Obstetrics and Gynaecology Notes PDF

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Obstetrics and Gynaecology NotesGynaecological conditionsPrimary Amenorrhoea  Not starting menstruation by age 14 (if no other evidence of pubertal development) or 16 (if other signs of puberty e. breast buds)  Normal: starts age 8-14 in girls and 9-15 in boys. Takes 4 years from start to finish. ...

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Obstetrics and Gynaecology Notes Gynaecological conditions Primary Amenorrhoea  Not starting menstruation by age 14 (if no other evidence of pubertal development) or 16 (if other signs of puberty e.g. breast buds)  Normal: starts age 8-14 in girls and 9-15 in boys. Takes 4 years from start to finish. o Girls: starts with developing breast buds, then pubic hair and finally periods (takes about 2 years from start of puberty)  Hypogonadotropic hypogonadism o Deficiency of LH and FSH from pituitary. Leads to lack of sex hormones (testosterone and oestrogen) production by gonads (hypogonadism). o Tells you the problem is in hypothalamus or pituitary gland. Hormonal profile will show low LH and FSH o Causes  Kallmann’s syndrome  Prader-Willi syndrome  Pituitary tumours  Hyperprolactinaemia  Cranial tumour  Radiation treatment  Drug use (opiates, alcohol abuse)  Systemic or chronic illness  Idiopathic  Hypergonadotropic hypogonadism o Gonads fail to respond to stimulation from gonadotrophins. No negative feedback so hormonal profile will show high LH and FSH o Causes  Hypothyroid  Hyperprolactinaemia  Congenital adrenal hyperplasia  Turners syndrome  Androgen Insensitivity syndrome  PCOS  Assessment o Look for evidence of puberty and assess for possible underlying causes o Evidence of puberty  Height and weight  Development of pubic hair, breast tissue and acne o Hypothalamic causes  History of excessive exercise, stress, eating disorder and chronic disease  Low BMI or signs of an eating disorder or chronic disease o Hormonal causes  Androgen excess, thyroid problems or high prolactin 1

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 Dysmorphic features o Structural causes  Abdominal and pelvic examination Investigations o Pelvic US o Hormones (LH, FSH, TSH and prolactin) Management o Establish underlying cause and treat that. Osteoporosis o Low oestrogen levels are associated with an increased risk of osteoporosis

Secondary Amenorrhoea  No menstruation for more than 3 months after having previously started periods – investigate if lasts more than 6 months  Causes o Pregnancy o Menopause o Hypothalamic causes – occurs when physiological stress stops the hypothalamus from producing GnRH.  Excessive exercise  Low weight/eating disorders  Chronic disease  Psychological cause o Pituitary causes  Pituitary tumour (e.g. prolactinoma)  Pituitary failure (e.g. Sheehan Syndrome) o Ovarian causes  PCOS  Premature ovarian failure  Menopause o Uterine causes – Asherman’s Syndrome o Hypothyroidism  Hormonal tests o High FSH suggests primary ovarian failure o High LH or LH:FSH ratio suggest PCOS o Do MRI head if hyperprolactinaemia o TSH raised in hypothyroidism Androgen Insensitivity Syndrome - Normal male sexual characteristics do not develop - Results in female phenotype other than the internal pelvic organs - Normal female external genitalia and breast tissue but internally there are testes in the abdomen or inguinal canal and no uterus, upper vagina, fallopian tubes or ovaries

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Cause: testes normally produce Mullerian inhibiting factor that prevents a male developing female sexual organs. X-linked. Male karyotype (46 XY), insensitivity to androgen means no pubic hair, facial hair or male type muscle development. Patients are infertile and risk of testicular cancer - Management: oestrogen therapy. Bilateral orchidectomy Premenstrual syndrome - Caused by fluctuation in hormones during premenstrual period, particularly in oestrogen and progesterone associated with corpus luteum degenerating prior to menstruation - Features: bloating, headaches, backaches, anxiety, low mood, irritability. Symptoms improve with the onset of menstruation. If symptoms are severe and have a significant effect on quality of life, this is called premenstrual dysphoric disorder - Management: symptom diary, lifestyle changes, COCP, SSRIs -

