Refresher Course OB-GYN KKU 2020

Gynaecologic Oncology Division

Department of Obstetrics and Gynaecology
Faculty of Medicine, Khon Kaen University

Naratassapol Likitdee, M.D.

Gynaecologic oncology unit,
Department of Obstetrics and Gynaecology,
Faculty of Medicine, KKU
NL1
GYN
OB
GYN
OB
GYN
OB
GYN
OB
GYN
OB
GYN
OB
Scope in OB
1. Antenatal care: screening, vaccination, drug in preg
2. APH: 2nd half bleeding
3. Small & Large for date: IUGR, Twins
4. Post term pregnancy
5. Fetal assessment
6. Labor and delivery
7. PPROM and Preterm labor
8. PIH
9. Obstetrics emergency: PPH, Prolapsed cord,
shoulder dystocia,
10. Infectious in pregnancy: HBV, Syphilis, HSV, HIV
11. Puerperal complication: Disorder of breast, lactation
Antenatal care
Antenatal care: Initial lab in ANC
- CBC with platelet: If Hct <11 st, rd <10 5 nd trimester
MCV <80 work-up cause Thalassemia, iron deficiency
- DCIP: Thal E
- ABO blood group, Rh
- STDs profile: Anti HIV, VDRL, HBsAg
- UA: screening glucosuria, proteinuria
- UC: screening bacteriuria
Antenatal care: Thalassemia screening

Hb A = 2 2

Hb A2 = 2 2

Hb F = 2 2

Hb H 4

4
Antenatal care: Thalassemia screening

Hb A = 2 2

Hb A2 = 2 2

Hb F = 2 2

Hb H 4

4
2014
Antenatal care: Thalassemia screening

Hb A = 2 2

Hb A2 = 2 2

Hb F = 2 2

Hb H 4

4
2014
 Antenatal care: Iron deficiency
Initial evaluation- Hb, Hct, MCV, serum iron or ferritin
level or both (serum ferritin < 10-15 mg/L confirm iron
deficiency anemia)

Treatment- daily oral supplementation from 60 mg

up to 200 mg of element iron and 400 mcg of folic acid
is recommended

- When given adequate iron therapy, response is

detected by elevated reticulocyte count. Rate of
increase of Hb/Hct is typically slower than nonpregnant.

Williams Obstetrics 24th , Hematological Disorders, P 1103.

 DM GDM
Antenatal care: DM screening

- High risk:
st ANC

GA
24 28 week

- Average risk:
GA 24 28 week

- Low risk:

Williams Obstetrics 24th , Diabetes Mellitus, P 1137

 Antenatal care: Ultrasound screening

NT

Williams Obstetrics 24th , Fetal imaging P196

Antenatal care: Prenatal Diagnosis
- Chorionic villous sampling (CVS): GA 11 week
- Amniocentesis (AC): GA 15 week
- Cordocentesis: GA 18 week
Antenatal care: Drug in pregnancy
Category X: ACEI ARB ,
simvastatin , Isotretinoin , warfarin, syntocinon,
cytotec, ergotamine,

Category C:
Glipizide , Omeprazole, Ibuprofen, Norfloxacin
Lab ANC

ANC
anemia
U/S

PND
Drug
in
preg

Drug
in
preg
Drug
in
preg

Vaccine
in preg
Antepartum hemorrhage
APH: 2nd half > Placenta previa

Management:
Practically undergo cesarean
delivery.
 APH: 2nd half > Abruptio placenta

Management:
With a living viable-size fetus and with vaginal delivery not imminent,
emergency cesarean delivery is chosen by most.
PPROM
APH: 2nd half > Uterine rupture
The classic signs and symptoms of uterine rupture are
(1) fetal distress (as evidenced most often by abnormalities in fetal heart rate)
(2) diminished baseline uterine pressure
(3) loss of uterine contractility
(4) abdominal pain
(5) recession of the presenting fetal part
(6) hemorrhage and shock
APH
APH
APH
APH
Small & large for date
Small and large for date: Differential diagnosis
Large
for date

Large
for date
Small
for date

Large
for date
Post term pregnancy
 Post term Mx
40 wks
Fetal surveillances: NST 2/wk, U/S for AFI

41 wks
Labor induction
 GA 41+5 wk EFW 3000 g
PV: os dilate 1 FB, no effacement, uterus mid position

