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Abnormal uterine bleeding

Adenexal mass
Antenatal care
Antepartum haemorrhage
Breastscreening and cancer prevention
Cervical dysplasia
Common gynaecological problems
Common postnatal problems
Contraception
CTG lntro
Endometriosis
Infections in pregnancy
Labour and delivery
Multiple pregnancy
Obstetrics anaesthesia
Postnatal mood disorders
Pre-conceptual counselling
Prenatal diagnosis
Problems with labour and delivery
Sudden and unexpected death of infants
Termination of pregnancy
Uro-gynaecology
Normal pregnancy
Neonatal case discussion
Normal variants, minor disorders and syndromes
Monitoring in labour
Reproductive anatomy and physiology throughout life cycle
Preterm birth
Breastfeeding
Perinatal infection
Pelvic pain
Menopause
Fetal malpresentation
Ectopic pregnancy
Hypertension
Pernatal indigenous health
Infertility
Principles of Gynaecological oncology
HPV vaccine and cervical cancer prevention
neonatal abstinence syndrome
hypoglycemia
ethics in neonatology

PWH - Endometriosis
______________________________
finished - added to pwh notes
______________________________
PWH - Infections in pregnancy
______________________________
- severity of infection = risk of miscarriage/intrauterine death
- indirec = reducing oxygenation of placental blood and nutrient exchang
e thru palcenta
- direct invasion (virus multiplies in trophoblast and then invades fetu
s
- congenital defects: rubella, CMV, HSV => microcephal, congeital hear d
isease, eye damage (cataract), deafness, hepatosplenomegaly + jaudince, purpura,
mental handicap
- Fetus is immunologically competent by 14th week

UTI
- eti:
. pregnancy = relaxation of ureter and bladder = urinary stasis
ASYMPTOMATIC BACTERIURIA
- greater then > 100,000 bacterial / mL urine
- risk of lower birthweight, premature, postpartum endometriitis, pyelon
ephritis
- screen early in pregnancy (MSU)
- Ecoli 85%
- amoxycillin/clavulanic acid 500/125 mg, or
- cefalexin 2g
PYELONEPHRITIS
- urinary stasis - grwoth - bladder - ureter - renal pelvis
. haematog is rare
- risk of rupture of membranes and death
- pregnancy 20th week
- PC
. fatigue
. urinary frequency
. dysuria
. chills
. rigors
. fevers
. renal angle pain
. dehydrtion
- Dx
. MSU
. exclude appendicitis and placental abruption
- Tx
. fluid resusc
. test sensitivity
. initial empirical = amoxyillin or cephalosporin
. MSU follow up 2 week later
VAGINAL INFECTIONS - candida spp and trichomonas and bacterial (amine) vaginosis
- Dx (KOH/saline slide of vaginal swab)
. thrashing tails = trichomonal flagellates
. vaginal epithelial cells - "Clue cells" / "hundreds and thousa
nds" of coccobacilli = bacterial vaginonis + fishy odour
. hyphae of candida
- trichomonas vaginalis (flagellate)
. profuse vaginal discharge (green, frothy if long standing) + i
tching + irritation inside the vagina
. sexually transmitted to male urethra
. risk of prematurity
. tx
- single dose PO - tinidazole 2g, PO or metronidazole 2
g,
- same for partner
- F/U swab 1 weel later
- candidiasis (thrush) = candida spp
. vaginal epithelial cells, spores,, threads (hypae)
. recurrent = diabetes, broad specturm abx, immunosuppressive (c
orticosteroids), HIV
. severe vulvovaginal irritation + vaginal discharge
. "thick and cheesy"
. single dose clotrimazole (an imidazole)

. if recurrent prophylactic ketoconazole 100 mg PO, OD (LFTs)

. wipe vulva from front to rear to avoid faecal contamination
. do not wear tight clothing
- Bacterial vaginosis
. 20% women
. incr in vaginal flora
. incr in vaginal pH (more basic bc decr in lactobacilli produci
ng hydrogen peroxidase) => growth of gardnerella vaginalis, mycoplasma hominis,
mobiluncus
. discharge = thin greyish, fish smell
. tx - single dose metronidazole 2g PO
BACTERIAL INFECTIONS
- Group B streptococcus
. vaginal delivery - neonate infectoin
. risk of GBS neonatal sepsis, preterm, placental abruption
. mx
- positive screen at 36 weeks by swab- prophylaxis
- OR - RFs
. preterm 37 wk
. previous GBS
. 38C during labor
- prophylactically penicillin
- if positive = 1.2 g IV benzylpenicillin for known carr
iers during labor then 600 mg IV 4-hr until delivered
- (clindamycin 600 mg IV 8hrly if allergic)
- Neisseria Gonorrhoea
. infected endocervical cells and bartholins galnd (NOT FROM vag
inal mucosa bc cannot penetrate vaginal stratified epithelium)
. Thayer martin medium
. dysuria, discharge w/i 5 days intercourse
. tx
single dose probenecid 1 g + cetriaxone 250 mg IM
followed with 100 mg doxycyclin PO - twice daily for 3 w
eeks
- Syphilis (treponema pallidum)
. treponemes can penetrate placenta after 15 wk pregnancy and in
fect foetus = congenital symphilis/death
. screen VDRL or rapid plasma reagin
- 1st antenatal visit
- at 30 weeks
. if positive check for false positive with
- TPHA treponema pallidum haemaglltination test
- fluorescent treponemal Ab test FTA-Abs
. 1g procaine benzylpenicillin OD for 10 days
TOXOPLASMOSIS
- toxoplasma gondii
- risk miscarriage, congenital CNS/eye damage
- prevention
. avoid cat faeces
. avoid touching mouth/eyes wile handling raw meat
. wawsh vegetable and fruit
- Tx
. pyrimethamine + sulfadiazine + folic acid
VIRUSES
- Rubella
. infection in pregnant women within 1st 14 wks = fetal varaemia

.
.
.

- eye lenses (cataracts)

- ears (deafness)
- chmabers of the heart
- fetal growth restrictions
- thrombocytopena
- hepatosplenomegaly
- vasculitis
- renal artery stenosis
prevention
. immunisation pre-puberty using live attenuated strain
screen
. rubella antibodies
Dx
. rubelliform rash
. srology (IgG positive = immunity)
herpes
HSV crosses placenta to infect fetus
greater risk of transmission during childbirth esp if primary

- genital
.
.
infection
. v low risk if hx of recurrent infections (cf primary = hi risk
) = can give vaginal birth
. if lesions are present - do caesarian
. risk neonatal death, neuro damage
- hepatitis B
. (africa, SE asia) have HBsAg = infectioius
. vertical transmission
. risk of hepatcellualr carcinoma in adultnood
. tx babies with Hep B Ig + hep B vaccine at birth and following
- hepatitis C
. IVDU, blood transfusion, peiricing, vertical
. avoid fetal scalp electrodes
. no advantage to avoiding breastfeeding or doing caesarean sect
io
. DO NOT USE antiviral (interferon, ribavirin) bc they are terat
ogenic
- CMV
. 50% prevalence in pregnant owmen
. some risk of congenital
. no vaccine, no screening
- HIV
. 30 risk transmission to fetus (they will be antibody positive
and develop AIDS)
. no adverse effect on pregnancy
. caesarean reduces risk of transmission by 50%
- give azothiprine within 8 hrs of delivery to baby + next 6 wee
ks
- single dose nevriapine 200 mg at onset labour reduces vertical
transmission risk
- Chickenpox (varicella)
. 80% prevalence of pregnant with IgG antibodies to VZV
. mother complications
- pneumonia
. fetus (1st trimester)
- limb hypoplasia
- microencephalic
- cortical atrophy
- cataracts
- psychomotor retardation
- convulsions
- intrauterine growth restriction

HELMINTH,
-

- disseminated varicella inection

. test fo anti-VZV, IgG, IgM antibodies
. 12.5 mg /kg VZVimmunoglobin VZIG IM with 96 hr exposure
. aciclovir 10-15 mg/kg every 8 hrs wif severe
HOOKWORM
hookworms - ancylostoma duodenale and necator americanus
worms attach to intestinal villi by suckers and feed on blood
causes iron deficient anaemia
tx
. bephenium hydroxynapthoate , 5 mg for 3 days
. iron supplement

MALARIA
- plasmodium falciparum can immobilise in placetna
- prophylaxis
. avoid fansidar and maloprin which inhibit folic acid synthesis
resulting in stevens-johnson fatal syndrome
. if chloroquine non-resistance = use chloroquine or proguinai 6
00 mg
PWH - Endometriosis
___________________
. ectopic endometrial tissue
- eti
. retrograde passage of endometrial tissue along fallopian tubes
during menstruation (retrograde menstruation)
. possible haematogenous to distant sites
. metaplasia of mesothelial coelemic cells into endometrial cell
s
. tf most of the sites where it is found
- ovaries
- uterosacral ligament
- pouch of douglas
. One established
- growth occurs by exposure to cyclical estrogen (in pre
gnancy with low estrogen, lesions are phagocytosed)
- cystic formation
- bleeding of the endometrial tissue occurs into the cys
t during menstruation - enlarges with each month = endrometrioma
. bursting = peritonitis, spread of endometrial
tissue
- pathophysiology
. Large inflammatory bilateral ovaerian masses
. inflammatory mass = uterus immobile and sticks to utero-sacral
ligament
. posterior fornix nodules - dysparaeunia
. deposits on serosa near bladder = pain on voiding
. Deeply infiltrating mass - mass extends deep into pelvis - inf
iltrating into lumbrosacral plexus - plexopathy - obturator nerve distribution
. Mass is continous with rectal mass - exacerbations during peri
od - irritates bowel - menstrual diarrhoea
. Higher estrogen, prostaglandins, inflamm cytokines IL-1,,6, tn
f-alpha
. Prostaglandin also induced by incr COX and VEGF
. PG causes pain (PGE2) and vasoconstriction and uterine contrac
tion PGE2a
- Dx
. pelvic exam soon after menstruation to detect pouch of douglas
lesions
. laparoscopic dx and confirmed by biopsy

- PC
. pain (acute pericyclic on chronic backgroudn) - no correlation
bw severity of pain and extent of endometriosis
. infertility
. other women in family also affected
. dyspareunia
. menstrual irregularieis
- intermenstrual bleeding
- menorrhagia
- Mx - depends on stage of life (whether had children or not)
. Hormonal -> general SE = amenorrhea, hot flushes, weight gain,
bone loss
- estrogen inhibitors
. danazol (derivative of 17-alpha-ethinyl testosterone)
- reduce GnRH receptors in pituitary gland => decr sex-hormone-bidning-globulin
=> incr free testosterone and decr unabound estradiol)
. GnRH agonists (suppress ovarian steroid secretion)
. gestrinone (progestogen)
. medroxyprogesterone acetate (progestogen)
. Mirena IUD (progesterone)
- Surgical Mx
. ovarian conserving laparascopy
- laparoscopic diathermy (electrocautery) or CO2 laser/d
iathermy ablation/debulking
- hysterectomy
. if > 2.5 cm, then conservative surgery, hormones, hysterectomy
, salpingooophorectomy
. cystectomy
. drainage of cysts
- Ix
. Blood
- haem
- biochem
- beta-HCG
- cancer markers
CEA
CA125 (uterine) (came back as 100, n= < 35)
beta-HCG
alpha feto protein
CA19.9
. urinalysis
. faecal occult blood
. PID screen (1st pass urine, urine PCR)
. US
- normal uterus size 9x9x7 cm
- 8 cm complex ovarian cyst R side
- 5 cm ovarian L side
- ovaries are fixed to uterosacral ligament on transvagi
nal US (cannot see appendix, minimal free fluid)
- DDx
Malignant
. Cancer
Benign
Inflammatory, infectious
. diverticulitis
. endometriosis benign)
. cysts
. infection
ADENOMYOSIS

- infiltration of basal endometrial cells into the uterine muscle (myome

trium)
- Eti
.
.
.
.

infilatration from basal endometrium

non hormone sensitive layer
tf smaller nodules with less blood
nodules stimulate myometrial proliferation - slow growth

- PC
. progressive incr menstrual pain
. menstrual irregularities
- Pelvic exam
. enlarged tender uterus
- Tx
. hysterecotomy if symptomatic (not hormone responsive)
UTERINE FIBROIDS
- most common tumour of genital traact
- eti
. encapsulated bundles of whorled whitish-grey smooth muscle (cf
laminar, concentric normal myometrium) interspersed wiht connective tissue, dev
eloping in myometrium - either intramural or growing into the uterine cavity
. if blood supply insufficient, central part undergoes hyaline d
egeneration, cystic transformation or calcification (womb stones)
. grow in respond to estrogen (atrophy after menopause)
- PC
. detectable by 4th decade (grow slowly) - incidence 20%
. nulliparous/single child women
. menorrhagia (incr endometrial surface + uterine vascularity)
. anaemia
. uterine cramps
. peristent blood discharge if pedunculated (submucous fibroids)
. larger = dysuria, frequency, constipation, backache, rectal bl
eeding
- worse in pregnancy (incr estrogen) - > risk of necrobiosis (re
d degeneration) = pain, fever, risk of miscarriage (distort uterine cavity), obs
truct birth canal
- Dx
. "knobbly uterus" OE
. whole cervix moves as one
. US
- Mx
. observation
. myomectomy (laparascopy) to remove fibroids and reconsistitue
uterus
. hysterectomy
. GnRH
PWH - Labour and delivery
___________________
normal labour: 20 - 30 hours, 0.3-0.5 cm cervical dilaton/hr
stages:
- prelabour
- 1st stage with 3 phases
- 2nd stage
- 3rd stage
- 4th stage
Prelabour
- uterine activity
- cervix thins and softens (effacement) - only 1 Os remaines
- multiple days

- assoc with back pain, sleep disturbance

Risks associated with early hospital admission
- unnecessary intervention (caesarean, analgesia)
- decr activity (activity progresses labour)
1st stage
- from onset of painful regular contractions, cervical dilatation until
cervix is fully dilated ~ 10 cm
- phases - latent, active, transition
- uterine contraction
- cervical dilation -> descent
- uterine fundus thickening puts pressure to flex and move baby down
- fetal occiput pressure on pelvic floor to rotate it anterior
- moulding of fetal skull to fit pelvic canal
- monitor - vitals, abdominal palpation, vaginal assessment
Abdominal palpation
- uterine fundus height
- baby position and rotation
- breach/normal presentation
- engagement with pelvic floor
. engagement when half of baby head (widest part) has breached t
he pelvic brim
Vaginal assessment
- external genitalis
- certical effacement
- dilatation
- prior to analgesia
- confirm presentation
- exclude umbilical cord prolapse
Fetal well being
- auscultation of fetal heart rate
. pinard stethoscope
. hand held doppler US
- electrong fetal heart rate monitoring
2nd stage
- full dilation (10cm) to birth of baby
- ~ primiparous > 2 hours
- multiparous < 2 hours
- slow and steady progress allows perineal skin and mm to stretc
h
- sx
. descent on abdominal palpation
. grunting, gutteral sounds
. pushing
. perineal flattening against pelvic floor
. vaginal gaping
. anal pouting
. defecation
. head visible
Maternal psoitions for birth
- assoc with less tearing
. laterla
. squatting
. all fours
- assoc with more tearing
. semi recling
. birth stool
. lithotomy
. bath
Mechanisms of labour
components

- descent
- flexion
- internal rotation
- crowning
- restitition
- external rotation
- lateral flexion
- Flexion, descent & internal rotation-allows 1st stage progress
- Further flexion- allows occiput to present
- Extension- allows head to be born as it sweeps perineum
- Restitution-head rotates 45 degrees
- External rotation - shoulders turn to AP of mother
- Lateral flexion- allows anterior shoulder to pass under pubic arch - Posterior shoulder sweeps vaginal floor
Pushing in 2nd stage
- active
. ie encouraged to push / voluntary
. reduces fetal oxygenation (reduces APGAR score)
. reduces length of 2nd stage
. risk of perineal trauma
- physiological
. incr if upright and active
minimising Perineal trauma
- 80% 1st time mothers require stitches
Episiotomies
- indicated for fetal distress
- severe impending tear
- previous scar tissue
- b/g female genital mutilation
Analgesia
- NO2
- opiates (SC morphine, 7.5-10 mg 2hourly, less repsiratory depression i
n neonate than pethidine)
- epidural
3rd stage
- from birth of baby, to delivery of placenta and membranes
- post partum hemorrhage is 25% of maternal mortality/morbidity
- Active management
. giving IM synctocinon in shoulder - encourages uterine contrac
tions
. early cord clamping
. signs of separation (lengthening of cord, blood loss)
. controlled cord traction
. 30 min)
- physiological
. cord left alone
. signs of separation
. woman upright and pushes placenta down
. placenta born within an hour
4th stage
- neonate adapts to extra-uterine life
- haematological stability and bonding (skin to skin)
- natural oxytocin released
- breast feeding initiation
------------------PWH - Prenatal diagnosis
___________________
Major anomalies

- 5 %
- 30% perinatal deaths
Perinatal deaths
- prematurity, growth retardation, infeciton, asphyxic
- congenital abnormality difficult to tx
COngenital abn in order of prevalent causes
- 80% = most commonly unknown or multifactorial (cannot screen for them
bc don't know the high risk patients)
- single gene defects (thalassemia, haemophilia, tay-sachs - fhx / prena
tal dx via chorionic dx - can offer terminations)
- teratogenic (exposure to lithium, anticonvulsants, cocaine)
- chromosomal (age women, aniocentesis, chorionic sampling)
Prevention
- teratogens
- con-sanguinity (incr risk from 5% in non related parents to 8% in 1st
cousins)
- perconceptual folic acid (folic acid fortified bread)
Strategies
- structural anomaly
. serum screening
. US
- chromosomal abn
. serum screening
. US
. CVS / amnio / fetal blood smpling
- single gene defects
. fhx
. cvs or amniocentesis
Amniocentesis (for amniotic fluid)
chorionic villus sampling (transvaginally for placenta sampling)
Amniocentesis / chorionic sampling
- risks of miscarriage = cannot do as screening test for entire populati
on
1st screening test - 18 weeks - fetal morphology assessment
- US
- early enough to still do termination bc not yet viable
- can date the pregnancy
- can determine if twins are present
- assessment of placental position and cervical length
- early enough to do amniocentesis
- disadv
. reliant on operator expertise = 80% detection of abnormalities
(down to 30%)
. many abnormalities not evident at this stage
- eg achondroplasia people have normal limb lengths at t
his stage.
. pregnancy already public
. late termination method requiring
- cervagem induction of labour (abdominal pain, be in ho
spital, vaginally deliver the foetus)
- GA dilatation of cervix and evacuation of uterus (diff
icult to pass thru cervix resulting in some cervical damage)
. does not detect chromosomal abn
- eg downsyndrome
Downsyndrome = tr 21
- 1/660, increasing incidence due to increasing maternal age
. 30 yr = 1/1000
. 40 yr = 10/1000
. 50 yr = 40/1000

> 35 year mother = 30%

< 35 year mother = 70%
- 95% sporadic, 5% non-disjunction
- sx
. mental retardation
. slanted eyes
. epicanthal fold
. VSD
. intestinal defects
. simian crese
. shortened 5th finger
. wide big toe/ next toe gap
. protruding wrinkled tongue
. alzheimers at lower age
. congenital detectable at 3rd trimester= 30%
- duodenal atresia
- tracheo esophageal fistula
- esophageal atresia
. cardiac abn = 50%
- AV canal defects
- VSD
- ASD
- Mx
. no cure
. blastocyst biopsy for pre-implantation diagnosis
. prenatal diagnosis + termination of pregnancy
- diagnostic tets
. amniocentesis (v reliable, 15weeks, US guidance, samples the f
etal cells floating in the amniotic cell, cells are grown)
- > 35 year mother = 30%
- < 35 year mother = 70%
. chorionic villus (13 weeks, placental sample, vaginally if pla
centa on back wall, not as reliable as amniocentesis due ot maternal cell contam
ination or mosaicism so that cell lines sampled don't represent the rest of the
fetus)
. fetal blood sampling
- screening test for downs - offered to all women which include nuchal t
ranslucency screening and 2nd trimester materal serum screening (triple test)
. US marker screening
. materal serum screening (triple test)
- estriol
- afp
- bHCG
- used in communities withou access to US nuchal
screening
- it is gestation dependent levels tf if you don
't accurately know the age of the fetus (via a good US) can be misleading
. nuchal translucency screening
- 12 week
- ultrasound - relies on technician skill
- midsagittal section
- positioned off the posterior wall
- atlantoaxial membrane and the skin
- fetal medicine foundation multi centre trial calculato
r for risk
- relies on technical expertise
- assesses gestational age well

- done early (not showing) in pregnancy so that terminat

ion done by D+C
- 80% detection rate
- also detects nonviable pregnancies and twins
- 5% false positives (-> invasive testing to confirm)
. combined 1st trimester nuchal and serum screening
. nasal bone hypoplasia 11-13 + 6 weeks (fetal crown-rump length
of 45-84 mm)
- done at same time as nuchal screenng
- 3-line sign (skin, nasal bridge, nasal bone)
- 95% detection (if included with fetal NT, bHCG, PAPP-A
)
- midsaggital
- also detects 50% of trisomy 18 adn 30% of trisomy 13
. ductus venosus waveforms 11-13 + 6 weeks
- abn flow in ductus venosus refers to reverse flow of A
-wave
- 80% tri 21
- 75% all chromosomal abn
. 3D ultrasound
- can detect omphalocele, cleft lip, talipes, rocker bot
tom feet (tri 18), tongue protrusion (tri 21, beckwith-weidemann syndrome)
- even as early as 8 weeks
. 95% of downs is detected by combination of - free bHCG, PAPP A
, nuchal translucency and age, nasal bone
- 10-14 weeks - placental glycoproteins
- free beta HCG (decr bw 10-14 wks but incr in tri 21)
- PAPP A (incr bw 10-14 weeks, decr in tri 21)
- Fast FISH
- tri 13, 18, 21
When an abnormality
What is the
What is the
What can be
What is the
What is the

is found - questions
sonographic accuracy for diagnosing this condition?
likelihood of perinatal death or long term handicap?
done to correct the defect or improve the outcome?
best time and method of delivery?
recurrence risk for future pregnancies?

Aims of prenatal diagnosis

To obtain an accurate diagnosis as early as possible in the pregnancy
To provide information on prognosis & recurrence
To provide counselling for the family
To provide the options of in-utero treatment if available; pregnancy ter
mination if the outcome is dismal ; the best method of delivery and optimal peri
-natal care
------------------PWH - Pre-conceptual counselling
___________________
components:
- IDENTIFY risks for mother/fetus
- EDUCATE about and mx for mitigate risk
- INTERVENTIONS to optimise helath and reduce risk
- for all women of reporductive age, whether or not planning
50% pregnancies are unplanned

Issues in preconceptual counseling

Lifestyle factors (Tobacoo, Marijuana, Exercise, Nutrition, Caffeine, Al
oohol, Other drugs)
- Medical history
- Obstetric & Gynae. history
- Family history
- Immunisation history
- Psychosocial screening
- Age
Tobacco
-

modifiable RF
20% pregnant women smoke (higher in teenageers and ndigenous)
babies 200 g lighter - dose dependent, reversible with early cessation
highest impact in 3rd trimester (>10 cigarettes/day)
risks
. perinatal morbidity
. mortality (PROM, abruption, preterm delivery, stillbirth RR =
3, SIDS RR = 7)
. ectopic/ tubal
- smoking itself contributes to infertility
- augmented intervention (small, frquent interventions, follow up, suppo
rt materials)
- aids - patches, nicorette gum
Marijuana
- 3% of users continue in pregnancy
- 1st trimester withdrawal - N/V
- >6 joints/week associated with smaller circumference head and decrease
d ececutive funtioning by the time the babies grow to young adolescents
Drugs
-

benzos, heroin, cocaine, amphetamines

negative affects in pregnancy
requires referral to methadone or rehab prior to pregnancy
rehab has downflow benefits (decr prostitution)

Alcohol
- if hi risk/usage - advise postpone pregnancy whilst reducing or abstin
ence goals
- risks to fetus
. no safe level of consumption
. binge drinking wrose then chronic ingesttion
. growth restriction, neurobehbavioural
. fetal alcohol syndrome in heavy use
Fetal alcohol syndrome
- Prenatal aloohol exposure
- Growth restriction pre and postnatally
. small if exposed to alcohol - tend to remain small
. cf placental dysfunction - low birthweight with long term card
iovascular risk factors BUT can catch up after birth)
- Facial majfonnation
. short palperbral fissures,
. thin upper lip
. abnormal philtrum
. hypoplastic mid-face
- Neurodevelopmental disorders eg
. language,

. motor.
. learning,
. decreased IQ
Screening for excess alcohol use = T-ACE screening insument for pre-pregnancy ri
sk
- [informally (> 7 /week, or >3 on any day)]
1. T - tolerance = How many drinks does it take for you to feel high?
.(if >2, score 2)
2. A - annoyed = Do you ever feel Annoyed by people complaining about yo
ur drinking?
. (If yes, score 1)
3. C - cut down = Have you ever felt the need to cut down on your drinki
ng?
. (if yes, score 1)
4. E - eye opener Have you ever had a drink first thing in the morning?
(Eye-opener).
. If yes, score 1)
Positive score = 2 or more.
If positive, a woman should have oomprehensive alcohol assessment and in
tervention
Exercise and nutrition
- regular exercise
- folate supplementation
. neural tube defects
. 1 mo before conception -> thruout 1st trimester
. 0.5 mg - 5 mg daily (hi risk)
. hi risk
- preveious neural tube defects
- fhx defects
- mother on valproic acid or carbamazapine
- insuline dependent DM
. diet - green vegetable, nuts, wholegrain bread
. iodine consumption
. limit caffein (<2 cups/ 250 mg/day) preconception to avoid wit
hdrawal later during pregnancy
BMI
> 30 = risks
. gestational diabetes
. pre-eclampsia
. caesarean section requirement
. macrosomal infant
. risk death
. reduced fertility (preconception)
< 17 = risk
. low birth weight infant
Diseases to ask woman about
- DM - aim for < 6%
- htn - < 120 for DM, less then 130 otherwise
. avoid ACE-I
. aldemet, nifedipin, BBs
- asthma
- hypothyroid (cretinism in the babies)
. thyroxine
- epilepsy
- CVS disorders (congenital or acquired)
- AID disorders

. thrombophilias
- depression
Immunisation to ask woman about
- rubella titre (test before pregnancy, give top up, delay pregancy 3 mo
)
. worst effect if contracted in 1st trimester
- varicella titre (chickenpox - offer vaccination if no hx; worst effect
of disease of fetus if contracted bw 13-20 weeks - BUT can kill mother at any t
ime (pneumonitis, encephalitis)
- HepBs Ag
- HIV counselling
- HepC counselling
- Mantoux test for TB
- toxoplasmosis titre
. cat litter/faeces
- CMV titre
. especially from contact in childcare centers
- STI screen (chlamydia, gonorrhoea, syphilis)
FHx
-

cystic fibrosis (1/25 caucasian have genetic marker), thalaseemia

gives time for partner testing and risk for affected fetus
referr to geneticist
DM - fasting BSL, GTT
thromboembolic disorders - thrombophilia screen

Ob/Gyn history
- contributors to infertility and preg complication RFs
. uterine abnormality
. DES (diethylstilbestrol) exposure of fetus = fetus has later r
isk of
- cervical incompetence
- clear cell carcinoma of vagina
. PCOS
- hx
. recurrent miscarriage
. prev abn child
. incr risk of chromosomal abn in parent (balanced translocation
)
. recurrence risk of adverse outcome
- miscarriage
- pretern birth IUGR
- PET
- GDM
Age
- risk of chromosoaml abn with incr age of pregnancy
- definition of advanced maternla age = > 35
Psychosocial RFs
- socials upplor
- financial, hosing
- career
- psych - anxiety, mental illness
- domestic violence -> depression, cannot cope
. marital conflict
. partners troubles
. drugs, alcohol
. gambling

- incest
------------------PWH - Antepartum haemorrhage
___________________
Antepartum hemorrhage
- bleeding bw 20 wk - delivery
- 5% preg
- Causes
. Other (47%)
- local - vaginitis, vaginal neoplasm, vaginal polyp
- unexplained - marginal separation of placenta (bleed o
f small vessel at edge)
- cervical incompentence (20-24 wk) - ie opening with mi
nimial symptoms
- cervical dilatation (+ mucous)
. Placental abruption (30%) . Placenta praevia (20%) . Uterine rupture,vasa praevia
Placental abruption (30%) - premature separation of placenta caused by rupture of maternal vessels
in the decidua basalis, splitting the decidua and separating its placental att
achment from the uterus
- 1.3% pregs (stillbirth in 1/800 deliveries; hi recurrence risk)
- acute causes =
. trauma/ mva - external compression, decompression
- RFs
Previous abruption
trauma / mechanical (rupture due to polyhydramnios) eg.
. increased lichal volume
. after delivery of twin 1 - subsequent change in volume
. implantation of placenta over fibroid or septum -> ina
dequate decidualisation = greater chance of comming away from wall
Hypertension RR = 5
. chronic effect on vascularity - causes bleeding
. pharmacological control does not decrease this
. worse with superimposed pre-eclampsia
Cigarette smoking (RR=2) - ischemic peripheral necrosis of the d
ecidua
Parity > 4
. endometrial scarring,
. impaired decidualisation,
. aberrant uterine arterial vasculature
Maternal age
Cocaine (10% risk if using cocaine)
. induce vasoconstriction - ischamiea - effect also on f
etal brain
. reflex vasodilation - vessel damage
Prolonged preterm rupture of membranes (PPROM)
. 5% risk of abruption in this condition
. 10% if assoc with infection
Inherited thrombophilia
. thombus irritating membranes
Multiple pregnancies and polyhydramnios (RR = 3 risk with twins)
. rapid decompression after 1st twin
Placental abnormalities
. circumvellate placenta (fibrous ring aroudn edge of pl
acenta)
- Dx is CLINIAL
- PC - acute, partial or on ultrasound

