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Obs - and - Gyn Integrated Notes
Obs - and - Gyn Integrated Notes
Gynaecology Notes
Different Modalities of Delivery
2
Normal vaginal delivery, Assisted delivery, Caesarean section (C/S)
Malposition & Malpresentation 3
Management of common problems in pregnancy
4
Diabetes Mellitus, Hypertension, Multiple pregnancy
Integration & Summarization of important Common disorders in obstetrics
5
topics Cardiovascular disorders, Anaemia, Malaria
Perinatal infection (TORCH) 6
Drugs in Obstetrics 7
Gynaecology
Early antepartum haemorrhage 8
Late antepartum haemorrhage 9
Postpartum haemorrhage 9
Menstrual disorders 10
Menorrhagia, Dysmenorrhoea, Amenorrhoea
Contraception
11
Hormonal, Progesterone only contraception, IUCD
Infertility 12
Common disorders in gynaecology
13
PCOS, Fibroid, Endometriosis, Prolapse, Menopause
Ovarian tumour 14
Malignant Gynaecological tumour
15
Cervical, Endometrial, & Ovarian tumours
Infection in gynaecology 16
Appendix
Obstetrics & gynaecology Instruments 17
References 18
HistOry & examinatiOn
History Examination
My patient name is ……………………………………, ……..years old (date of birth ….../…../…..…….), The patient lying ……..........., ……………….………….. on her bed, (mention any connecting device
originally from ……………….. & live in …………………. the patient’s tribe is ……………………….. if present, like canula, catheter…..……). of …………………… weight & height (BMI).
education: ………...…………., occupation: ……..…..…………., duration of marriage: ………..….………. The patient is ………… anaemic, ………… jaundice, ………… cyanosed.
o
her husband name is ……………………………..………, …..years old, education/occupation:…………….. Vital signs: pulse: …..……… beat/min (mention the 6 characteristics), BP: -------, temp.: …..……… C
consanguinity: …………………………, patient blood group is …….……….. “NOTE: measurement of BP when women seated or on semi-recumbent position only (why?)”
the patient admitted …………..…. days ago. Oral cavity: …………….. oral hygiene, ………… dental caries,….…… denture, …….… artificial teeth.
C/O:a pregnant woman, who is GA …… week, presented with………………………………………………… Thyroid………….……...., JVP……….………..…., Cervical LNs ……..…...…………, Trachea ………..…..……..
…………………………………………………………………………………………………………………………….……………………………..…… Breast: 1) Inspection: - normal symmetrically developed breasts with normal nipple & areola
Gynecological history: menarche: …... year (normal at 13), ….……. regular, …….……. character - there is …………. scar, fissure, or area of hypo/hyperpigmentation
Kata = ---------- , ……..………. intermenstural bleeding, …………..…. dysmenorrhoea - there is …………. Montgomery tubercle (dilated sebaceous gland “areola”)
……..… vaginal discharge (colour, amount, odour, itching, consistency) ………. contraceptive - there is …………. discharge (colostrum, milk, blood, pus)
user (type, duration)…………………………… “colostrum = normal from 16 wk onward, milk = IUFD or lactation, blood = cancer, pus = infection”
……..…..… history of gynecological operation, ……......……. infertility, ……..………. prolapse 2) Palpation:- using the palm of the hand palpate the 6 areas including the axillary tail
NOTE:- Importance of COCP: post-pill amenorrhoea “may contribute to wrong date” - examine the axillary lymph nodes “any palpable mass/tenderness”
- Importance of gyn. operation: scar uterus Abdomen: 1) Inspection: a) abdomen is distended (symmetrical or not ?????)
Obstetric history: G ….……… P …….…..+……….... b) comment on the umbilicus (flat, everted or inverted)
“G = (all pregnancies) / P = (delivered fetuses & stillbirth) + (spontaneous abortion)” c) comment on linea nigra (due to ACTH)
History of previous pregnancy: ………………..…………………………………………………………………………..... d) comment on striae gravidarum (stretch of smooth muscle)
“Mention: number of previous birth, type -vaginal delivery or C/S-, at home -attended or not- e) comment on any scar(s) / visible pulsation / dilated vein
or at hospital, term or not, outcome -male or female-, any complications, alive & well or not” f) comment on fetal movement if visible, hirsutism if present
History of current pregnancy: LMP: …..…../…..…../20…….…. g) comment on hernial orifices
EDD: ……….../……../20…...….. GA:……..….… weeks 2) Superficial palpation: the abdomen is:
“NOTE: Naegele’s rule; add 1 year, add 7 days, & subtract 3 months in a regular cycle of 28 a) soft (normal) or tense (due to excessive liquor) or rigid (extravasation of blood)
days length. if the cycle is more than 28 days, add the difference to the expected date” b) comment on any tenderness / superficial mass / (temperature “examiner policy?” better avoided)
The patient is ………..…. on regular antenatal care (DD of tenderness: chorioamnionitis, abrupto placentae, red degeneration of fibroid, scar dehiscence)
First trimester: …….. vaginal bleeding, .……. infection, ….... radiation, ….... drugs, …..… trauma c) describe amount of liquor (average: if abdomen is not tense & fetal part is not easily palpable)
(confirm her pregnancy by HCG “raise after 1 wk of missed cycle” &/or U/S “+ve at 5-6 wk”) 3) Deep palpation: for organomegally (liver, spleen & kidney)
Second trimester: ………..… quickening, ………. symptoms of UTI, ………. symptoms of anaemia, Obstetric examination:
vaccination: ……………………, (mention if she is on haematinics “oral iron”) 1) Fundal level: with the palm of your hand, palpte to determine the dome. then with the
NOTE: ulnar side of your hand determine the upper limit and calculate accordingly..(1finger = 2wk’s)
- Quickening occur at about 18-20 wk in primagravidae & earlier “16-18 wk” in multiparous (Tape method: zero point at symphysis pubis, centimeter marks face down, measure up to top of the
- Predisposing factor for UTI: progesterone “relaxation of smooth muscle”, & gravid uterus fundus, then turn the tap to the other side & read the result in centimeter)
st 2) Fundal grip: determine which part of the fetus occupy it. “96.5% breech”
- Tetanus vaccine taken twice in the 1 pregnancy, & once in the following two pregnancies
Third trimester: ……… appreciate the fetal movement. (& if she is still on haematinics) (Characteristic of breech: soft, not palatable, broad “than the head”, irregular)
Systemic review: CVS, RS, GIT, GU, CNS ………………………………………………………………………..………. 3) Lateral grip: to determine the lie, position & where the back of the fetus is “right or left”
…………………………………………………………………………………………………………………….……………………………………..…… (Characteristic of back: hard, broad, continuous) “60% left occipitolateral”
Past medical history: .…….. DM, .……... HTN, ..…….. hospitalization, ……..…. surgical operation, 4) First pelvic grip: with one hand, thumb against 3 fingers: fix one side & move the other and
……….... blood transfusion, …………. radiation. vice versa (if not cephalic presentation, it will be empty)
Family history: ……………..……. HTN, ……..…………. DM, ………..….….…... other inherited diseases, (Characteristic of the head: small, smooth, hard, round, palatable)
……................... congenital anomalies, …………..……… multiple pregnancy “on maternal side”. 5) Second pelvic grip: with your two hands, determine the head engagement
Drug history: ……..... HSR,…..….. on long term medication, current medication ……………………… “Engagement occur at about 37 wk in nulliparous, & until onset of labour in multiparous”
Social history: ………………… socioeconomic status. (live in their house or renting house, water Fetal heart sound: if cephalic; below the umbilicus, if breech: above it (DD: uterine soufflé)
& electricity supply, number of members per room, animals in the house, smoking, alcohol...) Lower limb oedema: 1 finger, 1 inch, 1 minute. Lower limb varicosity “pt standing”..............