A.
B.
C. Fetal suveillance
D. F/U 1 wk
E. amniotomy
Fetal assessment
Fetal assessment: EFHRM
Findings >> Interpretation >> Management
Fetal assessment: EFHRM
Findings >> Interpretation >> Management
IPM Cat 1: IPM Cat 3:
- Baseline 110-160 - Sinusoidal pattern:
- Variability 6-25 (symmetrical up and down)
- Early dc present or absent - Absent dc with
- Late and variable dc must not present Repeat late dc or
- UC every 10 minutes : NST vs IPM Repeat variable dc or
bradycardia
Mx. IPM Cat 2, 3 >> IUR
- Decubitus position If done for 30 minutes:
- Iv fluid loading large bore needle Still IPM 2, 3 >> need
- Off syntocinon if present other management
- Non rebreathing Mask with bag 10 LPM
Labor and delivery
Labor and delivery
- Protracted (dilate / descent)
- Arrest (dilate / descent)

Prolonged latent phase

Prolonged secondary stage

D. C/S
 Refresher Course OB-GYN KKU 2020
Gynaecologic Oncology Division
Department of Obstetrics and Gynaecology
Faculty of Medicine, Khon Kaen University

Naratassapol Likitdee, M.D.

Gynaecologic oncology unit,
Department of Obstetrics and Gynaecology,
Faculty of Medicine, KKU
Preterm and PROM
 PPROM

Premature Rupture of Membranes, ACOG Bulletin January 2016

 PPROM

Premature Rupture of Membranes, ACOG Bulletin January 2016

 PPROM

Premature Rupture of Membranes, ACOG Bulletin January 2016

 PPROM
!!
1. ATB for GBS prophylaxis: GA < 37 week

Ampicillin 2 g iv then 1 g iv q 4 hr

2. ATB for prolong latency in preterm PROM (expectant mx)

Ampicillin 2 g iv + erythromycin 250 mg iv q 6 hr X 2

Then Amoxicillin 250 mg po q 8 hr + erythromycin base 333
mg po q 8 hr for 7-day course of therapy

Premature Rupture of Membranes, ACOG Bulletin January 2016

 Preterm labor

Management of Preterm Labor, ACOG Bulletin January 2016

 Preterm labor

ACOG Practice Advisory: Antenatal Corticosteroid Administration in the Late Preterm Period,
April 2016
Preterm labor

Preterm labor, Recommendation RTCOG 2558

Preterm labor

Preterm labor, Recommendation RTCOG 2558

Pregnancy induced
hypertension
 PIH
Classification of Hypertensive Disorders of Pregnancy
Four categories:
1. Preeclampsia-eclampsia (BP elevation after 20 weeks of
gestation with proteinuria or any of the severe features)
2. Chronic hypertension (of any cause that predates
pregnancy)
3. Chronic hypertension with superimposed preeclampsia
(chronic hypertension in association with preeclampsia)
4. Gestational hypertension (BP elevation after 20 weeks of
gestation in the absence of proteinuria or any of the severe
features of preeclampsia)

Revision of Preeclampsia Management, ACOG 2013

 PIH
Proteinuria
- Defined as the excretion of >300mg of protein in a 24-hour
urine collection.

- Alternatively, a timed excretion that is extrapolated to this

24-hour urine value, or a protein/creatinine ratio of at least
0.3 (each measured as mg/dL).

- The dipstick method is discouraged for diagnostic use unless

other approaches are not readily available. 1+ is considered as
the cutoff for the diagnosis of proteinuria.

http://www.acog.org/~/media/Districts/District%20VIII/HypertensionPregnancy.pdf?
dmc=1&ts=20140527T0350044350
 PIH

Cunningham, Leveno, Bloom. Williams Obstetrics. 24th ed. New York: McGraw Hill;
Figure 40-2 on P 730.
 PIH

TASK FORCE RECOMMENDATIONS

4. Mild gestational hypertension or preeclampsia without severe

features at or beyond 37 0/7 weeks of gestation, delivery rather
than continued observation is suggested.

