OB Gyne at Glance

(GYNE
1)
Abortion

Incomplete Abortion:

Clinical features:
Vaginal Bleeding with passage of products of gestation
Pain lower abdomen
Vitals - disturbed according to the blood loss
Vaginal examination: Cervix is dilated with hanging of
fetal products and uterus size will be lesser than
amenorrhea

Diagnosis:
Ultrasound

Treatment:
Stabilize vitals and Suction evacuation / curettage
After 12 weeks Under GA and IV oxytocin drip products
are removed by ovum forceps / Curettage.

Complete Abortion:

Clinical features:
Vaginal Bleeding with passage of products of gestation
Pain may be less or absent
Vitals - disturbed according to the blood loss
Vaginal examination: Cervix is closed and uterus size is
lesser than amenorrhea
Diagnosis:
Ultrasound
Treatment:
No active intervention

OB/GYNE At A Glance | A Simple Contribution Done by: Othman M. Omair, Mohammed I. Alhefzi | 2011
Septic Abortion:

Any abortion associated with evidence of infection in the
uterus and its contents.

Clinical features:
Temperature 100.4 degree F for 24 hrs or more
Offensive or purulent vaginal discharge
Lower abdominal pain and tenderness
This is mostly due to incomplete and illegal abortions or
also following spontaneous abortion
Investigations:
Endo cervical swab for culture & sensitivity
High vaginal swab for culture & Sensitivity
CBC
DIC profile if required
Blood culture
Urine Culture
Ultrasound
Treatment:
IV Antibiotics for aerobic, anaerobic organisms IV
Ampicillin, Gentamycina and Metronidazole
Anti Gas Gangrene serum
Treatment of complications
Cervical Incompetence:

Causes:
Congenital
Iatrogenic Dilatation and Curettage, Amputation of the
cervix, cone biopsy

Clinical features:
History of recurrent mid trimester abortions where
leaking followed by painless expulsion of fetus

Diagnosis:
Ultrasound Cervical length less than 2.5 cm and cervical
dilatation more than 1.5 cm with funneling of cervix and
bulging of membranes
Periodic per speculum examination

Treatment:
Cervical Circlage with Merseline tape at 16 18 weeks
(Mc Donald operation)
Shiridkars operation

Surgery Evacuation of uterus and Laparotomy if

necessary depending on peritonitis features

Antepartum Haemorrhage

Bleeding from or within the genital tract after fetal viability
(20weeks) and before fetal expulsion.

Placenta Previa:

Clinical Findings:

Most common symptom is painless, causeless and
recurrent bleeding (inevitable bleeding)
Not catastrophic
DIC is uncommon, unless massive bleeding

Diagnosis:
DO NOT DIAGNOSE via vaginal exam!
Ultrasound is
Transvaginal or transabdominal

Delivery:
Stage 4 (complete previa) C/S.
Rest - Vaginal


Abruptio Placentae:

Pain and tenderness
Often I.U.F.D
Bleeding from abruption may be all intrauterine-vaginally
detected bleeding may be much less than with placenta
previa
DIC occurs as a consequence of hypofibrino-genemia in
chronic abruption, this process may be indolent
Hypotension on hypertension
Renal impairment

Management:
Check Abdomen previous C/S scar, fundal height and
uterine tenderness.
Resuscitate - FDP, whole blood.
Monitor BP and urine output.
Check FHR and detailed U/S examination
Vaginal examination and ARM (Vaginal delivery should be
tried)
Give oxytocin infusion or prostaglandin if necessary to
induce contractions
Avoid Caesarean Section unless living baby, or no
progress or continuous heavy bleeding
Watch out for PPH
Rho(D) immunoglobulin should be administered to Rh-
negative mothers within 72 hours of a bleeding episode.

PreTerm Labor (PTL)

Prediction:
The 2 most important tests up to date are:
1. Fetal fibronectin
2. Cervical length measurement by TVUS

Risk Factors:
Race.
Age: <17 yo >35 yo
Low socioeconomic status.
Poor/over weight.
Smoking
Previous hx of PTL
Multiple Gestation
Polyhydrominos.
Abdominal surgery.
Asymptomatic Bacteriuria
Systemic Infection
Medical condition complicate pregnancy

Management:
Admission
Bed rest
Hydration / sedation
Progesterone
Tocolytics
Antibiotics
Steroids

PROM:

Before onset of delivery, after 37wks.

Diagnosed by:
speculum vaginal examination of the cervix and vaginal cavity
1. Pooling of fluid in the vagina or leakage of fluid from the
cervix
2. Ferning of the dried fluid under microscopic examination
3. Alkalinity of the fluid as determined by Nitrazine paper
4. A new product, AmniSure

Management:
Wait for spontaneous delivery for 12-24hours.
Induction of labor after 24 hours.

PPROM:

Occurs 24-34wks of gestation.

Management:
Avoid digital examination
Admission
Bed rest
Antibiotics
Corticosteroids
* Delivery according to maternal and fetal states.


