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GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU State Exam RSU January 2022 Gynaecology 1  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU 1. Evaluation of gynaecological patients: types and indicat...

GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU State Exam RSU January 2022 Gynaecology 1  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU 1. Evaluation of gynaecological patients: types and indications of different examination methods. Evaluation of gynaecological patients: types and indications of different examination methods.  Complete gynaecological examination includes o inspection of the vagina with the aid of a speculum o and, if needed, colposcopy and bimanual palpation  Depending on the clinical presentation, other laboratory diagnostics and imaging procedures may be indicated Inspection of external genitalia  Pubic area and hair  lesions, folliculitis, and lice  Perineum  redness, swelling, excoriations, abnormal pigmentation, lesions (e.g. ulcers, pustules, nodules, warts, tumors)  Structural abnormalities due to congenital malformations or female genital mutilation Palpation  Inguinal lymph nodes  Vagina and cervix – position, shape, consistency, regularity, mobility, tenderness  Uterus (bimanually) – size, form, consistency, mobility, pain  Ovaries (bimanually) – when normal, should not be palpable  Rectovaginal palpation  in Pat. with suspected pelvic masses (colorectal cancer) o Palpation of ureterosacral ligament, rectal sphincter function & integrety Speculum examination  Inspection of vaginal walls and ectocervix o vaginal discharge – smell, consistency, colour o Erosions, Ulcerations o Growths, Polyps o Inflammation, Bleeding  Pap smear o For cervical cytology – from endocervix and external cervix: If abnormal findings  cervical biopsy o Infections:  Vaginal candidiasis  Trichomoniasis  bacterial vaginosis  microscopy  Gonorrhoea  gram staining, intracellular diplococci  PCR and serological tests  Chlamydia  HPV typing  pH level estimation (normal 4-4.5) – if increased, suspect bacterial infection Ultrasound  Transvaginal: ovaries, uterus (myo- and endometrium) and adnexal structures  Transabdominal: urogenital tract, fetal development, pelvic organs  Indications for transvaginal and transabdominal US: pregnancy, PCOS, malignancies, cysts etc.  Breast US: breast lesions  detected by palpation, mammography and/or breast MRI Colposcopy  Examination of the vagina and cervix with a magnifying lens  Assessment of precancerous or cancerous lesions with acetic acid or iodine Hysteroscopy  Fiberoptic scope  introduced into the uterus (e.g. abnormal uterine bleeding, polyps, displaced IUD, scar tissue)  combined with diagnostic/therapeutic uterine curettage 2  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU Laboratory tests  hCG  pregnancy testing  Inflammatory markers (CRP, leu)  infection  Hormone levels  infertility  Tumor markers, e.g. CA15-3 (breast cancer) and CA125 (ovarian and/or endometrial carcinoma) Other  Mammography  Hysterosalpingography  Sonohysterography  Diagnostic laparoscopy  Endometrial aspiration 2. Types and indications for different surgical treatment modalities in gynaecology. Operative hysteroscopy: To remove polyps, fibroids or to perform dilation and curettage (D&C) Endometrial ablation  Destruction of endometrial lining of uterus  Heavy menstrual bleeding  only in women who no longer wish to become pregnant and permanent treatment is desired Laparoscopy  Diagnostic  Therapeutic: o pelvic pain o removal of an ectopic pregnancy o pelvic masses o treatment of endometriosis o congenital anomalies o ovarian cystectomy and oophorectomy o hemoperitoneum o hysterectomy o endometriosis o myomectomy o fertilization procedure o vulvectomy o ovarian tumors o trachelectomy Hysterectomy  Removal of uterus over either abdominal or vaginal route  Types o Subtotal: supracervical excision o Total / simple: Excision of uterus and cervix o Radical: en bloc excision with parametrium and upper vagina, fallopian tubes  Indications o Fibroid tumors o Cancer o Endometriosis o Uterine prolapse o Abnormal uterine bleeding o Chronic pelvic conditions (e.g. PID) Tubal ligation  cut, cauterize, or band the fallopian tubes  prevent the egg from being transported to the uterus  Permanent method of birth control 3  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU 3. Family planning, efficiency and evaluation of possible side effects of different contraceptive methods Family planning allows people  to attain their desired number of children  to determine the spacing of pregnancies  achieved through use of contraceptive methods and the treatment of infertility  Benefits of family planning/ contraception o preventing pregnancy related health risks in women o reducing rates of unintended pregnancies  reduces the need for unsafe abortions o Reducing infant mortality (closed spaced and ill-timed pregnancies and births) o Helping to prevent HIV/Aids o Empowering people and enhancing education o Reducing adolescent pregnancies o Slowing population growth Effectiveness of contraception  Pearl Index (PI) o number of unintended pregnancies in 100 women per year with perfect use of the method of contraception o PI is the most common measure of contraceptive efficacy used in clinical studies. o is very easy to calculate but comes with the problem that it does not take into account that failure rates typically decline with prolonged use. o PI assumes that this rate remains constant regardless of how many years the individual has been using a contraceptive method o it can be misleading when used to compare studies that took place over different lengths of time. Assess patients for risk factors and contraindications before initiating contraceptive method  including e.g. history of smoking, history of DVT, concominant diseases (cancer, hypertension, DM), drug use Side effects  Hormonal Contraception o Oestrogen & combined pill  Venous thromboembolism (VTE) (increased rate due to estrogen mediated coagulopathy)  Pulmonary embolism  Cardiovascular events  Hypertension  Risk increased in patients with history of HTN during a pregnancy and/or family history of HTN  Headaches  Hepatic adenoma development  Mastopathy  Breast/ cervical cancer  Gallstones  Mood changes o Progestin  Breakthrough bleeding  Follicular cysts  Venous thromboembolism (VTE)  Acne  Breast tenderness  Mood changes o Patch: Skin irritation  IUD o Uterine wall perforation o Dysmenorrhea, Bleeding o Increased menstrual cramping  Tube ligation o Sugical injuries  bowel/ bladder/ major blood vessel damage 4  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU o Impaired wound healing o Adhesions  Vasectomy o Scrotal hematoma o Blood in seminal fluid o Impaired wound healing o Discomfort 4. Effective contraception: types and contraindication Hormonal  Oral contraceptive pill o Combined: estrogen and progesterone  prevents ovulation (effectiveness: > 99% with correct and consistent use, 92% as commonly used) o Progestogen only pill (POPs) “Minipill”  thickens cervical mucus, prevents ovulation (effective: 99% with perfect use, 95-97% as commonly used)  Implant (small, flexible rod subcutan in arm)  thickens cervical mucus, prevents ovulation (>99% effective)  Intrauterine device (IUD) o Copper: damage of sperm o Levonorgestrel: thickens cervical mucus  Injectables o Progesterone only injectables  Every 3 months  Thickens cervical mucus, prevents ovulation o Monthly injectables or combined injectable contraceptives (CIC)  Patch (Combined contraceptive)  prevents ovulation  Vaginal ring (CVR) Combined contraceptive  prevents ovulation Surgery  permanent methods  Vasectomy  Tube ligation Other methods: (non hormonal)  Condoms: o Male/ Female  also STD prevention o Contraindication: Latex allergy  Lactational amenorrhea  Copper IUD: o