on the cause

Surgical

e.g. HRT or OCP if the problem is oestrogen

deficiency
Treatment

(rarely: cervical dilatation,

3) Measurement of LH & FSH (6 wk after first

mefenamic acid, asprin
Mefenamic acid & NSAID

2) Oral active oestrogen for 21 days followed

pregnancy test, prolactin, TFT, LH & FSH,
naproxen, ibuprofen,

used in Scandinavia

1) Progesterone withdrwal test (medroxy-

Oral contraceptive

test & 2 wk after oestrogen or progesterone):

- efficacy as that of surgery
- reduce MBL by 50-100 ml

* if bleeding: hypothalamo-pituitary- ovarian

progesterone acetate for 5 days then stop it)
- comp.: their side effects
Tranexamic acid

- comp.: androgenic S/E

Hysterectomy)
- reduce MBL by 100 ml

According to cause, further inv. followed

Nifedipine
- reduce MBL by 35 ml

- reduce MBL by 50%

- reduce MBL by 95%

Medical

NSAIDs
LNG-IUS
Danazol

* if no bleeding: outflow tract disorder

- comp.: risk of VTE

COCP
- antiprostaglandin

If ve (i.e. no menstruation) then DD:

* insufficient endogenous oestrogen,

- antifibrinolytics

* if not high: hypothalamus disorder

- adv.: pain relief

- anti-oestrogen

e.g. karyotyping in Turners synd...

testosterone

* outflow tract disorder OR

by progesterone as above:

- FBC: for degree of anaemia & need for * if high: ovarian failure
- endocervical swap
Investigation

iron therapy (only mandatory test)

axis. then go to:
- high vaginal swap
-TFT, B-hCG, serum androgen, prolactin
then go to:

- pelvic U/S
- pelvic/transvaginal U/S: fibroid, polyp
- laproscopy
Menstrual Disorders

- hysteroscopy/endometrial biopsy: if age

- hysteroscopy
more than 40 years
- general: signs of endocrinopathy, - height (Turners synd., androgen insensitivity)
Examination

anaemia, liver disease or coagulopathy General examination to - development of secondary sexual characteristics
- abdominal: liver enlarge., pelvic mass exclude other or virilization
- bimanual pelvic examination: vaginal or pathologies - visual field disturbance / papilloedema
cervical disorders - pelvic examination
- number of towels or tampons developmental history, age at menarche, cyclical
- duration of the problem symptoms, chronic illness, anorexia nervosa,

(*) Metrorrhagia: bleeding not related to the cycle. e.g. submucous fibroid bulging into the cavity
- impact of the problem on the patient Crampy suprapupic pain excessive exercise, FH of insomnia, menstrual
History

- irregular, intermenstural, postcoital start at menstruation history, PMH, menopausal symptoms, current
bleeding, sudden change in symptoms, and last for 8 - 72 hrs medication, FH of premature menopause,
dyspareunia, pelvic pain, bleeding from virilizing signs or galactorrhoea, psychological
other site history, stressful event
- disordered endometrial prostaglandin - Endometriosis - Reproductive outflow tract disorders
Aetiology

production - PID (e.g. Gonorrhoea) (e.g. Ashermans synd., imperforate hymen)

- abnormalities of endometrial vascular - Adenomyosis - Ovarian disorders (e.g. PCOS, Turners synd)
development - Ashermans syndrome - Pituitary disorders (e.g. adenoma, necrosis)
(See other physiology at the Notes) - Cervical stenosis (rare) - Hypothalamic disorders (e.g. anorexia nervosa)
Secondary

Cessation of menstruation for more than six

Due to organic cause Due to organic
months in a normal female, of reproductive age,
(e.g. fibroid, endometrial polyps) pathology
Classification

not due to pregnancy

no organic pathology;
risks: Failure to develop secondary sexual
Primary

Idiopathic or dysfunctional uterine

menstrual flow > 5days, characteristics by 14 years age or failure of
bleeding (DUB)
younger than normal at menstruation by 16 years age
menarche, smoking
Prevalence: 5% in age 30 to 49 years Prevalence: 45-95%
%

Menorrhagia: prolong increase menstrual Amenorrhoea: absence of menstruation for more

flow (more than 80 ml per period) than 6 months
Definition

Hypermenorrhoea: excessive regular Oligomenorrhoea: menstruation occurring at

Painful menstruation
menstrual loss more than 35 days interval (& less than 6 months)
Polymenorrhoea: menstruation occurring Hypomenorrhoea: decrease in amount or
at less than 21 days interval duration of menstrual flow
Menorrhagia Dysmenorrhoea Amenorrhoea
 Contraception (Hormonal, Intrauterine, Barrier methods, Coitus interruptus, Natural family planning, Emergency contraception, Sterilization)
Type FR Formulation Intake Mode of Action Advantage Complication Contraindication Notes
Absolute Relative

placebo pills instead of pill-free interval

- Every day preparation; contain 7
7-day pill free interval
- Progesterone:

