Vaginal candidiasis

Overview

This is an extremely common condition which many diagnose and treat

themselves

Predisposing factors

Diabetes mellitus
Drugs
o Antibiotics
o Steroids
Pregnancy
Immunosuppression
o HIV
o Iatrogenic

Features

'Cottage cheese', non-offensive discharge

Vulvitis:
o Dyspareunia
o Dysuria
Itch
Vulval erythema
Fissuring, satellite lesions may also be seen

Investigations

A high vaginal swab is not routinely indicated if the clinical features are
consistent with candidiasis

Management

Options include local or oral treatment

Local treatments include clotrimazole pessary (for example clotrimazole
500mg PV stat)
Oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole
150mg PO stat
If pregnant then only local treatments (for example cream or pessaries) may
be used - oral treatments are contraindicated

Recurrent vaginal candidiasis

Compliance with previous treatment should be checked

Confirm initial diagnosis i.e. high vaginal swab, exclude differential diagnoses
such as lichen sclerosus
 Exclude predisposing factors (refer above)
Consider the use of an induction-maintenance regime, with daily treatment for
a week after by maintenance treatment weekly for 6 months

Pelvic inflammatory disease

Overview

This is a term used to describe infection and inflammation of the female pelvic
organs which includes:
o The uterus
o Fallopian tubes
o Ovaries
o The surrounding peritoneum
It is typically the result of ascending infection from the endocervix

Risk factors

Age < 25
Previous STIs
New sexual partner/multiple sexual partners
Uterine instrumentation such as surgical termination of pregnancy
Intrauterine contraceptive devices
Post-partum endometritis

Causative organisms

Chlamydia trachomatis - The most common cause

Neisseria gonorrhoeae
Mycoplasma hominis
Mycoplasma genitalium

Features

Lower abdominal pain

Fever
Deep dyspareunia
Dysuria and menstrual irregularities may occur
Vaginal or even cervical discharge
Cervical excitation
Perihepatitis (also known as Fitz-Hugh Curtis Syndrome) occurs in
approximately around 10% of cases
o It is characterised by right upper quadrant pain and maybe possibly
confused with cholecystitis

Investigation

Screen for Chlamydia and for Gonorrhoea

Management

Because due to the difficulty in making an accurate diagnosis, and the

potential complications of untreated Pelvic inflammatory disease, the
consensus guidelines have recommended having a low threshold for
treatment
Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral
doxycycline + oral metronidazole
RCOG guidelines have also stated that in mild cases of Pelvic inflammatory
disease intrauterine contraceptive devices may be left in. However, the more
recent BASHH guidelines suggest that the evidence is limited but that '
Removal of the IUD should be considered and may be linked with better short
term clinical outcomes'

Complications

Infertility
o The risk may be as high as around 10-20% after a single episode
Chronic pelvic pain
Ectopic pregnancy

Urinary incontinence
Overview

This is a common problem,

And it does affect approximately around 4-5% of the population.
It is more common in elderly females.

Risk factors

Hysterectomy
Family history
Advancing age
Previous pregnancy and childbirth
High body mass index

Classification

Overactive bladder (OAB) or urge incontinence:

o Due to detrusor overactivity
Stress incontinence:
o Leaking small amounts when coughing or laughing
Mixed incontinence:
o Both urge and stress
Overflow incontinence:
o This is due to bladder outlet obstruction, for example, due to prostate
enlargement
Initial investigation

Bladder diaries should be completed for a minimum of 3 days

A vaginal examination should be done to exclude pelvic organ prolapse and
the ability to initiate voluntary contraction of pelvic floor muscles ('Kegel'
exercises)
Urine dipstick and culture

Management
This depends on whether urge or stress UI is the predominant picture

If urge incontinence is predominant the following should be done:

Bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually

increase the intervals between voiding)
Bladder stabilising drugs:
o Antimuscarinic is first-line.
o NICE has also recommended the use of oxybutynin (immediate-
release),
o Tolterodine (immediate-release) MNEOMINIC (HELP ME TOLERATE
MY PEE)
o Darifenacin (once daily preparation).
o Immediate release oxybutynin should be avoided in 'frail older women'-
remember this point for the exam

If stress incontinence is predominant:

Pelvic floor muscle training:

o NICE has also recommended at least 8 contractions performed 3 times
per day for a minimum of 3 months
Surgical procedures:
o For example Retropubic mid-urethral tape procedures

Uterine fibroids
Overview

These are benign smooth muscle tumours of the uterus.

They are through to occur in around 20% of white and approximately in
around 50% of black women in the later reproductive years

Associations

It is more common in Afro-Caribbean women

This rare before puberty, and it develops in response to oestrogen, don't tend
to progress following menopause.

Features
 Maybe asymptomatic
Menorrhagia
Lower abdominal pain
o Cramping pains
o This is often during menstruation
Bloating
Urinary symptoms,
o For example, frequency may occur with larger fibroids.
Subfertility

Symptoms of fibroids (SUMMARY)

Menorrhagia
Pain (with torsion)
Subfertility
As fibroids get larger they cause symptoms due to their size such as dysuria,
hydronephrosis, constipation and sciatica.

Fibroids location

Submucosal fibroids
o Are located beneath the endometrium and bulge into the uterine cavity
Intramural fibroids
o Are located within the muscular uterine wall
o The most common type of fibroid
Subserosal fibroids
o Located on the external surface of the uterus and project to the outside
of the uterus

Diagnosis

Transvaginal ultrasound

Management

Symptomatic management with a levonorgestrel-releasing intrauterine system

is the first line and this is recommended by CKS
Other options
o Tranexamic acid
o Combined oral contraceptive pill etc.
GnRH agonists
o These may reduce the size of the fibroid but are typically useful for
short-term treatment
Surgery is sometimes needed:
o Myomectomy
o Hysteroscopic endometrial ablation
o Hysterectomy
Uterine artery embolization
Ulipristal acetate
 o is ONLY considered for the intermittent treatment of moderate to
severe symptoms of uterine fibroids in premenopausal women if:
o
Surgery and uterine artery embolisation for fibroids are
not suitable or
Surgery and uterine artery embolisation for fibroids have
failed
The woman declines surgery and uterine artery
embolisation for fibroids. ( NICE 2021)

Complications

Red degeneration
These commonly occur during pregnancy
o Haemorrhage into tumour

Endometriosis
Overview

This is a common condition characterised by the growth of ectopic

endometrial tissue outside of the uterine cavity.
Approximately 10% of women of reproductive age have a degree of
endometriosis

Clinical features

Chronic pelvic pain

Dysmenorrhoea
o Pain often starts days before bleeding
Deep dyspareunia
Subfertility
Non-gynaecological
o Urinary symptoms for example dysuria, urgency, haematuria,
dyschezia (painful bowel movements)
On pelvic examination, the following is observed
o Reduced organ mobility
o Tender nodularity in the posterior vaginal fornix
o Visible vaginal endometriotic lesions may be seen

Investigation

Laparoscopy is the gold-standard investigation

There is little role for investigation in primary care (i.e. using ultrasound) if the
symptoms are prominent the patient should be referred for a definitive
diagnosis

Management
This depends on clinical features – there is a poor correlation between laparoscopic
findings and severity of symptoms. Based on the NICE guidelines, the following are
mentioned:

NSAIDs and/or paracetamol are the recommended first-line treatments for

symptomatic relief
In case analgesia does help, then consider giving hormonal treatments such
as the combined oral contraceptive pill or progestogens for example
medroxyprogesterone acetate

In case analgesia or hormonal treatment does not improve symptoms or if fertility is

a priority the patient should be referred to secondary care.

Secondary treatments

Gonadotrophin-releasing hormone (GnRH) analogues

o This said to induce a 'pseudomenopause' due to the low oestrogen
levels
Drug therapy unfortunately does not seem to have a significant impact on
fertility rates
Surgery:
o Some treatments such as laparoscopic excision and laser treatment of
endometriotic ovarian cysts may possibly improve fertility

Endometrial hyperplasia
Overview

Endometrial hyperplasia is a premalignant condition, that can predispose to,

or be associated with, endometrial carcinoma.
It is characterized by the overgrowth of endometrial cells and is caused by
excess unopposed oestrogens, either endogenous or exogenous, similar to
endometrial cancer, with which it shares a common aetiology

Presentation

Generally presents clinically as abnormal vaginal bleeding (intermenstrual,

polymenorrhoea or postmenopausal)
It is most commonly diagnosed in women over 40 years old with irregular
menstruations or in those with post-menopausal bleeding

Investigation

Transvaginal ultrasound (TVUS) is an appropriate first-line procedure. In

general, the thicker the endometrium seen on ultrasound, the higher the
likelihood of important pathology, ie endometrial cancer, being present.
Endometrial sampling or formal endometrial curettage is necessary for
diagnosis.
Management of endometrial hyperplasia (no atypia)

It primarily depends on the age of the patient, histology, symptoms, and

desire for retaining fertility.
Both continuous oral progestogens and levonorgestrel-releasing intrauterine
system are effective in achieving regression of endometrial hyperplasia
without atypia. However, the Royal College of Obstetrics and Gynaecology
(Green-top Guideline No. 67, 2016) clearly states that the levonorgestrel-
releasing intrauterine system should be the first-line medical treatment
because compared with oral progestogens it has a higher disease regression
rate with a more favourable bleeding profile and it is associated with fewer
adverse effects.

Reference: Oxford Handbook of Obstetrics and Gynaecology 3rd Edition page 732

Bacterial vaginosis
Overview

BV describes an overgrowth of predominately anaerobic organisms such as

Gardnerella vaginalis.
This leads to a consequent fall in lactic acid-producing aerobic lactobacilli
resulting in a raised vaginal pH.
This is not a sexually transmitted infection, but it is seen almost exclusively in
sexually active women.

Features

Vaginal discharge
o 'Fishy'
o Offensive
Asymptomatic in 50% of the cases

Diagnosis
Amsel's criteria for diagnosis of BV - 3 of the following 4 points should be present

Thin, white homogenous discharge

Clue cells on microscopy: Stippled vaginal epithelial cells
Vaginal pH > 4.5
Positive whiff test (addition of potassium hydroxide results in fishy odour)

Management

Oral metronidazole for 5-7 days

70-80% initial cure rate
Relapse rate > 50% within 3 months
Topical metronidazole or topical clindamycin are alternatives
Bacterial vaginosis in pregnancy

Results in an increased risk of the following

o Preterm labour
o Low birth weight
o Chorioamnionitis
o Late miscarriage
Based on Recent guidelines it is recommended that oral metronidazole is
used throughout pregnancy. But previously it was believed that oral
metronidazole should be avoided in the first trimester and topical clindamycin
used instead. The BNF still advises against the use of high dose
metronidazole regimes.

Ectopic pregnancy
Overview

Definition: Implantation of a fertilized ovum outside the uterus results in an

ectopic pregnancy

Epidemiology

Incidence = around 0.5% of all pregnancies

Risk factors (anything slowing the ovum's passage to the uterus)

Damage to tubes
o Salpingitis, surgery
Previous ectopic
Endometriosis
IUCD
Progesterone only pill
IVF ( around 3% of pregnancies are ectopic)
Pelvic inflammatory disease - the most common cause of ectopic pregnancy.

Symptoms
A usual history is a female with a history of 6-8 weeks amenorrhoea who presents
with lower abdominal pain and then later develops vaginal bleeding

Lower abdominal pain:

o Usually the first symptom
o Pain is typically constant and may be unilateral
o This is due to tubal spasm
Vaginal bleeding:
o Typically less than a normal period
o And this may be dark brown in colour
History of recent amenorrhoea:
o Usually 6-8 weeks from the start of the last period
 o If longer (for example 10 wks) this suggest other causes, For example,
inevitable abortion
Peritoneal bleeding can cause shoulder tip pain and pain on defecation or
urination

Examination findings

Abdominal tenderness
Cervical excitation ( this also known as cervical motion tenderness)
Adnexal mass:
o NICE has advised NOT to examine for an adnexal mass due to an
increased risk of rupturing the pregnancy.
o However, A pelvic examination to check for cervical excitation is
recommended

Management
Expectant management

Size <30mm
Unruptured
Asymptomatic
No fetal heartbeat
serum B-hCG <200IU/L and declining
Compatible if another intrauterine pregnancy
Expectant management involves closely monitoring the patient over 48 hours
and if B-hCG levels rise again or symptoms manifest intervention is
performed.

Medical management

Size <35mm
Unruptured
No pain
No fetal heartbeat
serum B-hCG <1500IU/L
Not suitable if intrauterine pregnancy
Medical management involves giving the patient methotrexate and can only
be done if the patient is willing to attend follow up

Surgical management

Size >35mm
Can be ruptured
Severe pain
Visible fetal heartbeat
serum B-hCG >1500IU/L
Compatible with another intrauterine pregnancy
Surgical management can involve salpingectomy or salpingotomy
Premature ovarian failure
Overview

This is defined as the onset of menopausal symptoms and elevated

gonadotropin levels before the age of 40 years
It occurs in around 1 in 100 women

Causes

Idiopathic and that’s the most common cause

Chemotherapy
Autoimmune
Radiation

Features are very similar to those of the normal climacteric but the
actual presenting problem may be different

Climacteric symptoms
o Hot flushes
o Night sweats
Infertility
Secondary amenorrhoea
Raised FSH
o Two raised levels (more than 25 IU/L) taken at least four weeks apart
are diagnostic
Raised LH levels

Management

Hormone replacement therapy (HRT) until at least the average age of

menopause (51 years). The average age of menopause in women in the UK
is 51 years

Menorrhagia
Overview

This was previously defined as total blood loss > 80 ml per menses, but it is
difficult to quantify.
The assessment and management of heavy periods have therefore shifted
towards what the woman considers to be excessive and aims to improve
quality of life measures.

Causes

Dysfunctional uterine bleeding

 o This describes menorrhagia in the absence of underlying pathology.
This generally accounts for approximately half of patients.
Anovulatory cycles
o These are more common at the extremes of a women's reproductive
life
Uterine fibroids
Hypothyroidism
Intrauterine devices
o This refers to normal copper coils
o Note that the intrauterine system (Mirena) is used to treat menorrhagia
Pelvic inflammatory disease
Bleeding disorders, for example, von Willebrand disease.

Investigations

A full blood count should be performed on all women

NICE has also recommended arranging a routine transvaginal ultrasound
scan if symptoms (e.g. intermenstrual or postcoital bleeding, pelvic pain
and/or pressure symptoms) suggest a structural or histological abnormality.
Other indications are abnormal pelvic exam findings.

Management

Before the 1990s, many women underwent a hysterectomy to treat heavy

periods but since that time the approach has altered fundamentally.
The management of menorrhagia now depends on whether a woman needs
contraception

Does not require contraception

Both are started on the first day of the period

o Mefenamic acid 500 mg tds (mainly if there is dysmenorrhoea as well)
or
o Tranexamic acid 1 g tds
If no improvement then try another drug whilst awaiting referral

Requires contraception

Intrauterine system (Mirena) should be considered first-line

Combined oral contraceptive pill
Long-acting progestogens

NOTE: Norethisterone 5 mg tds can be used as a short-term option to rapidly stop

heavy menstrual bleeding.

Contraception summary
Young woman, not sexually active

Only menorrhagia: Tranexamic acid

 Menorrhagia with dysmenorrhoea: Mefenamic acid
Menorrhagia/dysmenorrhoea/metrorrhagia (irregular menses): COCP

Sexually active women (those who require contraception)

Menorrhagia/dysmenorrhoea or those suffering from fibroids (which do not

distort the uterine cavity) IUS Mirena (first-line).
o It is vital to note that these questions will also mention possible
contraindications for COCP
o If a woman is younger than 20 years old, IUS Mirena is not first-line
because it is considered to be UKMEC 2. If no contraindications,
COCP PCP or implant may be more suitable as they would be UKMEC
1
Women with sickle cell disease and menorrhagia
o Depo-Provera IM

Emergency contraception

Within 72 hours of unprotected sex - Levonelle pill

Within 120 hours of unprotected sex - IUCD or ellaOne pill

Termination of pregnancy
Key points

Two registered medical practitioners must sign a legal document (in an

emergency setting only one is needed)
Only a registered medical practitioner can perform an abortion, which must be
in an NHS hospital or licensed premise

The method used to terminate pregnancy depends upon the

gestation

Less than 9 weeks:

o Mifepristone (an anti-progestogen, often referred to as RU486) after
that, 48 hours later prostaglandins is given to stimulate uterine
contractions
Less than 13 weeks:
o Surgical dilation and suction of uterine contents
More than 15 weeks:
o Surgical dilation and evacuation of uterine contents or late medical
abortion (induces 'mini labour')

1967 Abortion Act

Subject to the provisions of this section, a person shall not be guilty of an offence
under the law relating to abortion when a pregnancy is terminated by a registered
medical practitioner if two registered medical practitioners are of the opinion, formed
in good faith
 That the pregnancy has not exceeded its 24th week and that the continuance
of the pregnancy would involve risk, greater than if the pregnancy were
terminated, of injury to the physical or mental health of the pregnant woman or
any existing children of her family; or
That the termination is necessary to prevent grave permanent injury to the
physical or mental health of the pregnant woman; or
That the continuance of the pregnancy would involve risk to the life of the
pregnant woman, greater than if the pregnancy were terminated; or
That there is a substantial risk that if the child were born it would suffer from
such physical or mental abnormalities as to be seriously handicapped.

Vulval carcinoma
Overview

Approximately around 80% of vulval cancers are squamous cell carcinomas.

Most cases occur in women over the age of 65 years.
Vulval cancer is relatively rare with only around 1,200 cases been diagnosed
in the UK each year.

Apart from age, risk factors are:

Immunosuppression
Lichen sclerosus
Human papilloma virus (HPV) infection
Vulval intraepithelial neoplasia (VIN)

Features

Lump or ulcer is found on the labia majora

This may be linked with itching, irritation

Female genital mutilation

Overview

This refers to all procedures involving partial or total removal of the external
female genitalia or other injury to the female genital organs for non-medical
reasons.

WHO Female genital mutilation Classification is mentioned below :

Type 1

Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).

Type 2
 Partial or total removal of the clitoris and the labia minora, with or without
excision of the labia majora (excision).

Type 3

Narrowing of the vaginal orifice with creation of a covering seal by cutting and
appositioning the labia minora and/or the labia majora, with or without
excision of the clitoris (infibulation).

