MA Obs n Gynae Lectures PDF

Obstetrics and Gynecology Ectopic Miscarriage Emergency contraception / burst condoms Ectopic pregnancy - Rising incidence – 1 % of all pregnancies - 95% located in fallopian tubes - Delay in diagnosis can be catastrophic - “ALWAYS RULE OUT ECTOPIC PREGNANCY” - Counselling on fu...

Obstetrics and Gynecology Ectopic Miscarriage Emergency contraception / burst condoms Ectopic pregnancy - Rising incidence – 1 % of all pregnancies - 95% located in fallopian tubes - Delay in diagnosis can be catastrophic - “ALWAYS RULE OUT ECTOPIC PREGNANCY” - Counselling on future pregnancies o Recurring rate -12% to 20% o Early conformation of future pregnancy site o Early USS to confirm site of pregnancy Any young female with pallor and lower abdominal pain = ectopic until proven otherwise. TRIAD: AMENORRHEA, PAIN, VAGINAL BLEEDING Presentation and diagnosis Acute or chronic pain Usually symptomatic at 5 – 8 wks POA Pain ++ & minimal per-vaginal bleeding Shoulder tip pain & “fainting spells” UPT – mandatory – urine pregnancy test. Serum b-HCG Ultrasonography – preferably TVS Diagnostic laparoscopy / mini- laparotomy Management ❖ Ruptured Resuscitate & emergency laparotomy ❖ Criteria for conservative management (expectant and medical): (pt diagnosed with ectopic by clinically stable) ❖ Expectact: If serum b-HCG suggests “non-viable” ectopic (checked 1st day, 4th day, 7th day) In a normal pregnancy, the β-HCG level doubles every 48-72 hours until it reaches 10,000-20,000mIU/mL. In ectopic pregnancies, β-HCG levels usually increase less. Mean serum β-HCG levels are lower in ectopic pregnancies than in healthy pregnancies. No single serum β-HCG level is diagnostic of an ectopic pregnancy.  1 If “unruptured” and/or asymptomatic If patient is staying nearby and will comply with follow up ❖ Criteria for medical management If gestational sac < 3cm in diameter & no foetal heart activity No fluid in the POD & pt is stable (pouch of Douglas) If b-HCG < 3000IU( if>3000IU – Methotrexate not likely to work) Staying nearby and able to come for follow up d4 & 7 IM Methotrexate 50 mg/m2/kg – 1st dose (folate antagonist) Have to do a FBC and LFT every month on this treatment. b-HCG on D4 & D7 – expect a minimum 15 % decrease, if less→ send the pt. to the theatre. If the patient has > 15% decrease in bHCG, it means the medicine is working properly. Criteria for surgical management: ❖ Unstable (ruptured) (hemodynamically / clinically) ❖ bHCG > 3000 IU/L ❖ On U/S pt has fluid in the pouch of Douglas or blood in uterus ❖ pt on methotrexate but does no fulfil the requirements (decrease on D4 and D7 AND D14) ❖ pt does not stay near the hospital. NB: Previous EP increases the risk of subsequent EP Management Surgical intervention If stable Laparoscopy If unstable Laparotomy Laparoscopy – preferred, less complications ★ Salpingostomy (Tube is preserved) or salpingectomy (Tube removed) ❖ (either make a hole and remove it, or remove whole tube) ❖ Ask about other children. - Check the contralateral tube. - Completed family - Detailed operative & discharge notes - Counsel pt o Counsel on recurrence  2 o Infertility o Establish how many children she has already has o Emotional status. o Reduce risk of anything that can worsen infertility STI’s – barrier protecting One partner Treats any discharges early. o Next pregnancy – early location determination. Miscarriage Bleeding before 22 weeks of gestation* (ectopic and miscarriage) After 22 weeks, >500mg bleeding = antepartum haemorrhage = placenta previa = abruptio placenta Defined as the “expulsion of product of conceptus or foetus less than 500mg or 22 weeks gestation with no evidence of life at delivery” Habitual abortion is defined as someone who has had 3 consecutive miscarriages Very early miscarriages can sometimes be assumed as delayed period Types of miscarriages : Spontaneous miscarriage and Induced miscarriage (abortion) SPONTANEOUS : MITICS Missed/ Silent Miscarriage Inevitable Miscarriage– Def happen Threatened Miscarriage– might or might not Incomplete Miscarriage– started but did not evacuate Complete Miscarriage Septic Miscarriage– hypo + shock ➔ Any one of the types can lead