. acute
vaginal bleeding (>80%)
abdominal pain (>50%)
uterine contractions (>35%)
uterine tcnderness (70%)
non reassuring CTG
coagulopathy
. partial
recurrent antepartum hemorrhage
. ultrasound
- exclude pl. pracvia and check fetal growth} well being
; only 2% abruptions detected on ultrasound
Placenta praevia
- presence of placental tissue overlying or close to internal cervical o
s
- 6% incidence at 10-20 wk (90% resolve), 0.5% 3rd trimester
. 4/1000 incidence
. 8% recurrence
- 2 categoris (major and minor) with 4 types
Major
. complete (placenta covers internal os)
. partial (edge of placenta partially covers internal os)
Minor
. marginal (comes down to os but does not cover it)
. low lying placenta
- RFs
. endometrial scarring
- assoc with incr materanl age, incr parity, caesarean d
eliveries
. incr placetnal surface for uteroplacental transport of oxygen
and nutrients
- multiple gestations
- higher altitudes
- materal smoking
. early gestational age
- inadequate uterine segment lengthen bc too soon
- PCs
. painless (APH) bleeding 80% ****
- fetal distress - low blood volume
. uterine contractions 20%
. asymptomatic
- Assoc conditions (incr suspsicion of pl praevia)
. placenta accreta (accretions) (esp previous caesarean incr ris
k of subsequent low lying placental implantation or implantation over caesarean
scar = indication for management in tertiary unit)
. malpresentation
- non-descension into uterus, remaining transverse or ob
lique
. preterm premature rupture of membranes (PPROM)
. intrauterine growth restriction
. vasa praevia and velamentous umbilical cord
- Dx
. suspected if painless APH after 20 weeks
. requires US for dx
Vasa praevia
- a vessel goes over cervix (usually assoc with a minor pl praevia)
Velamentous insertion of umbilical cord

- cord comes in at edge of placenta

Management of APH
- AVOID VAGINAL EXAMINATION until exlcuded pl praevia (by US)
Case 1
- 40F, multiparous, 30 wk gestation; acute abdominal pain, small bright
APH, CTG shows later deceleration, uterine tenderness, hypotensive 70/40, PR 120
- suspect major abruption
Mx major abruption
- 2 large bone canulas (16 g)
- get multidisciplinary help (anaesthetist, other drs, midwives)
- Assess maternal haemodynamic status
- Assess fetal conditiomcontinuous CTG monitoring, notify OT and NICU
- IV resuscitation - start with crystalloid
- Urgent blood tests. G+H,
. X match 2-4 units,
. FBC,
. Haematocrit,
. Coags,
. DIC screen (INR, APTT , Thrombin time, D-Dimer, fibrinogen)
. QFMH or or kleihauer test
. IDC
- if fetal bradycardia BUT still viable gestation
. O2
. check left lateral positioning
. deliver by C/S
. transfuse with FFP, platelets
- if CTG reactive
. more time to stabilise mother
. maintain urine output > 30 mL/hr
. packed RBCs if hct < 0.3 (n = 0.36-0.46)
. platelets if < 50,000 (N 150-400)
. ffp if coagulopathy (d-dimer incr > 0.25, INR and APTT > 1.5 (
inr n=0.9-1.2 and aptt 25-37), fibrinogen < 1 g/L (n 2-4.5), thrombin time > 13
(n=10-13_
- if fetus dead
. commmon if > 50% placental surface separated
. goal now becomes materal well being
. ie may pass vaginally
- post partum
. hi risk of POST PARTUM HEMORRHAGE - can kill
. oxytocin
. massage uterus
. DIC correction
. Prostaglandin-F2-alpha
. Ergometrine if not htn
. B-lynch suture (put over uterus to help it contract)
. uterine artery embolisation or hysterectomy if ongoig bleeding
. fluid resusc
. ICU
- give anti_D if Rh negative
. need to do QFMH test - quantitative feto-maternal hemorrhage b
lood test to determine amount of anti-D required to mop up fetal blood cells
Case 2
- 30F, primiparous, small APH, 32 wk, mild localised tenderness, normal
tone, vital signs nromal, ctg reactive, placenta clear of cervix on US at 19 wks

Mx minor abruption
= Small APH, with reassuring CTG, no hypotension, no uterine tenderness,
no coagulopathy
- Expectant Mx with observation in hospital until no further APH and no
other symptoms suggestive of abruption
- Corticosteroids x 2 if between 24 - 34 weeks
Ultrasound to check placental location, fetal growth, dopplers and liquo
r
Check blood results including QFMH or Kleihauer
Consider tocolysis (anti-contraction medication to relax the uterus) if
active labour or cervical change and <34 weeks with mild abruption as provisiona
l diagnosis, while getting covered with steroids
- Perform speculum examination to check no other LOCAL cause of small AP
H (eg large cervical polyp)
CTG = cardio toco graph
Case 3
- 39F, multiparous, moderate APH (0.5 cup), painless, 32 weeks, no anten
atal record.
- must suspect pl praevi
- avoid vaginal exam
Case 4
- 32F, hx 2 previous lower segment caesarean section, 33 wk, large (1 cu
p) bright APH, mild tightening, no tenderness/pain, steroid coverage at 26 wk du
e to hi risk. Continued bleeding
- 1st question = what is the US result
- prev caesars = risk of anterior pl praevi with placenta accreta
Mx - pl praevia + major APH
- major APH protocol
Mx - pl praevia
- indication sof delivery
. non reassuring CTG (fetal hypoxia, anaemia, persistent minimal
variabiity, fetal tachycardia, recurrent later decelerations, sinusoidal heart
rate)
. refractory maternal hemrorhage
. significant vaginal bleeding after 34 weeks gestation
- conservative mx after an acute bleed
. hospitalisation until delivery
. supportive if 1st bleeding episode and stopped after 48 hours
with no complications
. correct aneamia (Fe tablets + stool softeners)
- Steroids x 2 for women between 24 and 36 weeks (as C/S planned)
- Anti D for Rh Negative women
- Ultrasound for fetal growth, liquor and dopplers every 4 weeks, or mor
e if IUGR or PPROM
- Have a current G + H in blood bank
- Delivery
. plan CS for 36-37 wk with steroid cover
. CS for all pl praevia
- unless low lying placenta with placenta > 2 cm from in
ternal os at 36 weeks
. vaginal delivery if fetal demise
. 4 units packed red cells in OT
. hysterectomy instruments in OT
. avoid disruption of placenta on entry to prevent hemorrhage

- tx assoc conditions
. placenta accreta
. malpresentation etc
CASE 6
- 25F, painless APH, placenta celar, 19 weeks, FHR normal.
- dx = local cause eg polyp, post coital
------------------PWH - Termination of pregnancy
___________________
Epi
- 41 mil worldwide/yr
- ~85,000 /yr in australia (20/1000 women of reproductive age)
- 8.7 per 1000 in netherland
- 68000 deaths/yr
- 5 mil complications/yr
- 13% pregnancy related deaths
- 1/4 population live in countries where it is illegal
- 1/1000,000 deaths in australia 1st trimester
Law
- depends on stage
- still in criminal law except for ACT and victoria (true decrim)
- SA, WA, Tas, NT - has stat expl of when it is not unlawful
- NSW, QLD, relay on common law
- NSW
. 1971, Levine J
- doctor
- has honest belief
- on R grounds
- operation necessary to preserve woman from serious dan
ger to her life, physical or mental health
- mental health should take into account the effects of
economic or social stress pertaining at the time
. no legislation wrt gestatonal age
. surgical abortion > 20 wks unavailable in nsw
. medical abortion > 20 wks requires medical indication + ethics
committee
. age of consent
- competent minor 14-16 yrs (Gillick competency) w/o par
ental consent
. father has no legal right to restricting access to abortion
- Victoria
. Victorian abortion law reform bill 2008
. unrestricted access up to 24 weeks
. > 24 weeks requires approval from 2 doctors who R believe the
abortion is appropriate in all the circumstances
Unplanned pregnancy:
- keep, termination, adoption/fostering
- 50% women (60% of these were using some type of contraception)
. 50% of these continue, 30% termination, 20% miscarry
- her decision
- supportive, non-judgemental
Abortion services
- most in private health secor
- public hospital - mostl for foetal abnormalities
- surgical abortion mostly by GPs with training
- LA, IV, GA options

- early medical abortion possible

Choice of method wrt to last menstrual period
- 4-9 weeks
. medical abortion (mifepristone + prostaglandin) - usually in w
omans home
. aspiration abortion
- 7-15 wks
. suction termination + GA/LA
- 10-24 wk
. medical abortion (mifepristone + multiple dosed prostaglandin)
- 15-24 wk
. surgical abortion dilatation and curettage
Choice of method
- 50% choose medical abortion (avoid surgery, less invasive, perceived t
o be safer)
Pre-TOP assessment
- gestational age
- LNMP - last normal menstrual period
- pregnancy sx - nausea, tender breasts - occurs 5 weeks after L
NMP
- UCG, qUANT bHCG (bHCG rises and reaches peak toward end of 1st
trimester and then falls - cannot accurately label)
- abdo exam
- US
- medical and surgical hx
- O+G hx
. previous C/S
. ectopic pregs
. uterine abn (fibroids)
- Rh group (anti D for Rh negative women)
- STI screen esp chlamydia
- informed consent
- after care + F/U
. advise not to use tampons or have sex for ~1 week after
- Discuss future contraception
Medical abortion
- 3 combinations
. mifepristone RU-486 + a prostaglandin
- MOST EFFECTIVE < 7 wks and still appropriate 7-9 wk
. methotrexate + prostaglandin
. prostaglandin
- MTX is not as effective as mifeprisone
Mifepristone
- not licensed with TGA in australia
- only accessed thru Authorised Prescribers Scheme
- progesterone antagonist
. causes decidual necrosis
. stops pregnancy from growing
. causes it to separate away from wall of uterus
- 2o
. softens and dilates the cervix
. sensitiises the myometrium to action of prostaglandin so that
it incr likelihood of expulsion when PG is taken ie increases uterine contractil
iy

Misoprostol
- PG of choice for medical abortion
- licensed use in australia to prevent gastic ulceration caused by NSAID
s
- causes uterine contraction, cramps, bleeding
- SE
N/V
diarrhoea
fever, chills
- pharmacokinetics
. rapidly absorbed - orally, vaginal**** (+ less side effects),
sublinguial, buccal
Medical abortion
- indications
. any age
. any number of previous prgnancies
. previous CS
. uterine abn
. very early
. breast feeding (baby may have diarrhoea)
- contra
. greater than 9 wk
. ectopic pregnancy (ineffective for this)
- no intrauterine pregnancy on US
. adrenal failure or long term corticosteroid therapy
. hemorrhageic disorder or anticoagulat
. allergy
. IUD in situ - mustbe removed first
. anaemia
. diarrhoea + ill
- regimens
. 200 mg - Mifepristone PO + Misoprostol 800 mcg (24-48 hrs la
ter) PV up to 63 days ***** MOST COMMON
. 600 mg - Mifepristone PO + Misopristol (36-48 hrs later) 400
mcg PO, up to 49 days gestation
. 600 mg - Mifepristone PO + Gemeprost 1mg PV, up to 63 days
- Mx cramping with NSAIDS
- average light (~end of a period type) bleeding duration 9-12 days
- most pass pregnancy within 4 hours of taking misoprostol
- heaviest bleeding in 3 days after misoprostol
- Warning signs
. heavy - soaking 2 or more pads per hour for more then 2 hours
. rfractory cramping/pain
. sx infection - fever, chills, maaise >6 hrs or occurring > 24
hours after
- F/U ESSENTIAL ~2 wees
. Hx
. US
. urine pregnancy test may still be +ve
. determine in complete
. implanon or IUD/IUS may be inserted
- complications
. continuing pregnancy in 1%
. incomplete requiring surgical intervenion 1%
. excessive bleeding requiring transfusion
. infection - 0.3% low bc no surgical instruments (Clostridium s
ordelli toxic shock ~5 cases ever)
Surgical TOP

- 95% of TOPs are peferomed at less than 14 wks

- suction curettage is most common
- cervical dilation + LA
- cannula up to fundus and gently rotated
- electric suction
- sharp curette
- manual vaccum aspiration MVS
. up to 10 wk
. flexible cannula
. minimal dilation
. no rigid or sharp instruments used
- easier to train
- fewer risks of perforation
. syringe used to generate suction
- MUST INSPECT PRODUCTS OF CONCEPTION
- Antibiotic propylaxis
. chlamydia and bacterial vaginosis
. doxycycline or azithromycin +/- metronidazole
. treat partner as well
Surgical TOP in 2nd trimester
- 5% of TOPS
- > 20 wks is < 1 %
- indications
. fetal abnormality
. social - youth, low SES
. misdiagnosis
- dilation + evacuation
. cervical prepration (to preserve cervix)
- prostaglandin/misoprostol 2-3 hr before; or
- hygroscopic dilation o/night (laminaria or dilapan-S)
Delayed abortion > 20 wks
- fetal abnormality
- induction of labour - most common
- only in victoria - surgical allowed with referral from doctor
Complications of surgical TOP (STOP)
- immediate (hrs)
. Uterine perforation (0.1%) (lateral causing dg to uterine arte
ry; fundus most common **)
. Cervical injury (<1%)
. Haematometra (blood clot accumulation in uterus - large tende
r uterus - requires re-aspriation)
. Haemorrhage
. Atonic uterus
. Anaesthetic complications/ allergic reactions
. Insuffcient products of conception (?ectopic)
. Hydatidiform mole (1:5,000)
- delays (4 weeks)
. retinaed products of conception 1% - either med or surg
- misoprostol for further expulsion
. endometritis / pelvic 0.5%
. continuing pregnancy 0.2% - common in early pregnancy (MUST IN
SPECT THE TISSUE)
. haemorrhage
- late/long term
. cervical stenosis (scarring of opening of cervix - PC of no pe
riod for 3 mo after - but sx of the periods nevertheless eg cramping)
. intra-uterine adhesions

. endometrial hypoplasia
. PTSD - 1/100
STOPs vs later fertility and pregnancy
. uncomplicated STOP does not compromise future fertlity
- must advise them to start contraception straight away
. multiple STOPs incr ris of miscarriage and premature labour
typical/ normal PC after TOP
- bleeding (
. up to 2 wk
. ~7 days usual
- cramping
. bad period < few days
- nausea dissappears fter 24 hr
- breast symptoms can persist for 2 weeeks
- urine pregnancy can still be +ve for 2 weeks
- next menstrual period 4- 6 weeks
Signs of complications
- bleeding >2 days or soaking 2 or more pads per hour for > 2 hrous
- persistent/severe pain rfractory to analgesia
- fever > 38 C orflu like illness
- malodorous vaginal discharge
- persistent pregnancy sx
Post termination chekc Qs and checks
- Bleeding pattern
- Pain
- Fever
- Resolution of pregnancy symptoms
- Emotional well-being
- PV examination is essential
- Check contraception has commenced or planned
In Australia
- medicare coverage + out of pocket expense of $ 400
------------------PWH Adenexal mass
___________________
Adnexial mass: any palpable anb in the pelvis
ddx:
- fallopian tube
. Salpingitis
.TOA
.Hydrosalpinx
.Paraovarian cyst
.Ectopic
.1 or 2 tumour
- uterus
. Intrauterine pregnancy
. Bicornuate uterus
. Cervical fibroid
. Pedunculated fibroid
- bowel
. faeces
. IBD
. appendicitis, abscess

. mucocele appendix
- other
.
.
.
.
.

distended bladder
urachal cyst
abdo wall abscess or haematoma
pelvic kidney
lymphoma

.
.
.
.
.
.

functinoal cysts
endometrioma
cystadenoma
dermoid
fibroma (benign)
malignancies

- ovary

Ovary
- suspended
. infundibular pelvic ligament
- attached to uterus by utero-ovarian ligaments
- larger premenopause
Ovarian cancer
- epithelial (80%)
. serous
. mucinous
. endometrioid
. other
- clear cell
- transitional cell
- germ cell (15%)
. dysgerminoma (most common)
. endodermal sinus tumour
. embyronal carcinoma
. choriocarcinoma
. teratoma
- sex cord stroma (5%)
. granulous cell (most common)
. thecoma
. fibroma
. sertoli cell
. sertoli leydig
Character:
omal
age
side
most common
markers
testosterone
Tx
F/U Mx
rapy

Germ cell

vs

- younger women
- unilateral
- dysgerminoma
- LDH, AFP, b-HCG
- fertility spare sx

sex cord and str

- old + young
- unilateral
- granulosa cell
- E2, FSH, LH, inhibin,
- THBSO

- chemo

THBSO = Total Hysterectomy With Bilateral Salpingo-oophorectomy

NFT = no further therapy
Epithelial ovarian cancer
- 80% ovarian cancer
- 2 dx /day
- 3 die/day
- most common in upper/middle class

- No further the

- incidence and death rate increasing

- 20% are under age 50
- eti 1: ovarian surface epithelium - incessant ovulation - in repairing
of this trauma + genetic predisposition - error in repair
- eti 2: spread from columnar epithelium of distal fallopian tube
- types
. borderline (not really benign but not exactly malignant)
. invasive(most common, classical type of ovarian cancer)
Feature
- age
- side
- stage
- tx
- f/u mx
- prognosis

Borderline
- young
- unilat
- early
- fertility spare
- NFT
- good

Invasive
- old
- bilat
- advanced
- THBSO + debulking
- chemo
- poor

PC
-

GI upset
abd distension
wt loss
satiety and fatigue
palpable mass

Dx
- Hx
- OE
- US + imaging
- NOT LAPAROSCOPY
- assign risk of malignancy to direct mx to either gynecologist or gyne
oncologist
Preoperative evaluation
- age, pre/post menopausal
- parity
- last period
- menopausal status
- fhx
- sx
. pain
. pressure
. distension
. GU/GI sx
. incessant ovulation sx
Epi
-

most
most
RR =
risk

ovarian cancer is in older

begnign is in younger
12 moving from 20-29 to 60-69
malignancy
. premenopause 10%
. postmenopauseal 56%

OE
- abd distension and ascites
- enlarged nodes
- abd or pelvic mass
. fixed
. bilateral
. irregular and not smooth

. nodularity in pouch of douglas

- ddx - endemetrioma, fibroma
Ascites
- EXUDATE
. Malignancy, TB, peritonitis, chylous
. specific gravity <11gIL
. Total protein >30g/L
. Increased LDH
- TRANSUDATE
. CRF, CCF, liver disease, Meig s Synd (begning ovarian fibroid),
IVC obstruction
. Low protein
. Low LDH
. Low LDH
Why laparoscopy should not be part of pre-op workup
- smooth wall doesn't mean begnign
- iregular surface doesn't mean cancer
- size not necessarily indicate malignancy
Tumour markers
- Epithelial (older)
. CA 125
. CEA
. CA 19.9
. HE-4
- germ cell (younger)
. LDH
. AFP
. b-HCG
- sex cord stromal (older)
. E2, FSH, inhibin
. testosterone
CA 125
-

hi Sn, but low Sp

elevated in 80% of non-mucinous ovarian Ca (BUT most Ca is serous)
only elevated in 50% OF STAGE 1 cA
also elevated in benign contexts
. pregnancy
. PID
. endemetriosis
. anything irritating peritoneal cavity
- hi MW glycoprotein antigenic determinant
- recognised by murine MAb = OC 125
- < 33-65 U/mL in health
CA 19.9
- 76% mucinous
- 27% srous carcinoma
- lower Sn and Sp
CEA
- 37% mucinous
HE 4
- elevated in most of carcinomas that make CA 125
- also hi in 50% of Ca that do not make CA 125

- not elevted in benign conditions

- human epididymis protien 4
- expressed in metaplastic mullerian epithelium of cortical inclusions c
ysts
- expressed in ovarian carcinomas
. 93% serous
. 100% endometrioid
. 50% clear cell
. 0% mucinous
- also expressed in lung adenocarcinomas, breast and some pancreaticobil
iary carcinomas
Monitoring ovarian cancer - assigning risk of malignancy
- Ca125, Ca19.9, CEA
- 105 pts with ovarian cancer
- 83% elevated ca125
- 37% elevated cea
- 17% elevated ca19.9
- ca125 correlated better with disease progression/regression
. ie used to track response to treatment
Imagining
- US +/- CT
- cystic, solid, complex (combination)
- benign lesions may also be complex
US
- morphology
. inner wall
. septa
. echogenicity
- size
- excrescence
- ascites
- incr colour flow
- abn resistive indices
International ovarian tumour analysis
- Unilocular ovarian cyst
- Unilocular solid cyst
- Multilocular cyst
- Multilocular solid cyst
- Solid tumour
- Not classified
Transabdominal vs transvaginal sonography
- transvaginal better bc close to ovaries
Colour flow assessment of ovarian and adnexal tumours
- tumor neo-angiogenesis
- lack intimal smooth muscle
- incr tumour flow
CFD spectral waveform
- diastolic flow incr in malignancies compared to diastolic flow
- not a good basis for hi/ low risk
CT scans
- gives poor morphology
- only useful to ix upper abdoment, omental disease

Risk of malignancy index

- algorithm
- (menopausal status M) x (ca 125) x (US morphology score)
- if risk of malignancy score > 200
. Sn 80-87%
. Sp 89-92%
. PPV 75-83%
US scoring for risk of malignancy index
- 1 point each for
. multilocular lesion
. solid areas
. bilateral lesions
. ascites
. intra-abdominal metastates
- U-0 = score 0
- U-1 = score 1
- U-3 = score 2-5
Menopause score
- 1 = premeno
- 3 = postmenopausal or > 12 mo amenorrhoea or > 50yr + hysterectomy
-Pregnancy -Postmenopausal cysts -Dermoids -Aspiration -Tumour Spill -Port si
te recurrence
Masses in
-

pregnancy
1/1000 pregnancies are actually an ovarian tumour
6% risk of malignancy
1:25000 pregnancies have coexisting ovarian cancer
most dermoid, cystadenoma, functional cyst
markers not helpful
MRI
indicatio to intervene if
. risk of torsio
. malignancy
. obstruction in labour

post menopausal ovarian cysts

- unilocular asymptomatic cysts that is < 5 cm
- conservative mx
- can use laparoscopy for active Mx
Rupture of dermoids
- germ cell tumour
- 2 % risk malignancy
- 100% spillage risk in laparoscopy
- 4% spillage risk in laparotomy
- tx complication risk of chemical peritonitis, rupture, further seeded
malignancy
Aspiration (FNA)
- little value alone
- cytology has poor correlation with histology
- better to do definitive surgery
Port site recurrence after laparoscopy
- most common open wound implantantion
- poor prognosis

TUmor rupture intra/intra operative

- causes upstage of FIGO staging
- pre-operative rupture prognosis is poorer then intra-operative
------------------PWH
Antenatal care
___________________
maternal mortality
- bleeding (600 mL/min thru uterine artery)
- infection
- incr BP (stroke)
- VTE (hypercoagulability)
epi: 1/min world wide; millions
indirect causes of death
- cystic fibrosis
- heart disease
. congenital (eg aortic stenosis, transposition)
. acquired - rheumatic fever, IHD (older and fatter)
- obesity
- age
- fortuitous
. trauma
. mva
. domestic violence
- depression/suicide
Biggest killers: cardiac, eclampsia, VTE
Fetus mortality
- congenital
- infection
- prematurity
- placental insufficiency
. abruption
. interuterine growth restriction
Dating the pregnancy
- date of last menstrual period (28 day cycle, 14 days from ovulation ti
ll period)
Fetal ante-natal
- folic acid - neural tube defect (anencephaly is lethal)
- iron deficiency
- medications - lithium, epilepsy
- immunisation - rubella (deafness, heart abn, blindness)
- Calcium
GOlden rule
- condition eg htn, before 20 wk assumed to have had the condition prece
diing pregnancy
Blood tests
- sti blood screen (HIV, Hep B, Hep C, syphilis)
- blood group
- antibodies
- FBC
- iron studies (anaemia)
- BSL, GTT

- US (viability, uterus, dates, congenital abn, chromosomal abn)

Edinburgh psychiatric assessment form
------------------------------PWH - Common postnatal problems
_______________________________
Postnatal check
- psych, depression
- breasts nipples, continence
Puerperium
- involution descent of uterus past umbilicus after pregnancy
- genital tract involution
- secretion of breastmilk
- hormone derangement (human placental lactogen, hcg, estrogen, progeste
rone)
- incr oxytocin (involution of uterus + breast milk) + prolactin (breast
milk)
- menstruation is anovulatory for 1st cycle BUT 25% may have ovulation
- Lochia = blood from vagina after delivery
. rubra - bright red for 5 days
. serosa - pinker/brown
. alba - white discharge at the end (6 weeks)
- involution of uterus
. decr in size but due to pregnant hyperplasia will alays be big
ger then before pregnancy
. decr uterine tone
. ischaemia - uterus muscles retract, blood vessels constsrict,
decr circulating blood volume
. autolysis of redundant actin and myosin mm fibres
. phagocytosis - remove excess fibrous and elastic tissue
- cervix - loses vascularity
- ovaries and fallopian tube return with uterus in pelvic cavity
- vulva/vagina/pelvic floor recover to normal tone due to decr progester
one
-CVS
. decr estrogen => diuresis
. plasma volume decr, haematocrit incr to normal
. decr cardiac output to normal
. decr compression of lungs due to obstruction = decr CO + O2 le
vels return to normal
. RR drops to normal
- renal
. kidneys have to excrete excess fluids and breakdown protein
- alimentary
. SM tone returns to normal with decr progesterone
Education:
- vit K
- SIDS
- immunisation
- breastfeeding
- bathing, massage
- nappy
Self care
-

mastitis
PV blood loss
fundus
DVT

SIDS safe
-

bladder
bowel
wound/ perineum
abdominal rectus
pelvic floor exercises
sleeping
feet at the end
head uncovered to avoid overheating
on back
no clutter in cot

common problems
- PPH (primary & secondary)
- 3, 4 Tear
- Caesarean Section (ileus etc)
- Infection
- HDP (Hypertensive Diseases of Pregnancy)
- Complications from Epidural/Medical complications
- Bladder function (retention, UTI, self catheterisation)
- PND (Postnatal Depression)
- Endometritis
- Rhesus ve
- DVT/ PE
- GDM (Gestational Diabetes)
PC of milk coming in - looks like something wrong
- malaise
- flu like
- low grade temperature
- > 100 bpm
- pale, listless
Primary PPH
- < 24 hr
- > 500 mL
- hard uterus
Secondary PPH
- > 24 hr-6 weeks
- Lochia, dark red, offensive odour, clots, utuerus boggy, tender fundus
Causes of PPH
4Ts
-

Tone 70%
trauma
tissue
thrombin

Parity
Multiple pregnancy
Full bladder
Trauma to uterus, cervix or vaginal wall - during delivery eg

RFs

forceps
- Retained products
- Clotting disorders
acute Mx
- massage uterus to cause a contraction
- Expel clots from the uterus
- Call for help

Airway, Breathing, Circulation

Two large-bore IV cannulars: 14-16 g
FBC, G&H, x-match, co-ags
Fluid replacement and Oxytocics
Oxygen
Empty the bladder
Laboratory: cross match, FBC, coagulation studies
D & C may be required

Mx
- atony - bimanual compresson and massage
- oxytocin agonists
. syntocinon 40 units IV
. ergometrin 250 mcg IM and 250 mcg IV
. PGF2-alpha
. misoprostol
- retained production
. MROP
. DC in OT
- trauma
. repair lacerations, clots, rupture
- reverse coagulopathy
. replace lost factors
Bimanual compression
- right hand at the fundus
- left fist inside vagina
- trying to squeeze the uterus to expel products
Anaemia
- lethary, tachy, SOB, pale, Hb < 90
- tx
. vit C, Fe
. blood transfusion
Perineal wounds (tears, epesiotomies)
- edema and bruising
. ice packs, analgesia
- swelling/pain
. check haemotoma
. excision and drainage
- swab for infection
- f/u in gynae clinic
3rd degree tears are to the anal sphincter but not thru.
4th degree is right thru the anal sphincters
Caesarean
-

wounds
prophylactic abx
a wound that is hot, tender, pyrexia
swab
BCs
IV abx
observe inflamm, discharge, wound breakdown

Pre-eclampsia
- PC
.
.
.
.