- Estrogen: ethinyl oestradiol

- 21 pills; one taken daily followed by

- Peripheral:
progesterone inhibit FSH & LH
- Central: inhibit ovulation; estrogen &

- Treatment of acne
endometrial cancer
- Protection against ovarian and
- Reduce the risk of PID
- Improve PMS
- Treatment of heavy painful periods

broad spectrum antibiotic)

- Drug interaction (e.g. antiepileptic,
- Breast cancer
- Arterial disease (MI, Stroke..)
- Venous thromboembolism

-This is the most commonly used type of

contraception because its easy to use,
- Increase in the dose of estrogen lead
to increases the risk of complications
migraine, weight gain, loss of lipido
Combined oral contraceptive pills
Hormonal Contraception

viscosity) to prevent ascend of sperm

b) altering cervical mucous (increase
hostile to implantation
a) making endometrium atrophic &

high protection against pregnancy

b) 3 generation: gestodene

a) 2 generation:

- Focal migraine
- Estrogen dependent neoplasm
- Severe or acute liver disease
- Circulatory disease (IHD, CVA.)

- Less risk factor for CVD (obesity.)

- Irregular vaginal bleeding
- Long term immobilization
- Generalized migraine

- S/E: depression, hypertension,

nd
rd
levonorgestrel
norethisterone acetate

mestranol
0.1 - 1
(COC)

norgestimate
desogestrel

OR
Types FR Formulation Intake Mode of Action Advantage Side effect Indication Notes
Progesterone only Contraception

nd - If POP fail, there is

the ovulation
- Higher dose act centrally by inhibiting

- Local effect:

- Acne
- Breast tenderness
- Functional ovarian cyst
- Absent menstrual bleeding
-2 generation progestron:
Progestrone

Ideal for women: - Breastfeeding

slightly high risk of
only pills

norethisterone Every day - Cant take COC - Older age

(POP)

13

b) making endometrium atrophic

a) making cervical mucous hostile
rd ectopic pregnancy
- 3 generation progestron: without break - At time of low - Cardiovascular risk factors
- Has worse bleeding
desogestrel fertility - Diabetes
profile than COC
-Depot medroxyprogestrone
Progestrone

Particular side effect:

Injectable

acetate (Depo-Provera): - Improve PMS Useful for women have

0.1 2

Injection - Weight gain

last 12-13 weeks - Treatment of difficulty remembering to
(deep IM) - Menstrual irregularity
- Norethisterone enanthate: heavy period take a pill
- Risk of osteoporosis
last about 8 weeks
- Single silastic rod Subdermal
Implanon

Useful for women have Return to ovulation

- Release the progesterone under local - Last for 3 years
difficulty remembering to after removal within 30
0

etonogestrel which is anathesia to - Highly effective

take a pill days
metabolized to desogestrel upper arm

Types FR Formulation Intake Mode of Action Advantage Side effect Contraindication Notes
- Copper Toxic effect on Increase: - It is radio-opaque
Last for 3-5 years, - Previous PID
personnel immediately
Inserted by healthcare
Copper-

- Fine thread left

bearing

Induce inflammatory

- Some has silver-cored sperm - Menstrual loss

after menstruation
1-2

& may be up to 10 - Previous ectopic protruding to vagina

copper for added (prevent - Dysmenorrhoea
endometrium
response on

pregnancy
IUCD

years - If thread not visible:

efficacy fertilization) - Pelvic infection - Malformation of uterus Speculum exam, U/S
Local hormonal -Highly effective - Irregular bleeding - Copper allergy (can use - If fail, there is high risk
Hormone
releasing

Levonorgestrel-releasing IUS) of ectopic pregnancy

effect on cervical -Reduce menstrual - Progesterone side
0.5

intrauterine system (IUS) - Rheumatic heart - Should be removed if

mucous & blood loss effect (e.g. acne, pregnancy occur
(Mirena) disease
endometrium -Protect against PID breast tenderness) - Not protect against STDs
(*) FR Pearls index: Failure Rate; Number of failures per 100 women-years (HWY) i.e. the number of pregnancies if 100 women were to use the method for 1 year.
 Infertility
Definition Failure to conceive within 1 year of unprotected regular sexual intercourse. can be primary (i.e. no history of previous conception) or secondary
maternal age: rate of conception rapidly decline after the age of 35 year (single most important factor regarding infertility)
History parity & gravidity, menstrual cycle, contraception (depo may have prolong effect), disorders suggestive of endocrinopathy, tubal disease or history of PID or pelvic surgery,
general history (smear history, rubella status, blood group), history & examination of male partner (if he have children from other relationship, smoking, alcohol, occupation)
Examination signs of raised BMI, signs of hirsutism & other endocrinopathy, secondary sexual characteristics, signs of abdominal/pelvic surgery, vaginal exam, swabs for Chlamydia