Type 4

All other harmful procedures to the female genitalia for non-medical purposes,
for example, pricking, piercing, incising, scraping and cauterization.

Source: RCOG

Ovarian cancer
Overview

This is the fifth most common malignancy in females.

The peak age of incidence is 60 years and it usually carries a poor prognosis
due to late diagnosis.

Pathophysiology

Approximately around 90% of ovarian cancers are epithelial in origin, with 70-
80% of cases being due to serous carcinomas.
It is now increasingly recognised that the distal end of the fallopian tube is
often the site of origin of many 'ovarian' cancers.

Risk factors

Family history
o Mutations of the BRCA1 or the BRCA2 gene
Many ovulations
o Early menarche
o Late menopause
o Nulliparity
o It was previously taught that infertility treatment increases the risk of
ovarian cancer, as it increases the number of ovulations, but, Recent
evidence however suggests that there is not a significant link. The
combined oral contraceptive pill reduces the risk (fewer ovulations) as
does having many pregnancies.

Clinical features are very vague

Abdominal distension and even bloating

Abdominal pain
 Pelvic pain
Urinary symptoms for example urgency
Early satiety
Diarrhoea

Investigations

NICE has recommended a CA125 test to be done initially.

The conditions that may also rise CA125 level are
o Endometriosis
o Menstruation
o Benign ovarian cysts
o Other conditions
In case the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound
scan of the abdomen and also should be ordered

The staging of ovarian cancer can be broken down into the

following:

Stage 1
o Tumour confined to ovary
Stage 2
o Tumour outside ovary but within the pelvis
Stage 3
o Tumour outside pelvic but within the abdomen
Stage 4
o Distant metastasis

Diagnosis

This is difficult and typically involves diagnostic laparotomy

Management

Typically a combination of surgery and platinum-based chemotherapy is

needed

Prognosis

Around 80% of women have advanced disease at presentation

The all stage 5-year survival is around 46%

Exam tip
Ovarian cancer should be suspected and further tests should be carried out in any
woman (particularly those over 50 years of age), who persistently have any of the
following symptoms:

Abdominal distension/bloating
 Feeling full (early satiety) or loss of appetite
Pelvic or abdominal pain
Increased urinary urgency or frequency

Benign breast lesions

Fibroadenoma
o Features
Develop from a whole lobule
They are mobile, firm breast lumps.
Found in around 12% of all breast masses
Over a 2 year period up to around 30% will get smaller
No increase in the risk of malignancy
o Treatment: If > 3cm surgical excision is usual, Phyllodes tumours
should be widely excised (mastectomy if the lesion is large).
Breast cyst
o Features
7% of all Western females will present with a breast cyst
Usually presents as a smooth discrete lump (may be fluctuant)
Small increased risk of breast cancer (especially if younger)
o Treatment: Cysts should be aspirated, those which are blood-stained
or persistently refill should be biopsied or excised.
Sclerosing adenosis, (radial scars and complex sclerosing lesions)
o Features
Usually presents as a breast lump or breast pain
Causes mammographic changes which may mimic carcinoma
Cause distortion of the distal lobular unit, without hyperplasia
(complex lesions will show hyperplasia)
Considered a disorder of involution, no increase in malignancy
risk
o Treatment: Lesions should be biopsied, excision is not mandatory.
Epithelial hyperplasia
o Feature:
Variable clinical presentation ranging from generalised
lumpiness through to discrete lump
Disorder consists of increased cellularity of terminal lobular unit,
atypical features may be present
Atypical features and family history of breast cancer confers
greatly increased risk of malignancy
o Treatment: If no atypical features then conservative, those with atypical
features require either close monitoring or surgical resection
Fat necrosis
o Features
Up to 40% of cases usually have a traumatic aetiology
Physical features usually mimic carcinoma
The mass may increase in size initially
o Treatment: Imaging and core biopsy
Mammary duct ectasia
o It is the dilatation of the large breast ducts
o It is most common around the menopause
 o May present with a tender lump behind the nipple with or without a
green nipple discharge
o Smoking is a known risk factor

Periductal Mastitis
o Common in young women, remember, Mammary duct ectasia is
common around the menopause
o The mass may develop around the nipple, remember, in mammary
duct ectasia, mass tends to develop behind the nipple.
o Presents with
Periareolar inflammation
Nipple retraction
Green nipple discharge from the nipple
Sometimes a mass may be palpable
o Treated with antibiotics. If the abscess is formed it needs to be drained
using a fine needle.
Duct papilloma
o Features
Usually present with bloodstained nipple discharge
Large papillomas may present with a mass
The discharge usually originates from a single duct
No increase risk of malignancy
o Treatment: Microdochectomy

Cervical cancer
Overview

Approximately around 50% of cases of cervical cancer occur in women under

the age of 45 years,
Incidence rates for cervical cancer in the UK are highest in people aged 25-29
years, And according to Cancer Research UK. It may be divided into:
o Squamous cell cancer ( around 80%)
o Adenocarcinoma (around 20%)

Features

These may be detected during routine cervical cancer screening

Abnormal vaginal bleeding:
o Postcoital,
o Intermenstrual or
o Postmenopausal bleeding
Vaginal discharge

Human papilloma virus (HPV), particularly the following serotypes 16,18 & 33 is
the most important factor in the development of cervical cancer.

Other risk factors are:

 High parity
Lower socioeconomic status
Smoking
Human immunodeficiency virus
Early first intercourse, many sexual partners
Combined oral contraceptive pill
o The strength of this link is sometimes debated but a large study
published in the Lancet (2007 Nov 10;370(9599):1609-21) confirmed
the link

Mechanism of HPV causing cervical cancer

HPV 16 and 18 produces the oncogenes E6 and E7 genes.

o E6 inhibits the p53 tumour suppressor gene
o E7 inhibits RB suppressor gene

Cervical cancer screening

The UK has a well-established cervical cancer screening program which is

estimated to prevent 1,000-4,000 deaths per year.
It should be noted that cervical adenocarcinomas, which account for around
15% of cases, are frequently found undetected by screening

A smear test is offered to all women between the ages of 25-64 years

25-49 years:
o 3-yearly screening
50-64 years:
o 5-yearly screening

How is performed?

Currently many prefer to use liquid-based cytology (LBC) over traditional

Papanicolaou (Pap) smears to. Instead of smearing the sample onto a slide, the
sample is either rinsed into the preservative fluid or the brush head is simply
removed into the sample bottle containing the preservative fluid.

Advantages of liquid-based cytology are:-

Reduced rate of inadequate smears

Increased sensitivity and specificity

Note that the best time to take a cervical smear is around mid-cycle. In Scotland,
women from the ages of 20-60 years are screened every 3 years.

Interpretation of results
Results and their respective management are mentioned below

Cervical intraepithelial neoplasia is abbreviated to CIN

 Inflammatory changes
o Repeat cervical swab in 6 months, consider taking swabs for infection if
severe inflammation
Borderline or mild dyskaryosis
o The original sample is tested for HPV
High-risk subtypes of HPV such as 16,18 & 33
If negative the patient goes back to routine recall
If positive the patient is referred for colposcopy
Moderate dyskaryosis
o Consistent with CIN II. Refer for urgent colposcopy (I.e. within 2 weeks)
Severe dyskaryosis
o Consistent with CIN III. Refer for urgent colposcopy (I.e. within 2
weeks)
Please refer NHS Cervical Screening Programme link for more
details regarding this recommendation
Suspected invasive cancer
o Refer for urgent colposcopy (within 2 weeks)
Inadequate
o Repeat smear - if persistent (3 inadequate samples), assessment by
colposcopy

Polycystic ovarian syndrome

Overview

Polycystic ovary syndrome (PCOS) This is a complex condition of ovarian

dysfunction
It affects approximately between 5-20% of women of reproductive age
The cause of PCOS is not fully understood.
Both hyperinsulinaemia and high levels of luteinizing hormone are seen in
polycystic ovary syndrome and there appears to be some overlap with the
metabolic syndrome

Features

Subfertility and infertility

Menstrual disturbances
o Oligomenorrhea and
o Amenorrhoea
Hirsutism,
Acne ( this is due to hyperandrogenism)
Obesity
Acanthosis nigricans ( this is due to insulin resistance)

Investigations

Pelvic ultrasound
o Multiple cysts on the ovaries
The following are useful for diagnosis
 FSH
o
LH
o
Prolactin
o
TSH
o
Testosterone
o
NOTE: Raised LH:FSH ratio is a 'classical' feature but is no longer
o
thought to be useful in diagnosis. Prolactin may be normal or mildly
elevated. Testosterone may be normal or mildly elevated - however if
markedly raised consider other causes
Check for impaired glucose tolerance

Management
General management

Weight reduction if the patients are obese.

In case the women require contraception then a combined oral contraceptive
(COC) pill may help regulate her cycle and induce a monthly bleed (refer
below)

Hirsutism and acne

COC pill may be used to help manage hirsutism.

Possible options are a third-generation COC which has fewer androgenic
effects or co-cyprindiol which has an anti-androgen action. Both of these
types of COC may also carry an increased risk of venous thromboembolism
It doesn't respond to COC then topical eflornithine should be tried
The following drug should be used under supervision
o Spironolactone
o Flutamide and
o Finasteride

Infertility

The management of infertility in patients with PCOS should be supervised by

a specialist.
There is an ongoing debate as to whether metformin, clomifene or a
combination should be used to stimulate ovulation in the patient.
A 2007 trial published in the New England Journal of Medicine suggested
clomifene was the most effective treatment. There is a potential risk of
multiple pregnancies with anti-oestrogen therapies such as clomifene.
o Anti-oestrogen: Work by occupying hypothalamic oestrogen receptors
without activating them. This interferes with the binding of oestradiol
and thus prevents negative feedback inhibition of FSH secretion
The RCOG published an opinion paper in 2008 and concluded that on current
evidence metformin is not a first-line treatment of choice in the management
of PCOS
Metformin is also used, either combined with clomifene or alone, particularly
in patients those who are obese
Gonadotrophins
Pelvic pain
Overview

In women, the most common cause of pelvic pain is primary dysmenorrhoea.

Some women also experience transient pain in the middle of their cycle
secondary to ovulation (this is known as the mittelschmerz).

Usually acute pain presentation:

Ectopic pregnancy
o A usual history is a female with a history of 6-8 weeks amenorrhoea
who presents with lower abdominal pain and this later develops vaginal
bleeding
o Shoulder tip pain
o cervical excitation may be also seen
Urinary tract infection
o Dysuria and frequency are common but women may also experience
suprapubic burning and this is secondary to cystitis
Appendicitis
o Pain initial in the central abdomen before localising to the right iliac
fossa
o Anorexia is common
o Tachycardia
o Low-grade pyrexia
o Tenderness in RIF
o Rovsing's sign:
More pain in RIF than LIF when palpating LIF
Pelvic inflammatory disease
o Pelvic pain
o Fever
o Deep dyspareunia
o Vaginal discharge
o Dysuria and Menstrual irregularities may occur
o Cervical excitation may be also found on examination
Ovarian torsion
o Typically sudden onset unilateral lower abdominal pain
o Onset may coincide with exercise
o Nausea and vomiting are common
o Unilateral, tender adnexal mass on examination
Miscarriage
o Vaginal bleeding
o Crampy lower abdominal pain after a period of amenorrhoea

Usually chronic pain presentation

Endometriosis
o Chronic pelvic pain
o Dysmenorrhoea
 Pain often starts days before bleeding
o Deep dyspareunia
o Subfertility
Irritable bowel syndrome
o Extremely common.
o The most consistent features are the following
Abdominal pain
Bloating
Change in bowel habit
o Features such as
Lethargy
Nausea
Backache and bladder symptoms may also be present
Ovarian cyst
o Unilateral dull ache may be intermittent or only occur during intercourse
o Torsion or rupture may lead to severe abdominal pain
o Large cysts may cause abdominal swelling or pressure effects on the
bladder
Urogenital prolapse
o Seen in older women
o Sensation of pressure, heaviness, 'bearing-down'
o Urinary symptoms
Incontinence
Frequency
Urgency

Ovarian cysts
Benign ovarian cysts are extremely common.
They may be divided into the following types
o Physiological cysts,
o Benign germ cell tumours,
o Benign epithelial tumours and
o Benign sex cord-stromal tumours

Physiological cysts (functional cysts)

Follicular cysts
o This is the commonest type of ovarian cyst
o This is due to non-rupture of the dominant follicle or failure of atresia in
a non-dominant follicle
o It commonly regresses after several menstrual cycles
Corpus luteum cyst
o Occurs during the menstrual cycle if pregnancy doesn't occur the
corpus luteum usually breaks down and disappears. If this doesn't
occur the corpus luteum may fill with blood or fluid and form a corpus
luteal cyst
o It is more likely to present with intraperitoneal bleeding than follicular
cysts
Benign germ cell tumours
Dermoid cyst

Also called mature cystic teratomas. Usually lined with epithelial tissue and
hence may contain skin appendages, hair and teeth
Most common benign ovarian tumour in woman under the age of 30 years
The median age of diagnosis is 30 years old
Bilateral in 10-20%
Usually asymptomatic. Torsion is more likely than with other ovarian tumours

Benign epithelial tumours

These generally arise from the ovarian surface epithelium

Serous cystadenoma

It is the most common benign epithelial tumour which bears a resemblance to

the most common type of ovarian cancer ( i.e. serous carcinoma)
It is bilateral in approximately around 20% of the cases.

Mucinous cystadenoma

It is the second most common benign epithelial tumour

They are usually large and may become massive
In case it ruptures may cause pseudomyxoma peritonei

Dysmenorrhoea
Overview

Dysmenorrhoea is characterised by excessive pain during the menstrual

period.
It is traditionally divided into two types
o Primary and secondary dysmenorrhoea.

Primary dysmenorrhoea

There is no underlying pelvic pathology.

It affects up to around 50% of menstruating women and typically appears
within 1-2 years of the menarche.
Excessive endometrial prostaglandin production is thought to be partially
responsible.

Features

The pain usually starts just before or within a few hours of the period starting
Suprapubic cramping pains which may radiate to the back or down the thigh
Management

NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of

women. They work by inhibiting prostaglandin production
Combined oral contraceptive pills are used as second-line

Secondary dysmenorrhoea

Secondary dysmenorrhoea typically develops many years after the menarche

and is the result of underlying pathology.
In contrast to primary dysmenorrhoea, the pain typically starts 3-4 days before
the onset of the period.

Causes

Intrauterine devices
o This refers to normal copper coils. Note that the intrauterine system
(Mirena) may help dysmenorrhoea
Endometriosis
Adenomyosis
Pelvic inflammatory disease
Fibroids

NOTE: Clinical Knowledge Summaries have recommended referring all patients with
secondary dysmenorrhoea to gynaecology for investigation

Amenorrhoea
Overview
This may be divided into two stages

Primary
o Failure to start menses by the age of 16 years
Secondary
o Cessation of established, regular menstruation for 6 months or longer.

Causes of primary amenorrhoea

Congenital adrenal hyperplasia

Congenital malformations of the genital tract
Turner's syndrome
Testicular feminisation

The definition of Secondary amenorrhoea is when menstruation has previously

occurred but has now stopped for at least 6 months.

Causes of secondary amenorrhoea (that’s after excluding

pregnancy)
 Hypothalamic amenorrhoea (for example stress and excessive exercise)
Polycystic ovarian syndrome (PCOS)
Hyperprolactinaemia
Premature ovarian failure
Thyrotoxicosis
o Remember that hypothyroidism may also cause amenorrhoea
Sheehan's syndrome
Asherman's syndrome (is also known as intrauterine adhesions)

Initial investigations

Exclude pregnancy with urinary or serum bHCG

Gonadotrophins:
o Low levels indicate a hypothalamic cause whereas raised levels
suggest an ovarian problem (for example Premature ovarian failure)
Prolactin
Androgen levels
o Raised levels may be seen in PCOS
Oestradiol
Thyroid function tests

Specifics to look for in the Questions for Plab

Short stature
o May indicate Turner syndrome
Hirsutism, acne (androgen excess)
o May indicate PCOS or hyperprolactinaemia
Menopausal symptoms in women before age 40
o May indicate premature ovarian failure
Eating disorder
o May indicate anorexia nervosa
Galactorrhea
o May indicate hyperprolactinemia

Endometrial cancer
Overview

This is typically seen in post-menopausal women but approximately around

25% of cases occur before menopause
It typically carries a good prognosis due to early detection

Risk factors

Obesity
Nulliparity
Early menarche
Late menopause
Diabetes mellitus
 Tamoxifen
Polycystic ovarian syndrome
Unopposed oestrogen. The addition of a progestogen to oestrogen reduces
this risk (for example in HRT). The BNF states that the additional risk is
eliminated if progestogen is given continuously.

Features

Post-menopausal bleeding is the classic symptom

Pre-menopausal women may have a change in intermenstrual bleeding
Pain and discharge are unusual features

Investigation

First-line investigation is a transvaginal ultrasound

o A normal endometrial thickness (< 4 mm) has a high negative
predictive value
Hysteroscopy with endometrial biopsy

Management

Localised disease is treated with total abdominal hysterectomy with bilateral

salpingo-oophorectomy
Patients with high-risk disease may have postoperative radiotherapy
progestogen therapy is sometimes used in frail elderly women not consider
suitable for surgery

Menopause
Overview

The average women in the UK go through menopause at 51 years old.

Menopause is defined as the permanent cessation of menstruation.
It is caused by the loss of follicular activity.
Menopause is a clinical diagnosis usually made in primary care when a
woman has not had a period for 12 months.
Menopausal symptoms are very common and affect roughly 75% of
postmenopausal women.
Symptoms generally last for 7 years but may resolve quicker and in some
cases take much longer. The duration and severity are also variable and may
develop before the start of the menopause and in some cases may start years
after the onset of menopause.
It is recommended to use effective contraception until the following time:
o 12 months after the last period in women > 50 years
o 24 months after the last period in women < 50 years

Management
The CKS has very thorough and clear guidance on the management of menopause
and is summarised below.

The management of menopause can be split into three categories:

Lifestyle modifications
Hormone replacement therapy (HRT)
Non-hormone replacement therapy

Management with lifestyle modifications

Hot flushes
o Regular exercise
o Weight loss
o Reduce stress
Sleep disturbance
o Avoiding late evening exercise and maintaining good sleep hygiene.
Mood
o Sleep, regular exercise and relaxation.
Cognitive symptoms
o Regular exercise and good sleep hygiene.