Summary: ..……….years old, G ….. P …….+….., GA ……., complain of ……………………..………………… Summary: fundal level ….….…. which is ……..…. equivalent to date, ………………….. presentation,
(mention any known medical condition, or +ve PMH), admitted for …………..………………….………. ….……...…. lie, …..…….. position, head is …. engaged, ..….......amount of liquor, …..… fetal heart.
Different mODalities Of Delivery
Normal Vaginal Delivery Assisted Vaginal Delivery Caesarean Section (S/C)
Def.: Spontaneous delivery of single, term, vertex well flexed, alive & Def.: Delivery of a baby vaginally using an instrument for assistance. Def.: an operation performed to deliver a baby via transabdominal
viable, not complicated, in not less than 4 hr & not more than 24 hr. Forceps (traction, rotation, protection) route. (Incidence: should be less than 25%)
IF less than 4hr: precipitant & more than 24hr: obstructed labour Indication Contraindication Indications
Symptoms:1- true labour pain, due to: - face presentation Maternal Fetal
a) increase in steroid due to lung maturity - gestation less than 34 wk - head not fully engaged - repeat C/S (two or more) - malpresentation
b) increase in oxytocin which cause uterine contraction - active fetal bleeding - cervix not fully dilated - CPD (major degree) - dystocia
2- show: bloodstained plug of mucous that close the - after coming head of breech “Piper’s” - pelvic tumours - multiple gestation
cervix, & drop down when the cervix dilated Design: - consists of two blades: each blade consists of handle, shank, - placenta praevia (major) - macrosomia
Signs: 1- dilatation of the cervix 2- fore water drop lock, fenestrated blade with pelvic curve & cephalic curve. - medical disorder (e.g. HTN) - fetal distress
Stages of labour: Types: - Outlet: scalp visible at introitus, without separating the labia - successful repair of vesico- - congenital anomalies
First stage: (in primagravidae 12-16 hr, in multiparous 6-8 hr): vaginal fistula - maternal infections & HIV
- Low forceps: leading edge of skull below +2 station. (e.g.Wrigley’s)
= from diagnosis of labour to full dilatation of cervix (10 cm) - previous upper segment - post mortem C/S (within 10
- divided into latent (up to 4cm dilatation) & active phase - Mid-cavity: leading edge of skull above +2 station & it should be uterine incision min to deliver viable baby)
Second stage: (in primagravidae 2 hr, in multiparous 1 hr): engaged. (e.g. Simpson’s) Contraindication
= from full dilatation of cervix to delivery of fetus or fetuses - High forceps: used for rotation of the head, & asynclitism. it has no a) dead fetus (except in severe pelvic contracture, severe accidental
- divided into passive & active phase (maternal urge to push) pelvic curve. know, abandoned in favour of C/S (e.g. Kjelland’s) haemorrhage, & neglected shoulder)
Third stage: (it take about 30 min): Ventouse (Vacuum extractor) b) DIC c) extensive scar or pyogenic infection
From delivery of fetus or fetuses to delivery of placenta(s) Indication Contraindication Types
Mechanism of labour: - delay in the second stage - face presentation - According to time: elective or selective (emergency)
1) Preparation in uterus & head: - fetal distress in second stage - gestation less than 34 wk - According to site: upper segment (classical) or lower segment
* uterus: - contraction & relaxation - maternal condition requiring - active fetal bleeding Pre-operative care
- differentiation between upper & lower segment short second stage - counseling, consent - urine analysis
- cervix: become short, soft, dilated Design: - suction cup: silastic, plastic or metal connected via tube to - fasting for 6-8 hours - shaving suprapubic hair
* fetal head: moulding (to reduce the diameter of the skull) vacuum source - CBC, blood grouping & X– - urinary catheter (after
2) Engagement: widest diameter of presenting part pass successfully Types:- Electric vacuum - Manual vacuum - Kiwi hand held pump matching anaesthesia) advantage???
through the inlet (less than 2/5 of it palpable abdominally). * Pressure is 0.6-0.8 kg/cm², & NOT used for more than 3 times Note: fasting is due to delayed gastric empty in pregnancy, & fear of
o
- angle of inclination is 130 & should not be more than that. Application (of Forceps or Ventouse) Mendelson’s syndrome (aspiration of gastric acid), if not fasting
- engagement of head occur in right oblique diameter (why?)... A: Address, Ask for help, and G: Gentle traction should be treated with antacid or suction.
3) Descent: due to uterine action & Valsalva manoeuvre. Anaesthesia (e.g. pudendal) H: Handle elevated to follow Post-operative care
4) Flexion: passive movement due to surrounding structure. B: Bladder empty - observation of vital - IV Fluids in form of Dextrose 5% in
the J shaped pelvic curve
- important in minimizing the diameter of presenting part signs: PR, RR, BP…. water around 3 liters/24 hrs
C: Cervix must be fully dilated I: Incision, possible need for
5) Internal rotation: from OP to OA position. - continue fasting until - analgesia
D: Determine position of the episiotomy
6) Extension: crowning of the head to distend the vulva bowel sounds heard - thromboprophylaxis, antibiotics ??