Ovulation commonest cause of 1ry infertility Tubal Implantation &/or

Hypothalamus
- stress, weight gain
- psychological disturbance
- systemic illnesses
Disorder
Pituitary Ovarian commonest cause of 2ry infertility Mucosal
- PCOS commonest cause
- submucous fibroid
- premature ovarian failure - PID commonest cause
- smoking
- hypothyroidism e.g. Turner synd., XY gonadal dysgenesis - pelvic infection / surgery

- tumour or structural lesion
- renal, hepatic failure
- drug: phenothiazine
Female Infertility
(abnormal endometrium
- hyperthyroidism - acquired: damage by virus, toxin - endometriosis
development, or
- hyperprolactinaemia - iatrogenic: pelvic surgery, irradiation, (impair oocyte pick-up OR cause tubal
abnormalities in growth
cytotoxic treatment epithelium damage)

adhesion molecules)
(impair pulsatile release of GnRH) - autoimmune problem
(1)
- gonadotrophin evaluation (at day 3 of the cycle) a) hysterosalpingography (dye & X-ray)
--------------------------------------------------------------------
b) hysterocontrast synography (HyCoSy) - Spinnbarkeit describe:
Regular cycle: * mid-luteal progesterone at the second half of the cycle (at day 21 of the cycle)
Investigation

(contrast & U/S) ferning of the cervical

* serial follicle tracking scans at middle of the menstrual cycle
- both above tests done at follicular phase mucous (which is oestrogen
regular cycle suggests but not confirm ovulation
prior to menstrual cycle ( at day 8 of cycle); dependent)
Irregular cycle: * endocrinopathy: TFT, prolactin level, androgen level.
-------------------------------------------------------------------- to avoid ectopic pregnancy, & fetal affection - abdominal or transvaginal
- endometrial biopsy (at day 26 of the cycle); secretory endometrium c) laparoscopy (invasive): indications; U/S
LH surge in urine (at day 14 of the cycle): one of the best method to predict the occurrence of ovulation pelvic pain/infection OR abnormal a or b
Counseling, Detect the defect in the hypothalamus - pituitary - ovarian axis & correct it - intrauterine insemination
depend on the severity, location, & surgeon
ovulation induction with anti- (IUI)
Treatment

- avoidance of stress skills:

oestrogen (clomiphine citrate, - oestrogen: soften the
- treatment of systemic illness Human menopausal - surgical: laparoscopic adhesiolysis
tamoxifen, exogenous gonadotrophin) cervix ferning
- resection of the tumour gonadotrophin - in-vitro fertilization (IVF): in case of
- administered at follicular phase - for fibroid: transvaginal
And so on (2) extreme damage
- monitor with serial U/S (why???) myomectomy
(1) Hysterosalpingography: Indications: a) tubal patency b) uterine content & shape Complications: a) anaphylactic shock b) allergy to dye c) pelvic infection d) severe pain that may need analgesia
(2) This may lead to ovarian hyperstimulation & multiple pregnancy, the patient complain of abdominal fullness & pain which is due to haemoconcenteration. ttt; fluid replacement & infusion of plasma protein.
Disorders of spermatogenesis Sperm transport Ejaculatory dysfunction
- high scrotal temperature - malformation of epididymis - drug induced
Disor.

- microdeletion of Y chromosome - malformation of vas deferens - idiopathic

Male Infertility

- drugs (psychotropic, anti-epileptic, antihypertensive, antibiotics, chemotherapeutics) - obstruction due to inflammation/infection - metabolic or systemic disease (e.g. DM)
Semen analysis (WHO); sample taken after 3 - 5 days of sexual abstinence
- volume: 2 - 5 ml - liquification time: within 30 min - sperm concentration: 20 million/mL - sperm motility: > 50 % - sperm morphology: > 30 % - WBCs: < 1 million/mL
Inv.

In case of low concentration: endocrine profile, chromosomal studies. In case of low motility: search for antisperm antibodies.
Postcoital test: examine the ability of the sperm to reach & survive in the mucous. sample obtained from the female partner 6 - 10 hrs after coitus
- hypogonadotrophic hypogonadism oligospermia: exogenous gonadotrophin & hCG
- idiopathic oligospermia: * intrauterine insemination with ovarian stimulation OR * in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI)
ttt

- sperm parameter very low: donor sperm

- azoospermia: sperm aspiration followed by IVF with ICSI treatment (counseling & advising is the most important part of the treatment)
 Common Disorders in Gynaecology
Prevalence Aetiology Clinical Features Examination / Investigation Treatment Notes
Definition: Syndrome of ovarian dysfunction along with the cardinal features of hyperandrogenism & polycystic ovary syndrome
1- Increase ovarian - high testosterone (free > 5 nmol/L) - for amenorrhoea: cyclical progesterone, or OCP &
increase risk of
androgen production: - oligomenorrhoea/amenorrhoea (75%) - decrease sex hormone binding globulin Metformin (increase ovulation rate)
endometrial cancer
- for hirsutism: Eflornithine acetate, Cyproterone
PCOS

