JWH, JM, AJS, VA

O & G PACES
case not es
2016

Joe Heylen
James M orris
Alex Scarborough
Vaki Ant oniou
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O&G previous stations

Obstetrics
Pre Eclampsia

M iscarriage (wit h speculum)

VBAC

Ect opic Pregnancy

Recurrent M iscarriage

SGA (smoking, drugs)

Gest at ional Diabetes (explain GTT result s)

HIV in pregnancy

Down’s Screening

PE/ DVT in pregnancy

Chicken Pox Exposure

Normal Preg, Vaginal vs C-sect ion

Threat ened miscarriage, domest ic abuse

Subst ance misuse in pregnancy

Breech Counselling

PPH

Hyperemesis gravidarum

Obst et ric Choleost asis

Gynae
Cervical Smear

Post menopausal bleeding

TOP (15 year old)

Fibroids

St erilisat ion in Young Woman

Secondary Amenorrhoea (st ress)

Cont racept ion (hypert ensive obese)

Emergency Cont racept ion

Girl wit h LD asking for cont racept ion

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Lady want s HIV t est – counselling

STI (wit h mult iple sclerosis)

PID

Urogynae – st ress incont inence + prolapse

Urogynae – Urge incont inence

Post -coit al bleeding (25 yo)

M enorrhagia

M enopause + HRT

Breast feeding cont racept ion

PCOS

Other Possible Stations

∑ Large for dat es – polyhydramnios
∑ Lat er pregnancy problems
o APH
o Pre t erm labour
o Reduced foet al M ovement s
o PROM / PPROM
o Post t erm pregnancy
o M at ernal GBS infect ion
∑ Epilepsy in pregnancy
∑ M olar pregnancy
∑ Dysmenorrhea
∑ IM B
∑ Prolapse
∑ Ovarian cyst torsion/ rupt ure
∑ UTI
∑ Fert ilit y + subfert ilit y
∑ IVF

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Antepartum Haemorrhage

Review a 29 year old woman, Mary French, in antenatal triage who has
presented with PV bleeding

Presenting complaint:
 Noticed a small gush of blood
HPC:
 This evening noticed a small gush of blood and discovered a bright red
stain in her underclothes
 No clots in the blood, and difficult to quantify as she wasn t wearing a pad
 No actual abdominal pain, but some intermittent crampy abdominal
discomfort around the time of the bleeding
 No discharge
 Baby was moving normally during the day
 No urinary or rectal symptoms
O&G:
 39+5 gestation
 Nulliparous, one previous termination at 7 weeks, 10 years ago
 Periods previously regular with COCP for last 7 years
 Smears up to date, no STIs
PMH:
 No longstanding medical issues
 No regular medication
 No allergies
FH:
 No conditions
SH:
 Well supported at home with loving husband
 Non drinker, non-smoker

Examination:
 General examination
 Bedside obs
 Abdominal examination
 Speculum
Results:
 Warm and well perfused
 BP 158/87 HR 84/min
 Symphysiofundal height 36cm, cephalic with 3/5 palpable abdominally
 Moderate uterine tenderness noted.
 Uterus is soft but during palpable, two moderate uterine tightenings are
noted
 Speculum: cervical os closed but small amount of vaginal blood noted

Investigations:
 Urinalysis
 CTG
 USS for fetal size, presentation, placental position

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Define Risk: PV bleeding

Contractions: present and regular
Baseline RAte: 130
Variability: present
Accelerations: present
Decelerations: not present
Overall impression: reassuring

Top differentials:
 Abruption
 Placenta praevia
 Vasa praevia

In this case:
 Bleeding in presence of uterine tenderness and irritability is highly
suggestive of placental abruption.

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 Show can be ruled out as blood is fresh rather than mucus like and dark
 Placenta praevia would have been detected at anomaly scan, and bleeding
placenta praevia is typically painless
 No features of infection
 Vasa praevia bleeding normally occurs with rupture of membranes
 BP is high and protein in urine: placental abruption associated with pre-
eclampsia

Why must caution be taken with any placental bleed, especially in abruption:
1. Smaller bleed may lead to further larger bleed
2. May be concealed bleed
3. Women may not show signs of hypovolaemic shock until large amount of
blood is lost

Management:
 Any woman with APH should be admitted for observation
 Airway: clear
 Breathing: oxygen not necessary
 Circulation:
o IV access
o Group and save
o FBC
o Clotting
 Urea and electrolytes, plus LFT to look for signs of pre-eclampsia
 BP checked at regular intervals and antihypertensives if necessary
 Ultimately, induction of labour is indicated as woman is >37 weeks

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Breech presentation counselling

History

You are asked to see a woman in the antenatal clinic. She is 37 years old and
pregnant with her third child. Her previous children were both born by vaginal
delivery after induction of labour for post dates.

First-trimester ultrasound confirmed her menstrual dates and she is now 37

weeks. At her last appointment at 36 weeks’ gestation, the midwife suspected
that the baby was in a breech presentation. An appointment has been made for
an ultrasound assessment and to discuss the situation.

Examination

Blood pressure is 140/85 mmHg and abdominal examination suggests a breech

presentation with the sacrum not engaged.

Questions

 What are the options available to the woman? 


 What management would you recommend in this case?

About three in 100 (3%) babies are breech presentations, meaning their bottoms
are closest to the cervix. The most common fetal mal-presentation is breech.
There are three types of breech:
 Extended (hips flexed, legs extended)
 Flexed (hips flexed, legs flexed)
 Footling

Predisposing factors for breech:

1. Maternal
 Fibroids
 Congenital uterine abnormalities e.g. bicornuate and septum uterus
 Previous uterine surgery
2. Fetal

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 Multiple pregnancy
 Placenta praevia
 Fetal abnormality: neuromuscular or hydrocephalus
 Oligo or polyhydramnios

Antenatal management of breech

If a breech is suspected at or after 36 weeks, this needs to be confirmed by

ultrasound scan. This scan should look at fetal biometry, amniotic fluid volume,
placental site and the position of the fetal legs.

3 management options
1. C-section
2. Vaginal breech delivery
3. External cephalic version

Always talk to your obstetrician as local guidelines vary.

1. C-section
 Planned caesarean section carries a reduced perinatal mortality and
early neonatal morbidity for babies with a breech presentation at
term compared with a planned vaginal birth.
 There is no evidence that the long-term health of babies with a breech
presentation delivered at term is influenced by how the baby is born.
 She should be advised that planned caesarean section for breech
presentation carries a small increase in serious immediate
complications for her compared with planned vaginal birth. It does
not carry any additional risk to her long-term health outside
pregnancy.
 The long-term effect of planned caesarean section on future
pregnancy outcomes is uncertain.
 However, a small proportion of women due to choice or precipitous
labour with breech presentations will deliver vaginally. It is therefore
important that clinicians and hospitals are prepared for vaginal
breech

2. Vaginal breech delivery

Pre requisites for vaginal delivery

1. Feto-maternal
 Presentation should be extended or flexed.
 No evidence of feto-pelvic disproportion.
 Hyperextension of the fetal head and fetal abnormalities would
preclude safe delivery.

2. Management of labour
 Labour should be monitored carefully

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 Epidural analgesia ensures pushing does not start before full

dilatation.
 Fetal blood sampling from the buttocks provides accurate
assessment of acid base status when fetal heart rate is suspect.
 Operator experienced in delivery of breech babies should be
available.

3. External cephalic version (ECV) Actual techniques in ten teachers

99-101

What is an external cephalic version (ECV)?

This is a procedure to turn your baby around so that it is in the correct position
for delivery. It is usually done around week 37 of pregnancy. During an ECV an
obstetrician will gently move your baby by pressing their hands on your
abdomen.

The aim
We do an ECV to turn your baby so it is in the correct position for delivery.

The method

 She will be monitored by cardiotocogram CTG to check the baby’s heart

rate before the procedure is commenced. An ultrasound scan will be
performed to check baby is still breech and to identify where the fetal
back is positioned.
 Tocolysis (uterine relaxation) will be offered as it has been proven to
improve success rates (usually by IV or subcutaneous beta-
sympathomimetics). nifedipine
 She will be positioned in a slightly head down position (to try to elevate
the breech out of the pelvis) with a wedge under her right hip (to prevent
aorto-caval compression from the pregnant uterus when lying flat).
 Pressure will be used on the maternal abdomen to try to elevate the
breech out of the pelvis and turn the baby through a forward or backward
roll to a cephalic presentation. Ultrasound can be used to guide the
procedure.
 Following the procedure, whether successful or not, she will be put back
on the CTG to make sure the baby is healthy.

The benefits
A successful ECV can allow you to avoid caesarean section and have a normal
vaginal delivery. The success rate is aproximately 40% with a first baby and
approximately 60% in parous women. If it is successful, less than 5% of babies
will turn back to breech.

Are there any alternatives?

If your baby stays in a breech position we usually advise delivery by Caesarean
section. Some obstetricians may be willing to deliver a breech presentation
vaginally.

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Risks
 Placental abruption
 PROM
 Transplacental haemorrhage

Contraindications
 Previous caesarean or undergoing a caesarean
 Fetal abnormality e.g. hydropcephalus
 Oligo or polyhydramnios
 Placenta praevia
 Previous APH
 Multiple gestation
 Pre-eclampsia

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Cervical smear/ colposcopy/ cervical cancer

Case 1 – cervical smear

 Mrs Thomson is a 29 year old housewife who has come for a routine smear
4 months after the birth of her son (she was due during pregnancy but
delayed it) – explain what it involves, why she is having and what the
results will show

What is the purpose of a cervical smear and why is it important?

 A smear is not a cancer test, it is designed to detect early abnormalities of
the cells in the cervix which left untreated for years could develop into
cervical cancer
 Early detection and treatment can prevent cancer in 3 out 4 women
 2000 new cases of cervical cancer every year – mostly in women who have
not engaged with the screening program
 Estimated that the program prevents 3900 cases every year

When are women called for routine smear?

 The NHS cervical screening program calls women for screening as follows:
o First invitation age 25 in England (20 everywhere else in UK)
o 25-49 years: 3 yearly
o 50-64: 5 yearly
o 65: screening ceases unless:
 Not had smear since 50
 Not had three previous negative smears

What does the test involve?

 Done in GP practice – often by the practice nurse
 Remove clothing from waist down – lie on examination couch – knees up to
bottom and let legs fall open
 Important to relax – will make it easier
 Place lubricated speculum in – open it up to visualise the cervix (looks like a
doughnut – central hole, the os, opens into the uterus above)
 A sample of cells is then taken from the cervix:
o Taken from the squamocolumnar junction/ transformation zone
(where the columnar cells of the uterus meet the squamous cells of
the cervix) – the cells in this area are constantly dividing and so are
more likely to become cancerous
o Thin plastic stick with a brush on the end is used to remove cells – the
bristles are longer in the middle allows the brush to fit in the os and
then as the brush is rotated the shorter bristles around the outside
sweep cells off the transformation zone
o For older women an endocervical brush may be used as the TZ may
have moved up into the cervix over time
 The brush is then placed into a pot of liquid – this is known as liquid based
cytology – the liquid preserves the cells and in the lab the cells are separated

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from the liquid and other materials such as blood and mucus and examined
under the microscope

What are they looking for in the cells?

 They are looking for the presence of abnormal cells – this is known as
dyskariosis
 The results are reported as:
o Normal
o Inadequate (happens in 1 in 50 due to few cells or wrong type e.g.
endometrial)
o Abnormal
 1 in 20 smears come back as abnormal indicating some degree of dyskariosis
BUT in nearly all cases this does not mean cancer.
 Dyskariosis is determined by:
o Irregularity in shape and outline of the nucleus
o Increased nuclear to cytoplasmic ratio.
 Degrees of dyskariosis:
o Borderline: 3-4/100 – changes almost always revert with no
treatment
o Mild (20% chance of CIN 2/3): 2/100 changes almost always revert
with no treatment
o Moderate/ severe (65-95% chance of CIN 2/3): 6-7/1000 very
unlikely to be cancer but require treatment at colposcopy
 Invasive/ glandular neoplasia
o Less than 1 in 1000
o Invasive neoplasia suggests cervical cancer but cannot be proven
until biopsy
o Glandular neoplasia can suggest endometrial cancer – follow up with
hysteroscopy
 If abnormal (depends on area):
o Follow up in 3-12 months with a repeat smear
o Colposcopy for further investigation/ treatment (moderate/ severe)
 Will take about 6-8 weeks to get results – informed by GP

What causes cervical cancer?

 Caused by the oncogenic HPV virus – it is NOT A FAMILIAL CANCER
 Infection with HPV is very common – 70-80% lifetime risk (mostly acquired
around the time women start having intercourse)
 High risk types are 16 & 18
 NHS vaccination program for girls are 12 – 13 against strains 16 and 18

Other important factors:

 Screening test is 80% effective – out of every 10 cases of women who would
have developed cancer of the cervix – 8 cases can be prevented
 Test is recommended in those who have never had sex although they are at
very low risk
 Test is recommended for lesbians

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 If patient has had a total hysterectomy they do not require a screening test
 It is possible to do a cervical smear if menstruating. However it is
recommended to be done mid cycle as blood and mucus could result in an
insufficient number of cells being acquired
 Tests performed during pregnancy are more likely to be inadequate and it is
recommended that the patient waits until 12 weeks postnatally
 Those with HIV and those who have had a kidney transplant are at greater
risk of CIN and should be followed up every year
 Immunosuppressive drugs, steroids, chemotherapy and tamoxifen have not
been shown to increase risk

Future of screening:
 Sentinel implementation project – being run in 6 centres in the UK
 Only 1 in 5 women with mild dyskariosis need treatment
 If a woman has mild dyskariosis and does not have a high risk strain of HPV
she is highly unlikely to need treatment and can return to normal screening
and hence the project is looking at routinely testing samples for HPV

Case 2
 Mrs Tho so ’s s ear shows oderate dyskariosis a d she is referred for
colposcopy – inform her what this will involve

What is a colposcopy?
 It involves a doctor or specialist nurse examining the cervix using a specialist
microscope, called a colposcope, looking for the presence of abnormal cells,
taking biopsy samples if necessary and carrying out treatments

Why am I going for colposcopy?

 Screening test showed abnormal cells (1 in 20 samples) – in the vast majority
of cases this does not mean cancer. However, it often means there is CIN
present – this short for cervical intraepithelial neoplasia. This a pre-
cancerous condition which can be identified on colposcopy and highly
effectively treated
 Other reasons include:
o Repeat inadequate smears
o Infection
o Inflammation
o Polyp

Before colposcopy
 Period – it is hard to conduct colposcopy whilst a woman is on their period
because the blood can obscure the field of view – it is can also be unpleasant
for the woman. Ring on the morning if you are on your period and it can be
rescheduled for the following week
 Avoid sex and do not wear a tampon for the preceding 24 hours
 Do not use vaginal creams and pessaries for the preceding 24 hours

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 May wish to bring someone with you to take you home especially if you have
been told you may be having treatment

During colposcopy

The whole procedure normally takes about 15-20 minutes. It may be longer if you
have treatment at the same time (see below). It is best to allow an hour for the
whole visit:
1. The doctor or nurse will usually start by asking you some questions. These
may include information about your periods, the date of your last period,
what contraception you use and your general health.
2. You will then be asked to remove your clothing from the waist down. (You
can usually keep a loose skirt on.)
3. You will be asked to lie in a reclining chair, or on a couch, in the same
position as during a cervical screening test. This is with your knees bent and
your legs apart. In some clinics your legs may be placed apart in padded
supports called stirrups.
4. An instrument called a speculum (the same instrument that is used during a
cervical screening test) will be inserted into your vagina. It is gently opened
to bring the cervix, at the top of the vagina, into view.
5. The doctor or nurse will then look through the colposcope to get a good view
of your cervix. The colposcope itself does not go inside your vagina. It is
essentially like a big pair of binoculars on a stand that can be moved around.
There is also a light to help see inside your vagina. Sometimes, the
colposcope can be attached to video equipment so that the examination can
be viewed more clearly on a TV screen. This means that you have the
opportunity to watch too (but only if you would like to!).
6. A long swab (like a fat cotton bud) is used to apply liquids to the cervix. These
liquid stain any abnormal cells that may be present. Two different liquids are
normally used - acetic acid (like vinegar) and iodine.
7. A biopsy (a small sample of tissue) from your cervix may also be taken. This
will be sent to the laboratory for further examination. The biopsy is only
about the size of a pinhead, but taking it can be slightly uncomfortable. If this
is anticipated, local anaesthetic is usually used to numb the cervix first.
8. Sometimes it is suggested that you have treatment at your first colposcopy
visit (see below). However, often, you may be asked to return for treatment
once the biopsy results are back.
9. It is worth bringing a sanitary towel or panty liner with you, to use after your
colposcopy. It is unlikely you would have much bleeding, but you might have
some discharge or staining from the iodine used in the examination. There is
more likely to be discharge or bleeding if you have had a biopsy or treatment.
You should not use a tampon, but don't worry if you forget sanitary
protection - the clinic will give you a pad (but it might be thicker and more
bulky than the usual products you prefer).

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After your colposcopy

 Return to work or carry on with your normal day

 Likely to have a small amount of bleeding, especially if you have had a biopsy
This can last for three to five days and you should wear a sanitary pad. Do not
use tampons. You should not have sex or use vaginal creams or pessaries
until the bleeding has stopped. Generally you should wait for five days.
 You may notice a dark fluid-like material on the pad. It is sometimes green or
looks like coffee granules. This is normal and is the liquid that is painted on to
your cervix during the examination.

What are the risks or complications of colposcopy?

 Procedure may be uncomfortable

 Rare complications: heavy bleeding and infection.
 If you experience any heavy bleeding, smelly vaginal discharge or severe
lower abdominal pain, you should see a doctor as soon as possible.

What the operator is looking for on colposcopy:

 Initial examination to exclude any obvious signs of cancer

 Weak acetic acid (3-5%) is applied – abnormal areas (CIN) turn white and
capillary blood vessel patterns are also seen in CIN. Bizarre/ abnormal vessels
indicate invasive disease
 Lugol’s iodine (aqueous iodine) can be applied and stains normal squamous
epithelium brown (as it contains glycogen) but is not taken up by CIN

Biopsy results:

 Visual colposcopy identifies areas of abnormality. However, histological

diagnosis on biopsy is the gold standard for diagnosis CIN
 CIN relates to the thickness of the epithelium, which has become dysplastic.
 There are 3 levels of CIN depending on how many thirds of the epithelium is
dysplastic
 In CIN1 – 6 out of 10 return to normal with no treatment, 1 in 10 develop into
CIN 3 and only 1 in 100 turn in to cancer – so it is often not treated but
followed up with repeat coloposcopy in 6 to 12 months
 CIN 2/3 – likely to need treatment

Treatment:

 Treatment aims to remove the abnormal cells

 Can lead to discomfort and pain similar to a period pain
 Treatment depends on type of lesion and operator preference

 Loop diathermy: a thin wire loop cuts through and removes the abnormal
area of cells. This is also known as a large loop excision of the

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transformation zone (LLETZ). It is the most common form of treatment used

in the UK.
 Cryotherapy: freezing the affected area of the cervix, which destroys the
abnormal cells.
 Laser treatment: this destroys or cuts away abnormal cells.
 Cold coagulation: a heat source is used to burn away and remove the
abnormal cells.

 A local anaesthetic is usually given before any treatment, to numb the cervix.
The treatment is normally very straightforward and quick. There is a small
risk of bleeding at the time of treatment.

Occasionally, the doctor or nurse may suggest that you have a cone biopsy
or, very rarely, a hysterectomy (removal of your uterus and cervix) as a
treatment for CIN. If this is the case, you will need to be admitted to hospital.
 TREATMENT OF CIN IS ALMOST 100% effective

Colposcopy and pregnancy

 Colposcopy can be done safely in pregnancy and does not affect delivery/
future fertility
 Treatments (if needed) are usually deferred until after having the baby -
unless the abnormality is very severe and it is thought to be dangerous to
wait until after the baby is born

Follow up

 Important for detecting treatment failure/ recurrence

 Those treated for CIN have a relative risk increased risk x8 of developing
cervical cancer in the future
 CIN 2/3 – 10 year follow up in England
 CIN 1 – 2 year follow up

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What? Advantages Disadvantages

Condoms Effective if used with Reduce transmission Does ’t prote t agai st STDs
98% effective spermicides of most STDs, but affecting the perineum – protects
not those against gonorrhoea and chlamydia
but not syphilis or herpes
Caps Diaphragms stretch from the Give females control UTIs, rubber sensitivity
92-96% pubic bone to the posterior Protect against Requires careful teaching and
effective fornix – must check that the ascending pelvic fitting
cervix is covered infection
Insert less than 2 hours
before intercourse
Effective if used with a
spermicide
Natural Fertile times = 6 days prior to Acceptable to those Requires significant concentration
methods ovulation (the life of a sperm) ho do ’t use and willpower
Can be 99% to two days after (the life of contraception for
effective an ovum) religious/social
Cervical mucus becomes reasons
clear and sticky at the
beginning of the fertile time
and dry at ovulation
Basal body temperature
increases by 0.3 degrees
after ovulation
IUDs Plastic shapes ~3cm long Easily removed so Contraindications: previous PID,
99% effective with copper wire wound contraceptive effect previous ectopic pregnancy,
around, and a plastic thread can be reversed at known uterine malformation,
from the tail any time copper allergy
Inhibit implantation and may No compliance They tend to be expelled by a
impair sperm migration by necessary uterus that is nulliparous or
inducing an inflammatory Long-term method distorted (e.g. by fibroids)
response in the of contraception Associated with pelvic infection in
endometrium independent of the first few weeks after insertion
Copper IUDs are toxic to intercourse and infertility
sperm Protects against Produce painful and heavy periods
Need changing every 5 or 8 both intrauterine
years and ectopic
Can be inserted at any time pregnancy (but if
as lo g as the o a is ’t pregnancy does
pregnant occur, there is a
higher chance that it
will be ectopic)
IUS Contain progesterone Make periods lighter May be expelled as with IUDs
99% effective Local hormonal effect makes Protects against PID Can cause persistent spotting and
the endometrium thin and irregular bleeding in the first few
atrophic and thickens cervical months of use
mucus to prevent sperm Acne

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migration Breast tenderness

Need changing every 5 years
COCP Contain varying Woman takes Contraindications: obesity,
99% effective concentrations of oestrogen control diabetes, hypertension, smoker,
with a progestogen either in Periods remain migraines, hx of thrombosis, IHD,
a fixed ratio (monophasic) or Makes periods TIA, liver disorders, porphyria, SLE,
in a varying ratio throughout lighter, less painful breast or genital tract tumours,
the month (biphasic or and more regular breastfeeding, undiagnosed
triphasic) Improves vaginal bleeding
Taken daily for three weeks premenstrual Higher oestrogen concentrations
follo ed y o e eek’s syndrome (PMS) are linked to increased rates of
break – inhibits ovulation and symptoms arterial and venous thrombosis
gives a withdrawal bleed in Reduces the risk of Must be taken at the same time
the break PID every day – requires good
Inhibits ovulation by Protects against compliance
suppressing the release of ovarian and How to advise if they miss a pill: if
pituitary FSH and LH endometrial cancer its <12 hours late, take the pill and
Makes the endometrium Can treat acne continue as usual, if > 12 hours
atrophic and hostile to an late, take the pill and use extra
implanting embryo precaustions (e.g. barrier
Alters cervical mucus to methods) for the next 7 days
prevent sperm ascending Any women using the COCP who
into the uterine cavity smoke should be advised to stop
taking it at age 35 ( increased
risk of arterial disease)
POP Thickens cervical mucus to Can be used if the Must be taken at the same time
99% effective make it hostile to ascending woman has CVD risk every day
sperm factors or DM Erratic or absent periods
Makes the endometrium thin Useful if breast Functional ovarian cysts
and atrophic  prevents feeding Breast tenderness
implantation and sperm Safe in older women Acne
transport Makes periods Greater failure rate than with
Taken every day without a lighter/absent COCP
break
Does ’t pre e t o ulatio
Depot Depo-Provera given IM 12- As above Irregular vaginal bleeding initially
Injection 13 weekly Good for people and then amenorrhoea
99% effective Inhibit ovulation and thicken who struggle to Weight gain (up to 3kg in the first
cervical mucus remember to take year, then settles as the body
the pill – less absorbs the extra fluid)
compliance needed Acne
Improves PMS Can take time for fertility to be
restored
Sub-dermal Progesterone implants give As above Fertility returns as soon as it is
implants up to three years’ removed
No failures to contraception
date Implanted into the lower

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surface of the lower arm

Inhibits ovulation and
thickens mucus
Contraceptive effect stops
when the implant is removed
Patches Contain oestrogen and As above Same as with the COCP
99% effective progesterone Better compliance
Applied weekly for 3 weeks, than with OCP
then there is a patch-free Same advantages as
week the COCP

Contraception
History
38 year old female – delivered 3rd child two weeks ago wants to go back on contraception
PC:

 Wants reversible form of contraception as unsure if wants to continue family.

Previously was on COCP 10 years ago before starting family and wants to go back on
it
POHx :

 P3+1 – 3x SVD + 1 x TOP

 Pre-eclampsia in last pregnancy
PGHx:

 Regular periods – 5/28

 Smears up to date
 STI negative (tested at booking)
PMH:

 Hypertension
DHx:

 Ramipril
SHx:

 House wife
 Nil ETOH
Examination

 BP: 139/ 85
 BMI: 40

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A 37 week pregnant woman comes in saying she has been booked in for caesarean
section, but doesn’t understand what the doctor meant. Please explain to her the
procedure and address her concerns.

Caesarean:
 Indications
o Emergency
 Fetal distress
 Cord prolapse
 Vasa praevia
 Abruption
 Failure to progress
o Elective
 Previous C/s
 Malpresentation
 Placenta praevia
 Multiple gestation
 Structural abnormality e.g. cervical fibroid
 Maternal disease e.g. diabetes, heart disease
 Previous uterine surgery
 HIV
 Sites

o Lower segment transverse/Pfannestiel

 Less future rupture (VBAC), less blood loss, less dehiscence, less
visible
 Difficult to extend the excision, poor visualisation of uterus
o Lower segment vertical
 Easier to extend than transverse incision, good visualisation of
uterus
o Classical
 Indications
 Preterm labour (lower segment poorly formed)
 Lower segment abnormality
 Fibroids
 Placenta praevia
 Adhesions
 Transverse lie
 More likely to rupture – no future VBAC
 Baby delivered legs first
 Analgesia – spinal (quick) + epidural (slow) or GA (emergency)
 Complications
o Infection/Endometritis
o PE
o PPH (>1l)

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o Fetal trauma
o Wound dehiscence
o Paralytic ileus
o Adhesions
o Transient tachypnoea of newborn
o Long term
 ↑risk of placenta praevia, placenta accrete
 ↑risk of uterine rupture
 ↑risk of Asherman’s syndrome

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Sterilisation

History:

A surgical procedure that aims to permanently block or remove part of the

female reproductive tracts to prevent fertilisation
Benefits:
 Can be 99% effective
 Will not affect sex drive or sexual health long term
 No effect on hormone levels

Disadvantages:
 No protection against STIs
 Difficult to reverse tubal occlusion
 Risks of surgery
 1 in 200 risk that sterilisation fails
 Increased risk of ectopic after procedure- if preg test positive seek attention

INDICATIONS
Both doctor and woman must be satisfied that there will be no regret. Normally,
an older woman who has a complete family or when disease contraindicates
pregnancy

Before the procedure:

 GP strongly recommends counselling before sterilisation.
o The woman, and preferably partner, must be certain
o Alternative contraception is discussed
o Warn of 1 in 200 lifetime risk of failure
o Risk of ectopic if pregnancy
 Use contraception until the day of the operation, and continue using it:
o Until next period if tubal occlusion
o For 3 months if fallopian implants (hysteroscopic sterilisation)
 Pregnancy test. High risk of ectopic subsequently
 Reversal not possible with hysteroscopic sterilisation and not guaranteed with
Filshie clips
 Risk of surgery

During the surgery

May be done under local or GA, depending on procedure type:

Methods
1. Tubal occlusion- eg clips
 Via laparoscopy or mini-laparotomy
 Mini-lap for
o Recent abdo/pelvic surgery, obesity or PID
 Blocked using clips, rings or tying and cutting tube
2. Hysteroscopic Sterilisation- fallopian implants/Essure
 Hysteroscopic: placement of microinserts into the proximal part of each lumen
 Inserts expand  fibrosis  occlusion of the lumen. No abdominal scars
Confirmed 3 months later with a hysterosalpingogram
3. Removal of tubes- salpingectomy

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Method of choice when blockage has been unsuccessful.

After the Procedure:

Once the anaesthetic has worn off, passed urine and eaten, discharged.
Cannot drive home if performed under GA.
Normal to feel a little unwell after surgery: anaesthetic
May have some slight vaginal bleeding: use sanitary towel not tampon
Some pain similar to period pains. Use painkillers but if too severe seek attention
Stitches may be dissolvable or require removal
Normal intercourse as soon as comfortable

Complications:
 Pain after surgery- up to 8/10
 Implants inserted incorrectly: 2/100
 Bleeding after surgery- many had light bleeding, up to a third bled for three days

REVERSAL (not on NHS)

 Performed microsurgically via laparotomy
 Less likely to be successful if tubal ligation
IVF is an alternative to reversal

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Dysmenorrhoea

You are in gynae outpatients and have been asked to see a 43 year old woman
who presents with painful periods.

PC:
 Painful periods
HPC:
 Referred from GP
 Pain starts around 36 hours before bleeding starts, and lasts until day 5
 Pain is constant, dull and severe
 Cannot do any housework or social activities
 GP prescribed paracetamol and mefanemic acid in combination which
takes the edge off, but does not fully relieve symptoms
O&G:
 Periods have always been quite heavy and painful, but in last 2-3 years
have become almost unbearable
 Bleeds every 24 days and the period lasts for 7-9 days with heavy flow
from day 2 to day 6
 Four normal deliveries and husband had vasectomy several years ago
 No hx of intermenstrual or postcoital discharge
 Smear was normal 18months ago
PMH:
 Citalopram for depression, but mood is currently fine
SH:
 Housewife
 Affecting ability to do work
 No EtOH or smoking
FH:
 No gynae cancers

Examination:
 Abdominal, speculum, bimanual
Results:
 Abdomen soft and vague tenderness in suprapubic area
 Cervix appears normal
 On bimanual uterus is approximately 10 weeks size, soft and bulky
 Tender on palpation but no cervical excitation, adnexal tenderness or
adnexal masses

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Investigations:
 TVUS
 Swabs
 FBC: FBC, inflammatory markers, group and save

In this case:
 Dysemenorrhoea and menorrhagia combined with USS suggest
adenomyosis

What is adenomyosis
 Benign condition whereby functional endometrial glands and stroma
found in myometrium
 With each cycle, bleeding occurs into smooth muscle, with associated pain
 Tends to occur in women >35 years old

Risk factors:
 Increased parity
 Termination
 Previous c/s
 Often found alongside endometriosis

Further investigation:

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 If the diagnosis is in doubt then an MRI scan may be requested.

