Compilation of O&G Lectures - Clinical Short Notes PDF

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Antepartum hemorrhageA Define antepartum haemorrhage Bleeding from/in the genital tract from 24+0 weeks of pregnancy & prior to the birth of the baby. B What are the different causes of antepartum haemorrhage? Undetermined 45% Placental causes - Placental previa 30% - placental abruption 20% * 2...

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Antepartum hemorrhage A

B

Define antepartum haemorrhage Bleeding from/in the genital tract from 24+0 weeks of pregnancy & prior to the birth of the baby. What are the different causes of antepartum haemorrhage? Undetermined 45% Placental causes - Placental previa 30% - placental abruption 20% * 2 most life threatening causes - placental circumvallate Fetal causes - vasa previa Uterine/cervical causes - endocervical polyp > cervical polyps (reproductive age group; vs ectocervical polyps in postmenopausal women) - cervical ca - cervical erosion/ectropion - cervicitis - vaginal infarction - uterine rupture Miscellaneous - Vulva varices - trauma - blood stained show

C

How will you differentiate clinically placenta praevia from placenta abruption? PP PA = premature separation of placenta from uterine wall, in a normally situated placenta - causeless recurrent, painless/provoked - abdominal pain +/- PV bleeding bleeding - continuous pain - without warning, without contractions - head can be engaged = sentinel bleed Mild 1/3 (large retroplacental hematoma) - high presenting part - hypovolemic shock: - abnormal presentation (transverse, breech) tachycardia, hypotension *out of proportion or cephalic x engage to the amt of PV bleed - maternal cardiovascular compromise - tense woody uterus - Only speculum examination: placenta seen - difficult to palpate fetal parts with cervical dilatation - change in FHR Can do vaginal ex + speculum

D

Discuss the management for each type of placenta praevia. 1. Prevention and tx of anemia during ANC period 2. 3rd trimester – counselling about the risks of preterm delivery & obst hemorrhage 3. Major previa previously bled admitted from app 34weeks 4. Minor previa/asymptomatic -> Outpatient care Mild to mod bleeding 2days of bleeding cessation: pelvic rest, when to return Severe bleeding  Admit, resuscitate, - RED ALERT (obst, anaes, sister oncall, blood bank; ABCDE & transfusion) Airway, O2 5-8L/min, circulation 2 iv drips 14-16G crystalloids e.g. Hartmann’s/NS or colloids e.g. Hemaccel/plasma, GXM 2-4u, Drainage of bladder with Foley’s, IO chart  EM-LSCS Assess pt amt blood loss, pallor, BP, PR (30min) padchart, continuous CTG, GXM 4u, maternal steroids Complications:

Placental accrete – spectrum of disorder ranging from abnormally adherent  deeply invasive placental tissue 1. Accreta: villi adhere superficially to the myometrium without interposing decidua (total/partial/focal) 2. Increta: villi penetrate deeply into the myometrium down to serosa 3. Percreta: villous tissue perforates through the entire uterine wall, may invade surrounding pelvic organs e.g. bladder

PPROM & PROM: a

Definition: premature ROM = >24weeks but before labour [1m] PPROM (preterm prelabour rupture of membrane) = spontaneous rupture of fetal membranes from 24 weeks – before 37 completed weeks but before the onset of labour. Term PROM (prelabour rupture of membranes) = spontaneous rupture of membranes beyond 37 completed weeks but before onset of labour

b

c

d

Causes [1+1m] a) vaginal infection (ascending infection) in most cases, GBS, chorioamnionitis b) bleeding: APH – abruptio placentae, placenta praevia c) Uterine overdistension : Multiple pregnancy ,polyhydramnios d) uterine abnormality, cervical insufficiency 35+0w)  induction and deliver* 18h in unknown culture status)

Antenatal care: A

A 25-year-old woman books for shared antenatal care in her first pregnancy. What screening is performed on the booking bloods? [6m] - FBC: Hb - Blood group (ABO, RH) + Red cell Ab screen - Rubella status - VDRL (syphilis) - HIV - HBsAg (Hep B)

B

What is the purpose of routine antenatal ultrasound scans? [4m] - confirm gestational age, detect multiple pregnancy, viability, CRL (dating scan 8-13weeks) >13Weeks use BPD, HC, FL (biometry) Serial AC most useful to detect Macrosomia - serial scan for fetal growth, detect IUGR - placenta location (detect PP) - anomaly scan @ 18-22weeks