5-10 % (due to disordered - hirsutism (30-70%): due to androgen - high LH level (n.: 0.5 - 14.5 IU/L)
(unopposed
------------- ovarian cytochrome - subfertility (75%): due to anovulation - high LH : FSH ratio (inverted) (n.: 1:2) acetate, Metformin & Dianette, GnRH analogues
oestrogen),
On U/S: P450 & increase LH - obesity (40% of patients are obese) - high fasting insulin with low dose HRT, surgical removal of hair follicle
diabetes,
About 25 % stimulation) - recurrent miscarriage (50-60%) - U/S: eight or more subcabsular - for subfertility: Clomiphine with or without
cardiovascular
2- Insulin resistance - acanthosis nigricans (2%) follicular cyst < 10 mm in diameter & gonadotrophin, Metformin, Ovarian drilling
diseases
3- Genetic role increased ovarian stroma - for obesity: weight reduction, Metformin
Definition: Benign tumour of uterine smooth muscle, termed leiomyoma. can be submucous, intramural, subserous, intracavity, pedunculated, or cervical fibroid
(majority asymptomatic) Examination: NO treatment if asymptomatic (& < 12 wk in size)
Aetiology unknown.. - degeneration: red,
- menstrual disturbance -abdominal: firm mass arising from pelvis 1) Medical: GnRH agonist, Mifepristone in low dose
20 % in over BUT growth is hyaline, cystic,
Fibroid

- pressure symptoms (e.g. frequency) -bimanual: mass felt as part of the pelvis 2) Surgery according to patient complain & fertility
30 years old oestrogen dependent calcification,
- pain; if undergo red degeneration Investigation: - for submucous: vaginal hysteroscopic resection
------------- Risk factors: malignant change
- menorrhagia (how?) -Hb: low indicate significant menorrhagia - bulky fibroid: myomectomy OR hysterectomy
Common in Nulliparity, obesity, - complications:
- recurrent abortion, subfertility (how?) -U/S: diff. uterine from ovarian mass surgery can be facilitated by GnRH agonist for 2m.
Negro +ve FH, African racial a) polycythaemia
- with pregnancy: abnormal lie, -Renal inv.: to exclude hydronephrosis no surgical removal during pregnancy or C/S (why?)
origin b) hypoglycaemia
obstructed labour, PPH -Needle biopsy: to exclude sarcoma 3) New method: embolization of uterine arteries
Definition: Presence of endometrial surface epithelium and/or presence of endometrial glands & stroma outside the lining of the uterine cavity
Theories: Examination: Medical:
- recurrent problem
Endometriosis

1) Menstrual - dysmenorrhoea - pain in pouch of Douglas by palpation - simple analgesia, danazol, synthetic progesterone
10-15 % - histological
regurgitation & - cyclical pelvic pain - ovarian mass(es) & fixed retroverted - inhibition of ovulation: COCP & GnRH analogues
In age subtypes:
implantation - deep dyspareunia uterus (DD: chronic PID) Surgical: 1) conservative treatment:
between * free implants
2) Coelomic epithelium - history of subfertility or infertility - pelvic mass on bimanual examination - laparoscopic with intra-abdominal lasers:
20-30 years * enclosed implants
transformation - cyclical haematuria, ureteric Investigation: easier, but complicated by severe adhesion
------------- * healed lesions
3) Genetic & obstruction - U/S: to exclude endometriomata 2) definitive treatment:
Common in * ovarian
immunological factors - cyclical rectal bleeding or pain on - CA 125: slightly raised (of little uses) - ablation, resection or total abdominal
Caucasians endometriosis or
4) Vascular lymphatic defecation - diagnostic laproscopy & biopsy of the hysterectomy & bilateral salpingo-oophorectomy
chocolate cyst
spread lesion: confirmatory Should be followed by HRT after 6 months
Definition: Protrusion of an organ or structure beyond its normal confines. & classified according to their location & the organs contained within them. (uterovaginal prolapse)
- non-specific symptoms usually (lump, - abdominal: to exclude organomegally - lifestyle modification & 7 days topical oestrogen
Prolapse

12-30 % of - congenital
local discomfort, backache, bleeding, or mass Medical: Ring pessaries (silicon-rubber or shelf) OR Surgical:
multiparous - childbirth & increase
infection, ulceration, dyspareunia) - vaginal: - in dorsal position to inspect - cystourethrocele: ant. colporrhaphy - rectocele: post. colporrhaphy
-------------- intra-abdominal pres.
- specific: introitus (e.g. ulcer, atrophy...) - uterovaginal prolapse: vaginal hysterectomy & support of pelvic floor
2 % of - ageing
rectocele: digitations, splinting - as pt straining to assess vaginal walls OR: Manchester operation & sacrohysteropexy
nulliparous - postoperative
cystourethrocele: frequency, urgency.. - Sims speculum - vault prolapse usually follow hysterectomy: sacrocolpopexy
Menopause

