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Obstetrics and Gynecology

September 2009

Herpes In Pregnancy

DNA virus.

Greatest risk of primary infection after 28 weeks of gestation.


May cause miscarriage and preterm labor. High mortality and morbidity. Asso. with mental retardation and developmental delay.

Vertical transmission during labor.

Ref:JM(1047) ,Oxford handbook (105)

Risk factors for intra partum infection

Primary infection. Recurrent herpes.


Multiple lesions. Premature rupture of membranes.

Preterm Labor.

Management

Symptomatic. Prophylactic anti viral like Acyclovir from 38 weeks until delivery, to prevent recurrent herpes.

Arrange caesarean if active lesions at time of delivery or within preceding 4 days, membranes ruptured for more than 4 hrs.
In vaginal delivery ,acyclovir to neonate.

Long term effects of Hormone Replacement Therapy

Decreased risk of endometrial and bowel cancer. Increase risk of breast cancer after more than 5 years use.
Helps primary prevention of CVS disease only if HRT is started within 4 years of menopause.

Increased risk of Stroke in all age groups. (Ref:Therapeutic Guidelines)

Types Of HRT
Cyclical Combined HRT. (Daily Oestrogen +Cyclical Progestin) Use within 1 or 2 years of the last period and in those having some spontaneous menses. No break thorough bleeding.
For those with more than 2 years of amenorrhea or those who have only light bleeding. Chance of break thorough bleeding.
Patients undergone hysterectomy.

Continuous combined HRT.

Unopposed estrogen

Transdermal Oestrogen therapy

In patients with H/O Venous thrombo embolism, Hypertension, Significant Liver disease, Smokers, Symptoms not controlled by Oral therapy.

Oestrogen Implant therapy

Hysterectomy patients Unresponsive to Oral or transdermal therapy Intra vaginal Estrogen Therpy Genitourinary symptoms, Syetmic estrogen C/I or does not produce releif

Therapy
Initiation: Start at low or ultra low dose. Cessation

Oral

Ultra low dose

Low dose
1 mg

Med dose
2mg

High Dose
4mg

For those with mild symptoms: Gradual tapering over 6 weeks. For those with severe symptoms: Taper over 6 months.

Oestra 1mg diol on alt days Oestra 1 mg diol on alt valerat days e Conju gated Oestro gens

1 mg

2 mg

Progynova Oestradiol valerate. Conjugated Oestrogens: Premarin.

0.3 mg 0.3 mg 0.625 on mg alterna te days

1.25 mg

Hormone Replacement Therapy


Indications: Symptomatic women.

Symptom free cases to prevent osteoporosis, atherosclerosis, CVS diseases, Urogenital atrophy, Alzheimer's.
Special Group: Premature Ovarian Failure, Gonadal dysgenesis, Surgical or Radiation Menopause.

ContraIndication: Hormone dependent cancer. H/O recent thrombo embolism. Acute /Chronic liver disease. Relative C/I : Past H/O venous thrombo embolism. Cerebrovascular disease, CVS disease.

Rectus Sheath Haematoma


Benign but Uncommon cause of abdominal pain. Bleeding into rectus sheath from damage to superior or inferior epigastric arteries or their branches or from direct tear to rectus muscle.

Risk Factors:

Age: Elderly. Sex: Females more prone.


Pregnancy: During gravid, labor, Post partum.

Anticoagulant therapy: Most common. Coughing : URTI, Tuberculosis, Bronchitis, Asthma.

Abdominal Surgery. External Trauma.


Vigorous uncoordinated rectus muscle contraction : Activities with significant Valsalva effort, such as coughing, sneezing, straining from constipation, urination, and sexual intercourse, have been implicated in rectus sheath hematoma

Signs and Symptoms.


Most Common presenting complaint is severe acute abdominal pain. In Pregnancy , D D : 1. Uterine rupture. 2. Placental Abruption. 3. Ovarian torsion. 4. Degenerating uterine leiomyoma.