Management with HRT

Contraindications:
o Current or past breast cancer
o Any oestrogen-sensitive cancer
o Undiagnosed vaginal bleeding
o Untreated endometrial hyperplasia
Roughly 10% of women will have some form of HRT to treat their menopausal
symptoms.
There is a current drive by NICE to increase this number as they have found
that women were previously being undertreated due to worries about
increased cancer risk.
If the woman has a uterus then it is vital not to give unopposed oestrogens as
this will increase her risk of endometrial cancer. Thus oral or transdermal
combined HRT is given.
If the woman does not have a uterus then oestrogen alone can be given either
orally or in a transdermal patch.
Women should be advised that the symptoms of menopause generally last for
2-5 years and that treatment with HRT brings certain risks:
o Venous thromboembolism:
A slight increase in risk with all forms of oral HRT. No increased
risk with transdermal HRT.
o Stroke:
Slightly increased risk with oral oestrogen HRT.
o Coronary heart disease:
Combined HRT may be associated with a slight increase in risk.
o Breast cancer:
 There is an increased risk with all combined HRT although the
risk of dying from breast cancer is not raised.
o Ovarian cancer:
Increased risk with all HRT.

Management with non-HRT

Vasomotor symptoms
o Fluoxetine, citalopram or venlafaxine.
Vaginal dryness
o Vaginal lubricant or moisturiser.
Psychological symptoms
o Self-help groups, cognitive behaviour therapy or antidepressants.
Urogenital symptoms
o If suffering from urogenital atrophy vaginal oestrogen can be
prescribed. This is appropriate if they are taking HRT or not.
o Vaginal dryness can be treated with moisturisers and lubricants. These
can be offered alongside vaginal oestrogens if required.

Stopping treatment

For vasomotor symptoms, 2-5 years of HRT may be required with regular
attempts made to discontinue treatment.
Vaginal oestrogen may be required long term.
When stopping HRT it is essential to tell women that gradually reducing HRT
is effective at limiting recurrence only in the short term.
In the long term, there is no difference in symptom control.
Although menopausal symptoms can be managed mainly in primary care,
there are some instances when a woman should be referred to secondary
care.
She should be referred to secondary care if treatment has been ineffective, if
there are ongoing side effects or if there is unexplained bleeding.

Post pill amenorrhoea

Post pill amenorrhoea occurs when stopping oral contraceptives does not
lead to a resumption of a normal menstrual cycle.
It is described as the loss of menstrual periods for at least 6 months after
stopping birth control pills.
Post-pill amenorrhea is believed to be due to suppression of the pituitary
gland by birth control pills.

Investigations

Investigations are generally needed if menstrual cycles do not resume after

three months post-pill. It may be that the cause of amenorrhoea started whilst
taking the contraceptives which induced an artificial cycle, masking the issue
until they were stopped
 Ultrasonography will reveal ovaries with no signs of developing follicles and
ovulation even after having stopped the pills for 6 months
Blood tests showing a low level of FSH, LH and oestrogen is generally
sufficient to confirm the diagnosis

Treatment

The first line of treatment in case of post-pill amenorrhea is waiting for

spontaneous remission of the amenorrhea and a spontaneous occurrence of
periods.
The time limit is typically six months. But if the patient is anxious to get her
periods, active treatment may be started after waiting for only 3 months.
The standard treatment of post-pill amenorrhea is by stimulating the pituitary
to produce FSH and LH. Clomiphene citrate is the choice of drug

Mastalgia

Cyclical mastalgia

Commonly bilateral (may worsen on one side)

The pain usually starts 1 to 3 days prior to the menstrual cycle and settles
when the menstruation ends
Examination: General swelling and lumpiness but no lump
Management: Supportive bra and simple analgesia

Non-cyclical mastalgia

Unilateral or focal
No relation to menstrual cycles

Cervical ectropion
Overview

On the ectocervix, there is a transformation zone where the stratified

squamous epithelium meets the columnar epithelium of the cervical canal.
Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral
contraceptive pill use) results in a larger area of columnar epithelium being
present on the ectocervix.
The term cervical erosion is less commonly used now

The following features may result

Vaginal discharge
Post-coital bleeding

Treatment
 It is managed if symptoms are bothersome, Treatments include cautery with
silver nitrate, diathermy and cryotherapy. It is essential to obtain a cervical
smear and ensure it is normal prior to any treatments.

Miscarriage
Threatened miscarriage (2021 NICE Guideline Update)

Painless vaginal bleeding that occurs before 24 weeks, but usually occurs at
between 6 - 9 weeks
The bleeding is often less than menstruation
The cervical os is closed
Complicates up to around 25% of all pregnancies
Advise a woman with a confirmed intrauterine pregnancy with a fetal
heartbeat who presents with vaginal bleeding, but has no history of previous
miscarriage, that:
o If her bleeding gets worse or persists beyond 14 days, she should
return for further assessment
o If the bleeding stops, she should start or continue routine antenatal
care.
Offer vaginal micronised progesterone 400 mg twice daily to women with an
intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and
have previously had a miscarriage.
If a fetal heartbeat is confirmed, continue progesterone until 16 completed
weeks of pregnancy.

Missed (delayed) miscarriage

A gestational sac which contains a dead fetus before 20 weeks without the
symptoms of expulsion
The mother may have light vaginal bleeding or discharge and the symptoms
of pregnancy which disappear.
o Pain is not typically a feature
The cervical os is closed
When the gestational sac is > 25 mm and no embryonic or fetal part can be
seen it is sometimes described as a 'blighted ovum' or 'anembryonic
pregnancy'

Inevitable miscarriage

There is heavy bleeding with clots and pain

The cervical os is open

Incomplete miscarriage

Not all products of conception have been expelled

Pain and vaginal bleeding
The cervical os is open
Epidemiology

Around 15-20% of diagnosed pregnancies will miscarry in early pregnancies

Non-development of the blastocyst within 14 days occurs in up to
approximately 50% of conceptions
Recurrent spontaneous miscarriage affects around 1% of women

Factors that are linked with an increased risk of miscarriage are:

Recreational drug use

High caffeine intake
Obesity
Infections and food poisoning
Increased maternal age
Smoking in pregnancy
Consuming alcohol
Health conditions
o Thyroid problems
o Severe hypertension
o Uncontrolled diabetes
Medicines
o Ibuprofen
o Methotrexate
o Retinoids
Unusual shape or structure of the womb
Cervical incompetence

Factors that have not been linked with an increased risk of miscarriage are:

Having sex
Air travel
Being stressed
Heavy lifting
Bumping your tummy

Recurrent miscarriage
Overview

This is defined as 3 or more consecutive spontaneous abortions.

It occurs in around 1% of women

Causes

Antiphospholipid syndrome
Endocrine disorders:
o Poorly controlled diabetes mellitus or thyroid disorders.
o Polycystic ovarian syndrome
Uterine abnormality: for example uterine septum
Parental chromosomal abnormalities
 Smoking

Vaginal discharge
Overview

Vaginal discharge is a common presenting symptom and it is not always

pathological

Common causes

Trichomonas vaginalis
Bacterial vaginosis
Physiological
Candida

Less common causes

Gonorrhoea
Chlamydia can also cause a vaginal discharge although this is rarely the
presenting symptoms
Ectropion
Foreign body
Cervical cancer

Key features of the common causes

Candida
o Discharge with the following characteristic
'Cottage cheese'
o Vulvitis
o Itch
Trichomonas vaginalis
o Discharge with the following characteristic
Offensive
Yellow or green
Frothy discharge
o Vulvovaginitis
o Strawberry cervix
o Management: Metronidazole 400mg bd for 5 days
Bacterial vaginosis
o Discharge with the following characteristic
Offensive
Thin
White or grey
'Fishy'
o Management: Metronidazole 400mg bd for 5 days

Cervicitis
Causes

Commonly by Chlamydia and Neisseria gonorrhoeae

Signs and symptoms

Usually asymptomatic
Can present with vaginal discharge, low abdominal pain, intermenstrual
bleeding or postcoital bleeding

Diagnosis

Endocervical or vulvovaginal swab with NAAT, culture or microscopy

Hysterectomy
Common complications of vaginal hysterectomy with antero-posterior repair
are
o Enterocoele- longterm complication
o Vaginal vault prolapse- longterm complication
o Vesicovaginal fistula- acute complication
Urinary retention may occur acutely after hysterectomy, but it is not typically a
chronic complication.

Vesicovaginal fistula

Vesicovaginal fistula is a fistulous tract extending between the bladder and

the vagina that allows the continuous involuntary discharge of urine into the
vaginal vault.
Gynaecological and uterine surgery is the most prevalent cause of bladder
lesions leading to the formation of a vesicovaginal fistula with hysterectomy
carrying the highest risk for fistulae formation.
A 3 swab test could aid to identify a vesicovaginal fistula.
o This involves 3 gauze swabs placed into the vagina using a speculum.
One at the top, one in the middle, and one at the bottom. Blue dye is
injected into the bladder by passing through a catheter.
o The catheter is then removed and the patient is asked to walk around
for an hour without urinating. After this, the swabs are taken out and
assessed for blue dye.

Hormone replacement therapy

Overview

Hormone replacement therapy (HRT) is used to replace decreasing oestrogen

levels around the perimenopausal period
Hormone replacement therapy (HRT) involves the use of a small dose of
oestrogen (combined with a progestogen in women with a uterus) to help
ease menopausal symptoms.
 Continuous combined HRT is usually recommended for women who are
postmenopausal.
Cyclical HRT, also known as sequential HRT, is often recommended for
women taking combined HRT who have menopausal symptoms but still have
their periods

Side-effects

Nausea
Breast tenderness
Fluid retention and weight gain

Potential complications

Increased risk of breast cancer

o Increased by the addition of a progestogen
Increased risk of endometrial cancer
o Reduced by the addition of a progestogen but not eliminated
completely.
o The BNF does also states that the additional risk is eliminated if a
progestogen is given continuously
Increased risk of venous thromboembolism
o Increased by the addition of a progestogen
Increased risk of stroke
Increased risk of ischaemic heart disease if taken more than 10 years after
menopause

Breast cancer

In the Women's Health Initiative (WHI) study there was a relative risk of 1.26
at 5 years of developing breast cancer
The increased risk does relate to the duration of use
Breast cancer incidence is higher in women using combined preparations
compared to oestrogen-only preparations
The risk of breast cancer begins to decline when HRT is stopped and by 5
years it reaches the same level as in women who have never taken HRT

Women should be prescribed cyclical combined HRT if their LMP (Last

Menstrual Period) was less than 1 year ago and continuous combined HRT if
they have:

Taken cyclical combined for at least 1 year or

It has been at least 1 year since their LMP or
It has been at least 2 years since their LMP if they had premature menopause
(menopause below the age of 40)

Infertility
Overview
 This affects around 1 in 7 couples.
Approximately around 84% of couples who have regular sex will conceive
within 1 year, and 92% within 2 years

Causes

Male factor 30%

Unexplained 20%
Ovulation failure 20%
Tubal damage 15%
Other causes 15%

Basic investigations

Semen analysis
Serum progesterone that should be done 7 days prior to expected next period

Interpretation of serum progestogen

< 16 nmol/l
o Repeat, if consistently low refer to a specialist.
16 - 30 nmol/l
o Repeat
>30 nmol/l
o Indicates ovulation

Key counselling points

Advise regular sexual intercourse every 2 to 3 days

Advice to quit smoking or drinking
Folic acid
Aim for BMI 20-25

Infertility
Overview

This affects around 1 in 7 couples.

Approximately around 84% of couples who have regular sex will conceive
within 1 year, and 92% within 2 years

Causes

Male factor 30%

Unexplained 20%
Ovulation failure 20%
Tubal damage 15%
 Other causes 15%

Basic investigations

Semen analysis
Serum progesterone that should be done 7 days prior to expected next period

Interpretation of serum progestogen

< 16 nmol/l
o Repeat, if consistently low refer to a specialist.
16 - 30 nmol/l
o Repeat
>30 nmol/l
o Indicates ovulation

Key counselling points

Advise regular sexual intercourse every 2 to 3 days

Advice to quit smoking or drinking
Folic acid
Aim for BMI 20-25

Ovarian enlargement: Management

Overview
The initial imaging modality for suspected ovarian cysts or tumours is ultrasound.
The report will typically report that the cyst is either:

Simple
o Unilocular
o More likely to be physiological or benign
Complex
o Multilocular
o More likely to be malignant

Management

This depends on the age of the patient and whether the patient is
symptomatic.
It should be remembered that the diagnosis of ovarian cancer is often delayed
due to a vague presentation.

Premenopausal women

A conservative approach may be taken for younger women (especially if < 35

years)
This malignancy is less common.
 If the cyst is small (example: < 5 cm) and reported as 'simple' then it is highly
likely to be benign.
A repeat ultrasound should be arranged for 8-12 weeks and referral
considered if it persists.

Postmenopausal women

By definition, physiological cysts are very unlikely

any postmenopausal woman with an ovarian cyst regardless of nature or size
should be referred to gynaecology for assessment

Delayed puberty
Delayed puberty with short stature

Prader-Willi syndrome
Noonan's syndrome
Turner's syndrome

Delayed puberty with normal stature

Kallman's syndrome
Klinefelter's syndrome
polycystic ovarian syndrome
androgen insensitivity

Premenstrual syndrome
Overview

This describes the emotional and physical symptoms that women may
experience prior to menstruation.

Common symptoms are:

Fatigue
Mood swings
Anxiety
Stress

Management

The type of treatment is determined by the severity of symptoms, patient

preference and desire for pregnancy.
Management of PMS includes lifestyle advice - healthy diet, exercise,
reduction in stress levels and regular sleep.
The combined oral contraceptive pill and selective serotonin reuptake
inhibitors are recommended for moderate to severe symptoms.
Ovarian tumours
There are 4 main types of ovarian tumours

Sex cord-stromal tumours

Metastasis
Surface derived tumours
Germ cell tumours

Surface derived tumours

These account for approximately around 65% of ovarian tumours.

These include the greatest number of malignant tumours.

Germ cell tumours

These are more common in adolescent girls

Account for around 15-20% of tumours.
Similar cancer types to those seen in the testicle.
Sex cord-stromal tumours

Represent in approximately around 3-5% of ovarian tumours.

Often produce hormones.
Metastatic tumours

This account for around 5% of tumours.

Gynaecological causes of abdominal pain

Overview

In addition to the routine diagnostic workup of abdominal pain, all-female

patients should also undergo the following:
o A bimanual vaginal examination
o Urine pregnancy test
o Consideration is given to abdominal and pelvic ultrasound scanning
If the diagnostic doubt persists a laparoscopy provides a reliable method of
assessing suspected tubulo-ovarian pathology.
Differential diagnoses of abdominal pain in females are

Mittelschmerz
o Features
Typically mid-cycle pain
Often sharp onset
Little systemic disturbance
May have recurrent episodes
Typically settles over 24-48 hours
o Investigation
Full blood count - Typically normal
Ultrasound - May show a small quantity of free fluid
o Treatment
Conservative
Endometriosis
o Features
25% asymptomatic, in a further 25% associated with other pelvic
organ pathology.
The remaining 50% may have menstrual irregularity, infertility,
pain and deep dyspareunia.
Complex disease may result in pelvic adhesional formation with
episodes of intermittent small bowel obstruction.
Intra-abdominal bleeding may produce localised peritoneal
inflammation.
Recurrent episodes are common.
o Investigation
Ultrasound - This may show free fluid
Laparoscopy will usually show lesions
o Treatment
Typically managed medically, complex disease will often require
surgery and some patients will even require formal colonic and
rectal resections if these areas are involved.
Ovarian torsion
o Features
Typically sudden onset of deep-seated colicky abdominal pain
Linked with vomiting and distress
A vaginal examination may reveal adnexal tenderness
o Investigation
Ultrasound may show free fluid
Laparoscopy is usually both diagnostic and therapeutic
o Treatment
Laparoscopy

Ectopic gestation
o Features
Symptoms of pregnancy without evidence of intrauterine
gestation.
Present as an emergency with evidence of rupture or impending
rupture.
 Open tubular ruptures may have a sudden onset of abdominal
pain and circulatory collapse, in others the symptoms may be
more prolonged and less marked.
A small amount of vaginal discharge is common.
There is typically adnexal tenderness.
o Investigation
Ultrasound showing no intrauterine pregnancy and beta HCG
that is elevated
May show intraabdominal free fluid
o Treatment
Laparoscopy or laparotomy is haemodynamically unstable. A
salphingectomy is usually performed.
Pelvic inflammatory disease
o Features
Bilateral lower abdominal pain associated with vaginal
discharge.
Dysuria may also be present.
Peri-hepatic inflammation secondary to Chlamydia (Fitz Hugh
Curtis Syndrome) may produce right upper quadrant discomfort.
Fever > 38°
o Investigation
Full blood count - Leucocytosis
Pregnancy test negative (Although infection and pregnancy may
co-exist)
Amylase - Usually normal or slightly raised
High vaginal and urethral swabs
o Treatment: Usually medical management

Atrophic vaginitis
Atrophic vaginitis often occurs in women who are post-menopausal women.
It presents with vaginal dryness, dyspareunia and occasional spotting.
On examination, the vagina may appear pale and dry.
Treatment is with vaginal lubricants and moisturisers, if these do not help then
topical oestrogen cream can be used.

Ovarian hyperstimulation syndrome

Overview

This is a complication seen in some forms of infertility treatment.

It is postulated that the presence of multiple luteinized cysts within the ovaries
results in high levels of not only oestrogens and progesterone but also
vasoactive substances such as vascular endothelial growth factor (VEGF).
This results in increased membrane permeability and also loss of fluid from
the intravascular compartment
Whilst it is rarely seen with clomifene therapy is more likely to be seen after
gonadotropin or hCG treatment.
 Up to one-third of women who are having IVF may experience a mild form of
Ovarian hyperstimulation syndrome.