to septic abortion ➔ Usually an incomplete  3 Threatened vs Inevitable Per vaginal spotting or minimal bleeding Slight to heavy per vaginal bleeding Either no pain or only mild Moderate to severe lower abdominal pain Uterus equals to date Uterus equals to date Cervix tubular and closed OS IS CLOSED Cervix shortened and OS MAY BE OPEN Scan shows viable fetus Fetus may or may not be viable on scan  4 Incomplete vs Complete Moderate or severe pain Has severe pain early but now mild or no pain Moderate to heavy per vaginal loss Heavy pv loss earlier but now minimal loss Uterus less than date Uterus less than date OS OPEN AND POC (products of OS USUALLY STILL OPEN +/- conception) MAY BE FELT Patient in distress Patient is not distressed Positive pregnancy but empty uterus Scan my be helpful Missed Miscarriage ★ Pt gives a history of absence of symptoms of early pregnancy ★ PV spotting or brownish discharge with slight abdominal discomfort ★ Uterus less than date ★ OS CLOSED ★ Scan to confirm diagnosis ★ Need to “ripen” cervix before ERPOC (Evacuation of Retained Products of Conception) give prostaglandins such as MISOPROSTOL before Dilation and curettage (D&C) ( lithotomy position) ★ before 9 weeks, lt comes out on its own ★ After 9 weeks, d and c ★ After 12 weeks deliver Septic Miscarriage ➔ Any types of miscarriage complicated with infection esp. criminal abortion ➔ Foul smelling PV discharge/bleeding with fever and lower abdominal pain/tenderness ➔ Cover with appropriate antibiotics for at least 6 hours before ERPOC ➔ Continue antibiotics for a total of 14 days. ➔ In all these pt you have to resus + evacuation of the uterus. Stop bleeding, prevent sepsis and adhesions.  5 MEDICINE TREATMENT Oxytocin, IV: given when Cervical os is Open (incomplete and inevitable). Used to induce contractions Misoprostol, IM: given before D&C to ripen cervix, when cervical Os is Closed. Used to degrade collagen and reduce cervical tone. Antibiotic therapy : given when Sus sepsis Amoxicillin/clavulanic acid, IV, 1.2 g, 8 hourly. (Change to oral treatment after clinical improvement) Penicillin allergy: Clindamycin, IV, 600 mg 8 hourly. AND Gentamicin, IV, 6 mg/kg daily (Change to oral treatment after improvement: Clindamycin, oral, 450 mg 8 hourly for 5 days. Ciprofloxacin, oral, 500 mg 12 hourly for 5 days) Bloods (FBC, U&E, LFT, Creatinine, Type and screen) should be done. (CULF) Do routine: T, RR, HR, Glu, BP Note: The addition of metronidazole to Amoxiclav and clindamycin is unnecessary as clindamycin has adequate anaerobic cover. INDUCED: Abortion ➔ Legal miscarriage: Top protocol: ➔ Illegal miscarriage Lochia 1. Rubra: Dark red heavy flow with clots, lasts 3 to 4 days post delivery. 2. Serosa: pinkish brown lighter flow, occurs from day 4 to day 10 post delivery. 3. Alba: whitish yellow light flow, occurs from day 10 to around day 28 post delivery.  6 I want pancakes 😀  7 Fundal massage/ uterine massage to expel clots  8 Emergency contraception Emergency contraception is a way of preventing unwanted pregnancy in case of unprotected intercourse or ineffective application of the other methods of contraception (breaking or slipping of the condom, skipped birth control pill, the error of the calendar method, etc) the essence of the emergency contraception involves taking the specially developed medicines. Within a certain time (not later than 72 hrs after unprotected intercourse happened), or installing an intrauterine device (IUD) in no later than 120 hours or 5 days after the unprotected intercourse. According to WHO recommendations, emergency contraception must not be a regular method of contraception. Emergency contraceptive tablets must be taken as soon as possible, preferably within 72 hours of unprotected intercourse, and not later than 5 days Mifepristone is a drug that blocks progesterone that is needed for a pregnancy to continue. Misoprostol: PGE that causes cervical softening and dilation and uterine contractions. Prescribe ➔ Pre Exposure Prophylaxis (Rape) Adults TLD (Tenofovir + lamivudine + dolutegravir) for 4 weeks children PEP (AZT (Zidovudine), 3TC (Lamivudine), KALETRA(Lopinavir / Ritonavir or LPV/r)) ➔ Post exposure