5. Severe preeclampsia at or beyond 34 0/7 weeks of gestation,

delivery soon after maternal stabilization is recommended.

http://www.acog.org/~/media/Districts/District%20VIII/HypertensionPregnancy.pdf?
dmc=1&ts=20140527T0350044350
Cunningham, Leveno, Bloom. Williams Obstetrics. 24th ed. New York: McGraw Hill;
Figure 40-10 on P 756.
 Antihypertensive Therapy
reserved for BP is persistently higher than 160 systolic
mmHg or higher than 105 to 110 mmHg diastolic

Hydralazine given intravenously as a bolus infusion

beginning with 5 to 10 mg, which is repeated at 20-minute
interval until the desired control
Cunningham, Leveno, Bloom. Williams Obstetrics. 24th ed. New York: McGraw Hill;
Figure 40-10 on P 758.
Obstetrics emergency
Obstetrics emergency: PPH

Cause: Tone, Trauma,

Tissue, Thrombin
Obstetrics emergency: Prolapsed cord
PV !!
Call for help

Tendelenburg position

foley NSS 500-750ml

FHR
+
Set C/S emergency, notify ped, x match
Supportive
IV: Nss/LRS iv 100ml/hr
O2 mask c bag 10 LPM
Obstetrics emergency: Shoulder dystocia
Management: HELPERR
1 Call for Help
2 Evaluate for Episiotomy
3 Legs McRobert maneuver
4 Pressure suprapubic
5 Enter rotational maneuver Rubin Wood corkscrew
6 Remove posterior arm
7 Roll the patient All 4, Gaskin maneuver
Infectious in pregnancy
Infectious in preg:
Asymptomatic bacteriuria

Benefits of treatment for

asymptomatic bacteria are
limited to reduction the
incidence of pyelonephritis
Infectious in preg:
Bacterial vaginosis (BV)
- BV asso with
Preterm, PROM,
intra-amniotic
infection and
postpartum
endometritis.
- Treatment is
recommended for
all pregnant
Infectious in preg:
Trichomonas vaginalis (TV)
- TV asso with
Preterm, PROM,
and low birth
weight
- Treatment is
recommended for
all pregnant
Infectious in preg:
Vulvovaginal candidiasis (VVC)
Infectious in preg:
Hepatitis B infection

All infants should receive

hepatitis B immune globulin and the first dose of
hepatitis B vaccine within 12 hours of birth***
second dose of vaccine should be given at aged
1 2 months
third dose at aged 6 months
Can be BF immediately
Infectious in preg:
Syphilis

treponemal-specific test : FTA-ABS, TP-PA

confirm positive
remain positive throughout life
Infectious in preg:
Condyloma acumonata
Infectious in preg:
Genital Herpes
During pregnancy:
Acyclovir, 400 mg orally three times daily, is highly
effective for treatment of primary or recurrent
infection 5 to 10 days.
In labor:
- Only way of preventing neonatal infection is to avoid
contact between the fetus and the infected maternal
lower genital tract by means of cesarean delivery.
Puerperal complication
Puerperal complication:

Endometritis , Metritis
Ampi+Genta+Metro
Cef-3 + Metro
Clinda+Genta

Mastitis ATB
Breast abscess ATB + I&D
 C/S 39 FH 2/4
above umbilicus , tender , PV : Os open 1 cm, foul smell blood
discharge, tender uterus, parametrium tender both side
ATB
A. Genta+cloxa
B. Ampi+Genta+metro
C. Genta+vanco
D. Genta+clarithro
E. Cef-3+high dose penicillin
50
 Refresher Course OB-GYN KKU 2020
Gynaecologic Oncology Division
Department of Obstetrics and Gynaecology
Faculty of Medicine, Khon Kaen University

Naratassapol Likitdee, M.D.

Gynaecologic oncology unit,
Department of Obstetrics and Gynaecology,
Faculty of Medicine, KKU
Scope in GYN
1. Leukorrhea and STDs
2. Pelvic pain
3. Pelvic mass
4. Abnormal uterine bleeding
5. Amenorrhea
6. Menopause
7. Contraception
8. POP and UI
Leukorrhea and STDs
1.1 Leukorrhea

Characteristic of pathologic leukorrhea:

- pH > 4.5
- Greenish, yellowish
- Foul smell
- Burning, itching

Cause:
- Inflammation
- Infection e.g. BV, TV, VVC, GC
- Tumor
- Foreign body
1.1 Leukorrhea: Differential diagnosis***
Parameter Candidiasis Bacterial vaginosis Trichomoniasis