Maternal mortality is 13% and fetal mortality is 50%.


The Cullen sign, periumbilical ecchymosis, in a patient with a rectus sheath hematoma

Diagnosis: USG or C T scan.

Management

In Pregnancy: Non surgical management preferred. Rest, Analgesics, Haematoma compression ,Icepacks and treatment of predisposing conditions.

Ante Partum Haemorrhage

Bleeding any time after 20 weeks of gestation (but before delivery of baby).

Before 20 weeks: R/O cervical causes and other local causes. After 20 weeks: Placenta praevia Accidental haemorrhage/Abruptio Placenta.
(REF: Llewellyn jones, Oxford handbook (231) and Emedicine)

Placenta Praevia

Implantation of placenta over the lower segment.

Painless, causeless, profuse, recurrent.


Common in Multiparous, Prev Caesearen and prev h/o PP. Blood loss is maternal. Diagnosis: Ultrasound. Confirmed only after 30 weeks.

Types of Placenta Praevia.


Major: Completely covers the internal os (Type 4) or partially covers the internal os. (Type 3) Minor: Approaches the border of the internal os (Type 3) or low lying (Type 1).

Presenting part is unengaged. Malpresentation is common. Uterus is non tender.


Bleeding in second half of pregnancy is PP unless proven othewise.

Management
Minor: Continue till term or labor can be induced. Major always caesarean. Usually at 37- 38 weeks. Mgmt: Admission Check vital signs. No vaginal examination. USG.

If before term, Mgmt depends on severity of bleeding.

Severe bleeding: Urgent treatment to deliver. Less severe : Expectant mgmt till 36 weeks.

Placental abruption/Accidental haemorrhage.


Premature separation of a normally situated placenta. Can be due to direct trauma.

Risk Factors

Maternal hypertension Multiple pregnancy Multiple pregnancy Polyhydramnios Smoking, Substance abuse

Presentation
Abdominal pain with or without vaginal bleeding. Pain is sudden and severe Uterine contractions. Fetal distress may be present. Severe cases: S/O shock, rising fundal height. Diagnosis is clinically. USG is not an accurate tool.

Management
Depends on severity, asso. complication and fetal gestational age. In severe cases, Deliver, irrespective of whether fetus dead or alive. Delivery by caesarean or vaginal.

Complications
Maternal: 1. Hypovolaemic shock, 2. DIC 3. Acute renal failure, 4. PPH Fetal: 1. IUGR 2. Pre term delivery 3. Anemia

Vasa Praevia
Fetal blood vessels overlying the internal os, in front of the presenting part. Rupture of membranes involving the overlying vessels leads to vaginal bleeding. Fetal blood is lost ,leading to fetal exsanguination and death.

Recurrent Pregnancy Loss


Three or more successive miscarriages. Causes: Unexplained (50-70%) Genetic cause (70%) most seen during first trimester. Auto immune causes: APLA (Late second trimester) ,SLE. Endocrine like diabetes, luteal phase deficiency. Anatomical causes: Incompetent cervix. Seen in second trimester.
Ref: Emedicine, L and Jones(107)

Incompetent cervix
Painless cervical dilatation in 2 trimester or early 3 trimester. Asso .with rupture of membranes. Unless treated ,recurrent.

Causes and Management


Causes include prev trauma to cervix like D and C. Mgmt: After 14 weeks. Not usually done after 24-26 weeks. Reinforcement of weak cervix by sutures.

Oral Contraception

Venous thromboembolism associated with the combined oral contraceptive pill will usually occur in the first year of its use. Most common in women with a genetic thrombophilia. While it is not cost effective to screen all women before they start taking a combined oral contraceptive pill, women with a first degree relative who has a history of venous thromboembolism should be screened for a thrombophilia before commencing a combined oral contraceptive pill .