Menorrhagia - Causes: fibroids, hormone imbalances (PCOS, thyroid disease, obesity), copper coil, CTD e.g. Ehlers-Danlos syndrome, bleeding disorders (e.g. vWD), endometrial cancer - Investigations: o Pelvic examination o Pelvic/transvaginal ultrasound if: abnormal pelvic exam, postcoital bleeding, intermenstrual bleeding, pelvic pain - Management: o Exclude underlying pathology (anaemia, cancer) and manage underlying causes o Management when they do not want contraception:  Tranexamic acid when no associated pain (antifibrinolytic)  Mefenamic acid (NSAID – reduces bleeding and pain) o Management when contraception is wanted or acceptable  Mirena coil, COCP, POP (norethisterone), Depo injection o If other management fails  Endometrial ablation, hysterectomy Fibroids (uterine leiomyomas) - Very common in late reproductive age (towards menopause) and more common in Afro-Caribbean. Oestrogen sensitive and grow in response to oestrogen. - Locations: o Intramural is within the myometrium. As they grow they change the shape and distort the uterus o Subserosal means below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity o Submucosal means just below the lining of the uterus (the endometrium) o Pedunculated means on a stalk - Presentation o Asymptomatic o Menorrhagia is number 1 presenting symptom o Menstruation lasting > 7 days o Abdominal pain, worse during menstruation 3

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o Bloating or full feeling abdomen o Urinary or bowel symptoms o Deep dyspareunia o Reduced fertility Diagnose with pelvic/transvaginal ultrasound Conservative management o symptomatic - Analgesia, tranexamic acid o Mirena coil (1st line) – requires the fibroid 10ml) - Insulin resistance o High levels of insulin result in higher levels of androgens o Metformin can improve insulin resistance and reduce circulating insulin levels. Diet, exercise and weight loss also improve insulin resistance - General management o Weight loss o COCP - Managing infertility o Weight loss o Metformin o clomifene - managing hirsutism o co-cyprindiol (Dianette) – has an anti-androgenic effect, contraceptive, increased risk of VTE o topical eflornithine o specialist medication: spironolactone, finasteride (5a-reductase inhibitor that decreases testosterone production), flutamide (nonsteroidal antiandrogen)

Premature Ovarian Failure - menopause before the age of 40 years - hormonal analysis will reveal raised LH and FSH - causes 7

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idiopathic chemotherapy/radiotherapy autoimmune Turners syndrome

Menopause - Can be diagnosed 12 months after the last menstrual period - Contraception is recommended for 2 years after the LMP in women under 50 and 1 year in women over 50 - Caused by drop in oestrogen and progesterone - LH and FSH are usually high, in response to the drop in the gonadal hormones - Perimenopausal symptoms o Hot flushes, emotional lability, premenstrual syndrome, irregular periods, heavier or lighter periods, vaginal dryness, reduced libido - Management of perimenopausal symptoms o HRT o Tibolone (only when 12 months period free) o SSRIs e.g. fluoxetine/citalopram o Clonidine o CBT Hormone Replacement Therapy - Non-hormonal treatments o General lifestyle o SSRIs e.g. fluoxetine o Venlafaxine o Clonidine - 3 considerations o Perimenopausal vs menopausal  Perimenopausal – give cyclical treatment  Post menopause – give continuous treatment o Local vs systemic affect  Local – give topical treatment e.g. oestrogen cream  Systemic o Uterus  Has uterus – add progesterone  No uterus – don’t add progesterone - Contains oestrogen o Combined with progesterone to lower risk of endometrial cancer (caused by unopposed oestrogen) o Combination with progesterone increases the risk of breast cancer o No need to combine with progesterone when there is hysterectomy in past