7) Restitution: rotation of occiput through 1/8 of a circle fetal head J: remove forceps when Jaw is Anaesthesia
8) External rotation: occiput rotate through further 1/8 of a circle (so, E: Equipment ready reachable - Regional anaesthesia (spinal, epidural)
the shoulder rotate to direct AP plane). F: Forceps ready After end: DOCUMENTATION - General anaesthesia - Local anaesthesia ??
Anasthesia:- pudendal: best for preineal anasthesia (most frequent) Complications of Instrumental delivery Note: - spinal anaesthesia complication: hypotension, headache
- epidural: best for active phase of labour & delivery Maternal Fetal - general anaesthesia complication: aspiration of vomitus
Conduction of labour: using Partogram. - failure - cerebral haemorrhage Complications: 1- Intra-operative
- 3 contractions per 10 min (each last about 45 sec)... a) maternal mortality: 2-4 times that of C/S (e.g. due to shock...)
- cervical tears - cephalhaematoma
- auscultate for fetal heart rate every 15 min during active labour b) injury to fetus c) injury to bladder & uretur
After delivery: - catch the baby from the leg to remove any secretion - vaginal lacerations - retinal haemorrhage
rd d) injury to the bowel e) complications of anasthesia
& to increase the brain blood supply. - perineal tears: 3 degree and - skull bone fracture
2- Post-operative
- milk the cord (in diabetic mother should be away from the baby due extended episiotomy - low Apgar score Early Intermediate Late
to polycythaemia). - uterine rupture - need for phototherapy - pulmonary embolism
- cut the cord away from the baby (hernia, vessels for exchange uses). - ventouse is less likely to injure the mother, but has high failure rate - DVT (third day) - scar rupture
- PPH
-PV to confirm delivery of placenta, & observe for missing cotyledons. Note: don’t use both instrument at the same time, if one fail; C/S - sepsis & infection - incisional hernia
- paralytic ileus
Signs of placental separation: gush of blood, lengthening of umbilical Note: epidural block increase the length of second stage of labour, so - bursed abdomen - depression
- post spinal headache
cord, uterus rises in abdomen & become globular in shape… increase the need for augmentation & instrumental delivery.
malpOsitiOn
Type Incidence Aetiology Diagnosis Management
Definition: where the fetus is lying longitudinally and the vertex is presenting, but it is not in the OA position.
Common in - Anteriorly situated placenta - Abdominal palpation, shape - Epidural anaesthesia
Occipitoposterior primagravidae - Anthropoid pelvis - Flat sacrum - Vaginal examination - Transverse arrest may require operative intervention
“causes of - Pendulous abdomen - Early caput formation - Lack of progress may warrant C/S
nonengagement” - By chance - PROM - Vacuum preferable to Forceps
malpresentatiOn
Types Incidence Aetiology Diagnosis Management
Definition: where the fetal buttocks or lower extremities present into the maternal pelvis.
(1)
1) External Cephalic Version (ECV) , contraindication:
- Fetal: premature, multiple, fetal
Breech - Abdominal shape, palpation - placenta praevia - ROM, oligohydraminous
anomalies (e.g. hydrocephalus)
a) Frank (65%) - 40% at 26 wk - Vaginal examination in labour: - uterine anomalies - multiple gestation
- Liqour: oligo or polyhydraminous
b) Complete (25%) - 20% at 30 wk * anus has sphincter tone - pre-eclampsia - indication for C/S or vaginal
- Uterine: anomalies
c) Footling (10%) - 3% at term * anus is in line with the ischial 2) Elective C/S, indication: failed ECV, hyperextended head,
- Placenta: praevia
tuberosities footling breech, contraindication for ECV “see above”
- Pelvis: contraction, tumour... (2)
3) Vaginal breech delivery (only for frank or complete)
Definition: extreme extension of the fetal head so the face (rather than the skull) presents to the birth canal. “Presenting diameter: submentobregmatic (9.5cm)”
- Vaginal examination in labour: - Internal rotation to MA, 60-80% will deliver spontaneously
- Fetal goitre, Cystic hygroma,
Face * mouth has no sphincter tone - If MP or MT not convert to MA: C/S indicated
1:500 Anencephaly
* mouth forms a triangle with the malar - Oxytocin should not be used
- High maternal parity
prominences - Forceps may be used on MA face presentation
Definition: head is extended such that attitude is halfway between flexion (vertex) and hyperextension (face) -usually transitional-
On vaginal examination, palpate: - 50-75% convert to vertex or face presentation: delivered
when the head is in the process of
Brow - Anterior fontanelle vaginally
1:2000 converting from a vertex to a face or
- Supra-orbital ridges - persistent brow: delivered by C/S (because mentovertical
vice versa
- Nose diameter is presenting 13.5cm “non delivered vaginally”)
Definition: long axis of the fetus is perpendicular to long axis of the mother (i.e. occurs in transverse lie). other presentation: hand & arm, cord, nil ”i.e. unstable lie”
- Abdominal palpation; no fetal pole
- Vaginal examination; may palpate ribs, - If diagnosed before labour: ECV
Shoulder - As breech presentation (FLUPP)
1:300 scapula, clavicle - If diagnosed in labour: C/S (classical type, or by low
- High maternal parity
- In advanced labour; fetal hand and arm vertical incision)
may prolapse into the vagina
Definition: when a fetal extremity prolapses alongside the presenting part, and both enter the maternal pelvis at the same time.
- Exclude cord prolapse (occurs in 20%)
Compound - Abdominal palpation
- Fetal: multiple, premature - Mostly doesn’t interfere with normal delivery
1:1000 - Vaginal examination
- Maternal: multiparity - Vertex-foot: gently reposition the lower extremity
- During labour
- Vertex-hand convert to shoulder: C/S
(1) Risks of the ECV: placental abruption, PROM, cord accident, transplacental haemorrhage, & fetal bradycardia
(2) Breech vaginal delivery: - Factors that increase the likelihood of a successful: normal size baby, flexed neck, multiparous, breech deeply engaged, & positive mental attitude of women
- Prerequisites: presentation should be either flexed or extended, no evidence of CPD, estimated fetal weight < 3500g, no evidence of fetal abnormalities...
