IMLE Preparatory Course

Lecture 56
Obstetrics and Gynecology

Spontaneous Abortion
Endometriosis, Adenomyosis
Gynecologic Infections
Spontaneous Abortion
Spontaneous Abortion (SAB)
 Defined as loss of products of conception (POC) prior
to the 20th week of pregnancy.

 Approximately 60% of chemically evident pregnancies

and 15–20% of clinically diagnosed pregnancies
terminate in a SAB.

 More than 80% will occur in the first trimester.

 Risk factors
 Chromosomal abnormalities
 Maternal trauma, ↑ maternal age, infection, dietary
deficiencies.
 Inherited thrombophilias
 Immunologic issues: Antiphospholipid antibodies
 Anatomic issues: Uterine abnormalities, incompetent
cervix, cervical conization or loop electrosurgical excision
procedure (LEEP), cervical injury, DES exposure, anatomical
abnormalities of the cervix.
Risk factors
 Endocrinologic issues: Diabetes
mellitus (DM),
hypothyroidism, progesterone deficiency.

 Environmental factors: Tobacco (with > 14

cigarettes/day, the risk is two fold), alcohol,
caffeine (> 500 mg caffeine/day), toxins, drugs,
radiation.

 Fetal factors: Anatomic malformation.

Types of spontaneous abortion
 Complete
 Incomplete
 Threatened
 Inevitable
 Missed
 Septic
 Intrauterine fetal demise
 Recurrent
 Complete
 POC is expelled. Complete abortion and its product.
 Pain ceases, but spotting may
persist.
 Closed os.
 Ultrasound shows an empty
uterus.
 POC should be sent to
pathology to confirm fetal
tissue.
 Incomplete
Incomplete abortion and its product.
 Some POC is expelled.
 Bleeding/mild cramping.
 Visible tissue on exam.
 Open os.
 Ultrasound shows retained
fetal tissue.
 Managed by manual uterine
aspiration (MUA) or D&C.
 Threatened
 No POC is expelled.
 Uterine bleeding and
abdominal pain.
 Closed os + intact
membranes + fetal cardiac
motion on ultrasound.
 Managed by pelvic rest for 24–
48 hours and follow-up
ultrasound to assess the viability
of conceptus.
 Inevitable
 No POC is expelled.
 Uterine bleeding and
cramps.
 Open os +/− ROM.
 Managed by MUA, D&C,
misoprostol, or expectant
management.
 Missed
 No POC is expelled.
 retention of dead POC in utero f
or more than 8 weeks.
 No fetal cardiac motion.
 No uterine bleeding.
 Brownish vaginal discharge.
 Closed os.
 No fetal cardiac activity, retained
fetal tissue on ultrasound.
 Managed by MUA, D&C, or
misoprostol.
Septic

 Endometritis leading to septicemia.

 Maternal mortality is 10–15%.
 Hypotension, hypothermia, ↑ WBC count.
 Managed by MUA, D&C, and IV antibiotics
 Intrauterine fetal demise
 Absence of fetal cardiac activity.

 Uterus small for GA, no fetal heart tones or

movement on ultrasound.

 Managed by induction of labor and evacuation of

the uterus (D&E) to prevent DIC at GA > 16
weeks.
 Recurrent
 If early in pregnancy, often due to chromosomal
abnormalities.

 If later in pregnancy, often due to hypercoagulable

states (e.g., SLE, factor V Leiden, protein S deficiency).

 Incompetent cervix should be suspected with a

history of painless dilation of the cervix and
delivery of a normal fetus between 18 and 32
weeks.
 Recurrent Abortion Management
 Karyotyping of both parents.

 Evaluate for uterine abnormalities.

 Managed by surgical cerclage procedures to suture

the cervix closed until labor or ROM occurs with
subsequent removal prior to delivery.
 Elective termination of pregnancy
 In the western world it is estimated that 50% of
all pregnancies are terminated electively.

 First Trimester (90%)

 Second Trimester (10%)
 First trimester elective abortion
Medical management:
 Oral mifepristone (low dose) + oral/vaginal
misoprostol
 IM/oral methotrexate + oral/vaginal misoprostol
 Vaginal or sublingual or buccal misoprostol (high dose),
repeated up to three times

Surgical management:
 Manual aspiration
 D&C with vacuum aspiration
 Second trimester elective abortion

Obstetric management:
 Induction of labor (typically with
prostaglandins, amniotomy, and oxytocin)

Surgical management:
 D&E

 Can be done at 13–24 weeks’ GA (depending on state laws)

 Diagnosis of SAB
 ↓ levels of hCG.