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o The mirena coil can be used to provide the progesterone component of combined HRT Benefits o Reduces symptoms of menopause o Reduces osteoporosis Downsides o Increases risk of breast and endometrial cancer o Increases risk of stroke and thrombosis o Risks increase with duration of use Side effects o Bloating o Breast swelling and tenderness o Weight gain o Headaches

Congenital structural abnormalities - Uterus develops from the paramesonephric ducts (Mullerian ducts). - Bicornuate Uterus o Two horns to the uterus. Associated with adverse pregnancy outcomes, however successful pregnancy is expected. Complications include miscarriage, premature birth, malpresentation - Imperforate hymen o Where the hymen at the opening of the vagina is completely formed without any opening. Usually only discovered when girl starts to menstruate and the menses is sealed in the vagina. o Causes intense cyclical pelvic pain/cramping that is normally associated with menstruation but without any vaginal bleeding o Diagnosis by examination and treatment is surgical incision o If not treated – retrograde menstruation – endometriosis - Transverse vaginal septum o Error in development where a septum (wall) forms transversely across the vagina. This can either be perforate (with a hole) or imperforate (completely sealed). o Perforate – difficulty with intercourse or tampon use o Imperforate – similar presentation to imperforate hymen o Diagnosis by examination, US or MRI o Treatment is with surgical correction o Complications – stenosis of the vagina or recurrence - Vaginal agenesis o In vaginal hypoplasia, the vagina can be abnormally small o In vaginal agenesis, it is absent all together – due to failure of the Mullerian ducts to develop. o It can be associated with an absent uterus and cervix o Ovaries typically remain in place Pelvic Organ Prolapse 9

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Uterine prolapse Rectocele o Defect in posterior vaginal wall. Associated with constipation and urinary retention. Cystocele o Defect in the anterior vaginal wall. Can also be a prolapse of the urethra (called a urethrocele) or both the bladder and urethra (cystourethrocele) Grades of uterine prolapse o Grade 0: normal o Grade 1: remaining above the introitus by more than 1cm o Grade 2: less than 1cm away from the introitus (above or below) o Grade 3: between 1cm below the introitus and at least 2cm of vagina remaining above the introitus o Grade 4: full eversion of the vagina Presentation o Urinary, bowel or sexual dysfunction o Feeling or something coming down in the vagina o Dragging or heavy sensation in the pelvis o Lump/mass o Worse on straining or bearing down Management o Conservative  Physiotherapy (pelvic floor exercises)  Lifestyle changes for associated stress incontinence (reduced caffeine intake, incontinence pads etc)  Treat associated symptoms such as stress incontinence e.g. with anticholinergic meds like oxybutynin  Vaginal oestrogen cream o Vaginal pessary  Different types e.g. ring, Gellhorn, cube, donut and hodge  Removed and cleaned every 4 months  Can cause vaginal irritation/erosion over time, oestrogen cream can help this o Surgery  Hysterectomy for uterine prolapse  Mesh repair controversy  Complications – infection, bleeding, damage to bladder/bowel, chronic pain

Urinary incontinence - Urge incontinence: due to overactivity of the bladder (detrusor) muscle - Stress incontinence – due to weakness of the sphincter allowing urine to lead during coughing or laughing - Risks: increased age, increase BMI, previous pregnancy and vaginal deliveries - Investigations o Urination diary 10

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o Urine dipstick with culture o Post-void residual bladder volume using a bladder scan o Urodynamic tests Management of stress incontinence o Weight loss o Avoiding caffeine/diuretics/overfilling the bladder o Pelvic floor exercises o Duloxetine (SNRI) o Surgery (tension free vaginal tape procedure) Management of urge incontinence o Bladder retraining (gradually increasing time between voiding) o Antimuscarinic medication (oxybutynin, tolterodine)

Bartholin’s Cyst - Typically unilateral and forms a fluid filled cyst between 1-5cm. Bartholin’s cysts will usually resolve with simple treatment such as good hygiene, analgesia and warm compresses. - If become infected – become Bartholin’s abscess – hot, tender, red and may be draining pus - Management of abscess o Requires antibiotics o Swab of any pus or fluid o Staph and strep and E.coli and gonorrhoea o Flucloxacillin or erythromycin (if penicillin allergy) are appropriate. Coamoxiclav will give broader coverage o May need surgical incision and drainage.