Prevalence Aetiology Clinical Features Physiological changes Treatment

Definition: The end of the monthly or menstrual cycle, manifested by range of anatomical, physiological & psychological events. occur at age of about 51 years.
Hormone Replacement Therapy (HRT)
Menopause

- Skeletal system: greater bone

- tiredness - absolute contraindications: pregnancy, breast cancer, endometrial
resorption than formation, increasing risk
Fall in circulating - hot flushes cancer, acute active liver disease, uncontrolled HTN, VTE
of osteopaenia & osteoporosis
40 % oestrogen (below - night sweats - relative contraindications: uterine fibroid, PH of benign breast disease,
so, increase pathological fractures
absolute level < 100 - insomnia chronic stable liver disease, migraine.
- CVS: increase incidence of MI, due to
pmol/L) - vaginal dryness - types: topical, oral, transdermal, subcutaneous implant
change in lipid profile (low HDL, high LDL,
- urinary frequency - sequential HRT for age < 54y or amenorrhoeic for < 2y
high total cholesterol level)
combined HRT for age > 54y or amenorrhoeic for > 2y
 - low grade malignancy
Sertoli
Leydig

- virilization features
- rare < 0.2%, small, unilateral
- ttt: oophrectomy
Management: - asymptomatic simple ovarian cyst often resolves spontaneously (criteria: unilateral, unilocular, 3-10 cm diameter in premenopausal or 2-6 cm in postmenopausal, normal CA 125)

- various cells secrete: androgen, oestrogen

Sex cord stromal tumour

- unusual tumour
Fibroma

tumor

- derived from stromal cell

cord

- hard, mobile, lobulated, white, bilateral in < 10%

- 4% of all neoplasm

Malignant features
- secrete hormones
- occur at any age

- Meigs syndrome represent 1%

2) Laparoscopic procedure indications: a- no pathology regarding the cyst. & b- suitable tumour for laparoscopy criteria??.

Theca - all are benign

cord t. - solid, unilateral -secrete oestrogen
- all are malignant - commonest sex cord tumour
- good prognosis if: 1) confined to ovary 2) slow growth - associate with endometrial tumour
Granulosa cord

3) late recurrence - tend to recurs after more than 5 years

tumor

- solid: Call- Exner bodies: pathognomic in 50%, and secrete following diagnosis
oestrogen & inhibin. - ttt: laparoscopic oophrectomy
- high oestrogen lead to: - if advanced: chemotherapy
1) precocious puberty 2) postmenstrual bleeding - yellow appearance indicate
3) endometrial hyperplasia 4) endometrial cancer haemorrhage
- arise from serosal cells
Clear cell - rarely benign, associate with hypercalcaemia & hyperpyrexia - least common
(mesonephroid) - histology: hobnail cells in mixed pattern (nuclei found in apical - associate with endometriosis
cytoplasm)
- 1-2% of all neoplasm - bilateral 10-15%
Ovarian Tumour

- wallfian metaplasia of surfuce epithelium

Brenner tumour
- majority: solid (transitional epithelium & fibrotic stroma)
Epithelial tumour

- secrete oestrogen - associate with abnormal vaginal bleeding

Malignant features

- unilocular, turbid brown fluid

endometrioid DD: ovarian endometriosis - 15% associate with endometrial

3) Laprotomy: if < 35 year old; ovarian cystectomy/unilateral oophrectomy. OR if > 35 year old; pelvic clearance
uterine Ca
- second commonest epithelial tumour
- unilateral, multilocular cyst with smooth inner surfuce lined by
columnar secreting cells
Mucinous
- cystic fluid: thick & glutinous - 10% of malignancy of ovary
cystadenoma - Pseudomyxoma peritonei: associate with mucinous tumour of appendix - largest tumour of ovary (25 cm)
Seedling growth, secreting mucin lead to obstruction of bowel.
- 5y survival rate 5% / 10y survival rate 18%
- commonest benign epithelial tumour
- bilateral unilocular cyst + papilliferous process
Serous - serious tumour, cystic & solid
- epithelium in inner site (cuboidal or columnar may be ciliated)
cystadenoma - Psammoma bodies (concentric calcification) - glandular structure: adenocarcinoma
- cystic fluid: thin
- rare - bone

mesoderm
None
- commonest ovarian tumour in

Rupture
teratoma
- arise from totipotential germ cells:

dysgerminoma
- classification to solid & cystic

Mature - contain mature tissue like - cartilage

(4%)
solid

e.g. carcinoid tumour, stroma overii..

dermoid + cystic area
- 20-30y: 2-3% malignant

- smooth
Germ cell tumour

- <20y. : 80% germ cell tumour

= non-squamous histology
- DD: immature teratoma muscle
has no significance

choriocarcinoma

(malignant)
- endometrial
sinus tumour

Clinical features
young (<30y)

embryonic

- 2% squamous Ca. > 40y

- ovarian

endoderm
- thyroid

Torsion
Extra-

(10%)