- Management of labour: fetal wellbeing, if non-reassuring fetal buttocks blood sample./ progress of labour & possible need for induction or augmentation...
- Complications: cord prolapse, abnormal CTG, damage to visceral organ or brachial plexus, asphyxia for large fetus, intracerebral haemorrhage for small fetus...
- Manoeuvres: Pinard’s for extended leg, Loveset’s for extended arm, Mauriceau - Smellie - Veit manoeuvre for aftercoming head “if difficulty; Piper’s forceps”...
management Of cOmmOn prOblems in pregnancy
Antepartum Intrapartum
Postpartum
Maternal Fetal Time & Mode of Delivery During Delivery
- tight glycaemic control precoceptual One day before induction: - half the rate of infusion in
- Early dating U/S scan:
- patient on insulin should continue on it normal diet, normal insulin, no need for type 1 & 2 diabetes
is important to confirm GA
- patient on oral hypoglycemic should overnight fasting… - maintain serum glucose
- At 18-22wks:
convert to insulin TIME: controversial On the day of induction: between 4-9 m.mole
detailed anomaly scan with
- insulin requirement fluctuates during Induction at 38-39 wks - half the morning dose of insulin before - continue insulin infusion until
Diabetes Mellitus (1)
and folic acid supplements 2) scan for fetal anomalies: provided that mother & - rupture membranes
- treatment of hypertension, gestational U/S at 20 wk, karyotyping, fetus are well (37 wk) - oxytocin infusion The risk of postpartum
diabbetes if developed amniocentesis & chorion - exclude cord prolapse (if occur; emreg. haemorrhage increase due to
- antepartum surveillance: more frequent villus sampling (CVS) TYPE: Depend on lie and LSCS) and monitor fetal heart rate large placental site, uterine
visits & serial U/S. 3) scan for fetal well-being: presentation of the first - hasten labour if bleeding or non- over-distension, so prepare:
- prevention of preterm labour: by U/S every 3-4 wk (for twin: reassuring heart rate * IV line & saved blood group
screening & treatment of other risk factor growth & amniotic fluid - Vaginal: If the second is oblique or transverse: * high dose oxytocin
like bacterial vaginosis & GBS. also; volume), Doppler, & CTG if the first is cephalic - try external cephalic version
transvaginal U/S cervical length at 20-24 For TTTS: - C/S: - if failed try internal podalic version Management of any fetal
wk - amniocentesis every 1-2 wk if the first is breech (fear - if failed or cervix contract: C/S complications
- maternal education, planning for intra- - fetoscopic laser of locked twin) After delivery of second twin:
partum care. coagulation of placental - Elective C/S: clamp the cord, active management of
vessels for other presentations third stage of labour
(1) DM Defined by WHO as: raised fasting blood glucose level of > 7.8 m.mol/L or a level of > 11.1 m.mol/L 2 hours following a 75 g oral glucose load
(2) HTN Defined as change of blood pressure on at least two occasions of either diastolic PB > 90 mmHg or systolic > 140 mmHg OR raise in diastolic at least 15 mmHg or of systolic at least 30 mmHg
cOmmOn DisOrDers in Obstetrics
Cardiovascular Diseases Anaemia (Iron deficiency anaemia) Malaria
Rare (1%) BUT potentially serious… Def.: haemoglobin concentration < 11 g/dl (or Hct less than 30%) Differential diagnosis:
Physiology during Pregnancy: Physiology during Pregnancy: meningitis (stiff neck), viral hepatitis (jaundice)
- blood volume & cardiac output increase by 40% - plasma volume increase by 40% - red cell mass increase by 20% For unconscious patient;
Maternal risks (mortality): physiological dilution with decrease Hb & haematocrit (Hct) ABCs, estimate the body weight for drugs, IV canula
- pulmonary hypertension & Eisenmenger’s syndrome (40-50 %) Iron: - only 10-30% of Fe available is absorbed Through examination:
- Marfan’s syndrome (up to 50%) - amount absorbed depend on Hb level; lower Hb, greater absorption - Glasgow coma scale - exclude bacterial meningitis
- Fallot’s tetralogy (5%) - in plasma, it links with transferrin (ferritin, hemosidrin) - plasma HCO 3 \venous lactate - arterial\capillary pH & gases
- others: cardiomyopathy, dissection of aorta (15%), IHD… Diagnosis: low MCV & MCHC, low ferritin, high iron binding capacity - X-match, clotting studies - blood culture (septicaemia)
Fetal risks: Methods of correction in iron deficiency anaemia: Risk factors for traveler: no pre-immunization (prophylaxis)
- growth restriction, preterm delivery, fetal death a) blood transfusion b) total dose iron infusion (cosmofer) Cycle: (infection & reinfection of RBCs)
- fetus with congenital heart disease (5%) c) injectable iron d) oral iron + folic acid sporozoite (infectious form, develop in liver) merozoite (cause
Management: - Pre-pregnancy: Counseling about: cosmofer + folic acid 5 mg\day + vitamin C tablet or in food RBC destruction) ring form trophozoite (development in RBC)
- risk of maternal death S/E (iron dextracomplex): anaphylaxis multinucleated schizon (rupture) merozoite
- reduction in maternal life expectancy injectable iron ferrum ambole (2 ambole\ week up to 10-15 inj.) Defensive mechanism of malaria:
- risk of fetus with congenital heart disease S/E (iron sorbitol complex): abscess, painful - cytoadhesion: membrane of red cells attach to the endothelium,
- risk of preterm labour, IUGR Follow up: raise in reticulocyte count after 1 wk preventing RBCs from reaching the spleen