C

How is the screening for gestational diabetes performed? [3m] - OGTT @ booking if risk factors present Fasting >5.1mmol/L ; 2hr postprandial >7.8mmol/L = DM if no  repeat OGTT @24-28weeks (‘’) = GDM Women age 25 and above with no other RF do OGTT @ 24-28weeks

1-2 days prior test, normal carb diet 9-10pm prior day of test, start fasting 8am @ KK, draw 1st sample of venous plasma blood Drink a glass of glucose 75g in 250-300ml of water 2hr after that, 2nd venous sample taken (Plasma glucose level) D What is the purpose of physical examination at each of the antenatal visits? [2m] - BMI (compare with value before pregnancy) Ht >150 = adequate pelvis Wt gain during pregnancy (12kg) 2kg in 1st 20 weeks  10 kg in remaining 20weeks - PR, BP - Pallor - oral hygiene, dental caries (*existing cardiac lesion) - thyroid enlargement - pedal edema (Bilateral) Systemic: CVS, RS Abdominal: SFH, lie, presentation, engagement, FHS, fetal movement Ultrasound Outline principles of antenatal care of a known diabetic mother who was using oral hypoglycaemic agents before pregnancy, presented for booking at the antenatal clinic at 8 weeks gestation. [2m] - Investigation: Urinalysis (glycosuria, proteinuria) UFEME, RFT, ophthalmic assessment (fundoscopy), HbA1c (past 3month glycemic control), good control @ conception reduce malformation NO ROLE FOR MOGTT, Dextrostix (for follow up)

- Stop the OAD *metformin BD continued (NIDDM women should change from OAD  insulin) - refer dietician - 4x Dextrostix (BSP) prebreakfast, prelunch, predinner & prebed AIM: 4-6mmol/L - low dose aspirin 75mg daily from 12weeks  term

Labour: Describe in detail the mechanism of labour of a fetus in left occipito anterior position. 1. Engagement: Vertex presentation, biparietal diameter is @ the level of pelvic inlet / lower = occiput palpable @ station 0 2. Descent: Head reaches pelvic floor by the time cervix is fully dilated *Active phase of 1 st stage *facilitated by – uterine contractions & retraction - bearing down effort - straightening of fetal ovoid esp after ROM 3. Flexion: As vertex descends into maternal pelvis, encounter resistance from pelvic floor muscles 4. Internal rotation: e.g. LOA  OA = anterior internal rotation Engagement and descent of vertex into the pelvis (fetus usually in transverse), because of the anatomic configuration of pubococcygeus & iliococcygeus muscles, occiput will be forced to rotate to the symphysis pubis = widest area of the pelvic floor allowing passage of fetus Prerequisites – Well flexed head - efficient uterine contraction - favourable midpelvic plane shape - tone of levator ani muscles *Can be affected by epidural anaes; if pelvic floor musculature is suddenly relaxed by a strong epidural block, IR could be directed toward the sacrum/asynclitism (fetal head x in the same longitudinal axis as its VC) *major problem  larger diameter to the maternal pelvis 5. Crowning: after internal rotation, further descent till subocciput lies underneath the pubic arch. *Max diameter of the head (biparietal diameter) stretches vulval outlet without any recession of the head even when contraction is over 6. Extension: Delivery of fetal head *Combined effects of uterine contractions + pelvic floor 7. Restitution & External rotation: As a consequence of alignment of head with its spine as the pressure from maternal pelvis and muscles on the fetal head is alleviated 8. Expulsion of the trunk: Anterior shoulder will descend under the pubic bone & follow the external rotation of the head a

b

Occipitoposterior Describe occipito-posterior (OP) position [2m] foetal occiput posterior to transverse diameter of pelvis, directly on the sacrum associated with deflexed head and dystocia. Classified into right, left, and direct. Causes: Abnormal pelvis, placenta previa, polyhydramnios, pelvic tumours, flat sacrum, lax abdomen/sudden relaxation by epidural anaes. Describe the different mechanisms and management of labour in occipito-posterior (OP) position.[3m] 1. Right and left - occiput touches pelvic floor, rotate to transverse, then to anterior (internal rotation). 2. If arrested at transverse, called deep transverse arrest. 3. Deflexed - sinciput touch pelvic floor first. Rotates sinciput anteriorly, occiput posteriorly (short rotation),