The following is based on RCOG:

Mild
o Abdominal pain
o Abdominal bloating
Moderate
o As for mild
o Nausea and vomiting
o Ultrasound evidence of ascites
Severe
o As for moderate
o Clinical evidence of ascites
o Oliguria
o Haematocrit > 45%
o Hypoproteinaemia
Critical
o As for severe
o Thromboembolism
o Acute respiratory distress syndrome
o Anuria
o Tense ascites

Postcoital bleeding
Overview

Postcoital bleeding describes vaginal bleeding after sexual intercourse

Causes

No identifiable pathology is found in around 50% of cases

Cervical ectropion is the most common identifiable causes, causing around
33% of cases. This is more common in women on the combined oral
contraceptive pill
Cervicitis for example
o Secondary to Chlamydia
Cervical cancer
Polyps
Trauma

Preterm prelabour rupture of the membranes

Overview
 This occurs in approximately around 2% of pregnancies
But is linked with approximately around 40% of preterm deliveries

Complications of Preterm prelabour rupture of the membranes

Fetal:
o Prematurity,
o Infection,
o Pulmonary hypoplasia
Maternal:
o Chorioamnionitis

Investigation

A sterile speculum examination should be performed

Digital examination should be avoided due to the risk of infection.
Ultrasound may also be useful to show oligohydramnios

Management

Admission
Regular observations to ensure chorioamnionitis is not developing
Oral erythromycin should be given for at least 10 days
Antenatal corticosteroids should be administered to reduce the risk of
respiratory distress syndrome
Delivery should be considered at 34 weeks of gestation
o There is a trade-off between an increased risk of maternal
chorioamnionitis with a decreased risk of respiratory distress syndrome
as the pregnancy progresses

Postnatal depression
Postnatal blues

This occurs in around 50% of women after delivery

Evident by 3rd day, peak at 5th day, subside within 10 days
Symptoms
o Tearfulness( most common symptom), irritability, anxiety about the
baby and poor concentration
Management
o Reassurance

Postnatal depression

Occurs in around 5-10% of women

Can last months in case it is not treated
Presents with the usual features of depression and fears about baby's health,
maternal deficiencies and marital tensions including loss of sexual interest
Management
o Antidepressant or CBT
Puerperal psychoses/Postnatal psychoses

Incidence of 1:1,000 deliveries

Symptoms tend to develop within first 2 weeks
This can take form of manic depression or schizophrenia
May present with a high suicidal drive
Exam Tip
o Features that you may see in questions regarding Puerperal psychoses
:
o Thoughts of harming their newborn baby
o Delusional ideas that the baby is deformed, evil or otherwise affected in
some way
o Hallucinations, insomnia and disorientation
Management
o Admission to the hospital with a specialist mother-baby unit if possible
o Electroconvulsive therapy (ECT), mood stabilisers, and
antidepressants

Disseminated intravascular coagulation

Overview

Under homeostatic conditions, coagulation and fibrinolysis are coupled.

The activation of the coagulation cascade yields thrombin that converts
fibrinogen to fibrin; the stable fibrin clot being the final product of hemostasis.
The fibrinolytic system breaks down fibrinogen and fibrin.
Activation of the fibrinolytic system generates plasmin (in the presence of
thrombin), which is responsible for the lysis of fibrin clots.
The breakdown of fibrinogen and fibrin results in polypeptides (fibrin
degradation products). In a state of homeostasis, the presence of plasmin is
critical, as it is the central proteolytic enzyme of coagulation and is also
necessary for fibrinolysis.
In DIC, the processes of coagulation and fibrinolysis are dysregulated, and
the result is widespread clotting with resultant bleeding.
Regardless of the triggering event of DIC, once initiated, the pathophysiology
of DIC is similar in all conditions.
One critical mediator of DIC is the release of a transmembrane glycoprotein
(tissue factor =TF). TF is present on the surface of many cell types (including
endothelial cells, macrophages, and monocytes) and is not normally in
contact with the general circulation, but is exposed to the circulation after
vascular damage. For example, TF is released in response to exposure to
cytokines (particularly interleukin 1), tumour necrosis factor, and endotoxin.
This plays a major role in the development of DIC in septic conditions. TF is
also abundant in tissues of the lungs, brain, and placenta. This helps to
explain why DIC readily develops in patients with extensive trauma. Upon
activation, TF binds with coagulation factors that then triggers the extrinsic
pathway (via Factor VII) which subsequently triggers the intrinsic pathway (XII
to XI to IX) of coagulation.
 Causes of pregnancy-related DIC are eclampsia, postpartum haemorrhage,
retention of a dead fetus, amniotic fluid embolism, retained placenta or
bacterial sepsis.

Presentation

Ecchymoses or spontaneous bleeding at venepuncture sites, and the site of

trauma
Bleeding from ears, nose and throat, gastrointestinal tract
Petechiae, purpura

Diagnosis

No single laboratory test that can establish or rule out the diagnosis of DIC,
thus assess the whole clinical picture, considering the clinical condition of the
patient, and all available laboratory results
Thrombocytopenia (in up to 98% of cases) in this Up to around 50% of them
would have a platelet count less than 50 x 10 9/L
Activated partial thromboplastin time (aPTT) is increased
Fibrinogen level decreased
Fibrin degradation products (including D-dimer) is increased
Prothrombin time (PT) is increased

Just remember, everything is elevated except platelets and fibrinogen.

Treatment

Treat the underlying condition

Transfusion of platelets or plasma (components) for patients with severe
bleeds
In bleeding patients with DIC and prolonged PT and aPTT, administer fresh
frozen plasma (FFP)

Keynotes:

Warfarin administration
o Prothrombin time: Prolonged
o APTT: Normal
o Bleeding time: Normal
o Platelet count: Normal
Aspirin administration
o Prothrombin time: Normal
o APTT: Normal
o Bleeding time: Prolonged
o Platelet count: Normal
Heparin
o Prothrombin time: Often normal (maybe prolonged)
o APTT: Prolonged
o Bleeding time: Normal
 o Platelet count: Normal
DIC
o Prothrombin time: Prolonged
o APTT: Prolonged
o Bleeding time: Prolonged
o Platelet count: Low

Hyperemesis gravidarum
Overview

Whilst the majority of women experience nausea (previously termed 'morning

sickness') during the early stages of pregnancy it can become problematic in
a minority of cases.
RCOG now use the term 'nausea and vomiting of pregnancy' (NVP) to
describe troublesome symptoms, with hyperemesis gravidarum being the
extreme form of this condition.
It occurs in approximately around 1% of pregnancies and is thought to be
related to raised beta hCG levels.
Hyperemesis gravidarum is most common between 8 and 12 weeks but may
persist up to 20 weeks and in very rare cases it may be even beyond 20
weeks

The Royal College of Obstetricians and Gynaecologists (RCOG)

recommend that the following triad should be present before
diagnosis hyperemesis gravidarum is made:

Electrolyte imbalance
5% pre-pregnancy weight loss
Dehydration

Signs and Symptoms

 Ketonuria
Weight loss > 5%
Tachycardia
Signs of dehydration:
o Decreased skin turgor
o Prolonged capillary refill
o Sunken eyes
Vomiting
Nausea
Food and fluid intolerance
Lethargy

Validated scoring systems for example Pregnancy-Unique Quantification of Emesis

(PUQE) score can be used to classify the severity of 'nausea and vomiting of
pregnancy'

Associations

Hyperthyroidism
Nulliparity
Multiple pregnancies
Trophoblastic disease
Obesity

NOTE: Smoking is associated with a decreased incidence of hyperemesis

Management

IV fluids
o If potassiun is found to be low i.e. < 3.5 mmol, sodium chloride O.9%
with 20-40 mmol/litre
Antihistamines should be used first-line
o BNF has suggested promethazine as the first-line.
o Cyclizine is also recommended by the Clinical Knowledge Summaries
(CKS)
Ondansetron and metoclopramide may be used as a second-line drug
Ginger and P6 (wrist) acupressure:
o CKS suggest these can be tried but there is little evidence of benefit
Admission may be needed for IV hydration

Complications

Central pontine myelinolysis

Acute tubular necrosis
Wernicke's encephalopathy
Mallory-Weiss tear
Fetal:
o Small for gestational age,
o Pre-term birth
Epilepsy: pregnancy and breastfeeding
Overview

The risks of uncontrolled epilepsy during pregnancy usually outweigh the risks
of medication to the fetus.
All women thinking about becoming pregnant should be advised to take folic
acid 5mg per day well before pregnancy in order to minimise the risk of neural
tube defects.
Approximately around 1-2% of newborns born to non-epileptic mothers have
congenital defects.
This rises to 3-4% if the mother takes antiepileptic medication.

Other points

Aim for monotherapy

There is no indication to monitor antiepileptic drug levels
Sodium valproate:
o Linked with neural tube defects
Carbamazepine:
o Often considered the least teratogenic of the older antiepileptics
Phenytoin:
o Linked with cleft palate
Lamotrigine:
o Studies to date suggest the rate of congenital malformations may be
low.
o The dose of lamotrigine may need to be increased in pregnancy

NOTE: Breastfeeding is usually considered safe for mothers taking

antiepileptics with the possible exception of the barbiturates. Also note that it
is advised that pregnant women taking phenytoin are given vitamin K in the
last month of pregnancy to prevent clotting disorders in the newborn

Sodium valproate

There is a significant risk of neurodevelopmental delay in children following

maternal use of sodium valproate.
Sodium valproate should not be used during pregnancy and in women of
childbearing age unless clearly necessary.
Women of childbearing age should not start treatment without specialist
neurological or psychiatric advice.

Perineal tears
Below is the classification of perineal tears based on the RCOG
guidelines:

First degree:
o Superficial damage with no muscle involvement
 Second degree:
o Injury to the perineal muscle, but not involving the anal sphincter
Third degree:
o Injury to perineum involving the anal sphincter complex (external anal
sphincter, EAS and internal anal sphincter, IAS):
3a: Less than 50% of EAS thickness torn
3b: More than 50% of EAS thickness torn
3c: IAS torn
Fourth degree:
o Injury to the perineum involving the anal sphincter complex (EAS and
IAS) and rectal mucosa

Risk factors for perineal tears are:

Shoulder dystocia
Forceps delivery
Primigravida
Large babies
Precipitant labour

Breech presentation
Overview

In a breech presentation, the caudal end of the fetus occupies the lower
segment. Approximately around 25% of pregnancies at 28 weeks are breech
it only occurs in 3% of babies near term.
Note that a frank breech is the most common presentation with the hips flexed
and knees fully extended.
A footling breech, where one or both feet come first with the bottom at a
higher position, is rare but carries a higher perinatal morbidity

Risk factors for breech presentation

Uterine malformations,
Fibroids
Placenta praevia
Polyhydramnios
Oligohydramnios
Fetal abnormality (for example CNS malformation, chromosomal disorders)
Prematurity (this is due to increased incidence earlier in gestation)

NOTE: Cord prolapse is more common in breech presentations

Management

If < 36 weeks:
o Many fetuses will turn spontaneously
If still breech at 36 weeks
 o NICE has recommended an external cephalic version (ECV) - this has
a success rate of around 60%.
o The RCOG has recommended that ECV should be offered from 36
weeks in nulliparous women and from 37 weeks in multiparous women
If the baby is still breech then delivery options are planned caesarean section
or vaginal delivery

Information to help decision making - the RCOG states:

'Women should be informed that planned caesarean section carries a reduced

perinatal mortality and early neonatal morbidity for babies with a breech
presentation at term compared with planned vaginal birth.'
'Women should be informed that there is no evidence that the long term
health of babies with a breech presentation delivered at term is influenced by
how the baby is born.'

Breastfeeding problems
Mastitis

This affects around 1 in 10 breastfeeding women.

The BNF has advised to treat if the following is present
o 'if systemically unwell,
o if nipple fissure present,
o if symptoms do not improve after 12-24 hours of effective milk removal
of if culture indicates infection'.
Treatment
o The first-line antibiotic is flucloxacillin for 10-14 days.
o Breastfeeding or expressing should continue during treatment.
Complications
o If left untreated, mastitis may develop into a breast abscess (
Staphylococcus aureus)
o This usually requires incision and drainage.

Engorgement

Breast engorgement is one of the causes of breast pain in breastfeeding

women.
It usually occurs in the first few days after the infant is born and almost always
affects both breasts.
The pain or discomfort is usually worse just before a feed.
Milk tends to not flow well from an engorged breast and the infant may find it
difficult to attach and suckle.
Fever may be present but typically settles within 24 hours.
The breasts may appear red.
Complications are
o blocked milk ducts,
o mastitis
o Difficulties with breastfeeding and, subsequently, milk supply.
 Treatment
o It will be painful initially, but hand expression of milk may help relieve
the discomfort of engorgement.

Post-term pregnancy
According to the World Health Organization, post-term pregnancy is defined as one
that has extended to or beyond 42 weeks.

Potential complications or consequences:

Neonatal

Reduced placental Perfusion

Oligohydramnios

Maternal

Increased rates of intervention including forceps and caesarean section

Increased rates of labour induction

Placental abruption
Overview

Placental abruption does describe the separation of a normally sited placenta

from the uterine wall, as a result, there is maternal haemorrhage into the
intervening space.

Epidemiology

Occurs in approximately 1/200 pregnancies

Cause – these are not known but associated factors are :

Maternal trauma
Increasing maternal age
Proteinuric hypertension
Multiparity

Clinical features

Normal lie and presentation

Fetal heart:
o Absent or distressed
Coagulation problems
Shock out of keeping with visible loss
Pain constant
Tender uterus
 Tense uterus
Beware of the following
o Pre-eclampsia
o DIC
o Anuria

Placenta praevia
Overview

This describes a placenta lying wholly or partly in the lower uterine segment

Epidemiology

5% will have low-lying placenta when scanned at 16-20 weeks gestation

Incidence at delivery is only around 0.5%, therefore most placentas rise away
from the cervix

Associated factors

Multiparity
Multiple pregnancies
Embryos are more likely to implant on a lower segment scar that is from a
previous caesarean section

Clinical features

Shock in proportion to the visible loss

No pain
Uterus not tender
Fetal heart typically normal
Coagulation problems are rare
Small bleeds before large
Lie and presentation may be abnormal

Investigations

Placenta praevia is often picked up on the routine 20-week abdominal

ultrasound
The RCOG has recommended the use of transvaginal ultrasound as it
improves the accuracy of placental localisation and is considered safe

Classical grading

I–
o Placenta reaches the lower segment but not the internal os
II –
o Placenta reaches the internal os but doesn't cover it
III –
 o Placenta covers the internal os before dilation but not when dilated
IV –
o Placenta completely covers the internal os

Management and prognosis

If low-lying placenta at 16-20 week scan

Rescan at 34 weeks
No need to limit activity or intercourse unless they bleed
If still present at 34 weeks and grade I or II then scan every 2 weeks
If high presenting part or abnormal lie at 37 weeks then a Caesarean section
should be performed

Placenta praevia with bleeding

Admit
Treat shock
Crossmatch blood
Final ultrasound at 36-37 weeks to determine the method of delivery,
o Caesarean section for grades III or IV between 37-38 weeks.
o If grade I then vaginal delivery

Prognosis

Death is now extremely rare

The major cause of death in women with placenta praevia is now Postpartum
haemorrhage

Postpartum haemorrhage
Overview

Postpartum haemorrhage (PPH) is defined as blood loss of > 500mls and also
may be primary or secondary

Primary Postpartum haemorrhage

This occurs within 24 hours

Affects approximately around 5-7% of deliveries
The most common cause of Postpartum haemorrhage is uterine atony (90%
of cases).
Other causes are:
o Genital trauma
o Clotting factors

Exam Tip

Remember the four T's for causes

 Tone (abnormalities of uterine contraction)
Tissue (retained products of conception)
Trauma (of the genital tract)
Thrombin (abnormalities of coagulation)

Risk factors for primary Postpartum haemorrhage are:

Previous PPH
Increased maternal age
Macrosomia
Ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)
Polyhydramnios
Emergency Caesarean section
Placenta praevia, placenta accreta
Prolonged labour
Pre-eclampsia

Management

ABC ( airway, breathing, circulation )

The following management should be initiated in sequence:
o Bimanual uterine compression to manually stimulate contraction
o Intravenous oxytocin and/or ergometrine
o Intramuscular carboprost
o Intramyometrial carboprost
o Rectal misoprostol
o Surgical intervention such as balloon tamponade
Other options are:
o B-Lynch suture
o Ligation of the uterine arteries or the internal iliac arteries
If it is a severe, and uncontrolled haemorrhage then a hysterectomy is
sometimes performed as a life-saving procedure

Secondary Postpartum haemorrhage

Occurs between 24 hours - 12 weeks

o Previously the definition of secondary Postpartum haemorrhage was
24 hours - 6 weeks. Please refer to the RCOG guidelines for more
details
Due to retained placental tissue or endometritis

Antenatal care
Lifestyle advice
NICE has made many recommendations regarding the advice that pregnant women
should receive:

Nutritional supplements
 Folic acid
o This should be at 400mcg and should be given from before conception
until 12 weeks to reduce the risk of neural tube defects.
o Certain women may require higher doses (women who take
antiepileptics)
Iron supplementation
o This should not be offered routinely
Vitamin A
o Supplementation (intake above 700 micrograms) might be tetragenic.
Liver is high in vitamin A so consumption should be avoided
vitamin D:
o 'Women should be advised to take a vitamin D supplement (10
micrograms of vitamin D per day), as found in the Healthy Start
multivitamin supplement. Women who are not eligible for the Healthy
Start benefit should be advised where they can buy the supplement'.
Particular care should be taken with higher risk women (i.e. those with
darker skin or who cover their skin for cultural reasons)

Alcohol

The government has now recommended that pregnant women should not
drink.
The wording of the official advice is as follows
o 'If you are pregnant or planning a pregnancy, the safest approach is not
to drink alcohol at all, to keep risks to your baby to a minimum. Drinking
in pregnancy can lead to long-term harm to the baby, with the more
you drink the greater the risk.'