 US Can identify the gestational sac 5–6 weeks

from the LMP, a fetal pole at six weeks, and fetal
cardiac activity at 6–7 weeks.
 Diagnosis of SAB

 With accurate dating, a small, irregular

intrauterine sac without a fetal pole on
transvaginal ultrasound is diagnostic of an
abnormal pregnancy.

 Maternal Rh type should be determined and

RhoGAM given if the type is Rh negative.
Endometriosis, Adenomyosis
 Endometriosis
 Functional endometrial glands and stroma
outside the uterus.
 Presents with cyclical pelvic and/or rectal pain
and dyspareunia (painful intercourse).
 Requires direct visualization by laparoscopy or
laparotomy.
 Classic lesions have a blue-black (“raspberry”) or
dark brown (“powder-burned”) appearance.
 Ovaries may have endometriomas (the
characteristic “chocolate cysts”).
 Endometriosis Treatment
 Pharmacologic: Inhibit ovulation. Combination OCPs are
first line, other options include GnRH analogs (leuprolide)
and danazol.

 Conservative surgical treatment: Excision, cauterization,

or ablation of the lesions and lysis of adhesions.
 Twenty percent of patients can become pregnant subsequent to
treatment.

 Definitive surgical treatment: TAH/BSO +/– lysis of

adhesions.
Which of the following medications is used first line therapy
in the treatment of pelvic pain endometriosis?

A. unopposed estrogen
B. Dexamethasone
C. Danazol
D. Gonadotropins
E. Parlodel
Which of the following medications is used first line therapy
in the treatment of pelvic pain endometriosis?

A. unopposed estrogen
B. Dexamethasone
C. Danazol
D. Gonadotropins
E. Parlodel
Danazol used in the treatment of endometriosis causes which
of the following changes within the endometrium and
endometriosis tissue?

A. Dysplasia
B. Hypoestrogenism
C. Hyperplasia
D. neoplasia
E. inflammation
Danazol used in the treatment of endometriosis causes which
of the following changes within the endometrium and
endometriosis tissue?

A. Dysplasia
B. Hypoestrogenism
C. Hyperplasia
D. neoplasia
E. inflammation
 Endometriosis Complications
 Infertility (the most common cause among menstruating
women > 30 years of age).

 Implants over the bowel or ureters may cause

obstruction and silent impairment of renal function.

 Endometriomas can cause ovarian torsion, or they

can rupture and spill their irritating contents into
the peritoneal cavity, resulting in a chemical
peritonitis.
Which of the following patients is unlikely to have endometriosis:

A. A 19-years old with cyclic pain and bicornuate uterus with a

non communication uterin hor
B. A 28 year- old patient with cyclic pelvic pain and who has a
mother and sister with indometriosis
C. A 25 year old female with a history of dysparunia, painful
nodular masses in the rectovaginal septum an a left adnexal mass
D. A 28 year old with menorrhagia a 4 cm submucosal myoma
E. A 32 year old with infertility and dysmenorrhea an a fixed and
retroverted uterus on physical examination
Which of the following patients is unlikely to have endometriosis:

A. A 19-years old with cyclic pain and bicornuate uterus with a

non communication uterin horn
B. A 28 year- old patient with cyclic pelvic pain and who has a
mother and sister with indometriosis
C. A 25 year old female with a history of dysparunia, painful
nodular masses in the rectovaginal septum and a left adnexal mass
D. A 28 year old with menorrhagia and a 4 cm
submucosal myoma
E. A 32 year old with infertility and dysmenorrhea and a fixed and
retroverted uterus on physical examination
 Adenomyosis
 Endometrial tissue in the
myometrium of the uterus.
 Presents with the classic triad of
noncyclical pain,
menorrhagia, and an
enlarged uterus.
 Ultrasound is useful but cannot
distinguish between leiomyoma and
adenomyosis.
 MRI can aid in diagnosis but is
costly.
 Adenomyosis Treatment
 Pharmacologic: Largely symptomatic relief. NSAIDs
(first line) plus OCPs or progestins.

 Conservative surgical treatment:

Endometrial ablation or resection using
hysteroscopy.

 Complete eradication of deep adenomyosis is

difficult and results in high treatment failure.
 Adenomyosis Treatment

 Definitive surgical treatment: Hysterectomy is

the only definitive treatment.