Hysterectomy to obtain histological diagnosis would be inappropriate.

Management

Analgesia

 The initial management involves analgesia such as mefenamic acid and

codydramol.
 Tranexamic acid reduces the amount of bleeding and this may secondarily
reduce the amount of pain.

Hormonal:

 IUS
 COCP
 Long acting progestogens
 Norethisterone (progestogen) days 5-26
 Suppression of menstruation with gonadotrophin-releasing hormone
analogues is a short-term measure.

Surgical

 Endometrial ablation
 Uterine artery ablation
 As a last resort hysterectomy should be performed.

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Ectopic Pregnancy

History

● 26 year old woman presents with 2 hour history of abdominal pain, initially in the lower
abdomen but is now generalized.
● Nauseated and dizzy, especially when she sits up. She also feels as if she has bruised her
shoulder.
● She has not noticed any vaginal bleeding or discharge, and there are no bowel or urinary
symptoms.
What else do we want to ask?

She does not keep a record of her period dates but thinks the last one was about a month ago. She
has a regular partner and says that they often forget to use a condom.

She had a termination 3 years ago. She was diagnosed with chlamydia when she was admitted to
hospital at the age of 19 years with a pelvic infection.

There is no other medical history of note.

Examination

● General
● Bedside tests: BP, HR, temp
● Abdo examination
● Vaginal examination
O/E: pale and looks unwell. She is intermittently drowsy. She is lying flat and still on the bed. The
temperature is 35.9°C, pulse 120/min and blood pressure 95/50 mmHg. Peripherally she is cool and
the hands are clammy. She is generally slim but the abdomen is symmetrically distended. There is
generalized tenderness on light palpation, with rebound tenderness and guarding. There are no
obviously palpable masses and vaginal examination has not been carried out.

Investigations

Urinary pregnancy test: positive

Basic info:

· = embryo development outside the uterus

· Usually 5-10 weeks
o So can be days after missed period
· RFs: PID, Endometriosis, Previous tubal surgery e.g. salpingotomy, Age, ART, (IUD, IUCD, POP)
§ If you become pregnant risk is higher, but your absolute risk is lower
· COCP is protective: Reduces PID risk by 50%
· 95% tubal (ampulla), but may be interstitial, ovarian, cervical or abdominal
· Signs/symptoms: Abdo pain
§ Severe, Iliac fossa, unilateral, continuous
o PV bleeding
§ Dark brown
o Shoulder tip pain
o Shock (from internal bleeding)
o Diarrhoea (blood in pelvis)

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o Cervical excitation on VE
o Normal sized uterus
How would you confirm diagnosis?
● TVUS
Extra-uterine sac
No intrauterine sac, giving PUL
· Should be visibile if hCG >1000
· Pseudosac (10%) may be mistaken for gestational sac
Adnexal mass
Fluid in pouch of Douglas (non-specific)
● Diagnostic laparoscopy (if TVUS is inconclusive)
● 48 hour hCG (if stable/asymptomatic)
In reases y <⅔

Management
● Expectant (stable/asymptomatic with decreasing hCG <1000)
○ 48 hour hCG
● Medical
○ IM Methotrexate (if stable)
Strict criteria
o Asymptomatic
o Haemodynamically stable
o hCG <3000
o <2cm diameter on US
o Reliable to follow up
hCG is measured on days 4 & 7
2nd dose given if hCG hasn’t fallen y 1 % after days
● Surgical
○ Laparoscopic Salpingectomy
· Counsel on reduced fertility (20%)
○ Laparoscopic Salpingotomy
· If other tube is diseased e.g. PID
○ Counsel on increased risk of future Laparotomy (emergency - unstable)
· Can use laparosopic salpingectomy if experienced operator
· ectopic

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Emergency contraception
Case
 21 year old just been on holiday
 PC: Unprotected sex 36 hours ago and 4 days ago – seeking emergency
contraception (important to time and date all episodes of unprotected
intercourse since LMP)
 PGHx:
o Regular cycle – 4 days in 27 days
o LMP – began 13 days ago
o Last STI check 2 months ago
 PMH:
o Epilepsy
 DHx:
o Carbamazepine
Examination
 Abdo exam unremarkable and internal examination not indicated

Investigations
 Urinary pregnancy test negative

Management

Assess risk of pregnancy

 Since LMP:
o Days 8-17 = 20-30% pregnancy risk
o Days <7 and days >17 = 2-3% pregnancy risk

Emergency contraception – two options:

 Levonorgestrel
 Copper IUD

Levonorgestrel
 Standard dose 1500ug
 Double the dose to 3mg if taking liver enzyme inducing drugs:
o Rifampicin
o Rifambutin
o St John’s Wart
o Griseofulvin
o Anticonvulsants e.g. phenytoin, carbamazepine, barbiturates,
primidone, topiramate, oxcarbazepine
o Tacrolimus
o Some antiretrovirals
 Licensed for use up to 72 hours after but can be used off licence up to 5 days
 Efficacy:
o <24 hours = 95% effective
o 25-48 hours = 85% effective

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o 48-72 = 58% effectice

 Side effects:
o Nausea – 14%
o Vomiting – 1 % NB if patient vomits give a second dose + anti-emetic
 Further advice:
o Abstain from sex until next period
o If next period is light or absent – pregnancy test

Copper IUD
 99% effective
 Can be inserted:
o 5 days post intercourse
o 5 days after the earliest calculated date of ovulation (14 days after
LMP in normal 28 day cycle)
 Can be difficult to insert in nulliparous women and requires local anaesthetic
 Give antibiotic cover to prevent PID
 Needs to return after next period to have removal/ threads check if she
intends to keep it

Other considerations
 Her intended contraception use going forward
 Offering STI check

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Condition – Epilepsy in pregnancy

Definition
Normal patient undergoing pregnancy with a pre-existing diagnosis of epilepsy.
History
A 26-year-old woman who has epilepsy controlled by treatment is planning to get married.
She is concerned about pregnancy and her epileptic medication. She has been seizure free
for 6 years on two antiepileptic drugs. She has not recently been reviewed by a neurologist.
Overview
PC
Patient will be normal on presentation.
Can be seen in GP practice, clinic or even A&E if fitting.
HPC
How long has she had epilepsy for/ when was it first diagnosed?
Has she had any hospitalisations from epilepsy in the past?
Does she still take any medication for her epilepsy? What happens if she doesn’t take
her epilepsy.
What type of epilepsy do you have?
Does anything precipitate attacks?
DH and allergies
This is important to ascertain what medications she is taking.
FMH
Are any family members epileptic? Did they have any problems conceiving and
throughout pregnancy.
SH
Smoking, recreational drugs, particularly avoid alcohol and any known precipitants of
epileptic attacks.

Differential Diagnosis

If fitting: Pre-eclampsia!

Examination
Basic obs: 100% 02 sats, 140/90, no protein in the urine
Abdominal examination: fine.
Vaginal examination: fine.
Speculum: fine.
Bimanual: Wouldn’t do.

Investigations
Mainly history led here.

Management
Risks to the mother
Increased fits - Increased plasma volume causes reduced drug levels. Other causes of
increased fit frequency include excessive tiredness and hyperemesis. Some women also
decide to stop their medication because of fears of adverse effects on the baby, although
this may actually increase the risk to the baby as a result of a higher likelihood of
prolonged fits.

Risks to the fetus

There is an increased risk of congenital abnormality due to antiepileptic drugs (7 per
cent risk for one drug, with risk increasing with multiple drugs). The risk probably
applies similarly to all antiepileptic medications used.
There is also an intrinsic increased risk of epilepsy (3%) in the offspring of an epileptic

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mother, and during the pregnancy the fetus is also at risk of fetal hypoxia from
uncontrolled maternal epilepsy.

Pre-natal Care:
Conservative
Discussion with the mother:
(1) Explain the associated risks with epilepsy.
(2) Make sure the patient understands the risk of not taking her appropriate
medications.
(3) If no fits have occurred for at least 2 years consider stopping all
medication.

Medical
(1) Recommend serum α-fetoprotein screening and a detailed USS at 18–20
weeks to identify fetal anomalies.
(2) Emphasize the importance of periconceptual folic acid. This should be 5 mg
rather than the usual 400 micrograms to minimize the risk of neural tube defects
occurring. Also anti-epileptic regimes may cause folate deficiency.
(3) Before and during pregnancy, the aim should be to prescribe the lowest dose
and number of antiepileptic drugs necessary to protect against seizures.
(4) Refer for neurology opinion and minimize the number of drugs, aiming for a
single drug regime.
(5) Avoid Sodium Valproate if possible – higher rate of congenital abnormalities.
(6) Carbamezapine and Lamotrigine are the safest.

Antenatal
(1) Plan for joint medical and obstetric care
(2) Monitor plasma levels of anticonvulsant regime (levels are likely to
diminish due to increased plasma volume).
(3) Advise the woman to take showers instead of baths to minimize the risk
of drowning if a fit occurs in the bath.
(4) Arrange detailed anomaly scan and a fetal echocardiography at around
18–20 weeks for cardiac abnormalities.
(5) Start vitamin K (10mg orally) from 36 weeks’ gestation, to correct any
potential clotting deficiency from the inhibition of clotting factor
production by anticonvulsants and thus reduce the chance of fetal
bleeding (e.g. intraventricular haemorrhage).
(6) The baby should also receive intramuscular (rather than oral) vitamin K
at birth.
(7) There are no specific differences in labour management from non-
epileptic women.

Postnatal
(1) Anticonvulsant therapy is not a contraindication to breast-feeding.
(2) Decrease medication doses as maternal physiology returns to normal.
(3) Adequate social support is vital and plans need to be made for safe care of
the infant (due to the risk of fits in the mother).
Fit during pregnancy

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ALWAYS TREAT PRE-ECLAMPSIA FIRST BEFORE CONSIDERING THE CAUSE OF

THE FIT. EVEN IF THE PATIENT IS A KNOWN EPILEPTIC.

Fit in a woman with epilepsy: The fact that the woman has epilepsy strongly
suggests that this fit is caused by the epilepsy. However, the initial management
is urinalysis and blood pressure measurements.

Reflexes are commonly brisk, with upgoing plantar responses in the post-ictal
phase.

This woman regained full consciousness after half an hour and the blood pressure
was normal with negative urinalysis and normal blood results. The magnesium was
thus dis- continued and she was discharged with her husband, for neurological
review within the next few days to discuss compliance and drug regime.

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Fibroids

Definition: Also known as leiomyomata, they are benign tumours of the myometrium.

History
39-year-old women
PC
o Menorrhagia
HPC
o Increasing menorrhagia (soaking sanitary towels- 40 for each period) and
increasing bleeding lengths over the past 5 years.
o Previously bled for 4 days and now she bleeds for 10 days.
o Cycle is still 28 days
o IMB but no PCB
o Periods become increasingly painful with cramps.
o She has never had any previous irregular bleeding or any other gynaecological
problems.

PMH + PSH (MSC SOUR) – Obx and gynae hx

 Menstrual – above
 Sexual – Still sexually active with husband
 Contraception – laparoscopic sterilization after last child
 Smear – Normal last one 4 months ago.
 Obstetric - 4 x SVD no complications
 Urinary – Normal
 Rectal – Normal
 Medical conditions / Previous surgery- Sterilisation
DH and allergies – None, NKDA
FMH – No ovarian, uterine, cervix, breast or bowel cancer.
SH – Lives at home with husband, doesn’t drink or smoke
System Review
 General – Normal
 Neuro – Normal
 Cardio – Normal
 Resp- Normal
 Gastro – Normal
 Musc – Normal
 Derm – Normal

N.B Extra questions to ask

 Seek indications of the quality of life (e.g. effect on social life, days off work,
etc.) to establish the severity of the problem. 


Differential Diagnosis
 Dysfunctional uterine bleeding : Primary – ovulatory or anovulatory or
Secondary – bleeding disorders e.g. VW disease (rarer)
 Uterine leiomyoma (fibroids)
 Uterine endometriosis (adenomyosis)

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Examination
General observations: Pale
Basic obs: afebrile, HR: 75, BP 110/70, RR: 14, SpO2: 98%
Abdominal examination: SNT and no palpable masses
Vaginal examination
Speculum: Normal cervix
Bimanual: Uterus is bulky (approximately 8 week size), mobile and anteverted. There
are no adnexal masses.

Investigations
 Bloods: FBC+ Iron studies (ferritin and folate)
 Renal function tests and renal ultrasound – local pressure effects of the fibroid
 USS
 Endometrial biopsy: Only women above 40.
 Hysteroscopy
 Laparoscopy (gold standard) but rarely indicated

Management
Asymptomatic patients with small or small growing fibroids need no treatment. Larger
fibroids should be serially measured by examination or ultrasound because of the
remote possibility of malignancy.

Medical
Anaemia- ferrous sulphate
Menorrhagia- Require contraception or not
Contraception required
 IUS- mirena
 COCP Contraception not required
 Tranexamic acid

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 JWH, JM, AJS, VA

 NSAIDs e.g. ibuprofen and  Danazol

mefenamic acid

Surgical- Depends on fertility to be preserved or not

Fertility required
 Hysteroscopic surgery: Trans cervical resection of the fibroid (TCRF)
Pretreatment with GnRH agonist for 1-2 months will shrink the fibroid, reduce
vascularity and make the procedure safer. Submucosal fibroids.
 Myomectomy: can be done open or laparoscopically. Bleeding is a common
complication and small fibroids may be missed. This is done once medical
treatment has failed and conservation of fertility is required. Pre-treatment with
GnRH agonist is common for 2-3 months. Intramural or sub serosal fibroids.

Fertility not required

 Endometrial ablation: several different types available e.g. laser, rollerball and
microwave.
 Hysterectomy: Again, pre-treatment with GnRH agonist will shrink the fibroids.

Unknown
 Uterine artery embolization: Less invasive but is less effective at managing
pain, has higher re-admission rates than myomectomy and hysterectomy may
still be required. Its effects on fertility are not known so should not be offered to
women desiring future pregnancy
Notes

Aetiology Fibroid growth is oestrogen and probably progesterone

dependent. Fibroids are equally like to grow, shrink or show no
change during pregnancy. Fibroids regress after the menopause
due to reduction in circulating oestrogen.

Size varies. Fibroids can be classified as intramural, subserosal or

submucosal. The the fibroid has whorled appearance.
Risk factors Afro-Caribbean women, obesity, nulliparity and those with a
family history.

Signs & Symptoms History:

 50% are asymptomatic and discovered on pelvic or
abdominal examination.

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 Menstrual problems (menorrhagia) occur in 30%

although the timing of the menses is usually unchanged.
IMB may occur if the fibroid is submucosal or polypoid.
 Pain: can cause dysmenorrhoea. They rarely cause pain
unless torsion, red degeneration or rarely, sarcomatous
change has occurred.
 Large fibroids pressing on the bladder can cause
frequency and occasionally urinary retention; those
pressing on the ureters can cause hydronephrosis
 Fertility can be impaired by blocking the tubal ostia or
preventing implantation
Examination: A solid mass may be palpable on abdominal or
pelvic examination. This mass will arise from the pelvis and be
continuous with the uterus. Multiple small fibroids can cause an
irregular knobbly enlargement of the uterus.
Complications  Torsion of pedunculated fibroid
 Degenerations: Red (particularly in pregnancy) is
characterised by pain and uterine tenderness and is when
the blood supply to growing fibroids is interrupted.
Hyaline (fibroid outgrows blood supply) and may
progress to cystic degeneration may occur in which the
fibroid is liquefied and soft.
 Malignancy transformation rarely.
 Pregnancy: premature labour, malpresentations,
transverse lie, obstructed labour.

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Gestational diabetes/ Glucose tolerance test (case 57)

History
 42 year old woman of Indian origin: 26+0
 Attending antenatal clinic for the results of her GTT (arranged by the midwife
due to family history of T2DM)
 P3 (c-section) + 2 (early miscarriage + TOP)

Examination
 BMI: 31kg/m2
 BP: 146/87 mmHg
 Fundal height 29cm
 FHHR

Investigations
 Urinalysis: 1+ glycosuria
 GTT (75g glucose drink):
o Pretest fasting glucose: 6.4mmol/L
o 2h level post glucose load: 11.3mmol/L

PACES QUESTION: Explain what these results show to the patient and counsel
them as to the risks this poses to the pregnancy and how they will be managed

Who should be offered a GTT (NICE)

 BMI above 30 kg/m2
 Previous macrosomic baby weighing 4.5 kg or above
 Previous gestational diabetes
 Family history of diabetes (first-degree relative with diabetes)
 Minority ethnic family origin with a high prevalence of diabetes
 Glycosuria: 2+ on one occasion or 1+ on 2 occasions
 Do not us the following to assess risk:
o Fasting plasma glucose
o Random blood glucose
o HbA1c
o Glucose challenge test

When to do GTT (NICE)

 Between 24-28 weeks
 If previous GDM: ASAP after booking + 24-28 weeks

What GTT involves

 Mother fasted overnight
 Pre-test (fasted) blood glucose
 75g glucose drink administered
 Blood glucose checked 1 and 2 hours after

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Diagnosis of GDM (NICE)

One or both of the following criteria:
 Fasting plasma glucose of 5.6 mmol/L or greater
 2 hour plasma glucose of 7.8 mmol/L or greater

Effects of GDM
Fetus:
 Fetal macrosomia
 Polyhydraminos
 Neonatal hypoglycaemia
 Neonatal respiratory distress syndrome
 Increased still birth rate
Maternal:
 Increased risk of traumatic delivery (shoulder dystocia)
 Increased c-section risk
 Increased risk of GDM in subsequent pregnancies
 50% increased risk of developing T2DM within 15 years

Good blood glucose control during pregnancy will reduce these risks

Management
 Offer women a review in the joint diabetes and antenatal clinic within 1 week
of diagnosis
 Educate women how to monitor blood glucose levels and that they are to
keep a diary of results:
o Fasting: 5.3 mmol/L
o 1 hour post meal: 7.8 mmol/L
o 2 hours post meal : 6.4 mmol/L
o Only aim for these results if it is not causing problematic
hypoglycaemia and ensure that women are aware of the dangers
and symptoms of hypoglycaemia
 Diet and exercise advice (offer to all):
o Eat healthily and replace high GI foods with low GI foods
o Refer all women to a dietician
o Regular exercise e.g. 30 min walk post meal
o Offer a one week trial of diet and exercise to those with fasting
glucose <7mmol/L. If blood targets are not met introduce
medication
 Metformin
 Insulin
 Proceed straight to insulin +/- metformin if
o Fasting blood glucose >7mmol/L
o Fasting blood glucose 6.0-6.9 mmol/L + complications such as
macrosomia and polyhydraminos
 Consider glibenclamide if:
o Cannot tolerate metformin

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 JWH, JM, AJS, VA

o Blood glucose targets are not achieved with metformin and decline
insulin

Other changes to antenatal care

Fetal scans
 32 weeks: Fetal growth and amniotic fluid volume
 36 weeks: Fetal growth and amniotic fluid
 38 & 39 weeks: Tests of fetal well being

Intrapartum care
Timing and mode of delivery
 Women with GD should give birth by 40+6 - offer induction or elective c-
section after this
 If complications – consider elective birth before these dates
 If macrosomic fetus go through all the risks and benefits of all modes of
delivery e.g. shoulder dystocia in normal vaginal birth
Anaesthesia
 If diabetes + complications - anaesthetic assessment in the third trimester of
pregnancy
 If mother is under GA – monitor blood glucose every 30 mins
Blood glucose monitoring and control
 Do BMs every hour and maintain between 4 and 7 mmol/L
 If this is not possible – IV dextrose and insulin
Neonatal care
 Give birth in facilities with advanced neonatal resuscitation 24 hours a day
 Main concern is neonatal hypoglycaemia – prevent this by:
o Check neonatal BMs 2-4 hours post delivery
o Women with diabetes should feed their babies as soon as possible
after birth (within 30 minutes) and then at frequent intervals (every
2–3 hours) until feeding maintains pre-feed capillary plasma glucose
levels at a minimum of 2.0 mmol/L
o Commence IV dextrose if:
 Not feeding orally
 2 consecutive readings below 2mmol/L
 Abnormal clinical signs
Postpartum care
 Women with GD should discontinue treatment immediately after birth
 NB women with pre-existing diabetes should half their insulin and be
cautious of hypoglycaemia especially when breastfeeding
 Measure BMs to exclude hyperglycaemia before discharge back to the
community and counsel about symptoms of hyperglycaemia. Give exercise
and diet advice
 Offer HbA1c or fasting blood glucose between 6 and 13 weeks postnatally to
exclude T2DM as women with GD are at higher risk of developing T2DM and
having GD in subsequent pregnancies

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Gestational trophoblastic disease

Definition
A spectrum of tumours resulting from the abnormal proliferation of trophoblastic tissue.
Types: complete hydatiform mole, partial mole, invasive mole, choriocarcinoma, placental
site trophoblastic tumour (very rare)

History
A 36-year-old woman presents with vaginal bleeding and eeks 3 days gestatio .
PC
 PV bleeding
HPC
 Bright red spotti g o e ed days ago.
 She thought was normal in early pregnancy
 However since then the bleeding is now almost as heavy as a period.
 There are no clots.
 First pregnancy
PMH + PSH (MSC SOUR) – Obx and gynae hx
 Menstrual – She has regular periods bleeding for 5 days every 28 days
 Sexual – Never had any known sexually transmitted infections
 Contraception – Condoms
 Smear – She had large-loop excision of the transformation zone (LLETZ) treatment
after an abnormal smear 6 years ago. Since then all smears have been normal.
 Obstetric- G1
 Urinary – Nil
 Rectal – Nil
 Medical conditions / Previous surgery- Nil
DH and allergies- Nil and NKDA
FMH- Nothing relevant
SH- Lives at ho e ith oyfrie d, feels ell supported. Has t s oke or dru k al ohol si e
she has learnt she is pregnant.
System Review
 General – Systemically she has felt nausea for 3 weeks and has vomited occasionally.
 Neuro – Nil
 Cardio – Nil
 Resp- Nil
 Gastro – No abdo pain
 Musc – Nil
 Derm – Nil

Examination
Basic obs: The heart rate is 68/min and blood pressure is 108/70mmHg.
Abdominal examination: The abdomen is soft and non-tender.
Vaginal examination
Speculum: Speculum reveals a normal closed cervix with a small amount of fresh blood
coming from the cervical canal.
Bimanual: Bimanually the uterus feels bulky and soft, approximately 10 weeks in size. There
is no cervical excitation or adnexal tenderness.

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Differential Diagnosis
 Gestational trophoblastic disease
 Miscarriage
 Fibroids

Investigations
 FBC
 Pregnancy test
o +ve
 USS
o Mixed echogenicity appearance in the uterus, typical of a complete
hydatidiform mole.
o There is no recognisable gestational sac or fetus.
o Characteristically USS shows a uterine cavity filled with multiple sonolucent
areas of aryi g size a d shapes gi es the appeara e of a ”s o stor of
s olle illi” ith o e ryo i /foetal stru ture.
o This appearance may also be seen occasionally in pregnancies where early
fetal demise has occurred but the sac has not been expelled (delayed
miscarriage) resulting in cystic degeneration of the placenta.






Normal findings at 8 weeks

 The normal findings at 8 weeks would be a fetus of approximately 18 mm, with a
positive fetal heart beat. The yolk sac would still be visible and the amniotic sac
would also be seen. The fetus would be beginning to develop visible arm and limb

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 JWH, JM, AJS, VA

buds and fetal movement may be seen.

 CXR- exclude lung metastases in choriocarcinoma

Gestational trophoblastic disease

 Complete hydatiform mole = haploid sperm duplicates to become diploid after
fertilising an empty ovum (75-80%) or two haploid sperms fertilise an empty ovum
(20-25%)  46 XX (no foetal parts)
 Partial mole = triploid moles with two sets of paternal chromosomes (either single
haploid sperm reduplicates or two haploid sperm fertilise one haploid ovum)  69
XXX or 69 XXY (may have foetal parts)
 Invasive mole = complete or partial mole that has invaded locally
 Choriocarcinoma = highly malignant tumour, commonly metastasises to the lungs,
liver and brain. 50% are from a molar pregnancy, 30% from a miscarriage and 20%
from an apparently normal pregnancy/live birth
 Signs and symptoms: Patient thinks they are pregnant (periods stop), may present
with heavy/irregular vaginal bleeding, uterine enlargement greater than expected
for gestational age, hyperemesis. Some women with choriocarcinoma may present
with dyspnoea, neuro symptoms and abdo pain from weeks to months after their
last pregnancy (due to malignancy).
 Complications: PIH/PET, hyperthyroidism and hyperemesis gravidarium. Rare now
due to quicker diagnosis at time of presentation.

Management
1. Evacuation of retained products
o Evacuation via suction curettage for complete moles and partial moles that
are small enough.

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o Medical evacuation with potent oxytocic agents if partial mole is too large
(medical evacuation should be avoided if possible as there is a risk of
embolization and dissemination of trophoblastic tissue through the venous
system).
o Anti-D prophylaxis is needed for evacuation of partial moles
2. Histological examination
 Gold standard
3. Refer to specialist centre (Charing Cross) for monitoring of B-HCG levels
o Monitor HCG levels 6-8 weeks after the end of the pregnancy to exclude
gestational trophoblastic neoplasia – persistenly high levels of BHCG
o If HCG is normal within 56 days of pregnancy, follow up for 6 months after
evacuation.
o If HCG has not returned to normal within 56 days, follow up for 6 months
after normalisation of HCG levels
o Women with persistently raised HCG levels are offered chemotherapy to
destroy the persistent trophoblastic tissue and minimize the chance of
development of choriocarcinoma.
o Gestational trophoblastic neoplasia should be treated with chemotherapy
 increase risk of early menopause.
4. Advice
o Not to become pregnant again until 6 months after the HCG is normal. 

o There is a 1 in 84 chance of a further molar pregnancy. 

o They should have HCG monitoring after any subsequent pregnancy (whether
live birth, 
fetal loss or termination). 

o The combined oral contraceptive pill may safely be used once HCG has
returned to 
normal (previous advice was to wait for 6 months). 