BP > 140/90
proteinuria
frontal headache
visual disturbances - sparkles

.
.
.
.
.

hyperreflexia + clonus
cerebral irration
eclamptic fit
oral antihypertensives
FU renal

Mx of eclampsia - eclamptic fit

- call help
- resuscitate
- protect woman from injury
- 2 cannulas 14G and 16G
- MgSO4 and hydralazine
Headache
- due to fatigue, hypertension, post-epidural, dehydration
- tx - caffeine, blood patch (for postural post-epdiural headache)
urinary retention
- tx - idc to rest bladder
. trial of voids
. bladder diary and bladder scanner
. self catheterisaton
. physio, continence, cnc, gynae
Post-natal depression
- 80% get post-natal drop in mood lasting 4 days
- 10% get depression within 3 mo
- RFs
. hx of depression
. support, stress, traumatic delivery
- Sx

. anxiety wrt baby

. cannot cope
. sleep dist
. sadness, inadeq, worthlessness
. loss of appetite
. lowered mood
. guilt, isolation,failure
Edinburg postnatal depression scale
support
. karitane
. tresillian
~2 yr for recovery
tx
. antedepressants
. mental health team

Endometritis
- PC - pyrexia, tender uterus
- tx - abx
- rfs
. prolonged rupture of membranes
. multiple vaginal exams
. lower segment caesarean section
. prolonged labour
Rhesus negative
- mother will get anti-D if baby is rhesus factor positive

DVT and PE
- pregnancy is hypercoagulative
- RFs
. advanced maternal age
. obesity
. decr movemet
. clotting disorder
. prev hx DVT/PE
- calf pain, swelling, SOB
- TEDS, heparin
Gestational diabetes
- day 3 post delivery
. fasting BSL then 2 hr post breakfast, lung and dinner
. BSL < 6 mmol
. after meals < 7
- F/U in clinic
-------------------------------------------PWH - SUDI Sudden and unexpected death of infants
____________________________________________
1. Understand current epidemiology of SIDS and SUDI
2. Identify at risk families for SUDI
3. Implement prevention messages at first encounter with the new baby (verbal),
via osters and handouts in the surgery/clinics/wards, SID and KIDS web sites
4. Undertake a multidisciplinary approach to management of the death and the fam
ily
SUDI = An infant under 1 yr who dies suddenly and unexpectedly.
SUDI is a descriptor including SIDS, deaths with explicable causes, and non-acci
dental
SIDS
-

sudden death of an infant

under one year
during apparent sleep
unexplained even after
. review of clinical case history
. examination of the death scene
. autopsy

Epi
- NSW - sids = 44/2007, non=sids - 22/2007
- most common cause amongst NON-sids = infection
- Australia ~0.25/1000 (plateaued)
Classes equivocal

probably unecessary differentiation

1A - Classic features of SIDS present
1B - Classic features of SIDS present
2 - Meets category I SIDS but differs
unclassified - Do not meet Category I
(includes deaths with no Post mortem)

Feature
Peak
hx ill
smoking
Risk groups

SIDS
2-4 mo
no
yes +++

non-SIDS
< 1 mo
yes
some

and completely documented

but incompletely documented
eg age range, other sib deaths
or II but alternative diagnoses

aboriginal (RR 6.5)

low SES (RR 2) (maternal education)
remoteness (RR 2)
any baby admitted to neonatal nursery
unsafe sleeping environments (90%)
co-sleeping

What is the main factor that has caused the drop in death rate ?
- putting them on the back
- sufficient evidence for Hill's criterion for causation
- being prone is causative
Why is side position not recommended ? - they roll prone.
2997-8:
85% NSW infants sleep on back
94% children in smoke free households
12% mothers smoke in pregnancy
What are the messages for prevention? - for 6 months
- back sleep (never tummy or side)
- face uncovered
- avoid cigarette smoke exposure
- no co-sleeping = shares same room (until 6 mo) not same bed + safe cot
, mattress, bedding
Obstacles to sleepng position
- concern about choking
. no incr in aspiration deaths since incr in supine sleeping sta
rted
. no reflux problems associated
. in hon kong where back sleeping is normal, SIDS is non existen
t
. back sleeping is protective
- laryngeal chemo reflex - receptors
- fluid build up is refleively swallowed
- swallowing reflex is more active in supine position vs
prone
- sedating drugs (antihistamines/phenergan) make this wo
rse
. anatomically
- prone - fluid won't enter into the laryngeal swallow r
eflex nerve centers
- flat heads
. transiet phenomena that rounds out
Is bed sharing safe ?
- Not if
. mother smokes
. caretaker shares a sofa
. parent under influence of alcohol or sedated
. sleeping environment is unsafe (clutter)
. infact < 12-16 wks
-----------------------------PWH - Postnatal mood disorders
______________________________
Disorder
blues
um pscyhosis
postnatal depression

postpart

(psych emergency)
prevalence
0.1%
when it occurs after birth
3 mo (40% starts during pregnancy)

70%
15%
10 d

3 wk

Sx
del

anx
mj dep
dep

hall

anx
teary

manic
mood swing
melancholic
irritable
indecisive
elation
disorg
fatigue
confusion
benign

Course
grad onset, chronic
transient

severe/hospitalise

good remission w tx
eti
bio/gen/estrogen
y

hormonal
poor r/ship, support, dysfun, personalit
stress resp

Post natal depression

- mj depression w/in 6 mo post partum
- 15% women
- RFs
. mj
- antenatal depression or anxiety
- prev Hx depression
- low income
. other
- premenstrual dysphoria
- life stress
- lack support (no father)
- marital conflict
- immigrant
- young maternal age
Suicide
- rates lower in postpartum period
- RR=3 if foetal/infant death in 1st post partum year
Post partum psychosis
- recurrence risk 70% (RR = 500)
- onset - first 4 weeks
- epi - 1/500
Effect of
-

maternal depression on reproductive outcomes

incr misscarriage rates
growth effect
pre term delivery

- neonatal - less activety, irritable, fewer facial epressio

Mx
- do not cease antidepressants during pregnancy (recurrence RR = 6 if an
tidepressants are ceased)
- effects of medications on developing foetus and pregnancy
- medications - risk of malformations, withdrawal at birth, breast feedi
ng
- avoid sleep deprivation
- mobilise family assistance
Screening
- screening for early detection and intervention
- screen for partner as well if they are distant or have signs
Tx
- psychotherpay
. individual
. grou
. cbt
. psychodynamic
- antidepressants
. SSRIs
. TCA
Antedepressants risks in pregnancy
- summary = major ones to warn of are
.neonatal neurobehavioural syndrome
.persistent pulmonary hypertension of newborth
- 13% of women take then during pregnancy
- paroxetine (cardiac defects)
- no significant risk of misscarriage slight ie. increase 12.4% (vs 8.7%
. no difference with classes of antedepressants
- reduction in brith weight with SSRIs
- structural malformations
. not with TCAs
. no incr cardiac malformation (? paroxetine - but not replicate
d in larger studies)
. heart defects in SSRIs + benzos
- neonatal neurobehavioural syndrome
. baby irritable, difficult to settle, tachypnoea, hypoglycemia,
temperature, crying, seizures
. assoc with TCAs and SSRIs
. 30% women who took SSRIs
. BUT - they resolve after < 2 wks
- persistent pulmonary hypertension of newborth
. severe respiratory distress
. 2/1000
. 10 % mortality
. exposure to SSRIs > 20 wk
- no long term effects with SSRIs or TCAs
Bipolar and schizophrenia
- incr risk of
. antepartum hemorrhage
. prematurity
. low birth weight
. intrauterine growth retardation
Mood stabilisers

- all mood stabilisers (valporate, carbamazepine, lamotrigine, Lithium a

re teratogenic)
- problem since 50% pregnancies are unplanned
- monitor
. fetal scans
. nuchal translucency
. bloot tests
. GTT
. serum drug levels
- if they present already pregnant then put them on atypical anti-psycho
tics in stead + put her on monitoring
Valproate
- malformations during intrauterine growth/pregnancy = 9%
. incr risk with dose > 1 g/d
. neural tube defects, cardiac, facial, urogenital
- withdrawal syndrome
- hepatic toxicity
- hypoglycaemia
- neurocognitive development
- breastfeeding - dose ie 0.68% of mothers dose
Lithium
- malformations
. Ebstein s anomaly = displaced tricuspid valve allowing blood ba
ck into right atrium
.RR = 10-20
.other heart defects baseline 8: 1000 cf 7.7 fold increase Li ex
posed
.trimester 2&3 diabetes insipidus, polyhydramnios, thryoid dysfu
nction and floppy baby syndrome
- if they come pregnant and are on it
. cease 24-48 hr prior to delivery
. monitor li level at deliver
- hydrate
. avoid nephrotoxins
. avoid breastfeeding
. resume at pre-pregnancy dose after birth
- neonatal problems
. floppy baby syndrome
.cardiac dysfunction
.diabetes insipidus
.hypothyroidism
.low muscle tone
.lethargy
.hepatic abnormalities
.respiratory difficulties
- breastfeeding
. not reccomended
. 50% maternal level
. renal toxicity to baby
Lamotrigine
- malformation = 2.7%
- hepatic toxicity
- breastfeeding dossage to baby = 22.7%
Carbamazepine
- malformation = 3%
- hepatic toxicity to neonate

- breastfeeding - 4.4%
Antipschotics
- atypicals - quitapine and alanzopine
. alanzopine has risk of gestational diabetes and macrosomia
- typicals
. transiet extra-pyramidal SE
. sedation
. withdrawal
- breastfeeding
.< 3% maternal dose
. sedation results in poor feeding and low weight gain
Case 1
-

psychotic
16 wk pregnant
venlafaxine + queitapine
mx
. discuss hi risk of recurrence if she stops anti-psychotics
. involve family (husband)
. sleep structuring - husband did night feeding
. express milk before taking the anti-psychotics
. involve psychiatrist and community mental health team
. admit if recalcitrant

Case 2
- 9 d post partum
- 1st presentation of incr disorganised and odd behaviour
- mx
. admission
--------------------PWH - Uro-gynaecology
_____________________
pelvic floor dysfunction
- Lwr urinary tract dysfunction
- uterovaginal prolapse
- rectal prolapse/incontinence
Incontinence
- epi - 30% in community, 1 million women in Australia
- sx
. freq (>6 per day), urgency (gr impact on QoL), nocturia (>1/ni
ght), infection, irritation
. impact QoL
. assoc meds - diuretics, ACE-I (causes cough and raised intraab
odominal pressure), minipres (reduces urethral tension)
. prev srugx
. assoc bowel problems
- eti
. urodynamic stress incontience (stress incontinence due to phys
ical/anatomical)
. overactive bladder (detrusor overactivity) - assoc with freq,
urgency, nocturia
. overflow incontinence (overdistension overcomes urethral/sphin
cter resistance)
. urinary tract fistulae (complications of gynae surgx; obstruct
ed labour)
. congenital causes eg ectopic ureter
. temporary causes eg UTI
- oe
. prolapse

.
.
.
.

urogenital atrophy (local/focal estrogens can be used to tx)

pelvic mass
local excoriation (~nappy rash, use barrier creams)
neurological disease (stroke, TIA, multiple sclerosis)

- Ix
.
.
.
.

MSU (UTI)
bladder diary
US scan for post void residual volume
urodynamic studies (main ones are uroflowmetry and cystometry)
- uroflowmetry - measuring flow parameters/voiding
- subtracted cystometry (bladder pressures measured duri
ng filling and voiding) - imaging (xray, US)
- urethral pressure studies
- urethroscopy, EMG
Cystometry
- measures pressure/volume r.ship of bladder
- bladder is catheterised - filling with variable fluids
- pressure transducers in bladder and rectum
- detrusor P = bladder P - rectal P
- unstable contraction is when there is a change in bladder pressure wit
hout a change in rectal pressure
Indications for urodynamics eg cystometry
- refractory to 1st line Mx
- before surgx
- when pain is one of the sx
Urodynamic stress incontience
- commonest cause of female incontience
- epi - 15% WOMEN, after childbirth
- Mx is conservative or sx if severe
- conservative
. pelvic floor physiotherapy (exercises, keigel)
. tampon inserted during exercise
. local estrogens
. cough prevention (reducing intraabdominal pressure)
. treat constipation
. wt Mx
. vaginal cones (weights inserted for 15 min twice per day - hav
e to contract to keep them in = exercise)
- Sx (gold standard = is mid urethral tapes/slings)
. Suprapubic procedures - Burch, MMK, Lap Colposuspension . Pubovaginal Slings
. Mid urethral tapes eg TVT
. Endoscopic BN Suspension eg Stamey
. Anterior Colporrhaphy
. Paravagjnal repair
. Peri-urethral bulking agents eg Collagen
. Artificial Sphincter
Burch colpo-suspension
- bladder rests on vagina - if you lift up the vagina, you can support t
he bladder neck
- paravaginal tissue sutured to ileopectineal ligament
- 3 sutures of no 1 ethibond each side
- initial suture at level of bladder neck
- subsequent sutures placed proximally

Laparoscopic colpo-suspension
- shorter hospitalisation and recovery
- BUT higher rate of bladder injury and poorer longterm results
TVT sling
-

procedure
tension free vaginal tape
polypropylene
placed under mid-urethra
behind pubic symphysis

Trans-obturator approach for TVT

- thru the obturator foramen
- avoids going into the peritoneal cavity
- safer, less risk of bladder trauma, bleeding, bowel perforation
Overactive bladder
- functional problem rather then anatomical problem
- Dx by symptoms rather then ix
- LUT sx - freq, urgency, nocturia, urge incontience
- eti - detrusor instability (bladder contracting inappropriately)
- prevalence incr with age
- aim is control rather tehn cure - requires bladder training
Motor innv of bladder
- PANs cholinergic (Ach)
- pre-ganglionic PANs fibres - S2,3,4 - pelvic splanchnic nerves
- Acetycholine (+) -> M(+) = bladder contraction
- other neutrotransmitters in bladder
. ATP, serotonin, DA, GABA, PGs, VIP
Anti-muscarinic to reduce detrusor contractility
- propantheline, darifenacin
- reduce unstable contractions and incr functional capacity
- target M2 and M3 receptors
- Anti-cholinergic SE = oppostive dumbbells = dry mouth, blurred vision,
constipation
Overactive bladder meds
- ditropan (oxybutynin) 2.5 -5 mg tds
- detrusitol (tolterodine ) 2 md BD
- probanthine (propantheline) 15-30 mg tds
- tofranil (imipramine = TCA) 25-50 mg nocte
- Best to combine anticholinergics with bladder trainng
New tx
- solifenacin (vesicare) 5-10 mg/d
- oxytrol (oxybutynin) patches 2/week - lower SE then oral
- intravesical botox inj
Reduction of urine production
- DD-AVP
. synthetic vasopressin (peptide hormone)
. trying to decr volume of bladder produced
. as nasal spray, oral tablet
. incr permeability in distal convoluted tubules = decr urine pr
oductio
. good for nocturia or noctural enuresis
. ie taken at night
Botox

. indic for OAB

. intravesical (bladder) inj of 100-300 units
. risk of need for self cathetirisation
Uterovaginal prolapse
- Types
. cystocele = prolapse of anterior vaginal wall - most common ty
pe
. uterine prolapse
. rectocele = bulging of rectum against posterior vaginal wall
. enterocele = bulging of intestine thru pouch of douglas agains
t posterior wall of vagina
- epi - by ~45 yr, ~95% will have some prolapse, 50% will have stage 2 o
r above
- impacts QoL
- eti
. childbirth - strong risk factor
. CT factors
. menopause
. chronic elevation of intra-abdominal pressure (constipation, l
ifting, chronic cough)
. iatrogenic
- VAGINAL child birth eti
. avulsion of puborectalis mm (levator ani) from the insertion p
oint on the bone during childbirth
. 20% of 1st deliveries
. incr risk
- forceps
- maternal age (RR=3 from 20yr to 40 yr)
. 70% risk of recurrence
. pudendal nerve denervation
. stretching of the nerves during vaginal birth
. 60% are reversible
. RF - forceps, multiple births, 3rd degree tear, macros
omia
- CT factors
. RF - FHx (OR = 3)
. depends on type of predominant collagen
- Menopause
. pelvic CT has estrogen receptors
. low estrogen after menopause => CT deterioration/weaken
. tx - estrogen therapy (local is sufficient)
- support levels and resultant prolapse types
. level 1 support = Cx / upper vagina - uterosacral lig and card
inal lig -> prolapse of uterus
. level 2 = vagina - pubocervical fascia and recto-cervical fas
cia -> cystocele or rectocele
. level 3 = perineal body
- vaginal axis angle
. horizontal in nulliparous women = protecting against prolapse
. more vertical axis predisposes to prolapse
- Conservative Mx
. avoid constipation and heavy lifting (intra-abdominal pressure
s)
. pelvic floor exercises
. local estrogens (peri, post menopausal)
. ring pessaries (fits behind cervix behind symphysis pubis)
. assoc urinary or bowel sx
- oe - Sims speculum, left lateral position

Cystocele - most common type of prolapse

- Surgx Mx . indications
- conservative not working
- sx
. heavy, dragging feeling, backache
. lump at vaginal opening
. abdominal approach
- colpo-suspension
- para-vaginal repair
. vaginal
. anterior col-porrphaphy
. anterior colporrhaphy with mesh
. paravaginal repair
Pelvic reconstructive surgx
- reposition pelvic struct to anatomical rship
- restore/maintain urinary/fecal continence
- maintain coital fn
- correct pathology
- indications for using grafts and mesh
. large defect
. poor tissues
. chrinic raise I/A pressure
. steroid therapy
- SURGICAL MESH PORE SIZE IS KEY FACTOR that determines
. inflamm response
. tissue ingrowth
. mesh stiffness
. needs to be large poor to allow infiltration by macrophages (
nb < 10 micron preventing access by macrophages)
. 50-200 micron optical pore size
- Mesh complications
. erosion
. rejections
. sinus tract formation
. removal
. pain with intercourse
--------------PWH - CTG lntro
_______________
CTG = cardiotocograph = measures fetal heart rate
Factors affecting maternal transport to placenta
- Maternal hypotension
. Supine position
. Epidural anesthesia
. Blood loss
- Maternal hypertension
. Decreased uterine flow due to peripheral vasoconstnction
- Uterine activity
. Due to spiral arterial occlusion
. Particularly where uterine activity is excessive
. inadequate resting tone
Factors affective
- Reduced
.
.
.

diffusion across the placenta

placental surface area
Small placenta
Placental abruption
Placental infarction

- Reduced
.
.
- Altered
.
- Uterine

O2 availabitiliy
Maternal hypoxia
Maternal hypotension
fetal O2 affnity
Fetal metabolic acidosis
activity/contraction

Factors affecting fetal transport to and from the placenta

- excessive uterine activity
- cord - entrapment or knotting
- fetal - anaemia, structural cardiac abn, arrhythimia, blood loss
Control of fetal heart
- SA node (pacemaker)
- ANS
- epi, norepi
- chemoreceptors
- baroreceptors
- cardio regulatory center of medulla oblongata (brainstem)
SA node
- 1st pacemaker, in RA, highest intrinsic rate, PANS + SANS
- intrinsic rate decr after 28 wks due to incr PANs maturation of foetus
(ACh)
ANS
- stimulatory (incr HR) SANs matures earlier then PANs
- via epi/norepi
- PANS reduces HR via ACh on SA node
Catecholamines (Epi, NorEpi)
- incr fetal
. HR,
. CO,
. vasoconstriction
. BP
Chemoreceptors (blood chemical change receptors)
- carotid artery, arch of aorta, brainstem
- sensitive to falling O2 levels and rising CO2 levels
- triggers SANs (incr fetal HR, O2 delivery, decr CTG variability)
- triggers PANS (decr fetal HR, reduced CO2 production)
Barcoreceptors (blood pressure change receptors)
- aortic arch, carotid artery, brainstem
- incr BP = reflex vagus N (+) = ACh release = SA node (+) = decr in BP
= fall in pressure = stimulate CRC to release catecholamine = correction of BP a
gain
Cardio regulatory center
- in medulla oblongata (brain stem)
- integrates inputs, ANS, chemoR, baroR,
Fetal response to hypoxia
- responses
. redistribution of cardiac output, or
. reduction in O2 consumption
- redistribution of cardiac output
. Incr SANs
. Incr

- HR/tachy
- CO
- peripheral resistance
- BP
- blood flow to vital organs
- O2 delivery to those vital organs
- reduction in O2 consumption
. MOA - cessation of all movement not necessary for survival (in
cl breathing mvment)
. reduces input/feedback to CRC (cardioregulatory cenre)
Fetal monitoring
- intermittent auscultation
- continuous electronic fetal monitoring (cardiac tocograph)
- fetal O2 saturation probe
- fetal ECG ST segment analysis
- US
Intermittent auscultation
- doppler on speaker mode
- No RFs
. every 30 min in active phase of 1st stage
. every 5 min in 2nd stage
. during active contractions and 30sec after
EFM electronic fetal movements monitoring
- indications
. Decreased movement
. Hypertension
. APH
. PG gel
. Clinical IUGR
. Diabetes
. PROM (premature rupture of membranes)
. TPL
. Abdominal trauma/MVA
. Prolonged pregnancy
. Medical conditions
. Spurious labour
. RH isoimmunization
Antenatal
-

RFs indicating intra partum CTG (during labour)

Abnormal doppler flow
APH
Abnormal antenatal CTG
Suspected IUGR
Oligohydramnio
Prolonged prengnancy > 42wk
Multiple pregnancy
Breech
Prolong ROM > 24h
Known fetal abnormality
Prior uterine scar
Pre eclampsia
DM on insulin

Intrapartum RFs indicating CTG

- IOL/Oxytocin augmentation
- Abnormal admission CTG
- Epidural

Excessive bleeding
Maternal pyrexia
Meconium/blood stained liquor
Oligohydramnio at amniotomy
1st stage > 12h
2nd stage > 1hr
Abnormal auscultation

Components of normal CTG

- baseline fetal n = HR 110-160
. at rest in absence of fetal movement, uterine activity
- variability n = 5-25 (beat to beat variation- from the baseline)
. indications of inadequate CNS oxygenation
. PANs vs SANs competition balance
- acceleration
. fetal response to stimulation
. incr in heart rate of at least 15 beats above the baseline las
ting for at least 15 seconds
. 2 accelerations within a 20 min period is considered reactive
. rise in fetal heart rate
. amplitude (from baseline to rise of peak)
. duration
abn ctg pattern ie
. decr variability
. tachy
. brady
. early deceleration
decr variability
. CNS depression due to
- deep fetal sleep
- narcotics
- hypoxia
- congenital anomalies
- prematurity
Tachycardia
- maternal tachy
- maternal fever
- drugs - slabutamol, atropine
- dehydration
- hypoxia
- fetal tachyarrhythmia
- infection
- high inherent rate (premature)
Bradycardia
- low inherent rate
- drugs (LA)
- maternal hypotension
- fetal heart conduction defects
- prolonged umbilical cord compression
- hypoxia
- maternal hypothermia
Early deceleration
- eti
. head compression (benign) -> vagus N stimulation
- assoc with uterine contractions

Variable deceleration
- eti
. cord compression (mostly benign)
- indications of hypoxia
. Rising baseline or baseline tachycardia
. Reduced baseline variability
. Presence of a smooth post deceleration oversho
ot
. Persistent large amplitude or long duration of
deceleration
. Siow return to the baseline after the contract
ion
. Loss of pre/postdeceleration shouldering
Prolonged deceleration
- lasting 1min to 1.5 min
- caused by hypoxia
. prolonged contr
. epidural
. excessive uterine activity
. supine hypotension
. ruptured uterus
. abruption
. VE
Late deceleration
- caused by contraction + hypoxia
- eti - reflex or myocardial
. contraction onset
. Decrease in lntravillous space blood flow
. Insufficient O2 transfer to fetus
. Fetal 02 levels begin to fall
. The 02 reaches a level low enough to result in myocardial depr
ession
. Deceleration of FHR after the onset of the contraction
. Uterine contraction begins to subside
. Intervlllous space blood flow improves then fetal 02 levels be
gin rise
. FHR returns to the baseline after the contraction has finished
Sinusoidal pattern
- oscillating pattern resembling a sine wave
- absent baseline variability or acceleration
- relatively fixed period 2-5 cycles/min
- amplitude of 5-15 bpm
- indicates severe fetal anemia
- termal pattern
DR C BRAVADO
- DR - detect risk
- C - contraction
- BRa - baseline rate
- V -variability
- A - accereraton
- D - deceleration
- O - overall assessment
Tx Brady in DS

CHICON
-

CH - change position
I - IV
C - cease synto
O - observations
N - notify

Case 1 - Sandie
- 34F multi-P, 40wk, spont labour
- no RFs
- for 3 hr FHR auscultated and normal
- suddently FHR at 170 bpm
- normal fetal HR = 110-160
Case 2 - Amy
- 21F, primi-P, 39 wk
- hx ruptured membranes for 3 d
- GBS negative
- irregular uterine activity
- Cx closed
- FHR abn
- T 36C
- IV abx
- induced w syntocinon then incr bc Cx remains closed
- finally dilates and syntocinon stopped
Case 3 - Kate
- 28F Primi-P, 41 wk
- 5hr contractions, then membrane rupture
- FHR auscultation 140 bpm following each contraction
Case 4 - beth
- 31F, multi-P, 44 wk, cephalic
- no RF
Case 5 - Rhania
- 39F, multi-P, 43 wk
- 3hr regular contractons
- prev births ok
- 30 min ruptures membranes draining meconium stianed liquor
Case 6 - Mia
- Primi-P, 43 wk, draining moderate meconium liquor
- 2cm dilated
- regular contractions
- syntocinon started
Case 7 - Jacqueline
- 36F, primi-P, 44 wk
- IOL gestational hypertension
- draining clear liquor
- BP 130/82, HR 86, 36.7C
- 6hr labour
- 6cm Cx dilated, 75% effaced,
---------------------------PWH - Obstetrics anaesthesia
____________________________
content
Epidurals
Caesarean Section anaesthesia
Labour analgesia

Spinals, Combined Spinal-Epidurals

Hx to know, Q to ask
- parity
- Cx dilatation
- risk
- age, PMHx, allergies, Meds, anaesthetic hx
Analgesic options?
dose COmplimentary analgesia (hypnosis) etc work
- acupuncture, hypnosis, water therapy
Pharm labour analgesia
- paracetamol, entonox
- parenteral opiates
. pethidine IM
. Remifentanil PCA
Entonox
-

50% NO, 50% O2

peak effect = 10 breaths
effective + safe
SE - drowsy, light headed, nausea

Epidural
- equipment
. tuohy needle (blunt tip needle to allow catheter to move thru
it - gives lots of textural feedback about where you are in the back)
. LOR syringe
. catheter
- site
. L3/4 @ iliac crests (below L2 end of conus medullaris), midway
bw lower sacral, thoracolumbar nerves
. layers
- skin
- subcut fat
- supra-spinous ligament
- intraspinous ligament
- ligamentum flavum
- not peircing dura/arachnoid
- which anaesthetic, how much, how often ?
. lo conc (minimise motor block)
. long acting
- bupivacine
- ropivacaine
. adjuvant
- fentanyl
. 20 mL initial bolus
. takes 20 min
. PRN bolus +/- constant infusion
- complications
. Common
Accidental durai puncture with PDPH 1:200
Hypotension - Nausea and vomiting
Shivering
- Failure 1/20
. Rare but serious
- Neurological injury 1:10.000 (permanent 1:237,000)
Epidural abscess 1:145,000
Epidural haemaioma 1:168.000
Local anaesthetic toxicity (accidental IV administration

)
.
.
- contras
.
.
.

bloody tap
puncture headache
thrombocytopenia
infection local or systemic
severe aortic stenosis

Urgency indicators
- fetal well being markers
- maternal factors
- epidural already
- age. pmhx, allergies, medications, anaesthetic hx
Regional anaesthetisa for LSCS
- spinal = subarachnoid inj (~small amount = 3 mL drug)
- combined spinal/epidural = epidural + subarachnoid (use the same needl
e to deliver both) - the epidural is back up - aim for block up to T4
- epidural
- difference spinal vs epidural ?
General anaesthetic for LSCS lower segment caesarean section
- complications of greater risk in CS then usual
. hypotension (due to aortocaval compression bc fetal weight upo
n IVC - solved by using lateral tilt)
. intubation diff
. aspiration
. rapid desaturation
. awareness
. neonatal respiratory depression
. uterine atony
- supine hypotension
. weight of baby when supine cause aortic/caval compression
. mostly after 2- wks
. prevent by left lateral tilit positioning with wedge
- intubation failure 1/300
. swollen airways, large breasts, pressure of the situation
. intubation drill
- aspiration after 1st trimester
. failed intubation
. reduced lwr esophageal sphincter tone
. incr intra-abd pressure
. mx
- antacid premedication
- rapid sequence induction
- cricoid pressure
- desaturation (decr O2 stores, FRC residual after breath, only store of
O2 in body, decr bc baby bearing on the diaphragm + incr consumption of O2)
. failed intubation
. mx
- rapid sequence induction
- pre-oxygenation
- awareness
. rapid sequence induction
. difficult intubation
. light anaesthesia
. hypovolemia - limited dosage can be used
. Mx
- adequate dose
- monitor anaesthesia depth