- need for frequent hospital attendance, intensive monitoring Complications: - rozitting: RBCs tend to become together
- Antenatal: - preterm labour - intercurrent infection Characteristics of severe malaria:
- continuity of care with obstetric/cardiac clinic - IUGR (asymmetrical) - PPH - impaired consciousness: coma - pul. oedema: tachypnoea
- symptoms of heart failure: a) breathlessness particularly at night -postpartum depression - DVT & thromboembolism - repeated seizure (>2 per day) - shock: low PB
b) change in heart rate or rhythm - lactate infertility (i.e. low amount of milk) - jaundice - acute renal failure
c) increase tiredness or reduction in exercise tolerance Management at time of labour: - abnormal bleeding: retinal haemorrhage
- admission according to patient condition (not as policy) i: blood transfusion is better than ferrus sulphate tab Lab finding in severe malaria:
- anticoagulation: a) warfarin throughout pregnancy, replaced by ii: oxytocin, oxygen by mask (if preterm labour) - severe anaemia (HCT<15%) - hypoglycaemia (B glu<40mg/dl)
heparin only for delivery (e.g. pul. HTN, artificial valve replacement) iii: continuous fetal heart monitoring - metabolic acidosis - renal insufficiency
b) replacing warfarin with heparin in 1sr trimester iv: when cervix is fully dilated; shorten the second stage of labour by -hyperparasitaemia (>5-10%) - high aminotransferrase
c) heparin throughout pregnancy using the forceps or the ventouse - high bilirubin - DIC
- heart failure treatment: admission, confirm diagnosis, diuretics, v: IV ergometrine when the shoulder appear
Causes of fetal death:
vasodilator, digoxin, oxygen & morphine. Fetal U/S & CTG… vi: deliver the placenta by cord traction o
fever (1 C 2 beat\min), hypoxia, hypoglycaemia
- Labour & Delivery: vii: episiotomy when the head is crowning
Treatment of severe malaria:
- await onset of spontaneous labour (induction of labour for obstetric viii: if bleeding occur: misopristol (3 tabs per rectum) or
- clinical assessment - specific antimalarial ttt
indication only) prostaglandin F2alpha intramyometrium
- supportive care - adjuvant therapy
- epidural anaethesia (decrease demand on cardiac function) ix: observe the patient for any sign of depression & look for milk
………………………………………………………………………………………………… - for fever: spondage, rectal supporities
- prophylactic antibiotics (reduce risk of bacterial endocarditis) - mature women have a total of 3500-4500 mg of iron (75% in RBCs & - for fluid: * balance between input & output
- monitoring: oxygen saturation, continuous arterial PB monitoring 20% as body store)… * if fluid given with ARF: haemodialysis
- echocardiography is very important in monitoring -dead RBC release 27 mg of iron, also 1 mg is lost daily without return Drugs:
- keep second stage of labour short (by forceps or ventouse) - minimum need per day is 1 mg, increase in pregnancy (to 10 mg in - Quinine: IV:- loading dose 20 mg/kg over 4 hr
NOTE: early pregnancy & 20 mg in late pregnancy) - then, 10 mg/kg/8 hr for 7 days
* C/S less tolerated by cardiac patient (only for obstetric indication) non- pregnant pregnant oral:- after recover consciousness; Quinine 10 mg/kg &
* ergometrine is contraindicated (cause hypotension & heart failure) Hb (g\dl) 12 – 15 11 – 15 clindamycin 5 mg/kg 3 times per day for 7 days
* third stage of labour managed with oxytocin alone, given slowly MCV (fl) 75 – 99 more S/E: hypomagnesaemia & hypoglycaemia (that kill the fetus)
…………………………………………………………………………………………………
NOTE: RBC (mmol\l) 45 – 72 increase - overdose; headache, dizziness, severe CNS disturbance & delirium
- cardiac output increase in: i) early pregnancy Se. Fe (mmol\l) 13 – 27 13 – 27 - rapid IV administration can precipitate hypotension & fatal
ii) immediately after delivery (why??) Fe (mmol\l) 15 – 300 15 – 300 cardiovascular toxicity
- mitral stenosis is the commonest acquired cardiac disease (90%) - despite increase demand for iron; Se. Fe & Fe remain at normal - Artesunate: IV:- 2.4 mg/kg at hr 0, 12, 24, & then every 24 hr
- surgical valvotomy for mitral stenosis can be done during pregnancy nd rd oral: 2 mg/kg for 7 days + clindamycin as above
- iron screening in pregnant women; at booking, 2 & 3 trimester
but better if done before that. - if it low; correct complications, then give iron as injection at 30 wk At time of delivery: avoid thrombocytopenia by active management
- termination of pregnancy in Eisenmenger’s syndrome ??? or as blood transfusion at labour. of third stage of labour.
perinatal infectiOn (tOrcH)
Infection Transmission Clinical features Fetal complications Diagnosis Treatment Notes
Primary Secondary Tertiary
3) TPHA (specific)
2) FTA (specific & 1 to be +ve) &
If +ve (DD: SLE, APS), then:
1) VDRL (non-specific): titre > 1/64
Sexually Transmitted
bone abnormalities..
- 3-6 wk after infection
insane, gummata
Disease (STD)
- highly contagious
- condylomata lata
miscarriage
Syphilis
on IgM)
deafness
st
Prevalence:
10 %
chorioretinitis, convulsion,
hydrocephalus or microcephaly
- Classical tetrad:
Less fetal damage
- 3 trimester (75-90%):
Severe fetal damage
- 1 trimester (10-25%):
- Sulphadiazine + Spiramycin
congenital toxoplasmosis
- Sabin-Feldman dye test
st
(Toxoplasma gondii)
st
- primary infection usually asymptomatic OR:
+ Sulphonamide
Toxoplasmosis
- uncooked meat
- glandular fever like illness with atypical lymphocytes
-rarely: fulminating pneumonitis, fatal encephalomyelitis,
chorioretinitis.