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Group B streptococcus
History

 28 year old: 26+0 gestation

 PC:
o One episode of PC bleeding
o Foetal movements present
o Nil pain or other discharge
 OHx:
o P1+3 (2xTOP + 1x1st trimester miscarriage)
o Nil concerns in pregnancy so far – booked at 7 weeks and both dating +
anomaly scan normal
 GHx:
o All smears UTD + negative
o Sexually active – regular partner
 PMH: nil
 DHx: nil + NKDA
 FHx: nil gynae cancer
 SHx: husband and 3 year old son at home – nil concerns. Works as receptionist
Examination

 Maternal:
o Speculum – cervical ectropion
 Fetal:
o Fundus measures 26cm
o Fetal heart beat heard and normal
Investigations

 Vaginal and endocervical swabs

 Full blood count
 Group and save

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Management
Anaemia

 This anaemia is mild for pregnancy and the MCV is low – suggesting IDA
 Conservative: iron-rich diet e.g. meat, lentils, spinach
 Medical: ferrous sulphate 200mg twice daily
 Repeat Hb in 4 weeks
Candida

 Common finding in the vagina – only treat if symptomatic (itchy or lumpy discharge)
and if so treat with vaginal clotrimoxazole
Group B streptococcus

 Incidence:
o 25% of women carry GBS commensally in the vagina
o Early-onset GBS disease in UK is 0.5-1000 births (most common cause of
neonatal sepsis)
 Why we are worried:
o Mortality from early onset GBS disease is 6% in term babies and 18% in pre-
term babies
o Risk of deafness and cerebral palsy in survivors is as high as 40-50%
 Screening:
o Routine screening for antenatal GBS carriage is not done in the UK
 Antenatal:
o Antenatal antibiotic prophylaxis is not recommended as it does not reduce
the likelihood of GBS colonization at the time of delivery
 Intrapartum:
o RCOG recommends that abx prophylaxis be discussed with women with the
following risk factors and argument for prophylaxis is stronger if more than
one risk factor is present;
 Intrapartum fever (>38)
 PROM (> 18hours)
 Prematurity (<37 weeks)
 Previous infant with GBS
 Incidental detection of GBS in current pregnancy (no evidence if
detected in previous pregnancy!)
 GBS bacteruria
o Regime:
 3g IV penicillin be given as soon as possible after the onset of labour
 1.5g 4 hourly until delivery
 Clindamycin IV 8 hourly to those allergic to penicillin
 NB those having c-section without membrane rupture do not require
abx regardless of status

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 JWH, JM, AJS, VA

 Postpartum/ neonate;
o Any newborn with signs of GBS disease (sepsis) e.g. collapse, tachypnoea,
nasal flaring, poor tone, jaundice etc should be given broad spectrum abx –
blood cultures should be collect ASAP, prior to commencing abx
o No clear guidelines on giving abx to well newborns whose mothers are GBS
+ve

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HIV in pregnancy
Case
 26 years old; 16+0; P0
 Recently arrived from Nigeria to join her husband who is working here
(booking initially in Nigeria and dating scan)
 Midwife carries out routine antenatal screening
 Blood results of note:
o HIV screen positive
o Hep B screen:
 Hep B surface antigen: positive
 Hep B core antigen: negative
 Hep B core antibody: positive
 Hep e Antigen: negative

EXPLAIN THESE RESULTS TO THE PATIENT AND EXPLAIN MANAGEMENT TO HELP

REDUCE THE RISK OF TRANSMISSION

HIV in pregnancy
 3 million HIV positive women give birth each year: 75% of whom are in sub
Saharan Africa – gives rise to 700,000 new cases annually
 Over 1000 cases each year in UK
 If untreated the transmission rate is between 15-30% - <1% with treatment
 Factors which increase transmission:
o Advanced disease
o High viral load
o Low CD4 count
o Vaginal delivery
o Deliver <32 weeks

Hep B in pregnancy
 Rate of transmission is related to viral load
 HbeAg +ve: >90% transmission
 HbeAg –ve: 40% transmission
 Active measures to prevent transmission:
o Hep B vaccination of infant at 1,2 and 12 months of age
o If HBeAg positive – give HBV immunoglobulin at birth
o Treat HBV in the mother
Breaking the news
 Confidentiality
 Empathy when communicating the results
 HIV status of partner?
 Encourage patient to disclose to partner
 Full assessment of social circumstances

Further investigations
 Plasma viral load (biggest predictor of transmission)

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 CD4 count
 HIV genotype
 Hep C screen
 FBC, baseline liver function and renal function tests
 Haemoglobinopathy test (due to ethnicity)
 Screen for genital infections (increased risk in women with HIV. Genital tract
infections increase the risk of: chorioamnionitis, PROM and preterm labour):
o Chlamydia trachomatis
o Neiserria gonorrhoea
o Bacterial vaginosis
o Treponema pallidum

Management
 MDT involved in care:
o HIV physician
o Obstetrician
o Paediatrician
o Specialist midwife
o GP
o Community midwife
o Social workers

Antiretroviral therapy
 Balance between reducing the risk of transmission and teratogenicity of ART
 Zidovudine (ZDV) (NRTI) is the only drug specifically indicated for use in
pregnancy
 Demonstrated teratogens: didanosine and efavirenz
Classification Examples Problems
NRTIs Zidovudine (ZDV) Well tolerated
Lamivudine Lactic acidosis
Stavudine Hepatic dysfunction
Protease inhibitor Indinavir GI side effects (common)
Saquinavir Anaemia and hepatic
dysfunction
NNRTI Nevirapine Hepatic toxicity
Rash, Stevens Johnson

Treatment regimes:
 Zidovudine monotherapy:
o Commence prior to 30 weeks
o Viral load <10,000 copies/mL
o Must be willing to deliver by PLCS
o Reduces transmission to <1%
 HAART:
o 2 x NRTI + PI or NNRTI

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o Use if viral load >10,000 copies/mL; maternal health; genotype

indicates drug resisitnance
Obstetric management
 Folic acid 5mg/day is recommended especially if mother is on co-trimoxazole
for PCP prophylaxis
 Repeat STI check in third trimester
 Plasma viral loads at least once every 3 months and at 36 weeks

Mode of delivery
 Vaginal delivery if undetectable viral load (<50 copies/mL) (avoid)
 Pre labour c-section indications:
o ZDV monotherapy (38 weeks)
o On HAART but detectable viral levels (39 weeks)

Postnatal care
Breastfeeding:
 Constitutes a transmission risk even if undectectable viral load
 Consider cabergoline for lactation suppression
Mental health:
 Increased risk of perinatal depression
Care of neonate:
 Follow up by paediatrician
 ZDV monotherapy for 4 weeks
 Triple therapy to those born to untreated mothers or those with a detectable
viral load

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Hyperemesis Gravidarum:

History:
o 28 year old Asian woman presents with persistent vomiting at 7 weeks
gestation
o Second pregnancy having given birth 3 years ago
o Vomiting up to 10 times in 24 hours, without tolerating food for 3 days
o Only tolerating small volumes of water
o Referred from GP as a week ago given prochlorperazine suppositories but
only helped for a few days
o Weak and unable to care for son
o Upper abdo pain. Sharp and burning; constant.
o Constipated for 5 days
o Passing dark urine infrequently, but no haematuria or dysuria
o No vaginal bleeding or discharge
o No PMH except vomiting in first pregnancy, requiring two overnight
admissions

Examination:
o Apyrexial
o BP lying 115/68 and standing 98/55
o HR 96/min
o Dry mucous membranes
o Abdo exam shows tenderness in epigastrium but no lower tenderness
o Uterus not abdominally palpable

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Differentials:
1. Hyperemesis gravidarum
2. UTI
3. Gastroenteritis
4. Thyrotoxicosis
5. Hepatitis

Definition
Severe or protracted vomiting appearing for the first time before the 20th week
of pregnancy that is not associated with other coincidental conditions and is of
such severity as to require the patient’s admission to hospital.
Only 2% of pregnancies affected, but 50% report vomiting or nausea when
pregnant.

The diagnosis in this case can be made because the urinalysis is negative apart
from the ketones, so urinary tract infection is very unlikely. She has not opened
her bowels but this is likely to be secondary to poor dietary intake and
dehydration. Liver function is normal, so liver disease causing vomiting is
unlikely (though abnormal liver function may occur as a result of hyperemesis
itself). Thyroid function is normal, so an alternative diagnosis of
hyperthyroidism causing the vomiting is unlikely.

RFs
o Multiple pregnancy
o Hydatidiform mole
o Nulliparity

Complications of hyperemesis gravidarum

o Electrolyte imbalance: hypokalaemia
o Wernicke’s encephalopathy from vitamin B deficiency 

o Korsakoff’s syndrome (from vitamin B, deficiency) 

o Haematemesis (from Mallory–Weiss tear) 

o DVT secondary to dehydration
o Psychological – resentment towards the pregnancy and expression of
desire to 
 terminate the pregnancy 


The fetus is not at risk from hyperemesis and the nutritional deficiency in the
mother does not seem to affect development. The risk of miscarriage is lower in
women with hyper- emesis. The risk of twins and molar pregnancy has
traditionally been thought to be greater in women with hyperemesis, but this is
refuted in more recent research.

Management
Hyperemesis is a self-limiting disease and the aim of treatments is supportive,
with discharge of the woman once she is tolerating food and drink and is no
longer ketotic on urinalysis.
Conservative:
1. Small frequent meals

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 JWH, JM, AJS, VA

2. Ginger
3. Acupuncture

Medical
• Fluids: 3–4L of normal saline should be infused per day. Dextrose solutions are
contraindicated as they may precipitate Wernicke’s encephaolopathy and also
because the woman is hyponatraemic and needs normal saline.
Early pregnancy 3
• Potassium: excessive vomiting generally leads to hypokalaemia, and
potassium chloride should be administered with the normal saline
according to the serum electrolyte results. 

• Anti-emetics: first-line antiemetics include cyclizine (antihistamine),
metoclopramide (dopamine anatagonist) or prochlorperazine
(phenothiazine). In severe cases, ondansetron or domperidone may be
effective. There is no evidence of teratogenicity in humans from any of
these regimes. 

• Thiamine and folic acid: vitamin B1 thiamine can prevent Wernicke’s
encephalopathy or the irreversible Korsakoff’s syndrome amnesia,
confabulation, impaired learning ability). 

• Antacids: for epigastric pain 

• Total parenteral nutrition (TPN): TPN is rarely indicated but may be life
saving where 
 all other management strategies have failed. 

• Thromboembolic stockings (TEDS) and heparin: women with hyperemesis
are at risk of 
 thrombosis from pregnancy, immobility and dehydration,
and should be considered for low-molecular-weight heparin regime as
well as TEDS. 
 Monitoring 
 Daily monitoring should be carried out, with
weight measurement and urinalysis for ketones and renal and liver
function. 


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Illegal Drug Use in Pregnancy

History (setting antenatal clinic)

 19 years old; P1 (18 months ago SVD)
 22+0
 Situation: 2 weeks ago attended A&E with suspected UTI but abdominal
palpation revealed a mass consisted with a gravid uterus and subsequent USS
was carried out to date the pregnancy
 Social history:
o Injects heroin several times per week
o Has ’t use crack cocai e for several o ths
o On 8 week program of methadone 60mL which she collects from
pharmacy
o Lives in flat with partner who also uses and is on same proram
o No domestic violence

Examination
Maternal
 Examination: abdominal exam reveals gravid uterus (fundus at umbilicus)
and she is malnourished and anxious
 Observations: BP 107/65mmHg
Foetal
 Heart beat heard and regular

Investigations
 Full bloods
 HIV screen
 Hep B screen
 Hep C screen
 STI screen (chlamydia, gonorrhoea, bacterial vaginosis , syphilis etc)
 Urine toxicology

Management
 MDT approach including social worker and substance misuse services
 Encourage engagement with methadone replacement program – better to
maintain regular methadone use during pregnancy than ween off and have
unquatifiable amounts of street drug use
 Serial growth scans to monitor for IUGR

Risks of recreational drug use

Drug Risks
Cocaine  placental abruption
 perinatal death and prematurity
 IUGR (arterial vasoconstriction)

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 JWH, JM, AJS, VA

Heroin  IUGR
 Premature delivery
 NB not teratogenic
Cannabis  No known specific risk in pregnancy BUT mixed with
tobacco
Tobacco  IUGR
 Low birth weight (20% decrease for every 10/day)
 Perinatal death and prematurity
 Neonatal smoke exposure increases the risk of: sudden
infant death syndrome, resp infections and asthma
Alcohol  Foetal alcohol syndrome

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 JWH, JM, AJS, VA

Induction of Labour/ Post term delivery

 Mrs Branthwaite is a 33 year old woman at 42 weeks in her first

pregnancy
 She has reported reduced fetal movements, prompting an USS and CTG
 Although USS found growth parameters to be on the 50th centile and CTG
was reactive, she was found to be oligohydramniotic.

How would you assess the readiness of the mother for induction of labour?

Bishop s score:

Indications for induction of labour:

Maternal
 Post dates (ie 12 days beyond EDD)
 Pre eclampsia
 Diabetes
 Prolonged ROM
 Unexplained APH
 Deteriorating maternal illness
 Other maternal hypertensive disorders
Fetal
 Fetal growth restriction
 Rhesus reaction
 Twin pregnancy beyond 38 weeks
Placental
 Other evidence of placental insufficiency (oligohydramnios)

Social IOL is controversial. May be performed to satisfy domestic and

organisational needs of mother.
Mostly discouraged, so careful counselling is important

Mrs Branthwaite scores 8, so what would you recommend?

 Induction of labour

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 JWH, JM, AJS, VA

Counsel her on induction of labour:

 Why?
 Methods
 Contraindications
 Risks

Why?
 Pregnancies beyond 42 weeks have increased risk of:
o Still birth
o Fetal compromise in labour
o Meconium aspiration
o Mechanical problems at delivery

Methods:
1. Prostoglandins (PGE2) gel is inserted into the posterior vaginal fornix
 Best method in nulliparous women and most multiparous women, unless
cervix is very favourable
 Either starts labour, or ripens cervix for amniotomy
 Second dose may be given minimum 6 hours later, provided no uterine
activity
2. Induction with amniotomy+- oxytocin.
 Amnihook ruptures membranes ARM
 Oxytocin infusion normally started within 2hours if labour has not
ensued
 Oxytocin may be used alone if ROM already occurred
3. Natural induction
 Cervical sweeping involves passing a finger through cervix and stripping
between the membranes and the lower segment of the uterus.
 Painful

Contraindications:
Absolute:
 Acute fetal compromise
 Abnormal lie
 Placenta praevia
 Pelvis obstruction eg mass or deformity, causing cephalo-pelvic
disproportion
Relative:
 One previous c/s
 Prematurity

Management of Induced labour:

 Fetus is at risk because of indication for procedure and use of drugs
 Use of CTG normally from start to end
 Induction commonly increases time spent in early labour , so warn of
this
 Epidural encouraged as labour process may be long

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 JWH, JM, AJS, VA

Complications:
 Induction may fail and c/s or instrumental be required
 Paradoxically, hyperstimulation can occur, risking rupture and distress
 IOL in presence of previous c/s may result in uterine scar
 Long labours with syntocin predispose to PPH due to uterine atony

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 JWH, JM, AJS, VA

Infertility
History

 37 year old woman and 34 year old man

 PC: Two year of failure to conceive – good coital frequency
 Female:
o OHx: P 1+2 (SVD 13 years ago + TOP + 1st trimester miscarriage) – all with ex
husband
o GHx:
 Menarche: 11
 Periods used to be regular but are getting progressively irregular –
sometimes missing for 3 months – bleeding is moderate and lasts 4/7
 Nil pelvic pain, discharge or any dyspareunia
 Previously on OCP
 Never any previous STIs
 Nil previous gynae conditions e.g. PID
o PMH: Nil
o FHx: Nil
o SHx: Occasional ETOH; nil smoking or drugs; officer worker
 Male:
o Never fathered any previous children
o Fit and healthy
o Lawyer
o Nil previous: mumps, measles, surgery or trauma to testicles
Differential diagnosis
Female:

 Ovulation:
o PCOS
o BMI >29; BMI<19
o Hyper/ hypothyroidism
o Hyperprolactinaemia
 Anatomical
o Adhesions:
 Previous PID: especially chlamydia
 Surgery
 Endometriosis
 Endometrium:
o Fibroids
o Polyps
 Menopause/ premature ovarian failure
Male:

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 JWH, JM, AJS, VA

 Low sperm count/ lack of motility

 Infection
 Chronic conditions e.g. CF
 Chromosome defects e.g. Klinefelters and Kallmanns
 Trauma, surgery, malignancy
 Immune
 Coital dysfunction
Examination
Male:

 Testicular exam: volume, consistency, masses, absence of vas deferens, varicocele,

evidence of surgical scars
Female:

 Speculum and bimanual: pathology such as fibroids

Both:

 Height, weight, pulse, BP etc

Investigations
Male:

 Semen analysis
 If azoospermia – check testosterone, LH and FSH levels (could be hypogonadotrophic
hypogonadism which is easily correctable) + screen for CF and congenital absence of
vas deferens (variant of CF)
Female:

 Hormone:
o Testing HPO axis:
 Day 3: FSH
 Day 3: LH
 Day 21 progesterone
o Testosterone (high in PCOS)
o Prolactin (check for prolactinoma)
o Thyroid function test
o AMH – anti-mullerian – gives an indication of follicle reserve (is almost zero
by the time of the menopause)
 Urinary chlamydia test
 Tubal patency:
o Hysterosalpingography (HSG)
 Outpatient test – radio-opaque dye is passed in and an x-ray is taken
to look for dye spill from the end of the fimbrial tubes

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o Hysterosalpingocontrast sonography (HyCoSy)

 Same as above but using US
o Laparoscopy and dye
 Gold standard
 Gives information on – adhesions, endometriosis, fibroids and tubal
patency

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Intermenstrual Bleeding – Endometrial Polyps

History

 42 year old woman

 PC:
o IMB, duration 1-6 days – any time in cycle
o No associated pain
o No menopausal symptoms: hot flushes, night sweats, vaginal dryness etc
 GHx:
o Normally regular cycle 6/28; started periods at 12 y.o: LMP 10 days ago
o On POP for last 5 years
o Sexually active – regular male partner (husband)
o Smears UTD and negative
o No urinary or bowel symptoms
 OHx:
o P 3+2 (1st T miscarriage)
o Nil complications
 PMH: nil
 DHx: vitamin supplements + NKDA
 FHx: nil gynae cancer
 SHx: At home with husband and three kids – nil concerns. Works as lawyer
Differential Diagnosis

 Ovary/ adenexa:
o Malignancy
o Cysts
o Tubal inflammation - PID
o Endometriosis
 Endometrium:
o Malignancy
o Polyp
o Fibroid (submucosal)
 Cervix:
o Malignancy
o Ectropion
o Endocervical polyp
 Vagina:
o Atrophic vaginitis
o Trauma
 Pregnancy
o Abortion
o Placenta praevia
o Placental abruptoin

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 Systemic:
o Bleeding associated with contraception e.g. COCP
o Clotting disorders
Examination

 Abdomen: nil
 Speculum: slightly atrophic vagina and cervix but no cervical lesions and no bleeding
 Bimanual: uterus is non-tender, normal size, axial and mobile, no adnexal masses
Investigations

 Bloods: FBC, WCC and platelets – nil to note

 Transvaginal ultrasound which showed an endometrial polyp

Management

 Endometrial polyps can occur in women of any age but are more common in older
women. Polyps can be :
o Sessile or pedunculated
o Single or multiple
 <40
o Unlikely to be of any significance- sometimes cause IMB or discharge
o Only treat if symptoms persist >3months
 >40 and pre-menopausal:
o Most polyps are due to simple hyperplasia
o Should be considered for removal – mostly in outpatient setting by
hysteroscopy using a loop diathermy technique
o Obtain a histological report to exclude malignancy (although unlikely)
 Post-menopausal:
o Hysteroscopic removal + histology is mandatory as increased chance of
malignancy

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Condition – IVF (Primary Infertility)

Definition
Patients who cannot conceive after months of regular ( -3 times a week) sex. IVF is
one mechanism of helping these patients conceive.

History
A 31-year-old woman and her 34-year-old partner are referred by the general
practitioner because of primary infertility.

PC
They have been trying for over 2 years.
They have not been able to conceive at all.
She is having regular periods, so she is worried about what could be going on down
below.

PMH + PSH (MSC SOUR) – Obx and gynae hx

Woman’s history
They have been trying to conceive for over 2 years.
The woman has regular menstrual periods bleeding for 4 days every 28–30 days.
Her periods are not heavy and have never been painful.
There is no intermenstrual bleeding or dis- charge and no postcoital bleeding.
She has never been diagnosed with any sexually trans- mitted infections. Her last one
was a long time ago
The last smear was normal 1 year ago. She is a non-smoker and drinks alcohol very
occasionally.

The partner’s history:

The partner s only previous medical history was an appendectomy and a course of anti-
helicobacter therapy after he developed epigastric pain and was diagnosed with the
infection.
He previously smoked 20 cigarettes per day and drank up to 28 units of alcohol per
week but has now stopped smoking and significantly reduced his alcohol intake. He
works as buyer for a retail company.

Combined history:
The couple have intercourse 1–4 times per week and there is no reported sexual
dysfunction or pain on intercourse. They both deny recreational drug use.

DH and allergies
N/A
FMH
Her parents had no problems conceiving.
SH
Her partner previously heavy smoker and drinker.
System Review
N/A

Differential Diagnosis
Anovulation
Male factors
Tubal pathology
Endometrial pathology
Uterine pathology

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Up to 30% have more than one

Examination
Basic obs: 100% Sats, BP 110/65, HR 72
Abdominal examination:
On examination the woman has a body mass index of 23 kg/m2. There is no hirsutism or
acne. There are no signs of thyroid disease. The abdomen is soft and non-tender.
Speculum and bimanual palpation are unremarkable. Genital examination of the partner
is also normal.
Vaginal examination: N/A
Speculum: Normal
Bimanual: No extra masses felt

Investigations

In this case the laparoscopy showed bilateral hydrosalpinges and adhesions as well as
peri- hepatic violin-string adhesions. These findings are consistent with previous
infection with chlamydia (or more rarely gonorrhoea). It is not unusual to find such

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severe pelvic adhesions even when there has never been a clear clinical history of pelvic
infection or sexually transmitted infection. Although the infection may be long ago, it is
sensible to treat both the woman and her partner with a course of antibiotics for pelvic
inflammatory disease.

Management

If the tubes are found at dye test to be patent, then this would suggest that it is feasible
to attempt pregnancy with in utero insemination.
However if blocked tubes are confirmed then in vitro fertilization (IVF) is indicated.
Abnormal tubes are usually removed prior to IVF, as success rates for pregnancy are
better and ectopic pregnancy rate reduced after bilateral salpingectomy.
Medical
General advice should be given to take folic acid 4 μg daily to reduce the risk of neural
tube defects, and to the partner to minimize his alcohol intake.

COUNCIL THIS PATIENT ON THE BENEFITS AND RISKS OF IVF

Superovulation – multiple pregnancy

Obtaining the egg risks – Intraperitoneal haemorrhage.
Pregnancy complications – Higher risk of adverse events during pregnancy. Higher risk
of an ectopic pregnancy.

Alternatives to IVF:
Intracytoplasmic sperm injection (ICSI) – better for male factor infertility.
Oocyte donation.
Preimplantation genetic diagnosis (PGD)
Surrrogacy – if the woman s uterus is unable to carry children.

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Condition – IVF (Primary Infertility)

Definition
Patients who cannot conceive after months of regular ( -3 times a week) sex. IVF is
one mechanism of helping these patients conceive.

History
A 31-year-old woman and her 34-year-old partner are referred by the general
practitioner because of primary infertility.

PC
They have been trying for over 2 years.
They have not been able to conceive at all.
She is having regular periods, so she is worried about what could be going on down
below.

PMH + PSH (MSC SOUR) – Obx and gynae hx

Woman’s history
They have been trying to conceive for over 2 years.
The woman has regular menstrual periods bleeding for 4 days every 28–30 days.
Her periods are not heavy and have never been painful.
There is no intermenstrual bleeding or dis- charge and no postcoital bleeding.
She has never been diagnosed with any sexually trans- mitted infections. Her last one
was a long time ago
The last smear was normal 1 year ago. She is a non-smoker and drinks alcohol very
occasionally.

The partner’s history:

The partner s only previous medical history was an appendectomy and a course of anti-
helicobacter therapy after he developed epigastric pain and was diagnosed with the
infection.
He previously smoked 20 cigarettes per day and drank up to 28 units of alcohol per
week but has now stopped smoking and significantly reduced his alcohol intake. He
works as buyer for a retail company.

Combined history:
The couple have intercourse 1–4 times per week and there is no reported sexual
dysfunction or pain on intercourse. They both deny recreational drug use.

DH and allergies
N/A
FMH
Her parents had no problems conceiving.
SH
Her partner previously heavy smoker and drinker.
System Review
N/A

Differential Diagnosis
Anovulation
Male factors
Tubal pathology
Endometrial pathology

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Uterine pathology
Up to 30% have more than one

Examination
Basic obs: 100% Sats, BP 110/65, HR 72
Abdominal examination:
On examination the woman has a body mass index of 23 kg/m2. There is no hirsutism or
acne. There are no signs of thyroid disease. The abdomen is soft and non-tender.
Speculum and bimanual palpation are unremarkable. Genital examination of the partner
is also normal.
Vaginal examination: N/A
Speculum: Normal
Bimanual: No extra masses felt

Investigations

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In this case the laparoscopy showed bilateral hydrosalpinges and adhesions as well as
peri- hepatic violin-string adhesions. These findings are consistent with previous
infection with chlamydia (or more rarely gonorrhoea). It is not unusual to find such
severe pelvic adhesions even when there has never been a clear clinical history of pelvic
infection or sexually transmitted infection. Although the infection may be long ago, it is
sensible to treat both the woman and her partner with a course of antibiotics for pelvic
inflammatory disease.

Management

If the tubes are found at dye test to be patent, then this would suggest that it is feasible
to attempt pregnancy with in utero insemination.
However if blocked tubes are confirmed then in vitro fertilization (IVF) is indicated.
Abnormal tubes are usually removed prior to IVF, as success rates for pregnancy are
better and ectopic pregnancy rate reduced after bilateral salpingectomy.
Medical
General advice should be given to take folic acid 4 μg daily to reduce the risk of neural
tube defects, and to the partner to minimize his alcohol intake.

COUNCIL THIS PATIENT ON THE BENEFITS AND RISKS OF IVF

Superovulation – multiple pregnancy

Obtaining the egg risks – Intraperitoneal haemorrhage.
Pregnancy complications – Higher risk of adverse events during pregnancy. Higher risk
of an ectopic pregnancy.

Alternatives to IVF:
Intracytoplasmic sperm injection (ICSI) – better for male factor infertility.
Oocyte donation.
Preimplantation genetic diagnosis (PGD)
Surrrogacy – if the woman s uterus is unable to carry children.

Steps in fertility management:

● Lifestyle: optimise BMI, reduce alcohol intake, smoking, stress, occupational risk
● If specific cause is found:
○ Anovulatory e.g. PCOS
■ Clomiphene
■ Metformin (if BMI>25 and unresponsive to clomiphene)
■ Gonadotrophins
■ Pulsatile GNRH
■ Dopamine agonists
○ Tubal patency issues
■ Tubal microsurgery
■ Surgical ablation/ resection of endometriosis
■ Male: correct blockages
● No specific cause found:
○ IUI for 6 cycles
○ IVF (3 cycles on NHS if 23-39; 1 cycle if 40-42)
○ Intracytoplasmic sperm injection
○ Donor insemination
○ Oocyte donation
○ Embryo donation
○ Gamete intrafallopian transfer

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Lower genital tract infections- Vaginal Discharge (Bacterial vaginosis)

Defintion: Sexually associated bacterial

infection. Growth and increase in anaerobic
species (Gardnerella vaginalis + Mycoplasma
hominis) with simultaneous reduction in the
lactobacilli in the vaginal flora causing an
increase in vaginal pH making it more alkaline.

History
19-year-old woman
PC- Vaginal discharge
HPC- /5 ago, creamy colour, non-ithcy,
malodourous- fishy . 2-3 previous episodes
before the pregnancy but that resolved
spontaneously. There is no bleeding or
abdominal pain.
Gynae – She has been with her partner for 3
years and neither of them have had any other
sexual partners. They have always used
condoms until 3 months ago. She has never had
a cervical smear test. No contraception being
used, used to use COCP.
Obs – G1 – 9 weeks into first pregnancy
Urinary- Nil
Bowel- Nil
PMH- Nil
PSH- Nil
FMH - Nil
SH - Nil

Differential Diagnosis for vaginal discharge

 BV- smooth, mild discharge
 Trichomonas - profuse, sometimes
frothy discharge with cervicitis
Other causes of vaginal discharge
1. Infective

o Sexually transmitted
 Trichomonas
 Chlamydia

 Gonorrhoea
o Non-sexually transmitted
 Candida
 Bacterial vaginosis
2. Physiological- most common cause of discharge in women of reproductive age. Diagnosis of
exclusion. Cyclical in nature.
o Pregnancy (non-offensive, non-itchy discharge is normal in pregnancy, goes against this
case)
o Ovulation

3. Cervical
o Ectopy – exposed glandular columnar epithelium of endocervix canal, produces
increased discharge.
o Polyp

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4. Foreign body
5. Iatrogenic – Contraception

At this stage the patient can be treated empirically for VVC or BV without an examination, if she gives a
clinical and sexual history that is:

 Consistent with a non-infective cause for her discharge

 Low risk for STIs

 She has no symptoms indicative of upper genital tract infection (pelvic pain and deep
dyspareunia).
 She is able to return for follow-up if symptoms do not resolve

You should safety net in these circumstances by saying if her symptoms do not settle or if they re-
occur she should make an appointment for swabs.

Examination
Basic obs: Normal
Abdominal examination: Normal
Vaginal examination
External genitalia appear normal
Speculum: Small amount of smooth grey discharge is seen coating the vagina walls. There is a small
cervical ectropion (causes clear discharge not malodorous and creamy) that is not bleeding.
Bimanual: Not indicated in this case

Investigations
• Swabs:
o 
 A high vaginal swab (HVS) taken from the lateral wall and posterior vaginal fornix can be
used for both dry and wet microscopy.
 This will test for BV, T. vaginalis and yeast.
o Endocervical swab to test for gonorrhea and Chlamydia. This is usually a nucleic acid
amplification test (NAAT).
 Perform gonorrhea swab first as you want to sample the discharge and
chlamydia you want to collect the cells as it is an intracellular organism.
o If she had refused examination, a self-obtained high vaginal swab and low vaginal NAAT
swab could be collected.

NB: Amsel criteria (3 of 4 criteria) for diagnosis of BV:

1. Presence of clue cells on microscopic examination. Clue cells are epithelial cells which are
covered with bacteria giving a characteristic stippled appearance on examination
2. Creamy greyish white discharge which is seen on naked eye examination
3. Vaginal pH of more than 4.5 (alkaline)
4. Release of a characteristic fishy odour on addition of alkali: 10% potassium hydroxide

Management

Conservative
 Spontaneous onset and remission is typical with BV, and 50 per cent of women are
asymptomatic.
 Avoidance of vaginal douching, shower gel, and antiseptic agents or shampoo in the bath, as
these interfere with the normal flora (lactobacilli) and allow an increase in BV organisms.
Medical
 BV only needs treatment if the woman is symptomatic or pregnant (can lead to late second
trimester miscarriages and preterm labour in pregnancy).
 Metronidazole for 5-7days

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Menopause and HRT

Definition
 Menopause: permanent cessation of menstruation resulting from loss of ovarian
follicular activity leading to a fall in oestradiol levels below that needed for endometrial
stimulation. Median age is 52. It is recognised to have occurred after 12 consecutive
months of amenorrhoea.
 Perimenopause: the time beginning with the first features of the approaching
menopause such as vasomotor symptoms and menstrual irregularity and ends 12
months after the last period.
 Premature menopause/ovarian failure: menopause before the age of 45.

History
Overview: 32 year old woman presents to GP.
PC: 32-year-old woman complains that she has not had a period for 3 months.
HPC
 Four home pregnancy tests have all been negative.
PMH + PSH (MSC SOUR) – Obx and gynae hx
 Menstrual – She started her periods at the age of 15 years and until 30 years she
had a normal 27-day cycle. After the birth of her daughter she had normal cycles
again for several months and then her periods stopped abruptly.
 Sexual – She reports symptoms of dryness during intercourse
 Contraception – She was using the progesterone only pill for contraception while
she was breast-feeding and stopped 6 months ago as she is keen to have another
child.
 Smear – There is no relevant gynaecological history.
 Obstetric- She had one daughter by normal delivery 2 years ago, following which
she breast-fed for 6 months.
 Urinary – Nil
 Rectal – Nil
 Medical conditions / Previous surgery- Hypothyroid for 10 years
DH and allergies- Th ro i e μg per da
FMH- Nil
SH- She does not take any alcohol, smoke or use recreational drugs.
System Review
 General – Experienced sweating episodes at night as well as episodes of feeling
extremely hot at any time of day.
 Neuro – Nil
 Cardio – Nil
 Resp- Nil
 Gastro – Nil
 Musc – Nil
 Derm – Nil

Examination
Basic obs: Normal
Examination results unremarkable

Investigations
Doctor can usually diagnose menopause clinically
But if any doubt:

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 FBC
 TFTs (thyroid disease can cause hot flushes)
 FSH days 1-4, will be high if in the menopause
 LH, oestradiol and progesterone
 Anti-Mullerian hormone: measure of ovarian reserve should be low.
 Other blood tests:
 Bone density estimation: DEXA scan or using biochemical markers of bone
metabolism.
 Catecholamines and 5-HIAA (phaeo and carcinoid syndrome)

Differential diagnosis
 Premature menopause
o Amenorrhea, vaginal dryness and hypo-oestrogenic symptoms
o Very high gonadotropin levels
 Sheeha s s dro e – would have inhibited breast feeding and all menstruation
since delivery
Causes of premature menopause:
 Premature menopause (before the age of 40 years) occurs in 1 per cent of women
and has significant physical and psychological consequences.
 Usually idiopathic
 Primary- something wrong with the actual ovaries
o Chro oso e a or alities e.g. Tur er s a d Fragile X
o Autoi u e disorder e.g. h poth roidis a d Addiso s
o Enzyme deficiencies e.g. galactosaemia
 Secondary- something happens to the ovaries
o Surgical menopause e.g. bilateral oophorectomy and hysterectomy
o Chemotherapy or radiation
o Infections e.g. TB
Management
Further investigations
 Repeat gonadotrophin level (4-6 weeks apart) is required to confirm the result and
exclude a mid-cycle gonadotrophin surge or fluctuating gonadotrophins.
 Bone scan is necessary for baseline bone density and to help in monitoring the
effects of hormone replacement.
 Chromosomal analysis identifies the rare cases of premature menopause due to

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fragile X s dro e or Tur er s s dro e osai is .