Contraindications: uterine abnormalities (e.g. bleeding, malignancy, anomalies, infection), suspected pregnancy, copper hypersensitivity Contraindications: for oestrogen containing OCP Absolute Relative Cardiovascular - Thromboembolism - coagulopathy, antiphospholipid antibodies - Coronary heart disease - Stroke - Hypertension (>160/95mmHg) - Heart defects Metabolic - Pronounced hypertriglyceridemia - Hypercholesterolemia - Metabolic disorders of the liver - DM - Insulin – dependent Diabetes Mellitus - Pronounced hypertriglyceridemia - Metabolic disorders of the liver - Insulin – dependent Diabetes Mellitus 5  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU Oncologic - Hepatic tumours - Oestrogen – dependent tumours Inflammatory - acute pancreatitis - Lupus erythematosus - Vasculitis - After herpes gestationis Others - Smoking, >35 years of age - Morbid obesity - genital bleeding of unknown cause - Smoking, > 40 years - Pregnancy - Epilepsy - Migraine - Lactation (progestin only preparations permitted) - Uterine leiomyomas (especially intracavitary) - Gastric / Duodenal Ulcers - UC 5. Perimenopause. Endometrial hyperplasia - causes, types, diagnostics, treatment principles Perimenopause (menopausal transition, MT)  time period from: first instance of climacteric symptoms caused by fluctuating hormonal levels  1 year after menopause  duration may vary greatly in different women  average length of perimenopause is 4 years  increasing shortage of ovarian hormones and anovulation  elevated FSH levels  menstrual disturbances Endometrial Hyperplasia Causes  increased risk of endometrial hyperplasia and endometrial carcinoma is more evident in peri-menopausal and post- menopausal women with abnormal uterine bleeding (30% higher)  Increased oestrogen stimulation without progesterone  excessive proliferation of endometrium (may lead to cancer)  May also be caused by: o PCOS o Oestrogen producing ovarian tumour (granulosa cell tumor) o Follicle persistence in anovulatory cycles o Hormone replacement therapy (HRT) without progestin administration o Obesity Types (WHO)  Hyperplasia without atypia (previously: Simple/ complex Hyperplasia without atypia) o gland-to-stroma ratio is increased o mildly crowded, dilated, and have luminal outpouching of glands o risk of carcinoma: 1 – 3%  Atypical hyperplasia (previously: Simple/ complex hyperplasia with atypia) o gland-to-stroma ratio is increased further o disorganization of glands with luminal outpouching, cellular mitoses, and nuclear atypia, prominent nucleoli o Risk of carcinoma: very high (40%) Diagnosis  Clinical features o Abnormal bleeding  Consistent bleeding  Intermenstrual bleeding  Postmenopausal bleeding  Pelvic examination usually normal  Ultrasound  nonspecific finding that requires further investigation o Endometrial thickening 6  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU  > 1cm premenopause  > 0.5cm postmenopause  Endometrial biopsy  histology  Laboratory (non-specific): FSH, estradiol, testosterone  Biomarkers  Immunohistochemical markers may help distinguish EH with atypia (EIN) from EH without atypia or endometrial carcinoma Treatment  Goal: identify coexisting, and prevent progression to, endometrial carcinoma.  EH without atypia o Progestin therapy: cyclic progestin administration from the 12th–25th day of the menstrual cycle  Premenopausal women: IUD, combined oral contraceptives, POP (Minipill)  Postmenopausal: progestin therapy o All patients receiving progestin therapy should undergo:  Ultrasonographic follow-up after 3-6 months  Hysteroscopy with biopsy in the case of suspicious findings on ultrasound  EH with atypia o Premenopausal  In women with completed childbearing or no future wish to conceive:  total abdominal hysterectomy with or without bilateral salpingo-oophorectomy (due to 25% of developing metastatic ovarian cancer)  wish to conceive: progestin therapy and close surveillance with regular endometrial sampling o Postmenopausal: Total abdominal hysterectomywith bilateral salpingo-oophorectomy 6. Symptoms during menopause caused by oestrogen deficiency. Hormone replacement therapy, indications, side effects, contraindications Menopause Symptoms  The onset and intensity of symptoms is dependent on the phase of menopausal transition  Irregular menses (which gradually decrease in frequency) → complete amenorrhea  Autonomic symptoms o Increased sweating, hot flashes, and heat intolerance  sports, spicy food o Vertigo o Headache o Palpitations  Mental symptoms o Impaired sleep (insomnia and/or night sweats) o Depressed mood or mood swings o Anxiety/irritability, distress  Atrophic features o Breast tenderness and reduced breast size o Vulvovaginal atrophy: Vaginal dryness, pruritus, loss of libido, amenorrhea, menstrual irregularity o Urinary tract atrophy: dysuria, urinary frequency, urgency  Others o Weight gain and bloating o Hirsutism o ↑ risk for osteoporosis o ↑ risk for coronary heart disease (↑ LDL, total cholesterol; ↓ in HDL and prostacyclin) Hormone replacement therapy  HRT is usually employed for the short-term treatment of menopausal symptoms  cases with psychoautonomic symptoms severe enough to hinder daily functionality 7  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU  administration of synthetic oestrogen and progestogen to replace a woman's depleting hormone levels and thus alleviate menopausal symptoms  Types o Oestrogen Therapy: for women with hysterectomy o Progestin + Oestrogen: in women with a uterus (CAVE: endometrial cancer without progestin o Route: transdermal, oral Indications  Symptomatic or preventive: short-term treatment of menopausal symptoms  cases with psychoautonomic symptoms severe enough to hinder daily functionality  Relieve of vasomotor symptoms  Improvement of urogenital symptoms  long-term therapy  Prevention of osteoporosis  Preserve bone  Reduction risk of unwanted pregnancy  Avoidance of irregularity of menstrual cycle during transitional menopause  Improvement of quality of life Side effects  Nausea  Fluid retention  Bloating  Mood swings  Weight gain  Breast tenderness  Risks: o Cancer (breast/ endometrial) o Cardiovascular disease  CAD, DVT, PE, stroke o Gallbladder disease o Uterine bleeding o Stress urinary incontinence o Thromboembolic events o Metabolic disease o Stroke Contraindications  Undiagnosed vaginal bleeding  Severe active liver disease  Pregnancy  Hyperlipidaemia/ hypertriglyceridemia  Endometriosis  Thromboembolic disorders  Fibroids  Recent DVT/stroke  Breast cancer/endometrial cancer  Coronary artery disease  Chronic liver disease  Porphyria 7. Disorders of menstrual cycle during reproductive period - causes, examination, tactics 8  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU Examination  Gynaecological history o age at menarche o cycle length and regularity o pregnancies o family history o recent complaints  Physical examination o source and severity of bleeding o pap smear o swab for microbiological testing  Laboratory testing – CBC, platelets, PT, PTT, beta-hCG, thyroid function tests, prolactin  US o structural abnormalities o endometrial thickness  Endometrial biopsy o if endometrial thickness is ≥ 4 mm in a postmenopausal patient OR 9  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU o patient is >35 years of age and has risk factors for endometrial hyperplasia (e.g. obesity) Tactics  Depends on nature of etiological factor  Oestrogen Replacement o Every patient with hypogonadism to avoid osteoporosis (Except oestrogen-sensitive tumour)  Progesterone Replacement: Protection against endometrial hyperplasia or cancer  Other (E. g. psychotherapy in stress- or eating- disorder related cases)  Polycystic Ovarian Syndrome o Cyclic or chronic progesterone treatment, spironolactone in hyperandrogenism o SERM Clomiphene or aromatase inhibitor frequently leads to ovulation  To achieve of conception o Adequate treatment of