Cause C. albicans G.vaginalis T.vaginalis

Major symptoms Itching Foul smell discharge Abnormal
discharge
Discharge Curd-like gray or white formy greenish
homogeneous,
Odor odorless malodors malodors

Vulvovaginal Marked Mod inflammation less inflammation

inflamation inflammation
Wet smear pseudohyhae Clue cell Motile organism

Whiff test negative positive positive

Vaginal pH <4.5 5.0-5.5 >4.5
 1.1 Leukorrhea: Treatment
Bacterial vaginosis:
Metronidazole 500 1x2 PO x 7 days

Trichomoniasis:
Metronidazole 2g PO single dose

Candidiasis:
Clotrimazole 100 1 tab vg hs x 6 days

STDs treatment guidelines, CDC 2015

 1.2 STDs: PID
Minimum clinical criteria:
- cervical motion tenderness or
- uterine tenderness or
- adnexal tenderness

Additional criteria: to enhance specificity and support diagnosis

- oral temperature >101°F (>38.3°C);
- abnormal cervical mucopurulent discharge;
- abundant WBC on saline microscopy of vaginal fluid;
- elevated ESR, CRP
- lab confirm cervical infection N. gonorrhoeae or C. trachomatis.

STDs treatment guidelines, PID, CDC 2015

 1.2 STDs: PID
The decision of hospitalization should be based on:
- surgical emergencies (e.g., appendicitis) cannot be excluded;
- tubo-ovarian abscess;
- pregnancy;
- severe illness, nausea and vomiting, or high fever;
- unable to follow or tolerate an outpatient oral regimen; or
- no clinical response to oral antimicrobial therapy.

STDs treatment guidelines, PID, CDC 2015

 1.2 STDs: PID

STDs treatment guidelines, PID, CDC 2015

 1.2 STDs: PID

Single daily dosing (3-5mg/kg) can be substituted

STDs treatment guidelines, PID, CDC 2015

 1.2 STDs: PID
Follow-Up

Women should demonstrate clinical improvement (e.g.,

defervescence; reduction in direct or rebound abdominal
tenderness; and reduction in uterine, adnexal, and cervical motion
tenderness) within 3 days after initiation of therapy.

If no clinical improvement within 72 hours after outpatient

IM/oral therapy, hospitalization, assessment of the antimicrobial
regimen are recommended.

STDs treatment guidelines, PID, CDC 2015

1.2 STDs: Genital ulcer

One to three
Grouped vesicles Painless and
extremely
mixed with small ulcers minimally tender ulcer
painful ulcers
1.2 STDs: Genital ulcer
GC: Ceftriaxone 250 mg IM single dose
Chancroid: Azithromycin 1 g PO single dose

Herpes simplex
First episode: Acyclovir (400) 1X3 PO x 7 days
Recurrent: Acyclovir (400) 1X3 PO x 5 days

Syphilis
Early: Benzathine Penicillin G 2.4 mU IM single dose
Late: Benzathine Penicillin G 2.4 mU IM weekly x 3 dose
1.2 STDs: Disease of Bartholin glands
Bartholin cyst: Marsupialization

Bartholin abscess:
Keywords >> rapidly enlarging, painful, inflammatory mass
I&D (recommended Marsupialization) + ATB
 40 PV: graynish pH 6, clue cell > 20%
A. Clindamycin 500 mg bid x 7 days
B. Doxycycline 100 mg bid x day
C. Azithromycin 1 g PO single dose
D. Ceftriaxone 250 mg IM single dose
E. Metronidazole 500 mg bid x 7 days

Pt stawberry cervix
A. iodine
B. metronidazole
C. metro
D. metro metro
E. metro
Pelvic pain
2. Pelvic pain: Dysmenorrhea

- Secondary dysmenorrhea must be R/O first by

History taking, physical examination +/- investigation
(ultrasound)
-
Primary dysmenorrhea is most likely

1st line tx for primary dysmenorrhea: NSAIDs e.g. Ponstan

Oral contraceptive pill
If not response to medication >> re-evaluation is recommended
Secondary dysmenorrhea is most likely
2. Pelvic pain: Dysmenorrhea
Pelvic mass
3. Pelvic mass: uterine mass
3. Pelvic mass: ovarian mass/cyst