Explain to women with premature ovarian insufficiency:

 The importance of starting hormonal treatment either with HRT or a combined
hormonal contraceptive and continuing treatment until at least the age of natural
menopause (unless contraindicated).
 That the baseline population risk of diseases such as breast cancer and
cardiovascular disease increases with age and is very low in women aged under 40.
 That HRT may have a beneficial effect on blood pressure when compared with a
combined oral contraceptive.
 That both HRT and combined oral contraceptives offer bone protection.
 That HRT is not a contraceptive.

Medical
 Osteoporosis may be prevented with oestrogen replacement and with progesterone
protection of the uterus.
 Traditional HRT preparations or the combined oral contraceptive pill are effective,
the latter aki g o e feel ore or al , ith a o thl ithdra al leed a d a
ou g perso s edi atio .
 Offer sex steroid replacement with a choice of HRT or a combined hormonal
contraceptive to women with premature ovarian failure.
Extra
 Information on the condition
 Patient support organizations are a good source for women experiencing such an
unexpected and stigmatizing diagnosis.

Menopause

Symptoms and consequences

 Short term
o Vasomotor symptoms: hot flushes and night sweats  sleep disturbance,
tiredness, irritability
 Long term
o Urogenital problems: vaginal atrophy  dyspareunia and cessation of sexual
activity, dryness, itchiness, burning. Urinary symptoms
o Sexual problems: loss of sexual desire, loss of sexual arousal, problems with
orgasm and sexual pain

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o Cardiovascular disease: increase to equal the rate of CVD in men.

o Osteoporosis  fractures

Management of menopause
1. Give information to menopausal women and their family members or carers (as
appropriate) that includes:
 An explanation of the stages of menopause
 Common symptoms
 Lifestyle changes and interventions that could help general health and
wellbeing- great opportunity to intervene in a patient to adopt positive lifestyle
practices.
 Benefits and risks of treatments for menopausal symptoms
 Long-term health implications of menopause.
2. Explain to women that as well as a change in their menstrual cycle they may
experience a variety of symptoms associated with menopause, including:
 Vasomotor symptoms (for example, hot flushes and sweats)
 Musculoskeletal symptoms (for example, joint and muscle pain)
 Effects on mood (for example, low mood)
 Urogenital symptoms (for example, vaginal dryness)
 Sexual difficulties (for example, low sexual desire).
3. Give information about the following types of treatment for menopausal symptoms:
 Hormonal, for example HRT
 Non-hormonal, for example clonidine
 Non-pharmaceutical, for example cognitive behavioural therapy.
4. Help to encourage women to discuss their symptoms and needs.
5. Info about contraception to women who are in the perimenopausal and
postmenopausal phase.
6. Discuss with women the importance of keeping up to date with nationally
recommended health screening.

HRT
 Most women do not have symptoms enough for treatment, only 1 in 10 women see
a doctor about their symptoms. Without treatment short-term complications last 2-
5 years, but in some women they last much longer.
 HRT consists of oestrogen alone for women who have had a hysterectomy or
combined oestrogen and progesterone for those who have not.
HRT can be started for:
1. Motor symptoms
o Offer women HRT for vasomotor symptoms after discussing with them the
short-term (up to 5 years) and longer-term benefits and risks.
o Do not routinely offer selective serotonin reuptake inhibitors, serotonin and
norepinephrine reuptake inhibitors or clonidine as first-line treatment for
vasomotor symptoms alone.
2. Psychological symptoms
o Consider HRT to alleviate low mood that arises as a result of the
menopause.
o Consider cognitive behavioural therapy to alleviate low mood and anxiety
that arise as a result of the menopause.

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o Ensure that menopausal women and healthcare professionals involved in

their care understand that there is no clear evidence for serotonin reuptake
inhibitors or serotonin and norepinephrine reuptake inhibitors to ease low
mood in menopausal women who have not been diagnosed with
depression.
3. Altered sexual functions
o Consider testosterone supplementation for menopausal women with low
sexual desire if HRT alone is not effective.
4. Urogenital atrophy
o Offer vaginal oestrogen to women with urogenital atrophy (including those
on systemic HRT) and continue treatment for as long as needed to relieve
symptoms.
o Consider vaginal oestrogen for women with urogenital atrophy in whom
systemic HRT is contraindicated, after seeking advice from a healthcare
professional with expertise in menopause.
o If vaginal oestrogen does not relieve symptoms of urogenital atrophy,
consider increasing the dose after seeking advice from a healthcare
professional with expertise in menopause.
o Explain to women with urogenital atrophy that:
 Symptoms often come back when treatment is stopped
 Adverse effects from vaginal oestrogen are very rare
 They should report unscheduled vaginal bleeding to their GP.
 Advise women with vaginal dryness that moisturisers and lubricants
can be used alone or in addition to vaginal oestrogen.
o Do not offer routine monitoring of endometrial thickness during treatment
for urogenital atrophy.

Classes of drug
HRT should be started at the lowest dose to reduce symptoms.
 Oestrogens: can be given orally, transdermally (patch or gel), vaginally or
subcutaneously (implant). Two types exist: natural (oestradiol, oestrone, oestriol)
and synthetic (ethinyloestradiol). The latter is used in the COCP and not HRT.
 Progestogens: can be given orally, transdermally (patch) or directly into the uterus
(IUS). The IUS has the additional advantage of contraception in the perimenopausal
o a a d is the o l a i hi h a o leed regi e a e a hie ed in a peri-
menopausal woman.
 Tibolone: has oestrogenic, progestogenic and androgenic properties. Used in peri-
menopausal women who desire amenorrhea and treats vasomotor, psychological
and libido symptoms. It also conserves bone mass.
 Androgens: Testosterone can be administered as a patch or subcutaneous implant.
Can be used to improve libido but is not successful in all women.

HRT regimens
 Oestrogen alone: women after hysterectomy. If there is residual monthly bleeding
then a remnant of the endometrium may be present in the cervical stump.
 Combined oestrogen and progestogen (women with a uterus): to reduce the risk of
endometrial cancer. Take oestrogen every day. Progestogen can be given for 10-14
days every 4 weeks (monthly bleed- 28 day cycle), for 14 days every 13 weeks (3-
monthly bleeds) or continuously (no bleed).
 Perimenopausal women or periods just stopped: cyclical combined therapy.
Alternatively, IUS with oral or patch oestrogen may be used.

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 Postmenopausal women: continuous combined regimens should be used. IUS may

be used but it may be technically more difficult to insert them in older women.
 Topical oestrogens: oestriol by cream or pessary or oestradiol by tablet or ring.
Used to treat urogenital symptoms. They do not increase systemic oestrogen levels
so additional progestogen to protect the endometrium is not required.

Benefits of HRT
 Menopausal symptoms hot flushes, vaginal soreness, dyspareunia, urinary
frequency and urgency respond well to oestrogen. Sexuality may be improved but
may need additional testosterone
 Osteoporosis: reduces fracture risk
 Colorectal cancer: reduces the risk by one third.

Risks
 Breast cancer
o Combined HRT > Oestrogen-only HRT
o Increases the longer you use HRT.
o If you have been off HRT for 5 years, same risk of breast cancer as someone
ho has t take H‘T.
o Background risk of 15/1000 of developing breast cancer. If you take HRT for
5 years from the age of 50 an extra four people will develop breast cancer.
 Endometrial cancer
o Unopposed oestrogen increases the risk
o Explain to women with a uterus that unscheduled vaginal bleeding is a
common side effect of HRT within the first 3 months of treatment but
should be reported at the 3-month review appointment, or promptly if it
occurs after the first 3 months
 VTE:
o Combined HRT > Oestrogen-only HRT
o Other routes of administration are associated with a lower risk e.g.
transdermally.
o HRT x 2 risk of VTE but background risk is small, so the overall impact of
increase is very small.
o Highest risk in first year of use.
 Stroke
o Small increased risk of stroke in women taking either oestrogen-only or
combined HRT.
o Safer in terms of your risk of stroke if you use HRT patches containing low
dose oestrogen rather than HRT tablets or patches containing higher doses
of oestrogen.

Contraindications
 History of endometrial, ovarian or breast cancer.
 History of blood clots (DVT or a PE) or family history of blood clots.
 History of uncontrolled high blood pressure, heart attack, angina or stroke.
 Pregnant.
 Undiagnosed breast lump.
 Abnormal vaginal bleeding.

Duration therapy
 Review each treatment for short-term menopausal symptoms:

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o At 3 months to assess efficacy and tolerability

o Annually thereafter unless there are clinical indications for an earlier review
(such as treatment ineffectiveness, side effects or adverse events).
 Refer women to a healthcare professional with expertise in menopause if:
o Treatments do not improve their menopausal symptoms or they have on-
going troublesome side effects.
o They have menopausal symptoms and contraindications to HRT
o There is uncertainty about the most suitable treatment options for their
menopausal symptoms.
 HRT continued for up to 5 years and then stopped to see if symptoms have resolved
or if they warrant continuation
 Osteoporosis: treatment may need to be life-long as bone density reduces as soon
as it is stopped. Younger women may later change to bisphosphonates because of
the increased risk of breast cancer with long-term HRT
 Premature menopause: women are usually advised to continue with HRT until the
median age of the natural menopause (52)
 Offer women who are stopping HRT a choice of gradually reducing or immediately
stopping treatment:
o Gradually reducing HRT may limit recurrence of symptoms in the short term
o Gradually reducing or immediately stopping HRT makes no difference to
their symptoms in the longer term

Other treatments besides HRT

 For hot flushes and night sweats:
o Progestogens Clonidine (limited value)
o SS‘I s are effe ti e i treati g hot flushes i short-term studies.
o Gabapentin (limited evidence)
 Vaginal atrophy: Oestrogen cream or pessary ( use everyday for 3 weeks then 2 a
week for a couple of months), lubricants and moisturisers
 Osteoporosis: HRT used to be considered front line for osteoporosis but no longer
used due to the potential risks of the treatment.
o Bisphosphonates: used in the prevention and treatment of osteoporosis.
o Strontium ranelate: decreases the risk of vertebral and hip fractures
o Raloxifene: SERM reduces the risk of fractures by 30-50%
o PTH: reduces the risk of vertebral but not hip fractures
o Denosumab: monoclonal antibody to RANK-L and reduces osteoclast
activity. Useful when oral bisphosphonates are contra-indicated or with
malabsorption.
o Calcium and vitamin D supplements (if insufficiency exists). There is a risk of
renal stones and CVD in women who have a replete diet.

Alternative treatments and complementary medicines

Little evidence that they work but they are still widely used:
 Phytoestrogens (isoflavones found in soya beans and chickpeas, lignans found in
oilseeds)
 Herbal remedies: black cohosh, kava kava, evening primrose, dong quai, gignko,
ginseng and wild yam cream
 Progesterone transdermal cream: no proven benefit for symptoms, bone or
endometrium protection.

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Menorrhagia/ heavy menstrual bleeding (HMB)

Definition of mennorhagia:
 >80mL per period
 NICE: e cessi e e strual loss that i terferes ith the o a ’s ph sical,
emotional, social and material quality of life
History
 45-year-old female
 PC: 4 month history of HMB + irregular cycles (approx. 14/28-42) – very
distressing as interferes with work and social life
 Gynae: normal age of menarchy; previously regular cycles; normal smear and
up to date; not using OCP or IUS/ IUD
 Obs: Para 2+0 – both c section
 PMH: Nil clotting disorders, thyroid disease, HTN or diabetes
 Family history: nil gynae, colon or breast cancer OR clotting diseases

Differential diagnosis

Endometrial:
 Dysfunctional uterine bleeding
 Fibroids
o Urinary symptoms
 Endometrial polyp
o IMB/ PCB
 Endometrial cancer
o Family history
o Risk increases between 40 and 55
o Risk factors: obesity, nulliparity, PCOS, unopposed oestrogen,
tamoxifen, feminizing ovarian tumours (thecoma/ granulosa cell
tumours)
 Endometrial hyperplasia
 Adenomyosis
Cervical
 Cervical polyps
o IMB/PCB
 Cancer
General
 Clotting disorders
o Excessive bruising, PPH, previous post op bleeding/ dental work
 Thyroid disease
o Weight change, fatigue, skin changes etc
 Pelvic inflammatory disease
o Vaginal discharge
 Drug therapy e.g. warfarin

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Examination

General
 BMI: 35
 No signs of anaemia (pallor or tachycardia)

Abdominal exam
 Nothing to note but difficult due to BMI
 Palpating for masses due to fibroids, adenomyosis or malignancy

Bimanual
 Similar to abdominal

Speculum exam
 Nothing to note
 Looking for: polyps, ecotopy, signs of obvious malignancy

Investigations

FBC
 Anaemia
 This patient – 110g/L
Test for coagulation disorders
 Only consider in those with HMB since menarche
Thyroid test
 If consider thyroid disease
High vaginal/ endocervical swabs
 Discharge/ risk factors for PID
Pelvic ultrasound
 Identify: structural abnormalities, endometrial polyps, uterine fibroids
 Indications:
o Pelvic mass is palpable on examination
o Symptoms suggest an endometrial polyp
o Drug therapy is unsuccessful
Endometrial biopsy
 Indications for pipelle in outpatients:
o Age >45 years
o Irregular/ IMB
o Drug therapy unsuccessful
 Indications for outpatient hysteroscopy and endometrial biopsy:
o Pipelle not tolerated
o Pipelle biopsy insufficient
o USS indicates structural abnormality e.g. endometrial polyp or
submucosal fibroid
 Consider inpatient hysteroscopy if not tolerated/ cervical dilation is required

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Medical Management of HMB

Method Efficacy Dose Advantages Disadvantages

NSAIDs e.g. 20-25% 500m Analgesic Contradindicated in
mefananic acid g TDS properties for duodenal ulcer/
(reduces dysmenorrhoea severe asthma
prostaglandin Conception
production) issues?
Tranexamic acid 50% 1g Fine for ? increase VTE risk
QDS conception
Only take on
heavy days
COCP Doubles up as Cannot be used in
effective those with
contraceptive contraindications
Norethisterone Days No contraceptive
(cyclical 6 to value
progesterone) 26 of Breakthrough
cycle bleeding
GnRH agonists (act Good for Irregular bleeding
on pituitary – associated Sweating and
hypooestrogenism) dysmenorrhoea flushing
Examples: goserelin Only short term use
(subcut depo), (6 months unless
decapeptyl (subcut combined with
depo), buserelin HRT)
(nasal spray)
Levonorgestrol IUS/ 95% Contraceptive Irregular menses
mirena decrease cover and bleeding for
RCOG recommends in MBL Effective for first 3-9 months
use instead of 30% associated
surgery in most amenorrh dysmenorrhoea
cases oeic after
one year

Surgical management

Type Indications Side Effects

Endometrial ablation: - Normal or small Vaginal discharge, pelvic
- Impedence uterus (<10 weeks) pain, infection
controlled - No desire to May not cause
(novasure) conceive amenorrhoea and further
- Thermal uterine - Small fibroids surgery may be required
balloon (<3cm diameter)
(thermachoice)
- Microwave
ablation

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(microsulis)
Hysteroscopic resection -Submucosal fibroid/ Infection, adhesions
of fibroid fibroid polyp (which may damage
- Fibroid size >3cm fertility), perforation,
- Desire to conceive haemorrhage, recurrence
Myomectomy - Large fibroids As above
- Want to retain
fertility
Uterine artery - Want to retain Vaginal discharge, post
embolization uterus embolization syndrome
- Want to avoid full (pain, fever, vomiting)
surgery POF
- Fibroids >3cm Rarely haemorrhage and
septicaemia
Hysterectomy - Final option when All surgical risks
NB leave ovaries to avoid all others failed
early menopause unless - No desire to
family history of cancers in maintain fertility
which case give HRT

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Miscarriage
Definition: Death of fetus <24 weeks
History
Overview: Mrs Smith, a 24-year-old para 0+1 is brought in to the early pregnancy
assessment unit by her husband with fresh vaginal bleeding.
PC: PV Bleeding
HPC
 She is very anxious as she had a similar episode in a previous pregnancy and
miscarried.
 A urine pregnancy test, which she did at home 2 days ago, was positive.
 Mrs Smith tells you that she had noticed fresh red blood, which was only spotting on
wiping herself.
 It was associated with cramping lower abdominal pain.
 She describes the pain as mild in intensity, non-radiating and present for the last
hour.
 She has not taken any analgesic as yet.
PMH + PSH (MSC SOUR) – Obx and gynae hx
 Menstrual – She has a regular = 5/30–35 day cycle. Her last period was 6 weeks
ago.
 Sexual + Cpntraception – Regular sexual partner. Used the COCP before starting to
conceive a child with no problems. Never had a sexually transmitted infection.
 Smear – No smears yet
 Obstetric- Her previous pregnancy was a spontaneous conception 8 months ago.
Unfortunately, she had a miscarriage at 7 weeks after an episode of spotting at 6
weeks’ gestation. She is terrified that this is going to happen again. She and her
partner have been trying to conceive since her last miscarriage. She had her last
miscarriage when she was on holiday, and no hospital records are available.
 Urinary – No changes
 Rectal – No changes
 Medical conditions / Previous surgery- Nil
DH and allergies- Nil
FMH- Nil
SH- Lives at home with partner. Does ’t dri k s oke or take re reatio al drugs.
System Review
 General – Nil
 Neuro – Nil
 Cardio – Nil
 Resp- Nil
 Gastro – Nil
 Musc – Nil
 Derm – Nil

Examination
 What would you look for in physical examination? 

o General examination
o Abdominal examination
 Elicit signs of rebound tenderness and acute abdomen (ectopic pregnancy)
o Pelvic examination
o Speculum examination

Basic obs: The heart rate is 68/min and blood pressure is 108/70mmHg.

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General observation: Does not look pale

Abdominal examination: Her uterus is not palpable on abdominal examination. There is
tenderness in the suprapubic area but there is no guarding or rigidity
Vaginal examination
Speculum: The cervical os is closed and there is a small amount of fresh blood on her pad. No
further bleeding can be seen from the external os. Her cervix is long with no evidence of
ballooning.
Bimanual: Bimanual examination does not reveal any mass or tenderness.

Type of miscarriage Clinical presentation

Threatened Per vaginal painless light bleeding
Speculum: Closed os
Inevitable Per vaginal painful heavy bleeding
Speculum: Open os
Incomplete Per vaginal painful heavy bleeding
Speculum: Open os with products of conception still present
Complete Per vaginal slightly painful light bleeding
Speculum: Closed os
Missed Per vaginal painless minimal bleeding
Speculum: Closed os

Investigations
1) Full blood count- a full blood count will assess if she has had a significant blood loss.
2) Blood group and save- she had her last miscarriage elsewhere we do not have any
records of her blood group. You need to identify if she is rhesus negative as if she
has further heavy bleeding she may require transfusion.
3) Ultrasound of the pelvis. A viable pregnancy can be seen from 5 ½ weeks by trans-
vaginal scan. You should warn her that we might not be able to see a pregnancy
even with a transvaginal scan, even if it is intrauterine, because of her early
gestatio . Although she gi es a history of eeks’ a e orrhoea, she ay be only 5
eeks’ preg a t as her y le le gth is 30–35 days. A pelvic ultrasound scan of the
pelvis is helpful in ruling out ectopic pregnancy. Where the crown–rump length
exceeds 6mm, a fetal heartbeat should be visible on transvaginal ultrasound in all
cases of a viable pregnancy.
 Intrauterine pregnancy- In addition to the presence of an intrauterine
gestation sac with yolk sac and fetal pole, there should be presence of a
fetal heart (seen pulsating) to call it a viable pregnancy.
 Ectopic pregnancy- If the uterine cavity is empty or if there is no definite
sign of intrauterine pregnancy (presence of at least a yolk sac or fetal pole),
you need to consider ectopic pregnancy.
 Molar pregnancy- The uterus is enlarged in size and reveals the classic
snowstorm appearance of mixed echogenic appearance indicating hydropic
villi and intrauterine haemorrhage
4) Serum and urine βHCG - The βHCG should double in 48 hours in cases of an ongoing
intrauterine pregnancy. If it
 rises, but less than double, it is an ectopic pregnancy
(66%). 
 If it falls to half in 48 hours it suggests miscarriage. 
 In cases of molar
pregnancy, very high levels of βHCG 
can be seen.

N.B- Despite high-resolution ultrasound, you may not be able to see evidence of
intrauterine pregnancy at trans- vaginal ultrasound scan if the levels of βHCG are less than
1000IU/L
.

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Results
 Ultrasound
o Her pelvic ultrasound scan reveals a thickened endometrium.
o A very small 2-mm sac is seen which cannot be differentiated from a pseudosac.
There was no evidence of fetal pole or yolk sac.
o Her right ovary is normal and the left ovary shows a 2-2.5cm cyst.
o There is minimal free fluid in the pouch of Douglas and an ectopic pregnancy
cannot be ruled out.
 BHCG
o βHCG result shows a value of 412IU/L and her blood group result shows that she
is group O rhesus negative.
 FBC
o Her full blood count is normal. 


Management
This case
 Make her return 48 hours later for repeat BHCG.
o She returns 48 hours later for a repeat βHCG having had a further episode of
spotting in the morning. The repeat blood test shows a value of 880IU/L.
 You should reassure her because her serum βHCG has doubled in 48 hours
it is most
likely an early o goi g i trauteri e preg a y as she ay e o ly eeks’ preg a t
considering her 30–35 day cycle.
 Ultrasound scan is not useful at present as the values of βHCG are still less than 1000
IU/L
 She should e ad ised to o e a k i a eek’s ti e for a ultrasound scan
 A 24-hour contact number for the early pregnancy assessment unit should be given
in case she has further questions

 Further support should be offered as the couple are very anxious
 You need to explain to her that one miscarriage is very common. Up to 15–20% of
pregnancies miscarry.
 Investigations for miscarriage are not advised until a couple has had at least three
consecutive miscarriages

Management (inevitable, incomplete and missed)

Conservative/ expectant
 1st line for 7–14 days as the first-line management strategy for women with a
confirmed diagnosis of miscarriage
 Allow it to be passed naturally
Medical
 Misoprostol (prostaglandins) (do not offer mifepristone)
 Take pregnancy (βHCG) test after 3 weeks
o +ve may indicate ectopic/molar pregnancy
Surgical
 ERPC (evacuation of retained products of conception)
o Manual vacuum aspiration under local anaesthetic in an outpatient/clinic
setting or surgical management in a theatre under general anaesthetic.
o Offer anti-D rhesus prophylaxis to all rhesus negative women who have a
surgical procedure to manage a miscarriage
Counselling services

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N.B: Success rates are greater in medical and surgical management for missed miscarriage
and greater for expectant management with incomplete.

Miscarriage
 Occurs in 20% of known pregnancies
 More likely earlier in the pregnancy (1st trimester)
 50% caused by fetal chromosomal abnormalities.
 RFs:
o Age
o Obesity
 Causes:
o Infection
o Drugs, smoking, alcohol
o SLE (APS) or other thrombophilia
o Anatomic
 Acquired
 Fibroids
 Asher a ’s sy dro e (fi rosis or
scarring of the uterus)
 Cervical incompetence
 Congenital
 Septate uterus
 Bicornuate uterus
o Endocrine
 Progesterone deficient
 Thyroid, diabetes and hyperprolactinaemia

Recurrent miscarriage
= 3+ consecutive miscarriages
 RFs
o Age
o Obesity

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o SLE (APS)
 Causes
o Idiopathic (50%)
o Anatomic (25%)
 Acquired
 Asher a ’s sy dro e
 Cervical incompetence
 Fibroids
 Congenital
 Septate uterus
 Bicornuate uterus
o Antiphospholipid syndrome (15%) or other thrombophilia
o Endocrine
 PCOS, Thyroid, Diabetes
 Progesterone deficient
o Infection e.g. Bacterial Vaginosis
o Drugs, smoking and alcohol
o Fetal chromosomal abnormalities (1%)
 Commonly causes miscarriage but rarely causes recurrent
miscarriage.
Anti-phospholipid syndrome
= autoimmune condition of thrombosis
 Associated with SLE
 Signs/symptoms:
o Recurrent miscarriage (usually 1st trimester)
o Arterial & Venous Thrombosis e.g. DVT, PE, stroke, MI
o Thrombocytopenia
 Complications:
o IUGR
o Pre-eclampsia
o Pre-term labour
 Diagnosis:
The presence of one of the clinical features:
 Three or more consecutive miscarriages 

 Mid-trimester fetal loss 

 Severe early-onset pre-eclampsia, intrauterine growth restriction or abruption 

 Arterial or venous thrombosis 

And haematological features: 

 Anticardiolipin antibodies or lupus anticoagulant detected on two occasions at
least 6 weeks apart 

 Management:
o Medical from the time of positive pregnancy test
 Aspirin
 LMWH
 Steroids
o Reassurance ultrasound scans and support improve outcome in women with
recurrent loss.

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Obstetric Cholestasis

Presentation:
 36 y/o woman complaining of 2/52 history of itching
 Initially over soles and palms, but now diffuse
 Used emollient cream for relief, but now not working
 Not aware of any change to washing powder etc and no one else suffering
from symptoms
 34 weeks gestation in first ongoing pregnancy, having had two previous
miscarriages
 No discharge or bleeding
 Movements more than 10 in 12 hours
 No abdo pain but some Braxton Hicks contractions

Examination:
Maternal
 Looks systemically well
 Blood pressure 118/76, pulse 82/min
 No visible rash on face, trunk, limbs, hand or feet.
 Some excoriation marks
Fetal:
 Symphysiofundal height 34.5cm
 Uterus soft and non-tender
 Cephalic with 4/5 palpable abdominally

Investigations:
 FBC- anaemia
 U&Es- kidney injury
 LFTs- hepatitis/jaundice. Use pregnancy-specific ranges
 Bilirubin
 Urinalysis
 Liver ultrasound- obstruction
 Fetal ultrasound for reassurance

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Differential diagnosis:
 Obstetric cholestasis
 Contact dermatitis/eczema
 Hepatitis
 HELLP

The woman is suffering from obstetric cholestasis (OC). This is a pregnancy-

specific con- dition in which there is intrahepatic reduction of bile excretion from
the liver, causing a build-up of serum bile acids. It usually develops in the third
trimester. The effect on the mother is of itching, which may be very distressing.
In more severe cases the liver function or coagulation become deranged and if
they do then other diagnoses such as HELLP syndrome (haemolysis, elevated
liver enzymes and low platelets – a severe form of pre-eclampsia) or hepatitis
should be considered. An ultrasound should be performed to exclude other
causes of obstruction such as gallstones.
There is no long-term harm to the mother. The effect on the baby however is
potentially much more serious with an association between OC and stillbirth.

Management:
 Symptomatic relief- chlorpheniramine (antihistamine)
 Ursodeoxycholic acid in more severe cases to reduce bile acids
 Vitamin K to boost absorption of fats for 2,7,9,10
 1-2 week monitoring of LFTs
 Induction at 37 weeks

Post-natal
 Maternal liver function returns to normal after delivery, but should warn
mother that recurrence occurs in 50% of subsequent pregnancies or with
use of COCP.