- neonatal depression
. volatile anaesthetic agents
. narcotics
. when there is indication for GA LSCS
. Mx
- minimise dose of volatile anaesthestis
- use NO instead
- avoid short acting narcotics
- neonatal resusc by neonatal team
- uterine atony/laxaty[[
. due to volatile agents or RFs
. Mx
- minimise volatiles
- use NO
- massage uterus
- tonic agents
. oxytocin
. ergometrine IM
. PG-F2A IM or intramyometrial
- resusc
-----------------------PWH - Cervical dysplasia
________________________
Colposcopy
- detect and tx dysplasia and cervical ca
Cervical dysplasia is not cancer
- not fatal
- BUT morbidity can result
- do not treat early, aggressively
spectrum of abn Smears
- low grade smear
- low gr SIL = HPV, CIN 1
- glandular abn = AGUS, ASCIS
- suspcious invasive carcinoma
- histo
. LGSIL - N/C ratio
. HGSIL
. CIN 1 - pattern of regular maturation; confined to 1/3 thickne
ss of epithelium
. CIN 3 - lost pattern of maturation; full thickness; NOT cancer
bc hasn't invaded basement membrane
Descriptions
- metaplasia = reversible change from cellular types eg squamous metapla
sia
- dysplasia = abn growth or differentiation of tissue that bears no rese
mblance to original tissue - > LOOK IN THE TRANSFORMATION ZONE
- transformation zone = area bw old and new squamocolumnar junction (end
ocerix = columnar, ectoCx = squamous;) - both columnar and squamous epithelium,
and the columnar is underoing metaplasia into squamous via exposure to vaginal f
luids/environment
Colposcopy
- indicated after abn smear
- microscope exam of Cx to take a biopsy
- colposcopy (labour intensive, invasive, uncomfortable)
. external device - just a magnifying device
- histo
- procedure - MUST KNOW THIS FOR OSCE
. hx

. oe vulva, vagina
. speculum
. saline, smear, identify trans zone
. vasc pattern
. dilute acetic acid wash (call it 'dilute vinegary solution')
. lugols iodine
. biopsy/haemostasis
- guidelines for indications for colposcopy
. 2 LGSIL smears in 12 mo
. any HGSIL
. any glandular abn on smear
. invasive carcinoma
. abn appearing cx
. persistenct post-coital bleeding
MUST KNOW THIS
- dysplastic cells express cytokeratin which precipitate forming white o
paque layer when exposed to acetic acid
- Mature normal squamous cells contain glycogen and take up lugols iodin
e when stained.
- Dysplastic cells are multilayered, hyperkeratotiC, and have abnormal v
asculature
-----------------------------------PWH - Common gynaecological problems
____________________________________
Heavy menstrual bleeding
IMB & postcoital bleeding
Ectopic pregnancy
Polycystic ovarian Syndrome
Heavy bleeding
- > 80 mL/cycle (n = 35mL)
. more often then 1 per 3hr - during peak flow
. > 21 pads/tampons / cycle
. need to change over night
. large clots > 2.5 cm diameter
. anaemia sx
- Sx
. intermenstrual bleeding
. post-coital bleeding
. pelvic pain (miscarriage, ectopic, neoplasia, endometriosis)
. pressure sx (fibroids) - urinary freq, nocturia, constipation
- eti
. Dysfunctional (dx of exclusion - imbalance bw prostacyclins an
d prostaglandins) - Ovulatory or non ovulatory
. Uterine - Fibroids, polyps, Adenomyosis (lining of uterus ie t
he endometrium deposits on the myometrium), DUB
. system - Thyroid, coagulation abnormalities
. Iatrogenic - Cu IUD, drugs
. Cancer
- epi - 10%
- Ix
. FBC
. coags (VWF)
. TFT
. DO NOT do FEMALE HORMONE TESTING
. US
- uterus is palpable abdominal
- vaginal examination reveals a pelvic mass
- pharmacetuical tx fails

- before IUD insertion

. Endometrial biopsy
- if > 40 yr
- persistent intermenstrual bleeding
- if risk of endometrial hyperplasia
. obesity
. unopposed estrogen
. PCOS (oligoamenorrhoea)
- Gynae referal < 40 yr
. if intermenstrual or post-coital bleeding
. risk of endometrial hyperplasia
- Mx if no structural or histo abn suspected
. 1st line = Mirena (levonorgestrol) - reduces blood loss by 90%
. 2nd line = transexamic acid, NSAIDS, OCP
. transexamic - is antifibrinolytic = stops clotting
. 3rd line = norethisterone 15 mcg /d (progesterone); for 1 mo,
or depo-provera
- Surgx
.endometrial ablation/burning - scars endometrial surface so tha
t there is no hormone response (resection, rollerball, laser, hot water) in 90%
amenorrhoea or an acceptable reduction in blood loss
. submucous fibroids - hysteroscopic resection
. myomectomy
. hysterectomy
Endometrial ablation/burning
- used if women do not want to conceive
- suitable normal uterus or fibroid < 3 cm
- ballon, thermal ablaton, microwave
Hysterectomy, myomectomy
- Fibroids>3cm (intramural, submucous, subserous, intracavity, peduncula
ted)
. heavy bleeding where the fibroids increase uterin area eg subm
ucous)
- Myomectomy or hysterectomy for Uterine artery embolisation (UAE)
- Unknown- long term impact of myomectomy and UAE on fertility, ovarian
function, recurrence
- hysterecomy vs embolisation complications 14% vs 4%
- surgx (18%) vs embolisation (11%) complication of ovarian failure
.
Fibroid ablation with ultrasound
- MRI guided - prone position
- heats fibroids up to 55C causing decrosis
Intermenstrual bleeding
- common RF - hormonal contraception, hormonal therapies, chlamydia inf,
cancer
- indications for referral
. risk of sti
- oe
. abd
. speculum
. cx / cervicitis
. poly/laceration
. discharge
. foreign bodies
- ix
. pap smear

. transvaginal US
. referral to gynae
. sti screen
Post coital bleeding
- recurring PCB = hallmark of cervical cancer = referral for colposcopy
+ essential follow up
- single episode BUT normal smear and normal Cx = no referral
Ectopics
- most common = tubal, caesarean scar
- difficult to manage - cervical, interstitial
PCOS
- most common endocrinopathy in women
- 10% women of reporductive age
- sx
. irregular menstruation
. acne
. hirsuitism
. US changes
. infertility
. obesity
- Dx = at least 2 of [ROTTERDAM CRITERION]
. oligo/anovulation
. hyperandrogenism (clinical or biochemical)
- hirsutism
- voice deepening
- male pattern balding
- ddx - congential adrenal hyperplasia, hyperthyroidism,
andreogen secreting tumour
- irregular periods
- metabolic sndrome
. polycsystic ovaries on US
- oe
. BP
. BMI
. waist circs (body fat)
. stigmata hyperandrogenism, insulin resistance
. acne, hirsutism, andorgenic alopecia, acanthosis nigricans
- hyperandorgenemia
. incr free + total testosterone
. sex hormone binding globulin
. metabolic abn
- 2 hr GTT (insulin resistance)
- fasting lipid, lipoprotein levels, total cholesterole
. exclusion of
- tsh
- prolactin
- 17-hydroxy-progesterone (adrenal hyperplasia due to 21
-hydroxylase def = no cortisol, no aldosterone end points BUT over production of
adrenal androgens)
- cushing syndrome
. emotional dist
. enlarged sella turcica
. moon fascies
. osteoporosis
. cardiac hypertrophy + hypertension
. buffalo hump

.
.
.
.
.
.
.
.

obesity
adrenal tumor or hyperplasia
thin, wrinkles skin
abdominal striae
amenorrhea
muscle weakness
purpura
skin ulcers (poor wound healing)

- US changes
. ring of pearls
. volume of ovary > 10 mL
. more then 10 follicles around periphery of ovary.
- implications
. infertility (use cloniphene)
. metabolic syndrome
- developing T2DM RR = 10
- incr risk of impaired flucose tolerance IGT
. endometrial carcinoma
- med Mx
. aims
- menstrual irregularity
- infertility
- hirsuitism, acne
. OCP with anti-androgen cyproterone acetate
. metformin to reduce fasting insulin levels, testosterone, LDL,
cholesterol
. clomiphene for ovulation induction - to get pregnant
. weight loss/ dietary mx
Polycystic ovaries - why ?
- dysfunction of hypothalamic pituitary axis with incr LH which stimulat
es ovarian androgen production
- metabolic due to insulin resistance (reduced glucose response to insul
in) and compensatory hyperinsulinemia
Ectopic surgx Mx
- salpingostomy (just the portion effected, not the ovary)
. indic if only 1 tube, or the other one is damaged
. but risk of reccurent
. requires follow up
- salpingectomy (whole tube)
. indic if ruptured or other tube ok
Ectopics Med Mx - indications
- capable of follow up
- < 3 mm
- no contra to MTX
- no haemodynamic unstable
- b-HCG < 300
- no free blood in cavity
- no live fetus (hi risk of rupture)
Ectopics
- epi - 2% incidence
- heterotopic risk 1/10,000
--------------------------------------PWH - Problems with labour and delivery
_______________________________________
normal pregnancy - 40 wk

labour starts with spontaneous uterine contraction

1st stage = latent + active phases
Latent phase
- 6-8 hr in primi-P
- 4 hr in multi-P
- cervix
. dilates and effaces (length of Cx shortens)
.
Active phase
- primi - 4 hr
- multi - 2 hr
2nd stage = expulsion
- primi-P - 2 hr
- multi = 1 hr
What can go wrong
- 3 Ps
. passage (shape/size of uterine pelvis)
. passenger (shape, position, direction)
. powers (strength of contractions)
- passage
. traumatic distortion
. gynecoid - open round basin
. anthropoid - oval
. android - male type - large opening but coning thin
. platypoid - narrow
- passenger
. macrosomia/large babies (maternal diabetes)
. overdue baby skull is harder and doesn't deform so easily
. hydrocephalus
. goiter/thyroid dz
. abdominal tumours
. breech position 1/30
. occiput to posterior = bigger diameter
. transverse
- powers
. in active phase of labour - dilates at 1-1.5 cm/hr
. partogram = Cx dilation and force of contractions
. less then normal = obstructed labour
. montevideo units
- if pressure in uterus x # contraction = 200 = effectiv
e contractions
. abnormal contraaction
- hypertonic (spasm, syntocin) - the placenta contracts
as well asn the o2 transfer from mother to fetus decr = fetal distress
. fetal scalp electrode
. n = decr in fetal heart beat with contraction
. but if big contraction and decr in fetal HR th
at doesn't recover quickly = type 2
. sample scalp blood - for LDH, acidotic
- hypotonic
--------------------------------------PWH - Neonatal case discussion
_______________________________________
Resp distress - common pulmonary causes
1. Transient tachypnoea of the newborn
2. Respiratory Distress Syndrome (Hyaline Membrane Disease)
3. Sepsis/Pneumonia

4. Pneumothorax
5. Aspiration: meconium, milk
Transient
-

tachypnoea of the newborn TTN

~4 wk premi but more common in full term
eti - retained fetal lung fluid
RF - CS, absence of labour
PC
. tachypnoea from birth
. resolution within 48 hr
- xray . bilateral haziness
. pulm venous congestion,
. fuid in pleural fissures,
. wet lung

Respiratory distress syndrome RDS, Hyaline membrane disease HMD

- 2 wk premi
- eti - lack of surfactant
- RF
. no AN steroids
. CS
. absence of labour
- PC
. tachnpnoea from birth
. worsening sx over 48 hr (due to micro-atelectasis)
- xray
. general opacity, cannot differentiate the lung borders
. ground glass appearance
. air bronchogram
Sepsis, pneumonia
- this is a ddx in ALL BABIES with respiratory distress
- RF/eti
. ruptured membrane
. chorioamnionitis (maternal fever, abdo tender)
. group B strep
. G-neg (ecoli)
- PC
. lethargy
. apnoea
. bradycardia
. temperature instability (hypothermia)
. feed intolerance
- xray
. focal or genderalied pneumonia
. opacity more on one side
- tx - abx, ventilation
Pneumothorax
- ddx in ANY BABY with acute deterioration
- sudden bradycardia, desaturation, incr work of breathing
- xray - heart pushed to one side
- mx - needle aspiration at R-2nd intercostal space
Meconium aspiration syndrome
- > 40 wk gestation
- eti - meconium aspiration
- prev hx of fetal compromise, abn ctg, reduced fetal movements, meconiu
m coming out

- RF
. growth restriction
. poor placental function
- PC
.
.
.
.

meconium stained liquor

resp illness/work of breathing from birth
assoc with pulmonary htn, secondary surfactant deficient
incr risk of pneumothorax and secondary infection

.
.
.
.

coarse patchy changes lung fields

bilateral haziness
hyperinflation foci
meconium aspiration leads to infection/pneumonitis - requires

- xray

cover with abx

Repiratory distress - structural respiratory abnormalities
1. Upper airway obstruction:
- choanal atresia (normally babies are obligate nose breathers but in choanal atresia the back of the nasal passage (choana) is blocked - babi
es turn blue)
- Pierre-Robin syndrome
. facial abnormalities in humans. PRS is a sequence, i.e
. a chain of certain developmental malformations, one entailing the next. The th
ree main features are cleft palate, retrognathia (abnormal positioning of the ja
w or maxilla) and glossoptosis (airway obstruction caused by backwards displacem
ent of the tongue base).
2. Tracheal abnormality:
- tracheo-oesophageal fistula
- working hard to breath and bubbling
- dx - NG-tube - begins to curl - do xray
3. Lung abnormality:
- pulmonary hypo lasia (associated with oligohydrammosg - congenital cystic adenomatoid malformation (CCAM)
4. Diaphragm: - diaphragmatic hernia
Respiratory distress - extra pulmonary causes
1. Neurological:
- perinatal asphyxia/hypoxic lschaemlc encephalopathy (HIE)
2. Cardiac/circulation:
- pulmonary hypertension of the newbom (PPHN)
- Congenital heart dnsease
3. Haematological:
- Anaemia eg fetomatemal bleed, haemolysis (Rh disease)
- Polycythemia (slow circulation/oxygenation)
4. Infection:
- Sepsis/pneumonia
5. Metabolic Dlsease:
- Metabolic acidosis.
6. Renal:
-Potter's syndrome/oligohydramnios/hypoplastic lungs
DDx by History
- NEONATAL
. gestational age
- preterm = TTN, HMD
- term/late = meconium aspiration
. delivery
- CS + no labour = TTN, HMD
- CS = fetal distress
. meconium stained liquor

. condition at birth, resusciation req

- asphyxia, sepsis
. onset of resp distress
- early but later rsolution = TTN
- worsening resp distress = HMD
- actue deterioration = pneumothorax
- ANTENATAL
. RFs for sepsis
- ruptured membrane
- maternal fever, infection, chorioamnionitis
- GBS on vag swab
. US finding (diaphragmatic hernia)
- FHx
. neonatal illness
. congenital abn
CASE 1
- 38 wk delivery
- CS - due to fetal distress
- 2 d ruptured membranes
- GBS
- IV penicillin bf delivery
- ddx - sepsis, TTN, meconium aspiration, pneumothorax
Signs of resp distress
- tachyp
- RR > 60
- nasal flaring
- exp grunt
- chest retraction, recessions
- cyanosis in air
Initial Mx
1. resusc
- ABCs
- O2 if cyanosed
- ventilation if resp distress or apnoea
2. admission to NICU/SCN
Dx
-

CXR
FBC
BC
inflamm markers, CRP
ABG (O2, CO2, pH)

Mx
- O2 sats
- CPAP / hi flow
NEONATAL SEPSIS
Sx of sepsis
- HR, RR up/down
- T up down
- CNS - lethargy, hypotonia, irritable, seizuer
- Resp - apnoea, resp distress
- feeding/GIT - por feeding, jittery, low BSL, vomiting
- skin - jaundice, rashes (herpes, staph inf), cellulitis, red umbilicus
NB erythema toxicum is a non-pathological transient rash

RF neonatal sepsis
- low birth weight
- low gestational age
Immature immunity bf 28 wk
- transplacental IgG during 3rd trimester
- at 30/40 wks IgG is 50% adult level
- no mucosal IgA at birth
- low levels of neutrophils
- complement at 50% of adult
Incr susceptibility
- decr immune response
- maternal flora
- peripartum ascending infection, ruptured membranes
- invasive procedures
- skin immaturity
- nosocomial infection
Origins of infection
- IN UTERO - transplacental/congenital
. TORCHES (toxoplasmosis, rubella, CMV, HSV2, syphilis)
. varicella, HBV, BCV, HIV
- ascending/intrapartum (most common, are ecoli, klebs, gbs)
. Gneg - ecoli, kleps, pseudomonas
. Grp B strep
. Herpes, N gonorrhea, chlamydia
- postnatal, acquired
. staph aureua/staph epidermidis
. G neg
. candida
COngenital TORCH infections
- no matneral immunisation
- serology
- urine
- swabs
- xray, US
- eye exam
- Sx
. large fontanelles
. micro/hydrocephaly
. eye defects (cataracts, microophthalmos)
. heart defects - PDS, pulmonary artery stenosis, myocarditis
. splenomegaly
. small for getational age
. thrombocytopenia
. purpura
. anaemia
. LNpathy
. mental retardation, spasticity, epilepsy, growth failure
. bone lesions
. hepatitis, hepatomegaly
. pneumonitis
. deaf
. blisters/ulcers
Intrapartum infection
- (amniotic fluid usually sterile)
- amnionitis precipitates preterm labour

- ascending infection leads to pneumonia, and secondary septicemia

- rarely trnasplacental
Preventing Group B streptococcus (intrapartum infection)
- 30% women pregnagnt women have this, 10% of their babies will be colon
ised = 0.5/1000 infected
- bimodal = early / late onset
- fatal in 20%
- prevention -2 approaches, thru screening ID, or treat those with risk
factors
. ante-partum screen at 35 wk (abx if positive)
. Tx with abx if risk factors
- intraparum > 37.5
- perterm labour
- prolong ruptured membranes > 18 hr
- intrapartum prophylactic guidelines at 35 37 weeks
. vag + rectal GBS screening swabs
. prophylaxis indications
- prev infant with GBS
- GBS during current
- unknown GBS status + delivery <37 wk, or membrane rupt
ure > 18 hr, intrapartum Temp > 38 C
. not indicated
- CS planned w/o labour or membrane rupture
- negative vag/rectal GBS culture
- recommended abx for perinatal prophylaxis
. 1st line
Penicillin G
initial - 5 million units, IV
4 hrly until delivery - 2.5 million
- alternative
Ampicillin,
initial - 2g IV
4hrly until delivery - 1 g IV
- allergic
Clindamycin, or
8 hrly until delivery - 900 mg IV
Erythromycin
6 hrly until delivery - 500 mg IV
- allergic + resistant
Vancomycin
12 hrly until delivery - 1g IV
EARLY ONSET neonatal sepsis
- RFs
. maternal - QUESTIONS TO ASK WHEN RUNG UP
- GBS
- preterm labour
- > 18 hr ruptured membranes
- fever/inf
- chorioamnionitis - uterine tenderness, offensive liquo
r
- labour > 12 hrs
- PC
. lethargy, poor feeding, hypothermia/fever, panoea
. respiratory distress, vomiting, abd signs
- Ix
. BC
. FBC, film
. CRP

.
.
.
- Abn FBC
.
.
.
.
- Mx
.
.

CXR
LP for CSF
gram stain - gastric aspirate, ear swab
neonatal
WCC < 5000 or > 25000
neutrophil < 1500
IT ratio (immature to total neutrophil count) > 0.2
plt < 100,000
resp, BP, IV fluids, incubator, obs
IV abx
- GBS - penicillin, ampicillin
- Gneg - gentamicin
- herpes - acyclovir

- epi
. 30 % mortality
LATE ONSET sepsis
- = iatrogenic = acquired due to medical/nrusing care
. hand washing, staff crowding, cannulas, TPN, ET ventilation, a
bx resistance
- colonisation, invasion, then sepsis
. URT
. mucous membranes
. umbilicus
. skin
- staph aureua, staph epidermidis, coag neg staph
- Gnegs
- fungal candida
- Ix
. BC
. FBC, film (left shift, IT ratio)
. CRP
. LP CSF
. urine culture
. CXR
. endotracheal aspirate
- Tx
. resp support
. CVS supp
. IV fluids
. incubator
. vital signs
. monitoring
- Abx
. staph = flucloxacillin, vancomycin
. G-neg = gentamicin, cefotaxime
. viral = acyclovir
. anaerbobic = metronidazole, clindamycin
. antifungal
. imipenem, aztreonam, ciprofloxacin, fetaxidine
- epi - 10% mortality
Vomiting in the neonate
- non pathological
. assoc with feeds
. milk/mucous only (yellow, white, clear)
. no blood/bile
. no projectile
. neonate no clinical PC

- pathological
. blood (red or black)
- swallowed blood (birth, cracked nipples/feeding)
- baby bleeding (oral trauma, stress ulceration, hemorrh
agic dz)
. bile (green, not yellow)
- bowel obst
duodenal or small bowel atresia
malrotation, volvulus
anal atresia
- meconium ileus, necrotising enterocolitis
. projectile vomiting
- duodenal obstruction
- pyloric stenosis
. unwell
- sepsis,
- inborn error of metabolism
- congenital adrenal hyperplasia
. older babies
- failure to thrive
. gastro-esophageal reflux
. sepsis, UI
. inborn error of metabolism
- gastroenteritis
. vomiting and diarrhoea
Bile stained vomiting
- Mx - requires surgery - surgical emergency "never let the sun set on b
ile stained vomiting
- duodenal atresia
. double bubble on cxr
. dilated stomach
. proximal duodenum
. assoc with polyhydramnios (swallowing the fluid) and trisomy 2
1
. pc - bilious or non-bilious vomiting
- intestinal atresia
. distension of bowel with multiple air/fluid levels
- small bowel atresia
. enlarged proximal bowel
. atrophic distal bowel
- volvulus
. malrotation of hind gut
. duodenal jejunal flexure to left of midline
. narrow mesentery prone to volvulus
. xray, contrast enema = spiral configuration of jejunum
- meconium ileus (obstructive lesion of thickened meconium)
. assoc with cystic fibrosis 80%
. delayed passage of meconium
. presents with vomiting from day of birth
. contrast enema = micro-colon
- necrotising enterocolitis
. xray - need lateral film (AP film will not show it)
. ischaemic gut
. invasion of bacteria into bowel wall
. pneumoatosis of bowel wall
. perforation
. gas in portal veins
- Ix
. AXR

. FBC, CRP
. BC
. electrolytes
- Mx
.
.
.
.
.
.
.

NICU, SCN
cardiac monitoring
NG tube
IV fluids
abx
surgx review consult
radiology - small bowel contrast

HISTORY
- vomiting
. onset
. frequency - feed vs other
. colour - blood, bile
- GI asso
. abdominal distension
. passage of meconium
. blood in stool
. diarrhoea
- antenatal
. polyhydramnios, double bubble
. unwell ? sepsis
. dysmorphic features - tri 21
- oe
. unwell, floppy, poor feeding
. HR, RR, T, hydration
. vomit discolour
. abd distension
. patent anus
. trisomy 21
. VACTERYL (vertebral, anal, tracheoesophageal, cardiac, renal ,
radial limb) - dysmorphia
------------------PWH - Contraception
___________________
epi
- 38% prenancies unplanned (60% of which are aborted)
- teenage pregnancy rates in rural areas = 87/1000, vs 16/1000 urban
Methods vs typical effectiveness
- sterilisation (~100%)
- depot implants/injection, intrauterine hormonal/copper (long acting re
versible contraception LARC)= most effective (~100%)
- vaginal ring (medium acting)
- hormone pills, progesterone pills (short acting) (91%)
- barrier (condoms, diaphragms, cervical caps) (< 90%)
- withdrawal (78%)
- Fertility awareness (cycle)
- Lactational amenorrheoa method
- Post coital emergency contraception
Typical vs perfect use:
- no difference for IUD but hi difference in OCP
Which means of contraception leads to a delay in return to fertility ?
- sterilisation (permanent)
- depot injection (up to a year)
Medical eligibility criteria for safe provision of contraception
- matches contraindications with appropriate contraception
- Mec 1 or 2 = benefits
- Mec 3 or 4 = the contraindication is significant or absolute

Most commonly use = OCP, condoms, vasectomy

Diaphragms
- must remain in place for 6 hr post sex
- best with spermicide (not available in Australia bc it causes irritati
on to vagina mucosa = incr risk of contracting HIV)
~ 10% failure
- inserted into vagina, covers Cx
Combined hormonal contraception
- estrogen (~35 mcg or less) + progesterone
- as pills or as a vaginal ring
- MOA - inhibits ovulation by stopping LH surge; by thickening Cx mucus,
thinning endometrium
- started 1-5 day of menses for immediate protection
- quick start = any time + additional precaution for 7 d
- 2nd gen
. levonorgestresl/norethisterone
- 3rd gen progestogens
. gestodene/desogestrel
- newer progestogens
. cyproterone acetate (DIANE)
. drospirenone (JASMINE)
. dienogest
. nomegestral acetate
- adv/ non contraceptic benefits
. skin, menstrual regularity, stop heavy periods, PCOS, reductio
n in bowel, endometrial and ovarian cancer
. stops acne (estrogen incr sex hormone binding hormone, binds t
estosterone to reduce it = less acne)
- disad
. daily use requires, $30/mo, drug interactions, VTE, arterial d
isease, breeast cancer, nausea, bloating, mood/libido, headache, break thru blee
ding
. drugs affecting liver enzymes can affect it
. overall on trial scale - no evidence for weight gain (but indi
viduals may do so)
- VTE
. RR = 3
. esp 1st year of use but decr over time
. less risk then the risk during pregnancy and post partum
. levonorgestrel or norethisterone have lower VTE risk
- Progestogen-only pills can be used in situations where the combined ho
rmone is contraindicated ie:
. pmhx of vte
. thrombophilia
. obesity > 35 BMI
. mj surgery
. post partum < 21 days
Vaginal ring (nuva ring)
- one ring per cycle
- 15 mcg Ethinyl Estradiol, 120 mcg estonogestrel
- inserted for 3 wk and removed for 7 d
- same SE as OCP
- not on the pbs = ~$20/mo
Extended pill and ring cycle
- involves pill/ring free break
- manipulation of menses
- reduces hormonse withdrawal sx (headache, pelvic pain)
- most common = 3 consecutive cycle (tricyclic)

- safety of continuous use established to 12 mo

what are the adv of estrogen in the pill ?
- better bleeding control (cycle control)
- doesn't stop ovulation
- mostly works by thickening mucus
Progestogen only pills (POPs)
- only levonorgestrel or norethisterone
- MOA - thickens Cx mucus + thin endometrium + 40% prevent ovulation
- same time every day (3 hr window) (vs 24 hr window for combined pill)
- immediate protection if started on day 1-5 menses
- quick start at any time + precautions for 3 days
- 10% failure
- probably more useful in breastfeeding (the lactation provides the addi
tional methd) and older women (for whom estrogen is a risk).
- adv
. low hormonal dose
. avoids estrogen
. minimal effect on clotting factors, carbohydrates, lipid mtabo
lism
. safe in breast feeding
- disadv
. menstrual cycle dist = irregu bleeding, amenorrhoea
. strict time frame
. SE - headache, breast tenderness, acne, mood swing
. drug interaction with liver enzyme inducers
LARC long acting reversible contraception = implant
- depot injection (medroxy progesterone acetate)
- IUD (levonorgestrel, copper)
- reduction in relative risk of unitended pregnancy = 20 , vs other type
s of contraception
Implanon NXT - etonogestrel PO implant - ie progesterone only
- 4cm rod in arm
- 40 mcg etonogestrel /d to inhibit ovulation, thicken cervical mucus, t
hin endometrium
- 3 yr lasting
- ~100%
- immediate efficacy in 1-5 d menses (other time must wait 7 d)
- reversible immediately
- can be used where contra to estrogen
- follicular levels of estradiol maintained, no concerns wrt bone densit
y
- compatible with breastfeeding
- affects by liver enzyme inducing medications
- SE - heaches, acne, breast tenderness, emotional lability, mood swings
, change in bleeding pattern (Mx - 3 mo combined contraceptive pill)
- progesterone only = no control of bleeding pattern
IUD LARC = copper type or progesterone (levonorgestrel) type
- plastic device into uterus via Cx
- copper T 380 or levonoregsterel releasing (mirena)
- have foreign body effect incr in white cells in unterine lining, cavit
y, and in tubal fluid
- copper ions are gametotoxic
- levonorgestrel thins endometrium and thickens Cx mucus
- ~100% effecitve
- 10 yr span for copper, 5 yr for LNG