Perform ultrasound to predict malignancy

e.g. Metastasis, Ascites, Bilat, Solid, Septate
RMI score = U x M x CA125

Reproductive age group:

Benign cystic < 8 cm: OCP 1-2 months then ultrasound F/U
Or ultrasound F/U at 3 months***
 30 6
uterus size 12 wk U/S
intramural myoma
A.
B. F/U 3
C.
D.
E.
A 26 year-old woman comes to the physician for a routine health
maintainance examination. Pelvic examination shows a 6 cm cystic adnexal
mass. An X-ray film of the abdomen shows calcifications. For each patient
with pelvic mass, select the most likely diagnosis
A. Cystadenocarcinoma
B. Dermoid cyst
C. Cystadenoma
D. Endometrioma
E. Follicular cyst
AUB
4. Abnormal uterine bleeding
4. Abnormal uterine bleeding
4. Abnormal uterine bleeding:
Abortion
Abortion Bleeding Pain Cervix Os Uterus Conceptus Treat
Threatened + + close =GA - observe
Inevitable ++ ++ open =GA - D&C
Incomplete ++ ++ open <GA + D&C
Complete +/- +/- close <GA + observe
Missed +/- +/- close <GA +/- D&C,
bleeding
precaution

Molar pregnancy
 4. Abnormal uterine bleeding:
Ectopic pregnancy
- The ideal candidates for MTX treatment
1.Hemodynamically stable
2.Have no renal, hepatic, or hematologic disorders
3.Able and willing to comply with post-treatment monitoring
4.Pretreatment serum hCG concentration < 5000 mIU/mL
5.Tubal size of < 3-4 cm and no fetal cardiac activity
Blighted ovum:
An anembryonic gestation is diagnosed when the mean

DFIU:
A 5-mm embryo without cardiac activity is likely dead.
GA = CRL + 6.5
https://www.uptodate.com/contents/ectopic-pregnancy-choosing-a-treatment-and-methotrexate-
therapy?source=search_result&search=ectopic%20pregnancy&selectedTitle=2~150
 Refresher Course OB-GYN KKU 2020
Gynaecologic Oncology Division
Department of Obstetrics and Gynaecology
Faculty of Medicine, Khon Kaen University

Naratassapol Likitdee, M.D.

Gynaecologic oncology unit,
Department of Obstetrics and Gynaecology,
Faculty of Medicine, KKU
Amenorrhea
5. Amenorrhea
5. Amenorrhea
1. Hx + PE physiology pregnancy, lactation, menopause

2. Serum T4, TSH, PRL R/O hypothyroid, hyperprolactinemia

3. Progesterone challenge test

- Bleeding Anovulation
- No bleeding EP challenge test

4. EP challenge test
- No bleeding defect of out flow tract Asherman s syndrome
- Bleeding FSH, LH

5. FSH, LH rising Ovarian failure

FSH, LH normal or decrease CNS pituitary axis CT, MRI R/O pituitary
tumor
 14 8

pregesterone challenge test: negative estrogen-progesterone challenge

test : negative
A. Ovarian failure
B. PCOS
C. Exercise amenorrhea
D. Asherman s syndrome

webbed neck, wide nipple distance and low

hair line
A. Decrease Insulin
B. Decrease GH
C. Increase estrogen
D. Increase GnRH
E. Decrease PTH
Menopause
6. Menopause
Definition: 12 consecutive months of amenorrhea
Indication for MHT:
1. Moderate to severe vasomotor and genital symptom
2. Premature or surgical menopause
3. Prevent osteoporosis Systemic symptom:
Contraindication MHT: Intact uterus: E +P
1. CA breast, endometrium No uterus: E alone
2. Undiagnosed AUB
Local symptom:
3. VTE
Tx local >> estrogen
4. Active liver disease
cream
6. Menopause

Advise for menopause woman

6
1.
2.
3.
4.
5.
6.
Examination
55 6
5
A. Oral estrogen Indication for MHT?
B. Estrogen pad Systemic or Local?
C. Estrogen cream vagina
Contraindication?
D. Androgen cream vagina
E. Oral estrogen and progesterone
Examination
51 12

Indication for MHT?