Lichen Sclerosus - Autoimmune - Symptoms: itching, pain, tight skin, painful sex (superficial dyspareunia) - Appearance: o Changes affect the labia, perianal and perineal skin o Associated with fissures, cracks, erosions or haemorrhages under the skin o Skin appears  Porcelain-white  Shiny  Papules/plaques  Tight and thin  Slightly raised - Complications o Pain and discomfort o Bleeding o 5% risk of vulval cancer – SCC - Management o Can’t be cured 11

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Followed up in secondary care Vulval biopsy can be performed if any lesions are suspicious Strong topical steroids are mainstay (dermovate) Emollients

Gynaecological Cancer Cervical cancer - Young women in peak reproductive years - 80% SCC, 20% adenocarcinoma - Causes o HPV (16, 18, 33) o Early sexual activity with many partners o Smoking o HIV o COCP - Presentation o Abnormal bleeding (intermenstrual, postcoital, post-menopause) o Vaginal discharge o Pelvic pain o Urinary symptoms (dysuria, frequency) - Staging o 1: confined to cervix o 2: invades uterus/upper 2/3 vagina o 3: invades pelvic wall/lower 1/3 of vagina o 4: invades bladder/rectum/beyond pelvis - Cervical intraepithelial neoplasia (CIN) – grading for level of dysplasia in cells of cervix o CIN I: mild dysplasia, likely to return to normal without treatment o CIN II: moderate dysplasia, likely to progress to cancer without treatment o CIN III: severe dysplasia, will progress to cancer if untreated. Sometimes called cervical carcinoma in situ - Screening o Smears that show mild dyskaryosis are tested for HPV - Program o Aged 25-49 every 3 years o Aged 50-64 every 5 years - Smear results o Mild (CIN I) – continue routine screening, no further investigation (unless HPV positive) o Moderate dyskaryosis (CIN II) – refer colposcopy under 2 weeks o Severe dyskaryosis (CIN III) – suspected cancer – refer colposcopy under 2 week 12

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o Inadequate – repeat smear o HPV positive – refer for colposcopy Management o CIN and stage IA: colposcopy with excision or ablation o Stage IB-2A with tumours 4cm: Chemotherapy + radiotherapy o Stage 4B: chemotherapy/palliative care HPV o Most common cause of cervical cancer o Linked to anal, vulval, vaginal, penis, mouth and throat cancers o Invades cells and interrupts the normal replication process, inhibiting tumour genes p53 and pRb o Sexually transmitted Strains o 6 and 11 – genital warts o 16 and 18 – cervical cancer Vaccination – Gardasil protects against 6, 11, 16 and 18

Endometrial Cancer - Risk factors o Age o Exposure to oestrogen  Early menstruation  Late menopause  HRT (especially oestrogen without progesterone)  No pregnancies o Obesity o Tamoxifen - Presentation o Post-menopausal bleeding o Inter-menstrual bleeding - Investigation o Transvaginal ultrasound for endometrial thickness (normal is 7.2) o concentration of sperm (more than 15 million per ml) o total number of sperm (more than 39 million per sample) o motility of sperm (more than 40% of sperm are mobile) o vitality of sperm (more than 58%) o percentage of normal sperm (more than 4%)