= capsular rupture
- common, result from

Types
- bronchus
differentiation into

(mature cystic
- intestine

Dermoid cyst

- poor prognosis:
embryonic tissue

teratoma)
- 40% of all ovarian

Asymptomatic
neoplasm - skin, teeth

ectoderm
embryonic

(60%)
- Def.: unilocular cyst < 15 - sebaceous
3 germ layers

1) Therapeutic U/S guided aspiration.

cm with predominant material,
ectodermal structure nerves tissue
- corpora leutea more than 3 cm
Large cyst form in ovary
Physiological cyst

during normal ovarian

Leuteal
- Intraperitoneal bleeding
- common on right side
cycle - occur on day 20 26 of cycle
- Commonest benign ovarian tumour

Follicular
- lined by granulosa cell
- due to non rupture of dormant follicle
- may be up to 10 cm or small
- symptoms due to oestrogen secretion (menstrual disturbance & endometrial hyperplasia)
 Malignant Gynaecological Tumour
Aetiology Types Clinical Pictures Diagnosis Treatment Prognosis Notes
Ia: complete local excision

- Adenocarcinoma (15-20%)
- Squamous cell cancer

- IVU
- exam. under anesthesia
Figo classification depend on:
- Cone biopsy
Intraepithelial Neoplasia (CIN)
Human Papilloma Virus (HPV)

- cause of death: renal failure

cytology pap & colposcopy)

- its the second commonest

Vary, depend on: volume &
(follow CIN which is usually
colposcopy directed cone biopsy

(screening for CIN: cervical

may appear after 10 years

both have same precursor

- its STD (remember HPV)

cells & biologic behavior
- asymptomatic
Ib - IV: surgery, radiotherapy or chemotherapy

stage of the disease

tumour worldwide
- postcoital, intermenstrual, &

following Cervical
(chemotherapy for spreading disease)
asymptomatic)

type 16 & 18
Cervical

post-menopausal bleeding
Surgery:
- profuse offensive vaginal

- cystoscopy
Wertheim hysterectomy (i.e. uterus, paracervical tissue,
discharge (blood stained)
upper vagina leaving only 2 to 3 cm, pelvic LNs)
- pain (late stage)
For lymph node invasion:
O/E:- friable polyp
*if large number: adjuvant radiotherapy
- bleeding on contact
*if 1 or 2 only involved: pelvic dissection
Radiotherapy: external beam VS internal beam ???
Surgery:
- Primary squamous cell (rare)
- Clear cell cancer (aggressive)
- Papillary serous (aggressive)
metaplasia)

- Pipelle sampler (biopsy)

IF endometrium > 5 mm thick;
- transvaginal U/S
- Adenocarcinoma (squamous
- Endometrioid (commonest)

follow uterine irradiation, aggressive

(obesity, nulliparity, diabetes.)

- poor gynecological malignancy

outpatient inv. & has advantage
*stage I, & undiagnosed stage II: total abdominal

of identify ovarian pathology)

myometrium & LNs invasion),

- Mixed mesodermal tumour:

(hysteroscopy can be used as
OCP, progesterone, smoking

- Sarcoma botryoides: affect

- depend on: stage (grade,
age, & body morphology
hysterectomy & bilateral salpingo-oophrectomy.
Oestrogen dependent

infant & young children

Endometrial

- Leiomyosarcoma
Protective agents:

*stage II: radical hysterectomy & bilateral pelvic

- postmenopausal bleeding lymphadenectomy with para aortic LNs sampling.
- postmenopausal discharge lymphadenectomy????
(blood stained) Radiotherapy:
- heavy period (33%) - for advanced disease
- followed by surgery for reminant tissue
Progestogens: (for palliation of recurrent disease)
- good result if: * well differentiated
* oestrogen receptor +ve
< 35y old: germ cell; curable chemotherapy
3) Genetic factors (e.g. BRCA1 & 2, FH ???)
2) Subfertility treatment
early menarche, late menopause)
1) Incessant ovulation theory (nullipra,

- Metastatic tumour
choriocarcinoma, teratoma, mixed)
endodermal sinus, embryonal cell,
- Germ cell tumour (dysgermimnoma,
stroma, androblastoma, gynandroblastoma)
- Sex cord stromal tumour (granulose
endometrioid, clear cell, Brenner)
- Epithelial tumour (serous, mucinous,

upper abdomen for metastasis

- exploration (laprotomy) of pelvis &
- for mets: FBC, U&E, LFT, IVU.
- ascetic fluid sample for cytology
- CA 125, abdominal U/S

cervical & endometrial tumours together

- generally good for the germ cell, & bad
> 35y old: epithelial; advance pelvic clearance

- ovary is the most radiosensitive organ

> 66% metastatic disease with

- cause of death: intestinal obstruction

- most serious is the serous epithelial...