 Can rarely complicate and progress to

endometrial carcinoma.
Gynecologic Infections
Cyst and abscess of Bartholin’s duct
Vaginitis
Cervicitis
Pelvic Inflammatory Disease
 Cyst and abscess of Bartholin’s duct

 Obstruction of the gland leads to pain,

swelling, and abscess formation.
 Presents with periodic painful swelling on either
side of the introitus and dyspareunia.
 A fluctuant swelling 1–4 cm in diameter is seen in
the inferior portion of either labium minus.
 Tenderness is evidence of active infection.
Cyst and abscess of Bartholin’s duct
 Asymptomatic cysts do not require therapy. Frequent
warm soaks may be helpful.

 If an abscess develops, treat with aspiration or

incision and drainage.

 Culture for Chlamydia and other pathogens.

 Antibiotics are unnecessary unless cellulitis is present.
Vaginitis
 A spectrum of conditions that cause
vulvovaginal symptoms such as itching,
burning, irritation, and abnormal
discharge.

 The most common causes are bacterial

vaginosis, vulvovaginal candidiasis,
and trichomoniasis
 Bacterial Vaginosis
 15–50% (most common).
 Reflects a shift in vaginal flora.
 Risks :pregnancy, > 1 sexual partner,
female sexual partner, frequent douching.
 Odor, ↑ discharge.
 Mild vulvar irritation.
 Bacterial Vaginosis
 Homogenous, grayish-white discharge,
fishy/stale odor.
 “Clue cells”
 Positive whiff test (fishy smell).
 Managed by metronidazole or clindamycin.
 Can complicate to chorioamnionitis
/endometritis, preterm delivery, miscarriage,
PID.
 Criteria for the clinical diagnosis of
bacterial vaginosis

Three of four are required:

 Abnormal whitish-gray discharge

 Vaginal pH > 4.5
 Positive amine (“whiff ”) test
 Clue cells comprise > 20% of epithelial
cells on wet mount
Clue cells
Epithelial cells coated with bacteria.
 Trichomoniasis
 5–50%.
 Protozoal flagellates (an STD).
 An STD.
 Risks are unprotected sex with multiple
partners.
 ↑ discharge, odor, pruritus, dysuria.
 Motile trichomonads (flagellated organisms that are
slightly larger than WBCs).
 Trichomoniasis

 “Strawberry petechiae” in the upper

vagina/cervix (rare).
 Profuse, malodorous, yellow-green,
frothy.
 Managed by a single-dose PO metronidazole
or tinidazole.
 Treat partners, test for other STDs.
 Yeast infection
 15–30%.
 Usually Candida albicans.
 Risks are DM, broad-spectrum antibiotic
use, pregnancy, corticosteroids, HIV, OCP
use, IUD use, young age at first
intercourse, ↑ frequency of intercourse.
 Presents as pruritus, dysuria, burning, ↑
discharge.
 Yeast infection
 Erythematous, excoriated
vulva/vagina.
 Thick, white, curdy texture
without odor.
 Hyphae.
 Managed by topical azole or PO
fluconazole.
 Oral azoles should be avoided
in pregnancy.
 Cervicitis
 Inflammation of the uterine cervix.

 Because the female genital tract is contiguous

from the vulva to the fallopian tubes, there is
some overlap between vulvovaginitis and
cervicitis.
 Cervicitis Etiologies
 Infectious (most common): Chlamydia, gonococcus,
Trichomonas, HSV, HPV.

 Noninfectious: Trauma, radiation exposure, malignancy.

 Presents as yellow-green mucopurulent

discharge, positive cervical motion tenderness,
absence of other signs of PID.
Pelvic Inflammatory Disease (PID)

 A polymicrobial infection of the upper

genital tract that is associated with
Neisseria gonorrhoeae (one-third of
cases), Chlamydia trachomatis (one-
third of cases), and endogenous
aerobes/anaerobes.

 The lifetime risk is 1–3%.

Pelvic inflammatory disease (PID) occurs in women
because of which of the following characteristics of the
fallopian tube?

(A) It is a conduit from the peritoneal space to the

uterine cavity.
(B) It is found in the utero-ovarian ligament.
(C) It has five separate parts.
(D) It is attached to the ipsilateral ovary by the
mesosalpinx.
(E) It is entirely extraperitoneal.
Pelvic inflammatory disease (PID) occurs in women
because of which of the following characteristics of the
fallopian tube?