Risk factors:
 South American, Indian
 Family history
 90% recurrence

Complications:
 ↑risk of stillbirth
 ↑risk of preterm labour
 ↑risk of fetal distress/meconium in utero
 ↑risk of PPH
 vitamin K deficient - ↓bile emulsification of fat

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 A 19 week pregnant woman presents with a fever and rash during pregnancy.
 The fever started 2 days ago, and she noticed the diffuse, red rash this
morning
 Diffuse red rash with vesicles
 Otherwise well, no issues during pregnancy.
 No PMH of note

Examination
 Maternal observations:
 BP 115/75mmHg
 HR – 83/min
 37.2 degrees
 Maternal examination:
 No abnormalities on full systems examinations
 Diffuse vesicular rash covering whole body
 Foetal observations:
 Too early
 Foetal examination:
 Too early

Differential diagnosis
TORCH
1. Toxoplasmosis
2. Others:
o Syphilis
o VZV
o Parvovirus
o GBS
o HIV
o Hepatitis
o
3. Rubella
4. CMV
5. HSV

Investigations
Thorough history would be basis for diagnosis of obstetric VSV.
However, if unsure of previous exposure, IgG VSV will confirm.
Second dose of acyclovir if 3 weeks have elapsed and re-infection

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● A 19 week pregnant woman presents with a fever and rash during pregnancy.
● The fever started 2 days ago, and she noticed the diffuse, red rash this
morning
● Diffuse red rash with vesicles
● Otherwise well, no issues during pregnancy.
● No PMH of note

Examination
● Maternal observations:
● BP 115/75mmHg
● HR – 83/min
● 37.2 degrees
● Maternal examination:
● No abnormalities on full systems examinations
● Diffuse vesicular rash covering whole body
● Foetal observations:
● Too early
● Foetal examination:
● Too early

Differential diagnosis
TORCH
1. Toxoplasmosis
2. Others:
o Syphilis
o VZV
o Parvovirus
o GBS
o HIV
o Hepatitis
o
3. Rubella
4. CMV
5. HSV

Investigations
Thorough history would be basis for diagnosis of obstetric VSV.
However, if unsure of previous exposure, IgG VSV will confirm.
Second dose of acyclovir if 3 weeks have elapsed and re-infection

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Ovarian cyst torsion

History
A 14-year-old girl presents to A&E
PC: Lower abdominal pain
HPC
 Developed suddenly
 1 day ago
 The pain is over the whole lower abdomen but worse on the right.
 It was intermittent at first but is now constant and very severe.
 Feels unwell in herself with no appetite and vomiting.
 She now feels sweaty as well.
 She has never had any previous episode of pain like this.
PMH + PSH (MSC SOUR) – Obx and gynae hx
 Menstrual – Her last menstrual period started 2 weeks ago and she has a slightly
irregular cycle.
 Sexual – Currently having sex with her boyfriend who is 15
 Contraception – Condoms
 Smear – Received Gardasil last year
 Obstetric - Nil
 Urinary – Waterworks are normal- no changes in volume, colour (blood) or smell
 Rectal – She says her bowels opened normally the day before and they are normally
regular.
 Medical conditions / Previous surgery- She has never had any gynaecological or
other medical problems in the past.
DH and allergies- Nil and NKDA
FMH- Nil
SH- In school. Li es at ho e ith u a d dad. Does ’t s oke, dri k alcohol or take
recreational drugs.
System Review
 General – Before this episode fit and well
 Neuro – Nil
 Cardio – Nil
 Resp- Nil
 Gastro – Above
 Musc – Nil
 Derm – Nil

Examination
Basic obs: Her temperature is 37.9°C, pulse 112/min and blood pressure 116/74 mmHg.
General observation: On examination she looks in pain and seems to find it difficult to get
comfortable.
Abdominal examination: She feels warm and well perfused. The abdomen is distended
symmetrically with generalized tenderness, maximal in the right iliac fossa region. There is
rebound and guarding in the right iliac fossa.
Vaginal examination
Speculum- Nothing to note

Differential Diagnosis
 Gynaecological:
o adnexal/ovarian cyst torsion

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 Gynae emergency 

o ovarian cyst rupture 

o ovarian cyst haemorrhage 

o ectopic pregnancy 

 Surgical:

o appendicitis 

 Urinary: 

o urinary tract infection 

o renal colic 


Investigations
 Pregnancy test- exclude pregnancy
 Urine dip and urine analysis and culture- urine infection and renal colic
 Bloods: FBC and Inflammatory markers (CRP + ESR)
 USS- assess for an ovarian cyst or for an inflamed appendix. 


Management
MDT: contact surgical gynae team, phone ahead to the theatres, call a porter, phone ahead
to wards to check bed availability and involve senior colleagues if necessary. Cross match
patients blood.

Surgical
 If an adnexal mass is confirmed, laparoscopy or laparotomy should be performed as
soon as possible since adnexal torsion is associated with loss of the ovarian function
if ischaemia is prolonged and necrosis occurs.
 Ovarian torsion can often be managed by detorsion, though oophorectomy
sometimes may be necessary. 

 If the diagnosis is not clear between appendicitis and ovarian torsion then joint
laparotomy or laparoscopy with the surgical team is an appropriate approach. 


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Overactive Bladder Syndrome

History:
 61 y/o woman complains of involuntary voiding of urine
 Noticed gradually over the last 10 years
 Presented to GP as heard an advert on the radio about treatment for
incontinence
 Leaking generally small amount, wears a pad all the time
 Occurs most often when she cannot get to the toilet in time
 Never when coughs or sneezes
 Urgency, especially when home after being out
 Frequency, passing urine every hour during day
 Nocturia, 2-3times a night
 Limiting oral input to two teas in am, coffee mid morning and tea mid
afternoon. One squash a day and one wine each night
 Non smoker
 Two uncomplicated vaginal deliveries
 Periods stopped aged 54 year
 No PMH or gynae of relevance

Examination
 Abdo examination is normal
 V/E: minimal uterovaginal descent and no anterior or posterior wall
prolapse- Sims speculum

Investigations:

 Urinary diary: may show frequent passage of small volumes of urine,

particularly at night, and may show intake of caffeine rich fluids
 Urine dip to exclude infection
 Cytometry generally not indicated until either failure of lifestyle and drug
treatments or if surgery is being considered for stress incontinence

Differentials:
 OAB syndrome
 Stress incontinence?

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Definition:
Urgency, with or without urge incontinence, usually with frequency or nocturia,
in the absence of proven infection. The symptom combinations are suggestive of
detrusor overactivity but can be due to other forms of urinary tract dysfunction
Detrusor overactivity: a urodynamic diagnosis characterised by involuntary
detrusor contractions during the filling phase which may be spontaneous or
provoked by, for instance, coughing

Pathology:
Detrusor contraction is normally felt as urgency. If strong enough, bladder
pressure may overcome urethral pressure and the patient leaks. This can occur
spontaneously or with provocation, for example with a rise in intra-abdominal
pressure (cough) or a running tap. Cough may therefore lead to urine loss and be
confused with stress incontinence

Management:

Conservative:
 Reduce fluid intake
 Avoid caffeinated drinks and alcohol
 Review drugs that alter bladder function such as diuretics and anti-
psychotics
 Bladder training: involves education, timed voiding with systemic delay in
voiding and positive reinforcement. This should be done for at least 6
weeks often in combination with anticholinergic therapy

Medical:
 Anticholinergics: block the muscarinic receptor that mediate detrusor
contraction. Main side effect is dry mouth.
 Desmopressin for nocturia
 Oestrogens: many post-menopausal women find that vaginal oestrogen
not only reduces vaginal atrophy and dryness but also symptoms of
urgency, urge incontinence, frequency and nocturia.
 Botulinum toxin A: blocks neuromuscular transmission. Toxin injected
cystoscopically. The most common complication is voiding dysfunction
and urinary retention

Surgical:
 Augmentation cystoplasty. Add section of bowel to bladder

 Causes of incontinence
Stress incontinence 50%
Overactive bladder 35%
Mixed 10%
Overflow 1%
incontinence
Fistulae 0.3%
Unknown 4%
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History:
 29 year old woman and partner seen in outpatient with primary infertility
 Stopped using condoms 2 years ago and have had regular intercourse
since then.
 Partner has no past medical history
 He drinks approx. 8 units/week and does not smoke
 Works as manager in hotel
 Woman had appendectomy aged 12 years
 Periods every 31-46 days
 Menorrhagia, but no dysmenorrhoea
 No intermenstrual or postcoital bleeding
 Normal smears
 No STIs
 No medication or allergies
 6 units Etoh/week and non-smoker
 Office worker

Examination
 BMI 29
 Slight acne on face and chest
 No abdominal scars and abdomen SNT. No masses
 Speculum and bimanual normal

Investigations
 Bloods
 ↑L(/FS( ratio
 Normal FSH
 ↑/ testosterone ↑free testosterone, due to low S(BG
 S(BG
 ↑/ prolactin
 ↑Blood glucose
 Normal TFT
 TVUS
o >= 12 small follicles

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Management: clinical issues

1. Hirsutsm
2. Menstrual issues
3. Fertility
4. Insulin resistance and obesity

Conservative:
 Diet and exercise- weight loss

Medical:
 Amenorrhoea and menorrhagia
o COCP
o IUS/cyclical progesterone(2nd line)
 Hirsutism
o Anti-androgens
 Dianette COCP (contains cyproterone acetate)
 Cyproterone acetate
 Spironolactone
 Diabetes
o Metformin
 Anovulation
o Clomiphene (SERM)(6months +/- metformin)
 Blocks oestrogen feedback at hypothalamus, to increase LH
and FSH production
 Risk of multiple pregnancy
 Taken on days 2-6, follicular phase
 Check day 21 progesterone to confirm ovulation
 Increase dose each month until ovulation occurs
o GnRH
 For clomiphene resistant

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 Risk of multiple pregnancy

Surgical
 Laparoscopic ovarian drilling

Pathology:

Diagnosis made by 2 of 3 Rotterdam criteria:

1. USS- ovarian cysts
2. Oligo/emenorrhoea
3. Hyperandrogenism
a. Clinical- hirsutism, acne
b. Biochemical- increased free testosterone

Other signs/symptoms:
 Menorrhagia
 Infertility
 Obesity
 Insulin resistance
 Hair thinning
 Recurrent miscarriage
 Acanthosis nigricans: dark skin around neck found in insulin resistance
Complications;
 Diabetes
 Cardiovascular complications
 Endometrial cancer
 OSA

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PID

Defintion: Pelvic inflammatory disease is characterized by inflammation and infection

arising from the endocervix leading to endometritis, slapingitis, oophoritis, pelvic
peritonitis, tubo-ovarian and pelvic abscesses.

History
46-year-old Indian woman
PC- month-long history of increasing abdominal pain and a green/yellow vaginal
discharge.
HPC- The pain is across the lower abdomen but worse on the left. For the last few days
she had been feeling feverish and unwell. She has a reduced appetite and mild nausea
but has not vomited.
Gynae – Menorrhagia – recently seen a consultant, taking norethisterone. No previous
detected STI and cervical smears are normal. No contraception.
Obs – G2P2+0 – both vaginal deliveries
Urinary- Nil
Bowel-Nil
PMH- Nil
PSH- 4 yrs old drainage of pelvic abcess
FMH - Nil
SH -Nil

Differential Diagnosis
PID
Other causes by symptom:
 Abdominal pain e.g. appendicitis (N+V), ectopic pregnancy,
diverticulitis/diverticulosis, torted ovarian cyst or ovarian cancer.
 Menorrhagia –Uterine (cancer and hyperplasia), cervical (cancer),
Hypo/hyperthyroidism, clotting disorders, fibroids, adenomysosis, bleeding of
unknown origin.
 Vaginal discharge- Physioloigcal (pregnancy and ovulation), Infective: STI
(chlamydia, trichomonas and gonorrhoea), Non-STI (BV and candida), Cervical
(ectropion and polyp), Iatrogenic (contraception) and Foreign Body.
 Dyspareunia e.g. endometriosis

Examination
Basic obs: temperature is 37.8°C, pulse 95/min and blood pressure is 136/76mmHg.
Abdominal examination: slightly distended and a mass is palpated arising from the
pelvis on the left. There is focal tenderness in the left iliac fossa without rebound
tenderness or guarding.
Vaginal examination
Speculum: Speculum examination reveals no discharge or blood, and the cervix appears
normal. Cervical excitation and bilateral adnexal tenderness are noted, more marked on
the left.
Bimanual: Not needed in this case because palpating adnexal masses could lead to
rupture of abscesses, suggested in history, causing shock and peritonitis

Investigations
 Bloods: FBC (b, WCC, Neutrophills, CRP , U+E’s, LFTs and )ron studies (ferritin
and folate) because of menorrhagia.
o Raised WCC (neutrophilia suggestive of acute inflammatory process)
o Reduced WCC (neutropenia in severe infections)

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o Raised CRP and ESR

 Blood culture
 Urinanalysis
 Pregnancy test
 Swab: High vaginal (lateral walls and posterior fornix)- BV, trichomonas and
yeast and Endocervical – chlamydia and gonorrhea
 USS
o Inflamed fallopian tubes and Adnexual masses
 Laproscopy

Management

 ABC
 Admit this woman because:
o Severe infection
o Adnexal masses suspicious of abscess
o Generalised sepsis
o Poor/ inadequate response to oral treatment
o Severe pelvic and abdominal pain

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Medical
Broad-spectrum antibiotics:
Ceftriaxone + doxycycline (not tolerated in pregnancy) + oral metronidazole
Okay in pregnancy
Ceftriaxone + Erythromycin + Metronidazole

Surgical
If improvement does not occur within 24–48 h, or the diagnosis is unclear, then
laparoscopy or laparotomy. In this case drainage of the abscess or adhesiolysis.

Advice
 Contact tracing and screened and there is a risk of reinfection if the partner is
not treated.
 Use condoms.
 Risk of tubal damage leading to subfertility, ectopic pregnancy and chronic
pelvic pain which increases with further episodes of infection.
 Prompt and early treatment will reduce the risk of subfertility.
 Seek early medical advice if pregnant, due to risk of ectopic pregnancy.

Aetiology Chlamydia and gonoccocal infections (common)

Bacterial vaginosis (less common)
Risk factors  A recent change of sexual partner. The risk goes up with the number of
changes of partner.
 A previous episode of PID or sexually transmitted disease.
o Existing chlamydia and gonoccocal infections and less
commonly bacterial vaginosis
 A recent termination of pregnancy (abortion).
 A recent operation or procedure to the uterus.
 An IUD inserted recently.
Complications/ prognosis  Fallopian tubes are commonly damaged.
 Inflammation destroy the cilia within the fallopian tube > scarring
in the tubal lumen > partial obstruction > predispose to ectopic
pregnancy
 In severe infection, mucopurulent discharge exudates through the
fimbrial end of the fallopian tube causing peritoneal inflammation
> scarring and adhesion formation of pelvic organs
 Perihepatitis > adhesions between liver and the peritoneal surface
> violin string appearance (Fitz-Hugh-Curtis syndrome)- image
below
 Reiters syndrome – conjunctivitis, urethritis and arthritis
 Abscess formation- this case
Common signs & symptoms  Abdominal, pelvic pain and dyspareunia
 Mucopurulent vaginal discharge
 Pyrexia (over 38 degrees)
 Heavy/ intermenstrual bleeding
 Pelvic tenderness and cervical excitation during examination
 Tender adnexal or palpable pelvic mass
 Generalised sepsis in severe and systemic infection
 Tubal damage leading to tubal occlusion, abscess and hydrosalpinx

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Fitz-Hugh-Curtis Syndrome- violin strings between the liver and the peritoneum

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Post-menopausal Bleeding
History
 58 year old female
 PC: PostBi menopausal bleeding
 HPC: 3 episodes of bright red blood, no pain, no clots
 PGHx:
o LMP age 49
o Hot flushes and night sweats but these subsided a few years ago
o Never taken HRT
o Sexually active but has noticed dryness with intercourse recently
o Last smear 7 months ago: always negative
o Contraception: laproscopic sterilization aged 34 years old
 POHx:
o Para 2: both SVD
 PMH: HTN and reflux
 DHx: Atenolol and omeprazole
 FHx: Nil gynae cancer
 SHx: Recently retired; was previously a secretary

Examination
 General: Slightly overweight but appears in good health
 Abdo exam: normal
 Bimanual and speculum:
o Vulva and vagina – thin and atrophic
o Cervix is normal
o Uterus is small and anteverted and there are no adenexal masses

Differential diagnosis
 Endometrial cancer: PMB is assumed to be endometrial cancer until proven
otherwise
 Endometrial hyperplasia: non-maliganant proliferation of the endometrium.
Common in obese women – peripheral conversion of androgens in sub-
cutaenous fat to oestrogens
 Atrophic vaginitis: This is a diagnosis of exclusion but fits with the
examination findings
 Local cervical lesions: causes include things such as polyps but these have
been excluded by examination
 Cervical cancer: excluded by the negative smear seven months ago
 Iatrogenic: Drugs which increase endometrial exposure to oestogen can
cause PMB e.g. HRT, IUDs, tamoxifen. Tamoxifen acts an oestrogen
antagonist in the breast but an agonist in the endometrium, bone and
cardiovascular system. Incidence of endometrial hyperplasia, polyps and
carcinoma is much higher in women who have taken tamoxifen. Tamoxifen is
still used as the risks are outweighed by the reduction in risk of the
recurrence of breast cancer. Anticoagulants can also cause PMB

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 Infective: agi al ca didiasis or chla ydia (do ’t forget this, a y o e

post menopausal women are still sexually active).

Investigations

Transvaginal ultrasound:
 Accurate method of excluding endometrial cancer
 Criteria for further investigation by endometrial biopsy include:
o Endometrial thickness >4-5mm
o Irregular endometrial outline
o Fluid in the uterine cavity
 50% of women will have a thin regular endometrium and these women can
be assured that they do not have endometrial cancer. The negative predictive
value is almost 100%

Endometrial biopsy:
 Pipelle in outpatients
 If the pipelle cannot be tolerated/ the pipelle results suggest malignancy –
hysteroscopy as either an outpatient or inpatient

Management
 Results: Endometrium is thin and regular and less than 4mm
 Excluding endometrial causes coupled with the vaginal dryness and atrophic
changes observed on examination suggest a diagnosis of atrophic vaginaitis:
o Conservative: vaginal lubricants (symptomatic but no reparative
value)
o Medical:
 Topical oestrogen given daily for two weeks and then
maintenance twice a week
 Systemic HRT which also has a protective effect on the
endometrium
 NB if it was cancer treat with TAH + BSO

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Polyhydramnios

Large for dates- Term used to describe a fetus with a corrected birthweight > 95th centile
for gestational age.
Polyhydramnios- Excess amniotic fluid (> 8 cm average liquor pocket depth or an amniotic
fluid index (AFI) > 25 on ultrasound, but is dependent on gestational age).

History
A 32-year-old woman in her third pregnancy attends the midwife antenatal clinic at 34
eeks’ gestatio .
PC: The midwife is concerned that the uterus feels large for dates.
HPC: A booking scan had shown a singleton pregnancy consistent with menstrual dates.
There were no anomalies noted on her 20-week scan.
PMH + PSH (MSC SOUR) – Obx and gynae hx
 Menstrual – regular 28 day cycles with bleeding for 7 days. Normal amount of
bleeding
 Sexual – Sex with her husband does not use contraception.
 Contraception – Nil urre tly ut pre iously used the COCP a d did ’t oti e a y
side effects
 Smear – Last smear at 31 years old and showed everything was normal
 Obstetric- Third pregnancy. Previous two pregnancies have been SVD at 38 and 39
weeks without any complications and not associated with this problem. No
terminations or miscarriages so G3P2
 Urinary – No changes
 Rectal – No changes
 Medical conditions / Previous surgery- Nil
DH and allergies: Nil
FMH: Nil
SH: Li es at ho e ith hus a d a d 2 other hildre . Does ’t dri k s oke or take drugs.
System Review
 General – Generally fit and well
 Neuro – Nil
 Cardio – Nil
 Resp- She has noticed an increase in shortness of breath.
 Gastro – The patient has experienced increasing abdominal discomfort during the
last 2 weeks, and she is having irregular uterine activity
 Musc – Nil
 Derm – Nil

Questions to ask
 A family history (e.g. first-degree relative with diabetes) or maternal obesity
increases the risk of gestational diabetes and macrosomia.
 Previous high birthweights would support a fetus that is constitutionally LFD.
 Rhesus factor and antibody checks are needed to exclude rhesus isoimmunization,
which may be associated with fetal hydrops.

Examination
Abdominal palpation is necessary to assess liquor volume. A tense uterus, difficulty in feeling
fetal parts and fluid thrill all support an increased liquor volume.
Abdominal examination: The symphysiofundal height measures 40 cm.

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Differential Diagnosis for large for dates

 Constitutionally large for dates (LFD). 

 Polyhydramnios. 

o The increased discomfort, irritable uterus and shortness of breath
suggest polyhydramnios. 

o Amniotic fluid is produced almost exclusively from the fetal urine from
the second trimester onwards. Polyhydramnios is given to an excess of
amniotic fluid, AFI > 95th centile for gestation on ultrasound estimation.
o Causes of polyhydramnios:
 Maternal
 Diabetes - causes fetal hyperglycemia and
resulting polyuria (fetal urine is a major source of
amniotic fluid).
 Placental
 Chorioangioma
 Arterio-venous fistula
 Foetal
 Multiple gestation
 Mono-chorionic – twin-twin transfusion syndrome
 Idiopathic
 Oesophageal atresia, Duodenal atresia, Neuromuscular
fetal condition and anencephaly – prevent swallowing of
the amniotic fluid
 Renal complications
 The previous dating and second-trimester USSs have excluded
multiple pregnancy and fetal anomaly which might be
associated with polyhydramnios (e.g. duodenal atresia). 

 Wrong dates.
 Multiple pregnancy. 

 Macrosomia (e.g. secondary to diabetes). 

 Hydrops. 


Investigations
 Glucose tolerance test of the mother
 USS
1. Confirm LFD (BPD, abdominal circumference); 

2. Measure liquor volume; 

3. Exclude multiple pregnancy; 

4. Exclude fetal anomaly that may have been missed on earlier scans
5. Identify evidence of hydrops (e.g. fetal oedema/effusions and/or ascites). 

 Rhesus status and antibodies – hydrops

Management
Directed towards:
1. Establishing the cause
a. If gestational diabetes is diagnosed, it should be managed with
dietary control and insulin if appropriate. 

2. Relieving the discomfort of the mother – if necessary amniodrainage
3. Assessing the risk of pre term labour due to over distension.
a. Assess the cervical length using ultrasound. If prior to 24 weeks,
following amniotic fluid drainage, the cervical length is less than

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25mm, consideration might be given for insertion of a cervical

suture.

 Polyhydramnios without symptoms and evidence of fetal anomaly does not require
any treatment. In cases near term where there is maternal discomfort, induction of
labour should be considered. 

 Indomethacin can reduce liquor volume, but the risk to the fetus is premature
closure of the ductus arteriosus and reduced cerebral perfusion. 

 If pre-term delivery is anticipated, two doses of steroids given 12h apart should be
given to the mother to promote lung maturity and reduce the risk of respiratory
distress syndrome. 


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Post-coital Bleeding
History
 20 year old female
 PC:
o PCB occurring a couple of hours post intercourse, last for a couple of
hours; bright-red blood; has occurred 7 times over the last six weeks.
o Nil discharge
o Nil dyspareunia
 GHx:
o LMP 3 weeks ago
o Regular cycles 4/28
o COCP for last 6 months
o Never been diagnosed with an STI (last check 8 months ago)
o Regular male partner
o Never had a smear
 POHx: P0
 PMH and PSH: Nothing to note
 FHx: Nil gynae cancer
 SHx: University student. Social ETOH. Nil smoking

Differential diagnosis of PCB

Uterine:
 Neoplasia
 Hyperplasia
 Polyps
 Fibroids
Cervical:
 Ectropion
 Endocervical polyp
 Complication of COCP
 Chlamydia or other STI
 Cervical malignancy
Vaginal:
 Trauma
 Atrophy
 STI
Urogenital:
 Haemorrhoids

Examination
 Abdomen: soft and non-tender
 Speculum: floridly reddened area surrounding the external cervical os
 Bimanual: normal sized, anteverted and non-tender uterus, no cervical
excitation tenderness, no adenexal masses

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Top differential
 Ectropion
 Malignancy
 STI

Investigations
 Full STI screen:
o Endocervical swab for chlamydia
o Endocervical swab for gonorrhoea
o High vaginal swab for trichomonas and candida (not an STI but could
cause vaginitis and thus PCB)
 Take a smear to exclude CIN/ malignancy although this is highly unlikely
considering her age
 Always investigate PCB to exclude significant pathology

Management
 All the above are negative and therefore the diagnosis is of an ectropion
 Ectropions are very common and benign
 Ectropions are common in
o Puberty
o COCP use
o Pregnancy
 Only warrants treatment if embarrassing and troublesome bleeding
 Three treatment options:
o Stop COCP and switch to another contraceptive
o Cold coagulation of the cervix
o Diathermy ablation of the ectocervix

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Post Partum Haemorrhage

32 year old woman Julie Rowe brought into delivery suite by ambulance 6 days
after vaginal delivery at 39 weeks

Presenting complaint:
 Sudden onset pain and heavy bleeding
HPC:
 This morning felt sudden crampy abdominal pain in lower abdomen
 Felt gush of fluid, followed by heavy PV bleeding
 Blood soaked through clothes and passed large clots, the size of her fist
 Feels dizzy when she stands up and is nauseated
Systems review:
 No vomiting or diarrhoea
 No headache
PMH:
 Gave birth 6 days ago
 Pregnancy and labour was unremarkable
 Placenta delivered by controlled cord traction
 Discharged home after 6 hours
 Lochia had been heavy for the first 2 days
 No allergies or medication

Examination:
 General examination
 Bedside obs
 Bimanual and speculum
Results:
 Well saturated, but resp rate 28
 BP 105/50, HR 112/min, cap refill 4s
 Drowsy but responsive.
 Abdominal palpation reveals minimal tenderness but uterus is palpable
6cm above symphysis pubis
 Speculum examination reveals large clots of blood in the vagina. Cervical
os is open

Diagnosis:
 Secondary post partum haemorrhage

Immediate management:
 Call for senior help
 Airway
 Breathing
o High flow oxygen, regardless of saturation
 Circulation
o Two wide bore cannulae and blood sent for FBC, U&Es, clotting
and crossmatch (4units) with potential further blood products
if necessary

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o IV fluids: crystalloid
o Urinary catheter to measure fluid balance

Halt bleeding:
 Uterine massage: initially suprapubically and if fails, bimanually
 500micrograms ergometrine IM and syntocin infusion
 Consider other uterotonics like misoprostol or carboprost

Ultrasound scan would not be indicated in this scenario:

1. First, an open cervix implies retained products and it would therefore be

superfluous.
2. Second, an examination under anaesthetic is warranted anyway to
establish any other cause of bleeding, such as vaginal or perineal trauma.
3. Third, retained products may be confused with blood clot on post- partum
ultrasound.

Subsequent management:
 Cervix open is pathognomonic of retained tissue, and evacuation of
retained products should be arranged once the woman has been
resuscitated and blood is available
 IV Abx
 Initially managed in high dependency setting until stable
 Although she is likely to have had a coagulopathy at admission, she is still
at high risk of venous thromboembolism as she is probably septic,
postpartum and has undergone anaesthetic. Thromboembolic stockings
and heparin should therefore be administered postoperatively.

If pharmacological measures fail:

 balloon tamponade
 haemostatic brace suturing (such as using procedures described by B-
Lynch or modified compression sutures)
 bilateral ligation of uterine arteries
 bilateral ligation of internal iliac (hypogastric) arteries G selective arterial
embolisation.

Causes for post partum haemorrhage:

 Tone
 Tissue
 Trauma
 Thrombophilia
 Infection
The most common cause of primary PPH is uterine atony.

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PPROM

History
A woman aged 26 years is referred by her general practitioner at 36 weeks gestation.
PC
 Generally unwell with a fever for 2/7
HPC
 In this pregnancy she has been seen twice in the day assessment unit:
o The first time at 31 weeks for an episode of vaginal bleeding for which no
cause was attributed.
o The second time was at 35 weeks after she awoke with damp bed sheets.
No liquor had been detected on speculum examination at the time and she
was discharged.
 She reports the baby moving less than normal for the last few days, with
approximately 8–10 movements per day.
 She has not noticed any vaginal bleeding but her discharge has been more than
normal and there is an offensive odour to it.
PMH + PSH (MSC SOUR) – Obx and gynae hx
 Menstrual – Nil
 Sexual – Husband
 Contraception – Nil
 Smear – Last year and was normal
 Obstetric- G4P2- 1 miscarriage and two term vaginal deliveries
 Urinary – Normal
 Rectal – Normal
 Medical conditions / Previous surgery - Nil
DH and allergies- Nil and NKDA
FMH- Nil
SH- Li es at ho e ith hus a d a d 2 hildre , does t s oke, dri k or use re reatio al
drugs
System Review
 General – Fit and well
 Neuro – Headache
 Cardio – Nil
 Resp- Nil
 Gastro – Decreased appetite and abdominal discomfort
 Musc – Nil
 Derm – Nil

Questions to ask
 Disti guish et ee rupture of e ra es gush of fluid agi ally follo ed y a
continuous dribble vs. leaking urine (frequency, urgency, leakage and dysuria) as
incontinence or UTI might present similarly.

Examination
Basic obs: Her temperature is 37.8°C, blood pressure 106/68mmHg and heart rate 109/min.
Abdominal examination: On abdominal palpation symphysiofundal height is 34 cm and the
fetus is cephalic with 3/5 palpable. There is generalized uterine tenderness and irritability.
Sterile Speculum examination: On speculum examination the cervix is closed and a
green/grey discharge is seen within the vagina.

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Investigations
 Bloods: FBC and CRP
 CTG

Confirming PPROM
 Nitrazine testing: Allows for the detection of amniotic fluid which alkaline compared
to vaginal secretions which are acidic. Elevated pH turns nitrazine stick black.
 Ultrasound: Amniotic fluid volume directly correlates to the latency period in
PPROM
 Amniocentesis: Sample amniotic fluid can be sent for Gram stain and MC&S to
establish the cause of the intrauterine infection

Results
 Bloods: Leucocytosis and elevated CRP
 CTG: Fetal tachycardia

Differential Diagnosis
1. PPROM with chorioamnionitis
o Although spontaneous rupture of membranes was not confirmed at the
previous attendance at 35 weeks, it seems probable that in fact this did
occur at that time. Ascending organisms have thus colonized the uterus and
resulted in infection.
o The result is a maternal systemic reaction causing her symptoms:
tachycardia, tenderness, leukocytosis and raised C-reactive protein.

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o The fetus is also affected as shown by the fetal tachycardia.

Other differentials for discharge not in the acute setting like above apart from PPROM:
2. Vaginal infection
3. Urine loss: incontinence and UTIs
4. Leukorrhea -cervical glands become overactive in pregnancy

Management
 Chorioamnionitis is a significant cause of both fetal and maternal morbidity and
mortality, and should be treated as an obstetric emergency.
 Proceed in an ABC approach
 Call for senior help

Conservative
Maternal
 ‘egular assess e t of the other s: BP, pulse a d te perature.
 Initial microbial specimens should be obtained from high vaginal swab and maternal
blood cultures.
Foetal
 Continuous CTG monitoring
Medical
 Intravenous broad-spectrum antibiotic should be commenced to cover both
anaerobic and aerobic organisms according to local.
o Newly diagnosed PPROM
 Erythromycin should be given for 10 days following the diagnosis of
PPROM
 If group B streptococcus is isolated in cases of PPROM penicillin
should be administered, or clindamycin in women who are allergic
to penicillin.
 Intravenous fluids should be commenced to counter the effects of vasodilatation
and pyrexia, and because the woman is unable to drink adequately.
 Paracetamol should be given regularly for the pyrexia and abdominal discomfort.
 Steroids (to prevent potential respiratory distress syndrome) are contraindicated in
this woman as they may increase the severity of infection.
o Newly diagnosed PPROM
 Administer corticosteroids
 Tocolytics in women with PPROM should not be administered as it does not improve
perinatal outcome
Delivery
 The baby needs delivery by induction of labour – women with chorioamnionitis
often labour rapidly.
 Risks of Caesarean section in the presence of infection are significant in terms of
bleeding, uterine atony and disseminated intravascular coagulopathy.
 Immediate Caesarean section should be performed if the foetus deteriorates.
o Newly diagnosed PPROM
o In pregnant women with diagnosed PPROM, delivery should be considered
at 34 weeks of gestation. Where expectant management is considered
beyond this gestation, women should be informed of the increased risk of
chorioamnionitis and the decreased risk of respiratory problems in the
neonate.
 The decision to deliver or manage expectantly in cases of PPROM requires an
assessment of the risks related to the development of intrauterine infection in those

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pregnancies managed expectantly compared with the gestational age-related risks

of prematurity in pregnancies delivered earlier.