hyperprolactinemia and thyroid disease o Surgical corrections of anatomic abnormalities o Pulsatile GnRH and/or gonadotropins o POF (primary ovarian insufficiency)  is not reversible 8. Polycystic ovary syndrome (symptoms, diagnostics, health risks, treatment principles)  one of the most common endocrine disorders in women  characterized by hyperandrogenism, oligoovulation/anovulation, and/or the presence of polycystic ovaries Symptoms  Menstrual irregularities o Primary or secondary amenorrhea o Oligomenorrhea o Menorrhagia o Infertility or difficulties conceiving  Insulin resistance and associated conditions o Metabolic syndrome (especially obesity)  risk of sleep apnea o Nonalcoholic fatty liver disease  Skin conditions o Hirsutism o Androgenic alopecia o Acne vulgaris o Oily skin o Acanthosis nigricans  Psychiatric conditions o Depression o Anxiety disorders Diagnostics  Early diagnosis is essential  Rotterdam criteria  Laboratory o Confirm hyperandrogenism: Obtain in all women with clinical features of PCOS, even if features are minimal or unclear  increased Testosterone: free testosterone, calculated bioavailable testosterone, or free androgen index  increased Androstenedione and dehydroepiandrosterone sulfate (for differential dg) o Rule out differential diagnoses: e.g., pregnancy, endocrine disorders o TSH o Prolactin o 17-hydroxyprogesterone o Patients with amenorrhea  Serum or urine hCG  Serum LH, FSH 10  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU o Features of hypercortisolism: Consider measuring cortisol in 24-hour urine, late-night salivary cortisol, or a dexamethasone suppression test  Ultrasound of ovary (transvaginally preferred over transabdominal)  assess volume, follicle count, volume of follicles  Evaluate comorbidities o Metabolic screening o Mental health  depression, anxiety, psychosexual dysfunction Health risks  Insulin resistance  metabolic syndrome (especially obesity), DM2, NAFLD  Cardiovascular risk   cancer risk (before menopause): Endometrial, ovarian, pancreatic   miscarriage risk Treatment  Exercise, healthy diet  Weight loss  Patient wishing to conceive: o Letrozole 2.5–7.5 mg PO daily/ 5 days (aromatase inhibitor: inhibits conversion of androgen  oestrogen, ↓ oestrogen  negative feedback  increasing GnRH  FSH secretion) o Clomiphene as alternative to letrozole o Exogenous FSH/ human menopausal gonadotropin o Metformin  second line  Patient not planning to conceive: o Combined oral contraceptives o Metformin o Antiandrogens (Spironolactone)  controversial treatment 9. Infertility: causes and examination principles Causes Female  Ovary-related causes o Premature ovarian failure o Menstrual cycle abnormalities (e.g., functional hypothalamic amenorrhea) o Hyperprolactinemia o Thyroid disorders o Systematic conditions: diabetes mellitus, hypertension, obesity, chronic diseases (e.g., hepatic or renal) o Pituitary adenoma o Diminished ovarian reserve (decline in functioning oocytes or normal consequence of age, or underlying disorder (e.g., endometriosis)) o Hypogonadotropic hypogonadism o Cushing syndrome o PCOS  Tubal/pelvic causes o PID o Endometriosis o Fallopian tube adhesions and/or obstruction  Following tubal or pelvic surgery  Following infections: appendicitis, chronic chlamydia infection, acute salpingitis, inflammatory bowel disease  Uterine causes o Anatomical anomalies (e.g., septate uterus, bicornuate uterus, Mayer Rokitansky-Kuster Hauser syndrome) o Uterine leiomyoma o Endometrial polyps o Asherman syndrome  Mostly iatrogenic (scarring, fibrosis, and/or adhesions of the endometrium caused by curettage) 11  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU  Reduces the sensitivity of the endometrium to progestogens  Cervical causes o Cervical anomalies (e.g., insufficient cervical mucus production) o Trauma (e.g., following cryotherapy, conization) o Immune factors (e.g., antisperm antibodies in the cervical mucus) o DES exposure in utero  Psychiatric causes o Vaginismus o Sexual arousal disorder Male  Sperm disorders (e.g., reduced sperm count, impaired motility, reduced ejaculate volume)  Testicular damage (e.g., scrotal injuries, testicular torsion, infections such as mumps, gonorrhea)  Scrotal hyperthermia (varicocele)  Medication (e.g., anabolic steroids, spironolactone, corticosteroids, cimetidine)  Thyroid disorders  Chronic diseases (e.g., liver cirrhosis, renal insufficiency)  Inherited disorders o Klinefelter syndrome o Kallmann syndrome  Often associated with structural/developmental abnormalities: cryptorchidism, cleft palate, scoliosis, renal agenesis  Characterized by delayed onset of puberty and hyposmia/anosmia  Sexual dysfunction (e.g., impaired libido, anejaculation)  Pituitary and hypothalamic tumors  Hyperprolactinemia  Cryptorchidism Examination Female  Physical examination (see Q. 1)  Menstrual history, basal body temperature  Ovulation prediction test  Lab o TSH, prolactin levels o Pap Smear o Antisperm antibodies o Serum progesterone levels (midluteal) o Ovulation prediction test  Endometrial biopsy  1-3 days prior to ovulation  Hysteroscopy and/or laparoscopy/ Hysterosalpingography  detect patency of fallopian tubes and uterus  Ultrasound (ovaries  antral follicle count, uterus) Male  Medical history of both partners  Semen analysis  Mixed antiglobulin reaction test for antisperm antibodies o Antisperm antibodies form in disruption of the blood-testis barrier (composed of Sertoli cell tight-junctions) o The antibodies can lead to immobilization and agglutination of sperm or have a spermatotoxic effect.  TSH levels  Prolactin levels  Karyotype test (Kallmann syndrome, Klinefelter syndrome) 10. Amenorrhoea: classification, causes and diagnostic principles. 12  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU Classification and causes  Physiologic: Before menarche, during pregnancy, during lactation, after menopause  Primary: o Absence of menarche at 15 years of age despite normal development of secondary sexual characteristics o OR absence of menses at 13 years of age in female individuals with no secondary sexual characteristics  Growth delay  Hypogonadotropic hypogonadism (Prader willy)  Hypergonadotropic hypogonadism (Turner)  Anatomic animalities  Müllerian agenesis  Imperforate hymen  Vaginal atresia  Transverse vaginal septum  Congenital adrenal hyperplasia  Complete androgen insensitivity syndrome  Secondary o Absence of menses for more than 3 months in individuals with previously regular cycles OR o Absence of menses for more 6 months in individuals with previously irregular cycles  Pregnancy / Lactation  PCOS  Medication (contraception, antipsychotics)  Hypothyroidism  Hyperprolactinemia  Sheehan syndrome  Ashermann syndrome (scarring, fibrosis)  Obesity  Anorexia nervosa  Hyper - or hypogonadotropic hypogonadism  Functional hypothalamic amenorrhea (excessive exercise, stress) Diagnosis  Anamnesis  Pregnancy test (Urinary hCG)  Physical examination o BMI o Look for secondary sexual characteristics – tanner staging o Evidence of virilization (deep voice, alopecia) o Pelvic exam – hymenal atresia, vaginal atresia etc  Pelvic US – Presence or absence of uterus  Transvaginal US: PCOS  Investigations o LH, FSH, TSH, Prolactin – present uterus but negative pregnancy test, galactorrhoea o Testosterone, DHEAS – if hyperandrogenism symptoms o Adrenal CT – if high BP and suspicion of CAH o Karyotyping – if absent uterus (for male/female genotype) 11. Pelvic inflammatory disease: aetiology, diagnostics, treatment principles, consequences  Bacterial infection that spreads beyond the cervix to infect the upper female reproductive tract, including the uterus, fallopian tubes, ovaries, and surrounding tissue. Aetiology  Most common o Chlamydia trachomatis o Neisseria gonorrhoea  Less common or coinfection: E. coli, Ureaplasma, Mycoplasma 13  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU  Risk factors: multiple partners, unprotected sex, previous STD’s, IUD Diagnostics  Clinical findings o Lower abdominal pain o Dysuria o Nausea o Menorrhagia/ metrorrhagia o Vomiting o Dyspareunia o Fever o Abnormal vaginal discharge  History  sexual activity, menstrual cycle  Vaginal examination (bimanual pelvic examination, Speculum, maybe Colposcopy) o Cervical, uterine, adnexal tenderness o Purulent, bloody discharge  Laboratory o Increased CRP, LEU o Pregnancy test  diff. dg. Ectopic pregnancy  Cervical/ urethral swab  Histology for offending agent (gonococcal and chlamydial PCR (DNA) and cultures)  US  free fluid, abscess, pyo-/ hydrosalpinx  Exploratory laparoscopy  if no response to treatment Treatment  Empiric antibiotics o Outpatient: single dose ceftriaxone i/m + doxycycline p/o o Inpatient: i/v clindamycin + gentamycin  change to oral route when clinical stabilization  Pain management, adequate hydration  Treat partner as well Consequences  Short term complications o Pelvic peritonitis o Fritz-Hubert-Curtis syndrome (perihepatitis) o Tubo-ovarian abscess  Long term complications o Infertility (adnexitis, tube adhesions etc) o Ectopic pregnancy o Chronic salpingitis or hydrosalpinx 12. Incontinence of urine in women: causes, examination, treatment principles.  Urinary incontinence is a common condition characterized by uncontrollable leakage of urine Causes  Neurological causes o Multiple sclerosis o Spinal injury  Genitourinary causes o Intrinsic sphincter deficiency o Urethral hypermobility in women o Impaired detrusor contractility o Bladder outlet obstruction o Pelvic floor weakness 14  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU  General risk factors o Recurrent urinary tract infections o Advancing age o Obesity o Parity o Pregnancy o Smoking o Menopause o Hysterectomy o Pelvic and perineal surgery o Ethnicity/Race  Potentially reversible causes o Diuretics o Urinary tract infections o Atrophic urethritis/vaginitis o Stool impaction Examination  Basic diagnostic testing o Voiding diary o Laboratory tests  Urine dipsticks and urine culture to exclude urinary tract infections o Sonography  Residual urine after micturition  Renal ultrasound  hydronephrosis? o Assessing pelvic floor muscles, neurological, vaginal, rectal examination o Pad test  quantification of urine  Additional o measurement of bladder pressure (urodynamic examination) o micturating cysto- urethrogram o Cystoscopy: to rule out tumours o pelvic MRI: to identify pelvic floor defects Treatment  General treatment (conservative): o Modify contributing factors (e.g., drugs) and treat reversible causes. o Physical measures to prevent leakage: Vaginal pessary (a device inserted into the vagina to provide more support for pelvic organs) o Lifestyle modifications  Weight loss  decrease consumption of alcohol, caffeine  Smoking cessation o Behavioural therapies and exercises  Bladder training  Kegel exercises o Pharmacological therapies  Oestrogen to treat overactive bladder symptoms in postmenopausal women with vaginal atrophy  Desmopressin against nocturia in women with urinary incontinence  Depends on type of urinary incontinence o Stress incontinence: conservative, Imiparime for ureter tone, surgery (midurethral sling, colposuspension, intramural bulking agent) o Urge incontinence: conservative, Anticholinergics (oxybutynin) o Overflow incontinence: complete urgent bladder catheterization (Foley), treat underlying cause 15  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU 13. Aetiology and pathogenesis of cervical cancer, primary and secondary prevention of cervical cancer. Aetiology  Almost all malignant lesions of the cervix are preceded by HPV infection  99%  Infection with high-risk HPV types: 16, 18 o Production of oncoproteins: E6 / 7 → inhibition of p53 protein → inhibition of intrinsic apoptotic pathway and inhibition of p21  Risk factors: o Early onset of sexual activity o Cigarette smoking and/or exposure to o multiple sexual partners (strongest risk second-hand smoke (for squamous cell factors) cancer types only) o High parity o Oral contraceptives o Immunosuppression (e.g., HIV o Low socioeconomic status infection) o In-utero exposure to diethylstilbestrol o History of sexually transmitted (DES) infections (e.g., herpes simplex, chlamydia) Pathogenesis  Persistent infection with high-risk oncogenic HPV types  inactivates tumor suppressor genes  induction of oncogenic transformation  Dysplasia  Cancer  Transformation from precancerous changes (CIN) to invasive cancer takes several years.  Cervical cancer commonly arises from metaplastic squamous cell epithelium in the transformation zone o squamous cell carcinoma (∼ 80% of cases) o adenocarcinoma (∼ 20%) Primary prevention  HPV immunization preferably before first sexual intercourse.  Current guidelines: o 2 doses should be administered 6 months apart to all individuals between the ages of 11 and 12 years  Immunization can be started as early as 9 years of age. o 3 doses of nine-valent HPV vaccine to all unvaccinated individuals between 15-26 years of age (0 – 2 – 6 months)  2nd dose should be given 1-2 months after the 1st dose an  3rd dose 6 months after the first dose.  Also preferred regimen for vaccination of immunocompromised individuals (e.g., HIV) o 3 doses of nine-valent HPV vaccine should be administered for all unvaccinated individuals between the ages of 27 and 45 years  FDA-approved vaccines o Bivalent vaccine (Cervarix®): protection against high-risk HPV types 16 and 18 o Tetravalent vaccine (Gardasil®): protection against high-risk HPV types 16 and 18, as well as against low-risk types 6 and 11 (most common cause of genital warts) o 9-valent vaccine (Gardasil®9): protection against high-risk HPV types 16, 18, 31, 33, 45, 52, and 58, as well as against low-risk types 6 and 11  Barrier protection (condoms) during sexual intercourse  Sexual abstinence Secondary prevention  Screening program (older guidelines) in ACS from 2020 age was raised from 21  25 years o Every woman aged 21–65 should participate in screening for cervical cancer o 21–29 years: Pap smear every 3 years o 30–65 years: Pap smear every 3 years OR Pap smear + HPV test every 5 years 16  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU 14. Causes of acute pelvic pain in gynaecology. Diagnostics and differential diagnosis Causes  Gynaecological o Endometriosis o Dysmenorrhoea o Pelvic inflammatory disease (PID) – o Ovarian mass most common cause o Mittelschmerz o Tubo ovarian abscess o Complicated ovarian cyst o Incomplete abortion  Torsion o Ectopic pregnancy  Rupture o Placental abruption  Haemorrhage Diagnosis  Objective is to rule out urgent life-threatening conditions like: o Ectopic pregnancy o Ruptured ovarian cyst o Appendicitis o Fertility threatening conditions o PID o Ovarian torsion 1) History  Present o Pain location, radiation, time of onset, duration, relation to menstrual cycle, frequency (constant, intermittent), type (severe, crampy, achy, dull), exacerbating and relieving factors, associated symptoms, treatment tried. o Time of onset  Minutes  Ovarian cyst rupture  Ovarian torsion  Appendicitis  Urolithiasis  Minutes to hours or few day  Dysmenorrhoea  Ovarian hyperstimulation syndrome (OHSS)  Diverticulitis  Days to weeks  PID  Cystitis  Weeks to months  Endometriosis  Fibrinoids  Sexual abuse  IBS  Inflammatory bowel disease  Neoplasm o Location  Mid lower  Fibrinoids  Dysmenorrhoea  UTI  RLQ only  late appendicitis  LLQ only  IBS, IBD, diverticulitis  Both sides  endometriosis, PID  On one side  ovarian cyst, ovarian torsion, endometriosis  Past o Surgery (abdominal and gynaecological) o Gynaecological problems  Sexual and STI history 17  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU 2) Physical examination  Vitals signs  Abdominal examination o Inspection, auscultation, and percussion o Test for peritoneal irritation  Pelvic