Abnormal Uterine Bleeding (AUB)

TREATMENT OF ORGANIC CAUSES

Medical
1) Treat hormonal causes. Or medical causes (e.g.
Hemophilia).

Surgical
1) MAINLY Surgical for organic causes.

Dysfunctional Uterine Bleeding (DUB)
Amenorrhea

Surgical Treatment:

1) Hysterectomy.
2) Ablation.
Diagnosis:
History:

Age, occupation, residence, habits and education.
Primary or secondary amenorrhea.
History of psychogenic disorders.
History of neurological disturbances.
History of endocrinological disorders.
Past history of operations, pelvic infections, T.B, long
drug course or irradiation.
Family history of similar condition, familial disease.


Amenorrhea (Cntd)

Physical Exam:
Psyche, height, weight and span measure. Nutritional
status should be also evaluated.
Secondary sexual characters.
Evidence of neurological disorders specially central
lesions.
Evidence of endocrinological disorders with special
reference to galactorrhea and hirsutism.
Evidence of general disease as heart, chest, renal or
hepatic disorder.
Abdominal masses (ovarian, adrenal, renal
hepatosplenomegaly or ascites).
External genital anomaly or hypoplasia.
Pelvic examination (PV or PR) for uterine and ovarian
abnormalities.

INVESTIGATIONS:
Special investigations Step I:
a. Search for specific disease if suspected.
b. Pregnancy test.
c. TSH assay.
d. Prolactin assay.
e. Progesterone challenge test:
1) If (+)ve withdrawal Normal outflow tract and well
estrogenized cases The cause is anovulation.
2) If (-)ve withdrawal Hypoestrogenic state or uterine
cause step II

Special investigations Step II:

a. Give estrogen + Progesterone:
1) If (+)ve withdrawal Normal outflow tract and uterus,
and there is ovarian failure Step III
2) If (-)ve withdrawal Uterine cause.
Special investigations Step III:
a. Measure FSH:
1) If high Ovarian cause.
2) If low Central cause.

Treatment:
Treat the cause.

Postmenopausal Hemorrhage
(GYNE 2)
HTN (Pre-eclampsia)

RISK FACTORS:
1) +ve family history in the firstdegree relatives. Increase
the risk of PET 4 8 fold.
2) Prime Parity
3) Medical disorders as:
a. History of PET.
b. Chronic hypertension.
c. Diabetes.
d. Obesity.
e. Antiphospholipid syndrome.
f. Molar pregnancy.
g. Multiple pregnancy.
h. Hydrops Fetalis.

Diagnosis:
(1) US
(2) Biochemical tests
a) Hb, and Hematocrit concentrations.
b) CBC with platelets count.
c) Serum uric acid .
d) Endothelial activation markers are increased.
e) Urinary excretion of Ca and microalbuminuria
f) Urine analysis.
g) 24h urine for protein, creatinine clearance,
Catecholamine metabolites and free cortisol.
h) Blood Urea and electrolytes as Na & K.
i) Lupus anticoagulant and anticardiolipin in APS.
j) Serum lipids.

(3) Fundoscopy. (4) ECG & ECHO. (5) X ray chest.

Signs & Symptoms:
Weight gain + HTN + Edema.

Criteria of Severe Preeclampsia:
(1) Blood Pressure:
o > 160 mmHg Systolic or
o > 110 mm Hg Diastolic
(2) Proteinuria: > 3g in 24 hours.
(3) Persistent and Severe cerebral or visual disturbances
o Headache
o Blurred vision
(4) Persistent and Severe epigastric pain or RUQ pain.
(5) Pulmonary edema or cyanosis.
(6) Oliguria (< 500 ml urine / 24 hours).
(7) Eclampsia (Grand Mal Seizures).
(8) HELLP syndrome.

Management:

A. PET Remote from Term

1) Placental insufficiency:
a) Monitoring of fetal movements.
b) Serial symphesis-Fundal Height .
c) Serial US.

2) Involvement of other organ systems:

a) Serial platelets count.
b) Hematocrit values
c) Clotting abnormalities
d) Raised uric acid
e) Severe proteinuria
f) HELLP syndrome
10
HTN (Cntd)

Indications of termination of pregnancy in PET:
1. Uncontrollable hypertension.
2. Deteriorating liver or renal function.
3. Progressive fall in platelets.
4. Neurological complications as cerebral Hge.
5. Deteriorating fetal condition as non-reactive CTG.

B. PET near term
a) Antihypertensive
b) Low dose aspirin
c) For prophylaxis:
a. Ca
b. Fish oil
c. Antioxidants
d. Vit. C
e. Vit. E

C. Severe cases:
1) IV antihypertensive
2) Anticonvulsant therapy
a. Magnesium Sulfate.
3) Fluid management.
Diabetes In Pregnancy

RISK FACTORS:
1) Diabetes in 1st degree relatives.
2) Maternal obesity. Wt.90kg.
3) Persistent glycosuria.
4) Previous hx. Of large baby.
5) Previous hx. Of unexplained still birth.
6) Previous birth of congenitally malformed baby.
7) Polyhydramnios/Macrosomia in current Pregnancy.