(A) It is a conduit from the peritoneal space to the

uterine cavity.
(B) It is found in the utero-ovarian ligament.
(C) It has five separate parts.
(D) It is attached to the ipsilateral ovary by the
mesosalpinx.
(E) It is entirely extraperitoneal.
PID risk factors

 Non-Caucasian ethnicity
 Douching
 Smoking
 Multiple sex partners
 Prior STDs and/or PID
 PID presentation
 Lower abdominal pain
 Fever and chills
 Menstrual disturbances
 Purulent cervical
discharge.

 Cervical motion
The chandelier sign is defined
tenderness (chandelier
as severe cervical motion
sign) and adnexal tenderness
tenderness that makes
are also seen. the patient “jump for the
chandelier” on exam
A 27year old woman present to the emergency department
complaining of vaginal discharge and abdominal pine have fever is
38.1c . and on abdominal examination she has tenderness is the
right upper guardant .and lower abdominal with minimal
peritoneal sings .she was found to have a mucous yellow discharge
on bimanual examination she has cervical motion tenderness and
bilateral adnexal tenderness her white blood count is 14.3 and
pelvic US shows a normal uterus and normal ovaries bilaterally
.the most likely diagnosis for this patient is which of the following?

a. cervicitis
b. Endomyometritis
c. PID
d. TOA
e. UTI
A 27year old woman present to the emergency department
complaining of vaginal discharge and abdominal pain have fever
is 38.1c . and on abdominal examination she has tenderness is the
right upper guardant .and lower abdominal with minimal
peritoneal sings .she was found to have a mucous yellow
discharge on bimanual examination she has
her whit blood
count is 14.3 and pelvic US shows a
.the most likely diagnosis for this patient is
which of the following?

a. cervicitis
b. Endomyometritis
c. PID
d. TOA (Tubo-ovarian abscess )
e. UTI
 PID Diagnosis
 Diagnosed by the presence of acute lower abdominal
or pelvic pain plus one of the following:
 Uterine tenderness
 Adnexal tenderness
 Cervical motion tenderness
 A WBC count > 10,000 has poor positive and negative
predictive value for PID.
 Order a β-hCG and ultrasound to rule out pregnancy
and to evaluate for the possibility of tuboovarian abscess.
PID can result in multiple problems
PID Diagnosis
In Ultrasound we look for:

 Thickening or dilation of the fallopian

tubes
 Fluid in the cul-de-sac
 Multicystic ovary
 Tubo-ovarian abscess
Ultrasound shows a dilated fallopian tube. The findings
support the diagnosis of hydrosalpinx resulting from
a prior infection.
 PID Treatment
Antibiotic treatment should not be delayed while awaiting
culture results.
All sexual partners should be examined and treated
appropriately.
 Outpatient regimens:
 Regimen A: Ofloxacin or levofloxacin × 14 days +/–
metronidazole × 14 days.
 Regimen B: Ceftriaxone IM × 1 dose or cefoxitin plus probenecid plus
doxycycline × 14 days +/– metronidazole × 14 days.

 Inpatient antibiotic regimens:

 Cefoxitin or cefotetan plus doxycycline × 14 days.
 Clindamycin plus gentamicin × 14 days.
 PID Treatment
Surgery:
 Drainage of a tubo-ovarian/pelvic abscess is
appropriate if the mass persists after antibiotic
treatment, the abscess is > 4–6 cm, or the mass is in the
cul-de-sac in the midline and drainable through the
vagina.

 If the abscess is dissecting the rectovaginal septum and is

fixed to the vaginal membrane, colpotomy drainage is
appropriate.
 PID Treatment

 If the patient’s condition deteriorates, perform

exploratory laparotomy.

 Surgery may range from TAH/BSO with lysis

of adhesions in severe cases to conservative
surgery for women who desire to maintain
fertility.
 PID complications
Some 25% of women with acute disease develop

 Repeated episodes of infection

 Chronic pelvic pain
 Dyspareunia
 Ectopic pregnancy
 Infertility.
 PID complications

 RUQ pain (Fitz-Hugh–Curtis syndrome) may

indicate an associated perihepatitis (abnormal liver
function, shoulder pain).

 The risk of infertility ↑ with repeated episodes

of salpingitis and is estimated to approach 10%
after the first episode, 25% after the second
episode, and 50% after a third episode
Fitz-Hugh–Curtis syndrome

Upper right-quadrant abdominal pain and

tenderness aggravated by breathing, coughing or
movement, and referred to the right shoulder following an
episode of PID.