- reverses with removal

- post partum and post abortal contraception
- copper type can be used if hormone contra
- coppyer type can be used in emergency contraindication up to 5 days po
st unprotected sexual intercourse
- no STI protection
- copper IUD assoc with heavier, longer, painful periods 50%
- LNG IUD effective for management of heavy menstrual bleeding syndrome
with reduciton in bleeding and pai
. disad = initialy unpredictable bleedings, contra in breast can
cer, no STI protection, SE of systemic progesterone - acne, breast tenderness, h
eadaches, mood changes
. nb incr in proportion of ectopic pregnancies (bc good at chang
ing lining of uterus) - but the absolute rate is actually lower
- complications
. pelvic infection, expulsion, perforation, ectopic pregnancy, p
erforation
- Cu-IUD disadv: heavier, longer and more painful periods
(depot) DMPA-injectable = 2nd tier LARC - progesterone injection
- 150 mg depot medroxy-progesterone acetate IM, every 3 mo
- gradual Pg release
- inhibits ovulation, thicken mucous, thin endometrium
- ~5% failure
- immediate effective if started day 1-5 cycle
- other time, must use other precautions for 1 wk
- Adv
. reduced blood loss (50% amenorrhea at 12 mo)
. good for menstrual disorders (heavy blleding, dysmenorrhea, en
dometriosis)
. not affected by liver enzyme inducing drugs
. can be used in breastfeeding
- disadv
. not immediately reversible
. 8 mo delay in return to fertility
. assoc wt gain
. bone density reduction
- depot does suppress estrogen -> thin endometrium = irritiation - risk
of STI transmission
Tubeal sterilisation
- 100% effective
- tubal ligation
- mechanical (filshie clips, rings)
- immediate effective
- scarring ?
- irreversible
- 3 mo to be completely effective
Vasectomy
)
ndrome
-

vas deferens incision OR non scalpel haemostat to puncture vas

takes 3 mo to be effective - to get rid of tubal sperm (for maturation
vas cut and tied, cautery and typing
LA
confirm azospermia after 3 mo
low risk complic - haematoma, inf, sperm granuloma, testicular pain sy
no assoc with testicular cancer
reversibility reduces with time

Emergency contraception
- emergency contraceptive pill
. pharmacy can distribute
. 1.5 mg dose of levogesterol
. works post coitally up to 5 days
. stops or delays ovulation for up to 5 days = not working if ta
ken too late or at the wrong time
- emergency copper IUD (within 5 d)
Emergency single dose LNG-ECP
- 1.5 mg
- over counter S3
- licensed up to 72 hr
- prevents, dealys ovulation; not an abortifaceint (no effect on develop
ing fetus)
- ulipristal acetate more effective up to 120 hrs
Can we supply to contraception to a 14 yr ?
- yes - based on maturity
- need to make sure the person is safe
- document the age of the partner
Fertility awareness
- identifies fertile days (temperature and symptoms)
Withdrawal
- pre-ejaculate risk
post-partum Laactational amenorrhoea method
- effective within 6 mo of delivery + amenorrhoea, + full breast feeding
- best to use additional method
------------------------------------------PWH - Breastscreening and cancer prevention
___________________________________________
- 50-74 yr targeted, free of charge, every 2 yr
- hi risk (mother < 50), BRCA1/2, HER2
- >50 or >74 only voluntary
- Aim
. detect < 15 mm
- prognostic factors
. nodal involvement
. tumour size
- views
. MLO - medial lateral oblique (most cnacners occur in upper outer quadr
ant)
. CC - cranial- caudal
. addional views if person recalled for further inx
- true lateral
- compression views
- picks up 6/1000 on first screen
- subsequent incidence is 3/1000
- microcalcifications
. premalignant change
. signify DCIS
- the lumpier the woman's breast the less accurate is the mammography
- biopsy
. core biopsy, 16G or 18G
- Accuracy of mammogram
- reduces under 50 yr (breasts are denser)

- DCIS
. 15-20% incidence
. 20% of all cancers
. pre-invasive mass
. Hi grade - leads to invasive cancer (tx ith excision)
- 10 yr survival ~72% (>90% for tumours < 15mm)
- MRI - hi risk patients
- infiltrating ductal carcinoma - most common type of cancer 90%
. mastectmy for > 3 cm
- lobular is next most common 10%
. bc littered across breast, most commonly indicatinon for mastectomy
- medullary 3%
- tubualar 2%
- mucinous 1%
- phylloides, pagets/nipple
- lymph node involvement
. sentinel node biopsy
---------------------PWH - Normal pregnancy
______________________
Menstrual
-

cycle
surge of LH before ovulation
before ovulation - lots of estradiol
after ovulation - more progesterone
day 21 progesterone - should be peaked
. gives indication of ovulation
. significant in PCOS

How does pregnancy occur

- fertile = 5 days prior to ovulation to day of ovulatin
- female ova survives 12-24 hr
- spermatozoa survive 72 hr in genital tract
- journy to ova takes 2 d
Highest rate of pregnancy
- sex every 2 d
- 85% after 12 mo unprotected sex
- therefore 12 mo is the cut off for infertility
Sx pregnancy
- as early as 5-6 wks
- missed menses
- breast enlargement, tender
- N/V (esp 1st trimester)
- incr micturition w/o dysuria
- fatigue
- ehart burn
- constipation
- pregancy test positive
Signs of pregnancy
- abdominal blating
- spider angiomas
- palmar erythema (incr estrogen)
- incr skin pigmentation (patches) of face. areola
- enlarged uterus (1 cm per week), becomes abdominal organ by 3 mo
. if a retroverted uterus, therefore in 1st trimester, can go in
to urinary retention = put in IDC until 2nd trimester when it will flip out
- fetal movement at 18 wk

. for multi-P earlier = 16 wk, for primi-P ~20 wk

Dx
- pregnancy history (prev prenancies, miscarriages, fullterm, abortions,
caesareans, vaginal, eclampsia)
- fhx - gestational diabetes, htn, eclampsia
. early GGT if in family
- hx menses stoped
- antenatal serology
. fbc
. G+H, Rh status
. syphyillis
. Hep
. HIV
. Rubella
- urinary MCS
- dating US
- bHCG
. hi = molar, twin
What does G5 P1 mean ?
- G = gravida.
The number of times the woman has been pregnant. Usually seen in associ
ation with:
- P = the outcome of those pregnancies.
- Examples:
G1P0 = the woman is pregnant for the first time and has not yet
delivered
G1P1 = the woman has had one pregnancy and has delivered once
There can be 4 numbers after the P for para.
The first number is how many term pregnancies.
The second number is how many premature babies.
The third number is how many abortions or miscarriages
The fourth number is how many living children survive.
- Examples:
G4P1111 = the woman is currently pregnant with her fourth pregn
ancy. She had one full-term delivery, one premature delivery which did not survi
ve, one abortion or miscarriage, and has one living child.
G3P2002 = the woman is pregnant with her third child and has tw
o living full-term kids
G6P21234 = the woman is pregnant with her sixth pregnancy. She
had 2 abortions or miscarriages, and surviving children include 2 full-term preg
nancies and one premie which survived. Since the last number indicates she has 4
living kids, then you have to figure that one of the pregnancies was a twin pre
gnancy and both the babies survived.
Early pregnancy
- conception day 14
- implantation 6 d later
- prolongation of corpus luteum with continued progesterone secretion
- modified trophoblast expression of HLA antigens to facilitate maternal
tissue acceptance of fetal graft
. implicated in corpus luteum
Corpus luteum
- "yellow body" = the left over follicle after ovulation. A temporary en
docrine structure.
- maintains the pregnancy for the first 8 wk by producing progesterone,
estradiol and inhibin A
- progesterone is needed for decidualisation and maintenance of endometr

ium
- removal of the corpus luteum in the 1st 10 wk of the pregnancy can lea
d to pregnancy failure
- then the placenta produces the hormones to maintain the pregnancy.
bHCG
-

produced by trophoblast
present from 8 d after ovulation
home pregnancy tests only pick it up 5 week after LMP
peaks 60d
doubles every 2 d
nadir - 15-18 wk

Fetal development
- embryonic period up to 8 wk
- primitive streak in 2nd wk
- heart 3rd wk
- gut 4th wk
- urogenital sinus 6th wk
- organs formed and embryo becomesfetus 7th week
- viability 24 wk
- preterm less than 37 wk
- term 37 to 42 wk
Accuracy of US dating = less accurate with incr gestation
. in 3rd trimester, head in pelvis
. dating is done by head circumference and femur head - therefor
e bc obscured, cannot see it very well.
- 1st trimester +/- 5 days
- 2nd trimester +/- 10 days
Gestational period
- 280 d (40 wk), from last menstrual period
- Nagels rule = LMP + 3 d - 3 mo
Placental
-

development
impantation during blastocyte stage
inner cell mass - forms embryo
trophoblast forms placenta
cyto-trophoblast produces hcg
syn-cytio-trophoblast - produces estrogen and progesterone

Placental
dilation

development
trophoblast invades endometrium with villi
maternal blood vessels develop from spiral arterioles in endometrium of arteries so that the spiral arteries are no longer spiral.
. implicated in eclampsia - if the arteries do not dilate proper
ly and remain spiral, then higher pressure is required to continue pumping to th
e baby = htn
- maternal blood sits in intervillous lakes
- fetal circulatioin is separated from intervillous lakes by trophoblast
ic covering (they maternal/fetal blood doesn't mix)
. impt for Rh discordancy
Functions
-

of plaenta
Gas Exchange (passive diffusion of O2 and CO2)
Provision of nutrients (active transfer methods)
Disposal of Waste Products
Hormone Synthesis (HCG, progesterone. oestrogen and other protein hor

mones)
- Drug transfer
- over > 40 yr of age, the placenta has lower function - baby will not b
e fully healthy.
Maternal Changes in Pregnancy
- UTERINE HYPERTROPHY
- Initially due to oestrogen
- Later due to pressure of the foetus
- Palpable above pubic symphysis at 12 weeks
-At level of umbilicus at 18 to 20 weeks
- UTERO-PLACENTAL BLOOD FLOW
- Increases progressively throughout pregnancy
- 450-650 mL/min by term
. implications for massiveness of post-partum haemorrhag
e
- FORMATION OF LOWER UTERINE SEGMENT
- Early third trimester
- Thinnest part of uterus, 5 to 7.5cm long
- impt for lower section caesarean section
- if it doesn't form, then need to go higher thru thicker muscle
, has greater risk of rupture.
- CERVICAL CHANGES
- Softening and cyanosis
- Shortening
- Proliferation of glands
- Formation of mucus plug
- Eversion of columnar epithelium (ectropion)
. columnar epithelium growth outside the uterus into the
cervix
- VAGINA AND PERINEUM
- Increased vaginal discharge
. still need to swab for infection check
- Colour change of vaginal mucosa
- Increased vascularity of perineum and vulva
- Thickening of vaginal mucosa
- Loosening of connective tissue
- Hypertrophy of smooth muscle
- ABDOMINAL WALL AND SKIN
- Striae gravidarum
- Diastasis Recti
- Pigmentation - linea nigra (black line on tummy) - face and
neck
- Spider naevi
- Palmar erythema
- BREASTS
- Tenderness and tingling in early pregnancy
- Increase in size from 8 weeks
- Colostrum
. women with gestational diabetes are encouraged to expr
ess and start pumping in 3rd trimester
. bc of the diabetes, the woman will over-express insuli
n, and so this can cause hypo-glycemic attacks in the baby.
- Increased pigmentation of areolae
- Appearance of surface veins
- accessory lactation glands in axilla
- METABOLIC CHANGES
- Weight gain (10-15 kg) - uterinene contents - fat deposition
- Fluid retention - decreased plasma osmolaltty - Increased ma

ternal blood volume - results in pining oedema

- HAEMATOLOGICAL CHANGES
- B|ood volume increased by 40-45%
- Increase in both plasma and RBC s
- RBC s increase by 33% (accelerated production)
- Relative decrease in Hb, RBC s and Hot
- Norma| Hb in pregnancy >100
- Decreased platelets (gestational thrombocytopenia)
. has implications for ability to have epidural
- normal blood loss in pregnancy is <500 mL
- if Hb < 110, started on iron tablets
- PREGNANCY IS PRO-THROMBOTIC STATE
- Increased ESR
- Increased fibrinogen
- Decreased protein S
- IRON METABOLISM
- Iron stores in women average 300mg
- Iron requirements of pregnancy 1000mg
- iron supplementation IF - twins - Hb < 120 at booking - Low
Ferritin (even if Hb normal)
- CARDIOVASCULAR CHANGES
- Increased resting pulse rate by 10-15 bpm
- Increased stroke volume
- Increased cardiac output
- Decreased Peripheral Vascular Resistance
- Decreased Blood Viscosity
- Decreased blood pressure (maximal 20 weeks)
- CVS AUSCULTATION
- Exaggerated splitting of the 1st heart sound
- Third heart sound
- Systolic ejection munnur in 90% of women
- ECG
- slight left axis deviation
- RESPIRATORY CHANGES
- No change in respiratory rate
- Increased tidal volume (40%)
- Physiological dyspnoea (bc of weight and mass of uterus pushi
ng on lungs)
- Increased awareness of the desire to breathe
- misinterpreted as dyspnoea
- RENAL CHANGES
- Increased renal size
- Dilatation of the pelvi-calyceal system and ureters ~ more mar
ked on the right
- Increased renal blood flow and GFR
- Lowered Renal Threshold (gryoosuria)
- Decreased serum creatinlne and urea
- Decreased brcarbonate and pCO2
- Decreased serum osmolality (10mOsmoIIL)
- GASTROINTESTINAL CHANGES
-Stomach and intestines are displaced upwards
- Delayed gastric emptying and intestinal transit times. (why th
ey vomit a lot)
- Reflux/heartburn - displacement of stomach - decreased LOS ton
e
- Bleeding gums
- Haemorrhoids + Constipation
Minor disorders
- N/V

~
-

Oesophageal Reflux
Constipation
Epistaxis
Varicose Veins
Haemorrhoids
Breast tenderness
Oedema
Compression neuropathies
Headache
Fainting
Fatigue
Backache
Muscle Cramps
Pruritis
Urinary Frequency
Insomnia

Antenatal care
- 1st visit
Medical History
Obstetric History
Gynaecological History esp. STD's
Family History
Social and Drug history
Nutritional Status and diet
Antenatal
-

Visits
First visit: 12 to 16 weeks
4 weekly visits until 28 weeks
2 weekly visits until 36 weeks
Weekly visits until term

The Antenatal visit

- checking dates
- Reviewing all Investigations
- Asking mother about foetal movements
- Addressing any concerns (birth classes)
- BP
- Assessment of foetal lie and station
- Auscultation of FOETAL HR (110-160)
- Ordering new investigations, follow-up
Antenatal
-

Ix
Chromosomal abn screen
Foetal Morphology Scan 18-20 weeks
FBC 28 and 36 weeks
Group and Ab (if Rh neg) 28 and 36 weeks
75 gm GTT 28 weeks
Low Vaginal Swab (Group B Strep)
screen depression, domestic vilence, drug and alcohol abuse

Stages of
-

labour
1st st - from onset of regular contraction until full dilatation
2nd - from full dilatation until delivery of baby
3rd st - from delivery of baby to placenta

1st stage
-

of labour
latent phase (effacement)
active phase (dilatation)
primi-P = 12 hr

- multi-P = 6 hr
- partogram - want 1 cm /hr ideally
Engagement, descent, flexion, internal rotation, extension, expulsion
---------------------------------------------------PWH - Normal variants, minor disorders and syndromes
____________________________________________________
Newborn examination
- after delivery, from 1-2 days
- only examine in presence of parents
- report findings to parents
oe - in presence of parents
- heart
- hips
Posture and colour
- normal = flexion of extremities
- abnormal = extension
- pink with transient acrocyanosis - discolouration of hands/feet
Skin
- normal mild peeling
Growth restricted baby (mostly due to placental function/diffusion issues; or ov
er crowding)
- scrawny < 2.5 kg
- long and thin with large head
- no subcut fat
- skin dry/cracked
- umbilical cord - thin reduced whartons jelly
Jaundice
- day 1 pathological - unconjugated bilirubin - mostly due to AB
O incompatibility
- days 3-6, resolves by 2 wk - physiological unconjugated
- 2-3 wk - pathological - conjugated - ddx - hypothryoidism, bil
iary atresia
Vernix caseosa
- protective greasy white material
- covers body of infacts bw 35-38 wk
Livedo reticularis
- mottling/marbeling of skin
- wrt to thermal regulation of skin
Lanugo
- fine facial body hair
- preterm babies
- lost during 1st month of life
Naevus flammeus (stork marks) = normal
- vascular birthmarks= normal
- 50% newborns
- irregular bordered pink macule composed of dilated, distended capillar
ies
- site
. nape of the neck
. upper eyelids
. bridge of tho nose
. upper lip
- blanches with pressure
- usually fades by 2 yr
Mongolian Blue Spot
- pigmented lesion - esp in asian
- buttocks, flanks, shoulders
- colour - grey/blue-green

- caused by melanocytes that infiltrate the dermis

- fades within 3 yr
- need to document in blue-book check
. ddx - bruising, child at risk
Milia = little whiteheads/sebaceous glands blocked = normal
- 40% of newborns
- face, newborn
- if found in mouth - Epsteins pearls
- yellow/white paules about 1mm
. epidermal cysts caused by blocked sebaceous gland
. resolve spontaneously
- present a birth or appear later
Erythemia
-

toxicum
erythematous rash with pustules
benign
70% newborn
small white, yellow papules with with an erythematous base
peak incidence is 24 hr

Harlequin phenomenon
- Reddening of one side of the body and blanching of the other half with
a sharp line of demarcation.
- Transient: seconds to minutes.
- Occur most often during the first few days of life
- Thought to be a vascular manifestation due to the immaturity of the au
tonomic system in newborn.
Neonatal pustular melanosis
- pustules (no erythematous base) - leave pigmented colour aftr they lea
ve (=melanosis)
- Begins with superficial, vesiculopustular lesions
. they rupture within 12 to 48 h after birth .
. leaves a spot of hyperpigmentation that may remain for up to 3
months after birth
. Benign, requires no trea ment
- Etiology is unknown.
- smears from the pustules reveal poly morphonuclear leukocytes with abs
ence of organisms, ie not infective
Staph skin sepsin
- erythematous base + prominent pustules (+ yellow pus)
- Discrete pustules that are typically seen after few days of life.
- May affect any part of the body, but have a predilection to t e neck,
axilla, and inguinal areas ie creases.
- Mum may have wound/episiotorny/scar infection.
- Almost always caused by Sfaphy/acaccus aureus.
Cafe au lait spots
- flat, Tan or light brown macules or patches with well defined border
- <3cm in length & <6 in number: - not pathological significant
- Larger spots or more than 6 may indicate cutaneous neurofibromatosis
Strawberry haemangioma
- bright red, raised, lobulated (like a red jelly bean on the surface o
f skin)
- Caused by dilated capillaries, with associated endothelial proliferati
on .
- Occur in up to 10% of newborns . Of these, 20-30% are present at birth

. remainder are usually apparent by 6 months (ie not generally present at birt
h)
- Increases in size for approximately 9 - 12 months then gradually regre
ss spontaneously . Complete regression may take years
- Complications include bleeding, ulceration, infection or compression o
f vital organs
- big ones are treated with propranolol
Pigmented
where
-

naevus
Dark brown or black macule
Most commonly seen on the lower back or butfocks, but it may occur any
Generally benign .
malignant changes may occur in up to 10%.
They should be observed closely for changes in size or shape
parents require counselling

Cradle cap
- normally in hair line/eyebrows
- waxy substance
- if you scrape it off, it can cause bleeding
- tx - aspirin, olive oil
- eventually disappears
Port wine
mis
-

stain
flat vascular irregular shape macule - Pink /reddish purple lesion
Consists of diluted, congested capillaries directly beneath the epider
Often occurs on the face, but may occur anywhere
Does not blanch with pressure
Does not grow in size or spontaneously resolve
ddx - sturge weber - trigeminal nerve

Miliaria
- little white head looking things
- Due to obstruction of sweat and rupture of The exocrine sweat duct .
. Commonly seen 2 to thermal stress eg over-wrapped .
. Once the heat stress is removed the lesions usually resolve qu
ickly
- Miliaria crystallina in which there are superficial vesicles which are
1-2mm in diameter.
. skin does not appear inflamed.
- Miliaria rubro (also called "prickly heat") results in popules and pus
tules from obstruction in The mid- epidermis.
Fontanelles
- large frontal fontanelle can be normal
- needs care not to puncture
Caput succedaneum
- crosses the suture lines of skull, bruising, fluctant welling, cone sh
ape head, lasts a few days
- subcut edematous
- crosses suture lines
Cephal-hematoma
q
- haemotoma underneath of scalp and periosteum of skull
Subgaleal haemorrhage

- underneath the scalp, just above periosteum

- results in large blood loss 250 mL - risk of hypovolaemic shock, anaem
ia
-

blood often tracks down scalp thru neck

most common following vacuum extraction
vague generalised scalp swelling/fluctance
present with haemodynamic instability
. tachycardia
. tachypnoea
. decr activity
. pallor
- head circumference
Head shape
- plagiocephaly - flattened - happens over time
- brachy-cephaly - very flat -happens overtime
- dolicho-cephaly - narrow, skinny heads; born like that
- tx - physiotherapist for positioning sleeping; helmets to trains the s
kull bones
Cephalo-haematoma
- bleeding beween periosteum and cranium
- eti - shearing or tearing of communicating veins during delivery
- often appears on 2nd day of life (slow bleeding)
- often has a hard irregular bondy margin surrounding it
- complications
. jaundince secondary to resorption
. linear skull #
. calcification
Tongue tie
- frenulum attaches to bottom of tongue - if attached to close, then can
not push tongue out, makes latchng on to nipple difficult
- assoc with short frenulum
- interference with feeding and later speech development is uncommon
Oral candidiasis
- white patvhes on tongue, gums, kups, buccal mucosal
- need to treat mother as well
- hygiene is required (bottles etc)
Pre-auricular skin tag
- anterior to ear
- assoc renal anomaly
Facial assymetry
- fcial nerve palsy
Eyes
- red reflex absent
- subconjunctival haemorrhage
Sacral dimple
- benign blind pit in the sacral region
- ddx - neural tube defect
- spina bifida oculta
Herpes simplex
- flexor surfaces, erythematous grouped vesicles, vesicular pustular, sc
ab ) mother with hx of coldsores)

acquired at time of birth

skin, mouth, eye
develops by end of 1st week
grouped vesicles often in linear distribution

Simian crease - one palmar crease (trisomy 21)

Talipes (club foot)
- structural or postural (cramped environment)
- structure - require orthopod review
. asoc with developmental dysplasia of hips
Syndactyly
- webbed fingers/digits
Polydactyly
- extra digits
- isolated, syndromic
- usually extra little finger
Sucking blisters (babies in utero do suck their thumbs)
- typically dorsal, lateral aspects of the wrist or fingers
- may be like demarcated bruises or vesciular
- assoc with XS sucking
- ddx bullous impetigo (multiple locations)
Pedal edema
- assoc with Turner syndrome (45XO)
Hips
- Barlow test
- ortolani test
Napkin dermatits
- contact dermatitis (static urine/stool)
- spares the skin fold and creases
- not in flexural areas
Genital thrush
- red and tender with satellite lesions
- inside skin folds and creases
Congenital hydrocele
- often transient
- translucent swelling surrounding testes
- assoc continuation of process vaginalis and contain peritoneal fluid
- usually resolves spontaenously by 1 year
- ddx - hernia, that the testes has descended.
Hydrospadius
Hymenal tag
- assoc with protrusion of redundant vaginal mucosa
. often regresses w/o tx over 1st 2 mo of life
Pseudo menses
. blood on nappy - normal
. effect of maternal hormones
------------------------------PWH Abnormal uterine bleeding

_______________________________
age of pt
not going to have fibroids in 12 year old
'Mrs X is 39F, parity, gravidas, last menstrual period
'
Abnormal bleeding
- 15% all visits to gyn
- 20% all gynae operating
- types - organic cause
Normal menstrual cycle
- what is there normal menstrual cycle
- incr in T at time of ovulation
- LH surge just bf ovulation; FSH also reaches a peak at ovulation
- estradiol only produced in ovary
- estradiol incr up to point o ovulation, then drops off sharply then in
cr a bit
- progesterone incr after ovulation
- when the progesterone starts decr, you get a break down in the endomet
rium leading to menses
Endometrium
- Basalis - does not change during cycle
- Functionalis - 2 layers - it is the layer that grows and sloughs
. stratum compactum (superficial thin)
. stratum spongiosum
- Follicular phase of ovary = proliferative phase of endometrium
- Luteal phase ofthe ovary = secretory phase of the endometrium
- if no blastocyst implantation
. Progesterone decr
. Endometrial glands involute
. infiltration PMNL and monocytes
. spiral arteries constrict = local ischaemia
. lysosomes release proteolytic enzymes
. PGs (esp PG-F2-alpha) cause arteriolar vaso-spasm = ischemia +
uterine contractions = expulsion of menstrual blood
Normal menstrual cycle
- day 1 - first blood in morning
- cycle - 1st day till beginning of next menstruation
- ovulatory cycles - 28+/-7 days
- Menses - 4+/-2 d
- Blood loss - 40 +/-20 mL
abn bleeding
- cycle length >
- duration > 6 d
- volume
> 80 mL
< 3 hr interval for a pad/tampon change
> 21 pads/tampons per cycle
changes at night
clots > 1cm
Patterns and definitions
- Oligomenorrhoea = Interval > 35 days, can be ovulatory of anovulatory
- Polymenorrhoea = Menses < 21 days, usually ovulatory
- Hypermenorrhoea = Regular menses > 7 days bleeding, ovulatory + anothe
r problem

- Menorrhagia = Menses > 80ml blood loss, ovulatory with another problem
- Metrorrhagia (HMB) = Irregular intervals > 7 days (usually with interm
enstrual bleeding)
- Menometrorrhagia = Excessive prolonged bleeding at frequent and irre
gular intervals; anovulatory
- Intermenstrual Bleeding(I MB) = In between cycles
- Post Coital Bleeding (PCB) = Within 24 hours of coitus
- Withdrawal Bleeding = Progesterone cessation bleed (eg when on progest
erone only pill)...ie due to withdrawal of hormone
Length of phases
- follicular = variable, but minimum 7 d
. it is the development of the egg
. when prescribing OCP - emphasise that for it to work, you have
to stop ovulation and stop the follicular phase - therefore have to start and f
inish regularly on time
- luteal = fixed, 14 d
Average age of menopause = 51.5
Pre-menarche bleeding
- eti
. vulvo-vaginitis
. trauma
. urological
. neoplasm
- ddx - precocious puberty (< 8 yr)
Adolescent bleeding
- within 2 yr of first period
- menarche ~12.5 yr means
- delayed (need to investigate)
. if > 15 yr no menstruation
. assoc absence breast development
- cycles highly variable for fisrt 2 yr after first menstrual period 20-45 d, avg 32.2
- ddx - prolonged, absence
. pcos
. eating disorders
. excess exercise
. thyroid dz
. co
- ddx - heavy
. coagulopathy
. von villebrand
. platelet dz
Child bearing age
- pregnancy, structural uterine, anovulation, trauma, infection
- Medications
. OCP, Cu IUD, depot-provera
. anticoag
. corticosteroids
. chemo
. dilantin (anti-epileptic) - stimulates liver enzymes, which me
tabolise OCP hormones
. anti-psych (incr prolactin)
. abx (stevens-johnson syndrome or toxic epidermal necrolysis)
Perimenopausal = 8 yr prior to menopause (menopause = last menstrual period)

cycles shorten then lengthen

variable blood flow + skipping and then normal
eti - eratic hormone and decr ovulation freq
abn
. heavy + clotting
. post coital
. intermenstrual spotting, bleeding
. cycles < 21 d
. menses > 10d (3 d longer then normal)
. more then 3 mo w/o period

Post menopausal (gap of 6 mo or more from last menstrual period)

- avg age 51.5
- eti
. Atrophy of vaginal epithelium/ or endometrium(60%)
. Endometrial polyps (12%)
. Endometrial Hyperplasia (10%)
. ENDOMETRIAL CARCINOMA (10%)
. Hormonal Effect (7%)
. Cervical Carcinoma (1%)
Genital tract disorders causing abnormal bleeding
- UTERUS (most common are pregnancy compli, haemostatic, noeoplastic)
. benign
- Endometrial Hyperplasia
- Polyps (are not sloughed off with endometrium)
- Adenomyosis (outgrowth of endometrium into myometrium
)
- Leiomyomas (fibroids) - submucosal or intramural
. malignant
- adenocarcinoma (endometrial cancer)
- sarcoma
. infection - endometritis
. anovulatory bleeding
- CERVIX
. benign
- polyps
- ectropion
- endometriosis
. cancer
- invasive carcinoma
- metastatic (uterine, choriocarcinoma)
. infection
- cervicitis
- sti
- VAGINA
. benign
- gartners duct cyst
- polps
- adenosis (aberrant glandular tissue)
. cancer
. vaginitis, infection
- bacterial vaginosis*** (impt for stimulating premature
labor)
- sti
- atrophic vaginitis (esp post menopausal women - irrita
tion/rupture during intercourse)
- VULVA
. benign
- sin tag