prophylaxis (occupational) ➔ Tenofovir + lamivudine + dolutegravir for 4 weeks ➔ Emergency Contraception ◆ Levonorgestrel within 72hrs OR ◆ IUD within 5 days  9 For spare-time reading:  10 Explanations: HBsAg (surface antigen): Acute asymptomatic infection, or carrier. Pt is positive for hepatitis. HBeAg (e antigen): Acute symptomatic infection, also helps determine severity. HBcAb (core antigen): IgM (recent/acute infection) and IgG (perpetual infection or means pt developed active immunity) Scenarios: Only HbsAb = immunity via vaccination. HbsAb + HbcAb IgG = immunity via previous infection. Only HBsAg = acute asymptomatic infection/ carrier. HbsAg + HbeAg + HbcAb IgM= acute symptomatic infection. (immune system actively fighting off virus) HbsAg + HbeAg + HbcAb IgG = late/chronic symptomatic infection. (immune system has been fighting off virus for a while) Rabies vaccine works in a similar manner.  11 Diabetes in general When diagnosing a normal pt with diabetes, follow the 11/7/11 rule: Random glucose test: If more than 11.1 w/ symptoms of diabetes, diagnose Fasted glucose test: pt fasts between 6 and 8 hours. Glucose is taken, if greater than 7.1 w/ symptoms, diagnose T2 Glucose tolerance test: pt fasts and is given 75g glucose water. Glucose taken 2 hrs after ingestion, if more than 11.1 and symptoms, diagnose. Symptoms of diabetes ○ polyuria ○ polydipsia ○ recurrent yeast infections (oral or vaginal candid) If the patient doesn't have the symptom, recheck in 2 weeks. 3 ways of diagnosis - Pt comes in with blood glucose > 11 + symptoms = diabetes - HBA1C > 6.5% + symptoms = diabetes. - fasted glucose and Glucose tolerance test done together + symptoms = diabetes Diabetes in pregnancy Diagnostic criteria for GDM Either Fasting plasma glucose ≥ 5.6 mmol/L OR Glucose tolerance test ≥7.8 mmol/L No need to consider symptoms as DM symptoms physiologically present in pregnancy.  12 Std screening “RuSHH”: rubella, syph, hepatitis, hiv Vaccines safe in pregnancy: “TDaP RHIM” tetanus/diphtheria/pertussis, Rabies, HepB, Influenza (inactive), Meningococcal. If pt is pregnant: Change DM meds to insulin Change hypertensive meds to Methyldopa. Baseline tests for pregnant women: ❖ Kidney function (Urea and creatinine) ❖ HBA1C ❖ Hpt, diabetes, gout, abdominal obesity, hyperlipidemia. ❖ Metabolic syndrome ********** According to the NCEP ATP III definition, metabolic syndrome is present if three or more of the following five criteria are met: Total cholesterol: < 6 mmol/L 5 - 6 mmol/L LDL cholesterol: < 3 mmol/L 3.3 - 4.1 mmol/L HDL cholesterol: > 1 mmol/L 1 - 1.5 mmol/L Triglycerides: 2 mmol/L 1.7 - 2.2 mmol/L  13 For spare time reading: Baseline ECG Fundoscopy – look for retinopathy Foot exam – look for ulcerations & peripheral neuropathy The STD tests we do during antepartum visit - Rubella, Syphilis, HIV, Hep B: RuSHH Gestational diabetes. A nulliparous woman is seen at the antenatal clinic 27 weeks into her first pregnancy. Routine screening with a 75 g oral glucose tolerance test for gestational diabetes mellitus (GDM) is performed. Which of the following would confirm a diagnosis of GDM? A. Fasting plasma venous glucose of greater than 5.0 mol/L B. 2-hour plasma venous glucose of greater than 7.8 mol/L C. Random plasma venous glucose of greater than 4.8 mol/L D. 2-hour plasma venous glucose of less than 7.0 mol/L E. 2-hour plasma venous glucose of less than 7.8 mol/L Answer – B Gestational diabetes criteria - The WHO definition of gestational diabetes encompasses both impaired glucose tolerance (2-hour glucose ≥ 7.8 umol/L) AND - Diabetes (random glucose ≥ 7 umol/L - Or 2 -hour glucose ≥ 7.8 umol/L  14 Pre-diabetics - If you don’t fulfil the criteria for DM but still have symptoms. - Impaired glucose tolerance, level after 2 hours: 7.8-11 umol. - Impaired fasting glucose: 5.6 to 5.9 Routine antenatal care A 29-year-old woman is seen at her booking visit and has blood taken for screening. Which of these is the most appropriate set of booking tests? A. Hepatitis C, human immunodeficiency virus (HIV), syphilis and toxoplasmosis B. Rubella, hepatitis B, hepatitis C and syphilis C. Syphilis, rubella, hepatitis B and HIV