Ref:Therapeutic guidelines

Contraindications for COCS


Absolute: 1. Pregnancy 2. First 2 weeks post partum 3. H/o thromboembolic disease. 4. CVS disease 5. Estrogen dependent tumor. 6. Recently impaired liver function. 7. Migraines with aura

Relative

Heavy smoking More than 35 years, Smoking and other risk of CAD. Breast feeding 4 weeks before surgery and 2 weeks after. Gall bladder or Liver disease. DM, HT,Complicated valvular disease, Hyperlipidaemia Sever depression. Undiagnosed vaginal bleeding.

Contraception
Failure rates: No method : 85% Barrier: Female Diaphragm 16% Condoms 21%. Male Condom 15%

IUCD -0.1- 0.8% OC pills 0.3 % (perfect use). Injectable or Implantable 0.05- 0.3%.
Sterilization: Male: 0.15-0.1% Female: 0.5%. Withdrawal 27%. Breast feeding 2-3%.

(Ref Therapeutic guidelines)

Benefits
Menstrual disorders PID Benign Breast disease and tumors. Functional ovarian cysts. Endometrial and Ovarian Ca. Rheumatoid Arthritis.

Risks

DVT
Stroke

Myocardial infarction
May be asso. cervical cancer.

Missed Pills.
If less than 24 hrs Take the pill ASAP If the pill is missed in the first week,use additional protection for next 7 days. . If more than 24 hrs Take active pills ASAP. Use protection for next 7 days. If the missed pill is in the third week or the pill free week, start the new packet.

If the missed pill was an active pill and was missed in the first week of a new packet, and the woman had intercourse at or after this time, she will need to use Emergency contraception.

Emergency Contraception
Also called Morning after pill Ideally to be taken ASAP after unprotected sex. Protection is till 5 days.

Methods
Levonorgestrel :Only method of emergency contraception registered for use in Australia. Single dose of levonorgestrel 1.5 mg given within 72 hours of unprotected sexual intercourse, or levonorgestrel 750 micrograms with the same dose repeated 12 hours later

Yuzpe Method
Four tablets of ethinyloestradiol 30 micrograms + levonorgestrel 150 micrograms within 72 hours of unprotected sexual intercourse, and repeating this 12 hours later. Used only if no alternative.

Protection of 85%.

Side Effects: Nausea ,Vomitting, Dizziness and fatigue. Headache, Breast tenderness. No adverse effects on fetal development.

Vulval Cancer:

Elderly Women. 3% of all genital cancers.

Vulval itching for months and years.


Hard nodule or an ulcer.

Mgmt : Vulvectomy with dissection of the inguino femoral lymph nodes.

Cyclic Vulvitis

Characterised by vulvar pain, which occurred in a cyclic fashion, generally in concert with the menstrual cycle. The pain could arise spontaneously or could be provoked by touch, pressure or friction. Redness might or might not be present on examination. Intermittent, low-grade candidiasis (usually without the typical physical findings of vulvovaginal candidiasis) is the cause.

The problem often improved when chronic, suppressive oral or topical anticandidal agents were used.

Ref: The Terminology and Classification of Vulvar Pain International Society for the Study of Vulvovaginal Disease

Vaginal Bleeding in I trimester


Differential Diagnosis 1. Implantation Bleeding 2. Miscarriage 3. Ectopic Pregnancy 4. Molar pregnancy 5. Local causes unrelated to pregnancy

Abortion

Clinical Features
Vag

Management

Threatened

Bleeding, may or may not be asso with pain. OS closed. No passage of POC.
Vaginal

Close Monitoring Evacuation Evacuation Expectant Mgmt

Inevitable

bleeding with cramps. Dilatation of Cx bt no POC passed.


Vag

Incomplete

bleeding Dilatation of Cx Passage of some POC. Severe pain. H/0 vag bleeding, abdo pain, and passage of POC. Aftr POC passed,pain , vag bleeding . OS closed. USG - empty uterus.

Complete

Missed Abortion

Nonviable intrauterine pregnancy that has been retained within the uterus without spontaneous abortion.
Typically, no symptoms exist besides amenorrhea No vaginal bleeding, abdominal pain, passage of tissue, or cervical changes are present. Detected when a fetal heartbeat is not observed or heard at the appropriate time.