- it kill women more than death due to

non specific symptoms Surgery:

for the epithelial cell tumour

* borderline in young: ovarian cystectomy or

- vary according to the type

- involvement of pelvic and
peritoneal organs: abdominal oophrectomy
distension ascites, & pain * Ia: unilateral salpingo-oophrectomy
Ovarian

(indigestion, frequency, weight interval debulking surgery????

loss) second look surgery (not done)
- metastasis to LNs under * Ib - IV: total abdominal hysterectomy with bilateral
diaphragm (44%) or above salpingo-oophrectomy & infracolic omentectomy
diaphragm Chemotherapy: (prolong survival, palliation)
- haematogenous spread (late) after surgery: 5-6 cycle at 3-4 weeks interval
metastasize to: liver, lung, * Cisplatin: has a lot of side effects
bone, & brain * Carboplatin: first line drug (less S/E than the above)
* Paclitaxel: first line with Carboplatin
FIGO Staging of cervical, endometrial & ovarian cancer
I confined to the cervix I confined to the corpus I confined to the ovaries
Cervical

Ovarian
Uterine

II involve up to upper two thirds of the vagina II involve the cervix, not outside the uterus II one or both ovaries with pelvic extension
III involve lower third of the vagina & pelvic wall III outside the uterus, not outside the pelvis III peritoneal implant outside the pelvis or +ve LNs
IV spread to distant organs IV involve mucosa of the bladder or rectum IV distant metastases
 Lower Genital Tract Infection
Infection Prevalence Risk Factors Clinical features complications Diagnosis Treatment Notes
> 75 % immunosuppression - If asymptomatic; no ttt

> 80% of cases

albicans cause
Candidasis

- itching & soreness of vagina & vulva

- Not STI but

triggered by
-------- HIV, DM, Pregnancy unlikely, unless the - microscopy & - Clotrimazole as vaginal
Vaginal

- Candida
- curdy white discharge, may smell
Few have Steroid, Antibiotic, women is severely culture of vaginal creams & pessaries

sex
yeasty
frequent COCP, high immunocompromised fluid - Fluconazole orally (C. alb)
- pH normal (3.5 - 4.5)
recurrence oestrogen, eczema - if pregnant: Imidazoles
- Afro-Caribbean - offensive fishy smelling discharge, - second trimester Amsel criteria:
- Metronidazole tabs

vaginal flora
- IUD which is thin, homogeneous, adherent miscarriage 1) vaginal pH > 4.5
Vaginosis

Caused by
anaerobic
Bacterial

- Metronidazole gel 0.75%

- elective termination to vaginal wall, may be white or yellow - preterm delivery 2) fishy smell on
(BV)

12 % or Clindamycin cream 2%
of pregnancy - this features apparent at time of - post-surgical infection addition of 10% KOH
- prophylaxis: 1-2/month
- common with other mensturation or following intercourse - not a cause of PID, but 3) clue cells on
Metronidazole
STIs - Ph: 4.5 7 (decrease no. of lactobacilli) can be found in PID pt microscopy
- vulvovaginitis, itching or soreness - can spread to infect the - Metronidazole tabs
Culture on Fineberg-

Metronidazole

toxicity from
Neurological
high dose of
- purulent, sometimes offensive vaginal bladder if not treated - treatment of sexual
Trichomonas
Vaginalis

20-30 % of Whittington medium

discharge which is thin, homogeneous, properly partner
pregnant STI show motile
yellow or green - BV may develop Alternative ttt:
women organism with 4
- strawberry cervix on examination - not a cause of PID, but - Arsphenamine pessaries
moving flagellae
- Ph: 4.5 7 (decrease no. of lactobacilli) can be found in PID pt - Clotrimazole

Upper Genital Tract Infection

Infection Prevalence Transmission Clinical features complications Diagnosis Treatment Notes
- PID, perihepatitis
- commonly asymptomatic - Cell culture - Doxycycline

genital infection
- serovars D-K:
- Reiters syndrome

- serovars A-C:
Trachomatis
Chlamydia

Commonest bacterial - mucopurulent cervicitis, that bleed - ELISA: less sensitive: - Azithromycin

trachoma
- tubal infertility

treatment of sexual partner

cause of STI easily on contact, increase vaginal endocervix sample - Ofloxacin
10 % - ectopic pregnancy
(gram ve obligate discharge - PCR: more sensitive; FOR pregnancy:
Neonatal complications:
intracellular parasite) - sore throat, conjunctivitis urine or vaginal swab - Azithromycin
- opthalmia neonatorum
- proctitis (LGV only) - DFA; cervical smear - Erythromycin
- neonatal pneumonitis
- Gram stained smear
- 50%: chronic asymptomatic infection -PID - Amoxicillin

taken from rectal

-ve two culture

STI of urethral, cervical &
Gonorrhoea

Test of cure:
following ttt
- proctitis with purulent green discharge, - Bartholins abscess - Ciprofloxacin
(Neisseria rectal swab (sen 50%)
bleeding & rectal pain - tubal infertility - Spectinomycin

swab
< 1% Gonorrhoeae is gram - Culture on blood
- exudative tonsillitis, conjunctivitis - ectopic pregnancy - Azithromycin
-ve intracellular agar using antibiotic
- in > 50% concomitant chlamydial Neonatal complications: - Ceftriaxone
diplococcic) & 7% CO 2 (sen 60-
infection - opthalmia neonatorum - Cefixime
70%)
H