A. Weight bearing exercise
Systemic or Local?
B.
C. High protein diet Contraindication?
D. Hormonal therapy
E. Bone mass density
Contraception
 Permanent or Transient
7. Contraception
Long or Short
Transient methods Hormonal or Non-hormonal
Non-hormonal methods
Special consideration
Coitus interruptus Breast feeding Fertility awareness
Condom Vaginal spermicides Vaginal barriers
Intrauterine device (Cu IUD)
Hormonal methods
Estrogen/Progestin Oral pill (OCP) Patch
Progestin only Oral pill Injection (DMPA) Implant
Intrauterine device (LNG-IUS)

Permanent methods
Sterilization
7. Contraception Special consideration
Examination
23 6 2
2
A.
B.
Permanent or Transient
C. Long or Short
D. Hormonal or Non-hormonal
E. Special consideration
Examination
21 25
HBsAg +, HB antibody

A. Permanent or Transient
B. IUD Long or Short
C.
Hormonal or Non-hormonal
D.
Special consideration
E.
POP and UI
8.1 POP
8.1 POP
8.1 POP
8.1 POP
8.1 POP
Stage I
Treatment:
1. Life style modification
2. Pelvic floor muscle exercise
3. Surgery:
Anterior >> Anterior colporrhaphy
Posterior >> Posterior colporrhaphy
Apical >> Vaginal hysterectomy
Colpocleisis
Stage IV
Special consideration
8.2 Urinary incontinence

SUI: Leaking of small amounts of urine during activities

that increase pressure inside the abdomen and push
down on the bladder
Medication: Aim to increased urethral bladder neck tone
e.g. ephedrine, imipramine

UUI: Involuntary loss of urine that usually occurs when

a person has a strong, sudden need to urinate
Medication: Aim to inhibit Acetylcholine
e.g. Oxybutynin (Anti-cholinergic drugs)
Benign and malignant neoplasm of cervix,
and uterus

1. Cervical cancer screening

2. Cervical cancer
3. Endometrial cancer
 1.Cervical cancer prevention and control

WHO guidance note: comprehensive cervical cancer prevention and control: a healthier future
for girls and women, World Health Organization 2013
Cervical Cancer Screening and Prevention, ACOG 2016
 Abnormal Pap smear

Updated Consensus Guidelines for Managing Abnormal Cervical Cancer Screening Tests and
Cancer Precursors, ASCCP August 2014
 Abnormal Pap smear

Updated Consensus Guidelines for Managing Abnormal Cervical Cancer Screening Tests and
Cancer Precursors, ASCCP August 2014
 Abnormal Pap smear

Updated Consensus Guidelines for Managing Abnormal Cervical Cancer Screening Tests and
Cancer Precursors, ASCCP August 2014
 Abnormal Pap smear

Updated Consensus Guidelines for Managing Abnormal Cervical Cancer Screening Tests and
Cancer Precursors, ASCCP August 2014
 Abnormal Pap smear

Updated Consensus Guidelines for Managing Abnormal Cervical Cancer Screening Tests and
Cancer Precursors, ASCCP August 2014
2.Cervical cancer Berek & Novak s Gynecology 15th ed
 PV & RV exam

IVP

Cystoscope & Palpate LNs

Proctoscope & CXR
2.Cervical cancer Berek & Novak s Gynecology 15th ed
2.Cervical cancer Berek & Novak s Gynecology 15th ed
2.Cervical cancer Berek & Novak s Gynecology 15th ed
 3.Endometrial cancer

Most of risk factors related to prolonged, unopposed estrogen

Clinical Features and Diagnosis
Symptoms
- 90% have vaginal bleeding or discharge.
- Perimenopausal and postmenopausal bleeding should always
investigated, no matter how minimal or nonpersistent.
Diagnosis
- Endometrial aspiration biopsy is first step in evaluating AUB
or suspected endometrial pathology.
- TVS may be a useful adjunct to endometrial biopsy for
evaluating AUB and selecting patients for additional testing.
- Endometrial thickness > 4 mm, a polypoid endometrial mass,
or collection of fluid within uterus requires further evaluation.

Treatment: TAH with BSO with surgical staging

Examination
23 G0P0 3-4 1
U/S
< 1 cm. 15-20 1

A. adrenal hyperplasia
B.
C.
D.
E.