After delivery
 The baby will need to be reviewed by the paediatrician and given a septic screen and
course of intravenous antibiotics.

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Pre-eclampsia
Pre-eclampsia is a complication of pregnancy. Women with pre-eclampsia have high
blood pressure, protein in their urine, and may develop other symptoms and
problems. The more severe pre-eclampsia is, the greater the risk of serious
complications to both mother and baby. The exact cause of pre-eclampsia is uncertain
but it is thought to be due to a problem with the afterbirth (placenta). The only way to
cure pre-eclampsia completely is by delivering (giving birth to) your baby. Medication
may be advised to help prevent complications of pre-eclampsia.
What are pre-eclampsia and eclampsia?
Pre-eclampsia is a condition that only occurs during pregnancy. It causes high blood
pressure and it also causes protein to leak from your kidneys into your urine. This can be
detected by testing your urine for protein. Other symptoms may also develop (see below).
Pre-eclampsia usually comes on sometime after the 20th week of your pregnancy and gets
better within six weeks of you giving birth. The severity can vary. Pre-eclampsia can cause
complications for you as the mother, for your baby, or for both of you (see below). The
more severe the condition becomes, the greater the risk that complications will develop.
Somewhere between 2 and 8 in 100 pregnant women develop pre-eclampsia.

Eclampsia is a type of seizure (a fit or convulsion) which is a life-threatening complication of

pregnancy. Less than 1 in 100 women with pre-eclampsia develop eclampsia. So, most
women with pre-eclampsia do not progress to have eclampsia. However, a main aim of
treatment and care of women with pre-eclampsia is to prevent eclampsia and other possible
complications.
Is pre-eclampsia the same as gestational high blood pressure?
No. Many pregnant women develop mild high blood pressure that is not pre-eclampsia. This
is known as gestational high blood pressure or pregnancy-induced high blood pressure.

Gestational high blood pressure is new high blood pressure that comes on for the first time
after the 20th week of pregnancy. Doctors can confirm this type of high blood pressure if
you do not go on to develop pre-eclampsia during your pregnancy and if your blood
pressure has returned to normal within six weeks of you giving birth. If you have gestational
high blood pressure, you do not have protein in your urine when it is tested by your midwife
or doctor during your pregnancy. With pre-eclampsia, you have high blood pressure plus
protein in your urine, and sometimes other symptoms and complications listed below.

Note: some women may be found to have new high blood pressure after 20 weeks of
pregnancy. At first, they may not have any protein in their urine on testing. However, they
may later develop protein in their urine and so be diagnosed with pre-eclampsia. You are
only said to have pregnancy-induced hypertension if you do not go on to develop pre-
eclampsia during your pregnancy.
What causes pre-eclampsia and who gets it?
The exact cause is not known. It is probably due to a problem with the placenta (the
afterbirth). This is the attachment between your baby and your uterus (womb). It is thought
that there are problems with the development of the blood vessels of the placenta in pre-
eclampsia and also damage to the placenta in some way. This may affect the transfer of

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oxygen and nutrients to your baby.

Pre-eclampsia can also affect various other parts of your body. It is thought that substances
released from your placenta go around your body and can damage your blood vessels,
making them become leaky.

Any pregnant woman can develop pre-eclampsia. However, there are some women who
may have an increased risk. Pre-eclampsia also runs in some families so there may also be
some genetic factor.

You have a moderately increased risk of developing pre-eclampsia if:

 This is your first pregnancy, or it has been 10 years or more since your last
pregnancy.
 You are aged 40 or more.
 You are obese (your body mass index (BMI) is 35 or over).
 You have a pregnancy with twins, triplets, or more.
 Your mother or sister has had pre-eclampsia.
You have a higher risk of developing pre-eclampsia if:
 You have had high blood pressure or pre-eclampsia during a previous pregnancy.
 You have diabetes or chronic (persistent) kidney disease.
 You had high blood pressure before the pregnancy started.
 You have antiphospholipid syndrome. (This is an autoimmune problem where your
body develops antibodies against phospholipids. In women of childbearing age this
may cause a tendency to recurrent miscarriage. It can also cause a tendency to
develop blood clots.)
 You have systemic lupus erythematosus. (This is an autoimmune problem that can
cause various symptoms, the most common being joint pains, skin rashes and
tiredness. Problems with kidneys and other organs can occur in severe cases. See
separate leaflet called 'Systemic Lupus Erythematosus' for further details.)
How is pre-eclampsia diagnosed?
Pre-eclampsia is present if:
 Your blood pressure becomes high, and
 You have an abnormal amount of protein in your urine
High blood pressure (hypertension) means that the pressure of the blood in your artery
blood vessels is too high. Blood pressure is recorded as two figures. For example, 140/85
mm Hg. This is said as '140 over 85'. Blood pressure is measured in millimetres of mercury
(mm Hg). The first (or top) number is your systolic blood pressure. This is the pressure in
your arteries when your heart contracts. The second (or bottom) number is your diastolic
blood pressure. This is the pressure in your arteries when your heart rests between each
heart beat.

Normal blood pressure is below 140/90 mm Hg. During pregnancy:

 Mildly high blood pressure is blood pressure between 140/90 and 149/99 mm Hg.
 Moderately high blood pressure is blood pressure between 150/100 and 159/109
mm Hg.
 Severely high blood pressure is blood pressure of 160/110 mm Hg or higher.

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Some women with pre-eclampsia develop certain symptoms (see below). These symptoms
may alert them to see their doctor or midwife who will check their blood pressure, test their
urine for protein and diagnose pre-eclampsia. However, other women, especially those with
mild pre-eclampsia, may not know that they have pre-eclampsia. They may not have any
symptoms. This is why it is very important to have regular checks of your blood pressure and
your urine during pregnancy.

Initially, a simple test can be used to check for protein in your urine. During this test, a
special stick called a urine dipstick is used. If you are found to have protein in your urine on
testing with a dipstick, your doctor or midwife may suggest that your urine be collected over
a 24-hour period so that the total amount of protein in your urine can be measured.
What are the symptoms of pre-eclampsia?
The severity of pre-eclampsia is usually (but not always) related to your blood pressure
level. You may have no symptoms at first, or if you only have mildly raised blood pressure
and a small amount of protein in your urine. If pre-eclampsia becomes worse, one or more
of the following symptoms may develop. See a doctor or midwife urgently if any of these
occur:
 Severe headaches that do not go away.
 Problems with your vision, such as blurred vision, flashing lights or spots in front of
your eyes.
 Abdominal (tummy) pain. The pain that occurs with pre-eclampsia tends to be
mainly in the upper part of your abdomen, just below your ribs, especially on your
right side.
 Vomiting later in your pregnancy (not the morning sickness of early pregnancy).
 Sudden swelling or puffiness of your hands, face or feet.
 Not being able to feel your baby move as much.
 Just not feeling right.
Note: swelling or puffiness of your feet, face, or hands (oedema) is common in normal
pregnancy. Most women with this symptom do not have pre-eclampsia, but it can become
worse in pre-eclampsia. Therefore, report any sudden worsening of swelling of the hands,
face or feet promptly to your doctor or midwife.

Rarely, pre-eclampsia and eclampsia can both develop for the first time up to four weeks
after you have given birth. So, you should still look out for any of the symptoms above after
you give birth and report them to your doctor or midwife.
What are the possible complications of pre-eclampsia?
Most women with pre-eclampsia do not develop serious complications. The risk of
complications increases the more severe the pre-eclampsia becomes. A recent study has
shown that the risk of some of these complications may be higher if you develop pre-
eclampsia and you are a smoker who continues to smoke during your pregnancy.

About six women, and several hundred babies, die each year in the UK from the
complications of severe pre-eclampsia. The risk of complications is reduced if pre-eclampsia
is diagnosed early and treated.
For the mother
Serious complications are uncommon but include the following:
 Eclampsia (described above).

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 Liver, kidney, and lung problems.

 A blood clotting disorder.
 A stroke (bleeding into the brain).
 Severe bleeding from the placenta.
 HELLP syndrome. This occurs in about 1 in 5 women who have severe pre-eclampsia.
HELLP stands for 'haemolysis, elevated liver enzymes and low platelets' which are
some of the medical features of this severe form of pre-eclampsia. Haemolysis
means that your blood cells start to break down. Elevated liver enzymes means that
your liver has become affected. Low platelets means that the number of platelets in
your blood is low and you are at risk of serious bleeding problems.
For the baby
The poor blood supply in the placenta can reduce the amount of nutrients and oxygen to
the growing baby. On average, babies of mothers with pre-eclampsia tend to be smaller.
There is also an increased risk of premature birth and of stillbirth. Babies are also more likely
to develop breathing problems after they are born.
What is the treatment for pre-eclampsia?
If you develop pre-eclampsia, you will usually be referred urgently to see a specialist (an
obstetrician) for assessment and care. You may be admitted to hospital. If you develop new
high blood pressure or new protein in your urine, you will also usually be referred for a
specialist opinion.

Tests may be done to check on your wellbeing, and that of your baby. For example, blood
tests to check on the function of your liver and kidneys. You may also be asked to collect
your urine over a 24-hour period so that the amount of protein in your urine can be
measured. A recording of your baby's heart rate may be done, as well as an ultrasound scan
to see how well your baby is growing and a scan to see how well the blood is circulating
from the placenta to your baby.

Your blood pressure will be checked often and your urine will usually be tested regularly for
protein. Tests of your wellbeing and your baby's wellbeing will usually be repeated regularly
to look for any changes. You should also look out for any symptoms of pre-eclampsia and
tell your midwife or doctor if you develop any of these.
Delivering your baby
The only complete cure for pre-eclampsia is to deliver your baby. At delivery, your placenta
(often called the afterbirth) is delivered just after your baby. Therefore, what is thought to
be the cause of the condition is removed. After the birth, your blood pressure and any other
symptoms usually soon settle.

It is common practice to induce your labour if pre-eclampsia occurs late in your pregnancy.
A Caesarean section can be done if necessary. The risk to your baby is small if he or she is
born just a few weeks early. However, a difficult decision may have to be made if pre-
eclampsia occurs earlier in your pregnancy. The best time to deliver your baby has to
balance several factors which include:
 The severity of your condition, and the risk of complications occurring for you.
 How severely your baby is affected.
 The chance of your baby doing well if they are born prematurely. In general, the later
in your pregnancy your baby is born, the better. However, some babies grow very

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poorly if the placenta does not work well in severe pre-eclampsia. They may do
much better if they are born, even if they are premature.
As a rule, if pre-eclampsia is severe, then delivery sooner rather than later is best. If pre-
eclampsia is not too severe, then postponing delivery until nearer full term may be best.
Other treatments
Until your baby is delivered, other treatments that may be considered include:
 Medication to reduce your blood pressure. This may be an option for a while if pre-
eclampsia is not too severe. If your blood pressure is reduced it may help to allow
your pregnancy to progress further before delivering your baby.
 Steroid drugs. These may be advised to help mature your baby's lungs if doctors feel
that there is a chance that labour will need to be induced or that they will need to
deliver your baby by Caesarean section and your baby is still premature.
 Magnesium sulphate. Studies have shown that if mothers with pre-eclampsia are
given magnesium sulphate, it roughly halves the risk of them developing eclampsia.
Magnesium sulphate is an anticonvulsant (it helps to stop you having a seizure) and
it seems to prevent eclampsia much better than other types of anticonvulsants.
Magnesium sulphate may be used, especially in women with severe pre-eclampsia
where there is a greater risk of them developing eclampsia. It is usually given for
about 24 hours by a drip (a slow infusion directly into a vein) around the time of
delivery.
Can pre-eclampsia be prevented?
There is some evidence to suggest that regular low-dose aspirin and calcium supplements
may help to prevent pre-eclampsia in some women who may be at increased risk of
developing it.

However, a recent review of research involving around 11,000 women showed that it seems
to be important to start aspirin at, or before, 16 weeks of pregnancy. During the research,
women who stared aspirin at, or before, 16 weeks had a reduced chance of developing pre-
eclampsia during their pregnancy. There was also less chance of their baby being born
prematurely or having intrauterine growth restriction (being small-for-dates). The same
research showed that the woman's risk of developing pre-eclampsia or the baby's risk of
having intrauterine growth restriction was not reduced if aspirin was started after 16 weeks.

The National Institute for Health and Clinical Excellence (NICE) provides guidance and sets
quality standards to improve people's health in the UK. NICE has suggested that women at
increased risk of developing pre-eclampsia should consider taking low-dose aspirin. If you
have at least two of the moderate risk factors for pre-eclampsia listed above, or at least one
of the high risk factors listed above, NICE suggests that you take low-dose aspirin (a 75 mg
tablet every day) from 12 weeks of your pregnancy until the birth of your baby. However,
NICE does point out that aspirin does not have a specific license for this use and that your
doctor should discuss this with you.

Another recent review of research involving almost 16,000 women found that calcium
supplements during pregnancy were a safe way of reducing the risk of pre-eclampsia in
women at increased risk, and in women who may have low levels of calcium in their diet.
The review also found that women with pre-eclampsia who took calcium supplements were
less likely to die or have serious problems due to their pre-eclampsia. Babies were also less

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likely to be born preterm. However, previous evidence about calcium supplements in

preventing pre-eclampsia has been conflicting and confusing. So, further research is needed
regarding calcium supplements and their role in pre-eclampsia prevention, including the
ideal dose of calcium supplements to take.

Aspirin or calcium supplements are not standard or routine treatments for all women during
pregnancy. However, one or other may be suggested by a specialist if you have a high risk of
developing pre-eclampsia. You should not take either aspirin or calcium supplements unless
you have been advised to do so by your specialist. Discuss it with them first.
What is my risk of developing pre-eclampsia again in a future pregnancy?
If you had pre-eclampsia in your first pregnancy:
 You have somewhere between a 1 in 2 and a 1 in 8 chance of developing gestational
high blood pressure in a future pregnancy.
 You have about a 1 in 6 chance of developing pre-eclampsia in a future pregnancy.
If you had severe pre-eclampsia, HELLP syndrome or eclampsia that meant that your baby
had to be delivered before 34 weeks, you have about a 1 in 4 chance of developing pre-
eclampsia in a future pregnancy.

If you had severe pre-eclampsia, HELLP syndrome or eclampsia that meant that your baby
had to be delivered before 28 weeks, you have about a 1 in 2 chance of developing pre-
eclampsia in a future pregnancy.

Being obese is a risk factor for pre-eclampsia (see above). If you have had pre-eclampsia in a
previous pregnancy and you are planning for another pregnancy but you are overweight or
obese, you should try to lose weight before you become pregnant again. Ideally, you should
aim for your BMI to be in the healthy weight range. This may help to reduce your chance of
developing pre-eclampsia in your next pregnancy. See separate leaflet called 'Obesity and
Overweight in Adults' for more details.
Could pre-eclampsia have any effects on my future health?
Some research has shown that women who develop pre-eclampsia may be have a slightly
increased risk of developing high blood pressure and cardiovascular disease (coronary heart
disease and stroke) some years later. However, the overall risk of developing these
problems is still low. But, bearing this in mind, you may wish to look at ways in which you
may be able to reduce your cardiovascular disease risk by making changes to your lifestyle.
These can include keeping to a healthy weight, exercising regularly, eating a healthy
balanced diet and not smoking. See separate leaflet called 'Preventing Cardiovascular
Diseases' for more details.

If you have had pre-eclampsia during your pregnancy, it is important that your blood
pressure be checked when you leave hospital after you have given birth. This will usually be
done by a midwife who visits you at home. Your blood pressure should also be checked at
your 6-8-week postnatal appointment to make sure that it has returned to normal. Your
urine should be checked for protein at this time as well.
Further help and information
APEC (Action on Pre-eclampsia)

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2c The Halfcroft, Syston LE7 1LD

Tel: 0116 2608088 Helpline: 020 8427 4217 (Weekdays 9 am-5 pm)
Web: www.apec.org.uk

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Pre-Eclampsia (case 86)

History

 17 year old (P0; 37+0) – severe headache and reduced fetal movements
 PC: 10 hour severe frontal headache (unhelped by paracetmol) + blurred vision
+ epigastric discomfort and nausea (no vomit). Nil leg or finger swelling
 BP last checked 1 week ago: 132/74mmHg and urine negative. Booking bloods
normal
Examination

 Maternal observations:
o **BP 164/106mmHg (repeated twice at 15min intervals – remains high)
o HR – 83/min
o Apyrexial
 Maternal examination:
o Cardiac and respiratory examination is normal
o Abdominally tender in epigastrium and below right costal margin
o Mildly oedmatous peripherally
o Neuro: Lower limb reflexes brisk
 Foetal observations:
o CTG:
 DR: Pre-eclamptic mother
 BR: 140/min
 A: occasional accelerations
 V: reduced variability
 D: variable decelerations
 O: overall impression – foetal distress
 Foetal examination:
o Cephalic and 3/5 palpable
Investigations

 FBC, U&Es, LFTs: All within normal range apart from:

o Elevated ALT
o Elevated urate
o Elevated creatinine
 **Urine dip: ++++protein
Differential diagnosis

 Pre-eclampsia (This is ar door a d a o stetri e erge y. This wo a ’s rapid

onset and severe symptoms suggest fulminant disease and she is at high risk of
developing eclampsia)

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 HELLP syndrome (this wo a ’s platelets are at the lower end of normal for a
pregnant woman and if coupled with an elevated bilirubin would suggest HELLP
(haemolysis; elevated liver enzymes and low platelets)
Management

 Obstetric emergency – inform: senior midwife, anaesthetist and senior obstetrician

 The only treatment for pre-eclampsia is delivery of the baby
 Stabilize mother first:
o Continuous obs
o Two large bore cannulae
o Blood sent for coagulation + group and save
o Urine catheterisation (monitor fluid input and output to check for impending
renal failure)
o BE CAUTIOUS ABOUT PUTTING UP FLUIDS:
 Pre-eclampsia is due to increase in extracellular fluid
 Wacking in loads of normal saline will tip the patient into pulmonary
oedema and worsen the current symptoms
 BUT if the patient has inadequate intravascular volume it will lead to
renal failure.
 Monitor volume status with anaesthetist and if require insert central
venous catheter
o Anti-hypertensive to reduce blood pressure and reduce chance of cerebral
haemorrhage (use a beta blocker such as labetalol as it is safe in pregnancy
and rapid acting – give orally first but if no response give IV)
o Magnesium sulphate IV – acts a membrane stabiliser and reduces the chance
of eclamptic fit (loading dose of 4 g should be given intravenously over 5
minutes, followed by an infusion of 1 g/hour maintained for 24 hours –
source RCOG)
 Delivery:
o CTG shows that there is foetal distress most probably due to utero-placental
insufficiency so deliver by C-section
Pathophysiology
My understanding:

 Pre-eclampsia is a complex multi-system disease

 It is caused by a failure of placentation, leading to widespread endothelial
dysfunction
 Blood pressure increases to ensure sufficient fetal perfusion
 Increased BP + leaky endothelium = increased ECF and consequently all the
symptoms:
o Headache due to increased ICP
o Fits (eclampsia) as the neuronal membrane potentials are disrupted by all the
fluid in the brain

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o Pulmonary oedema – leaking into the alveoli

o Peripheral oedema
o Renal failure (hence +++ protein)
o RUQ pain – subcapsular liver swelling and hepatic rupture in severe cases

PRE-ECLAMPSIA
Definition Hypertension + proteinuria (protein:creatinine ratio (PCR) >30mg/nmol
or >0.3g/24h) after 20 weeks gestation
Aetiology - A multi-system disease of placental origin
- Blood vessel endothelial damage accompanied by an exaggerated
maternal inflammatory response leads to vasospasm, increased
capillary permeability and clotting dysfunction
- Increased vascular resistance  hypertension
- Increased vascular permeability  proteinuria and oedema
- Reduced placental blood flow  IUGR
- Reduced cerebral perfusion  eclampsia
- Hypertension usually precedes proteinuria and is used to classify
disease
 Mild = 140/90
 Moderate = 150/100
 Severe = 160/110
Risk factors - Nulliparity/long inter-pregnancy interval
- Previous history
- Family history
- Extremes of maternal age – very young and very old
- Chronic hypertension
- Diabetes
- Multiple pregnancy
- Autoimmune disease e.g. Antiphospholipid syndrome, SLE
- Renal disease
- Obesity
- Black and Asian backgrounds
- (Smoking decreases risk)

…For pree la psia superi posed o PIH:

- Renal disease
- Maternal age >40
- Diabetes
- Connective tissue disease e.g. SLE, Antiphospholipid syndrome
- Coarctation of the aorta
- BP >160/100 mmHg in early pregnancy
Complications/Prognosis Maternal Complications:
- Early onset disease is more severe
- Eclampsia = grand mal seizures occurring in a woman with
established pre-eclampsia in the absence of any other neurological or

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metabolic cause  hypoxia

- Cerebrovascular haemorrhage  failure of cerebral blood flow
autoregulation at MAP> 140mmHg
- HELLP syndrome
 Haemolysis  dark urine, raised LDH
 Elevated liver enzymes  epigastric pain, liver failure, abnormal
clotting
 Low platelets (normally self-limiting)
- DIC, liver failure and liver rupture may occur
- Renal failure – determined by careful fluid balance monitoring and
creatinine measurement, haemodialysis is needed in severe cases
- Pulmonary oedema  can progress to ARDS
- Note these complications are a huge cause of POST-natal mortality
- Complications are an indication for delivery whatever the gestation,
they may also occur postpartum, as it takes at least 24 hours for
delivery to ure the disease

Foetal Complications
- IUGR
- Preterm delivery
- Stillbirth
- Placental abruption
- Hypoxia
Signs & Symptoms - Usually asymptomatic until late stages
- Hypertension (may be absent in early stages)
- Proteinuria
- Oedema (more than in normal pregnancies or more sudden onset)
- Epigastric tenderness suggests impending complications
- In severe pre-eclampsia/eclampsia  agitation, hyper-reflexia, facial
and peripheral oedema, RUQ tenderness, poor urine output, clonus,
papilloedema (rare)
DDx Gestational hypertension, Pre-existing hypertension, epilepsy
Psych/ethical issues
Ix Series - Bedside dipstick urinalysis – PCR ratio >30mg/nmol (24-hour urine
collection >0.3g/24h used to be routinely performed, but less so
now)
- Elevated uric acid
- High Hb ( haemolysing?)
- Low platelets <100 (due to platelet aggregation of damaged
endothelium indicated impending HELLP)
- Rise in transferases and LDH on LFTs
- Impaired renal function – rapidly rising creatinine suggests severe
complications and renal failure
- Glucose can help distinguish between HELLP and acute fatty liver
(normal in HELLP, deranged in acute fatty liver)
- USS to estimate foetal weight and growth
- Umbilical artery Doppler – shows notched wave forms and poor

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diastolic flow
- CTG if Doppler is abnormal
Mx Primary care - At risk women should be given prophylactic low dose aspirin (75mg)
starting before 16 weeks, where at risk women are those with any of
the following:
 Hypertensive disease during previous pregnancy
 Chronic kidney disease
 Autoimmune disease such as SLE or antiphospholiipid syndrome
 Type 1 or type 2 diabetes
 Chronic hypertension (NB ACEI, ARBs and clorothiazide
should t e used i preg a y)

On follow up after delivery, inform women that their risk of developing:

 Gestational hypertension in a fiture pregnancy is between 13-53%
 The risk of PET in future pregnancies is up to 16% or 25% if the
PET was complicated by severe pre-eclampsia, HELLP syndrome
or eclampsia and led to birth before 34 weeks
 The risk of PET in future pregnancies is up to 55% if it led to birth
before 28 weeks
Secondary care - Proteinuria 2+ on dipstick, diastolic blood pressure >160/110 mmHg
and suspected foetal compromise warrants admission
- In the absence of hypertension, patients with new proteinuria of 2+
or more should be admitted
- If there is 1+ proteinuria, quantification and subsequent review 2
days later is sufficient
- The only cure is delivery
 Indications for urgent delivery = persistent BP over 160/100mHg
with significant proteinuria, elevated liver enzymes, low
platelets, eclamptic fit, anuria, significant foetal distress
 Gestational hypertension without foetal compromise is
monitored and requires induction by 40 weeks
 Mild pre-eclampsia requires delivery by 37 weeks
 Moderate or severe pre-eclampsia needs delivery if the
gestation exceeds 34-36 weeks, after which time complications
of prematurity are less of a problem. Labour can be induced
with prostaglandins if needed, and epidural analgesia can help
reduce the blood pressure. Maternal pushing should be
avoided, as it raises intracranial pressure, and oxytocin should
be used rather than ergometrine in the third stage, as
ergometrine can increase blood pressure.
 Before 34 weeks, conservative management is appropriate in a
specialist unit with full neonatal care facilities, but the possible
benefits of increasing foetal maturity must be weighed against
the risks of disease complications
 Delivery is usually by Caesarean section if indicated
 Severe pre-eclampsia with complications of foetal distress

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requires delivery whatever the gestation

- Oral nifedipine for initial control of hypertension, followed by IV
labetalol in severe hypertension
- Methyldopa can be given orally, but it can take 24 hours to take
effect
- Magnesium sulphate for both prophylaxis and treatment of
eclampsia – IV loading dose followed by IV infusion (NB magnesium
sulphate is t a a ti-convulsant, but increases cerebral perfusion,
stabilises cell membranes and probably treats the underlying
pathology of eclampsia)
- Steroids to mature the foetal pulmonary system (IM dexamethasone)
- ICU in severe cases
- Oxygen and frusemide for pulmonary oedema, assisted ventilation if
severe
- Post-natal management
 Continue to monitor liver enzymes, platelets and renal function
 Fluid balance monitoring
 Aim to maintain blood pressure at around 140/90mmHg with a
beta-blocker (or nefidipine and ACE inhibitors), the highest level
tends to be reached about 5 days after birth, treatment may be
needed for several weeks
 At 6 weeks post-natal, women with persistent proteinuria or
hypertension should be referred to a renal or hypertension
clinic respectively
Emergency Mx - Place the woman in the recovery position
- ABC
- Give oxygen
- Gain IV access and take blood for FBC, clotting studies, LFTs, U&Es
and cross-matching
- 5g bolus of IV MgSO4 (check for toxicity by observing the patient and
testing for diminished reflexes – if necessary, effects can be reversed
with calcium gluconate)

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Pre-Eclampsia (case 86)

History
● 17 year old (P0; 37+0) – severe headache and reduced fetal movements
● PC: 10 hour severe frontal headache (unhelped by paracetmol) + blurred vision
+ epigastric discomfort and nausea (no vomit). Nil leg or finger swelling
● BP last checked 1 week ago: 132/74mmHg and urine negative. Booking bloods
normal
Examination
● Maternal observations:
o **BP 164/106mmHg (repeated twice at 15min intervals – remains high)
o HR – 83/min
o Apyrexial
● Maternal examination:
o Cardiac and respiratory examination is normal
o Abdominally tender in epigastrium and below right costal margin
o Mildly oedmatous peripherally
o Neuro: Lower limb reflexes brisk
● Foetal observations:
o CTG:
▪ DR: Pre-eclamptic mother
▪ BR: 140/min
▪ A: occasional accelerations
▪ V: reduced variability
▪ D: variable decelerations
▪ O: overall impression – foetal distress
● Foetal examination:
o Cephalic and 3/5 palpable
Investigations
● FBC, U&Es, LFTs: All within normal range apart from:
o Elevated ALT
o Elevated urate
o Elevated creatinine
● **Urine dip: ++++protein
Differential diagnosis
● Pre-eclampsia (This is ar door a d a o stetri e erge y. This wo a s rapid
onset and severe symptoms suggest fulminant disease and she is at high risk of
developing eclampsia)
● HELLP syndrome (this wo a s platelets are at the lower end of normal for a
pregnant woman and if coupled with an elevated bilirubin would suggest HELLP
(haemolysis; elevated liver enzymes and low platelets)
Management

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● Obstetric emergency – inform: senior midwife, anaesthetist and senior obstetrician

● The only treatment for pre-eclampsia is delivery of the baby
● Stabilize mother first:
o Continuous obs
o Two large bore cannulae
o Blood sent for coagulation + group and save
o Urine catheterisation (monitor fluid input and output to check for impending
renal failure)
o BE CAUTIOUS ABOUT PUTTING UP FLUIDS:
▪ Pre-eclampsia is due to increase in extracellular fluid
▪ Wacking in loads of normal saline will tip the patient into pulmonary
oedema and worsen the current symptoms
▪ BUT if the patient has inadequate intravascular volume it will lead to
renal failure.
▪ Monitor volume status with anaesthetist and if require insert central
venous catheter
o Anti-hypertensive to reduce blood pressure and reduce chance of cerebral
haemorrhage (use a beta blocker such as labetalol as it is safe in pregnancy
and rapid acting – give orally first but if no response give IV)
o Magnesium sulphate IV – acts a membrane stabiliser and reduces the chance
of eclamptic fit (loading dose of 4 g should be given intravenously over 5
minutes, followed by an infusion of 1 g/hour maintained for 24 hours –
source RCOG)
● Delivery:
o CTG shows that there is foetal distress most probably due to utero-placental
insufficiency so deliver by C-section
Pathophysiology
My understanding:
● Pre-eclampsia is a complex multi-system disease
● It is caused by a failure of placentation, leading to widespread endothelial
dysfunction
● Blood pressure increases to ensure sufficient fetal perfusion
● Increased BP + leaky endothelium = increased ECF and consequently all the
symptoms:
o Headache due to increased ICP
o Fits (eclampsia) as the neuronal membrane potentials are disrupted by all the
fluid in the brain
o Pulmonary oedema – leaking into the alveoli
o Peripheral oedema
o Renal failure (hence +++ protein)
o RUQ pain – subcapsular liver swelling and hepatic rupture in severe cases