Ovarian Hyperstimulation Syndrome - complication of infertility treatment that promote the development of eggs in the ovaries - result of multiple developing luteinised ovarian cysts - causes release of oestrogens, progressed ones and vascular endothelial growth factors - causes increased vascular permeability, resulting in fluid leaking from blood vessel - features o abdominal pain and bloating o nausea and vomiting o diarrhoea o hypotension o ascites o reduced UO o prothrombotic state with risk of VTE - severity o mild = abdominal pain and bloating o severe = evidence of ascites, oliguria, hypoproteinaemia, haematocrit >45% - management o simple supportive and treating the complication (e.g. ascitic drainage and anticoagulation). May require admission to ICU in severe/critical cases

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Early Pregnancy

Advice - Take folic acid 400mcg from before pregnancy to 12 weeks (reduces NTD) - Take vitamin D - Avoid vitamin A supplements and eating liver and pate (teratogenic at high doses) - Don’t drink, smoke (preterm/IUGR), eat unpasteurised dairy or blue cheese (listeriosis), undercooked or raw poultry - Continue moderate exercise but avoid contact sports - Sex is safe - Flying increases risk of VTE

Smoking increases risk of: - IUGR, miscarriage, stillbirth, pre-term labour, placental abruption, pre-eclampsia, cleft lip/palate

Ectopic Pregnancy - Usually presents 6-8 weeks of pregnancy. Before this time the embryo is too small. After this time it suggests a different cause - Presentation o Delayed menstruation and a history of sexual intercourse o Lower abdominal pain – constant and in the iliac fossa o Vaginal bleeding o Lower abdominal tenderness 22

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o Cervical excitation o Avoid palpating adnexa as may rupture pregnancy Management o All ectopics need to be terminated. This is done with methotrexate or surgery (salpingectomy/salpingotomy) o Criteria for methotrexate (as per NICE guidelines)  Follow up needs to be possible to ensure successful termination  Unruptured  Adnexal mass 200ng/l) o Folate (normally >4ng/ml) - Management o Anaemic women should be started on iron replacement e.g. ferrous sulphate 200mg TDS. If they are not anaemic, but they have low ferritin (indicating iron stores), they should also be started on supplementary iron o Test women with low B12 for pernicious anaemia (test IF antibodies). If present, or have low B12 levels (e.g. 35) o Multiple pregnancy Symptoms o Headache o Visual disturbance/blurriness o Upper abdominal/epigastric pain (due to liver swelling) o Reduced UO o Brisk reflexes o Nausea and vomiting o Oedema Management o Aspirin prophylaxis (75mg daily from 12 weeks to birth)  Given to women with a single high risk factor o Pre-eclampsia  Labetolol is first line as an antihypertensive  Nifedipine second line  Magnesium sulphate is given during labour and in the 24 hour period afterwards to prevent seizures  Fluid restriction is used in severe pre-eclampsia/eclampsia labour to avoid fluid overload o Monitoring  BP  Symptoms  Urine dipsticks  Pre-eclampsia blood tests (platelet count, liver enzymes, U&Es)

Monitor fetal movements, serial growth scans, amniotic fluid volume and umbilical dopplers o HELLP syndrome  Haemolysis, elevated liver enzymes, low platelets o Eclampsia  First line management is IV magnesium sulphate 

Rhesus incompatibility in pregnancy - Women who are rhesus positive do not need any additional treatment during pregnancy - If woman is rhesus negative – gives birth to rhesus positive baby – mother becomes sensitised – subsequent pregnancies – mothers anti-D antibodies can cross the placenta into the fetus. If that fetus is rhesus positive, these antibodies attach themselves to the RBCs of the fetus and cause haemolysis o Haemolytic disease of the newborn - Management o Treated with an IM anti-D injection o Acts as a prophylaxis for the mother becoming sensitised to the rhesus D antigen o Anti-D injections are given routinely at 28 weeks gestation and gain at birth (only required after birth if the babys blood group is found to be Rhesus positive) o Anti-D injections should also be given at any time where sensitisation may occur, such as antepartum haemorrhage (vaginal bleeding in pregnancy), amniocentesis procedures and abdominal trauma o There is no way to reverse the sensitisation process once it...