Direct OP, Face to pubis. (head deflexion) Management: Epidural for painful ineffective contractions. Intrauterine monitoring of contractions. Bladder catheter for urine drainage. Large episiotomy. Direct face to pubis. If prolonged/ arrested labour, proceed with ELSCS, Vacuum extraction, forceps extraction. a List different methods used for foetal monitoring during pregnancy and labour. [3m] Clinical signs - Weight gain, symphysiofundal height. Pregnancy - Fetal kick chart: Cardif count to 10 method Reassuring = 10 in 15bpm for >15sec but x >2min, usually within 20 min of starting the test *high risk pregnancies as early as 32weeks— 26 weeks 1. Suspected/confirmed IUGR (Dopp UA ok) 2. Pre-existing/GDM 3. Hypertensive disorders 4. Prolonged/postdate 5. Decreased fetal movement 6. Maternal trauma 7. Comorbid posing risk e.g. thyroid, cardiac, renal disease, multiple gestation, substance abuse, cholestasis of pregnancy, h/o IUD (if NST x reassuring then additional antenatal fetal testing is necessary eg BPP) - Contraction stress test (CST)

Labour - CTG: FHR normal baseline 110-160 Acceleration, variability, deceleration Uterine contractions (Montevideo unit = intensity in mmHg, as measured with an IUP catheter) - Electronic fetal monitoring to detect early fetal distress (from fetal hypoxia & metabolic acidosis) - Meconium stained liquour

b What are the constituents of Biophysical profile for foetus? [2m] biometry – HC, FL, BPD, AC BPP – done by Manning’s score when NST is non-reactive/for other obst indications BPP = NST + ultrasonographic scoring system over 30min period 8-10 = reassuring 6 = equivocal, suspect asphyxia; repeat in 4-6hr, consider delivery for oligohydramnios 4 or less = abnormal, suspect asphyxia if >36weeks/mature  deliver immediately if14hrs Active phase: nulli 30min) - Protracted delivery (assisted >15min) Precipitous labour = interval from onset of regular uterine contractions to delivery of fetus 10g%) - Infections treated (UTI, dental, RTI) - Dysrrhythmias - HPT - obesity - multiple pregnancy ANC: 2weekly visits till 36weeks  weekly >36w - fetal monitoring for SGA (IUGR) *Severe cardiac ds/ cyanotic CHD - TOP discussed in 1st trimester *Eisenmenger & primary pulm HPT: Excessive maternal mortality Admit: - class I (at least 2 weeks before EDD) 38w - class II (@ 28weeks) - Class III, IV (early, kept in hosp throughout pregnancy) Preferred mode of delivery in most pt: Vaginal delivery + effective analgesia & short 2nd stage Pain relief: Pethidine/morphine (reduce anxiety & tachycardia) Epidural anaes (avoid bearing down efforts) CI in Rt Lt shunt as may cause sys hypotension C-sec reserved for obst indications & sp cardiac conditions e.g. CoA

Q) Discuss the management of cardiac patient in labour [5m] Labour: Pt in lateral position to avoid aortocaval compression & possible hypotension O2 for selected pt Fluid balance followed closely to avoid pulm oedema intrapartum cardiac monitoring e.g. continuous electrocardiographic monitoring, pulse oximetry invasive hemodynamic monitoring e.g. pulmonary artery catheter, arterial line (high risk/deteriorating patients) Continuous FHR monitoring = standard

2nd stage assisted with forceps/ventouse delivery if SVD x achieved within 20min syntocinon im 10U during 3rd stage to minimize blood loss (x use ergometrine) Antibiotic prophylaxis against BE according to guidelines *to ALL with structural heart disease @ onset of IOL: Ampicillin iv 2g loading, 1g 6hrly + gentamicin iv 1.5g/kg in 3 divided doses (Vancomycin 500mg for those allergic to penicillin)