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PRE-ECLAMPSIA
Definition Hypertension + proteinuria (protein:creatinine ratio (PCR) >30mg/nmol
or >0.3g/24h) after 20 weeks gestation
Aetiology - A multi-system disease of placental origin
- Blood vessel endothelial damage accompanied by an exaggerated
maternal inflammatory response leads to vasospasm, increased capillary
permeability and clotting dysfunction
- Increased vascular resistance  hypertension
- Increased vascular permeability  proteinuria and oedema
- Reduced placental blood flow  IUGR
- Reduced cerebral perfusion  eclampsia
- Hypertension usually precedes proteinuria and is used to classify disease
● Mild = 140/90
● Moderate = 150/100
● Severe = 160/110
Risk factors - Nulliparity/long inter-pregnancy interval
- Previous history
- Family history
- Extremes of maternal age – very young and very old
- Chronic hypertension
- Diabetes
- Multiple pregnancy
- Autoimmune disease e.g. Antiphospholipid syndrome, SLE
- Renal disease
- Obesity
- Black and Asian backgrounds
- (Smoking decreases risk)

…For pree la psia superi posed o PIH:

- Renal disease
- Maternal age >40
- Diabetes
- Connective tissue disease e.g. SLE, Antiphospholipid syndrome
- Coarctation of the aorta
- BP >160/100 mmHg in early pregnancy
Complications/Prognosis Maternal Complications:
- Early onset disease is more severe
- Eclampsia = grand mal seizures occurring in a woman with established pre-
eclampsia in the absence of any other neurological or metabolic cause 
hypoxia
- Cerebrovascular haemorrhage  failure of cerebral blood flow
autoregulation at MAP> 140mmHg
- HELLP syndrome
● Haemolysis  dark urine, raised LDH
● Elevated liver enzymes  epigastric pain, liver failure, abnormal
clotting

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● Low platelets (normally self-limiting)

- DIC, liver failure and liver rupture may occur
- Renal failure – determined by careful fluid balance monitoring and
creatinine measurement, haemodialysis is needed in severe cases
- Pulmonary oedema  can progress to ARDS
- Note these complications are a huge cause of POST-natal mortality
- Complications are an indication for delivery whatever the gestation, they
may also occur postpartum, as it takes at least 24 hours for delivery to
ure the disease

Foetal Complications
- IUGR
- Preterm delivery
- Stillbirth
- Placental abruption
- Hypoxia
Signs & Symptoms - Usually asymptomatic until late stages
- Hypertension (may be absent in early stages)
- Proteinuria
- Oedema (more than in normal pregnancies or more sudden onset)
- Epigastric tenderness suggests impending complications
- In severe pre-eclampsia/eclampsia  agitation, hyper-reflexia, facial and
peripheral oedema, RUQ tenderness, poor urine output, clonus,
papilloedema (rare)
DDx Gestational hypertension, Pre-existing hypertension, epilepsy
Psych/ethical issues
Ix Series - Bedside dipstick urinalysis – PCR ratio >30mg/nmol (24-hour urine
collection >0.3g/24h used to be routinely performed, but less so now)
- Elevated uric acid
- High Hb ( haemolysing?)
- Low platelets <100 (due to platelet aggregation of damaged endothelium
indicated impending HELLP)
- Rise in transferases and LDH on LFTs
- Impaired renal function – rapidly rising creatinine suggests severe
complications and renal failure
- Glucose can help distinguish between HELLP and acute fatty liver (normal
in HELLP, deranged in acute fatty liver)
- USS to estimate foetal weight and growth
- Umbilical artery Doppler – shows notched wave forms and poor diastolic
flow
- CTG if Doppler is abnormal
Mx Primary care - At risk women should be given prophylactic low dose aspirin (75mg)
starting before 16 weeks, where at risk women are those with any of the
following:
● Hypertensive disease during previous pregnancy
● Chronic kidney disease
● Autoimmune disease such as SLE or antiphospholiipid syndrome

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● Type 1 or type 2 diabetes

● Chro i hyperte sio (NB ACEI, A‘Bs a d lorothiazide should t e
used in pregnancy)

On follow up after delivery, inform women that their risk of developing:

● Gestational hypertension in a fiture pregnancy is between 13-53%
● The risk of PET in future pregnancies is up to 16% or 25% if the PET
was complicated by severe pre-eclampsia, HELLP syndrome or
eclampsia and led to birth before 34 weeks
● The risk of PET in future pregnancies is up to 55% if it led to birth
before 28 weeks
Secondary care - Proteinuria 2+ on dipstick, diastolic blood pressure >160/110 mmHg and
suspected foetal compromise warrants admission
- In the absence of hypertension, patients with new proteinuria of 2+ or
more should be admitted
- If there is 1+ proteinuria, quantification and subsequent review 2 days
later is sufficient
- The only cure is delivery
● Indications for urgent delivery = persistent BP over 160/100mHg with
significant proteinuria, elevated liver enzymes, low platelets,
eclamptic fit, anuria, significant foetal distress
● Gestational hypertension without foetal compromise is monitored
and requires induction by 40 weeks
● Mild pre-eclampsia requires delivery by 37 weeks
● Moderate or severe pre-eclampsia needs delivery if the gestation
exceeds 34-36 weeks, after which time complications of prematurity
are less of a problem. Labour can be induced with prostaglandins if
needed, and epidural analgesia can help reduce the blood pressure.
Maternal pushing should be avoided, as it raises intracranial
pressure, and oxytocin should be used rather than ergometrine in
the third stage, as ergometrine can increase blood pressure.
● Before 34 weeks, conservative management is appropriate in a
specialist unit with full neonatal care facilities, but the possible
benefits of increasing foetal maturity must be weighed against the
risks of disease complications
● Delivery is usually by Caesarean section if indicated
● Severe pre-eclampsia with complications of foetal distress requires
delivery whatever the gestation
- Oral nifedipine for initial control of hypertension, followed by IV labetalol
in severe hypertension
- Methyldopa can be given orally, but it can take 24 hours to take effect
- Magnesium sulphate for both prophylaxis and treatment of eclampsia – IV
loadi g dose followed y IV i fusio (NB ag esiu sulphate is t a a ti-
convulsant, but increases cerebral perfusion, stabilises cell membranes
and probably treats the underlying pathology of eclampsia)
- Steroids to mature the foetal pulmonary system (IM dexamethasone)
- ICU in severe cases
- Oxygen and frusemide for pulmonary oedema, assisted ventilation if

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severe
- Post-natal management
● Continue to monitor liver enzymes, platelets and renal function
● Fluid balance monitoring
● Aim to maintain blood pressure at around 140/90mmHg with a beta-
blocker (or nefidipine and ACE inhibitors), the highest level tends to
be reached about 5 days after birth, treatment may be needed for
several weeks
● At 6 weeks post-natal, women with persistent proteinuria or
hypertension should be referred to a renal or hypertension clinic
respectively
Emergency Mx - Place the woman in the recovery position
- ABC
- Give oxygen
- Gain IV access and take blood for FBC, clotting studies, LFTs, U&Es and
cross-matching
- 5g bolus of IV MgSO4 (check for toxicity by observing the patient and
testing for diminished reflexes – if necessary, effects can be reversed with
calcium gluconate)

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Prenatal diagnosis – Down’s syndrome

Information should be given to pregnant women at first contact with a healthcare

professional:
 The screening pathway for both screen-positive and screen-negative results
 The decisions that need to be made at each point along the pathway and their
consequences
 The fact that screening does not provide a definitive diagnosis and a full
explanation of the risk score obtained following testing
 Information about chorionic villus sampling and amniocentesis
 Balanced and accurate information about Down's syndrome

Screening for Down's syndrome

Down's syndrome is a condition which is caused by an abnormal chromosome. Children
with Down's syndrome have learning disability and often have other medical problems.
There are different screening tests for Down's syndrome and so different tests may be
used in different areas. They include a blood test and a special ultrasound test, or both.
Screening for Down's syndrome is offered sometime between 11 and 20 weeks of
pregnancy, depending on the type of test used.

Your doctor or midwife will explain the type of test performed in your area, and the
implications of the results. For example, some women opt for termination of pregnancy
if they are found to have a Down's syndrome child. Note: the screening test is not a
clear-cut diagnostic test.

Therefore:
 A 'positive' test means that you may have a child with Down's syndrome. If you
have a positive screening test, further tests are needed to confirm the diagnosis.
In some positive tests the baby does not have Down's syndrome (a 'false
positive' result).
 A negative test does not completely rule out Down's syndrome. (That is, in some
cases there is a 'false negative' result.) Currently the screening tests identify
about 60-80 in 100 babies who have Down's syndrome.
You do not have to have a screening test for Down's syndrome if you do not want one.

Screening for Down's syndrome takes place during either the first or second trimester
by either ultrasound or maternal serum biochemistry, or a combination of both:

o Combined test - nuchal translucency, beta-human chorionic gonadotrophin and

pregnancy-associated plasma protein-A

o Ultrasound - soft markers (choroid plexus cyst, thickened nuchal fold, echoegnic
intracardiac focus, echogenic bowel, renal pyelectasis, humeral and femoral
shortening)

Blood test results in DS

 Low: PAPP-A (in 1st trimester), AFP (1st and 2nd trimester), oestriol (2nd
trimester)
 High: hCG (first and secondar trimester), inhibin (2nd trimester)

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Ultrasound findings

Nuchal translucency
 A measurement of the thickness of a pad of skin in the nuchal (neck) region of
the foetus
 Foetuses with Down's syndrome tend to have a thicker nuchal lucency

Additional measurements to the ones stated above:

 Nasal bone
 Frontomaxilllary nasal angle
 Presence of tricuspid regurdication
 Ductus venosus wave form

Diagnostic tests for Downs Syndrome

1. CVB/CVS
2. Amniocentesis

Chorionic Villus Sampling

What is chorionic villus sampling?

Chorionic villus sampling (CVS) is a procedure that is carried out during pregnancy to
diagnose or exclude various chromosome or genetic conditions in the unborn
developing baby. CVS is usually carried out between the 11th and 13th week of
pregnancy. A very small sample of tissue from a part of the developing placenta called
the chorionic villi is taken. The cells of the chorionic villi contain the exact same genetic
material (chromosomes and DNA) as the cells of the developing baby. So, tests can be
done on the placental tissue in the laboratory to look at the genetic make-up of the
developing baby.

CVS is usually carried out by passing a fine needle through the skin of your abdomen
and into your uterus (womb) to take the sample of the placenta. This is known as
transabdominal CVS. Sometimes, because of the position of your uterus or the position
of the placenta, transabdominal CVS may not be possible. CVS can also be performed by
passing a fine plastic tube or biopsy forceps through your cervix (the neck of your
womb). This is known as transcervical CVS.

CVS is a diagnostic test in pregnancy. In most cases, a diagnostic test tells you for
definite whether or not your baby has a certain condition. Contrast this with a screening
test in pregnancy (for example, blood tests and/or ultrasound screening tests for
Down's syndrome). Screening tests give you a risk estimate, or the probability, that the
baby has a certain condition. They do not give you a definite 'yes' or 'no' answer. If you
have a screening test that shows a high risk of a certain condition, you will usually be
offered a diagnostic test.

An alternative diagnostic test to CVS is amniocentesis. Briefly, amniocentesis involves

taking a sample of the amniotic fluid inside your uterus that is surrounding the
developing baby. This fluid contains the baby's cells and so examination of the fluid
allows genetic testing of the baby. Amniocentesis is carried out after 15 weeks of
pregnancy.

The advantage of CVS over amniocentesis is that CVS can be carried out earlier in
pregnancy. This means that decisions about how you would like to proceed with the

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pregnancy can be made sooner. However, there may be a slightly higher risk of
complications with CVS (see below).

How is chorionic villus sampling carried out?

The doctor carrying out the procedure will decide whether transabdominal or
transcervical CVS is best in your situation. This will depend on the position of your
uterus and the position of your placenta. As mentioned above, for most women
transabdominal CVS is done.

Transabdominal CVS
First you can expect to have an ultrasound scan similar to other scans during pregnancy.
For this, gel is put on the skin of your abdomen and the ultrasound probe is passed over
the skin to check the position of the baby and the placenta. The best position to take a
sample of placental tissue is found.

Transabdominal CVS is carried out under continuous ultrasound control. This means
that throughout the procedure, the doctor performing the CVS holds the ultrasound
probe on the skin of your abdomen to allow them to see an ultrasound picture
continuously. This allows them to keep a close eye on your uterus, the baby and the
position of the needle used to take the sample.

You may be given a local anaesthetic to numb an area of the skin of your abdomen. Once
the best position is identified, the skin of your abdomen is then cleaned and a fine
needle is passed through your skin, into your uterus and into the placenta. A syringe
attached to the end of the needle allows a sample of tissue from the placenta to be
drawn (sucked) up into the syringe. An ultrasound scan is usually carried out after CVS
to check the baby.

Transcervical CVS
You will first have an ultrasound scan to check the baby and look at the placenta.
Transcervical CVS is also carried out under continuous ultrasound control.

A speculum (the same instrument that is used when you have a cervical smear test) is
inserted into your vagina so that the doctor can see your cervix (the neck of your
womb). They will then clean the inside of your vagina and your cervix with an antiseptic
cleansing solution. A fine tube or some fine biopsy forceps are then passed through your
cervix, into your womb so that a sample of the placenta can be taken. As before, an
ultrasound scan is usually carried out after CVS to check the baby.

What tests are carried out on the placental tissue?

There are two main tests that can be done to look at the baby's chromosomes. The first
is called a rapid test. This usually gives results within three days. It can look for the
chromosome disorders e.g. Down's syndrome.

The second test is called a full karyotype test. This looks at all of the baby's
chromosomes in detail. It takes longer to get the results of this test, usually two to three
weeks. Sometimes only a rapid test is carried out. Your doctor or midwife will discuss
with you which tests are best in your situation.

Occasionally, the chromosome test results are uncertain. If this is the case, you may be
offered a repeat CVS or an amniocentesis. However, this is rare and in most cases,
definite results are possible. There is also a very small chance that the test results for the
rapid test are normal but that the full karyotype test shows up a problem. Very rarely, a
woman's full karyotype result may be reported as normal but she will still have a baby

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born with a chromosome disorder or other problem. This is because some chromosome
changes may be so small that they are very difficult to see. CVS cannot exclude all
possible disorders.

Also, it should be understood that the chromosome result does not provide information
about the physical development of the baby. The fetal anomaly ultrasound scan that is
done at around 18-20 weeks of pregnancy can help to look for these physical problems.
However, it is also not possible for this scan to show up all abnormalities.

You should ask your doctor or midwife to explain how long it will take for the results of
your CVS. You should also ask them how you will receive the results. For example, you
may be given another appointment or sometimes results are given by telephone.

Are there any complications of chorionic villus sampling?

Most women who have CVS during pregnancy have no complications. However, CVS
does carry some small risks of complications. You need to balance these small risks
against having the extra information about the baby and their genetic make-up.
Complications can include the following:

Miscarriage
There is a small risk of miscarriage with every pregnancy. This is the background risk of
having a miscarriage. However, for women who have had CVS, it is thought that there is
an additional (or 'extra') risk that they will have a miscarriage.

There is also an additional risk of miscarriage after amniocentesis. For women who have
had amniocentesis after 15 weeks of pregnancy, there is about a 1 in 100 additional, or
extra, risk that they will have a miscarriage. (Out of 100 women who have
amniocentesis, 1 will have a miscarriage that they would not otherwise have had.) But,
the additional risk of miscarriage after CVS is slightly higher than that for amniocentesis,
2 in 100. Many research studies have shown this slightly higher risk after CVS to be
about the same for both transabdominal CVS and transcervical CVS. The reason for this
slightly higher risk of miscarriage after CVS compared with amniocentesis may be
because CVS is carried out earlier in pregnancy.

Most miscarriages happen within two weeks of having CVS. A miscarriage after three
weeks is less likely. It is not certain why there is a small chance that CVS can lead to a
miscarriage. It may be that it is caused by infection, bleeding, or rupture of the amniotic
membranes (the bag/sac containing the amniotic fluid that surrounds the baby) caused
by the procedure.

Ask your doctor what the miscarriage rate is for CVS in the unit where you will be
treated. The chance of miscarriage may be slightly lower if CVS is carried out by
someone who is very experienced at the procedure.

Infection
Infection is another complication that can rarely occur after CVS. Less than 1 in 1,000
women who have CVS will develop a serious infection. Infection can be caused by a
number of things.

Limb abnormalities in the developing baby

Back in the 1990s concern was raised after a small study reported that five babies had
limb abnormalities such as missing fingers and toes after their mother had CVS.
However, in all cases CVS was carried out before 10 completed weeks of pregnancy.
Also, later studies showed that the risks of such problems after CVS were no higher than

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the risk in the general population (i.e. in those pregnancies where the woman had not
had CVS).

Still, CVS before 10 completed weeks of pregnancy is now not recommended. This is
because of the theoretical risk that a temporary interruption to the supply of blood to
the baby when the placental cells are taken may lead to limb and other defects and also
because of the fact that CVS is more difficult to carry out at this stage of pregnancy (as
described above).

Rhesus disease in the developing baby

If your blood group is rhesus negative and the baby's blood group is rhesus positive,
there is a risk that you may develop antibodies against the baby's blood cells after CVS.
These antibodies can attack the red blood cells of the baby. The baby can develop
anaemia, jaundice and in severe cases, death of the baby can occur. So, if you are rhesus
negative, you will be advised to have a special injection with anti-D immunoglobulin to
help to prevent this.

How can I expect to feel after chorionic villus sampling?

The procedure itself can be a little painful. Many women describe the discomfort as
being a bit like period pain. Some describe having a transcervical CVS as feeling a bit like
having a cervical smear test.

It is best if you can arrange for someone to drive you home after the CVS if possible. You
should also take things easy over the subsequent few days but total bed rest is not
necessary. Some mild, period-like cramping abdominal pains with a small amount of
light spotting of blood from your vagina can be normal immediately after CVS.
Paracetamol can be taken to help the pain.

However, if you develop any of the following, you need to seek medical advice
immediately as they may be signs of complications: severe abdominal pain;
contractions; persistent back pain; continuous bleeding from your vagina; a watery fluid
loss from your vagina; a smelly discharge from your vagina; fever; Flu-like symptoms.

What are my choices if the results are abnormal?

Deciding to have CVS can be a very difficult decision and a very anxious time. However,
most women who have a CVS will have a normal result. That is, the baby won't have the
genetic problem that the test was looking for. But, before you go through CVS, it is
important for you to think through carefully what difference an abnormal test result
would make to you. How would it be likely to affect your decision about whether or not
to continue with the pregnancy?

Once you know the results, and if the results show a problem, you need to make a
decision about what is best for you and the baby. This decision may be very difficult to
make. You may find it helpful to talk things through with your GP, your midwife, your
obstetrician, a paediatrician, a genetic specialist, a counsellor, etc. You may also wish to
talk things through with your partner or family where possible.

There is still time to terminate the pregnancy (have an abortion) after CVS if you choose
to. An advantage of CVS is that you usually get the results earlier in the pregnancy. This
means that if you do choose to terminate the pregnancy, it is likely that you will just
need a minor operation to remove the contents of your uterus. If you have an
amniocentesis (which is done later) and choose to end the pregnancy at a later stage,
this may mean an induced labour. However, in either case, the type of termination will
depend on how many weeks pregnant you are when you decide to end the pregnancy.

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You should discuss this with your doctor or midwife.

Equally, if the results of CVS do show a problem, you may choose to continue with the
pregnancy. With the knowledge of the results, you can start to prepare for the birth and
care of the baby who is likely to have special needs. The baby may need special care
immediately after they are born. For example, they may need surgery or some other
procedure. Prior knowledge that the baby has a certain condition means that you can
plan to give birth in a hospital where all of the appropriate facilities are available.

Amniocentesis – very similar structure and content to CVB/CVS apart from details
below

Amniocentesis is usually offered after 15 completed weeks of pregnancy (most

commonly between 15-18 weeks). This is because it has been shown to be safest at this
stage of pregnancy. Amniocentesis before 15 weeks is considered as early
amniocentesis. Before 15 weeks of pregnancy, the amount of amniotic fluid levels are
lower, making it more difficult to get enough amniotic fluid for testing. Early
amniocentesis is not usually recommended because it carries a higher risk of
miscarriage and also a higher risk of club foot in the developing baby.

How is amniocentesis carried out?

During the procedure itself, first you can expect to have an ultrasound scan similar to
other scans during pregnancy. For this, gel is applied to your abdomen and the
ultrasound probe is passed over the skin of your abdomen to check the position of the
baby and also the placenta. Amniocentesis is usually carried out under continuous
ultrasound control. This means that the doctor performing the amniocentesis uses the
ultrasound probe to allow them to see an ultrasound picture continuously throughout
the procedure. By doing this, they can keep a close eye on the baby and the position of
the needle used to draw off the amniotic fluid.

The doctor will use the scan picture to help them to find a clear 'pocket' or 'pool' of
amniotic fluid around the baby so that the fluid can be withdrawn without the needle
touching the baby or the umbilical cord. They will usually try to avoid inserting the
needle through the placenta. However, occasionally, this can be the only way to collect
the sample of fluid. If the needle does pass through the placenta it is unlikely to cause
any harm to either you or the baby.

When the best position is found, your skin is cleaned around the area where the needle
will be inserted. A fine needle is then pushed through your skin, the muscles of your
abdomen and then through the muscle wall of your uterus into the pocket of amniotic
fluid. A syringe will be attached to the other end of the needle so that some of the
amniotic fluid from around the baby can then be drawn off.

Usually between 10 and 20 mls of amniotic fluid are taken. The needle is then taken out
and you will have another scan to check the baby. The baby will quickly start to replace
the amniotic fluid that is removed during the procedure the next time they pass urine.
The amniotic fluid is normally a straw-like colour. However, sometimes it can be stained
with blood. This is not dangerous but can sometimes interfere with the test results and
the test may need to be repeated.

Occasionally, it is not possible to get enough amniotic fluid for testing and the needle has
to be removed and reinserted. This may be due to the position that the baby is lying in.
Hopefully, a second attempt at collecting fluid will be successful. If not, you will usually

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be asked to return on another day to try again.

You may prefer to have some support during the procedure. If you feel comfortable
about this, consider asking your partner, a friend or a family member to accompany you.
The whole procedure will probably take about 10 minutes but your appointment will
usually last longer than this because you will need some time to rest afterwards.

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Preterm Labour
History

 28 year old; P0; 32 weeks

 PC:
o Abdominal pain: 1/7, intermittent, every few minutes, nothing in between
o Discharge + dark vaginal bleeding
o Fetal movements are normal
 OHx:
o This pregnancy:
 Lower back pain
 2 UTIs
 Increased urinary frequency
 Constipation
 No history of leaking liquor
 GHx:
o Two LLETZ procedures 10 years ago after abnormal smear; all negative since
then with most recent 10 months ago
 DHx:
o Pregnacare
o NKDA
 FHx: nil
 SHx: Lives with husband; primary school teacher; no concerns

Differential diagnosis

 PPROM
 PTL
 UTI
 Red degeneration of fibroid
 Placental abruption
 Constipation
Examination
Maternal observations:

 Apyrexial; BP 109/60mmHg; HR 96
Maternal examination

 Fundal height 30cm; moderate contractions last approx. 35s; fetus is breech;
presenting part engaged
 Speculum: no liquor is visible

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 Vaginal examination: cervix is effaced; 3cm dilated, breech -2cm above ischial spines,
membranes intact
Fetal examination

 CTG:
o Baseline rate: 145/min
o Accelerations present
o Variability normal (15/min)
o No decelerations observed
o Uterine activity recorded 3 in 10
Investigations

 This case of PTL is clear so only investigation

o Repeat VE: in 1-4 hours
 If in doubt about PTL:
o Fetal fibronectin – fFN is produced by disruption of the choriodecidual
membranes – if performed correctly it has a better predictive value than VE
o TA-USS: to confirm presentation as palpation is notoriously unreliable
o TV-USS - to assess cervical canal length

Management

 Continuous fetal monitoring

 Maternal steroids:
o Betamethasone IM – ideally two doses between 12-24 hours apart
o Ideally >48 hours and <7days before delivery
 Tocolytics:
o Aim to prolong labour for 24 hours to:
 Allow steroids to be effective
 Transfer of mother to unit with NICU facilities
o Choice agents:
 Atosiban (oxytocin antagonist)
 Ritodrine (beta agonist)
 Nifedipine
 GTN
 Mode of delivery
o Consider augmenting labour with oxytocin if evidence of chorioamnionitis as
prolonging the delivery may lead to worsening infection
o In full term breech infants c-section delivery is indicated. However, in breech
pre-term infants vaginal delivery is suggested as it is relatively quick. Reasons
to procede to c-section include evidence of fetal distress and maternal
objection. Nonetheless lots of centres do carry out c-sections routinely for
cases of preterm breech – the guidance is not clear

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 Analgesia
o Epidural is recommend to prevent expulsive efforts before full dilation and to
allow quick switch to c-section if required
 Postnatal care
o Liaise with paediatric team to ensure appropriate arrangements are made for
pre-term infant on delivery

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Condition Prolapse
Definition
Descent of the uterus and/or vaginal walls beyond anatomical confines.
History
A 56-year-old shopkeeper presents to a gynaecology clinic with a 3-month history of a
sensation of something coming down . She feels a lump in her vagina, which is worse
towards the end of the day, in association with a dragging backache. She has had four
vaginal deliveries, one of which was assisted by forceps. There were no macrosomic babies.
She does not have urinary or bowel incontinence.

PC
Dragging sensation or a lump.
Worse on standing up.
Worse at the end of the day.
Fluid intake habits, particularly in relation to tea, coffee and alcohol, are important with
regard to the symptomatology.
Haematuria may indicate a bladder stone or tumour.
Involuntary urinary loss as a result of a rise in intra-abdominal pressure (e.g. caused by
exercise, sneezing or coughing) in the absence of voiding difficulties is suggestive of
sphincter incompetence (GSI).
Incontinence may be associated with symptoms of uterovaginal prolapse and faecal
incontinence (rectocoele).

HPC
(1) It is said that women who have a physically demanding job are at high risk of
prolapse.
(2) The sensation of prolapse is typically worse at the end of the day.
PMH + PSH (MSC SOUR) – Obx and gynae hx
 Menstrual – Normal.
 Sexual – Normal
 Contraception – Doesn’t affect
 Smear – Normal.
 Obstetric: Childbirth and particularly traumatic delivery indicates that there
may have been possible pelvic floor damage
 Urinary –

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 Rectal –
Medical conditions / Previous surgery
Neurological Disorders - In neurological disorders such as multiple sclerosis,
incontinence will usually be a secondary symptom.
DH and allergies
FMH
SH
System Review
 General –
 Neuro –
 Cardio –
 Resp-
 Gastro –
 Musc –
 Derm –

Differential Diagnosis
There are many different types of prolapse:
(1) Cystocele.
(2) Uterine prolapse:
฀ primary;
฀ secondary;
฀ tertiary (procidentia).
(3) Rectocele.
(4) (Enterocele – pouch of Douglas hernia, which contains loops of bowel.)

Examination
Abdominal examination:
Physical examination should be performed with a comfortably full bladder, when
incontinence may be demonstrated by asking the patient to cough.
Signs of oestrogen deficiency may be evident on inspection of the genitalia.
There may be uterovaginal descent on straining.
Pelvic examination may reveal a pelvic mass – which may be the cause of urinary
symptoms resulting from pressure effects.
Occasionally incontinence is associated with neurological disease. Examination of S2,
S3 and S4 dermatomes is essential.
Vaginal examination: May be able to see the protrusion on bearing down
Speculum: N/A
Bimanual: You may feel a lump.

Investigations
Pelvic USS
Assess the patient’s fitness for surgery.

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Management

Conservative
Weight control.
Stop smoking.
Pelvic floor exercises.
Vaginal pessaries (e.g. ring or shelf) may be used to provide symptom relief if the patient
is unfit for operation, or wishes to avoid, surgery. Pessaries are more likely to be helpful
in women with a prominent suprapubic arch and strong perineal body for support;
otherwise the pessary is easily expelled. Pessaries are generally replaced every 4–6
months.

Medical
Vaginal oestrogen cream or HRT.

Surgical
Cystocele: anterior repair (colporrhaphy) or (Burch) colposuspension. The latter
should be the preferred option if there is urodynamically established concurrent
genuine stress incontinence.
Uterovaginal prolapse: cervical amputation with shortening of the uterosacral ligaments
(Manchester–Fothergill repair). This operation should be performed only if a vaginal
hysterectomy is not possible.
Vaginal hysterectomy: this removes the prolapsed organ. Anterior repair and posterior
repair are performed if appropriate. The vaginal vault should be suspended.
Rectocele: posterior repair and perineal repair in cases where there is a deficient
perineum from previous childbirth (posterior colpoperineorrhaphy).
In all of these surgical interventions, the rate of recurrence is high if preventive
measures (e.g. HRT, reduction in body weight and stopping smoking in the case of
chronic cough) are not implemented. In any repair operation, the vagina and introitus
should not be obliterated, which would prevent dyspareunia or inhibit intercourse.

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Condition: Reduced Foetal Movements

Definition
History
Overview
PC
A 34-year-old woman at weeks and days gestation in her first pregnancy complains
of reduced fetal movements. She normally feels the baby move more than 10 times each
day but yesterday there were only two movements and today there have been none. She
has no significant medical, obstetric or gynaecological history. In this pregnancy she
booked at weeks gestation and all her booking blood tests were normal except that she
was discovered not to be immune to rubella and postnatal vaccination was planned. Her
11–14-week scan, nuchal translucency test and anomaly scan were all normal.
Examination:
The blood pressure is 137/73 mmHg and pulse 93/min. She is apyrexial. The symphysio-
fundal height of the uterus is 31 cm and the fetus is breech on examination. The fetal heart
is auscultated with hand-held Doppler and no heartbeat is heard. An ultrasound scan is
therefore arranged immediately, which confirms the diagnosis of intrauterine fetal death.

I have not felt my baby move since yesterday.

HPC
The history should explore whether there are any reasons (e.g. hypertension, diabetes,
fetal growth retardation and haemorrhage) for concern about fetal compromise.