An ultrasound usually confirms the diagnosis.

(Ref: Emedicine, L and Jones).

Parvovirus B19 in Pregnancy

Non Immune at risk. Risk of transplacental infection throughout pregnancy. Screen By Immunoglobins. Miscarriage is 4% < 20 weeks. If Infected : Fetal Monitoring by USG.

Fetal Parvovirus syndrome: Anaemia, Hydrops fetalis with cardiac failure.

If Hydrops ,Consider Early blood transfusion. (Ref: JM 1047)

Drugs and Pregnancy


(Ref: Therapeutic Guidelines ,RWH)

Amphetamines
During Ante natal

Developmental Defects:

Small head size. Eye problems Cleft lip and palate. Limb defects. Heart Defects

Miscarriage Prematurity Still birth

Cannabis/Marijuana
Not Asso.with Birth defects.
Asso with reduced growth and development.

Heroin

Not asso with physical abnormalities.


Crosses placenta,asso with withdrawal symptoms and miscarriages.

Benzodiazepines

Usually safe.
In late pregnancy Neonatal drowsiness. Floppy infant syndrome. Oxazepam ,ortemazepam preferred over diazepam.

PCOS
Diagnostic criteria - Two of the following three criteria.

Menstrual irregularity.
Hyperandrogenism. Polycystic appearance of the ovaries: 10 or more follicles in at least 1 ovary measuring 2-9 mm in diameter or a total ovarian volume of >10cm3

Presentation

Oligomenorrhea ,Secondary Amenorrhea. Hyperandrogenism : Hirsutism, Acne,Male pattern baldness.

Infertility- Chronic Anovulation.


Obesity. Diabetes Mellitus- Impaired glucose tolerance. Acanthosis nigricans and High Blood pressure.

Daignosis
Lab Findings: LH:FSH 2-3 : 1 LH > 10 IU/L Testosterone and androstenedione SHBG Insulin

USG

Echodense stroma or hyperechoic stroma String of pearls appearance.

Management

Life style modifications: Weight loss, Exercise.


For PCOS and impaired glucose tolerance, or with PCOS and type 2 diabetes Metformin. Sub fertility Clomiphene /Tamoxifene, Metformin.

Secondary Amenorrhoea
Cessation of menstruation for more than 6 months in normal female, not due to pregnancy. Unless organic disease is suspected or the women is desperate for trmt of infertility, investigation is delayed till 6 -12 months ,as most women start menstruating during this time.

Primary gonadal (Ovarian) failure

Unknown cause. Menopause before age of 40.


An FSH level above normal range of lab, confirmed by repeating the measurement indicates primary ovarian failure.

A level of more than 40 IU/l indicates menopause.

Common Causes {Ref:L AND JONES (224)}


Weight loss 20-40 %

Polycystic Ovaries
Post Pill

15- 30%
10-20%

Hyper prolactinaemia Primary Ovarian Failure


Ashermans Syndrome Hypothyrodism

10-20 % 5-10 %
1-2 % 1-2 %

Pre Eclampsia
(Ref :Ten Teachers , Williams, RWH,L and Jones)

Min Criteria:

B P 140/90 mm Hg after 20 weeks of gestation. Proteinuria of more than 300 mg / 24 hrs.

Severe PE : 160 /110 + Proteinuria ( > 300mg/l)

Imminent Eclampsia
Severe PE + Severe Headache Blurring of Vision Epigastric pain Exaggerated reflexes Oliguria

Risk Factors

Primigravida (young and elderly).


Family H/O

Placental Abnormality.
Multiple pregnancy

Complications
Maternal Ecclampsia Abruptio placentae. Oligohydramnios Preterm labor HELPP PPH Fetal IUD IUGR Prematurity

Indications for admission

B P 150/100 mm Hg on 2 occasions.
Maternal Symptoms. Concern for Fetal Well being.