Postpartum: major fluid shift in initial 24-72hrs  CHF - uncomplicated (monitor in labour room at least 6hr)  transfer to HDU - O2 continued - ECG monitoring for 24hrs, BP, oximetry - fluid balance chart maintained; watch out if brisk spontaneous diuresis x occur (Vigilance for pulmonary edema) - Complicated heart lesions: HDU 48-72hrs with facilities for invasive cardiac monitoring - Early ambulation, compression stockings, continued thromboprophylaxis - Breastfeeding encouraged (except in severely compromised pt) - Review previous contraceptive plan & implement: POP / long acting inj MPA 150mg 3mthly / sterilization if family is completed

A

B

C

A patient with a known rheumatic heart disease (mitral stenosis) presents to the antenatal clinic for booking. How do you assess her cardiac condition? [2m] - Hx, P/e, echocardiogram Symptoms: breathlessness, nocturnal cough, chest pain, hemoptysis Signs: Cardiomegaly, loud P2 (pulm HPT), murmurs, arrhythmias, central cyanosis Surgery done/antibiotic prophylaxis taken NYHA classification for functional status 1-4 Echocardiogram for type & severity of structural lesion ECG What maternal complications in pregnancy might worsen her cardiac condition? How would you counsel her in that regard? [3m] - anemia - infection - dysrrhymia - hpt Outline the principles of management in pregnancy, labour and puerperium. [5m] as above

Gestational trophoblastic disease: (a) What is molar pregnancy? [1m] (b) What are the clinical features of molar pregnancy? [4m] (c) Discuss your management for such a case. [5m] Gestational trophoblastic disease (GTD) - spectrum of proliferative abnormalities of trophoblasts associated with pregnancy. WHO classification of Trophoblastic diseases: Premalignant Malignant

- Partial molar pregnancy - Complete molar pregnancy - Invasive mole - Choriocarcinoma - Placental site trophoblastic tumour

Molar pregnancy - A GTD young placenta - degenerative and proliferative parts - benign - with malignant potential. Classified into partial (foetus present) and complete (foetus absent). Clinical features • Passing grape-like vesicles • PV bleeding • Hyperemesis gravidarum. • No foetal movement • Early pre-eclampsia 20 follicle/ovary or an ovarian volume 10ml or more on either ovary or dominant follicles present

DD, Other investigations: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Thyroid function test Prolactin levels LH FSH ratio. Serum testosterone. (PCOS patients elevated) (DHEA-S) Dehydroepiandrosterone (normal 35 – 430 ug/dL ; PCOS patients >200 ug/dL) Lipid profile Blood sugar profile, MoGTT Pelvic ultrasound (ring of pearls) CT scan or MRI to visualise the adrenals and ovaries. Endometrial biopsy to tule out malignancy if hyperplasia present.

- pregnancy - functional hypothalamic amenorrhea - primary ovarian insufficiency - androgen-secreting tumour - cushing syndrome - acromegaly

Management: Conservative Symptomatic

Metabolic syndrome Infertility

- lifestyle modification: diet, exercise Hirsutism - OCP (ethinyl estradiol 20-30mcg decreases ovarian androgen production) - Eflornithine - Shave/wax/hair bleaching/laser hair removal Acne - OCP (low dose estrogen) *Spironolactone 50-200mg/day = 1st line antiandrogen for hirsutism and acne) Androgenic alopecia - Minoxidil (topical) - Finasteride for adult, non-pregnant women 5mg PO Metformin Ovulation induction - Letrozole (Aromatase inhibitor): 1st line therapy - SERM Clomiphene citrate + Metformin (for better effect) *Don’t give HCG following Clomiphene if ovaries are abnormally enlarged, >3follicles of 15mm, an ovarian cyst is present, s. estradiol conc>2000pg/ml - Tamoxifen - Gonadotrophins Procedures: - Laparoscopic multiple ovarian drilling/stimulation (cautery/heat) - Oocyte retrieval - IVF, ICSI, transfer of embryos into uterine cavity COMPLICATIONS: Ovarian hyperstimulation syndrome (OHSS) – severe abdominal pain, pyrexia, increased 3rd space fluid loss (ascites/pericardial or pleural effusion, leg swelling, vulval edema), breathless, reduced urine output, a/w thrombosis

Clomiphene citrate: - Give from 5th day after menstruation, OD for 5 days, then start sexual intercourse