Diagnosis:
1) Random glucose Test.
Cut of value 6.4 mmol/l with in 2 hrs & 5.8mmol/l
after 2 hrs of meal ----- OGTT.
2) Fasting glucose Test.
Cut of value 4.8mmol/l -----OGTT.
3) Glucose challenge Test: At 28wks.
50g glucose given.
1hr later blood taken -- if >7.8mmol/l ---- OGTT.

Treatment:
Insulin + Diet.
Antenatal care.
DELIVERY:
a) Time of Delivery:
1) Well controlled DM --- 39-40 weeks
2) Uncontrolled DM ----- 38 weeks
b) Mode of Delivery:
1) Vaginal delivery is mode of choice
2) Low threshold for C- section
c) Management During Labour:
Insulin therapy: Give I/V insulin 1 unit/h
11
Benign Ovarian Tumors

Presentation:

Asymptomatic

Pain

Abdominal swelling

Pressure effects

Menstrual disturbances

Hormonal effects

Abnormal cervical smear

Follicular cyst
During treatment with clomiphene or gonadotropin
Lutein cyst
Amenorrhea or delayed onset of menstruation.
Hemorrhagic cyst
Haemoperitoneum.
Thecalutein cyst
high levels of hCG;
a) Ovulation induction with gonadotropins or clomiphene
b) Are usually bilateral
Surgical intervention if there is haemorrhage.

Granulosatheca cell tumor
precocious menarche
irregular and prolonged vaginal bleeding.
Postmenopausal bleeding

Sertoli-Leydig cell tumor
Hirsutism, deepening of the voice, clitoromegaly and
defeminizing change in body habitus to a muscular build.

Ovarian fibroma
Meigs' syndrome (ascites and hydrothorax in
association with an ovarian fibroma).

Investigations:
Bimanual examination
Pelvic ultrasonography
Tumor markers, such as Serum CA 125, may help to
distinguish between benign and malignant masses
Laparoscopy
Laparotomy

Treatment:
Surgery.
12
Fibroid

13
Fibroid (Cntd)
Conservative Treatment; if:

Less than 6-8cm.
Mild symptoms.
Not Sub-Mucosal.
Not Postmenopausal.

14
Urinary Tract Infection (UTI)

Pyelonephritis is a bacterial infection of the renal
parenchyma and the renal pelvicaliceal system.

Acute pyelonephritis is commonly associated with chills
and fever, flank pain, costovertebral tenderness, urinary
frequency, urgency and dysuria.

Cystitis is an inflammation of the urinary bladder.
Patients with cystitis usually have symptoms of lower
urinary tract irritation (dysuria, frequency, urgency,
suprapubic discomfort, hematuria).

Recurrent UTI is diagnosed when two UTIs occur within
6 months or 3 or more occur during a single year.

Investigations:

Urinalysis
Microscopic examination
Pyuria

Urine Culture and Microbiology

Radiologic Studies
Intravenous pyelography
Computed tomographic urography
Cystography and voiding urethrocystography

Endoscopic Studies
Urethroscopy
Cystoscopy
Renal Function Test
Urea nitrogen
Serum creatinine

Management:

1) Rest and hydration

2) Acidification of the urine

Ascorbic acid (500 mg twice daily)
Ammonium
3) Urinary analgesics
Phenazopyridine hydrochlorid (Pyridium), 100 mg
twice daily for 2 to 3 days
4) Antimicrobial therapy
Nitrofurantoin
Cephalosporins (e.g., Keflex, Duricef)
Antibiotics such as ampicillin, tetracycline, and
trimethoprimsulfamethoxazole (e.g., Septra, Bactrim)

15

This Document has been done by: Othman M. Omair & Mohammed I. Alhefzi
It does highlight on important topics at both Gyne I and Gyne II which are needed in Final OSCE Exam
.not completed by the time we made this Infertility, Isoimmunization lectures are not in this document as they were
Sorry for any inconvinence that this may cause you
However, most information were collected from lectures, powerpoint slides and PDFs
We hope you find this helpful

Please Dont forget to pray for us both!
Best of Luck,
Othman M. Omair
Mohammed I. Alhefzi
OB/GYN II | 2011
16

OB Gyne at Glance

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OB Gyne at Glance

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(GYNE

Surgery Evacuation of uterus and Laparotomy if

PreTerm Labor (PTL)

Dysfunctional Uterine Bleeding (DUB)

Special investigations Step II:

(3) Fundoscopy. (4) ECG & ECHO. (5) X ray chest.

A. PET Remote from Term

2) Involvement of other organ systems:

Benign Ovarian Tumors

Conservative Treatment; if:

Urinary Tract Infection (UTI)

2) Acidification of the urine

Please Dont forget to pray for us both!

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