D. HIV, cytomegalovirus, rubella and hepatitis B E. HIV, syphilis, rubella and group B Streptococcus Answer – C https://www.youtube.com/watch?v=YJ7iBvKbXD8 Normal workup for pregnant pt. - Blood sugar - Urine dipstick: Check for infections – leukocytes and nitrates are + - BP - Weight – if obese anthropometry (MUAC – mid upper arm circumference) - Simple haemoglobin (normal in pregnancy only investigate if symptomatic) - Blood work o HIV o Hep B o Rubella o Syphilis o ABO grouping. o Resus test Baby is Rh pos and mother neg – fine of first pregnancy (if blood mixes mother will build anti-bodies to D antigen , on subsequent pregnancies can cause hemolytic anemia in the fetus) If we know that mother is Neg – if there is touching of blood mother needs to be given anti D immunoglobulin. Prevents an immune response from occurring.  15 < 22 muac is indicative of a low birth weight baby. Disorders of placentation A 34-year-old woman attends antenatal clinic for a routine ultrasound scan. Abnormalities of placentation are detected and a magnetic resonance imaging (MRI) scan is organized by the fetal medicine consultant. The MRI report shows: The placenta is in the lower anterior uterine wall with evidence of invasion to the posterior wall of the bladder'. What is the most likely diagnosis? A. Placenta accreta B. Placenta percreta C. Placenta increta D. Placenta praevia E. Ectopic pregnancy Answer – D Know D and E – DDX - Praevia – after 22 weeks - Ectopic – before 22 weeks Previa vs Abruptia: Previa = painless bleed Abruptia = painful, rigid/ woody placenta PV EXAM IS CONTRAINDICATED IN PLACENTA PREVIA  16 PIH: pregnancy Induced Htn Placenta Abrubtion: Woody Hard Uterus and severe pain  17 Management PP: Admit, IV Fluid, Group and save, Steroid (Betamethasone IM), monitor 12 hrs and then send home. “AIGiSM” PA: Viable baby - C/S Dead baby - SVD (spontaneous vaginal delivery) Painless antenatal bleeding A 30-year-old nulliparous woman is 29 weeks pregnant. She presented to hospital with a history of a minor, unprovoked painless vaginal bleed of about a teaspoonful. Her anomaly scan at 20 weeks showed a low-lying placenta. Her fetus is moving well and continuous cardiotocography (CT) is reassuring. What is the most appropriate management? Placenta Previa  18 A. Allow home since the bleed is small B. Admit and give steroids C. Admit, intravenous access, observe bleed-free for 48 hours before discharge D. Admit, intravenous access, Group and Save and administer steroids if bleeds more E. Group and Save, full blood count and allow home; review in clinic in a week (Group and save = type and screen) Answer - D ******26-34 weeks- administer corticosteroids for foetal lung maturity, observe for 24 hours. And Tocolytics only when there’s contractions. Automatically assume that pt might go into labour so give corticosteroids and wait 24hrs to see if labour progresses, if not, send pt home. If labour progresses, treat accordingly (urgent C-sec) You HAVE TO admit every pt with antenatal bleeding. We want to prevent pregnant pt from staying in hospital thus we give steroids early to prevent that they have to wait in hospital for prolonged observation. Steroids give for asthma – and foetal lung maturity. Rupture of membranes A 28-year-old pregnant woman attends accident and emergency with a history of clear vaginal loss. She is 18 weeks pregnant and so far has had no problems. Her past medical history includes a large cone biopsy of the cervix and she is allergic to penicillin. She is worried because the fluid continues to come and there is now some blood. On examination it is apparent that her membranes have ruptured. What is the most appropriate initial management? Premature rupture of membranes, no contractions A. Discharge, ultrasound scan the next day B. Offer her a termination as it is not possible for this pregnancy to continue C. Admit, infection markers, ultrasound and steroids D. Ultrasound, infection markers (CRP, ESR) and observation E. Discharge and explain that she will probably miscarry at home Answer - D Admit pt and watch her. If inflammatory markers increase she will need termination.. risk of chorioamnionitis is high. If she is