Differential Diagnosis
Prolonged periods of fetal sleep without any compromise.
Fetal compromise.
Fetal death.
Fetal movement decreases with advancing gestational age, oligohydramnios, smoking,
betamethasone therapy.

Intrauterine Death DDx:

Examination
Basic obs:
Temperature (sepsis associated with intrauterine fetal death)

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High blood pressure (associated pre-eclampsia)

Abdominal examination:
Reduced foetal movements felt.
The abdomen should be examined to determine the symphysiofundal height, and
clinical assessment of liquor volume should be made (fetal compromise is associated
with growth restriction and reduced liquor volume).

Try to stimulate fetal movements by gently moving the fetus around at the time of
abdominal palpation.

Listen to the fetal heart to exclude fetal death (if you hear silence this will need to be
confirmed by ultrasound).

Speculum:
Check to rule out miscarriage, but beware of the dates, as this may not be appropriate.

Investigations
Urinalysis - To exclude proteinuria to detect pre-eclampsia
Most important! - Cardiotocography to assess fetal well-being, looking for variability,
accelerations and a lack of decelerations.
Ultrasound - is required only if there is concern about fetal growth or well-being, to:
(1) check fetal heart rate and
(2) assess fetal well-being by assessing liquor volume, fetal movements (which may not
be perceived by the patient), fetal tone, fetal respiration and umbilical Doppler (absent
or reversed diastolic flow) biophysical profile.

Fetal Movement Chart (Kickchart):

- Maternal appreciation of fetal movement is reliable.
- Fetal movement decreases with advancing gestational age, oligohydramnios,
smoking, betamethasone therapy.
- Kickcharts involve either counting all fetal movements in 12 hour or counting
the time it takes the fetus to kick 10 times. Measurements should be repeated at
least twice daily.
- Use of kickcharts in high-risk pregnancies can decrease perinatal mortality 4-
fold.

Fetal Death Investigations:

Maternal:
Full blood count and coagulation screen (to exclude disseminated intravascular
coagulopathy/thrombocytopenia secondary to fetal death)
Random blood glucose and haemoglobin (Hb)A1c
Kleihauer test (for fetal cells in the maternal circulation, implying significant
fetomaternal haemorrhage)
Anticardiolipin and lupus anticoagulant (for antiphospholipid syndrome)
Fetal:
• swabs for microscopy, culture and sensitivity from the fetus and placenta
• skin biopsy for karyotype
• post mortem if agreed by parents

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Management

Conservative - Confirm fetal well-being, and if this is satisfactory the patient can be
discharged home with advice to record daily fetal movements (using a kick chart). If
there are fewer than 10 movements over a 12-h period, the patient will need to return
for a CTG.

Medical/Surgical - If there is fetal growth retardation, investigations will have to be

performed to determine the cause. In addition, as the pregnancy is approaching term,
delivery may be contemplated.

If fetal death is confirmed, medical induction of pregnancy should be conducted

together with appropriate investigations (fetal postmortem examination, chromosome
analysis of fetus and parents, anticardiolipin antibodies, lupus and infection screen) and
bereavement counselling.

Feeling Fetal Movements

When you’ll first feel baby move quickening
Most women feel the first fidgets and squirms of their baby between weeks 14 and 26,
but generally closer to the average of week 18 to week 22 (though variations are
common). The position of the placenta can play a role (an anterior placenta can muffle
the movements).

What do kicks feel like? Maybe it ll feel like a flutter sort of like the butterflies you
get when you re nervous . Or a twitch. Or a nudge.

When you’re most likely to feel movement

During the day, the motion of your own body can lull the baby to sleep You will likely
find baby is more active when:
You've settled down for the night.
Or after you have a snack. The surge in your blood
When you're nervous. Adrenalin can have the same effect

Third trimester fetal movement:

You can expect to feel fetal activity every day from here on out. (ere s what to expect for
the rest of the trimester.
To ensure everything is progressing as expected, your doctor will want you to start
"counting kicks," or fetal movements, starting in week 28 through the rest of your
pregnancy. (ere s what you ll want to look out for:
Look for: 10 movements of any kind in an hour or less is normal, though sometimes it
will take longer.
If you haven't felt 10 movements within an hour: Have a snack or some fruit juice, lie
down, and continue counting. If it takes more than two hours to reach 10, contact your
practitioner. Though the absence of activity doesn t necessarily mean something s
wrong, it can occasionally be a red flag that needs quick evaluation.

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Secondary Amenorrhoea: Stress

History:
 18 y/o woman presents with absence of periods for 6/12
 Occurred twice previously, but resolved spontaneously
 Periods started at 12 and initially regular
 No PMH, no medication or allergies
 1st year university student
 Runs most days, healthy diet avoiding carbohydrate and meat
 Oldest of three siblings, parents separated when she was 12: minimal
contact with father but gets on well with mother.
 Previous boyfriend but avoided sexual contact

Examination:
 Tall and thin, with BMI of 15.5
 Fine downy hair on arms
 HR 86, BP 100/65
 Abdo no scars or masses
 Genital examination not performed

Investigations:
 FBC
 Blood hormones: FSH/LH, TFTs, testosterone, prolactin
 Pregnancy test

Causes of secondary amenorrhoea:

 Pregnancy
 Premature ovarian failure
 Asherman’s syndrome
 Endocrine:
o Hypothalamic
 Stress
 Weight loss
 Exercise
 Drugs

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o Pituitary
 Hyperprolactinaemia
Prolactinoma, drugs (dopamine antagonists) e.g.
metoclopramide, pregnancy, breastfeeding,
hypothyroidism, PCOS
 Sheehan’s syndrome
Hypo/hyperthyroidism
PCOS

Diagnosis:
o Pregnancy test
o Bloods
 Prolactin
 TFTs
 LH & FSH, Oestradiol, Testosterone
1. Progesterone withdrawal trial
 Withdrawal bleed = PCOS
2. Oestrogen + progesterone withdrawal trial
 No bleed = outflow obstruction
3. MRI
 Detects pituitary cause
 No pituitary cause means it’s hypothalamic

 The raised prolactin is consistent with stress and does not need to be
investigated further.
 At a BMI below 18 kg/m2, menstruation tends to cease, returning once
the BMI increases again.
 The previous episodes of amenorrhoea probably occurred when her
dietary intake was very low and it may be that starting at university may
have increased her stress levels with the consequence of worsening her
anorexia.

Further investigations:
 Liver and renal function
 Bone scan- hypo-oestrogenism as a result of anorexia may induce early
onset osteoporosis and fractures
 Psychological assessment as guide for treatment

Management:
 Encouraging the woman to eat a more normal diet and to avoid exercising
is the ideal management
 Anorexia is a chronic disease that is often refractory to treatment.
 Explanation that her periods will return if she increases her BMI may
possibly encourage her to put on weight. 

 The combined oral contraceptive pill should be prescribed in the
meantime, which will prevent osteoporosis and bring on periods, albeit
pharmacologically induced. 


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 Referral to a specialist eating disorders unit is vital in addressing the

long-term problem for this woman.
 Commonly, eating disorders arise out of childhood difficulties and family
or group therapy should be considered. 

 If the investigations suggest renal or hepatic impairment then inpatient
management is likely to be necessary. 


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The Nurse says my baby is small, what does this mean?

What is the likely differential diagnosis?

● Small for gestational age: normally growing but constitutionally small fetus. <10th centile
● Intrauterine growth restriction.
● Wrong dates.

What additional features in the history would you seek to support a particular diagnosis?

Checking the certainty of the patient’s dates is essential (i.e. accuracy of menstrual data, and
findings on USSs in the first and second trimester). This is because, if the pregnancy is not as
advanced as is believed, this could explain the discrepancy between the symphysiofundal
height and gestational age.

Risk Factors:
● Maternal
§ Placental
· Pre-eclampsia
· Diabetes
· Hypertension
· Anti-phospholipid syndrome
· Sickle-cell disease
§ Smoking, alcohol
§ Previous SGA baby
§ Drugs
· Cocaine
§ Hypoxia
§ Infection eg rubella, CMV
§ Malnutrition
§ Diabetes
§ Hypertension
o Fetal
§ Genetic/chromosomal
§ Infection
§ Multiple pregnancy


What clinical examination would you perform and why?

Examination would include blood pressure measurement to exclude hypertension and pre-
eclampsia, which are both associated with IUGR. A clinical assessment of liquor volume should
be made because IUGR can be associated with reduced liquor volume. The fetal heart should
be auscultated because fetal compromise is associated with IUGR.

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What investigations would be most helpful and why?

● Urinalysis. Proteinuria indicates pre-eclampsia if blood pressure is high.
● Cardiotocography. To identify evidence of fetal compromise
● USS. This should be performed:
(1) to measure abdominal circumference and BPD in order to confirm SGA,
(2) to assess liquor volume,
(3) to perform umbilical arterial, middle cerebral artery and ductus venosus
Doppler assessment if SGA confirmed and
(4) to perform a biophysical profile. Ultrasound may also indicate features of
congenital infection (brain calcification) or structural anomaly (cardiac defect).
● Aminocentesis or chorionic villus sample. This may be considered if there are features
on the USS that support a chromosomal anomaly or if severe early onset IUGR is
identified. This can be associated with a chromosomal anomaly.
● Fetal blood sample (cordocentesis). This is performed only in fetal medicine centres. It
may be useful if congenital infection is suspected.

What treatment options are appropriate?

The mainstay of management is to deliver a fetus as mature and in as good a condition as

possible.
● Serial ultrasound examination should be performed to monitor the velocity of fetal growth
in order to distinguish between a constitutionally small fetus and an IUGR fetus. The
fetus that is growing and not showing evidence of compromise does not require any
intervention.
● Umbilical Doppler waveform patterns in association with middle cerebral artery and
ductus venosus Doppler, which if abnormal suggest redistribution of fetal blood supply
and biophysical assessment, including cardiotocography, are required to identify
evidence of fetal compromise.
● Treat underlying cause
● Steroids to promote surfactant production and reduce the risk or severity of respiratory
distress syndrome in the case of pre-term delivery.

Complications:
● Fetal hypoxia
● Kidney damage – oligohydramnios
● Fetal acidosis
● Cerebral palsy
Increased risk of diabetes, hypertension and obesity in later life.


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STI- Chlamydia

Defintion: Sexually transmitted gram-negative intracellular bacterial infection.

 Chlamydia A, B, C: infect conjunctiva causing trachoma
 Chlamydia D to K: genital chlamydia infection, ophthalmia neonatorum
 Chlamydia pneumoniae and psitacci: infect lungs causing pneumonia
 L1-L3: Lymphogranuloma venereum (LGV) cause rectal infection and proctitis

History
21-year-old student
PC- IMB
HPC- 2/12 ago has had several recurrences. It is usually light and generally lasts from 1
to 3 days.
Gynae
 Contraception: COCP for 18/12, has regular periods, lasting for 3 days every 28
days. The periods are not heavy or painful. She has not noticed any other
discharge.
 Sexual: She first had sexual intercourse at the age of 17 years and has been with
her current boyfriend for 4 months. There is no pain on intercourse and no
postcoital bleeding. No previous ST)’s.
Obs – Nil
Urinary- Nil
Bowel- Nil
PMH- Simple ovarian cyst that resolved spontaneously
PSH- Nil
FMH - Nil
SH – Nil

N.B: The symptom of bleeding between the pill-free interval in a woman taking the
combined oral contraceptive pill is known as breakthrough bleeding. History should
include:
 Has she been missing any pills? 

 Has she taken any other medication, which might interefere with the COCP (e.g.

 antibiotics, enzyme inducers)? 

 Has she had any intercurrent illnesses causing diarrhoea or vomiting? 

 Has she ever had any sexually transmitted infections, or been investigated for
this? 

 How many sexual partners has she had in the last 3 months? 

 Has she recently changed the COCP that she uses? 


Differential Diagnosis

1. COCP related
o Poor compliance
o Infection causing poor pill absorption
o Drug interactions
o Inadequate oestrogen component
o Pregnancy

2. Unrelated to COCP
o STI: chlamydia, gonorrhea and trichomonas
o Non –STI: Candida
o Cervical: Ectropion or polyp

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o Bleeding disorder

Examination
Basic obs: Normal
Abdominal examination: SNT and not distended
Vaginal examination
Speculum: External genitalia are normal and a slight blood-stained discharge is noted
coming from the cervical os. There is a cervical ectropion which is not bleeding.
Bimanual: Bimanual examination reveals an aneteverted normal size mobile uterus.
There is no cervical excitation or adnexal tenderness.
Investigations
• Pregnancy test
• Swabs:
o 
 A high vaginal swab (HVS) taken from the lateral wall and posterior vaginal
fornix can be used for both dry and wet microscopy.
 This will test for BV, T. vaginalis and yeast.
o Endocervical swab to test for gonorrhea and Chlamydia. This is usually a
nucleic acid amplification test (NAAT).
 Perform gonorrhea swab first as you want to sample the
discharge and chlamydia you want to collect the cells as it is an
intracellular organism.
o If she had refused examination, a self-obtained high vaginal swab and low
vaginal NAAT swab could be collected.
 USS: if required

Management

Medical
 Oral azithromycin or doxycycline (not indicated in pregnancy) for 7 days

And
 Contact tracing of all partners when possible to allow treatment to start

Advice
 Avoid intercourse, including oral and rectal, before treatment of partners is
completed.
 Use condoms when treatment is complete, as this is the only contraception that
protects against ST)’s.
 A follow up interview within 2-4 weeks
 Retesting if any doubt about complete treatment. Test of cure should be
performed a minimum of 5 weeks after initiation of treatment
 If change of partner, retesting between 3-12 months

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More info:

Complications/  Pelvic inflammatory disease (PID) – Infertility,

prognosis ectopic pregnancy, perhepatitis: Fitz-Hugh-Curtis
syndrome
 Chronic pelvic pain
 Neonatal conjunctivitis and pneumonia
 Adult conjunctivitis
 Reiter’s syndrome aka reactive arthritis:
conjunctivitis, urethritis, arthritis can’t see, can’t pee
and can’t climb a tree
Signs & symptoms  Asymptomatic
 Vaginal discharge and lower abdominal pain
 Postcoital bleeding
 Intermenstrual bleeding
 Mucopurulent cervical discharge with contact
bleeding
 Dysuria with urethral discharge

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Stress Incontinence

History:
 49 y/o woman presents extremely embarrassed with leaking of urine
 Started around 10 years ago after birth of third child and has been getting
progressively worse
 Only just felt comfortable discussing it
 Mostly on coughing and laughing
 Recently started playing badminton to lose weight and symptoms has
worsened. Better if tampon whilst playing.
 Slightly constipated
O&G hx
 All induction of labour post term- 3.6kg, 3.8kg, 4.1kg
 Forceps for third after failure to progress to third stage
 Regular menstrual cycle with laparoscopic sterilisation
 No relevant PMH, no allergies or drugs
 No alcohol, 15 cigarettes/day

Examination:
 BMI 29
 No significant findings on abdo or vaginal examination

Investigations:

Differentials:
 Stress incontinence
 Overactive bladder

 Stress incontinence can be diagnosed from the history – involuntary loss

of urine when the intraabdominal pressure increases (such as with
exercise or coughing).
 Urodynamic stress incontinence (formerly referred to as genuine stress
incontinence) is the involuntary loss of urine when the intravesical
pressure exceeds the maximum urethral pressure in the absence of a
detrusor contraction and can only be diagnosed after urodynamic testing.
 Overactive bladder (detrusor instability) presentation is more random, so
may lead to evasion of drinking. Constantly aware of where toilets are. No
surgical treatment as not anatomical issue. Bladder contracts
involuntarily without normal trigger to void caused by bladder filling.

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Pathology

 Commonly arises as a result of urethral sphincter weakness.

 Normally an increase in intra-abdominal pressure compresses the
bladder and the bladder neck so there is no difference in pressure.
 If the bladder neck slips below the pelvic floor because its supports are
weak, it will not be compressed and so the bladder pressure exceeds the
urethral pressure and incontinence results

A Sims’ speculum may demonstrate a cystocoele or a urethrocoele. Leakage of

urine with coughing may be seen. The abdomen is palpated to exclude a
distended bladder

Management:

Conservative:
 Lifestyle
 Control exacerbating symptoms:
o Reduce weight
o Stop smoking to relieve chronic cough
o Alter diet and consider laxatives to avoid constipation
 Pelvis floor exercises: properly taught PFE can improve symptoms or cure
in up to 85% of women. 1st line for 3 months. 8 contractions, at least 3
times a day.

Medical:
 Duloxetine: SNRI drug. Common s/e is nausea

Surgical:
 Transvaginal or transobturator tape
 Colposuspension
 Periurethral bulking injection in refractory cases or unsuitable for
surgery.

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Termination of pregnancy

The law – the UK abortion act (1967) allows termination before 24 weeks of
gestations if it:
 Reduces the risk to a woman s life
 Reduces the risk to her physical or mental health
 Reduces the risk to physical or mental health of her existing children
 If the baby is at substantial risk of being seriously mentally or physically
handicapped
There is no upper limit on gestational time if there is:
 Risk to the mother s life
 Risk of grave, permanent injury to the mother s physical/ mental health
(allowing for reasonably foreseeable circumstances)
 Substantial risk that, if the child were born, it would suffer such physical
or mental abnormalities as to be seriously handicapped.
The UK abortion act form is signed by both medical practitioners prior to the
abortion being performed and posted to the Chief Medical Officer of the
Department of Health or of the Scottish Government

Ethics
Doctors may strongly held personal beliefs concerning abortion, if carrying out a
particular procedure or giving advice conflicts with your religious or moral
beliefs, and this conflict might affect the treatment or advice you provide, you
must explain this to the patient and tell them to have the right to see another
doctor. You should make sure that information about alternative services is
readily available to all patients.

Explanation to patient

Before
Assessment
 Assessment of the gestation:
o Date of the last menstrual period
o Pelvic or abdominal examination
o Ultrasound scan
 Blood tests
o FBC – able to tolerate surgical treatment
o Determination of ABO and Rh blood groups
 Confirmation of the pregnancy by a sensitive pregnancy test.
 STI/Infection screening e.g. Chlamydia
 Cervical cytology
 Venous thromboembolism risk assessment

Counseling
 The individual woman s feeling for the pregnancy, abortion, her partner,
her future life plans and her ability to care for a child at present and in the
future.
 The type of abortion to be performed.

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 The risks of the procedure – risk of fertility after an abortion

 Ensuring adequate personal support before and after the abortion.
 Specialist pre and post termination support if the decision is particularly
difficult.
 Contraception after the abortion.
 Arrangements for follow up.

During

1. Prophylactic antibiotics
 Metronidazole + azithromycin on the day of abortion
 Metronidazole + doxycycline for 7d post-abortion

2. Surgical methods
 Perform chest examination to see if they are up to general anaesthesia
 0-14 weeks of gestation
o Vacuum aspiration with suction cup and blunt forceps
 Either electric or manual vacuum aspiration
 Dilate the cervix
 Vacuum aspiration under 7 weeks of gestation should be
performed with appropriate safeguards to ensure complete
abortion
 After 14 weeks of gestation
o Dilatation and evacuation under general anaesthetic
 Cervical preparation for surgical abortions
o Should be considered in all cases
o Misoprostol vaginally or sublingually prior to surgery
o Prevents cervical trauma and haemorrhage leading to future
cervical incompetency
 Pain relief for surgical abortion
o NSAIDS

3. Medical methods
 Oral mifepristone followed by misoprostol 24-48 hours later
 Progesterone antagonist + prostaglandin
 Pain relief for medical abortion
o NSAIDS
N.B. If history of asthma can t use prostaglandins

After
 Follow-up
o 2 weeks after the procedure to check:
 Abortion is complete
 Exclude an ongoing pregnancy
 Check for possible pelvic infection
 Assess the woman s emotional state
 Advice on contraception and sexual health
 Medical

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o Anti-D to RhD-negative women

 Contraception
o OCP, IUCD
o All hormonal methods should be started on the day of the abortion.
o Female sterilisation is usually performed 6-8 weeks after an
abortion, as it has a higher failure rate when undertaken at the
time of surgical abortion.

Complications
Medical < surgical e.g. sepsis and perforation of the uterus
Common
 Infection
 Cervical trauma

Uncommon
 Traumatic injuries
 Psychological effects – many women feel emotionally vulnerable in the
weeks following an abortion, many women experience feelings of regret
and guilt after an abortion
 Failed abortion and continuing pregnancy
o Both surgical and medical methods of abortion carry a small risk of
failure to end the pregnancy
o There is a small risk (less than 5%) of the need for further
intervention
 Preterm birth - small risk but increases with the number of abortions.

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Urinary Tract Infection

You are a&e when a 40 year old pregnant woman presents with fever and
abdominal pain.

PC:
 Fever and abdo pain
HPC:
 Felt a bit unwell the last 10 days but become worse in last 48 hours
 Nauseated and has vomited several times
 Hasn’t measured temperature, but feels intermittently hot and cold
 Abdo pain generalised and constant, with some right sided loin-groin pain
 No dysuria but has had some frequency throughout pregnancy
 No recent change in bowel habit
 No vaginal bleeding
 Mild thin vaginal discharge
O&G:
 18 weeks, third pregnancy
 Previous pregnancies fine
 Smears up to date
PMH:
 None
FH:
 None relevant
SH:
 At home with husband and two children
 Well supported

Examination:
Maternal
 General inspection
 Bedside obs
 Cardiac and chest
 Abdominal and obstetric
Fetal:
 Heartbeat doppler

Investigations:
 FBC
 Inflammatory markers
 U&Es
 Urinalysis

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Diagnosis:
 Pyelonephritis, indicated by loin-groin pain and rigors
 During pregnancy, women with UTI can be very unwell with non specific
symptoms
 UTIs common in pregnancy due to progesterone causing stasis or urine
and pressure of gravid uterus

Further Investigations:
 Confirmed with urine microscopy, culture and sensitivity
 Blood cultures should be sent
 Renal tract USS to rule out congenital abnormality or obstructed kidney
that may need drainage
 However, renal tract USS difficult in pregnancy as physiological dilatation
of ureters occurs from uterine pressure

Management:
 Commence IV abx, usually cephalosporins (ceftriaxone), until cultures
available
 Regular paracetamol to control fever and pain
 Monitor improvement with daily WCC, CRP and U&Es
 IV fluids
 2 weeks treatment
 Repeat culture to confirm cure
 If recurrent infection, may require subsequent prophylaxis

Risks:
 Maternal sepsis is risk for miscarriage and preterm labour, so no delay in
treatment
 Recurrent UTIs, even asymptomatic bacteriuria, is associated with IUGR
and even preterm labour

Non complicated UTI:

Treat with antibiotic to which organism is sensitive for 1/52. Options (in order
of preference)
o Amoxicillin 250mg tds
o Nitrofurantoin 50mg qds, or 100mg MR bd

Trimethoprim generally avoided in first trimester due to folate antagonism

Nitrofurantoin avoided in final trimester due to haemolysis of fetus

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VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC) COUNSELLING

ALTHOUGH WE CAN PRESENT THE RISKS AND SUGGEST A MODE OF DELIVERY
IT IS STILL THE WOMANS AUTONOMOUS DECISION

DISCUSSION ABOUT RISKS OF VBAC AND WHETHER TO PROCEDE

WHAT IS VBAC?
 Vaginal birth after caesarean section

WHY WE ARE WORRIED ABOUT VBAC

 A woman with a prior Caesarean is at increased risk regardless of her mode of birth
 The likelihood of uterine rupture with attempted VBAC is 0.5%
 If the VBAC fails and an emergency Caesarean section is required there is a higher
rate of maternal and neonatal morbidity than a successful VBAC or an elective
repeat Caesarean.

WHY WE STILL ENCOURAGE MOTHERS TO GO FOR VBAC RATHER THAN C-SECTION:

A successful VBAC results in:
 Less morbidity
 Fewer blood transfusions
 Fewer postpartum infections
 Shorter hospital stays
 Have no increased perinatal mortality

ABSOLUTE CONTRAINDICATIONS TO VBAC

1. Previous classical caesarean section
2. Previous inverted T uterine incision.
3. Previous uterine rupture.
(Has been suggested that cephalo-pelvic disproportion (CPD) should be a contraindication
but evidence points to the contrary)

RELATIVE CONTRAINDICATIONS TO VBAC

 More than two previous Caesarean sections.
 SCOG: "Labour and vaginal delivery in women with more than one previous
transverse low segment incision is an acceptable option, although there are less
data available."
 ACOG: "A woman who has two, or more, previous c/section deliveries with lower
transverse uterine incisions, who has no other contraindications, and who wishes
to attempt vaginal birth, should not be discouraged from doing so".
 Non cephalic presentation
o But remember you can wait and see if the baby will turn/ try ECV

RISKS OF C-SECTION:
 Surgical e.g. haemorrhage, infection, long recovery, thromboembolic disease

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 Anaesthetic
 Increased risk of IRDS (infant respiratory distress syndrome)

RISK OF INDUCTION OF LABOUR:

 Increases the risk of uterine rupture from 0.5% to 1%

ANTENATAL MANAGEMENT
 An ultrasound scan should be performed to check placental localisation to look for
abnormal placentation.

INTRAPARTUM MANAGEMENT
 VBACs are excluded from the Family Birth Centre
 Advised to present to Delivery Suite early in labour.
 Intravenous access should be established and blood taken for a group and hold
serum or cross matching if appropriate.
 Labour should be monitored using the partogram and any abnormalities should be
notified to the registrar, who should perform an assessment.
 Continuous fetal heart rate monitoring is mandatory.
o Please note the SGOC guidelines (above) state... "One of the most consistent
early signs of scar dehiscence and/or rupture is an abnormal fetal heart rate
pattern. Thus, in cases of induction and/or augmentation, continuous
electronic fetal heart rate monitoring is advised. Intermittent fetal heart
monitoring is to be reserved for cases in which neither induction nor aug-
mentation with oxytocin is performed.
 There is no contraindication to epidural analgesia
 Any delay in latent/active phase of labour or fetal heart rate abnormalities should be
discussed with the consultant Obstetrician on call for Delivery Suite with a view to
Caesarean section.

 Be vigilant for the symptoms and signs of scar rupture, which may include:

 Suprapubic tenderness and/or severe constant abdominal pain which continues

between contractions
 Maternal tachycardia
 Vaginal bleeding
 Fetal tachycardia or fetal heart decelerations
 No progress in labour
 Cessation of contractions

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Venous Thromboembolism

Definition Pregnancy is prothrombotic. The incidence of VTE is increased sixfold.

History
42-year-old woman is referred by her general practitioner
PC
o SOB
HPC
o SOB for past 3 days
o Started when she was at work
o Felt particularly SOB running to catch the bus
o Left sided chest pain on breathing in.
o Nil cough or haemoptysis
o No previous episodes
o Nil calf pain
o Left left swollen and back pain
PMH + PSH (MSC SOUR) – Obx and gynae hx
 Menstrual – Normal
 Sexual – Normal
 Contraception – Previously had an implant
 Smear – Last one normal next on in two years
 Obstetric- G3 P2+1, 34 weeks into current pregnancy, emergency Caesarean
section for abnormal cardiotocograph in labour, followed by a 7-week
miscarriage. In this pregnancy she was seen by the obstetric consultant to
discuss plans for delivery, and is hoping for a vaginal delivery. Ultrasound scans
and blood tests have been normal. Her booking blood pressure was
138/80mmHg and has remained stable during the pregnancy.
 Urinary – Normal
 Rectal – Normal
 Medical conditions / Previous surgery- None
DH and allergies – No medication+ NKDA
FMH- Nil
SH- Doesn’t smoke, drink or use drugs. Lives at home with husband.
System Review
 General – Normal
 Neuro – Normal
 Cardio – Normal
 Resp- Above
 Gastro – Normal
 Musc – Above
 Derm – Normal

Differential Diagnosis
 PE
 Musculoskeletal pain
 Pleuritis
 Pericarditis

Examination
General observation: BMI 28 kg/m2 , women does not look unwell

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Basic obs: BP 127/78 mmHg, HR 98/min SpO2 is 96% RA and temp 37.2 degrees
Cardio examination: systolic murmur and no added sounds
Respiratory examination: Chest expansion is normal but the woman reports pain on
taking a deep breath. The chest is resonant to percussion and chest sounds are normal
except for a pleural rub on the left.
Lower limbs: The left leg is generally swollen but no redness or tenderness is apparent.

Investigations

 ABG
 D-dimer often raised in pregnancy so not useful
 ECG (S1 Q3 T3)
 CXR
 Doppler ultrasound
 Thrombophillia screen

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Management

Conservative
 Compression stockings
Medical
 Acute PE – subcut LMWH (adjust dose according to anti-Factor Xa level) Consult
local guidelines.
o More needed in non-pregnant women because of faster clearance.
o If possible stop before labour and restart and continue into the
puerperium.
 Massive life-threatening PE – assessment by on-call consultant obstetrician.
Decide on individual basis whether the Pt should receive UFH, thrombolysis or
thoracotomy and surgical embolectomy. Consider additional therapies:
o Leg elevation
o Mobilisation with graduated elastic compression stocking
o Temporary IVC filter in perinatal period for women with iliac vein VTE to
reduce risk of PTE
 Treatment with therapeutic doses of subcutaneous LMWH should be employed
during the remainder of the pregnancy.
 Should be stopped 12 hours before delivery started again straight afterwards.
 No epidural or spinal anaesthetic after LMWH dose.
 LMWH for at least 6 weeks postnatally and until at least 3 months of treatment
has been given in total.

Aetiology  Increased blood clotting factors (8,9,10 and fibrinogen

levels), reduced fibrinolytic activity (protein S and anti-
thrombin), blood flow altered by mechanical obstruction of
venous flow by the gravid uterus and immobility.
Risk factors  Risk is highest in postnatal period
 Inherited prothrombotic conditions
 Family or personal history
Complications  Pulmonary embolus is an important cause of maternal death
in developed countries
 Embolism in <0.3% with mortality of 3.5%
 DVT in 1% pregnant women – more often iliofemoral and on
the left
Signs &  DVT
Symptoms o Leg swelling (often swollen in pregnancy so in
particular look for unilateral swelling).
o Calf is tender to gentle touch.
 PE
o Mild breathlessness or inspiratory chest pain
o Not cyanosed but may be slightly tachycardic
(>90bpm) with mild pyrexia (>37.5C)
o Rarely PE may present with sudden
cardiorespiratory collapse

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