Smoking

Risks of smoking are:

o Low birthweight and
o Preterm birth
Nicotine replacement therapy:
o This may be used but woman must of stopped smoking and risks even
benefits need to be discussed
Neither varenicline or bupropion should be offered to pregnant or even for
breastfeeding women

Food-acquired infections

listeriosis:
o Avoid unpasteurised milk
o Ripened soft cheeses (Camembert, Brie, blue-veined cheeses)
o Pate or undercooked meat
Salmonella:
o Avoid raw or partially cooked eggs and meat, especially poultry

Work
 Should inform women of their maternity rights and benefits
For the majority of women it is safe to continue working.
Women should be asked whether they work.
The Health and Safety Executive should be consulted if there are any
concerns about possible occupational hazards during pregnancy

Air travel during pregnancy

This is linked with increased risk of venous thromboembolism

wearing correctly fitted compression stockings is effective at reducing the risk

Prescribed medicines

Avoid this unless benefit outweighs risk

Over-the-counter medicines

This should be used as little as possible during pregnancy

Complimentary therapies

NICE have stated the following

o 'Pregnant women should be informed that few complementary
therapies have been established as being safe and effective during
pregnancy. Women should not assume that such therapies are safe
and they should be used as little as possible during pregnancy'

Exercise in pregnancy

All women should be informed that beginning or continuing moderate exercise

is not linked with adverse outcomes
Certain activities should be avoided, for example, high-impact sports where
there is a risk of abdominal trauma and scuba diving

Sexual intercourse

This is not known be linked with any adverse outcomes

Antenatal care: Timetable

This is based on he NICE guidelines

10 antenatal visits in the first pregnancy if uncomplicated

7 antenatal visits in following pregnancies if uncomplicated
Women do not need to be seen by a consultant if the pregnancy is
uncomplicated

8 - 12 weeks (ideally < 10 weeks)

o Booking a visit
General information
 For example diet, alcohol, smoking, folic acid, vitamin D,
antenatal classes
BP
Urine dipstick
Check BMI
o Booking bloods/urine check
FBC
Blood group
Rhesus status
Red cell alloantibodies
Haemoglobinopathies
Hepatitis B
Syphilis
HIV test is offered to all women
Urine culture to detect asymptomatic bacteriuria
10 - 13+6 weeks
o Early scan to confirm dates, exclude multiple pregnancy
11 - 13+6 weeks
o Down's syndrome screening including nuchal scan
16 weeks
o Information on the anomaly and the blood results. If Hb < 11 g/dl
consider iron
o Routine care:
BP and
Urine dipstick
18 - 20+6 weeks
o Anomaly scan
25 weeks (only if primip)
o Routine care:
BP
Urine dipstick
Symphysis-fundal height (SFH)
28 weeks
o Routine care:
BP
Urine dipstick
SFH
Second screen for anaemia and atypical red cell alloantibodies.
If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
31 weeks (only if primip)
o Routine care as above
34 weeks
o Routine care as above
o Second dose of anti-D prophylaxis to rhesus negative women
o Information on labour and birth plan
36 weeks
o Routine care as above
o Check presentation
Offer external cephalic version if indicated
 o Information on breast feeding, vitamin K, 'baby-blues'
38 weeks
o Routine care as above
40 weeks (only if primip)
o Routine care as above
o Discussion about options for prolonged pregnancy
41 weeks
o Routine care as above
o Discuss labour plans and possibility of induction

Antenatal care: Specific points

Nausea and vomiting

Natural remedies
o Ginger and acupuncture on the 'p6' point (by the wrist) are
recommended by NICE
Antihistamines should be used first-line
o BNF has suggested promethazine as first-line

Vitamin D

NICE has stated the following

o 'All women should be informed at the booking appointment about the
importance for their own and their baby's health of maintaining
adequate vitamin D stores during pregnancy and whilst breastfeeding'
And also they have stated:
o 'Women may choose to take 10 micrograms of vitamin D per day, as
found in the Healthy Start multivitamin supplement'. This was
confirmed in 2012 when the Chief Medical Officer advised: 'All
pregnant and breastfeeding women should take a daily supplement
containing 10micrograms of vitamin D, to ensure the mothers
requirements for vitamin D are met and to build adequate fetal stores
for early infancy'
Particular care should be taken with women at risk (for example Asian, obese,
poor diet)

Antenatal screening
The following is based on the National Screening Committee (NSC)

Conditions which all pregnant women should be offered screening

Anaemia
Bacteriuria
Blood group, Rhesus status and anti-red cell antibodies
Down's syndrome
Fetal anomalies
Hepatitis B
HIV
 Neural tube defects
Risk factors for pre-eclampsia
Syphilis
The following should be offered depending on the history:
o Placenta praevia
o Psychiatric illness
o Sickle cell disease
o Tay-Sachs disease
o Thalassaemia

Conditions for which screening should not be offered

Bacterial vaginosis
Chlamydia
Cytomegalovirus
Fragile X
Hepatitis C
Group B Streptococcus
Toxoplasmosis

Rhesus negative pregnancy

Overview

ABO system and the Rhesus system are the most important antigen found on
red blood cells.
The D antigen is the most important antigen of the rhesus system
Approximately around 15% of mothers are rhesus negative (Rh -ve)
If an Rh -ve mother delivers an Rh +ve child a leak of fetal red blood cells may
possibly occur
This results in anti-D IgG antibodies forming in the mother
In later pregnancies, these can cross the placenta and cause haemolysis in
the fetus
This can also occur in the first pregnancy due to leaks

Prevention

Test for D antibodies in all Rh -ve mothers at booking

NICE has advised that giving anti-D to non-sensitised Rh -ve mothers at 28
and 34 weeks
The evidence has suggested that there is little difference in the efficacy of
single-dose (at 28 weeks) and double-dose regimes (at 28 and 34 weeks).
Due to this, the RCOG in 2011 advised that either regime could be used
'depending on local factors'.
Anti-D is prophylaxis
o Once sensitization has occurred it is irreversible
If the event is in the 2nd or 3rd trimester, give a large dose of anti-D and also
perform Kleihauer test – this determines the proportion of fetal RBCs present
Anti-D immunoglobulin should be given as soon as possible (but
always within 72 hours) in the following scenarios:

Ectopic pregnancy (if managed surgically, if managed medically with

methotrexate anti-D is not required)
External cephalic version
Antepartum haemorrhage
Delivery of an Rh +ve infant, whether live or stillborn
Any termination of pregnancy
Miscarriage if gestation is > 12 weeks
Amniocentesis,
Chorionic villus sampling,
Fetal blood sampling

Tests

All babies born to Rh -ve mother should have cord blood taken at delivery for
the following
o FBC
o Blood group
o Direct Coombs test
Coombs test:
o Direct antiglobulin, will demonstrate antibodies on RBCs of baby
Kleihauer test:
o Add acid to maternal blood, fetal cells are resistant

Affected fetus

Oedematous
o Hydrops fetalis, as liver devoted to RBC production albumin falls
Jaundice
Anaemia
Hepatosplenomegaly
Heart failure
Kernicterus
Treatment:
o Transfusions,
o UV phototherapy

Gestational trophoblastic disorders

This describes a spectrum of disorders originating from the placental trophoblastic
and these are:

Complete hydatidiform mole

Partial hydatidiform mole
Choriocarcinoma

Complete hydatidiform mole

Overview

It is a Benign tumour of trophoblastic material

Occurs when an empty egg is fertilized by a single sperm that then duplicates
its own DNA
All 46 chromosomes are of paternal origin

Features

Bleeding is found in the first or early second trimester

Exaggerated symptoms of pregnancy for example hyperemesis
Uterus large for dates
Very high serum levels of human chorionic gonadotropin (hCG) are seen
Hypertension and hyperthyroidism may also be seen
o hCG can mimic thyroid-stimulating hormone (TSH)

Ultrasound findings of a complete mole

"Snowstorm' appearance mixed echogenicity, representing hydropic villi and

intrauterine haemorrhage
Large theca lutein cysts

Management

Urgent referral to specialist centre –

o Evacuation of the uterus is performed
Two-weekly serum and urine samples until hCG concentrations are normal.
Women should be advised not to conceive until the hCG level has been
normal and follow up is complete
Also, effective contraception is recommended to avoid pregnancy in the next
12 months

NOTE: Around 2-3% go on to develop choriocarcinoma

Partial mole

In this, a normal haploid egg may be fertilized by two sperms, or even by one
sperm with duplication of the paternal chromosomes.
Therefore the DNA is both maternal and paternal in origin.
Typically triploid – for example, 69 XXX or 69 XXY. Fetal parts may also be
seen

Cord prolapse
Overview

This involves the umbilical cord descending ahead of the presenting part of
the fetus.
This occurs in 1/500 deliveries.
 If left untreated, this can lead to compression of the cord or cord spasm, and
this, in turn, can cause fetal hypoxia and eventually irreversible damage or
death.

Risk factors for cord prolapse are:

Cephalopelvic disproportion
Abnormal presentations
o For example Breech, transverse lie
Placenta praevia
Long umbilical cord
High fetal station
Prematurity
Multiparity
Polyhydramnios
Twin pregnancy

The majority of cord prolapses occur at artificial rupture of the membranes.

Diagnosis

This is typically made when the fetal heart rate becomes abnormal and the
cord is palpable vaginally, or if the cord is visible beyond the level of the
introitus.

Management

The presenting part of the fetus may be pushed back into the uterus to avoid
compression.
Tocolytics may be used.
If the cord is past the level of the introitus, it should be kept warm and moist
but should not be pushed back inside.
The patient is asked to go on 'all fours' until preparations for an immediate
caesarian section have been carried out.
Although this is the usual first-line method of delivery, an instrumental vaginal
delivery is possible if the cervix is fully dilated and the head is low. If treated
early, fetal mortality in cord prolapse is low.
Incidence has been reduced by the increase in caesarian sections being used
in breech presentations.

Gestational thrombocytopenia vs immune

thrombocytopenia (ITP)
Overview

Gestational thrombocytopenia is a relatively common condition of pregnancy

that results from a combination of the following
o Of dilution, decreased production and increased destruction of
platelets.
 The latter is thought to be due to the increased work of the maternal spleen
leading to mild sequestration.
Immune thrombocytopenia (ITP) is an autoimmune condition that is typically
linked with acute purpuric episodes in children, but a chronic relapsing course
may be seen more frequently in women.
Differentiating between ITP and gestational thrombocytopenia is difficult and
often this relies on a careful history.
Gestational thrombocytopenia may be considered more likely if the platelet
count continues to fall as pregnancy progresses, but this is not a reliable
sign.
If the patient becomes dangerously thrombocytopenic, she will usually be
treated with steroids and a diagnosis of ITP assumed.
If Pregnant women are found to have low platelets during a booking visit or
those with a previous diagnosis of ITP may need to be tested for serum
antiplatelet antibodies for confirmation.
Gestational thrombocytopenia does not affect the neonate, but ITP can do if
maternal antibodies cross the placenta.
This does depend on the degree of thrombocytopenia in the newborn, platelet
transfusions may be indicated.
Serial platelet counts can also be performed to see whether there is inherited
thrombocytopenia.

Group B Streptococcus
Overview

This is the most common cause of early-onset severe infection in the neonatal
period. It is thought approximately around 20-40% of mothers have Group
B Streptococcus present in their bowel flora and may therefore be thought of
as 'carriers' of Group B Streptococcus .
Infants may be exposed to maternal Group B Streptococcus during labour
and subsequently develop potentially serious infections.

Risk factors for Group B Streptococcus (GBS) infection:

Prematurity
Maternal pyrexia for example :- secondary to chorioamnionitis
Prolonged rupture of the membranes
Previous sibling GBS infection

Management

RCOG published guidelines on GBS in 2017. The main points are mentioned below ,
please refer link for more information

Universal screening for Group B Streptococcus should not be offered to all

women
The guidelines also state a maternal request is not an indication for screening
 Women who've had Group B Streptococcus detected in a previous
pregnancy should be informed that their risk of maternal Group
B Streptococcus carriage in this pregnancy is 50%. They should be offered
maternal intravenous antibiotic prophylaxis (IAP) OR testing in late pregnancy
and then antibiotics if still positive
If women are to have swabs for Group B Streptococcus this should be
offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date
Maternal intravenous antibiotic prophylaxis should be offered to women with a
previous baby with early- or late-onset Group B Streptococcus disease
Maternal intravenous antibiotic prophylaxis should be offered to women in
preterm labour regardless of their Group B Streptococcus status
Women with a pyrexia during labour (>38ºC) should also be given intravenous
antibiotics
Benzylpenicillin is the antibiotic of choice for Group
B Streptococcus prophylaxis

Offer intrapartum antibiotics during labour in the following

scenarios:

If in pre-term labour or
Mother has group B streptococcal colonisation, bacteriuria or infection during
the current pregnancy or
Mother has had group B streptococcal colonisation, bacteriuria or infection in
a previous pregnancy, and have not had a negative test for group B
streptococcus by enrichment culture or PCR or
The mother has had a previous baby with an invasive group B streptococcal
infection or
Mother has a clinical diagnosis of chorioamnionitis. Use Benzylpenicillin plus
gentamicin plus metronidazole. ( If using intravenous gentamicin during
labour, use once-daily dosing)
o Without chorioamnionitis: Use Benzylpenicillin.

Patient’s with prolonged prelabour rupture of membranes and who

have group B streptococcal colonisation, bacteriuria or infection

Offer an immediate birth (by induction of labour or caesarean birth) to women

who are between 34 and 37 weeks gestation who:
o Have prolonged prelabour rupture of membranes, and
o Have group B streptococcal colonisation, bacteriuria or infection at any
time in their current pregnancy. [NICE 2021]

NOTE:

When starting antibiotic treatment in babies who may have late-onset

neonatal infection, perform a blood culture before giving the first dose.
Do not perform skin swab microscopy or culture as part of the investigations
for late-onset neonatal infection if there are no clinical signs of a localised
infection.[NICE 2021]
Chorioamnionitis
Overview

This can affect up to 5% of all pregnancies

And is a potentially life-threatening condition to both mother and thus
considered a medical emergency.
It is typically the result of an ascending bacterial infection of the amniotic fluid
or membranes or placenta.
The major risk factor in this scenario is the preterm premature rupture of
membranes
However, this can still occur when the membranes are still intact
This exposes the normally sterile environment of the uterus to potential
pathogens.

Features

Fever
Abdominal pain, including contractions
Maternal pyrexia and tachycardia
Uterine tenderness
Fetal tachycardia
Foul odour of amniotic fluid
Speculum shows offensive vaginal discharge (usually yellow/brown)

Risk factors

Prolonged labour
Internal monitoring of labour
Multiple vaginal exams
Meconium-stained amniotic fluid

Treatment

Prompt delivery of the foetus (that’s via cesarean section if necessary)

Administration of intravenous antibiotics is widely considered the mainstay of
initial treatment for this condition.

Hypertension in pregnancy
Overview

Women who are at high risk of developing pre-eclampsia should take aspirin
75mg od from 12 weeks until the birth of the baby.

High-risk groups are:

Autoimmune disorders such as SLE or antiphospholipid syndrome

Type 1 or 2 diabetes mellitus
 Hypertensive disease during previous pregnancies
Chronic kidney disease
Chronic hypertension - Added to NICE guidelines in 2019

The classification of hypertension in pregnancy is complicated and

varies.
Remember, in normal pregnancy:

Blood pressure typically falls in the first trimester ( this is particularly diastolic),
and continues to fall until the 20-24 weeks
After this time the blood pressure typically increases to pre-pregnancy levels
by term

Hypertension in pregnancy is typically defined as the following :

Systolic > 140 mmHg and or diastolic > 90 mmHg

Or even an increase above booking readings of > 30 mmHg systolic or > 15
mmHg diastolic

After establishing that the patient is hypertensive it should be

categorised into one of the following groups mentioned below.
Pre-existing hypertension

A history of hypertension before pregnancy or an elevated blood pressure >

140/90 mmHg before 20 weeks gestation
No proteinuria, no oedema
Occurs in 3-5% of pregnancies and is more common in older women

Pregnancy-induced hypertension (PIH, also known as gestational

hypertension)

Hypertension (as defined above) occurring in the second half of pregnancy

(That means after 20 weeks)
No proteinuria, no oedema
Occurs in around 5-7% of pregnancies
Resolves following birth (typically after one month). Women with PIH are at
increased risk of future pre-eclampsia or hypertension later in life

Pre-eclampsia

Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24

hours)
Oedema may occur but is now less commonly used as a criteria
Occurs in around 5% of pregnancies

Breastfeeding: Contraindications
The following drugs can be given to mothers who are
breastfeeding:

Antibiotics:
o Penicillins
o Cephalosporins
o Trimethoprim
Endocrine:
o Glucocorticoids (avoid high doses)
o Levothyroxine
Epilepsy:
o Sodium valproate
o Carbamazepine
Asthma:
o Salbutamol
o Theophyllines
Psychiatric drugs:
o Tricyclic antidepressants
o Antipsychotics
Clozapine should be avoided
Hypertension:
o Beta-blockers
o Hydralazine
Anticoagulants:
o Warfarin
o Heparin
Digoxin

The following drugs should be avoided:

Antibiotics:
o Ciprofloxacin
o Tetracycline
o Chloramphenicol
o Sulphonamides
Psychiatric drugs:
o Lithium
o Benzodiazepines
Aspirin
Carbimazole
Methotrexate
Sulphonylureas
Cytotoxic drugs
Amiodarone

Other contraindications

Galactosaemia
Viral infections
 o This is controversial with respect to HIV in the developing world.
o This is mainly because there is such an increased infant mortality and
morbidity linked with bottle feeding that some doctors think the benefits
outweigh the risk of HIV transmission

Pre-eclampsia
Overview

This is a condition seen after 20 weeks gestation and is characterised by

pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24
hours).
Oedema used to be the third element of the classic triad but is now often not
included in the definition, because it is not specific

Pre-eclampsia is important as it can cause the following problems

Fetal:
o Prematurity,
o Intrauterine growth retardation
Eclampsia
Haemorrhage:
o Placental abruption,
o Intra-abdominal,
o Intra-cerebral
Cardiac failure
Multi-organ failure

NICE have divided the risk factors into high and moderate risk and
its mentioned below:
High-risk factors

Chronic kidney disease

Autoimmune diseases, such as systemic lupus erythematosus or
antiphospholipid syndrome
Type 1 or type 2 diabetes
Chronic hypertension
Hypertensive disease in a previous pregnancy

Moderate risk factors

Body mass index (BMI) of 35 kg/m² or more at the first visit

Family history of pre-eclampsia
Multiple pregnancies
First pregnancy
Age 40 years or older
Pregnancy interval of more than 10 years
Features of severe pre-eclampsia

Hypertension:
o Typically > 170/110 mmHg and proteinuria as mentioned above
Proteinuria:
o Dipstick ++/+++
Headache
Visual disturbance
Papilloedema
Right upper quadrant or epigastric pain
Hyperreflexia
Platelet count < 100 x 106/l, abnormal liver enzymes or HELLP syndrome

Management

Consensus guidelines have recommended treating blood pressure > 160/110

mmHg although many clinicians do prefer to have a lower threshold
The NICE guidelines also advise using anti-hypertensive treatment if BP
remains over 140/90 mmHg
Women at high risk of pre-eclampsia are advised to take 75 mg of aspirin
daily from 12 weeks until the birth of the baby according to the NICE
guidelines.
Oral labetalol is now considered first-line
Nifedipine and hydralazine may also be used
Delivery of the baby is the most important and definitive management step.
The timing of the delivery depends on the individual clinical scenario

Eclampsia
This may be defined as the development of seizures and is linked to pre-
eclampsia.