- sebaceous cyst
- condylomata
- angiokeratoma
. cancer
. infection - sti
- UPPER GENITAL TRACT
. fallopian tube ca
. ovarian-estrogen producing tumor
- granulosa cell
- theca cell
- mature cystic teratoma (most common - esp young girls)
. pelvic inflamm dz
. pregnancy complications
- threatened miscarriage
- ectopic pregnancy
- missed abortion
Uterine bleeding
- systemic
. coagulation - VWF, ITP, acute leukaemia
. thyroid
. liver dz
. sepsis
. vulva dz - crohns, behcets
. vascular tumors
- iatrogenic
. ocp, hrt
. progesterone only pill, depo-provera
. iud, foreign body
signs of ovulation
- incr temp 0.25-0.5
- cervical mucus incr viscosity
- mittleschmerz
- incr sense of smell
- ovulation 8-20 d from 1st day of LMP
- ovulation is 14 d before menstruation
Endometrial polyp
- benign
- endometrial growths
- fibrous tissue covered by columnar epithelium
Adenomyosis
- benign dz of uterus
- extension of endometrial tissue into myometrium
- bc in myometrium, the blood sloughing off during menstruation cannot b
e lost and is trapped
- uterus swells, cramps, bleeding
- bleeding is prolonged and later becomes brown
Fibroids
-

benign
pelvic tumor - above fundus, subserosal, submucosal, intramural
25% women
can progress to cancer - Lieomyosarcoma LMS

Ix
- pap smear
- chlamydia, gonorrheal

b-hcg
fbc
iron studies
coags
hormones
biopsy endometrium

Qs
- sex activity - pregnancy risk
- menstrual history
. menarche
. lmp
. length of cycle, duration of bleeding
. heaviness of flow - tampons per day, degree of soaking, floodi
ng or clots
. premenstrual sx, bladder, bowel sx
. menstrual irregulatiry, post coital,, intermestrual
. have you been told that you are anaemic
-

WHy is it
tting rid

normal menstrual cycle

sx of ovulation (mittleschmitz, mucus, temperature)
nature of abn bleeding
impact on her life ?
reproductive hx
. menstrual hx
. obst hx
. gyna hx
. contraception
. breast
. general med hx
. social, impact on QoL
important to ask how large the clots are
greater then 1cm = bleeding
menstrual blood is not bleeding - it is endometrial sloughing
if clots form, then the bleeding is faster then bodies mechanism of ge
of it

Most common cause of menorrhagia

- in pre-menopausal = distortion of endometrial cavity from submucosal f
ibrois, endometrial polyp or adenomyosis
- peri-menarche = haemostatic, coags
PCs
-

pallor
fever
enlarged thyroid gl
hyperandrogenism (hirsutism, acne, clitoromegaly, male pattern baldnes

s)
- acanthsosi nigrican (insulin resistance and anovulation)
- galactorrhoea (hyperprolactinemia)
OE
bimanual

abd/pelvic tender
guarding
rebound tenderness
mass
fluid

- size, contour, uterine tenderness

- adenxa for ovarian tumour
- cervical motion tenderness
Speculum exam
- bleeding site is vulva, vagina, cervix
- masses, laceration, ulceration, vaginal discharge, foreign body
Ix
=
-

fbc
serum bhcg
iron studies ferrtin
coags
TFT
PCOS androgen hormones
LFTs
RFT
transvaginal US
HYCOSY

Pelvic US
- endoemtrium
- myometrium
- adnexal pathology
Transvaginal US
- gold st
- close to pelvic organs and resolution
- best d5-7 cycle = endometrium is thinnest
- endometrial thickness
. 4-8 mm proliferative phase (>12 abn or > 4 in postmenopausal o
r > 8 on HRT)
. 8-14 mm secretory
- polyps, hyperplasia
- ovaries
. PCOS
. endometrioma
. functional cysts
. ovarian cysts
Saline infusion sonography
- identifies intracavitary lesions but without endometrial sampling
- detects polpys, submucoous fibroids, feasbility of resection
Non invasvie imaging
- HYCOSY, CT scan, MRI
- HYCOSY
. hysterosalpingo-contrast-sonography (saline infusion sonogram
+ TVUS)
. distinugish bw focal thickening, polyps and fibroids
- CT scan
. radiation
- MRI
. more accurate then CT
Endometrial sampling
- pipelle or curettage
- aim = xclude endometrial hyperplasia and cancer
- indications
. > 35 yr

.
.
.
.
.
.

incr endometrium but no focal lesion

obese BMI > 30
chronic anovulation PCOS
hypertensive/diabetes
tamoxifen use
unopposed estrogen therapy

Hysteroscopy
- indicated for
. focal endometrial abn on SIS or HYSCOY
. suboptimal visualisation of endometriumon TVS
. abn cavity ie fibroid
. inadequate or failed endometrial sampling
Mx heavy bleeding (no pathology)
- IF
. no patholoty
. but a hx of heavy bleeding, conseuctive cycles without IMB or
PCB - then you can reassure them, trial pharm, treat anaemia
- reassure
- pharm
. combined OCP
. transexamic acid
. nsaid
. progestagen
. levonorgestrel system iud mirena
. gnrh agonist
- correct aneamia - diet, iron supplement
combined ocp
- 43% reduction in MBL
- can be given consecutively, 3 cycles in a row, missing glucose tablets
, have withdrawal bleeding at the end.
- contra
. cvd
. thrombophilia, fhx
. obesty
. hypercholesterolemia
. smoker > 40 yr
Transexamic acid
- antifibrinolytic
- 1 g QID during menstruation
- retains fertility and avoids hormonal tx
- 30% reduction in blood loss
- se - NV, leg crampls, diarrhoea, vte/dvt
nsaid
- bc hmb assoc with incr PG
- MOA - inhibit COX to reduce PG
- must take at onset of heavy bleeding
Progesterone - progestagens
- inhibit endometrial growth
- organises and supports estrogen primed endometrium (only works in wome
n producing estrogen ie won't work in post menopausal)
- effective sloughing upon withdrawal
- reverses endometrial hyperplasia
-types
. norethisterone (primolut) regime 5 mg TDS 5-26 d of cycle

. DMPA depot medroxy-pregesterone acetea - 14 wk

. implanon - 3 yr
- se - amenorrheoa, irregular bleeding
Mirena IUD
- best treatment (next ebst is a progestagen)
- 94% reuction in bleeding within 6 mo
- best
- can be used up to 5 yr
- levonorgestrel 52 mg
. releases progestin 20 mcg/d into endometrium)
. thins endometrium
. either decr blood loss or amenorrhoea
- also good for dysmenorrhea, contraceptive
- immedate reversibility
- good at surgx risk obese or endometrial hyperplasia
- complications
. spotting
. breast tenderness, mood, acne
. perforation at time of insertion
. dislodgement
GNRH analogue
- only as a temporary measure - last line bf surgery
- induces medical menopause
- se - flushes, night sweats, osteoporosis if > 6 mo
- must use HRT to minimise SE
Surgx
- only if family complete
- endometrial ablation
. for fibroids < 3 cm
- myomectomy to reduce fibroids
- uterine artery embolisation
- options
. hysterectomy
- firboids > 3cm
. radiofrquecy
. rectoscope - endometrial resection
. roller ball endometrial ablation
------------------------------PWH - Monitoring in Labour
_______________________________
who are we monitoring in labour ? - mother and baby
what do we monitor inmother ?
- BP - eclampsia, hypotension (regional neuromuscular blocks SE)
- PR - tachy (pain, uti, bleeding, infective shock, chorioamniitis
- temperature - infection, chorioamniitis
. cultures, BC
. abx - penicillins, clindamycin
- loss of sensation - if they have an epidural
. worried about ascending block - diaphragmatic paralysis
. if infusion rate is too hi, concentration is to hi, migration
of cannula
. sx with ascending block
- lost sensation
- trouble breathing
- upper limb weakness
- blood loss

Contractions
- measured by
. self reported
. midwife
. ctg (but doesn't tell how strong they are)
- midwife reports as
. frequency
. length
. strength (mild, moderate, strong)
what things are measured for the baby?
- HR (PR stethoscope - good bc can differentiate maternal from fetal pul
se)
- doppler
- US
- CTG
- amniotic/ lichor
- presence/absence of meconium in lichor
- lactate
------------------------------PWH - Multiple pregnancy
_______________________________
chorion is one of the membranes that exist during pregnancy between the developi
ng fetus and mother (the fetal membranes)
The chorion and the amnion together form the amniotic sac
It is formed by extraembryonic mesoderm and the two layers of trophoblast that s
urround the embryo and other membranes. The chorionic villi emerge from the chor
ion, invade the endometrium, and allow transfer of nutrients from maternal blood
to fetal blood
Aside from protection, the amnion provides a gateway to transfer nutrients and o
ther essential necessities for the unborn embryo. The amnion is expandable and f
lexible in size as it tries to accommodate the development of the embryo to its
later stages. The amnion is found on the innermost part of the placenta. It line
s the amniotic cavity and holds the amniotic fluid and the developing embryo. Th
e membrane is made up of tresodeum on the outside and ectoderm on the inside whi
ch has specific cells with specific functions.
The rupture of the amnion and the release of the amiotic fluid is a signal for t
he start of the pregnancy s delivery stage.
The chorion, on the other hand, is the outer membrane that surrounds the amnion,
the embryo and other membranes and entities in the womb. It is considered as th
e support platform of the fetus and the aminon
1.Both the amnion and the chorion are extra embryonic membranes found in reptile
s, birds and mammals.
2.The amnion is the inner membrane that surrounds the embryo while the chorion
surrounds the embryo, the amnion and other membranes.
3.The amnion is filled with amniotic fluid, which holds the embryo in suspension
while the chorion also acts as a protective barrier during the embryo s developme
nt.
4.The amnion comprises of tresodeum and ectoderm while the chorion includes the
trophoblast and the mesoderm.
5.The chorion has a special feature called chorion villi, which acts like a bar
rier between maternal blood and fetal blood. It absorbs maternal blood for the e
mbryo s substance and other necessities while the amnion plays a part in the stage
of delivery. The rupture of the membrane is a signal that the fully-formed offs
pring is ready to come out of the womb.

Epi
- twins 1/90
. 2/3 di-zygotic (africa, > 35 yr, > 4 preg, > ovulation inducti
on)
. 1/3 mono-zygotic (> IVF) - 1/250
- triplets 1/8000
- quads 1/729000
Types
- 2 oocytes fertilised (nonidentical, fraternal)
- blastocyst/morula divides after fertilisatioin (identical)
dizygotic
centas
-

(usually non identical, but can occaionally occur)

each has own gestation sac, and placenta => 2 gestation sacs and 2 pla
2 amnions and 2 chorions
cannot get entangled in each other umbilical cord
have own blood supply thru their own placenta
types
. fraternal (same father - 2 sperm, same cycle)
. super fecundation (differnt fathers, same cycle)
. super fetation (different cycles)

Mono-zygotic
- one egg
.
.
- 1/250
- types
.

.
.

ovulated and fertilised by 1 sperm

splits bw d 3-13
if late split - implant separately
di-chorionic di-amniotic (early separation)
- 2 placenta
- 2 amniotic sacs
- 2 fetuses
- best scenario
mono-chorionic di-amniotic
- 1 placenta
- 2 amniotic sacs
- 2 fetuss
mono-chorionic mono-amniotic (late separation)
- 1 placenta
- 1 amniotic sac
- 2 fetuses
- risk of cord entanglement
- worst scenario
conjoined (such late separation, so that it never occurs)
- 1 amniotic sac
- 1 placenta
- attached fetuses
duplicata incompleta (incomplete duplication)
- 1 amniotic sac
- 1 placenta
- attached fetuses
- fetus embedded in sibling
ecto-parasitic twin (partial fetus attached to sibling)
- 1 amniotic sac
- 1 placenta
fetus-in-fetu (fetus embedded in sibling)
- 1 amniotic sac
- 1 placenta

- splits 3-13 d after fertilisation

- may implant separately or incompletely
- monochorionic placenta
. single layer of continuous chorion which limits villous growth
, the apposed amnions for a thin membrane separating the 2 amniotic cavities
. T-intersection
. very thin chorion < 1 mm
- diochorionic placenta
.both amnions and chorions reflect away from the placental surfa
ce creating a space which is filled with chorionic villi
. Twin peak sign = Y-intersection = separate placentas
- 2nd trimester US
- chorion has not regressed from between the amnio
- placenta goes up like peak into base of membrane
- sign of dichorionicity
complication of twin pregnancy
- early fetal demise
- late fetal demise (greater effect of other fetus)
- miscarriage (esp monochorionic twins; dichorionic is lower then monoch
orionic but still double rate for singleton)
- perinatal mortality
- fetal abnormalities (eg omphalocele/ant abdominal wall - 40% of these
are assoc with chromosomal abn eg tri-18)
- preterm delivery
- growth restriction
- 3rd trimester demise of one twin
- twin-twin transfusion syndrome
Early fetal demise in twin pregnancies
- missed abortion at 11-14 week scan
. 5% of twins one demise
. 24% of twins both demise
- even if both alive at 11-14 wk scan
. 5% miscarry
Late death of one fetus
- if dichorionic twin, death of one of the fetuses results in the follow
ing for the surviving twin
. preterm delivery - cytokine and PG release by resorbing dead p
lacenta)
. death or handicap of co-twin in 10%
- mono-chorionic
. neurological handcap in 25% - hypotension due to hemorrhage fr
om live fetus into dead feto-placental unit
Structural abn
- mono-zygotic
. RR = 3 (vs singletons)
. due to vascular abn, crowding, psoition
. gene expression
- post-zygotic non-dysfunction, parental imprining, asym
metric X-inactivation
- assymetric splitting inner cell mass very early in ge
station
- splitting after laterality gradients are detemrined re
sulting in malformation of laterality, cardiac and midline defects
- haemodynamic factors resulting in abnormal flow patter
ns, cardiac defects, twin refersed arterial perfusion sequence.
. eg

- sirenomelia (mermaid syndrome)

- VATER complex - Vertebral anomalies, Anal atresia, Car
diac defects, Tracheoesophageal fistula and/or Esophageal atresia, Renal & Radia
l anomalies and Limb defects
- anencephaly
- holoprosencephaly
- CHD
- conjoined twins
Preterm delivery risk with twins
- hi risk due to
. incr wt
. incr volume uterus
. incr stress on cervix
- screened via cervical length (internal-os to external- os)
- cut off of 15 mm - bf 28 weeks (Sn drops off at 36 wk)
- avg gestational age for twins is 36 wk
- gestational age distribution - most 36 wk, but many are earlier with t
hose complications
Growth restriction
- can only use US to get estimated fetal weights (not a clinical diagnos
is)
- can measure each placenta and volume of amniotic fluid separately
- can find the umbilical cords and so doppler flow studies to gauge the
differential flow to the different fetuses
- singletons - genetic, placental fn (5% below 5th centile)
- MC twins . unequal splitting of single cell mass
. imbalance of flow across placental vascular communications
. 34% have 1 twin below 5th centile
- DC twins
. different genetic potential
. 23% have 1 twin below 5th centile
3rd trimester complication - Demise of co-twin =
- di-amniotic di-chorionic twins = little risk to survivor
- but in monochorionic twins
. if the cotwin dies, then 25% of neurological damage to survivi
ng twi
. thromboplastin released into circulation
. DIC survivor may soon die
. structural damage
- ventriculomegaly, porencephaly
- cerebral atrophy, hydranecphaly
- bowel atresias, renal necrosis
- GIT atresias, limb necrosis
. we don't know how to save the remaining fetuse from the damage
. try to preempt the damage before it occurs - eg identify if on
e of them has an abnormality which will lead to its death - monitor
Hydrops fetalis is a condition in the fetus characterized by an accumulation of
fluid, or edema, in at least two fetal compartments
Locations can include:
subcutaneous tissue/scalp
pleura (pleural effusion)
pericardium (pericardial effusion)
abdomen (ascites)
The edema is usually seen in the fetal subcutaneous tissue, sometimes leading to

spontaneous abortion. It is a prenatal form of heart failure, in which the hear

t is unable to satisfy its demand for a high amount of blood flow.
Twin-twin transfusion syndrome
- UNIQUE to monochorionic twins (30% of MC twins) ie one placenta, thin
membrane
- placental arterio-venous anastomoses across the shared placenta - allo
w uni-directional blood flow
. these connections are present in 100% of MC twins but the synd
rome only affects 30% of them due to balance flow or little flow
. results in one twin taht is hyper-volemic and the other which
is hypo-volemic
- flow intermittent across the placenta which is shared by the fetuses
- affects 30% MC twins thru connection - but present in 100%
- donor STUCK twin
. small
. hypovolaemic, anaeamic
. empty bladder
. oligo-hydramnios
. hydropic (heart failure)
- recipient twin
. big
. hypervolaemic, polycythemic
. full bladder (trying to get rid of volume)
. polyhydramnios
. hydropic
Quinetro staging of twin-twin transfusion syndrome
- survival of twins is poorer with progresion to higher stages over time
.
- 50% will progress, 30% do not progres, 20% improve
- stage
liquor volume
flow studies/hydrops/death
1
oligo or poly hydramnios
ladder seen
2
not seen
3
donor-absent or reversed flow in umbilical a

bladder
donors b

recipient-abn ductus venosus, tricuspid regurg

4
hydrops in 1 or both fetuses
5
death of one or both fetuses
- Tx for twin twin transfusion
. maternal indomethacin (suppresses renal output - stops big twi
n micturating so much = reduce polyhydramniotic sac BUT also affects smaller twi
n = can send smaller twin into renal failure)
- NOT DONE ANYMORE BC OF RISK OF SMALLER TWIN
. amnio-reduction
. STILL USED SELECTIVELY
. objective is trying to avoid premature labour due to i
ncr volume of amniotic fluid
. remove fluid of needle, reduces this risk BUT doesn't
address pathogenesis
. laser division of placental connections
- OPTIMAL CURRENT TREATMENT

. selective fetucide (cord coagulation, cord clip)

- IF FOUND TOO LATE ie smaller fetus too small to be via
ble
. termination of pregnancy
. septostomy
. NOT USED MUCH ANYMORE
Amnio-reduction
- indicated for milder cases of twin-transfusion syndrome ie stages 1 or
2 (mild and occurring late)
- removes 3 L
- needs to be repeated reguarly
- cannot be used for Quinetro stages 3 or 4
- reduces success rate of laser
- complications
. early delivery 3%
. PROM 6% premature rupture of membranes
. infection 1 %
. abruption 1%
. survival 20-80%
. 20% survivors have developmental delay
Septostomy
- used in 1980s - dividing membrane to bring about sharing of amniotic f
luid in 2 sacs.
- 3% cases hole gets larger and twins share same space
- risk cord entanglement
- 80% at least 1 twin survives
Selective laser ablation of placental anastomoses
- GIVING BEST OUTCOMES AT THE MOMENT
- St 2 TTTS and above
- fetoscope direct visualisatioin blood vessels and use laser to obliter
ate the communicating vessels
- time consuming
- problematic if placenta on anterior wall (instruments enter anteriorly
tf cannot see the anterior placenta)
- folowed by amnio-reduction
- complications = PROM, placental separation, infection
- 80% survival of 1 twin
. death of 1 twin also beneficial since risk of complications dr
ops from 35% to 7%
- 30% survival both twins
- 30% of cases neither twin survives
- 8% have long term handicap ( = half the rate of handicap seen in amnio
reduction)
Selective cord coagulation
- indic if laser ablation not posible or 1 has poor prognosis = sacrific
e one of the twine
- umbilical cord grasped with forceps and electrical current applied
- complications PROMS 25%, 85% one fetus survives
Twin reversed arterial perfusion sequence TRAP
- identical twins, monochorionic, have own placental circulation
- Perfusion of the affected twin via paired a-a & v-v placental communic
ations
- Blood enters perfused fetus through Its umbilical artery
- blood exits through its umbilical vein
- Pump twin in a state of persistent high cardiac output

. high renal perfusion . poiyhydramnios

. CHF & hydrops
- 1/150000
- recipient twin
. is acardiac
. may fail to develop other body structures
. circulaton is mantained by pump twin to acardiac twin via umbi
lical artery connections
. recipient twin is non viable
. w/o tx 50% cases of TRAP will result in death of pump twin
- tx
. cord occlusion
. RF ablation (needle in fetus to occlude major blood vesse) - r
isk PROM, 90% pump twin survival
Antenatal Mx of twins
- prenatal dx
. nuchal, serum screen
. cvs or amniocentesis if indicated
. 18 wk anomaly scan
- frequent antenatal visits
. 2 weekly until 36 wk then weekly
- iron and folate supplementation
- frequent scans for growth wellbeing and cervical length screening 26,
30, 34 wk
------------------------------PWH - Reproductive anatomy
_______________________________
round ligament (gubernaculum) goes into the labium major by the inguinal canal
phasese of menstrual cycle
- follicular phase-ovary (proliferative phase - endometrium)
- ovulation
- luteal-ovary (secretory phase-endometrial)
higher centers influencing brain - hypothalamus and anterior pituitary
Hypothalamus
- lateral wall of 3rd vent
- unmyelinated fibres - peptide release and synthesis eg gnrh (to act on
anterior pituiary)
- myelinated fibres - secrete Norepi + serotonin to regulated GnRH secre
tion
- pulsatile gnrh secretion (NOT CHRONIC - which would cause medical meno
pause)
. centraly modulated by Norepi, DA, endog opioids
. pituitary feedback of fsh and lh
. ovarian modulation thru steroids, activins and inhibins
. autoregulation of gnrh receptors
Pituitary
- base of brain, in sell turcica
- under hypothalamic control
- pulsatile release of lh and fsh
Gonads
- stimulated by lh and fsh

- secrete
. activin = stimulates fsh
. inhibin = inhibits fsh
. estradiol, progesterone, testosterone = negative feedback on h
ypothalamus/gnrh and pituitary
Anterior pituitary
- secrete fsh and lh
. Growth Hormone (GH), Prolactin (PRL), Follicle-Stimulating Hor
mone (FSH), Luteinizing Hormone (LH), Adrenocorticotropic Hormone (ACTH), and Th
yroid-Stimulating Hormone TSH).
- fsh
. stimulates follicle maturation and aromatitsation of androgens
to estrogens
- lh
. stimulates theca cells to produce androgens
. ovum maturation and resumption of meiotic division
. ovulation and luteinisation of granulosa cells
. corpus luteum formation
Primordial follicle
- originate in endoderm of yolk sac, allantois, and hindgut of embryo
- migrate to the genital ridge by 5-6 wk
- rapid mitosis followed by attrition
. 16-20 wk = 6 mil
. birth = 2 mil
. puberty = 300,000
. ovulation = < 500
Follicle development
- recruitment, aromatisation, 2 cell theory (theca and granulosa)
Ovulation
- LH surge due to positive feedback by estradiol peak
- lysis of follicular wall
Luteal phase (= endometrial secretory)
- reorganisation of granulosa cells of the dominant follicle into the co
rpus luteum
. rapid vascularisation]
. luteinisation of granulosa cells
- incr progesterone
. progesterone + estradiole = negative feedback action on gonad
otropin secretion
- demise if corpus luteum (and the progesterone it produces) in 14 d unl
ess supported by hcg (if hcg is around, the corpus will continue to make progest
erone - without it, the endometrium breaks down and sheds...it will continue pas
t 14 days if the implanted blastocyst/placenta is making progesterone itself)
Endometrium
- basal zone = adjacent to myometrium - undergoes little histologic chan
ge
- intermediate spongy zone - above the basalis
- compact zone - directly beneath the surface
- the spongy zone and compact zone are cyclically shed
Proliferative phase
- proliferation of basal layer
- endometrial gl are tubular, straight and narrow with low columnar epit
helium

- incr mitotic activity on stromal and glandular cells

- late proliferative phase assoc with gland hyperplasia
Menstruation
- progesterone withdrawal
- vasoconstriction - to regulate bleeding (epi, norepi, endothelins)
- shedding
- fibrinolysis (enzyme so that normally menstrual fluid doesn't clot; in
incr bleeding, the enzymes are exahusted; clots cause the uterus into spasm/dys
menorrhoea)
. need to ask wether pain coincides with heavy bleeding = primar
y dysmenorrhoea
. otherwise - culd indicate endometriosis
- haemostasis
- re-epithelialisation
------------------------------PWH - Preterm birth
_______________________________
1/12 births are < 40 wk
incr bc multiple pregnancies (IVF, incr age)
chance of survival of preterm birth incr as you approach 29 weeks, then plateus
RF for preterm birth
- Multiple pregnancy
- Spontaneous preterm labour
- Preterm rupture of membranes (PROM)
- Cervical incompetency
- IUGR
- Preeclampsia
- Antepartum haemorrhage
Complications (esp < 32 wk)
- chronic lung dz
- neuro disability eg hearing, vision, epilepsy, cerebral palsy
Mx
- antepartum glucocorticoid tx for prevention of respiratory distress sy
ndrome in premature infants (26-34 wk)
. betamethasone 11 mg IM, 2 doses given 24 hr apart
. also beneficial in twin (although no incr in dose is required)
. single course should be routine for pre-term delivery (incl PR
OM and HT)
. reduces risk of
- neonatal death,
- RDS,
- cerebroventricular hemorrhage,
- NEC, neonatal necrotizing enterocolitis
- systemic infections in 1st 48 hr,
- need for respiratory support and
- NICU admisions
. no incr in risk for the mother
- death, chorioamnionitis,
- puerperal sepsis
. no role
- in prophylaxis
- no role if prev hx of preterm
- weekly repeat courses NOT recomended bc of reduction i
n wt and head circumference

- no benefit to repeat at 1 yr, 2 yr or 5 yr (no differe

nt in benefits, or harms, disability, growth outcomes, nuerodevelopmental disabi
lity)
- tocolysis (tocolytic drugs) - suprress labour
. CCBs eg nifedipine (adalat) - only really used in Australia (e
lsewhere not worked)
. DOESN"T really work
- only incr time by 7 days
- no difference in morbiditiy/mortality
. infection is the usual cause of pre-term birth
. tocolysis masks the reason for the pre-term
. therefore it prolongs time baby in adverse env
ironment
. only recommended if the 1 wk extra can be used to give a cours
e of corticosteroid or in utero transfer
. or, in an emergency situation
. CCBs don't work as shown in poor PPROM outcomes
- no difference in perinatal mortality
- longer latency
- fewer births within 48 hr
- incr risk of 5 min APGAR < 7
- incr need for ventilation of the neonate
- incr chorioamnionitis (in beat-mimetic subgroup and <
34 weeks)
- non-pharm (hydration, bed rest) - no benefit
- abx in context of intact membranes (60% preterm due to infection)
. no benefit on neonatal outcomes with an incr in neonatal morta
lity
. not recommended
. incr risk of cerebral palsy (RR = 2)
- abx in context of ruptured membranes
. improves outcomes in short-term
. erythromycin 250 mg QID oral for 10 days
. NOT augmentin (assoc wih incr necrotising enterocolitis)
. reduces chorioamnionitis
. reduces babies born within 48 hr
. reduces
- neonatal infecton,
- use of surfactant,
- O2 therapy and
- abn cerebral USS prior to discharge from hospital
. No difference in perinatal mortality or longer term outcome
- MgSO4 magnesium sulfate for neuroprotection of fetus (cerebral palsy)
- given to all babies born up to 33 weeks (requires nursing bc o
f side effects)
- give within 4 hr of birth
- 4 g loading dose, 1 g hour thereafter (not changed for twins e
tc)
- MOA
. reduces neuronal injury
- down regulates excitatory stimuli (glutamate)
- blocks NMDA receptor preventing influx of Ca t
hat causes cell death
. vasodilation may incr cerebral blood flow and minimise
cerebral hypoxic ischaemic damage