examination 3) Laboratory testing  Urine analysis  Pregnancy test  Vaginal wet mount o Vaginal discharge is seen under microscopy, look for vaginitis, vulvitis etc  PCR: Chlamydia and gonorrhoea  Other tests based on history and physical examination o Rh blood typing (if pregnant ) o Urine culture o CBC o ESR o Fecal occult blood test 4) Imaging  Goal: accurate diagnosis using the least amount of radiation  Transvaginal US  CT or MRI o If negative or inconclusive US o Most sensitive strategy o Abdominal or pelvic CT 5) Diagnostic laparoscopy  Rarely needed to make diagnosis Differential diagnosis  Gastrointestinal o Acute appendicitis (most common non o Constipation gynaecological cause) o IBD and IBS o Acute cholecystitis and Cholelithiasis o Malignancy o Intestinal obstruction o Mesenteric ischemia o Diverticulitis o Acute pancreatitis o Colitis  Urologic o Acute cystitis and pyelonephritis o Urinary tract stone  Other o Peritonitis o Hernia o Porphyria o Rectus hematoma o Abdominal aortic aneurysm rupture o Abdominal wall trauma 18  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU 15. Ectopic pregnancy: causes, clinics, diagnostics, and treatment options  Ectopic pregnancy: a pregnancy in which the fertilized egg attaches in a location other than the uterine endometrium  Fallopian tube (95% of cases) o Ampulla (70%) o Isthmus (15%) o Fimbriae (8%) o Interstitial/cornual pregnancy (2%)  Ovary (3%)  Abdomen (1%)  Cervix (< 1%) Causes  Anatomic alteration of the fallopian tubes o History of PID (e.g., salpingitis) o Previous ectopic pregnancy o Surgeries involving the fallopian tubes o Endometriosis o Ruptured appendix o Kartagener syndrome o Exposure to diethylstilbestrol (DES) in utero o Bicornuate uterus  Non-anatomical risk factors o Smoking o Advanced maternal age o Pelvic inflammatory disease o Intrauterine device o In vitro fertilization o Hormone therapy Clinical features  Patients usually present with signs and symptoms 4-6 weeks after their last menstrual period.  Lower abdominal pain and guarding (ectopic pregnancy is often mistaken for appendicitisdue to the similarity of symptoms)  Possibly, vaginal bleeding  Signs of pregnancy o Amenorrhea o Nausea o Breast tenderness o Frequent urination  Tenderness in the area of the ectopic pregnancy  Cervical motion tenderness, closed cervix  Enlarged uterus  Interstitial pregnancies tend to present late, at 7-12 weeks of gestation, because of myometrial distensibility  Tube rupture  acute severe lower abdominal pain, signs of hemorrhage (tachycardia, hypotension, syncope) Diagnosis  If unstable patient: stabilize first, then continue with ß-hCG test  Positive beta-hCG test (> 1000 IU/l)  CBC o Anemia may be seen in patients with vaginal bleeding. o Blood type and screen  ABO and Rh testing to identify patients who might need Rho immunization  Liver function test, BMP: to determine baseline liver and renal function  Imaging o Transvaginal US  Determine the localization of pregnancy 19  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU  Supportive findings: empty uterine cavity, tubal ring sign, free fluid in Douglas pouch, possible extraovarian adnexal mass, Tubal ring sign (blob sign) o Transabdominal US  Exclude diff diagnosis (e.g., acute appendicitis)  general picture of the pelvic anatomy  Exploratory laparoscopy o Unstable patients with suspected Ectopic pregnancy o Pregnancy of unknown location still uncertain after 10 days  Endometrial biopsy o Only if location of ectopic pregnancy is unknown and nonviability is certain o Ectopic pregnancy: decidualization of the endometrium without chorionic villi or fetal parts Treatment  Conservative treatment o Methotrexate inhibits folate-dependent steps in DNA synthesis to terminate the rapidly dividing ectopic pregnancy.  Indication: uncomplicated ectopic pregnancy in stable pat., mass size 150ml), menorrhagia (>80ml)  can cause anemia  Submucosal leiomyomas are most frequently associated with significantly prolonged or heavy bleeding o Metrorrhagia – abnormal bleeding between periods o Dysmenorrhea – pain shortly before or during menstruation o Dragging sensation in lower abdomen 3. Features of mass effect o Enlarged and firm uterus during bimanual pelvic examination o Back or pelvis pain: labor like pain may occur if the mass is situated in the cervical orifice o Urinary or defecation problems - extrinsic compression of the bladder or sigmoid colon.  Urinary frequency  if the fibroid is large enough and pushes on the bladder  Constipation  Features of hydronephrosis 4. Reproductive abnormalities o Infertility - Related obstructed uterine cavity and/or impaired contractility of the uterus  in submucous myomas o Dyspareunia – pain during intercourse (Anterior or fundal fibroids are often associated with severe pain during intercourse) Diagnosis  Pelvic examination o Bimanual examination o Subserosal and intramural myomas o Enlarged, irregularly shaped, firm, and non-tender uterus Imaging  US – best initial test (Abdominal, Transvaginal) o For submucous myomas o Concentric, hypoechoic, heterogeneous tumors o Calcifications or cystic areas suggest necrosis o Saline-infused sonography: can be used to better visualize submucosal and intramural fibroids  Hysteroscopy: to assess submucosal fibroids (after US confirmed fibroids)  MRI: o to evaluate the uterus and ovaries for potentially complicated surgical cases o visually differentiate between leiomyomas, adenomyomas, and adenomyosis Treatment  Expectant management  Asymptomatic patients with leiomyoma of the uterus of less than 12 weeks  especially those approaching menopause  Should only be considered in symptomatic patients because of the side effects of medical therapy and surgery  Asymptomatic fibroids  no treatment  frequent follow-ups (approx. every 6–12 months) to monitor any potential growth  Medical therapy 1. line: drugs to reduce heavy bleeding and manage symptoms  Hormonal:  Combined oral contraceptive pill  Progestin-only contraceptive pill  levonorgestrel-releasing IUDs  Antifibrinolytics (e.g., tranexamic acid)  NSAIDs – to control pain, dysmenorrhea 21  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU 2. line: GnRH agonists (goserelin)  Androgenic agonists – suppress growth, has many side effects (e.g. acne, edema, hair loss)  Selective progesterone receptor modulators (SPRMs): e.g., ulipristal acetate, mifepristone  Surgery 1. Myomectomy (surgical removal of fibroids)  Hysteroscopic myomectomy: submucosal fibroids and some intramural fibroids that are primarily intracavitary  Abdominal myomectomy: (laparoscopic or open incision): subserosal and intramural fibroids 2. Hysterectomy (definitive treatment) with/without bilateral salpingo-oophorectomy  for rapidly growing fibroid, recurrent refractory bleeding secondary to medical therapy, severe symptoms, diffuse uterine myomatosis, suspected malignancy 3. Interventional: Uterine artery embolization 17. Endometriosis: clinical features, diagnostics, and treatment options common, benign, and chronic disease in women of reproductive age that is characterized by the occurrence of endometrial tissue outside the uterus due to retrograde menstruation Clinical Features  Up to 1/3 of patients are asymptomatic  Chronic pelvic pain that worsens before the onset of menses.  Uterosacral tenderness, uterosacral nodularity  Dysmenorrhea  Pre- or postmenstrual bleeding  Dyspareunia  Infertility  Dyschezia (painful defecation) Diagnostics  History  pain occurrence, pain scale, first time pain  Physical examination o Rectovaginal tenderness o Adnexal masses  Transvaginal ultrasound (best initial test) o The uterus is generally not enlarged. o Evidence of ovarian cysts (chocolate cysts) o Nodules in bladder or rectovaginal septum  Laparoscopy (confirmatory test) shows endometriotic implants and adhesions Treatment  Medical therapy o Mild to moderate pelvic pain without complications  NSAIDs  continuous hormonal contraceptives, Progesterone only pill  Synthetic androgens (e.g., danazol) o Severe symptoms:  GnRH agonists (Goserelin) + oestrogen-progestin OCPs GnRH: activates the gonadotropin-releasing hormone receptor in the pituitary gland.  