Prevalence: - association with AIDS: recurrent toxoplasmosis and
Vary according to multiple brain abscess
eating habit
antiviral for
(herpes virus)
- mild fever, sore throat, enlarged cervical gland, rash, throat, urine, faeces
Common in spring & defect, & deafness. available abortion
painful joint for 3-7 days - IgG Ab after 6 month
early summer - also: hepatitis, mental ret. - no vaccination - MMR vaccine
- abortion, stillbirth, & preterm birth can occur - rubella specific IgM
thrombocytopenia, bone during reduce the
- infection pass unnoticed in children found for 3-9 months
involvement, microcephaly pregnancy incidence
- incubation period: 2 wk Congenital - IV Aciclovir
Varicella zoster
(herpes virus)
- in children: mild disease, handful of lesion only varicella Neonatal - intensive care Other exanthems
From adult with syndrome: - electron microscopy support
- in adult: headache, general aches, pain, & malaise chickenpox: - smallpox
chickenpox or shingles hypoplastic - culture of scraping - for the fetus:
- cluster of vesicle emerge at different stages Mortality - eczema
through droplet spread limb, scar, & from vesicles * VZIG
- pregnant are more vulnerable to chickenpox & may rate: 30% herpeticum
CNS * IV Aciclovir
develop pneumonitis (fatal) anomalies
Drugs in Obstetrics
Drug Action Indication Contraindication Complication/Side effect Route of adm. Note
- rapid onset of action (tonic - induction of labour - CPD - uterine hyperstimulation - for induction:
(1) contraction) - augmentation of labour - hypertonic uterine - uterine rupture continuous infusion in high dose can
Oxytocin
- act on uterus mainly - prevention/treatment of PPH dysfunction - fetal compromise NS or 5% dextrose cause neonatal
(Syntocinon) (increase prostaglandin level) (safe in nulliparous, & less safe in - uterine scar - excessive fluid retention & (titration method) jaundice
- best action after ARM multiparous) - fetal distress - dilutional hyponatraemia - for PPH: IM
- dyspnoea, bradycardia not used for
Utrotonic Drugs
Drug Indication Action Side effect Drug Indication Action Side effect
Ritodrine increase cAMP in cell, which hypotension, tachycardia, Methyl-dopa false neurotransmission, CNS postural hypotension,
suitable area (<48 hr)
aiming of diastolic PB
2) give steroid to the
- lower BP gradually
1) transfer the pt to
Antihypertensive
decrease free calcium anxiety, chest pain, ECG change effect (dopamine antagonist) depression, insomnia
- prevention of CVA
(Beta-agonist) (orally)
mother (fetal lung)
90-100 mmHg
Hydralazine relaxation of arteriolar smooth flushing, headache,
Tocolytics
Steroid single course of maternal steroids (two injections IM 12-24 hrs apart) given between 28 & 34 wks gestation & received within 7 days of delivery (for fetal lung maturation) “dexamethasone”
Heparin cause prolongation of APTT (low molecular weight, assessed by factor X assay). complication: 1) osteoporosis “if used for > 6 months” 2) idiosyncratic thrombocytopenia “rare”
Anticoagulant st nd rd
Warfarin given orally & prolong prothrombin time (PT). Complication: 1 trimester; limb & facial defects / 2 & 3 trimester; fetal intracerebral haemorrhage “so, used in high risk pt only”
- Increase age
- Assisted conception
- Uterine anomalies
- Multiple pregnancy
- Constrictive surgery
- Obstructed labour
- Grand multiparity
- Previous scar
- Multiple pregnancy
- Placenta previa
- Scar (e.g. repeat C/S)
Risk factors
2- Uterine infection
other causes: endometritis, hormonal contraception, bleeding disorders, and
choriocarcinoma..
PPH, DIC, PPH, IPH, Circulatory Fetal
Complication Management:
ARF, shock shock collapse death
General: 1- ABC’s according to the patient condition, IV line…
3) hysterectomy
- C/S if fetal heart is +ve or cervix is closed
- Libral blood transfusion
shut down)…
- ARM (decrease uterine tension & uterorenal
1) repair
of rupture, condition of patient, then:
- Laprotomy, & according to parity, age, site
- Blood as twice as needed (> 4pint)
- No bleeding: conservative (till maturity)
- Heavy bleeding: C/S
- Oxytocin
(after putting 2 IV lines, sending sample for
2- stop bleeding
3- remove tissues
Cervix, vagina, perineum….
b) without visualization:
- abdominal, vaginal or
therapy, microwave or
cervical endometrial
Reduce MBL by 90%
Interrupting the
- total or subtotal
resection (TCRE)
Hysterectomy
about 30-45 min)
heated saline
laparoscopic
the uterus
Treatment depend on the cause
Surgical
used in Scandinavia
Hysterectomy)
- reduce MBL by 100 ml
NSAID’s
LNG-IUS
Danazol
COCP
- antiprostaglandin
- anti-oestrogen
by progesterone as above:
then go to:
- pelvic U/S
- pelvic/transvaginal U/S: fibroid, polyp
- laproscopy
menstrual DisOrDers
anaemia, liver disease or coagulopathy General examination to - development of secondary sexual characteristics
- abdominal: liver enlarge., pelvic mass exclude other or virilization
- bimanual pelvic examination: vaginal or pathologies - visual field disturbance / papilloedema
cervical disorders - pelvic examination
- number of towels or tampons developmental history, age at menarche, cyclical
- duration of the problem symptoms, chronic illness, anorexia nervosa,
(*) Metrorrhagia: bleeding not related to the cycle. e.g. submucous fibroid bulging into the cavity
Crampy suprapupic pain excessive exercise, FH of insomnia, menstrual
History
- Peripheral:
progesterone inhibit FSH & LH
- Treatment of acne
endometrial cancer
- Protection against ovarian and
- Reduce the risk of PID
- Improve PMS
- Central: inhibit ovulation; estrogen &
a) 2 generation:
- Focal migraine
- Estrogen dependent neoplasm
- Severe or acute liver disease
- Circulatory disease (IHD, CVA….)
mestranol
0.1 - 1
(COC)
norgestimate
desogestrel
OR
Types FR Formulation Intake Mode of Action Advantage Side effect Indication Notes
Progesterone only Contraception
the ovulation
- Higher dose act centrally by inhibiting
- Local effect:
- Acne
- Breast tenderness
- Functional ovarian cyst
- Absent menstrual bleeding
Progestrone
nd
-2 generation progestron: Ideal for women: - Breastfeeding
only pills
1–3
Types FR Formulation Intake Mode of Action Advantage Side effect Contraindication Notes
- Copper Toxic effect on Increase: - It is radio-opaque
personnel immediately
- Previous PID
Inserted by healthcare
Copper-
Induce inflammatory
- systemic illnesses - hypothyroidism e.g. Turner synd., XY gonadal dysgenesis - pelvic infection / surgery
(abnormal endometrium
- tumour or structural lesion - hyperthyroidism - acquired: damage by virus, toxin… - endometriosis
development, or
- renal, hepatic failure - hyperprolactinaemia - iatrogenic: pelvic surgery, irradiation, (impair oocyte pick-up OR cause tubal
abnormalities in growth
Female Infertility
In case of low concentration: endocrine profile, chromosomal studies…. In case of low motility: search for antisperm antibodies….