. prevent neuronal injury by protecting agaainst proinfl

ammatory cytokines
. anti-apoptotic effects thus directly reduced neuronal
loss
- outcomes
- reduces cerebral palsy
- reduces gross motor dysfunction
- no effect on mortality
Preterm parturition syndrome
- eti
. infection - 60%
. ischaemia
. uterine overdistension
. congenital disease
. abnormal allograft rxn
. allergic phenomenon
. endocrine disorder
Preterm birth - abx
- in presence of intact membranes
Cerebral palsy
- motor, postural dysfunction non-progressive + cognitivie impairment
- 2/1000 live births
- RFs
. pre term birth
. chorioamnionitis
. APH
. multiple preg
. placenteal insuff
. perinatal asphyxia
. neonatial IVH
. periventricular leucomalacia
. low birth weight
. preterm < 34 wk
Outcomes for preterm better if tertiary hospital
PPROM - preterm (<37 wk) premature (not in labour) rupture of membranes
- betamethasone
- erythromycin (if ruptured membranes)
- MgSO4 if < 33 wk (4 hr window)
- move to tertiary hospital
- not nefidipine (not in labour)
PROM and TPL - preterm rupture of membranes and threatended preterm labour
- betamethason
- erythromycin
- MgSO4
- nefidipine
- move to tertiary hospital
Intact membranes and TPL
- betamethasone
- NO abx
- MgSO4
- nefidipine
- move to tertiary hospital
PPROM 35 wk (ruptured membranes)
- erythromycin
- no corticosteroids (too late - no benefit in outcomes)

ot giving
-

no nefidipine (not in labour, don't need to buy time for steroids bc n

steroids)
don't need to move to a tertiary hospital
not MgSO4 (too late)

premature - not in labour rupture of membranes

------------------------------PWH - Breastfeeding
_______________________________
FETAL RISKS OF NOT BREASTFEEDING = incr risk/rate of folowing
- infection (otitis media, LRTI, URTI, diarrhoea, bacterial meningitis,
sepsis)
- SIDS, necrotising entero-colitis,
- atopia: dermatitis, leukaemia, lymphoma, hodgkins dz, asthma, diabetes
- Temp, resp disregulaton
- decr cog, dev
- incr obesity
MATERNAL RISKS OF NOT BREASTFEEDING
- htn, DM, hyperlipidemia, CVD, metabolic syndrome
- breast ca, ovarian ca, RA, post natal depression
- bone health
- incr sleep dist
- decr post partum weight loss
- lack of amenorrhoea
What breastfeeding does for mothers
- involution of uterus
- hormone (oxytocin) release inducing mothering behaviour (wellbeing, lo
wer BP, relaxed)
- delayed ovulation and menstruation
- protection against breast and ovarian cancer and osteoporosis
Breast development
- mammogenesis
. prepubertal
- primary and secondary ducts from fetal development
- dependent on estrogen and EGF
- does not occur in absence of ovaries
. puberty
- branching of ducts
- proliferation of end of alveoli
- connective tissues formed
- changes throughout menstrual cycle
- ductal and lobular proliferation during follicular sta
ge and luteal phase
- regresses after menstrual phase
- ovulatory cycle enhances mammary growth up to 30 yr as
post menstrual regression of glandular alveolar growth after each cycle is not
complete
. pregnancy
- incr in ductular sprouting, branching and lobular fomr
ation due to
. placental lactogen
. prolactin (essentail for complete lobular-alve
olar)
. chorionic gonadotrophin
- colostrum appears from wk 12
- lactogenesis 1
. milk production inhib by hi progesterone and estrogen

. from wk 28 (colustrum is thick, different colours - yellow to

bloody)
. incr in lactose, total protein, immunogloubulin, decr in NaCl
. milk produced in an alveolus
. it is surrounded by a layer of myoepithelial (muscle) - which
are stimulated by oxytocin (also causes uterine contraction)
. pushes milk to ductal system
- lactogenesis 2
. incr blood flow and O2 and glucose uptake in breast 3 d post p
artum + incr milk production (+all components)
. plean in alpha-lactalbumin
. postpartum fall in progesterone and hi prolactin levels
. change in secretion of protectgive factor
. compositions changes to mature milk over next 10 days
- variants
. engorgement (bilaterally, firm + red, mx with frequent feeding
)
. mastitis (unilaterally, red and lumpy and painful, unwell, mal
aise, common in early)
- lactogenesis 3
. also know as galactopoiesis
. establish mature milk supply
. maintenance of lactation until weaning
. blue/white colour - fat sits at top
Hormones in breastfeeding
- prolactin - miokk producting
. stimulated by baby sucking
. stimulates IgA from gut associated lymphoid tissue for develop
ment of mammary gland immune system
- oxytocin - let down reflex
. contraction of myoepithelial cells arund alveoli
- sheehan syndrome
. if post partum hemorrhage - ischemia to pituitary gland - shut
s down breast milk production
. followed by pituitary dysfunction
Helping breastfeeding start
- skin to skin soon after birth for at least an hour - finds its way to
breast to feed - also helps regulate baby temperature - and respiratory and hear
t rate
- bonding
- suckling stimulates uterine contractions
- accelerates lactation
- exposes baby to mothers skin flora
- transmission of colostrum antibodies
. mother ingests pathogen
. activates GALT (B cells in peyers patches)
. B cells migrate to breast and become plasma cells
. secreted IgA into milk
Feeding
- Baby led feeding is the gold standard - self attachment
- positions - reduces blockages, mastitis, good supply
- chest to chest and babies chin to breast
- takes a long time at first, then gets quicker
10 steps to successful breastfeeding
1- Have a written breastfeeding policy that is routinely communicated to
all health care staff
2 - Train all health care staff in the skills necessary to implement thi
s policy
3 - Inform all pregnant women about the benefits and management of breas

tfeeding.
4 - Help mothers initiate breastfeeding within a half hour of birth
5- Show mothers how to breastfeed, and how to maintain lactation even i
f they should be separated from their infants.
6- Give newborns no food or drink other than breastmilk, unless medicall
y indicated (eg hypoglyceia, distress/meconium, mother DM).
7- Practice rooming in allow mothers and infants to remain together 24 h
ours a day.
8- Encourage breastfeeding on demand.
9- Give no artificial teats or pacifiers (also called dummies or soother
s) to breastfeeding infants.
10- Foster the establishment of breastfeeding support groups and refer m
others to them on discharge from the hospital or clinic.
Breast milk components
- fats, tags, lipid - half of total caloires
. breastfed infants accumulate DHA in cortex for duratioin of br
eastfeeding (whereas formula fed infacnts maintain the amount present at birth)
- implicated in visual performance of breastfed infants
- CHO, lactose (enhacne Calcium absorbpion), oligosaccharide (helps grow
th of lactobacillus bifidus incr gut acidity and stemming growth of pathogens),
galacvtose, fructose
- protein - whey 60% (forms curds in acid stomach for easy digestion containts lactalbumin, lactoferrin, serum albumin, immunoglobulins, lysozyme), c
asen 40%
. Lactoferrin inhibits the growth of iron dependent bacteria in
the GIT
. Immunoglobulin and lysozyme play important roles in immunologi
cal defence.
. Colostrum and milk contain IgA and IgG
. Lysosyme is a non specific antimicrobial factor.
- Colostrum contains higher concentrations of protein than mature milk,
due to the presence of?ntibody rich proteins and additional amino acids
- babies may need vit K, vit D supplements, vit B12 in vegan women
lysozyme - pulls bacteria from cell wall
mucins - adhere to bacterial receptor, bacteria cannot attach
Lactoferrin : Deprives pathogens of iron
Oligosaccharides Block bacterial attachment to GIT wall
Bifidus factor , Promotes gram+ lactobacilli
Lipids , Envelope viruses and inactivates them
------------------------------PWH - Perinatal infection
_______________________________
adaptive immune decr
innate imm incr
physiological adapt
- urinary stasis (UTIs)
- respiratory
mode of transmission
- transplacental
- ascending infection from vagina to cervix
- retrograde seeding from peritoneum via fallopian tubes
- iatrogenic - invasive procedures eg amniocentesis/CVS
Indications for testing for infection
- antenatal screening
. hep B, hep C, HIV, syphilis, rubella immunity, GBS
. gonorrhea, chlamydia in hi risk (< 25 yr, HIV)

- mother exposed to pathogen

. eg from daycare
- sonographic markers found on ultrasound
- symptomatic maternal infection
- pre term rupture of membranes PPROM
. low vaginal swab GBS
. mid stream urine
Infections
- TORCH toxoplasmosis, rubella, cytomegalovirus, herpes simplex, and HIV
,
- viral - rubella, varicella, cmv, parvovirus, hsv, hiv, hep B/C
- parasite - toxoplasmosis
- bacterial - syphyilis, listeria
Rubella
- teratogen
- trans - respiratory droplet to mother
- maternal inf
. rash, fever, cough, conjunctivitis, arthralgia, lymphadenopath
y
. only 50% are symptomatic
- ix - materal serology =
. IgM positive, conversion to IgG
- risk of congenital rubella varies with timing
. < 8 wk = 100 %
. 8-12 wk = 50%
. 12-20 wk = 20%
. > 20 wk = < 1%
- Dx
. amniocentesis -> PCR, rubella IgM
- GREGGs triad = COngenital infection PC
. eyes - cataracts, salt and pepper retinopathy
. heart - pds, ps
. ear - sensorineural deafness
- prevention - vaccination
. live vaccine
. if they are pregnant at the time of vaccine -> be reassuring no reports of congenital rubella from the vaccine
- treatment
. termination of pregnancy
Varicella
-

zoster virus
3/1000 in pregnancy
2/100,000 congenital
transmission
. to mother via - secretions from nasopharynx, vesciular fluid c
ontact, airborne
. crosses placenta
. reactivates inutero, migrates down azon
- check for infectio at the 1st visit
- prevention - VZIG
- Ix - varicella Ab
- Dx
. vesicular lesions on erythematous base
- fetal effects after reactivation - issue is activation witin the 1st 2
0 weeks of gestation
. skin scars
. limb hypoplasia
. mm atrophy

. chorioretinitis
. cortical atrophy
. low birth weight
- maternal complications - major complication is the pneumonia which has
40% mortality
. prodrome - fever, malaise, myalgia
. vesicular rash
. infectino of vesicles, pneumonia, glomerulonephritis, myocardi
tis, CNS involvement
. varicella pneumonia - 40% mortality, supportive + acyclovir
- if mother is IgG negative within 96 hours - can give passive Immunoglo
bulin
- if outside of 96 hours, then can only give acyclovir
- infection rates bw 5 days before or 2 days after delivery - 50% transm
ission rates
. give baby VZIG, acyclovir
- infectious starts from 2 d before lesion until crusting over
Risk of amniocentesis of miscarriage is ~ 1%
CMV is not screened for in transfused blood
CMV
- most common congenital infection 2% live births
- transmission
. to mother - urine, nasopharynx, blod
- maternal primary infection - asympt or fever, malaise, LNpathy
- reactivation of maternal infection can cause fetal, or perinatal infec
tion
- congenital cmv
. microcephaly
. deafness
. ascites
. hydrops fetalis (fluid in 2 or more body cavities eg lungs, ab
domen, brain, pericardial effusion, pleural effusions, calcificaiton in brain of
abdomen on ultrasound)
. oligo/poly hydramnos
. hydrocephalus
. IUGR
. intra-cranial calcification
. abn calcification
- serology
. IgM + initially
. need to test for IgM 2 wk later as well bc IgM can remain posi
tive for 12 mo
. hi IgG = primary infection
. IgG avidity (how well the antibodies bind to the IgG) = indica
tes whether it is a primary or reactivation
- if low avidity = primary (no time to develop)
- if hi avidiity = reactivation
. eg
IgG(+), IgM(-) = past infection
- Dx
. amniocentesis PCR
. fetal serology 6 wk after infection
- vaccination ?
. none available
- tx during pregnancy
. hyper-immune globulin (but CRISP trial found no difference in

congenital infection + incr risk of harm)

. anti-virals (no strong evidence)
- screening
. why is this not screened for along with the other things at th
e antenatal visit
. bc most women are IgG positive
. we don't have any real treatment for CMV
. we don't good diagnostic test for it ie IgG
- blood transfusions in pregnancy
Parvovirus B19
- PC = erythemia infectiosum OR Fifth diseease
. red maculopapular rash (slapped cheek), arthralgia
- risk of acquiring in pregnancy = 1/400
- Dx
. maternal serology
. IgM detectable within 3 wk of exposure
- no intervention to prevent fetal infection available
- Fetal effects
. abortion
. fetal death
. hydrops fetalis
. aneamia
. myocarditis
- Mx
. monitor titres for seroconversion
. monitor fetal aneamia (fetal movement, US assessment of MCA bl
ood flow)
- look at the velocity in the MCA bc with anemia, the MC
A velocity increases.
- interuterine transfusions (umbilical cord -> into umbi
lical vein; risk of 10% fetal loss
HSV
- maternal infection - vesicles on genitalia, painful ulcer on rupture,
fever, malaise, jaundice, encephalitis
- neonatal
. acq thru delivery
. rarely intra-uterine infection (spontaneous abortion, IUGR, pr
eterm labour)
- Mx if lmaternal esions during delivery
. IF primary infection (lesions/vesicles) = CS recommended
. IF secondary infection =
. use acyclovir to reduce risk of neonatal hsv
- previous maternal lesions
. acyclovir from 36 wk to decr chance of reactivation at birth +
asymptomatic viral shedding
HIV
-

90% of HIV in children due to vertical transmission

Australian prevlance in pregnant women = 1/10000
neonatal transmission reduced with anti-retroviral therapy
mode of transmission - mostly worried about breastfeeding
. antenatally in utero
. intrapartum (best to do CS + HAART)
. breastfeeding 45% (decr with HAART, 8%)
. haematogenous (when hi viral load)
- Mx
. routine screening
. perinatal transmission preventable - HAART
. deliver at 36 + detectable viral load + HAART = LSCS delivery

. deliver at 26 wk + non-detectable viral load + HAART = NVD (no

rmal vaginal delivery)
. bottle feeding best
. infant prophylaxis
- screening
. first visit
. 28 weeks
- risks of HAART in pregnancy
. preterm birth
. gestational diabetes
- post natal
. bottle feeding
. infant propylaxis
Hep C
- perinatal transmission occurs in women who are RNA positive 5% - rarel
y if RNA negative
- mode of delivery
. normal delivery
. nothing to cause blood transmission eg fetal scalp clips etc
- breast feeding recommended as long as no cracked nipples
Toxoplasmosis
- pc - fatigue, myalgia, LNpathy, asymptomatic
- not screened for in Australia
- trans
. eating raw meat
. soil contaminated with occytes in infected cat faeces
- ix
. serological
. raised IgG
- fetal infection more likely if maternal infection later in pregnancy
- congenital infection
. venticulomegaly
. intracranial calcifications (ddx - CMV)
. hydrocephalus
. microcephaly
. developmental delay
. chorioretinitis
. low birth weight
. hepatosplenomegaly
. jaundice
. anaemia
- Mx
. abx tx reduces risk of fetal sequelae
. spiramycin (reduces load of toxoplasmosis)
. pyrimethamine/sulfadoxine + folinic acid
Symphilis
-

VDRL a screening test (risk of false positive)

TPHA used to correct false positives
can be transmitted to fetus from 2nd trimester
tx - with benzathine penicillin
notifable disease
also treat partner

Listeria
- food born (raw vegetable, milk, fish, poultry
- materal sx
. sepsis

. flu sx
. fever
. malaise
. abd pain
- serology not useful
- dx requires listeria monocytogenes = swabs, culture
- fetal infection
. fetal death
. prematurity
- meconium stained liquor + preterm labour
- (ddx meconium stained liquor - usually post term t/f preterm stained l
iquor = listeria)
- tx with penicillin
Pertussis
-

(whooping cough)
~12000 cases in 2015
1/200 babies under 6/12 die from pneumonia complications
3rd trimester pregnant women recommended for DTPa
. transplacental transfer (pertussis antibodies passive protecti
on of newborn)
. antibody levels peak 2 wk after vaccination, transport from 30
/40
. given each pregnancy
. vaccinate all contacts of the baby
- transmission = transplacental or ascending
- prevention = immunisation
COmplication summary - TORCH
- Toxo (spiromycine)
- OTHER
- parvovirus - fetal aneamia, hydrops (US)
- listeria - milk products, meconisum green liquor in preterm (n
ot post term), cultures (not serology), antibiotics
- HIV - CA + HAART
- HepB/C no invasive interventions in labour
- Rubella - bad early pregnancy, less so later (GREGGS)
- CMV - commonest perinatal infect, IgG avidity
- HSV - acyclovir for prev infected women
------------------------------PWH - Pelvic pain
_______________________________
hyperalgesia
- is an increased sensitivity to pain, which may be caused by damage to
nociceptors or peripheral nerves
- Hyperalgesia is induced by platelet-activating factor (PAF) which come
s about in an inflammatory or an allergic response. This seems to occur via immu
ne cells interacting with the peripheral nervous system and releasing pain-produ
cing chemicals (cytokines and chemokines
ddx
- PID
- endometriosis
- ectopic pregnancy
- appendicitis
- renal
------------------------------PWH - Menopause
_______________________________
secondary amenorhoea
- PCOS
- pregnancy

- hypoprolacintemia
- hypothalamic (stress, eating disorders, overexercise)
- eary menopause (ovarian insufficiency)
defn
- permanent cessation of menstruation resulting from loss of ovarian fol
licular activity
- ie 12 mo of amenorrhoea
- mean age 51
- no independent biological marker
oocytes
-

born 200,000
sx when less then 1000
menopause - when all gone
different ages - lose them faster, or different numbers to start with

Hypothalamus-pituitary ovarian feedback

- hypothalamus makes GnRH
- anterior pituitary - gonadotropins (LH, FSH)
- stimulates ovary
- ovary produces
. inhibin (negative feedback on pituitary)
. estradiol and progesterone = negative feedback on hypothalamus
, pituitary
. AMH antimullerian hormone
peri-menopausal profile due to loss of ovarian follicular activity
- incr
. FSH
. LH
- decr
. inhibin
. AMH
. E2 + P
compare in hypothalamic amenorrhoea
- problem is in the hypothalamus
- low FSH, LH and estrogen
STRAW classiciation of reproductive age
- menopause transition
. menstrual irregularities (length > 7 d, variable lengths, inte
rvals of cycles)
post menopause
- low fsh, amh, inhibin
Menopausal signs and symptoms
- universal across races - but different dominant manifestations
- Central
. Hot flushes, night sweats. insomnia,
- Muswloskelelal
. Aches and pains, osteoarthritis
- Vulva and Vagina
. Dryness (loss of estrogen - > re-colonisation with different f
lora profile -> incr risk of UTI), loss of elasticity, thinning labia, dyspareun
ia
- Skin
. Dryness. thinning, loss of elasticity. formication

- Bladder
. Urgency. frequency, increased UTI; stress incontinence (cannot
be treated with estrogen)
- Hair
. Thinning scalp and pubic hair, increased fine facial hair
- CNS
. Mood and memory changes
- Cardiovascular
. Increased metabolic disease
- Skeletal
. Increased bone loss, osteoporosis and fracture
Hot flushes
- epi
.
.
.
.

70% women
sudden onset after oophorectomy
1-5 yrs but 10% still experience past 70yr
best not to remove ovaries before 65 yr unless indicated by BR

CA-1/2
- ddx
. Fever Anxiety Alcohol consumption Narcotic withdrawal Roseac
ea Migraine Parkinson's disease Diabetes Hyperthyroidism
. Anaphylaxis Pheochromocyloma Carcinoid The dumping syndrome R
enal cell carcinoma Cushing Syndrome Thyroid carcinoma Alcohol dehydrogenase de
?ciency
. vasodilators. Ca channel blockers. narcotics, SERMs (tamoixfen
, clomiphene). Aromatase inhibitors
Mx menopausal sx - gold standard = HRT
- reassurance - normal, expected
- Life style changes
. Avoid . spicy food, alcohol. coffee. excitement. tight ftting
clothes
- Clonidine
. A(+)
. reduction in hot flushes - 50 mg TDS
. SE - dry mouth, drowsiness, constipation
- SSRI /SNRI
. paroxetine, venlafaxine, desvenlafaxine, citalopram, escitalo
pram
. 67% reduction in flushes within 2 weeks
- Gabapentin
. hypothalamus MOA on temperature center
. effective in doses 600-2400 mg
. causes somnolence/sleepy/cognition
- HRT
. gold standard
- CBT
- no evidence for
. phytoestrogens
. chinese herbs (= placebo)
. acupuncture
HRT
- E
.
.
.
.
.

only after hysterectomy

no role for P other then protecting uterus
do not use estrogens in breast cancer
reduces risk of CHD
incr risk of stroke, VTE (esp in 1st yr, but low overall absol

ute risk, decr risk with using low dose patches rather then oral)
. best if < 60 yr or 10 yr after menopause.
. no incr risk in breast cancer (possible reduced risk for 20 yr
of use)
- E + P
. when uterus is present
. use sequentially so that you get withdrawal bleed, or use cont
inously for no periods
. do not use estrogens in breast cancer
. reduces risk of CHD
. incr risk of stroke, VTE (esp in 1st yr, but low overall absol
ute risk, decr risk with using low dose patches rather then oral)
. best if < 60 yr or 10 yr after menopause
. incr risk of breast cancer in LONG TERM /CONTINUING users (but
small, incr with duration of use, decr after stopping use, reduced risk in NEW
USERS)
- low genital tract
- topical low dose E is preferred for thos women whose symptoms are limi
ted to vaginal dryness and dyspareunia
- effective and appropriate for prevention of osteoporosis related fract
ure in at-risk women bf age 60 yr or within 10 yr after menopause
. 2nd line for osteoporosis (after bisphosphonates, ranelates, R
ANK-L inhibitors (denosumab))
- CVD
. standard dose estrogen alone - decr coronary disease and all c
ause mortality in women younger then 60 yr and within 10 yr of menopause
. harm in women over 70 yr
- Breast cancer
. incr risk with E + P combination for CONTINUING/LONG TERM user
s
. risk decr after treatment is stopped
. risk linked to duration of use
. decr risk in NEW USERS
- VTE / stroke
. incr risk
. but low absolute risk below go yr
. greatest risk in 1st year of therapy
. reduced risk in low dose patches (rather then oral)
Tissue specific estrogen complex (TSEC)
- HRT combining estrogen + SERM
. conjugates equine estrogens CEE / bazedoxifene (0.625, 0.45 /
20 mg)
- Acts entirely via Estrogen receptors
- Alleviates vasomotor symptoms (hot flushes)
- Protects endometrium
- Preserves bone density and reduces fracture
- Risk of VTE no greater than for E alone
- Does not stimulate breast tissue
A practitioners tool kit
- post menopausal
. removal of ovaries
. LMP > 12 mo ago
. cycle unawareness + sx
1. when was your last period
< 3 mo + regular bleeding
. pre- menopausal
< 12 mo + irregular bleeding

. peri-menopausal
> 12 mo
. removal of both ovaries
- YES = post menopausal
- NO
> 56 ?
. YES - post menopausal
. NO - are you using hormonal c
ontraceptino or HRT ?
2. are you using hormonal contraceptino or HRT ?
NO + age > 56 yr, LMP > 12 mo
- hsyterectomy, IUD, ablation
. YES
- cycle awarenss = pre-menopausal
- hot flushes, night sweats = post menop
ausal
- cycle unaware = post menopausal
. NO - post menopausal
what we need to know ?
- HX
. Gynae
- LMP, bleeding pattern
- hysterectomy/oophorectomy
- use of hormonal therapy
- contraceptive needs
. illnesses
- VTE/PE
- thyroid dz
- CVD
- osteoporosis
- DM
- depression
- liver/renal
- meds
. FHx
- CVBD
- osteoporosis/fracture
- cancer
- dementia
. Social
- OE
.
.
.
.
.
.
.
.
.

ht
wt
BP
CVD
resp
pelvic Ex
pap smear
breast check
thyroid assessment

- IX
. FSH, LH
- don't do if on hromonal contraception
. progesterone / AMH
- no value
- MID LIFE ASSESSMENT
. pap smear
. mammogram
. lipids

.
.
.
.
.
.
.
.

fasting BSL
TSH
FBC / ferritin
renal fucntion
liver fn
FOB
vit D
bone desnity

What to consider
- pre- or peri- menopausal
. health concerns including FHx
. general health and dz mx
. lifestyle issues - smoking, etoh, physical activiy, diet, bmi
. contraceptive requirements
- post menopausal, < 60 yr, < 10 yr since LMP
. the above PLUS
. mx of
- menopausal sz
- vulvo-vaginal atrophy
- sexual dysfunction
- osteoporosis prevention
Prescribing HRT/MHT
- perimenopausal, LMP < 12 mo, intact uterus
. continuous OCP (COCP) for contraception + cycle control
. sequential MHT
. IUD + estrogen
- post menopaus, LMP > 12 mo, intact uterus
. sequential MHT
. continuous combined MHT
. IUD + estrogen
- peri/post meno, post hysterectomy
. estrogen only
summary
The menopause is natural but its consequences may not be.
MHT is indicated for relief of vasomotor menopausal symptoms
Initiate therapy when symptoms are troublesome i.e. early
Start with a low dose and adjust as necessary
Use progestins only when necessary to protect the uterus Individualise t
reatment
Continue therapy for as long as required for symptom relief
In recently menopausal women MHT is bene?cial for cardiovascular and bon
e health
Always monitor long term health
------------------------------PWH - Fetal malpresentation
_______________________________
obstruction
- baby head too big
. macrosomia (abn big) - most common
- esp DM1
- also gestational DM
. hydrocephalus + assoc congenital
. hydrops +/- ascites
. tumors
- placenta previa (umbilical cord blocking cervix)
. differnt grades
- uterine fibroids

- cervical
. fibroid (most common) ~ 10 cm or bigger
. cerclage cervix
. cervical stenosis due to previous - LETs, cone biopsy
- pelvis
. non gyneoid pelvis (android pelvis)
. rickets
. displaced fracture from trauma
- vagina
. agenesis of the vagina
. stenosis eg stevens johnson
. female genital mutilation - (introitus) - mx with anterior epi
ziotomy (need to avoid the urethra by catheterisation)
- COrd
. shortened
. wrapped around neck
Difference bw mal-presentation and mal-position
- presentation = part of baby that is coming first eg breech
- anything other then head vertex is a mal-presentation
- withtin in presentation there are numerous positions - some are more o
ptimal then others
------------------------------PWH - Ectopic pregnancy
_______________________________
Ectopic preg = implantation outside of uterus/endometrial cavity
incidence = 2%
reasons for incr in ectopic
- assisted reproductive technologies
- incr in PID
- incr in diagnosis of ectopics (US, preg tests, awareness of population
)
- incr in maternal age
Historically what was the classic presentation ?
- 8 wk amenorrhoea
- vaginal bleeding
- acute onsent abdominal pain
- peritoneal irritation = shoulder tip pain, diarrhoea, incr rectal irri
tation/tenesmus
- collapse (shock)
Now
-

asymptomatic
incidental
slight pain
amenorhea

Site of ectopic
- tubes
- ampulla
- fibrillae
- less common - perineal, ovarian, abdominal, cervical
Heterotopic preg
- ectopic + normal preg

- 1/10000
US for ectopic
- starts with abdominal US
- move on to transvaginal US
When you ask which they would prefer trasvag or abdominal ?
- abdominal - requires full bladder, pushes hard
- they prefer vaginal bc don't require full bladder, better pictures
Likelihood of picking them up on US
- when hcg is > 1000 for transvag (higher resolution)
- hcg > 1500 for abdominal
- will never see a normal pregnancy at hcg 500
. can't say its normal, ectopic or abnormal
. follow expectant management (watch and wait)
- if normal pregnancy, hcg doubles (actually 70%) every 2 days
Never send a collapsed patient to
- US or MRI (donut of death)
- send to exploratory laparotomy
Medical management of ectopic
- indicated if
.
- contra
. fetal cardiac activity in tube
. lower then ~5000 hcg
- pharm
. MTX - 50 mg/m2 IM (chemo trained nurses)
- hcg will rise subsequently bc killin of trophoblasts w
hich lyse and release hcg; hcg will rise and peak by day 4 and then drop
- take baseline hcg
- lft - transaminitis
- take bloods - d 0, 4, 7
- determine effectiveness based on drop in hcg bw d 4 an
d 7
- expect 15% drop bw d 4 and 7\
- if no drop, or continuing to rise
. ? repeat dose, incr dose, laparotomy
- must track it down to a negative value
- monitoring takes 3 weeks
Surgicval options
- laparotomy or laparoscopic
- make hole in a tube - salpingostomy
- remove tube - salpingectomy = 95% ectopics
- no difference in subsequent pregnancy rates bw salpingostomy, salpinge
ctomy, medical management (assuming other tube is normal)
- salpingostomy
. need to be able to do it so that you can maintain the function
of the tube
. so that you don't rupture the ectopic
. don't cause bleeding into the peritoneum
Chance of recurrence after an ectopic
- 10% - need to document recurrence risk
- need to have vaginal scan at 6 wk of pregnancy
COnsenting someone for laparoscopy
- need to consent hysterectomy, laparoscopy, laparotomy, D+C

- laparoscopy
. GA
. overnight stay
. incision in umbilicus thru which camera is put
. secondary pores, same size as little finger
. pain
. risks (1/500 for any of the following - GA, infeciton - wounds
/pelvis, damage to bowel/vascular structures/ureter, coversion to laparotomy
. complicated by obesity, midline incisions.
- laparotomy
. GA
. overnight stay
. midline scar
. pain
. risks
- GA
- infection
- wounds/pelvis
- dg to bowel, vascular sructure/ureter (esp hysterectom
y 1% - lapaoscopic is most then vaginal, abdominal)
- VTE/DVT
- recvoery 3-6 wk
- D+C
. GA
. day surgery
. infeciton, bleeding, retained products
. ashermans syndrome
. perforation
. conversion to laparoscopy/laparotomy
Golden rule in laparoscopy
- patients get better every day
Give anti-D if the ectopic is rhesus positive
------------------------------PWH - Hypertension in pregnancy
_______________________________
SOMANZ - guideline for mx of hypertensive disorders of pregnancy
htn >140 or > 90 DBP (korotkoff 5)
severe = > 170 SBP, > DBP
. at this htn, cerebral autoregulation is overcome
. results in cerebral hemorrhage, PRES and hypertensive encephal
opathy
. emergency
Systolic pressure is more predictive of having a cerebrovascular event
Classifications
Preeclampsia-eclampsia
Gestational hypertension
Chronic hypertension
- essential
- seoondary
- white coat
Preeclampsia superimposed on chronic hypertension
Pre-eclampsia