Deliver
Gestation > 37 weeks B P uncontrolled. Deterioration LFT/RFT Neurological symptoms /Eclampsia Abruptio Fetal welfare.

Management

Mainstay Deliver the fetus. PE before 32 weeks: Continue preg till 35 weeks or longer. Steroids for fetal maturity. Daily DFMC / 3 weekly CTG. PE btwn 32 35 : Same mgmt. After 35 Weeks: Terminate by Caesarean or induction.

Potential PE : See patient in 7 days. Mild PE : See pat in 3 days. Severe PE : Admission. Drug of choice: Alpha Methyl Dopa. Other drugs: Labetalol,Atenolol/ Acute Crisis : I V hydrallazine.

Eclampsia
Severe P E + Convulsions. Drug of choice : Mag Sulphate. Anti convulsant. Not to treat hypertension. Acts on cerebral cortex.

Intoxication

Avoided by maintaining urine output. Signs:

Patellar and biceps reflex disappear first. Respiration depression Respiratory paralysis. Rx Stop Mag sulphate.

Antidote : Ca Gluconate.

Down Syndrome Screening. (Ref:


Therapeutic Guidelines)

Nuchal Translucency: 10 -13 weeks.

Serum levels: Triple test : 15-18 weeks .serum chorionic gonadotrophin , - feto protein, unconjugated serum oestriol.

Diagnosis

Chorionic Villus sampling: 10 weeks -13 weeks. Fetal loss is1.5%. Amniocentesis: 15-20 weeks. Fetal loss is 0.8%.

Risk
Age in years 25 35 40 45 Risk 1:1376 1:424 1:126 1:31

PAP SMEAR

In case of unsatisfactory smear, repeat the pap test in 6-12 weeks after correcting the factor responsible for the smear to be unsatisfactory.
If your result shows signs of inflammation, but the smear is otherwise satisfactory, you do not need a repeat smear sooner than the usual two years between Pap smears .

PUPP (Pruritic urticarial papules and plaques of pregnancy)


Rashes that itch strongly. Never involve the face. Usually appears in 3 trimester. No harm to baby. Disappears after delivery.
Rx: Topical steroids (Betamethasone cream ).

Malformation of Female Reproductive system. (Ref:Emedicine)

Malformations asso. with renal (50%)and bony anomalies. Uterus Didelphys. Investigation: Pelvic USG. HSG- For uterine cavity and fallopian tubes.

i. ii.

iii.

MRI- Best.

Infertility (Ref:Therapeutic Guidelines)


Severe oligospermia :< 5 million motile sperm/ml. For men with very low numbers of functional sperm, intracytoplasmic sperm injection techniques.

Empirical or nonspecific therapies -Include hormones and hormone antagonists (Gonadotrophins, androgens, antioestrogens), nutritional supplements, antiinflammatory drugs, antibiotics and physical therapies (testicular cooling, varicocele ablation). Systematic reviews (using conception rate as a measure) have shown that none of these therapies consistently improves fertility.

Group B Streptococcal Infection.


(AMC Clinical Assessment pg432)

Routine Screening 34-36 weeks.


Antibiotics given to mother only when she presents in labor. No risk to mother with the organism, may affect baby.

Treatment with parenteral Penicillin in labor or if membrane rupture before labor. If allergic to Penicillin, Use Erythromycin.
Parenteral Penicillin to baby after birth is optional unless signs of infection or High risk cases (Prolonged ROM)

Ectopic Pregnancy
Sites and frequencies of ectopic pregnancy. Fallopian tube is the commonest site.
A. B. C. D. E. F. G.

Ampullary, 80%; Isthmic, 12%; Fimbrial, 5%; Cornual/Interstitial, 2%; Abdominal, 1.4%; Ovarian, 0.2%; Cervical, 0.2%.

Ref: Emedicine

Signs/Symptoms
Amenorrhea Vaginal Bleeding Abdominal pain.