Postcoital test: examine the ability of the sperm to reach & survive in the mucous. sample obtained from the female partner 6 - 10 hrs after coitus
- hypogonadotrophic hypogonadism oligospermia: exogenous gonadotrophin & hCG
- idiopathic oligospermia: * intrauterine insemination with ovarian stimulation OR * in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI)
ttt
5-10 % (due to disordered - hirsutism (30-70%): due to androgen - high LH level (n.: 0.5 - 14.5 IU/L) - for hirsutism: Eflornithine acetate, Cyproterone
(unopposed
------------- ovarian cytochrome - subfertility (75%): due to anovulation - high LH : FSH ratio (inverted) (n.: 1:2) acetate, Metformin & Dianette, GnRH analogues
oestrogen),
On U/S: P450 & increase LH - obesity (40% of patients are obese) - high fasting insulin with low dose HRT, surgical removal of hair follicle
diabetes,
About 25 % stimulation) - recurrent miscarriage (50-60%) - U/S: eight or more subcabsular - for subfertility: Clomiphine with or without
cardiovascular
2- Insulin resistance - acanthosis nigricans (2%) follicular cyst < 10 mm in diameter & gonadotrophin, Metformin, Ovarian drilling
diseases
3- Genetic role increased ovarian stroma - for obesity: weight reduction, Metformin
Definition: Benign tumour of uterine smooth muscle, termed leiomyoma. can be submucous, intramural, subserous, intracavity, pedunculated, or cervical fibroid
(majority asymptomatic) Examination: NO treatment if asymptomatic (& < 12 wk in size)
Aetiology unknown.. - degeneration: red,
- menstrual disturbance -abdominal: firm mass arising from pelvis 1) Medical: GnRH agonist, Mifepristone in low dose
Fibroid
1) Menstrual - dysmenorrhoea - pain in pouch of Douglas by palpation - simple analgesia, danazol, synthetic progesterone
10-15 % - histological
regurgitation & - cyclical pelvic pain - ovarian mass(es) & fixed retroverted - inhibition of ovulation: COCP & GnRH analogues
In age subtypes:
implantation - deep dyspareunia uterus (DD: chronic PID) Surgical: 1) conservative treatment:
between * free implants
2) Coelomic epithelium - history of subfertility or infertility - pelvic mass on bimanual examination - laparoscopic with intra-abdominal lasers:
20-30 years * enclosed implants
transformation - cyclical haematuria, ureteric Investigation: easier, but complicated by severe adhesion
------------- * healed lesions
3) Genetic & obstruction - U/S: to exclude endometriomata 2) definitive treatment:
Common in * ovarian
immunological factors - cyclical rectal bleeding or pain on - CA 125: slightly raised (of little uses) - ablation, resection or total abdominal
Caucasians endometriosis or
4) Vascular lymphatic defecation - diagnostic laproscopy & biopsy of the hysterectomy & bilateral salpingo-oophorectomy
chocolate cyst
spread lesion: confirmatory Should be followed by HRT after 6 months
Definition: Protrusion of an organ or structure beyond its normal confines. & classified according to their location & the organs contained within them. (uterovaginal prolapse)
Prolapse
- non-specific symptoms usually (lump, - abdominal: to exclude organomegally - lifestyle modification & 7 days topical oestrogen
12-30 % of - congenital
local discomfort, backache, bleeding, or mass Medical: Ring pessaries (silicon-rubber or shelf) OR Surgical:
multiparous - childbirth & increase
infection, ulceration, dyspareunia…) - vaginal: - in dorsal position to inspect - cystourethrocele: ant. colporrhaphy - rectocele: post. colporrhaphy
-------------- intra-abdominal pres.
- specific: introitus (e.g. ulcer, atrophy...) - uterovaginal prolapse: vaginal hysterectomy & support of pelvic floor
2 % of - ageing
rectocele: digitations, splinting… - as pt straining to assess vaginal walls OR: Manchester operation & sacrohysteropexy
nulliparous - postoperative
cystourethrocele: frequency, urgency.. - Sims’ speculum - vault prolapse “usually follow hysterectomy”: sacrocolpopexy
menOpause
Sertoli
Leydig
- virilization features
- rare < 0.2%, small, unilateral
- ttt: oophrectomy
Management: - asymptomatic simple ovarian cyst often resolves spontaneously (criteria: unilateral, unilocular, 3-10 cm diameter in premenopausal or 2-6 cm in postmenopausal, normal CA 125)
- various cells secrete: androgen, oestrogen
Sex cord stromal tumour
- unusual tumour
Fibroma
tumor
- derived from stromal cell
cord
- 4% of all neoplasm
Malignant features
- secrete hormones
- hard, mobile, lobulated, white, bilateral in < 10%
- occur at any age
2) Laparoscopic procedure “indications: a- no pathology regarding the cyst. & b- suitable tumour for laparoscopy “criteria??”.
Theca - all are benign
cord t. - solid, unilateral -secrete oestrogen
- all are malignant - commonest sex cord tumour
- good prognosis if: 1) confined to ovary 2) slow growth - associate with endometrial tumour
Granulosa cord
- solid: Call- Exner bodies: pathognomic in 50%, and secrete following diagnosis
oestrogen & inhibin. - ttt: laparoscopic oophrectomy
- high oestrogen lead to: - if advanced: chemotherapy
1) precocious puberty 2) postmenstrual bleeding - yellow appearance indicate
3) endometrial hyperplasia 4) endometrial cancer haemorrhage
Malignant features
- unilocular, turbid brown fluid
endometrioid DD: ovarian endometriosis - 15% associate with endometrial
3) Laprotomy: if < 35 year old; ovarian cystectomy/unilateral oophrectomy. OR if > 35 year old; pelvic clearance
uterine Ca
- second commonest epithelial tumour
- unilateral, multilocular cyst with smooth inner surfuce lined by
columnar secreting cells
Mucinous
- cystic fluid: thick & glutinous - 10% of malignancy of ovary
cystadenoma - Pseudomyxoma peritonei: associate with mucinous tumour of appendix - largest tumour of ovary (25 cm)
Seedling growth, secreting mucin lead to obstruction of bowel.