Continued stimulation of the receptor leads to desensitization of the pituitary gland  thereby reducing the secretion of gonadotropins (LH and FSH)  decreasing estrogen in females and testosterone in males  induce a hypoestrogenic state in women with menorrhagia, endometriosis, or uterine fibroids.  Surgical therapy o First-line: laparoscopic excision and ablation of endometrial implants  To confirm the diagnosis and exclude malignancy  If there is a lack of response to medical therapy 22  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU  Treat expanding endometriomas and complications (e.g., bowel/bladder obstruction, rupture of endometrioma, infertility) o Second-line: open surgery with hysterectomy with or without bilateral salpingo-oophorectomy  Treatment-resistant symptoms  No desire to bear additional children 18. Most common causes of abnormal vaginal discharges: types, differential diagnosis, evaluation and treatment principles. Differential diagnosis  Vaginal yeast infection  white cottage cheese like consistency, itching, burning, odourless  Bacterial vaginosis  grey or milky with fishy odor  Chlamydia  purulent yellow malodorous discharge  Gonorrhea  purulent yellow malodorous discharge  Trichomoniasis  foul smelling, frothy, yellow-green, purulent discharge, pruritus, burning sensation, strawberry cervix  Postpartum endometritis  foul smelling lochia  Cervical/ endometrial cancer  blood stained discharge Types Evaluation  Patient anamnesis – eg. sexual history, onset, HPV vaccine  Appearance and consistency of discharge  Physical examination o Inspection of external genitalia o Palpation of lower abdomen o Bimanual pelvic examination o Speculum examination (discharge characteristics and smell)  Vaginal smear o  pH (N 4-4.5)  bacterial suspection o clue cells – bacterial vaginosis o Gram stain: Chlamydia o PCR and/or serological tests (N.gonorrhea) o HPV typing  Pap smear  Peliv US Treatment  Topical azole (Clotrimazole)  yeast infection  Metronidazole p/o  bacterial vaginosis  Doxycycline p/o for 7 days  Chlamydia (also treat partner)  Ceftriaxone i/m single dose  Gonorrhea (also treat partner)  Clindamycin i/v + gentamycin  postpartum endometritis  Surgery  excision, cone biopsy, hysterectomy  cervical/ endometrial cancer 23  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU 19. Ovarian formations: diagnostics, differential diagnostics, tactics Diagnostics 1. Imaging  1st: Pelvic US (transabdominal + transvaginal): should assess the following: o Size and structural characteristics o Laterality o Mass margins o Vascularity o Pelvic fluid in pouch of Douglas  MRI - not routine o May be helpful in determining the origin of pelvic masses that are not clearly arising from the ovary o Useful for assessing the feasibility of surgical resection  CT - Not recommended in the initial evaluation of adnexal masses o unnecessary ionizing radiation and do not allow for good structural evaluation of the pelvis o Extent of ovarian metastases (e.g., omental, liver, and lung lesions) 2. Tumour markers  CA-125 – elevated in 80% (monitor disease progression or recurrence after treatment)  LDH, AFP, B-hCG 3. Surgical evaluation  Recommended method for diagnosing ovarian cancer  Should only be utilized in patients with a high probability of a malignant ovarian mass  If a malignancy is found, it can be staged and cytoreduction can be performed  FNA is absolutely CI because of tumour cell spread!! Differential diagnosis  Ovarian cysts / PCOS  PID  Leiomyoma  Hydrosalpinx  Metastatic cause  GI cancer  Appendiceal abscess Treatment 1. Surgical staging and surgical debulking o Surgical staging: used to obtain pathologic specimens and evaluate the extension of cancer spread  Peritoneal cytology  Hysterectomy with bilateral salpingo-oophorectomy  Pelvic and paraaortic lymph node dissection  Omentectomy o Surgical debulking: Whenever possible, maximal cytoreduction (i.e., removal of visible tumor) should be completed to improve long-term outcomes  Residual disease < 1 cm defines optimal debulking.  Utilized in disease stages I-III 2. Chemotherapy (after initial debulking) 3. Targeted molecular therapy o BRCA1 or BRCA2-positive disease o Maintenance after surgical debulking and chemotherapy o Poly (ADP-ribose) polymerase inhibitors  Olaparib, Niraparib, Veliparib (in combination with chemo) 4. Radiation – symptomatic treatment for recurrent or metastatic diseases 24  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU 20. Most common gynaecological cancers (cervical, endometrial, ovarian): symptoms and diagnostic principles. Symptoms Cervical cancer  Abnormal vaginal bleeding: o menometrorrhagia, postcoital spotting, irregular vaginal bleeding  Abnormal vaginal discharge: o blood-stained or purulent malodorous discharge (not necessarily accompanied by pruritus)  Cervical ulceration  Late symptoms: o Tumor spread in this condition commonly occurs per continuitatem to the vagina, bladder, rectum and parametria. o Hydronephrosis: obstructive nephropathy caused by compression of the ureters o Leg oedema  Compression of veins or lymphatic vessels in the pelvic area o Features of disseminated disease: lymphadenopathy, rarely abdominal/ bone/ chest abnormalities (e.g., pain) Endometrial cancer  Abnormal uterine bleeding o Post-menopausal  any amount of bleeding/ spotting/ staining o Perimenopausal/ premenopausal  metrorrhagia, menometrorrhagia o Vaginal bleeding usually does not occur in Type 2  Later stages: o Pelvic pain o Palpable abdominal mass o Weight loss  Pelvic exam  mostly normal o Possible findings:  Abnormal cervix  Enlarged uterus  Local metastases  Metastases o Localized: contiguous spread to vagina, cervix, fallopian tubes, ovaries o Lymphogenic  late stages  Retroperitoneal spread  Involvement of pelvic  Involvement of para-aortic lymph nodes o Hematogenic  rare: 25  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU  Very late stage  Usually located in lungs Ovarian cancer  In most cases, there are no early symptoms.  In advanced stages, the size and growth of the tumor can lead to: o Abdominal pain and ascites o Cancer cachexia o Possible disruption of menstrual cycle o Dyspnea due to malignant pleural effusion o Abdominal or pelvic mass  Complication: tumor can cause ovarian torsion→ tissue infarction → surgical emergency  Abnormal vaginal discharge  Pseudomyoma peritonei Diagnosis Cervical cancer  Pap smear (cervical smear)  Cytology  Colposcopy o Cervical leukoplakia: atypical cells that form a white membrane that cannot be scraped off  May indicate hyperkeratosis, parakeratosis, or cervical intraepithelial neoplasia o HPV testing if low grade glandular changes  HPV test  Conization: excision of a cone of cervical tissue that contains parts of both the ectocervix and endocervix Endometrial cancer  Pelvic Exam  no gross evidence mostly  Endometrial biopsy with histology o Procedures: most performed as part of a pelvic exam  Alternatives include hysteroscopy-guided biopsy or dilatation and curettage o Results: endometrial hyperplasia, with or without atypia is seen, pronounced proliferation of glandular tissue o If there is no detectable pathology on biopsy and no further symptoms  endometrial cancer ruled out.  