Treatment
Magnesium sulphate is used to both prevent seizures in patients with severe pre-
eclampsia and treat seizures once they develop. Guidelines on its use suggest the
following:

Should be given once a decision to deliver has been made

In eclampsia, an IV bolus of 4g MgSO4 in 100 ml 0.9% normal saline over 5-
10 minutes should be given followed by an infusion of 1g / hour
Urine output, reflexes, respiratory rate and oxygen saturation should be
monitored during treatment
Recurrent seizures should be treated with either a further bolus of 2 g of
magnesium sulfate or an increase in the infusion rate to 1.5 g or 2.0 g/hour.
Treatment should continue for 24 hours after the last seizure or delivery
(around 40% of seizures occur post-partum)
NOTE: Other important aspects of treating severe pre-eclampsia or eclampsia are to
include fluid restriction to avoid the potentially serious consequences of fluid
overload

Pregnancy: Jaundice
Intrahepatic cholestasis of pregnancy
Overview

This is also known as obstetric cholestasis

It occurs in approximately around 1% of pregnancies and is usually seen in
the third trimester
It is the most common liver disease of pregnancy

Features

Pruritus is often in the palms and soles

No rash (though skin changes may be seen due to scratching)
Raised bilirubin

Management

Ursodeoxycholic acid is mainly used for symptomatic relief

Weekly liver function tests
Women are usually induced at 37 weeks

Complications

Complications are an increased rate of stillbirth

It is not usually linked with increased maternal morbidity

Acute fatty liver of pregnancy

Overview

Acute fatty liver of pregnancy is a rare complication that may occur in the third
trimester or the period immediately after delivery.

Features

Jaundice
Hypoglycaemia
Severe disease may result in pre-eclampsia
Abdominal pain
Nausea and vomiting
Headache

Investigations
 ALT is typically elevated for example 500 u/l

Management

Support care
Once stabilised delivery is the definitive management

NOTE: Gilbert's and Dubin-Johnson syndrome may also be exacerbated during

pregnancy

HELLP Syndrome

Haemolysis
Elevated Liver enzymes
Low Platelets
Increased blood pressure and other features of pre-eclampsia
RUQ pain and tenderness
Management
o Delivery
o Supportive and as for eclampsia (magnesium sulfate (MgSO 4) is
indicated)
o Although platelet levels may be very low, platelet infusions are only
required if bleeding, or for surgery and <40

Bleeding in pregnancy
The major causes of bleeding during pregnancy are listed below

1st trimester

Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole

2nd trimester

Spontaneous abortion
Hydatidiform mole
Placental abruption

3rd trimester

Bloody show
Placental abruption
Placenta praevia
Vasa praevia

Antepartum hemorrhage is defined as bleeding after 24 weeks

Alongside the pregnancy-related causes, conditions such as sexually transmitted
infections and cervical polyps should be excluded.

The most important investigation is an ultrasound. It helps determine the cause of

the bleeding Placenta abruption is a clinical diagnosis and should be considered if
the pain is continuous.

The key features of each condition are listed below:

Spontaneous abortion
o Threatened miscarriage - painless vaginal bleeding typically around 6-9
weeks
o Missed (delayed) miscarriage - light vaginal bleeding and symptoms of
pregnancy disappear
o Inevitable miscarriage - complete or incomplete depending or whether
all fetal and placental tissue has been expelled. Incomplete miscarriage
- heavy bleeding and crampy, lower abdominal pain. Complete
miscarriage - little bleeding
Ectopic pregnancy
o Usually the history of 6-8 weeks amenorrhoea with lower abdominal
pain (typically unilateral) initially and vaginal bleeding later.
o Shoulder tip pain and cervical excitation may also be present
Hydatidiform mole
o Usually bleeding in the first or early second trimester linked with
exaggerated symptoms of pregnancy, for example, hyperemesis.
o The uterus may be large for dates and serum hCG is very high
Placental abruption
o Constant lower abdominal pain and, a woman may be more shocked
than is expected by visible blood loss.
o Tender, tense uterus with normal lie and presentation.
o Fetal heart may also be distressed
Placental praevia
o Vaginal bleeding, no pain.
o Non-tender uterus but lie and presentation may be abnormal
Vasa praevia
o Rupture of membranes followed immediately by vaginal bleeding.
o Fetal bradycardia is classically seen

Induction of labour
Overview

Induction of labour describes a process where labour is started artificially.

This happens in around 20% of pregnancies

Indications

Prolonged pregnancy, For example, >12 days after the estimated date of
delivery
 Prelabour premature rupture of the membranes and the where the labour
does not start
Diabetic mother > 38 weeks
Rhesus incompatibility

Pharmacological and mechanical methods for inducing labour

Breaking of waters (Amniotomy )

Dinoprostone as a vaginal tablet
Vaginal gel
Low dose oral misoprostol tablets
Oxytocin
Membrane sweep
Intravaginal prostaglandins

NICE 2021 Update:

For women with a Bishop score of 6 or less, offer induction of labour with
dinoprostone (PGE2, prostaglandin E2) as a vaginal tablet, vaginal gel or
controlled-release vaginal delivery system or with low dose (25 micrograms)
oral misoprostol tablets.
For women with a Bishop score of more than 6, offer induction of labour with
amniotomy and an intravenous oxytocin infusion.
o Advise women that they can have an amniotomy and can choose
whether or not to have an oxytocin infusion, or can delay starting this,
but that this may mean labour takes longer and there may be an
increased risk of neonatal infection.

Point to note

If a woman has a preterm prelabour rupture of membranes after 34+0 weeks

(but before 37+0 weeks) or at term (at or after 37+0 weeks) and has had a
positive group B streptococcus test at any time in their current pregnancy,
offer immediate induction of labour or caesarean birth
For women who have had a previous caesarean birth: Some methods
used for induction of labour may not be suitable (for example, both
dinoprostone and misoprostol are contraindicated in women with a uterine
scar).

Osteoarthritis
Overview

This is the commonest joint condition.

It usually occurs in those aged more than 50 years of age and is typically
monoarthritis.
Bouchard’s nodes and Herbeden’s nodes are typically present.
Female:male ratio is 3:1 - usually affects 50 years and above
 The Hip and Knee joints are commonly affected. Typically affects big joints
like hip and knee.

Symptoms

Single joint usually affected, with pain on movement worsening by the end of
the day go together with by stiffness and joint instability
In polyarthritis Osteoarthritis herbeden’s nodes are seen in the following
o DIP, involvement of cervical and lumbar vertebrae
o Knee
o Thumb
o MCP joints

Investigation

X-ray
Subchondral sclerosis of cysts
Marginal osteophytes

X-ray changes of osteoarthritis

Decrease of joint space

Subchondral sclerosis
Subchondral cysts
Osteophytes forming at joint margins

Management

All patients should be given help with weight loss,

Should be given advice about local muscle strengthening exercises and
general aerobic fitness
Paracetamol and topical NSAIDs are first-line analgesics.
Note that Topical NSAIDs are specified only for OA of the knee or hand
Second-line treatment is
o Oral NSAIDs/COX-2 inhibitors,
o Opioids, capsaicin cream and intra-articular corticosteroids.
o NICE 2020 for chronic pain conclude that:
There is little evidence that opioids are helpful for chronic pain.
Only a small proportion of people may obtain good pain relief
with opioids in the long-term if the dose can be kept low and use
is intermittent
Opioids should be discontinued if the person is still in pain
despite using opioids, even if no other treatment is available.
A proton pump inhibitor should be co-prescribed with NSAIDs and COX-2
inhibitors and note that these drugs should be avoided if the patient takes
aspirin
Non-pharmacological treatment options are
o Supports and braces,
o TENS and shock absorbing insoles or shoes
 In case conservative methods fail then consider joint replacement

What is the role of glucosamine?

It is a normal constituent of glycosaminoglycans in cartilage and synovial fluid

A systematic review of several double blind RCTs of glucosamine in knee
osteoarthritis reported significant short-term symptomatic benefits this
includes considerably decreasing joint space narrowing and improved pain
scores
More recent studies have been mixed
Based on the 2008 NICE guidelines , they suggest it is not recommended
2008 Drug and Therapeutics Bulletin review advised that at the same time as
glucosamine provides modest pain relief in knee osteoarthritis it should not be
prescribed on the NHS due to limited evidence of cost-effectiveness

Key Points

It is important to remember that you should never prescribe pain relief to

pregnant women as junior doctors other than paracetamol.
Osteoarthritis - paracetamol + topical NSAIDs (if knee/hand) first-line
Periarticular erosions are seen in rheumatoid arthritis.
Osteoarthritis - paracetamol + topical NSAIDs (if knee/hand) first-line

Oligohydramnios
Overview

In this, there is reduced amniotic fluid.

Definitions vary but mean that less than 500ml at 32-36 weeks and an
amniotic fluid index (AFI) < 5th percentile.

Causes

Premature rupture of membranes

Fetal renal problems
o For example renal agenesis
Intrauterine growth restriction
Post-term gestation
Pre-eclampsia

Antenatal screening
The National Screening Committee (NSC) suggests the following policy regarding
antenatal screen
Conditions which all pregnant women should be offered screening

Anaemia
Bacteriuria
Blood group, Rhesus status, and anti-red cell antibodies
Down's syndrome
Fetal anomalies
Hepatitis B
HIV
Neural tube defects
Risk factors for pre-eclampsia
Rubella immunity
Syphilis

The following should be offered depending on the history

Placenta praevia
Psychiatric illness
Sickle cell disease
Tay-Sachs disease
Thalassaemia

Conditions for which screening should not be offered

Bacterial vaginosis
Chlamydia
Cytomegalovirus
Fragile X
Hepatitis C
Group B Streptococcus
Toxoplasmosis

Pregnancy: Physiological changes

Cardiovascular system

SV up 30%, HR up 15% and cardiac output up 40%

But systolic BP is unaltered
And the diastolic BP is reduced in the 1st and 2nd trimester, returning to non-
pregnant levels by the term
Due to the enlarged uterus, the venous return may interfere which can lead to
ankle oedema, supine hypotension and varicose veins

Respiratory system

Pulmonary ventilation up by 40%

Tidal volume from 500 - 700ml ( this due to effect of progesterone on
respiratory centre)
 Oxygen requirements increase by only 20%, thus over-breathing leads to a
fall in pCO2 – this will, in turn, give rise to a sense of dyspnoea that may be
accentuated by elevation of the diaphragm
BMR up 15%
o This may be due to increased thyroxine and adrenocortical hormones -
women may hence find warm conditions uncomfortable

Blood

Maternal blood volume up 30%, this is mostly in 2nd half

o Red cells up 20% but plasma up 50%, Hb falls
Low-grade increase in coagulant activity
Rise in fibrinogen and Factors VII, VIII, X
Fibrinolytic activity is decreased
o Returns to normal after delivery (placental suppression?)
Prepares the mother for placental delivery
This leads to an increased risk of thromboembolism
Platelet count falls
WCC and ESR rise

Urinary system

Salt and water reabsorption is increased by elevated sex steroid levels

Urinary protein losses increase
Blood flow increase by 30%
GFR increases by 30-60%

Biochemical changes

Calcium requirements have increased during pregnancy

Especially during 3rd trimester + continues into lactation
Calcium is transported actively across the placenta
Serum levels of calcium and phosphate actually fall (with fall in protein)
Ionised levels of calcium remain stable
Gut absorption of calcium increases substantially - due to increased 1,25
dihydroxy vitamin D

Liver

Unlike renal and uterine blood flow, hepatic blood flow doesn't change
ALP is raised by 50%
Albumin levels fall

Uterus

100g → 1100g
Hyperplasia → hypertrophy later
Increase in cervical ectropion and discharge
Braxton-Hicks:
 o Non-painful 'practice contractions' late in pregnancy (>30 wks)
Retroversion may lead to retention (I.e. 12-16 wks), typically self corrects

Folic acid
Overview

Folic acid is converted to tetrahydrofolate (THF). Green, leafy vegetables are

a good source of folic acid.

Functions

Tetrahydrofolate plays a key role in the transfer of 1-carbon units (for example
methyl, methylene, and formyl groups) to the essential substrates involved in
the synthesis of DNA and RNA

Causes of folic acid deficiency

Pregnancy
Alcohol excess
Phenytoin
Methotrexate

The consequences of folic acid deficiency

Neural tube defects

Macrocytic megaloblastic anaemia

Women who are at high risk of having a child with neural tube
defects

Diabetes
Receiving antiepileptic medication
Previous pregnancy with neural tube defects
Sickle-cell disease (folic acid given throughout pregnancy)
Thalassaemia or thalassaemia trait (folic acid given throughout pregnancy)
In addition, NICE CKS also recommends using 5mg/day of folic acid for those
who have a:
o BMI more than 30 kg/m2
o Family history of neural tube defects

Prevention of neural tube defects during pregnancy

All women are advised to should take 400mcg of folic acid until the 12th week
of pregnancy
Women at higher risk of conceiving a child with a neural tube defect should
take 5mg of folic acid until the 12th week of pregnancy
Women are considered higher risk if any of the following apply:
 o Either partner has a neural tube defect, they have had a previous
pregnancy affected by a neural tube defect, or they have a family
history of neural tube defects
o The woman who is taking antiepileptic drugs or has coeliac disease,
diabetes, or thalassaemia trait.
o The woman is obese (this is defined as a body mass index [BMI] of 30
kg/m2 or more).

Lochia
Overview
This may be defined as the vaginal discharge containing blood mucous and
uterine tissue which may continue for 6 weeks after childbirth.

Labour: Stage
Labour is divided into three stages

Stage 1: From the onset of true labour to when the cervix is fully dilated

o In a primigravida, this stage lasts usually 10-16 hours

o There are two phases
latent phase = 0-3 cm dilation, normally takes 6 hours
active phase = 3-10 cm dilation, normally 1cm/hr
o Presentation
90% of babies are vertex
Head enters pelvis in occipito-lateral position.
The head normally delivers in an occipito-anterior position.

Stage 2: From full dilation to delivery of the fetus

o 'Passive second stage' refers to the 2nd stage but in the absence of
pushing (normal)
o 'Active second stage' refers to the active process of maternal pushing
o In this stage, it is less painful than 1st (pushing masks pain)
o This stage lasts approximately 1 hour
o In case this is longer than 1 hour (can be left longer if epidural)
consider Ventouse extraction, forceps delivery or caesarean section
o An episiotomy may be also necessary after crowning
o This Is linked with transient fetal bradycardia

Stage 3: From delivery of fetus to when the placenta and membranes have
been completely delivered

False Labor
o Occurs in the last 4 weeks of pregnancy
 o Presentation: contractions felt in the lower abdomen. The contractions
are irregular and occur every 20 minutes. Progressive cervical changes
are absent.

Antiphospholipid syndrome
Overview

This is an acquired disorder characterised by the following

o Predisposition to both venous and arterial thromboses
o Recurrent fetal loss
o Thrombocytopenia
It may occur as a primary disorder or secondary to other conditions, this is
most commonly systemic lupus erythematosus (SLE)
Important for the exam is to appreciate that antiphospholipid syndrome
causes a paradoxical rise in the APTT and this is due to an ex-vivo reaction of
the lupus anticoagulant autoantibodies with phospholipids involved in the
coagulation cascade

Features

Venous or arterial thrombosis

Recurrent fetal loss
Livedo reticularis
Thrombocytopenia
Prolonged APTT
Other features:
o Pre-eclampsia
o Pulmonary hypertension
A positive anti-Cardiolipin antibody can assist in making the diagnosis too

Associations other than SLE

Other autoimmune disorders

Lymphoproliferative disorders
Phenothiazines ( this is rare)

Management
This is mainly based on BCSH guidelines

Initial venous thromboembolic events:

o Evidence presently supports the use of warfarin with a target INR of 2-
3 for 6 months
Repeated venous thromboembolic events:
o Lifelong warfarin;
If occurred whilst taking warfarin then increase target INR to 3-4
Arterial thrombosis
o This should be treated with lifelong warfarin with a target INR 2-3
 If diagnosed in a pregnant woman, aspirin 75mg and heparin is indicated, this
is seen to lower further risk of miscarriages.

NOTE: Warfarin is contraindicated in pregnancy

Amniotic fluid embolism

Definition

This is when fetal cells or amniotic fluid enters the mother's bloodstream and
stimulates a reaction which in turn results in the signs and symptoms
mentioned below.

Epidemiology

A rare complication of pregnancy associated with a high mortality

rate.Incidence 2/ 100,000 in the U.K .

Aetiology

Many risk factors have been linked with amniotic fluid embolism but a clear
cause has not yet been proven.
A consistent association has been demonstrated with maternal age and
induction of labour.
It is widely accepted that maternal circulation must be exposed to fetal cells or
amniotic fluid in order for an amniotic fluid embolism to occur.
But the precise underlying pathology of this process that leads to the
embolism is not well understood, though suggestions have been made about
an immune-mediated process.

Clinical presentation

The majority of cases occur in labour, these can also occur during caesarean
section and also after delivery in the immediate postpartum.
Symptoms are:
o Chills
o Shivering
o Sweating
o Anxiety
o Coughing
Signs are:
o Cyanosis
o Hypotension
o Bronchospasms
o Tachycardia
o Arrhythmia
o Myocardial infarction

Diagnosis
 Clinical diagnosis of exclusion, because there no diagnostic tests

Management

Critical care unit by a multidisciplinary team

Management is mainly supportive

Hepatitis B and pregnancy

Basics

All pregnant women should be offered screening for hepatitis B

Babies born to mothers who are chronically infected with hepatitis B or to
mothers who've had acute hepatitis B during pregnancy should receive a
complete course of vaccination + hepatitis B immunoglobulin
Studies are currently assessing the role of oral antiviral treatment (for
example Lamivudine) in the latter part of pregnancy
The evidence is little to suggest caesarean section reduces vertical
transmission rates
Hepatitis B cannot be transmitted via breastfeeding (in comparison to HIV)

Antepartum haemorrhage: Determining the cause

This is defined as bleeding from the genital tract after 24 weeks of pregnancy, prior
to delivery of the fetus.