- 5y survival rate 5% / 10y survival rate 18%
- commonest benign epithelial tumour
- bilateral unilocular cyst + papilliferous process
Serous - serious tumour, cystic & solid
- epithelium in inner site (cuboidal or columnar may be ciliated)
cystadenoma - Psammoma bodies (concentric calcification) - glandular structure: adenocarcinoma
- cystic fluid: thin
- rare - bone
mesoderm
None
- commonest ovarian tumour in
Rupture
teratoma
- arise from totipotential germ cells:
- classification to solid & cystic
dysgerminoma
Mature
- cartilage
solid
choriocarcinoma
- endometrial
(malignant)
sinus tumour
Clinical features
young (<30y)
embryonic
endoderm
Torsion
- thyroid
Extra-
(10%)
= capsular rupture
Types
- intestine
- poor prognosis:
teratoma)
embryonic tissue
- 40% of all ovarian
Asymptomatic
(60%)
Leuteal
- Intraperitoneal bleeding
- common on right side
- occur on day 20 – 26 of cycle
cycle
- Adenocarcinoma (15-20%)
- Squamous cell cancer
- IVU
- exam. under anesthesia
Figo classification depend on:
- Cone biopsy
Intraepithelial Neoplasia (CIN)
Human Papilloma Virus (HPV)
tumour worldwide
following Cervical
- postcoital, intermenstrual, &
asymptomatic)
post-menopausal bleeding
Surgery:
- cystoscopy
- profuse offensive vaginal
Wertheim hysterectomy (i.e. uterus, paracervical tissue,
discharge (blood stained)
upper vagina “leaving only 2 to 3 cm”, pelvic LNs)
- pain (late stage)
For lymph node invasion:
O/E:- friable polyp
*if large number: adjuvant radiotherapy
- bleeding on contact
*if 1 or 2 only involved: pelvic dissection
Radiotherapy: external beam VS internal beam ???
Surgery:
- Primary squamous cell (rare)
- Clear cell cancer (aggressive)
- Papillary serous (aggressive)
metaplasia)
- Leiomyosarcoma
Protective agents:
- Metastatic tumour
choriocarcinoma, teratoma, mixed)
endodermal sinus, embryonal cell,
- Germ cell tumour (dysgermimnoma,
stroma, androblastoma, gynandroblastoma)
- Sex cord stromal tumour (granulose
endometrioid, clear cell, Brenner)
- Epithelial tumour (serous, mucinous,
Ovarian
Ute rine
II involve up to upper two thirds of the vagina II involve the cervix, not outside the uterus II one or both ovaries with pelvic extension
III involve lower third of the vagina & pelvic wall III outside the uterus, not outside the pelvis III peritoneal implant outside the pelvis or +ve LNs
IV spread to distant organs IV involve mucosa of the bladder or rectum IV distant metastases
lOwer genital tract infectiOn
Infection Prevalence Risk Factors Clinical features complications Diagnosis Treatment Notes
> 75 % immunosuppression - If asymptomatic; no ttt
- Candida
-------- HIV, DM, Pregnancy unlikely, unless the - microscopy & - Clotrimazole as vaginal
- curdy white discharge, may smell
sex
Few have Steroid, Antibiotic, women is severely culture of vaginal creams & pessaries
yeasty
frequent COCP, high immunocompromised fluid - Fluconazole orally (C. alb)
- pH normal (3.5 - 4.5)
recurrence oestrogen, eczema - if pregnant: Imidazoles
- Afro-Caribbean - offensive fishy smelling discharge, - second trimester Amsel criteria:
- Metronidazole tabs
vaginal flora
Vaginosis
Caused by
anaerobic
Bacterial
12 % or Clindamycin cream 2%
of pregnancy - this features apparent at time of - post-surgical infection addition of 10% KOH
- prophylaxis: 1-2/month
- common with other mensturation or following intercourse - not a cause of PID, but 3) ‘clue cells’ on
Metronidazole
STIs - Ph: 4.5 – 7 (decrease no. of lactobacilli) can be found in PID pt microscopy
- vulvovaginitis, itching or soreness - can spread to infect the - Metronidazole tabs
Metronidazole
Culture on Fineberg-
toxicity from
Neurological
high dose of
Trichomonas
genital infection
- serovars D-K:
- serovars A-C:
- Reiter’s syndrome
Trachomatis
Chlamydia
Commonest bacterial - mucopurulent cervicitis, that bleed - ELISA: less sensitive: - Azithromycin
trachoma
- tubal infertility
Test of cure:
following ttt
- proctitis with purulent green discharge, - Bartholin’s abscess - Ciprofloxacin
(Neisseria rectal swab (sen 50%)
swab
bleeding & rectal pain - tubal infertility - Spectinomycin
< 1% Gonorrhoeae is gram - Culture on blood
- exudative tonsillitis, conjunctivitis - ectopic pregnancy - Azithromycin
-ve intracellular agar using antibiotic
- in > 50% concomitant chlamydial Neonatal complications: - Ceftriaxone
diplococcic) & 7% CO 2 (sen 60-
infection - opthalmia neonatorum - Cefixime
70%)
H
Obstetric forceps Ventouse (Vacuum extractor) Ovum forceps Green Armytage’s Clamp
traction, rotation, “protection in the past” (Indication? Contraindication?) hold the soft pregnant cervix haemostatic in case of C/S two clamps to control bleeding
Volsellum forceps (single teeth) Volsellum forceps (multi-tooth) Willet’s scalp forceps Needle holder Clips (curved kocher)
used to grasp the non-pregnant cervix traction of dead baby in APH hold the needle during incision artificial rupture of membrane
Curette Hegar’s dilator (cervical dilator) Uterine sound Cusco’s vaginal speculum Sim’s vaginal speculum
Diagnostic: uterine bleeding, Ca drainage of haematometra or measure length of uterus & cervix, expose the vagina & cervix expose anterior vaginal wall
body, diseases of endometrium... pyometra, used before D & C, determine the direction of uterus, e.g. polyps, erosion, cancer, PROM e.g. vesicovaginal fistula, cystocele
Therapeutic: control bleeding ttt of dysmenorrhoea “rare” … detect intrauterine tumor or FB… Position of pt: lithotomy position Position of pt: Sim’s position
Decapitation Hook Doyen’s retractor Simpson’s perforator Rubber & Metalic catheter Suction Machine (evacuation)
lock twin, transverse lie in dead… protect the bladder during C/S craniotomy, hydrocephalus… monitoring, preoperative, urine ret. miscarriage, molar pregnancy
References
Obstetrics by ten teachers (18th edition),
Edited by Philip N. Baker, BMed (Sci) BM BS DM FRCOG; 2006