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.

Continuous combined HRT. For those with more than 2 years of

amenorrhea or those who have only

light bleeding. Chance of break

thorough bleeding.

Unopposed estrogen Patients undergone hysterectomy.

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

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

For those with severe symptoms: Taper over 6 months.

Progynova – Oestradiol valerate.

Conjugated Oestrogens: Premarin.

Oral Ultra

low

dose

Low

dose

Med

dose

High

Dose

Oestra

diol

1mg

on alt

days

1 mg 2mg 4mg

Oestra

diol

valerat

e

1 mg

on alt

days

1 mg 2 mg

Conju

gated

Oestro

gens

0.3 mg

on

alterna

te

days

0.3 mg 0.625

mg

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 Management

Threatened

•Vag Bleeding, may or may not be asso

with pain.

•OS closed. No passage of POC.

Close

Monitoring

Inevitable

•Vaginal bleeding with cramps.

•Dilatation of Cx bt no POC passed.

Evacuation

Incomplete

•Vag bleeding

•Dilatation of Cx

•Passage of some POC. Severe pain.

Evacuation

Complete

H/0 vag bleeding, abdo pain, and

passage of POC.

Aftr POC passed,pain , vag bleeding

.

OS closed.

USG - empty uterus.

Expectant

Mgmt

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

• Miscarriage

• Prematurity

• Still birth

Developmental Defects:

• Small head size.

• Eye problems

• Cleft lip and palate.

• Limb defects.

• Heart Defects

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 15- 30%

Post Pill 10-20%

Hyper prolactinaemia 10-20 %

Primary Ovarian Failure 5-10 %

Asherman’s Syndrome 1-2 %

Hypothyrodism 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 Risk

25 1:1376

35 1:424

40 1:126

45 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:

i. Pelvic USG.

ii. HSG- For uterine cavity and fallopian tubes.

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, anti-inflammatory 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. Ampullary, 80%;

B. Isthmic, 12%;

C. Fimbrial, 5%;

D. Cornual/Interstitial, 2%;

E. Abdominal, 1.4%;

F. Ovarian, 0.2%;

G. Cervical, 0.2%.

Ref: Emedicine

Signs/Symptoms

Amenorrhea

Vaginal Bleeding

Abdominal pain.