Management: - Outpatient for mild & moderate OHSS - Avoid NSAIDs (as may compromise RFT); PCM/opiates can be used - thromboprophylaxis with LMWH - paracentesis of ascitic fluid via abdominal/transvaginal under USG

Diabetes in pregnancy: A

B

C

Define gestational diabetes mellitus. [2m] Defect of glucose tolerance with onset/1st recognition during pregnancy; resolve 6 weeks postpartum. Universal screening done between 24-28weeks If RF present, done @ booking / as early as possible How do we screen for Gestational Diabetes Mellitus? [4m] MOGTT 75g - OGTT @ booking if risk factors present Fasting >5.1mmol/L ; 2hr postprandial >7.8mmol/L = DM if no  repeat OGTT @24-28weeks (‘’) = GDM Women age 25 and above with no other RF do OGTT @ 24-28weeks 1-2 days prior test, normal carb diet 9-10pm prior day of test, start fasting 8am @ KK, draw 1st sample of venous plasma blood Drink a glass of glucose 75g in 250-300ml of water 2hr after that, 2nd venous sample taken (Plasma glucose level) Discuss management of insulin controlled GDM in labour. [6m] Intrapartum care: - Delivery should ideally be planned - Aim for SVD - Timing: Uncomplicated, well controlled NIDDM, with normal fetal growth @ 38weeks GDM/IDDM requiring insulin - 38 or earlier - set up iv line for insulin infusion = 1U/hr - monitoring (in established labour): Capillary glucose est 2hrly AIM between 4-6mmol/L to prevent neonatal hypoglycemia Serum electrolytes & urine acetone 4hrly - analgesia *epidural - Continuous fetal monitoring - Shortened 2nd stage (x prolonged labour) *PARTOGRAM MUST BE STARTED

Pt on diet modification only, insulin infusion started when capillary glucose >7mmol/L, via perfuser solution 20U(0.2ml of 100U/ml solution) in 19.8ml NS  20ml syringe @ final conc 1U/ml Infusion requirement – Sliding scale regime: (insulin per500ml 10%D/w) >7-10mmol/L = 2U/hr 10.1 – 15 mmol/L = 3U/hr 15.1-20 mmol/L = 4U/hr Outline principles of antenatal care of a known diabetic mother who was using oral hypoglycaemic agents before pregnancy, presented for booking at the antenatal clinic at 8 weeks gestation. [2m] - Investigation: Urinalysis (glycosuria, proteinuria) UFEME, RFT, ophthalmic assessment (fundoscopy),

HbA1c (past 3month glycemic control), good control @ conception reduce malformation NO ROLE FOR MOGTT, Dextrostix (for follow up) - Stop the OAD *metformin BD continued (NIDDM women should change from OAD  insulin) - refer dietician - 4x Dextrostix (BSP) prebreakfast, prelunch, predinner & prebed AIM: 4-6mmol/L - low dose aspirin 75mg daily from 12weeks  term - ULTRASOUND

aDiscuss the value of preconception counselling in an insulin dependent diabetes woman. [2+3m] 1. Preconception HbA1c15mm/hr, CRP, urinalysis, STI testing - Ultrasound pelvis: very ill pts (Tuboovarian abscess) *transabd + transvaginal - MRI (if US inconclusive) - Laparoscopy, endometrial biopsy = MOST ACCURATE, but rarely userd - UPT, HIV testing Empiric tx: Antibiotics (against N.gonorrhea, Chlamydia trachomatis, BV)  Azithromycin (improved cure rates compared with doxycycline), Metronidazole new regime [1g Azithromycin weekly x2/52 + 250mg ceftriaxone im on D1] At least 1 dose of parental cephalosporin OPD  Ceftriaxone (single dose) & probenecid (single dose) + doxycycline +/- metronidazole (**oral therapy at least 14days) GOALS: 1. Eradicate infection 2. Preserve fertility 3. Prevent transmission Retested @ 3m (for those +ve for N. gonorrhea / C. trachomatis) Complications *Long term Cx are relatively common: - chronic pelvic pain - infertility - ectopic pregnancy - tubo-ovarian abscess - Asherman’s syndrome

Subfertility:

Define primary and secondary subfertility. [2m] Infertility = Disease of the male/female reproductive system defined by failure to achieve a pregnancy after 12 months or more of regular...