Imaging o Transvaginal ultrasonography  Thickening of the endometrium  regular monitoring required in postmenopausal women with thickening ≥ 5 mm  Cystic changes, variable echogenicity  Possibly visible tumor infiltration into neighboring organs o Abdominal ultrasonography  complete abdominal ultrasound is indicated to exclude metastasis. o Hydroultrasonography  ensure that it is not a false-positive result when the endometrium is thickened o Chest x-ray, CT, MRI: assessment of metastatic spread (lungs, pelvis)  Laboratory tests: o CBC and coagulation studies to assess anemia and possible other causes of heavy uterine bleeding o Pregnancy test Ovarian cancer  Hypercalcemia  Pelvic ultrasound (transvaginal, abdominal or rectal) o Irregular, thickened septae o Indistinct boarders, papillary projections o Hypoechoic, anechoic o Cystic or solid components present o Possible central vascularization o Possible free fluid in douglas pouch  Tumor markers  CA-125 (postmenopausal: increased CA-125  suscpicion of malignancy)  Histology  CT  metastases 26  GYNAECO LO GY - S TATE EXAM J ANU AR Y 2022 – RSU 21. Dysmenorrhea: causes, types, differential diagnostics, tactics  Primary dysmenorrhea: recurrent lower abdominal pain shortly before or during menstruation (in the absence of pathologic findings that could account for those symptoms, usually within 6 – 12 months of menarche.  Secondary dysmenorrhea: recurrent lower abdominal pain shortly before or during menstruation that is due to an underlying condition Primary dysmenorrhea Causes  Not known  Risk factors: o early menarche o nulliparity o smoking o obesity o positive family history Differential diagnosis  Differentiate primary from secondary  See below Treatment  Symptomatic treatment: o pain relief  NSAIDs o topical application of heat o exercise o decrease risk factors  smoking cessation, diet & weight control  Hormonal contraceptives o combined oral contraceptive pill o IUD with progestogen Secondary dysmenorrhea Causes  Uterine causes  Extrauterine causes o Pelvic inflammatory disease (PID) o Endometriosis o Intrauterine device (IUD) o Adhesions o Adenomyosis o Functional ovarian cysts o Fibroids (intracavitary or intramural) o Inflammatory bowel disease o Cervical polyps Differential diagnosis  endometriosis  ovarian cyst  adenomyosis  endometrial polyps  leiomyomas  Ovarian neoplasm  intrauterine devices  Peritonitis  PID  Pregnancy  Adhesions  Uterine neoplasm  cervical stenosis Treatment  Treat underlying cause  e.g. surgery, antibiotics  Heat application  Analgesics  NSAID’s  Lifestyle changes o Exercise may lighten symptoms o Smoking cessation o Decrease Alcohol intake o Weight control o Decrease stress levels 27  OBST ETRICS - ST AT E EX AM J ANUARY 2022 – RSU State Exam RSU January 2022 Obstetrics  OBST ETRICS - ST AT E EX AM J ANUAR Y 2022 – RSU 1. Physiological changes in a woman's body during pregnancy, related complaints and clinical symptoms System Changes Impact Cardiovascular ↑ progesterone → ↓ vascular tone: Masking of initial signs of sepsis ↓ peripheral vascular resistance ↓ mean arterial pressure ↑ hypoperfusion ↑ HR ↑ CO (Cardiac output) Inferior vena cava and pelvic veins are compressed by growing uterus ↑ risk of varicose veins, DVT,  impaired venous return hemorrhoids, peripheral oedema Blood ↑ plasma volume (50% to compensate maternal blood loss at delivery) Greater reduction of O2 supply to tissue ↑ Red cell volume (30%)  ↑ utilization of iron  anemia Coagulation ↑ Factors VII, VIII, IX, X, XII, vWF and fibrinogen ↑ risk of thromboembolic events ↓ protein S ↑ risk of DIC ↓ fibrinolytic activity Respiratory ↑ Tidal Volume, ↑ minute – ventilation by 30 – 40% Delayed physiological response to ↑ respiratory center simulation  ↑ respiratory rate metabolic alkalosis ↓ residual volume ↓ PaCO2 Impaired oxygenation Renal Ureteropelvic dilation and ↓ ureteral pressure due to smooth muscle relaxation Delayed identification of renal injury Flaccid bladder (capacity ↑ up to 1500ml) secondary to sepsis ↑ intravesicular pressure to due pregnant uterus weight ↑ vesicoureteral reflux Favorable to pyelonephritis ↓ peripheral vascular resistance – activation of RAAS system → ↑ water retention → ↑ Aldosterone → ↑ renal plasma volume + hypernatremia ↑ GFR (40 – 65%) ↓ urea and creatinine average values ↑ urinary glucose Asymptomatic bacteriuria Gastrointestinal ↑ salivation: Gums may become hypertrophic/ hyperemic ↑ risk of bacterial translocation ↓ muscle tone across digestive tract  progesterone-related relaxation of lower ↑ risk of gastric reflux esophageal sphincter ↑ risk for aspiration pneumonia Diaphragm elevation by pregnant womb (4 cm) ↑ risk of cholestasis, Delayed gastric emptying and gall bladder emptying hyperbilirubinemia, and jaundice Changes in bile composition ↑ production of pro inflam. Cytokines by Kuppfer cells Skin Hyperpigmentation (linea nigra and melasma (Exacerbated by sun exposure)) Striae gravidarum on abdomen, breasts, thighs, buttocks Other ↑ insulin levels  hypoglycemia may cause lower back pain Musculoskeletal: ↑ lumbar lordosis hypoglycemia Relaxation of the supporting ligaments supporting the joints of the pelvic girdle in preparation of the birth Metabolism Weight gain due to ↑ nutritional requirements (average: 12.5kg) Reproductive Uterus – ↑ size – height from 7.5 cm to 35, weight from 50 g to 1 kg system Cervix – becomes soft, mucus plug formation Vagina /vulva – vaginal discharge, varicose vein, ↑ glycogen in vaginal epithelium, ↑ risk of chorioamnioiitis ↓ vaginal pH 2  OBST ETRICS - ST AT E EX AM J ANUAR Y 2022 – RSU 2. Antenatal care in physiological course of pregnancy - examinations and their indications. Initial Office Visite 1. History o Obstetric History  Including all information about outcome and planning of previous pregnancies (Birth weight, length of gestation, length of labor, etc.) o Medical History  Preexisting conditions, permanent medication o Surgical History  Previous surgery might complicate caesarean section o Family History  Diabetes (Gestational), Congential Disorders o Social History  Tobacco and/or alcohol abuse, drug use, economic situation, work place exposure 2. Physical Examination  Speculum exam. YES, Bimanual NO ! o Uterus  Confirmation of gestational age in first half o Cervical length  Closed external cervical os in women with no previous vaginal delivery, Adnexal exam o Maternal weight + BP o Fetal heart rate/ fetal position (If already possible) 3. Laboratory Tests o CBC: Hematocrit/ Hemoglobin (screening for anemia: IDA) o Blood type (ABO and Rhesus)  In Rh neg. mother: prophylactic anti D Ig at 28th weeks to prevent alloimmunization o Pap smear  Epithelial Neoplasia o Screening for STIs:  Syphilis (all pregnant women)  HIV (all pregnant women)  Hepatitis B surface antigen (all pregnant women)  Hepatitis C (Anti-HCV antibody testing)  Rubella  Prenatal gonorrhea screening: in all patients < 25 years of age and > 25 years with high risk of infection  Chlamydia trachomatis o Urine  Dipstick: screening for proteinuria performed during every prenatal visit  Culture: screening for asymptomatic urinary tract infection  routine in 2nd trimester as untreated asympt. Abacteruria can lead to increased risk for pyelonephritis  increased risk for preterm labour o Tuberculin skin test in high-risk patients 4. Ultrasound assessment of the estimated gestational age through the crown-rump length (or Naegele rule: first day of last period + 7 days + 1 year – 3 months) 5. General advice for pregnant women o Vaccination against seasonal influenza recommended to all women o Nutritional recommendations during pregnancy are also provided o Tdap vaccine during the 3rd trimester of every pregnancy to provide fetal immunity to pertussis Subsequent Visits  Standard schedule o 0 to 28 gestational weeks: every 4 weeks o 28 to 36 gestational weeks: every 2 weeks o after 36th gestational weeks: every week  Each visit o maternal weight & BP o uterine fundal height o urinalysis by dipstick (proteinuria and Oedema  May be sign of preeclampsia) 3  OBST ETRICS - ST AT E EX AM J ANUAR Y 2022 – RSU o Fetal heart tones o Additionally: Fetal Size and Position (Always after 26 weeks´ gestation)  Leopold maneuver  1st trimester screening (week 1 – 13) o Different tests for screening of