Distinguishing placental abruption from praevia

Placental abruption

Normal lie and presentation

Fetal heart:
o Absent or distressed
Coagulation problems
Beware of the following
o Pre-eclampsia
o DIC
o Anuria
Shock out of keeping with visible loss
Pain constant
Tender uterus,
Tense uterus
o A vaginal examination should not be performed in primary care for
suspected antepartum haemorrhage - women with placenta praevia
may haemorrhage

Placenta praevia

Shock in proportion to the visible loss

 No pain
The uterus is not tender
o A vaginal examination should not be performed in primary care for
suspected antepartum haemorrhage - women with placenta praevia
may haemorrhage
Lie and presentation may be abnormal
Fetal heart usually normal
Coagulation problems rare
Small bleeds before large

Post-partum mental health problems

The Edinburgh Postnatal Depression Scale is used to screen for
depression:

This is a 10-item questionnaire, with a maximum score of 30

It indicates how the mother has felt over the previous week
Score > 13 indicates a 'depressive illness of varying severity'
Sensitivity and specificity is > 90%
This includes a question about self-harm

This can be classified into three categorised and these are

mentioned below :
'Baby-blues'

This is seen in around 60-70% of women

Usually seen 3-7 days following birth and is more common in primips
Mothers are characteristically anxious, tearful and irritable
Reassurance and support, the health visitor has a key role

Postnatal depression

Affects approximately around 10% of women

Most cases start within a month and usually peaks at 3 months
Features are similar to depression seen in other circumstances
Similar to baby blues reassurance and support are important
Cognitive behavioural therapy may also be beneficial.
Certain SSRIs such as sertraline and paroxetine may be used if symptoms
are very severe -
o But these drugs are secreted in breast milk it is not thought to be
harmful to the infant
o Paroxetine is recommended by SIGN because of the low milk/plasma
ratio
o Fluoxetine is best avoided due to a long half-life

Puerperal psychosis

Affects approximately 0.2% of women

 Onset typically within the first 2-3 weeks following birth
Features are severe swings in mood (that is similar to bipolar disorder) and
disordered perception (for example auditory hallucinations)
Admission to hospital is usually required
There is approximately around a 20% risk of recurrence following future
pregnancies

HIV and pregnancy

Overview

Due to the increased incidence of HIV infection amongst the heterosexual

population, there is an increasing number of HIV positive women giving birth
in the UK.
In London, the incidence may be as high as 0.4% of pregnant women.
The aim of treating HIV positive women during pregnancy is to minimise harm
to both the mother and fetus and also to reduce the chance of vertical
transmission.
Guidelines regularly change on this issue and the most recent guidelines can
be found in the links provided.

Factors that reduce vertical transmission (from 25-30% to 2%)

Neonatal antiretroviral therapy

Infant feeding (bottle feeding)
Maternal antiretroviral therapy
Mode of delivery (caesarean section)

Screening

NICE guidelines have recommended offering HIV screening to all pregnant

women

Antiretroviral therapy

All pregnant women should be offered antiretroviral therapy irrespective of

whether they were taking it previously

Mode of delivery

Vaginal delivery is also recommended if viral load is less than 50 copies/ml at

36 weeks. If not then a caesarian section is recommended.
A zidovudine infusion should be started four hours before beginning the
caesarean section

Neonatal antiretroviral therapy

Zidovudine is usually administered orally to the neonate if maternal viral load

is <50 copies/ml. if not triple ART should be used.
 Therapy should be continued for 4-6 weeks.

Infant feeding

In the UK all women should be advised not to breastfeed

Cardiotocography (CTG)
This records pressure changes in the uterus using internal or external pressure
transducers

The normal fetal heart rate varies between 100-160 / min

Baseline bradycardia

Heart rate < 100 /min

Cause:
o Increased fetal vagal tone
o Maternal beta-blocker use

Baseline tachycardia

Heart rate > 160 /min

Causes:
o Maternal pyrexia
o Chorioamnionitis
o Hypoxia
o Prematurity

Loss of baseline variability

< 5 beats / min

Causes
o Prematurity
o Hypoxia

Early deceleration

Deceleration of the heart rate which commences with the onset of a

contraction and returns to normal on completion of the contraction
Causes:
o Typically an innocuous feature and indicates head compression

Late deceleration

Deceleration of the heart rate lags the onset of a contraction and does not
returns to normal until after 30 seconds following the end of the contraction
Cause:
 o Indicates fetal distress, For example, asphyxia or placental
insufficiency

Variable decelerations

Independent of contractions
Causes:
o May indicate cord compression

The following mnemonic is helpful in interpreting CTGs; DR C BRA

VADO:

DR- define risk: why is this patient on a CTG monitor? e.g. pre-
eclampsia, antepartum haemorrhage, maternal obesity, maternal ill-
health
C- contractions. Look at the bottom of the trace, each contraction is
shown by a peak. In established labour, you would expect 5
contractions in 10 minutes. Each large square = 1-minute duration, so
count the number of contractions in 10 squares.
BRA- baseline rate. The fetal baseline rate should be approximately 110-
160 beats per minute. Each large square = 10 beats and each small
square = 5 beats. Fetal bradycardia is below 110 beats per minute and
fetal tachycardia is above 160 beats per minute.
V- baseline variability. The fetal heart rate should vary between 5 to 25
beats per minute. Below 5 beats per minute, the variability is said to be
reduced.
A- accelerations. Are there accelerations in fetal heart rate?
Accelerations are a rise in fetal heart rate of at least 15 beats lasting for
15 seconds or more. There should be 2 separate accelerations every 15
minutes. Accelerations typically occur with contractions.
D- decelerations. Are there decelerations in fetal heart rate? There is a
reduction in fetal heart rate by 15 beats or more for at least 15 seconds.
Decelerations are generally abnormal and should prompt senior review.
In particular, late decelerations, which are slow to recover, are indicative
of fetal hypoxia.
O- overall impression/diagnosis. As a medical student, it is important to
be aware of two features- terminal bradycardia and terminal
decelerations. Terminal bradycardia is when the baseline fetal heart rate
drops to below 100 beats per minute for more than 10 minutes. A
terminal deceleration is when the heart rate drops and does not recover
for more than 3 minutes. These make up a 'preterminal' CTG and are
indicators for Emergency Caesarean section.

The NICE guidelines on fetal monitoring have given a useful table for what should be
done for different CTG features, that depends on whether the CTG is considered
normal, non-reassuring or abnormal:
Ultrasound in pregnancy
Usually, a nuchal scan is performed at 11-13 weeks.

Causes of an increased nuchal translucency

Abdominal wall defects

Down's syndrome
Congenital heart defects

Causes of hyperechogenic bowel

Cytomegalovirus infection
 Cystic fibrosis
Down's syndrome

Shoulder dystocia
Overview

This is a complication of vaginal cephalic delivery.

It entails the inability to deliver the body of the fetus using gentle traction, the
head having already been delivered.
Shoulder dystocia is a cause of both maternal and fetal morbidity.
It is linked with postpartum haemorrhage and perineal tears with respect to
the former, and brachial plexus injury with respect to the latter, amongst other
complications.
Neonatal death occasionally occurs.
Key risk factors for shoulder dystocia are
o Pre-labour risk factors
Fetal macrosomia > 4.5 kg
Maternal BMI > 30 kg/m2
Diabetes mellitus
Previous shoulder dystocia
Induction of labour
o Intrapartum risk factors
Prolonged labour
Oxytocin augmentation
Assisted vaginal delivery
It typically occurs due to impaction of the anterior fetal shoulder on the
maternal pubic symphysis.

Management

Additionally, help should be called as soon as shoulder dystocia is identified

and McRoberts' manoeuvre should be performed.
o This manoeuvre entails flexion and abduction of the maternal hips,
bringing the mother's thighs towards her abdomen.
o This rotation increases the relative anterior-posterior angle of the pelvis
and often facilitates a successful delivery.
o The Royal College of Obstetrics and Gynaecology recommend that
'suprapubic pressure should be used to increase the effectiveness of
the McRoberts manoeuvre' in their shoulder dystocia guidelines.
An episiotomy will not relieve the bony obstruction but is sometimes used to
allow better access for internal manoeuvres.
Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal
morbidity and are not first-line options.
NOTE: Oxytocin administration is not indicated in shoulder dystocia.

(RCOG Green-top Guideline No. 42)

Bishop score
The Bishop score is used to analyse the requirement of induction of labour, during
labour. The table below gives more information on the bishop score:

Interpretation of the score (2021 NICE Guideline Update)

For women with a Bishop score of 6 or less, offer induction of labour with
dinoprostone (PGE2, prostaglandin E2) as vaginal tablet, vaginal gel or
controlled-release vaginal delivery system or with low dose (25 micrograms)
oral misoprostol tablets.
For women with a Bishop score of more than 6, offer induction of labour with
amniotomy and an intravenous oxytocin infusion.
o Advise women that they can have an amniotomy and can choose
whether or not to have an oxytocin infusion, or can delay starting this,
but that this may mean labour takes longer and there may be an
increased risk of neonatal infection.

Forceps
Indications for a forceps delivery

Fetal distress in the second stage of labour

Maternal distress in the second stage of labour
Failure to progress in the second stage of labour
Control of head in breech deliver

The requirements for instrumental delivery can be easily

remembered by the

Mnemonic FORCEPS:

Fully dilated cervix generally the second stage of labour must have been
reached
OA position preferably OP delivery is possible with Keillands forceps
and ventouse. The position of the head must be known as incorrect
 placement of forceps or ventouse could lead to maternal or fetal trauma
and failure
Ruptured Membranes
Cephalic presentation
Engaged presenting part i.e. head at or below ischial spines the head
must not be palpable abdominally
Pain relief
Sphincter (bladder) empty this will usually require catheterization

NOTE: There must also be a clear indication for instrumental delivery

Caesarean section
There are two main types of caesarean section

Lower segment caesarean section

o Now comprises 99% of cases
Classic caesarean section
o Longitudinal incision in the upper segment of the uterus

Indications (apart from CPD/ praevia, most are relative)

Failure of labour to progress

Malpresentations:
o Brow
Placental abruption:
o Only if fetal distress; if dead deliver vaginally
Vaginal infection e.g. active herpes
Cervical cancer (disseminates cancer cells)
Absolute CPD
Placenta praevia: grades 3/4
Pre-eclampsia
Post-maturity
IUGR
Fetal distress in labour or prolapsed cord

The RCOG has advised that clinicians should make the women
aware of serious and frequent risks

'Serious'
Maternal

Emergency hysterectomy
Need for further surgery at a later date, including curettage (retained placental
tissue)
Admission to the intensive care unit
Thromboembolic disease
Bladder injury
 Ureteric injury
Death (1 in 12,000)

Future pregnancies

Increased risk of uterine rupture during subsequent pregnancies/deliveries

Increased risk of antepartum stillbirth
Increased risk in subsequent pregnancies of placenta praevia and placenta
accreta)

'Frequent'
Maternal:

Persistent wound and abdominal discomfort in the first few months after
surgery
Increased risk of repeat caesarean section when vaginal delivery attempted in
subsequent pregnancies
Readmission to hospital
Haemorrhage
Infection ( for example wound, endometritis, UTI)

Fetal:

Lacerations, one to two babies in every 100

Other complications

Prolonged ileus
Subfertility:
o Due to postoperative adhesions

Vaginal birth after caesarean (VBAC)

If a woman has had a previous caesarean section due to a factor such as fetal
distress the majority of obstetricians would recommend a trial of normal
labour, before proceeding with another caesarean section.
Approximately around 70-75% of women in this situation have a successful
vaginal delivery
Contraindications include previous uterine rupture or classical caesarean
scar

Tips

Commonly asked question in obstetric operating theatres or in surgical vivas. A clear

confident answer demonstrates a good knowledge of local anatomy and what
structures need to be incised before reaching the fetus. During a lower segment
Caesarian section, the following lies in between the skin and the fetus:

Superficial fascia
 Deep fascia
Anterior rectus sheath
Rectus abdominis muscle
Transversalis fascia
Extraperitoneal connective tissue
Peritoneum
Uterus

Pregnancy: Anaemia
Pregnant women are screened for anaemia at the following weeks:

The booking visit (often done at 8-10 weeks), and also at

28 weeks

NICE usually use the cut-offs mentioned below to analyse whether

a woman should receive oral iron therapy:

< 11.0g/dl in the first trimester

< 10.5 g/dl in the second and third trimester
< 10.0 g/dl in the postpartum period

Normal physiological changes in pregnancy

Haematological changes

Plasma volume increases over the course of pregnancy by around 50%.

Dilutional anaemia is caused by the rise in plasma volume. Elevated
erythropoietin levels increase the total red mass by the end of the second
trimester but haemoglobin concentrations never reach pre-pregnancy levels
Usually, mean corpuscular volume (MCV) and mean corpuscular
haemoglobin concentration (MCHC) are unaffected.
Serum iron falls during pregnancy whilst transferrin and total iron-binding
capacity increase

Exam Tip

Knowing the new British criteria for diagnosing anaemia in pregnancy is very
important for the PLAB 1 exam
Also knowing the normal physiological changes in pregnancy.

References: Oxford Handbook of Clinical Specialities, 9th edition, page 6

Venous thromboembolism in pregnancy

Overview

Pregnancy is a risk factor for developing venous thromboembolism (VTE).

 A risk assessment should be completed at booking and on any subsequent
hospital admission.
A woman with a previous venous thromboembolism history is automatically
considered high risk and requires low molecular weight heparin throughout
the antenatal period and also input from experts.
A woman at intermediate risk of developing venous thromboembolism due to
hospitalisation, surgery, co-morbidities or thrombophilia should be considered
for antenatal prophylactic low molecular weight heparin.
The assessment at booking should include risk factors that increase the
woman's likelihood of developing VTE.

Risk factors

Low-risk thrombophilia
Multiple pregnancies
IVF pregnancy
Age > 35
Body mass index > 30
Parity > 3
Smoker
Gross varicose veins
Current pre-eclampsia
Immobility
Family history of unprovoked VTE

Treatment based on risk

Four or more risk factors warrants immediate treatment with low molecular
weight heparin continued until six weeks postnatal.
If a woman has three risk factors low molecular weight heparin should be
initiated from 28 weeks and continued until six weeks postnatal.
If a diagnosis of deep venous thrombosis is made shortly before delivery,
continue anticoagulation treatment for at least 3 months, as in other patients
with provoked DVTs.

VTE prophylaxis

Low molecular weight heparin is the treatment of choice for VTE prophylaxis
in pregnancy.

Human chorionic gonadotropin

This is a hormone first produced by the embryo and later by the placental
trophoblast.
Its main role is to prevent the disintegration of the corpus luteum
Human chorionic gonadotropin levels double approximately every 48 hours in
the first few weeks of pregnancy.
Levels peak at around 8-10 weeks gestation.
 Measurement of Human chorionic gonadotropin levels form the basis of many
pregnancy testing kits

Galactocele
Overview

This usually occurs in women who have recently stopped breastfeeding and is
due to the occlusion of a lactiferous duct.
A build-up of milk creates a cystic lesion in the breast.
The lesion can be differentiated from an abscess by the fact that a galactocele
is typically painless, with no local or systemic signs of infection.

Pregnancy: Diabetes mellitus

Overview

This may be a pre-existing problem or develop during pregnancy, gestational

diabetes.
It complicates up to 1 in 20 pregnancies.
NICE has estimated the following breakdown:
o 87.5% have gestational diabetes
o 7.5% have type 1 diabetes
o 5% have type 2 diabetes

Risk factors for gestational diabetes

Previous gestational diabetes

First-degree relative with diabetes
BMI of > 30 kg/m²
Previous macrosomic baby weighing 4.5 kg or above
Family origin with a high prevalence of diabetes ( for example South Asian,
Black Caribbean and Middle Eastern)

Screening for gestational diabetes

Women who've previously had gestational diabetes:

o Oral glucose tolerance test (OGTT) should be performed as soon as
possible after booking and at 24-28 weeks
o If the first test is normal. NICE also recommend that early self-
monitoring of blood glucose is an alternative to the oral glucose
tolerance tests
Women with any of the other risk factors should be offered an oral glucose
tolerance test at 24-28 weeks

Diagnostic thresholds for gestational diabetes

These thresholds have recently been updated by NICE

Gestational diabetes is diagnosed if either:
 o Fasting glucose is >= 5.6 mmol/l
o 2-hour glucose is >= 7.8 mmol/l

Management of gestational diabetes

Newly diagnosed women should be seen in joint diabetes and antenatal clinic
within a week
Women should be taught about self-monitoring of blood glucose.
They should be given advice about diet (these include eating foods with a low
glycaemic index) and exercise should be given
If the fasting plasma glucose level is < 7 mmol//l, a trial of diet and exercise
should be offered as a first-line treatment
If glucose targets are not met within 1-2 weeks of altering diet or exercise
metformin should be started
If glucose targets are still not met insulin should be added to diet and exercise
and metformin
If at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin
should be started
If the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of
complications such as macrosomia or hydramnios, insulin should be offered
Glibenclamide should only be offered for women who cannot tolerate
metformin or those who fail to meet the glucose targets with metformin but
decline insulin treatment

Management of pre-existing diabetes

Weight loss for women with a BMI of > 27 kg/m^2

Stop oral hypoglycaemic agents, apart from metformin, and commence insulin
Folic acid 5 mg/day from pre-conception to 12 weeks gestation
Detailed anomaly scan at 20 weeks including a four-chamber view of the
heart and outflow tracts
Tight glycaemic control reduces complication rates
Treat retinopathy as can worsen during pregnancy

The target

Fasting
o 5.3 mmol/l
1 hour after meals
o 7.8 mmol/l, or
2 hour after meals
o 6.4 mmol/l

NOTE (NICE 2020 update)

All pregnant women with type 1 diabetes: Offer continuous glucose monitoring
(CGM)
Who are unable to use continuous glucose monitoring: offer intermittently
scanned CGM
Pregnancy and drugs
Smoking

Increased risk of miscarriage

Increased risk of pre-term labour
Increased risk of stillbirth
IUGR
Increased risk of sudden unexpected death in infancy

Alcohol

Fetal alcohol syndrome (FAS)

Learning difficulties
Characteristic facies:
o Smooth philtrum,
o Thin vermilion,
o Small palpebral fissures
IUGR and postnatal restricted growth
Microcephaly
Binge drinking is a major risk factor for FAS

Cannabis

Similar to smoking risks due to tobacco content

Cocaine

Maternal risks
o Hypertension in pregnancy including pre-eclampsia
o Placental abruption
Fetal risk
o Prematurity
o Neonatal abstinence syndrome

Heroin

Risk of neonatal abstinence syndrome

Lithium

Lithium is a teratogen. Risk of cardiac malformations in the fetus

o If a woman taking lithium is planning a pregnancy, and is well and not
at high risk of relapse
o She should be advised to stop taking lithium
o This should be done by gradual discontinuation before conception.
o Lithium should be reduced gradually over 1 to 3 months because
abruptly stopping lithium may cause their moods to change drastically.
o Gradually stopping lithium is normally a decision that a psychiatrist
would need to take after weighing the risk of damage to a fetus
 especially in the first trimester against the risk of untreated bipolar
disorder.
Note these points with regard to Lithium in pregnancy
o Do not offer lithium to women who are planning a pregnancy or
pregnant, unless antipsychotic medication has not been effective.
o If a woman taking lithium becomes pregnant, consider stopping the
drug gradually over 4 weeks if she is well
o If a woman continues taking lithium during pregnancy, check plasma
lithium levels every 4 weeks, then weekly from the 36th week and
adjust the lithium dose to maintain plasma lithium levels at a
therapeutic range

Symphysis-fundal height
Overview

This is measured from the top of the pubic bone to the top of the uterus in
centimetres
It should match the gestational age in weeks to within 2 cm after 20 weeks, for
example, if 24 weeks then a normal SFH = 22 to 26 cm

Intrahepatic cholestasis of pregnancy

Overview
This is also known as obstetric cholestasis and it affects approximately around 1% of
pregnancies in the UK.