Infection Prevalence Transmission Clinical features/Complication Diagnosis Treatment

- Detect antibodies to gp-120 (seroconversion,
- STI - fever, generalized lymphadenopathy, - Reverse transcriptase inhibitors:
become +ve within first 3 months of infection)
- IV drug abuse macular erythematous rash, pharyngitis, Zidovudine, Didinasine, Nevirapine..
HIV/AIDS

- PCR; concentration of viral RNA in plasma

> 20 million - blood product.. conjunctivitis.. - Protease inhibitor (it interfere with
- FBC; lymphopenia, thrombocytopenia
worldwide - vertical transmission - opportunistic infections, hairy oral drugs that use cytochrome P-450 &
- polyclonal IgG; raised total protein level
(single strand RNA leukoplakia, Kaposis sarcoma with synthetic oestrogen): Nelfinavir
Monitoring: level of CD4 lymphocyte on
retrovirus) - genital wart, cervical Ca, vulval IEN - Antibiotic for opportunistic infections
peripheral blood (normal > 0.5/L)
Maternal to Fetal transmission of HIV (25-40%) decreased (for up to 2%) by: 1) antiretroviral medication in the second half of pregnancy 2) elective C/S 3) avoid breastfeeding
 Obstetrics & gynecology Instruments

Obstetric forceps Ventouse (Vacuum extractor) Ovum forceps Green Armytages Clamp
traction, rotation, protection in the past (Indication? Contraindication?) hold the soft pregnant cervix haemostatic in case of C/S two clamps to control bleeding

Volsellum forceps (single teeth) Volsellum forceps (multi-tooth) Willets scalp forceps Needle holder Clips (curved kocher)
used to grasp the non-pregnant cervix traction of dead baby in APH hold the needle during incision artificial rupture of membrane

Curette Hegars dilator (cervical dilator) Uterine sound Cuscos vaginal speculum Sims vaginal speculum
Diagnostic: uterine bleeding, Ca drainage of haematometra or measure length of uterus & cervix, expose the vagina & cervix expose anterior vaginal wall
body, diseases of endometrium... pyometra, used before D & C, determine the direction of uterus, e.g. polyps, erosion, cancer, PROM e.g. vesicovaginal fistula, cystocele
Therapeutic: control bleeding ttt of dysmenorrhoea rare detect intrauterine tumor or FB Position of pt: lithotomy position Position of pt: Sims position

Decapitation Hook Doyens retractor Simpsons perforator Rubber & Metalic catheter Suction Machine (evacuation)
lock twin, transverse lie in dead protect the bladder during C/S craniotomy, hydrocephalus monitoring, preoperative, urine ret. miscarriage, molar pregnancy
References
Obstetrics by ten teachers (18th edition),
Edited by Philip N. Baker, BMed (Sci) BM BS DM FRCOG; 2006

Gynaecology by ten teachers (18th edition),

Edited by Ash Monga, BMed (Sci) BM BS MRCOG; 2006

Obstetrics and Gynecology by Beckmann (5th edition)

Edited by Charles R.B. Beckmann, Frank W. Ling Roger P. Smith, Barbara M. Barzansky,
William N. P. Herbert, Douglas W. Laube; 2006

Oxford handbook of Obstetrics and Gynaecology (2nd edition),

Edited by Sally Collins, Sabaratnam Arulkumeran, Kevin Hayes, Simon Jackson, Lawrence
Impey; 2009

Obstetrics and Gynecology Recall (3rd edition),

Edited by F. John Bourgeois, Megan J. Bray, Catherine A. Matthews; 2008

Pre-Test Obstetrics and Gynecology (10th edition)

Edited by Michele Wylen; 2004

Multiple Choice Questions in Gynaecology & Obstetrics (3rd edition); 1996

BNF, British National Formulory

Obs & Gyn Tutorial,

by Dr. Duria A. M. Rayis; 2008-2009

Obs & Gyn Clinical Rounds,

by Dr. Hassan Abdullah, Dr. Duria A. M. Rayis, Dr. Nada Jaafer, Dr. Khalid Nour Eldin,
Dr. Mohamed Awad, Dr. El-Gazali; 2007-2009

Obs & Gyn afternoon session,

by Dr. Abubakr M.A. Nasr, Dr. Zaki Mustafa, Dr. Yasir Salih; 2008-2009
Mohamed Ataelmanan Abdalla Mohamed
Obs & Gyn old Final Exams, by different universities mohattta@hotmail.com
2010