chromosomopathies (10-13 weeks’ gestation)  US: nuchal translucency  beta-HCG  PAPP-A levels in maternal serum  Cell-free fetal DNA testing (cffDNA)  Also used for secondary screening after ultrasound (in patients with high risk of aneuploidy, e.g., abnormal first-trimester screening or quad test)  Finds chromosomal abnormalities and determines sex of fetus o If abnormal, provide counseling and perform  chorionic villus sampling (CVS): 10 – 13 weeks  Amniocentesis: from 15th week  Physical examination o Fundal height and position of the fetus (Leopold's maneuver) o Gravidogram: Used for determination of Fetal growth according to gestational week  Connection between Symphysis-fundus height and length of pregnancy is made o Fetal heart monitoring (via ultrasound or cardiogram)  2nd trimester (week 14 – 26) o CBC and Hb at 24th week o OGTT at 24 – 28th week o Repetition of rhesus testing – unsensitized Rh(D)-negative women should receive anti(D)- immune globulin  3rd trimester: (week 27 – 40) o Group B streptococcus screening by vaginal swab during 35-37 weeks to prevent chorioamnionitis and neonatal infection; positive in 1/3 o Leopold maneuver o Fetal movement count (>6x in 2 hours) 4  OBST ETRICS - ST AT E EX AM J ANUAR Y 2022 – RSU 3. Gestational diabetes: risk factors, diagnostics, tactics and impact on mother’s and newborn health  Impaired glucose tolerance diagnosed during pregnancy; associated with an increased risk of maternal and fetal morbidity  In 5 – 7% of pregnancies, usually in 2 nd or 3rd trimester Risk factors  Major risk factors for type 2 diabetes o Obesity, high-calorie diet o Ethnicity o High waist-to-hip ratio (visceral fat o Hypertension accumulation) o Dyslipidemia o Physical inactivity o History of gestational diabetes o First-degree relative with diabetes  Obstetric o Gestational diabetes in prior pregnancy o Recurrent pregnancy loss o At least one birth of a child diagnosed with fetal macrosomia o Excessive gestational weight gain Diagnosis  Pregestational DM in Pregnant women  1st and 2nd trimester (the first 24 weeks of pregnancy): o confirmed Dg: diabetes mellitus and gestational diabetes  two independent fasting glucose levels: >126 mg/dL and 92-125 mg/dL respectively  Gestational DM  3 rd trimester (at 24-28 weeks) o Recommended in all pregnancies! o Initial screening: 50-g, 1-hour oral glucose challenge test: blood glucose level should be < 135 mg/dl o Confirmation test: 100-g, 3-hour oral glucose tolerance test (oGTT): blood glucose level should be < 140 mg/dl  if one or more of three test results are above the limits, diagnosis of GDM is done. Tactics  Glycemic control o Dietary modification and regular exercise (walking) o Strict blood glucose monitoring (4x daily) o Insulin therapy – if glycaemic control is insufficient o Metformin – in pat who refuse insulin therapy  Regular US  evaluate fetal development and especially size  Consideration of inducing delivery in 39-40 weeks if glycaemic control is poor or complications occur. Impact  Maternal o Gestational hypertension, Preeclampsia, eclampsia, HELLP syndrome, UTI o Increased risk of developing DM type 2 (up to 50% over 10 years) o Mostly resolves after pregnancy o Increased risk of gestational diabetes recurring in subsequent pregnancies (∼ 50%)  Fetus o Diabetic fetopathy, Macrosomia, IUGR, spontaneous abortion, preterm delivery, still birth, respiratory distress syndrome, shoulder dystocia, polyhydramnios o After delivery:  hypoglycaemia, hypocalcaemia, hyperbilirubinemia, polycythaemia, inheritance for diabetes 5  OBST ETRICS - ST AT E EX AM J ANUAR Y 2022 – RSU 4. Prenatal genetic and fetal anomaly screening. Screening for aneuploidy  4/1000 births abnormalities (Including fetal death, pregnancy termination)  50% of 1st trimester abortions, 20% of 2ndtrimester losses o Trisomy 21 composes approximately 50% o Risk of trisomy increases with maternal age, especially after age of 35 Non-Invasive Test Timing Description Conditions 1st trimester 11 – 13 weeks Sonographic nuchal translucency Trisomy 21 – ↑ HCG, ↓ PAPP- A, thickened NT (> 95.percentile) combined gestation (NT) screening Trisomy 18 – ↓ HCG, ↓↓ PAPP-A, ↑ NT β-HCG (human chorionic gonadotropin) Trisomy 13: ↓↓ PAPP-A, ↑ NT Molar pregnancy PAPP- A (pregnancy-associated Ectopic pregnancy protein A) in maternal serum Neural tube defects Quad screen test 15 – 20 In maternal serum Trisomy 21 - HCG Trisomy 18 - Alpha-fetoprotein (AFP) Molar pregnancy Ectopic pregnancy - Estriol Neural tube defects - Inhibin A Abdominal wall defects Triple screen Test 15 – 20 In maternal serum - HCG - Alpha-fetoprotein (AFP) - Estriol Sequential 10–13, and First trimester combined test plus integrated test 15–20 Quad screen test Cell-free fetal DNA From 10 weeks Fetal DNA is isolated from a blood specimen for genetic testing testing (cffDNA) gestation maternal blood specimen for Identifies chromosomal aberrations (high specificity and onwards genetic testing: whole genome sensitivity for trisomy 21 > trisomy 18 > trisomy 13) sequencing, chromosome selective Determine the gender of the fetus sequencing Fetal growth and 18 – 20 weeks To screen for chromosomal abnormalities anatomy US Soft markers, e.g. short femur or humerus length, hydronephrosis, heart or gut abnormalities plexus choroideus cysts increased length of NT Invisible nasal bone in 1st trimester increases the risk of chromosomal abnormality Invasive Method Timing Description Conditions Chorionous after 11 weeks of Needle is inserted through abdominal Chromosomal aberrations villous sampling gestation wall into the uterus in US guidance to obtain placental tissue Amniocentesis After 15 weeks of Needle is inserted through abdominal Fetal genetic disorders gestation wall into the uterus in US guidance to congenital infections obtain amniotic fluid and fetal cells alloimmunization fetal lung maturity 6  OBST ETRICS - ST AT E EX AM J ANUAR Y 2022 – RSU Cordocentesis After 17 weeks of Fetal blood sampling via ultrasound- Identify the type of fetal hemoglobin and assess the gestation guided transabdominal needle insertion severity of fetal anemia into the umbilical cord (umbilical vein Performed for assessment of alloimmunization and fetal blood sample) karyotype determination Diagnose genetic defects in the fetus if amniocentesis, chorionic villus sampling, and/or fetal ultrasound are inconclusive 5. Physiological delivery - delivery periods, follow up and support during the delivery.  Labor: Uterine contractions that bring about demonstrable effacement and dilation of the cervix  Delivery: Mode of expulsion of the fetus and placenta Prelabour  3 - 4 days before birth  Irregular contractions of high intensity, occurs every 5-10 min  responsible for correctly positioning fetal head in pelvis  Mucus plug with/without blood may come off 1-7 days before labour  Labour is ongoing when contractions are regular and cervical canal is opening  Amniotic fluid can break prior to labour – observation in hospital is indicated Criteria 1. Term  37th- 41st + 6d 2. Spontaneous onset of contractions 3. Spontaneous vertex position + Vaginal delivery 4. No use of forceps/ suction 5. Blood loss not over 500ml 6. Amniotomy, Epidural Anesthesia, Oxytocin for augmentation 7. Pain 8. Perianal skin laceration  1st degree, 2nd degree 9. Episiotomy 10. Duration (starts with active stage)  6-12 hours primipara, 7,7 hours multipara Delivery periods 1. Stage: o Latent phase  Begins with mild, infrequent, irregular contractions  ends with cervical dilation of 3-4 cm (Amboss: 6cm)  Duration  20 hours in nullipara 14 hours in multipara  Prolonged: excessive sedation, epidural anesthesia, unfavorable cervical condition, false labor  Support: pain relief: Epidural (most efficient), laughing gas, massages o Active phase  Starts from cervical dilation 3 - 4cm (Amboss: 6cm)  full dilatation (10cm)  Cervical dilation progression: o Nullipara 1cm/ ho