Features

Pruritus
o May be intense
Usually worse palms
Soles
Abdomen
Clinically detectable jaundice occurs in approximately 20% of patients
Raised bilirubin is seen in around > 90% of cases

Risks

There is an increased risk of premature birth

Management

Induction of labour at 37 weeks is common in practice but may not be

evidence-based
Ursodeoxycholic acid
o Again widely used but evidence base not very clear
Vitamin K supplementation
Down's syndrome: Antenatal testing
This is based on the NICE guidelines

The combined test is now standard: nuchal translucency measurement +

serum B-HCG + pregnancy-associated plasma protein A
These tests should be done between 11 - 13+6 weeks
If women book later in pregnancy either the triple or quadruple test should be
offered between 15 - 20 weeks

The following results would be expected in a trisomy 21 (Down's

syndrome) pregnancy

Low alpha-fetoprotein (AFP)

Low oestriol
High human chorionic gonadotrophin beta-subunit (-HCG)
Low pregnancy-associated plasma protein-A (PAPP-A)
Thickened nuchal translucency

NOTE

Triple test means: alpha-fetoprotein, unconjugated oestriol, human chorionic

gonadotrophin

Quadruple test means: alpha-fetoprotein, unconjugated oestriol, human chorionic

gonadotrophin and inhibin-A

Chickenpox exposure in pregnancy

Overview

This is caused by primary infection with varicella-zoster virus

Shingles are a reactivation of the dormant virus in dorsal root ganglion
In pregnancy there is a risk for both the mother and the fetus, the syndrome is
now termed fetal varicella syndrome

Risks to the mother

This is 5 times greater risk of pneumonitis

Fetal varicella syndrome (FVS)

The risk of Fetal varicella syndrome after maternal varicella exposure is

approximately around 1% if occurs before 20 weeks gestation
Studies have shown a very small number of cases occurring between 20-28
weeks gestation and none after 28 weeks
Features of Fetal varicella syndrome are
o Skin scarring
o Eye defects (microphthalmia)
 o Limb hypoplasia
o Microcephaly
o Learning disabilities

Other risks to the fetus are

Shingles in infancy:
o 1-2% risk if maternal exposure in the second or third trimester
Severe neonatal varicella:
o If the mother develops rash between 5 days before and 2 days after
birth there is a risk of neonatal varicella, which may be fatal to the
newborn child in around 20% of cases

Management

In case there is any doubt about the mother previously having chickenpox
maternal blood should be urgently checked for varicella antibodies
If the pregnant woman is not immune to varicella then she should be given
varicella-zoster immunoglobulin (VZIG) as soon as possible.
RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days
post-exposure
Consensus guidelines have also suggested that oral aciclovir should be given
if pregnant women with chickenpox do present within 24 hours of the onset of
the rash

Prematurity: Risks
Risk of prematurity

Intraventricular haemorrhage
Necrotizing enterocolitis
Chronic lung disease
Hypothermia
Feeding problems
Infection
Jaundice
Retinopathy of newborn
Hearing problems
Increased mortality depends on gestation
Respiratory distress syndrome

Labour (normal)
Overview

Definition for labour is the onset of regular and painful contractions linked with
cervical dilation and descent of the presenting part

The signs of labour are:

 Regular and also painful uterine contractions
A show (this is due to the shedding of mucous plug)
Rupture of the membranes (and it's not always present)
Shortening and dilation of the cervix

Labour may be divided into three stages

Stage 1: From the onset of true labour to when the cervix is fully dilated
Stage 2: From full dilation to delivery of the fetus
Stage 3: From delivery of fetus to when the placenta and membranes have
been completely delivered

Monitoring
The following are monitored in Labour

Fetal heart rate should be monitored every 15min (or even continuously via
CTG)
Maternal pulse rate is assessed every 60min
Contractions are assessed every 30min
Maternal blood pressure and temperature should be checked every 4 hours
VE should be offered every 4 hours to check the progression of labour
Maternal urine should be checked for ketones and even protein every 4 hours

Amniocentesis
Amniocentesis is an invasive, diagnostic antenatal test. It involves taking a sample of
amniotic fluid in order to examine fetal cells found in this fluid.
The timing of amniocentesis can be divided into 3 stages

Early (between 12 and 14+6 weeks of gestation):

o This is not recommended, as it is associated with an increased risk of
miscarriage.
Mid-trimester (between 15 and 18 weeks of gestation):
o This is the most common time for the procedure.
Third trimester:
o It May be undertaken for late karyotyping

Amniocentesis is an invasive test posing risk to the fetus and mother. It is

therefore not used as a screening test.

Constipation in adults ( Faecal impaction)

The following can be tried

Bisacodyl suppositories
Phosphate enema
o Phosphate enemas contain sodium acid phosphate and sodium
phosphate. The osmotic activity of the former increases the water
content of the stool so that rectal distension follows and it is thought
that this induces defecation by stimulating rectal motility. It has a very
 quick onset of action which makes enemas useful for when a rapid
evacuation of a stony dull faecal impaction is required
Arachis oil retention enema to soften
An substitute is polyethylene glycol, Movicol taken for three days
Manual removal with the following
o midazolam, morphine, or caudal anaesthesia

Once the treatment is successful it is essential to start regular oral measures to

prevent recurrence of the problem

Steps wise management

For hard stools,

o consider using a high dose of an oral macrogol
For soft stools, or for hard stools after a few days treatment with a macrogol,
o consider starting or adding an oral stimulant laxative ( senna).
If the response to oral laxatives is insufficient or not fast enough,
o Use a suppository:
bisacodyl for soft stools or glycerol alone,
glycerol plus bisacodyl for hard stools.
o Using a mini enema
The final choice of laxative will depend on individual preference and what has
previously been tried.

Exam tip

It is important to remember the relation between elderly bedridden individuals and

faecal impaction.

Fecal impaction is a fairly common complication of long-term constipation in

the elderly and bedridden, occurring in around 30% of all nursing home
residents.
Note in the exam, it is likely they would have the words "Nursing home" in the
question.
Reference:
Oxford Handbook of Geriatric Medicine 2nd Edition page 544
Oxford Handbook of Clinical Medicine 9th Edition page 58
Oxford Handbook of Palliative Care 2nd Edition page 319

Twin pregnancies
Incidence of multiple pregnancies

Twins: 1/105
Triplets: 1/10,000

Twins may be dizygotic

Non-identical
Develop from two separate ova that were fertilized at the same time)
Around 80% of twins are dizygotic

Or they may be monozygotic

Identical, develop from a single ovum which has divided to form two embryos

Monoamniotic monozygotic twins are linked with:

Increased spontaneous miscarriage

Perinatal mortality rate
Increased malformations
 IUGR
Prematurity
Twin-to-twin transfusions:
o The recipient is larger with polyhydramnios (do laser ablation of
interconnecting vessels)

The rate of monozygotic twins is fairly constant.

The incidence of dizygotic twins is increasing mainly due to infertility treatment.

Predisposing factors for dizygotic twins include:

Increasing maternal age

Multigravida
Previous twins
Family history
Induced ovulation and in-vitro fertilisation
Race
o For example Afro-Caribbean

Antenatal complications

Anaemia
Antepartum haemorrhage
Polyhydramnios
Pregnancy-induced hypertension

Fetal complications - perinatal mortality (twins * 5, triplets * 10)

Prematurity (mean twins = 37 weeks, triplets = 33)

Light-for date babies
Malformation (*3, especially monozygotic)

Labour complications

Postpartum haemorrhage is increased (*2)

Malpresentation
Cord prolapse
Cord entanglement

Management

Rest
Ultrasound for diagnosis + monthly checks
Additional iron + folate
More antenatal care (for example weekly > 30 weeks)
Precautions at labour (for example 2 obstetricians present)
75% of twins deliver by 38 weeks. If longer, most twins are induced at 38-40
wks.
Hypothyroidism
Epidemiology

Hypothyroidism affects around 1-2% of women in the UK

Around 5-10 times more common in females than males.

Primary hypothyroidism ( common )

Autoimmune hypothyroidism : Hashimoto's thyroiditis (most common cause)

Primary Atrophic Hypothyroidism
Subacute thyroiditis (de Quervain's)
Riedel thyroiditis
Thyroidectomy or After radioiodine treatment
Drug therapy (e.g. lithium, amiodarone or anti-thyroid drugs such as
carbimazole) do TFTs and U & E prior to prescribing
Dietary iodine deficiency (Common in Africa where water is not iodized. )

Note how many causes of hypothyroidism may have an initial thyrotoxic phase.
Secondary hypothyroidism (rare)

Isolated Thyroid stimulating hormone deficiency

Hypopituitarism
o Neoplasm
o Infiltrative
o Infection
o Radiotherapy
Hypothalamic disorders
o Neoplasms and trauma

Tertiary hypothyroidism

This is due to low TRH in the hypothalamus.

Treatment: Levothyroxine

Clinical Symptoms

Weight gain
Bradycardia
Constipation
Cold intolerance
Menorrhagia
Tiredness
Hoarseness
Dementia
Dry skin
Goitre
Cholesterol raised
Signs

Dry coarse skin

Hair loss
Cold peripheries
Puffy face, hands and feet (myxoedema)
Bradycardia

In autoimmune hypothyroidism, patients may have features of other

autoimmune diseases, such as, thhe following

Vitiligo
Pernicious anaemia
Addison's disease
Diabetes mellitus

Management of Hypothyroidism

Levothyroxine should be started on a dose of 50-100mcg od with the

exception of elderly patients and those with ischaemic heart disease. The
BNF recommends that for patients with cardiac disease, severe
hypothyroidism and patients over 50 years the starting dose should be 25mcg
od and slowly increased
After every change in the dosage TFT should be performed every 8-12 weeks
Treatment goal is to aim a TSH value 0.5-2.5 mU/l
Pregnant women with hypothyroidism should have their dose increased 'by at
least 25-50 micrograms levothyroxine' (source: NICE Clinical Knowledge
Summaries) and The should be monitored carefully
Combination therapy with levothyroxine and liothyronine is not recommended,
because no proven value

Side-effects of thyroxine treatment

Patients with angina will have symptoms increased

Atrial fibrillation
Hyperthyroidism (over treating the patient)
Decrease in bone mineral density

Interactions

Iron does reduce the absorption of levothyroxine

Consume least 2 hours apart

Placenta accreta
Overview

This describes the attachment of the placenta to the myometrium

This is due to a defective decidua basalis
 As the placenta does not properly separate during labour there is a possible
risk of post-partum haemorrhage

Risk factors

Previous caesarean section

Uterine inversion
Definition

Uterine inversion is when the fundus of the uterus protruding from beyond the
endometrial cavity.
There are various degrees of uterine inversion.
The location of the inverted uterine fundus determines whether it is classed as
complete or incomplete.
This can also be further classified as acute, subacute or chronic.

Epidemiology

This is a rare life-threatening complication of childbirth

Causes

The cause is unclear

Proposed mechanisms failure of the placenta to detach from the uterus,
strong traction of the umbilical cord especially during the third stage of labour,
this is thought to be a particular issue when the placenta is located in the
uterine fundus.

Diagnosis

This is mainly based on examination findings

Management

ABCDE approach
If the patient has signs of shock
o IV fluid resuscitation. Senior help, further IV access to ensure shock is
adequately treated.
Insertion of a urinary catheter
Pain management
The uterine replacement

Rubella and pregnancy

Overview
 This is also known as German measles,
It is a viral infection caused by the togavirus.
After the introduction of the MMR vaccine, it is now rare.
If contracted during pregnancy there is a risk of possible congenital rubella
syndrome.
Remember that the incubation period is 14-21 days and individuals are
infectious from 7 days before symptoms appear to 4 days after the onset of
the rash.

Risk

In the first 8-10 weeks risk of damage to the fetus is as high as around 90%
Damage is rare after 16 weeks

Features of congenital rubella syndrome

Purpuric skin lesions

'Salt and pepper' chorioretinitis
Microphthalmia
Cerebral palsy
Sensorineural deafness
Congenital cataracts
Congenital heart disease (for example patent ductus arteriosus)
Growth retardation
Hepatosplenomegaly

Diagnosis

Suspected cases should be discussed immediately with the local Health

Protection Unit (HPU) as the type or timing of investigations may vary
IgM antibodies are raised in women recently exposed to the virus
It should be also noted that it is very difficult to distinguish rubella from
parvovirus B19 in a clinical setting. It is therefore important to also check
parvovirus B19 serology as there is a 30% risk of transplacental infection, with
around 5-10% risk of fetal loss

Management

Since 2016, rubella immunity is no longer routinely checked at the booking

visit
If a woman is however tested at any point and no immunity is demonstrated
they should be advised to keep away from people who might have rubella
Non-immune mothers should be offered the MMR vaccination in the post-
natal period

Puerperal pyrexia
Overview
 This may be defined as a temperature of > 38ºC in the first 14 days after
delivery.

Causes

Endometritis:
o Most common cause
Urinary tract infection
Wound infections (perineal tears and caesarean section)
Mastitis
Venous thromboembolism

Management

In case endometritis is suspected the patient should be referred to the

hospital for intravenous antibiotics (clindamycin and gentamicin should be
prescribed until afebrile for greater than 24 hours)

Miscarriage
Threatened miscarriage (2021 NICE Guideline Update)

Painless vaginal bleeding that occurs before 24 weeks, but usually occurs at
between 6 - 9 weeks
The bleeding is often less than menstruation
The cervical os is closed
Complicates up to around 25% of all pregnancies
Advise a woman with a confirmed intrauterine pregnancy with a fetal
heartbeat who presents with vaginal bleeding, but has no history of previous
miscarriage, that:
o If her bleeding gets worse or persists beyond 14 days, she should
return for further assessment
o If the bleeding stops, she should start or continue routine antenatal
care.
Offer vaginal micronised progesterone 400 mg twice daily to women with an
intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and
have previously had a miscarriage.
If a fetal heartbeat is confirmed, continue progesterone until 16 completed
weeks of pregnancy.

Missed (delayed) miscarriage

A gestational sac which contains a dead fetus before 20 weeks without the
symptoms of expulsion
The mother may have light vaginal bleeding or discharge and the symptoms
of pregnancy which disappear.
o Pain is not typically a feature
The cervical os is closed
 When the gestational sac is > 25 mm and no embryonic or fetal part can be
seen it is sometimes described as a 'blighted ovum' or 'anembryonic
pregnancy'

Inevitable miscarriage

There is heavy bleeding with clots and pain

The cervical os is open

Incomplete miscarriage

Not all products of conception have been expelled

Pain and vaginal bleeding
The cervical os is open

Epidemiology

Around 15-20% of diagnosed pregnancies will miscarry in early pregnancies

Non-development of the blastocyst within 14 days occurs in up to
approximately 50% of conceptions
Recurrent spontaneous miscarriage affects around 1% of women

Factors that are linked with an increased risk of miscarriage are:

Recreational drug use

High caffeine intake
Obesity
Infections and food poisoning
Increased maternal age
Smoking in pregnancy
Consuming alcohol
Health conditions
o Thyroid problems
o Severe hypertension
o Uncontrolled diabetes
Medicines
o Ibuprofen
o Methotrexate
o Retinoids
Unusual shape or structure of the womb
Cervical incompetence

Factors that have not been linked with an increased risk of miscarriage are:

Having sex
Air travel
Being stressed
Heavy lifting
Bumping your tummy
Recurrent miscarriage
Overview

This is defined as 3 or more consecutive spontaneous abortions.

It occurs in around 1% of women

Causes

Antiphospholipid syndrome
Endocrine disorders:
o Poorly controlled diabetes mellitus or thyroid disorders.
o Polycystic ovarian syndrome
Uterine abnormality: for example uterine septum
Parental chromosomal abnormalities
Smoking

Alpha feto-protein
This is a protein produced by the developing fetus

Causes of increase and decreased AFP

Increased AFP

Neural tube defects

o Meningocele
o Myelomeningocele
o Anencephaly
Abdominal wall defects
o Omphalocele and gastroschisis
Multiple pregnancies

Decreased AFP

Down's syndrome
Trisomy 18
Maternal diabetes mellitus

Herpes simplex virus

Overview

There are two strains of the herpes simplex virus (HSV) in humans
o HSV-1
o HSV-2
Before it was previously thought HSV-1 accounted for oral lesions (cold sores)
and HSV-2 for genital herpes, but it is now known there is considerable
overlap.
Features

Cold sores
Painful genital ulceration
Primary infection
o May present with a severe gingivostomatitis

Management

Gingivostomatitis
o Oral aciclovir
o Chlorhexidine mouthwash
Cold sores
o Topical aciclovir even though the evidence base for this is modest
Genital herpes
o Oral aciclovir
o Patients with frequent exacerbations may benefit from longer-term
aciclovir

Pregnancy

An elective caesarean section at term is advised

o If a primary attack of herpes occurs during pregnancy at greater than
28 weeks gestation
Women with recurrent herpes who are pregnant should be treated with
suppressive therapy and also be advised that the risk of transmission to their
baby is low