- due to placental dysfunction

- delivery remains only cure
- PREVENTABLE
Epi of pre-eclampsia
- 15% cause of maternal death
- cause of death commonly due to intracranial hemorrhage
epi htn in pregnancy
- 10% women
- eclampsia is 5% of women
Dx of pre-eclampsia
- htn at > 20 wk, + one or more of
- renal
. protein/Cr > 30 mg/mmol (~300mg protein in 24 hr)
. serum-Cr/plasma-Cr > 90 micromol/L (normally Cr decr bc of inc
r GFR)
. oliguria < 80 mL/4hr
- haem
. thrombocytopenia (<100,000)
. haemolysis (incr in LDH)
. DIC
- liver
. elevated transaminases (AST, ALT)
. epigastric, RUQ pain
- neuro
. convulsions
. hyperreflexia with clonus
. persistent new headache
. persistent visual distubrance
. stroke
- lungs
. pulmonary edema
- fetal growth restriction
. abn umbilical artery flow
. oligo hydramnios (placental dysfunction - baby not making enou
gh urine bc placenta not perfused enough)
Exceptions to criterion for pre-eclampsia being > 20 wk
- molar pregnancy
- trisomy
- multiple pregnancies
NOTE
- proteinuria NOT requred to make clinical diagnosis
- Hyperuriceamia NOT a diagnostic feature (although it is a marker of re
nal impairment)
- HELLP is a form of severe pre-eclampsia (haemolysis, elevated liver en
zymes, low platelets) "weinstein"
- BP returns to normal (<140/90) by 3 mo postpartum
. if still high, then probably pre-existing htn/chronic htn
Getational htn
- new onset htn > 20 wk, w/o materal or fetal feature of pre-eclampsia
- up to 25% of gestational htn go on to develop pre-eclp
. bf 32 wk = 50% go onto to pre-ecl
. 24-28 wk = predictive of severe pre-ecl/HELLP

Chronic htn
- htn pre-exists < 20 wk or > 3 mo post partum
- RF for developing pre-ecl
- if pre-existing proteinuria, Dx of PET is difficult and requires other
features
Epi - pre-eclampsia
- 8%
- 60,000
- most deaths occur in 3rd world
- 1/20 stillbirths occurs in women with PET
- 10% preterm births <34 wk result from htn
Eti
-

endothelial cell dysfunction

all the involved organs have endothelial cells which are disordered
you only get it if you have a placenta
genetic abn on chromosome 13
. tri 13 will cause PET
- due to abnormal placenta developing
. poor implantation of trophoblast cell (abn invasion)
. trophoblast cells don't proplerly invade the spiral arteries w
hich supply the placenta
. the normal remodelling of the spiral artery does not occur
. ischemia -> vasospasm -> re-perfusion injury -> oxidative stre
ss -> placenta produces toxins -> enter maternal blood supply -> affect all endo
thelial cells in body -> produces syndrome
- toxins responsible for endothelial dysfunction
. sFLT and sEng proteins
HTN inx
- urine dispstick for proteinria - > 1+
- pre-eclampsia bloods (HELLP syndrome)
. FBC (low Hb from haemolysis, low platelets)
. EUC (hi Cr >90, hypernatremia)
. LFTsb AST, ALT
. urate (renal impairment)
- US
. fetal growth
. AFI (amniotic fluid index looking for oligo-hydramnios)
. Uterine artery doppler flow
. biophysical profile (marker of fetal activity in uterus)
- assessment in hospital if BP > 140/90 mmHg
. day assessment unit
. delivery suite
If women have a BP > 170/100, must urgently seek to reduce it due to risk of str
oke/intracranial hemorrhage and adverse fetal outcomes
Mx
- assess need for delivery
- the earlier in the gestation the higher the threshold must be bc of ad
verse effects to baby
- ABSOLUTE INDICATION FOR IMMEDIATE TX = severe htn >170/110
- but commence tx from around 140/90
- if <34 wk, antenatal corticosteroids
- if 160/110 + new proteinuria - requires delivery within 48 hr
- aim
.<150/100

Antihypertensive medications
- DONT USE ACE-I or ARB - due to teratogenicity, fetal renal impairment
and pre-term birth, and congenital heart disease
- 1st line
. labetalol (unless the women has asthma), or
. oxprenolol
- 2nd line - add on
. methyl dopa, or
. hydralazine, or
. nifedipine
- for severe htn (170/110)
. 10 mg bolus of IV hydralazine
Indications for delivery
- MATERNAL
. already term ie Gestational age > 37 weeks, no benefit in wait
ing bc the cure is the delivery of the placenta
. uncontrolled hypertension
. progressive decr platelet count (to below 50 = risk of spontan
eous bleed)
. intravascular hemolysis
. end organ dysfunction - liver function, renal function
. neurological sx
. persistent epigastric pain, nausea, vomiting + abn LFTs
. pulmonary edema
. if bw 20-24 wk, you are terminating the pregnancy ot save the
mums wife
- FETAL
. placental abruption (placenta coming away from the uterus)
. severe fetal growth restriction (oligohydramnios, abn doppler
flow (reverse flows show the baby will be dead within 48 hr)
. fetal heart monitoring showing distress
Eclampsia - seizures, convulsions
- resus - ABCs
- seizures
. tonic clonic
- IV diazepam (2 mg/min up to 10 mg) or clonazepam (1-2 mg over 2-5 min)
if seizure prolonged
- MgSO4
- 2% mortality
Can we tell which women are at risk - are there tests ?
RF for pre-eclampsia
- MAJOR (RR > 3)
. antiphospholipid syndrome (number 1)
. prev history of pre-eclampsia
. prev diabetes
. FHx pre-eclampsia
. nulliparity, multiple pregnancies (more placental mass -> more
toxins)
. BMI 25-30
. changing partners (bc immune tolerance is different)
- OTHER (also RR > 1)
. age > 40
. systolic > 130 bf 20 wk
. diastolic > 80 bf 20 wk
. renal dz
. autoimmune

. interpregnancy interval > 10 yr

. teenagers (limited exposure to paternal antigens
- PROTECTIVE
. smoking
. asian
SCREENING TESTS FOR PRE-ECLAMPSIA
- screening is not recommended - does not meet the criterion for a scree
ning test
- bc no predictive tests or preventative treatments
PROPHYLAXIS
- probably only aspirin
- aspirin
. bc Preeclampsia is associated with deficient intravascular pro
duction of prostacyclin (a vasodilator) and excessive production of thromboxane
(a vasoconstrictor and stimulant of platelet aggregation)
. decr risk of
. PET
. preterm birth and < 34 wk
.fetal/neonatal death
. SGA babies (small for gestational age)
. start at < 16 wk
- calcium supplementation
- vitamin
------------------------------PWH - Pernatal indigenous health
_______________________________
Examinable content = the reading material on blackboard
Criteria for screening test
- DISEASE
. public health impact
. intermediate probability
. detection befor a critical point (bf diagnosis; asymptomatic;
no diagnosis otherwise; in time to affect outcome)
- TEST
. sensitivity
. specificity
. tolerable
- POPULATION
. hi enough prevalence to allow screening
. medical care available if screening test is positive
. patient willing to undergo further evaluation
Main concerns
- hi STI rate
- low ANC attendance
- iron deficiency anaemia - esp ante-natal
remote communities
- 1/4 women have an STI (chlamydia, gonorrhoea, syphilis, trichomonas)
- poor health, infertility, ectopic pregnancy
Acute presentation
- disseminated gonococcal infection
- PID/ acute abdomen
- sepsis + ICU
Indigenous women - leading causes of death
1. CVD
2. cancer
3. diabetes, malnutrition related, metabolic (obesity)
4. respiratory disease (smoking)
Cervical cancer - RR = 5 for ATSI women

cells of cervix
SCC - 66% (outer surface)
adenocarcinoma - 20% (glandular - canal)
screening - pap smears
. pick up pre malignant changes

Targets
- 1st presentation prior to 20 wk
- more than 5 ANC visits per pregnancy
- US in every pregnancy
- US at appropriate time for estimating gestastional age
- appropriate investigations - performed and checked in all pregnancies
Mortality
- perinatal mortality - 9/1000
- low birth weight baby - 8%
- birthweight - 3183 gm (3365 gm)
Poverty, low SES main facotr in worse health in ATSIC
------------------------------PWH - Infertility
_______________________________
PC of infertility
- 1/3 due to female
. ovulation
. pelvic - PID, fibroids
- 1/3 - male
- 1/3 - sexual dysfunction
Hx
- Female
. age, bmi
. duration of trying
. period hx,
. parity,
. sti
. pmhx (VTE/dvt, diabetes, breast cancer)
. social/occupation/alcohol/smoking
- male
. age, bmi, pmhx, STI, mumps, drugs
. surg hx - testicular/scrotal surg, hernia
. occupation/sedentary/chemicals
Ix
- female
. amh/afc (ovarian reserve), E2, day 2-FSH, LH, TFT
. day 21 progesterone
. BSL
. US for ovaries
. tubal visualisation
- hycosy (US + saline shows saline coming out of tubes)
- gives both tubes and ovaries
- HSG - dye injected and imaged (cannot see ovaries thou
gh)
- laparoscopic
. pap smear
. ante-natal screen (immune screen)
- male
. semen analysis
- volume (<1/5 mL, concentration < 15 Millon sperm/mL, m
otility 32%, vitality 58%, morphology 4%, antisperm antibodies > 50%)
CASE 1
- PC
- 28F, 29M

6mo trying
null parity
until 6 mo before on pill
previously regular, now irregular after pill
fat bmi 35
bp 140/85
acne/facial hair/male escutcheon
normal pelis
body normal sperm count

- ddx
- PCOS (US showing polycystic ovaries, hi androgens, TFT/Prolact
in ruled out as causes of amenorhea)
- ix
- HbA1c (DM) - fasting
- US for ovaries
- pelvic exame
- vitals, BP, BMI
- hormone profile
. LH, FSH, E2, androgens, GAI, serum HBG, prolactin, TSH
- lipids
- pelvic scan
- rotter dam criterion for PCOS = 2 of 3
. polycystic ovaries (incr ovarian volume OR > 12 follicles)
. hyperandrogenism
. oligo or amenor- rhea
- PCOS
. sx - amenorrhea, infertility, obesity, hirsuism
. excess LH and androgen
. assoc insulin resistance, DM
. hyperinsulinemia => incr ovarian androgen dysfunction => incr
LH
- mx
. weight loss (lifestyle)
. Diabetes management
. metformin (also has ovulation induction role - see bel
ow)
. ovulation induction - trying to get pregnant
. clomiphene 50 mg OD for 5 days d2-6 of cycle
- estrogen receptor blocker
. reduces number of receptors everywhere
including hypothalamus and pituitary
. therefore reduces negative feedback an
d induces incr hypothalamic-pituitary-gonadal axis and incr FSH/LH and t/f E2 responsible for ovulation.
- SE - hot flushes, sweats, pms
- complications - multiple pregnancies 7% (hyper
-ovulation)
. FSH + HCG injections - until ready to release egg; ind
uces follicular rupture
. aromatase inhibitor (letrozole)
- 5 mg OD, for 5 days d2-6 of cycle
. laparoscopic drilling (diathermy)
- same pregnancy outcomes as FSH injections
. metformin
- it lowers serum androgens and restores normal
menstrual cycles and ovulation.
CASE 2
- PC
. 35F P2, 45M no prev children, new r/ship
. 6 mo trying

. previously regular cycles/ normal pregnancies

- ddx
. male factor - sperm
- ix
. semen analysis / sperm count
- repeat if there is an abn result
. scrotal/testicular ex
. hormone profile
. testoserone
. LH/FSH
. prolactin
. TFT
. karyotype (klinefelters)
. US scane
- testicular masses/neoplams
- blood flow/varicocoele (more heat into the scrotum)
. ligation
. interventional radiologist coiling (higher rec
urrence risk)
- causes of male inferfility
. low count
. low motility
. dysmorphic
. anti-sperm antibodies (sperm is haploid)
- mumps, testicular sx - expose immune system to sperm
- Mx of male low sperm count, normal karotype
. IVF (less then 2 mil count), or insemination (higher then 2 mi
l count)
- ovulation tracked and semen harvested and injected at
the right time
- IVF - egg + 50,000 sperm
- ICSI - egg + 1 injected sperm into the ovum
FSH
- makes cohort of follicles grow
- as a result of growing follicles, they make E2
- E2 incr
- feedback to pituitary
- causes LH surge and ovulation
- therefore have to use GnRH-antagonist or GnRH-agonist
- allow follicles to grow
- at the time we want to harvest the follicles - trigger with HCG (simil
ar to LH but with longer halflife) - then harvesting is 36 hours laters
hCG
-

softens granulosa cells

matures eg
ruptures follicle
changes the hormone3s

corpus luteum
- normally, LH pulses maintain corpus for 14 days
- IVF - LH pulses are suppressed, faster involution
Follicle monitoring
- monitor estrogen
- scan to see how many eggs to recover
Suppressing LH

- GnRH agonist
. lucrin, synarel
. long down regulation protocol required
- GnRH antagonist
. orgalutran, cetrotide
. short down regulation protocol
Preparing the eggs
- cause follicular release/rupture via HCG (longer half life then LH)
- objective
. good timing for softening of granulosa cells and maturing of o
ccyte
- avoid
. release of egg
. changing of the hormones
Triggering ovulation/egg maturation
-hCG - pregnyl, ovidrel
- aim = trigger egg maturation w/o release
- SE = may trigger overstimulation of ovaries
Monitoring
- day
- day
nt)
- day
- day
- day
- day

0 - take eggs out

1 - check for pro-nucleosomes (1 set of chromosomes from each pare
2
3
4
5

4 cells
8 cells
morula
blatocyst differentiated cells (periphery and central)
ready for transfer back

Embryo transfer back

- like a papsmear into the uterus
- occurs ~ day 5 after harvest
Supporting the luteal phase with progesterone
- required bc with IVF there are so many corpus luteum that the body can
't support so many and runs out very quickly - supplement required to prevent on
coming menstruation
- options vaginal pessary or hcg injection (to stimulate LH to maintain
corpus luteum which then stimulates more progesterone)
- supplement
- vaginal progesterone
. crinon, pessaries
. SE - mood swings, discomfort
- hCG injections to maintain endogenous progesterone secretion
. pregnyl, ovidrel
. SE - ovarian hyperstimulation
Embryo freezing
- addtional embyros frozen
- used for sibling or subsequent cycles if unsuccessful
- storage viabilty = 10 yr
Success of putting frozen embryos back in
- need to figure out when she is ovulating
- implanted 5 days after ovulation (bc the embryos are 5 days old)
- IF she has ovarian failure an no periods - when to put it back in ?
. simulate ovulation with hormones
. slowly incr estradiol (thicken lining) - monitor with US

. add in progesterone (simulates ovulaton)

. wait 5 days - then implan
. maintain E+P for entire 1st trimester
- if she stops it she will menstruate
- past 11 weels - the placenta is operating by itself an
d she can stop the medication
IVF success rates
- dependent on femals age
- bc incr number of embryos - incr potential
Risks and
-

treatment side effects of IVF

multiple pregnancies (depends on how many embyros put back)
ectopics (even though we are bypassing the tubes) miscarriage
ovarian torsion (diaphoretic, elevated wcc, fever)
. laparoscopy + untwisting)
- hyperstimulation syndrome
. PC - abdominal bloating and pain, decr urin outpute, N/V, diar
rhoea, SOB, thirst
. 1%
. dependent on number of follicles produced
. VEGF cause intravascular fluid shift out -> ascite + pulm edem
a
. supportive therapy - FLUID BALANCE, anti-emetics, analgesia, c
lexane/teds (bc dehydrated), renal functio,
. prevention in hi risk women (lots of eggs, PCOS, thin, young)
. hcg makes it worse t/f decr hcg concentration at time of ovula
tion trigger and at pregnancies
Multiple pregnancies
- 8% ART cycles
- due to transferring > 2 embryos
- risks of multiple
. premature brith
. RR=3 of perinatal death
. RR=4 cerebral palsy
- IVF australia - policy is single transfer embryo
Preimplantantion genetic diagnosis
-----------------------------PWH - Principles of Gynaecological oncology
_______________________________
Gynae cancers
- endometrial, cervical, ovarian, vulval, gestational trophoblastic dz (
moles)
- need to refer to book for all of these
Endometrial Ca
- epi
. most common gynae Ca
. incidence ~500/a
. most curable type
. 5th most common Ca in women (after breast, lung, melanoma, col
on
. 1/80 women
- incidence
. commonly > 40 yr
. peri/post menopausal
- RFs

. age
. hi SES
. unopposed estrogen exposure (constant stimulation of endometri
um w/o any cycling with progesterone)
- obesity (adipocytes store androgens and can convert ad
renal androgens into estrogens
- null parity (having children is protective)
- infertiliy
- early menarche
- late menopause
- tamoxifen RR = 2.5
- unopposed exogenous estrogen
- PCOS
. insulin resistance
- PCOS
- diabetes
. htn
- Hereditary endometrial cancer = HNPCC = LYNCH 2
. bowel cancer syndrome you get when you don't have FAP ie it is
a complex of cancers, in women manifesting most commonly as endometrial Ca, als
o a risk of colon and ovarian
. eti - micro satellite instability = MSH2, MLH1, PMS-1 and 2, M
SH6
. risk of endometrial Ca 50%
- Ix
. universal screening for stained mismatch repair genes
- Sx
. bleeding after menopause/irregularity
- PV discharge
- postmenopausal
- irregular
. dysuria
. painful bleeding + heavy bleeding
- Dx
. GOLD STANDARD = hysteroscopy and curette (D+C) biopsy
. cytology / papsmear (BUT IF NEGATIVE IT DOES NOT EXCLUDE CANCE
R)
. US (in post-menopausal women endometrial thickness of < 4 mm m
akes cancer unlikely; BUT if in pre-menopausal, the thickness varies with cycle
- ie thicker in 2nd half of cycle)
. screening for stained mismatch repair
. endometrail sampling with papelle
- Mx
. surgery
- total hysterectomy (tubes + ovaries) = bilateral salpi
ngo-oophorectomy
- pelvic/apara aortic node dissection
. radiotherapy
. chemotherapy
. hi dose progesterone (~500 mg) to try and reverse the neo-plas
tic process (usually in younger women)
. lymphadenectomy
- indicated for hi grade, deep myometrial invasion, unus
ual cell type
. NOTE THAT THE OCP DOSE OF progesterone is insufficient.
- prognosis - worse the deeper myometrial invasion and the higher the gr
ade
Ovarian Ca
EPI

- leading cause of death from Gynae Ca (90% will die)

. cf endometrial Ca which is most common Gynae Ca
- incidence incr after 40 yr
- peak 65 yr
HISTO
- 90% from coelomic epithelium
- 3 types of cells in ovary - stromal cells (theca, granulosa), germ cel
ls (oocytes), epithelial
. give rise to the different types of tumours possible
- germ cell cancers - younger women/teenagers
. sensitive to chemotherapy bc rapidly dividing
. BEP - bleomycin, etopside, platinum
- stroma cell tumotr (granulosa cells, leydig cell)
. either benign or low grade
. tx with surgery
. good outcomes
- epithelial Ca = 5 subtypes
. from tube, peritoneum, ovary = all same cancer
. most ovarian ca arise from the tube
. 5 types
- serous
- mucinous
- endometrioid
- clear cell
- transitional cell cancer
. spectrum
- benign = cyst-adenenoma
- borderline tumours
. any of the 5 cell subtypes (most common serous
, mucinous)
. proliferative
. irregular architecture
. hi mitotic count
. cell atypia
. stop invading at the basement membrane
- invasive ca
. invade and destroy normal tissue (THRU THE BAS
EMENT MEMBRANE)
. spreads trans coelomincall
RF
- > 40 yr
- low parity, infertility
- late mmenopause, early menarch]
- incessant ovulation
- fhx
- brca1 or brca2
- hnpcc
PREVENTION
- OCP
. progesterone causes formation of plug, stops invasion/transfer
from the tubes
- surg - for hi risk people (brca, hnpcc) - tubal ligation, bilateral sa
lpingectomy
SCREENING
- Not effective (transvag US, serum Ca 125

DX
- exclude non gynae cause
- menopausal status
- transvag US
- tumor markers
- examination - laparoscopy/otomy
CA125
- embryonal glycoprotein
- expressed in both benign and malignant cysts
- incr is due to incr proliferative/production + incr permeability of ma
lignant vessels and cyst walls
- low positive predictive value (<10%) bc of low prevalence of ovarian c
ancer
SURG
. Prophylactic Salpingo-Oophorectomy
. Staging Laparotomy
. Primary Cytoreductive Surgery
. Interval Debulking
. 2nd Look Laparotomy
. Secondary Cytoreductive Surgery
. Palliative Surgery
PROPHYLACTIC OOPHORECTOMY
- peri/post menopausal women
- fhx ovarian ca
- brca
- done laparascopic
STAGING LAPAROTOMY
- usual spread is to abdomen
- stage 1 (mucinous, less spread)- different biological dz to late ca (s
tarts in tube and spreads)
- Vertical incision
Peritoneal washings
Peritoneal biopsies
TAHBSO
Omentectomy
Pelvic and paraaortic
Iymphadenectomy Appendicectomy
PRIMARY CYTOREDUCTIVE SURGERY = DEBULKING
- THIS IS A GOOD PROCEDURE - IT IS EFFECTIVE
- remove as much tumour as possible
- best if Ca is < 2 cm
- impt bc prognosis is determined by amount of residual dz after surgery
- removes hypoxic cells (chemoresistant), enhances chemo response, remov
es santuary sites, decr proportion of cells in G0 (Chemoresistant), eliminate re
sistant clones, enhance immune function
- timing = during 1st line chemo BUT before the completion of that prima
ry treatment
PALLIATIVE SURGERY
- indicated for
. bowel obstruction in end stage dz
. refractory to chemo

CHEMO
- 1st line TREATMENT for advanced ovarian cancer (surgery prescribed abo
ve is done as adjunct)
- carboplatin, taxol
Cervical Ca
EPI
- 1/218
- 2nd most common cause of cancer death in women worldwide
RFs
------------------------------PWH - HPV vaccine and cervical cancer prevention
_______________________________
HPV virology
- small 55 nm, dsDNA
genome protected within protein capsule
- E6,7 are oncogenes - inserted into the host genome
- L1,2 capsid genes - coat the genome (used in vaccination process)
- primary target is basal cell of squamous epithelium (mucosa)
- hi risk = 16/18 (cause 70% of cervical cancers)
- low risk = 6/11
- risk of progression = immune dysfunction eg smoking, steroids
- guardasil vaccination = 6,11,16,18
- 10% of cancer in either sex (equal proportion)
- most sq cell carcinoma
. anal 85%
. vulval, vag, penile 50%
. oropharyngeal 20%
. genital warts>90%
- > 50% women within 3 yr of first intercourse
- condoms do not stop transmission
- bw 14-20 yr old, 30% HPV 16, 20% HPV 18 within 4 yr
- time from acquisition to cancer presentation = 10 yr
RF
- multiple partners
Natural history
- exposure
- acute infection + viral replication
. cordocyte (abn papsmear cell)
- subclinical = transient, latent, persistent
- transient 90% - cleared infection w/in 3 yr
- latent = no HPV dna but low level HPV infection long term
- persistent 10% = long duration of infection + dna - usually HPV 16 = l
eads to cervical cancer
- clncial pc
-> condylomata (warts)
-> CIN 1
-> peristent ifnection
-> hi grade cellular dysplasia
-> carcinoma in situ
-> invasive
Cervical epithelium changes
- koilocytes (perinuclear clearing after infection
- viral microparticles
- CIN 1,2,3 = how much epithelium is affected based on basement cell (2=

2/3), 3= full
Hi grade lesion (CIN 2 and 3)
- 35% OF cervical HG lesions will regress in 6 mo
- 1 % of vulval/vaginal HG lesions will regress, 9% progress
Cervix cancer
- mostly 30s-40s
- incidence 720/a
- 215 deaths/a (mostly due to those that don't participate in the screen
ing program)
- 2/100,000 deaths
- disease is of the unscreened
- atsic RR = 2 (ie not screened)
Beenfit of screening extend beyond cervical eg anal, haed and neck
Vulval cancer
- warty/basaloid 20%
. HPV assoc 90%
. < 63 yr
. VIN 2/3
. multicentric
. same RF as cervix ca (ie they are also at risk of comorbid cer
vical ca)
- keratinising 80%
. HPV assoc 15%
. > 65 yr
. rare VIN 2/3
. no cervical ca risk factors
. assoc with long term skin condition
Genital warts can't be ignored
- short incubation time
- very common
- assoc with HPV 90%
Laryngeal papillomatosis
- benigin condition of new borns up to 5 yr
- warty appearance of resp tract
- causes hoarseness
- assoc hpv 6,11
- 1/500 births with genital hpv
- rarely after oral sex
- active HPV lesion is not an indication for caesar (not protective)
Gardasil
-

quadri-valent vaccine
derived from L1 capsid proteins of HPV types 6,11,16,18
recombinant (similar to heb B vac)
approved indications
. F 9-26 yr
. M 9-15 yr
- even if seropositive or PCR positive for one or more of the vaccine HP
V types - the vaccine is protective against the remaining HPV types.
- ~100% seroconversion of the antibody after 3 doses; the younger the be
tter the response.
- 80% coverage in females 12-18 yr
Cervarix

- type 16/18
Cross protection occurs
- 16/18 vaccine causes cross protection to the other hi risk types
Adverse outcomes of the vaccine
AUSTRALIA 4.7 mil doses
- 13 anaphylaxis (3/mil doses)
- 5 MS
- 1 pancreatitis
- no deaths
USA 23 mil doses
- 36 cases GBS
Results of vaccine
- decr HG SIL in under 18 yr
- no change in > 18 yr
Progression of the cancer is always associated with integration of the HPV genom
e into the cervical epithelium cells
------------------------------PWH - neonatal abstinence syndrome
_______________________________
mothersage.org.au
gaps in service
- due to stigma, discrimination, fear of DOCS removing baby
- 55 % of substance abuse pregnant women not regular use of antenatal ca
re
- failure in system to help baby
NSAHS
- CNC midwife
- mental health liaison nurse
- seen 2 wkly
- case worker at 24 wk
- antenatal case conference at 36 wks with DOCS
Substane spectrum in pregnant/breastfeeding women
- ETOH 53%
- tobacco 23%
- marijuana 7%
- illicit 8%
NSW infant deaths
- 162 deaths 2007
- 23 from SIDS (smoking, co-sleeping)
- most died in same bed as drug or alcohol affected parent
ETOH
- teratogen
- no safe limit
- Binge drinking assoc with fetal alcohol syndrom (>=5 drinks on one occ
asion)
- >= 3 SD/d incr psychomotor developmental delay
- brain dysmorphogenesis from above 100 mL/wk
- WA 60% drinking during pregnancy
Fetal alcohol syndrome
- prenatal and postnatal growth retardation
- CNS deficit
- facial
. short palpebral fissure
. elongated midface

. thin upper lip

. flattened maxilla
- behaviours
. completing tasks, recalling info, aggression, inhibition
. poor school performance
. poor impulse control
. deficit in language
. poor abstract thinking, arithmetic skills
- psych
. attention deficit hyperactivity disorder
. oppositional defiant disorder
. autism
. antisocial personality disorder
nb babies can get effects from caffeine withdrawal
Methadone
by DOCS

and preganncy
full opioid agonist
DON"T advise to quit heroin (cold turkey)
instead use methadone as substitution therapy
if mothers don't participate in methadone program - hi risk of removal
. risks of heroin - overdose, stoned, no regular mum for baby

Methadone maintenance
- reduces
. illicit drug use
. seeking
. fluctuation of opioid level
. malnutrition
. obstetric complications
- improves
. nutrtional status
. involvement in antenatal
- during pregnancy
. incr
- metabolism
- plasma volume
- renal blood flow
- during 3rd trimester, may need extra dosing bc of these physiological
cahnges
- objectives
- prevent withdrawal, cravings, euphoric effect of narcotics
Buprenorphine
- partial agonist of opioid receptor
- manages withdrawal
- fewer side effects then methadone
. less sedation
. OD of children
. drowsy
- dose
. sublinguial
. IM ampoules
. SC patch
- dosing every 3 days prolongs occupancy of opioid receptors
- t1/2 48 hr
- if combined with benzo = resp depression
Heroin
- miscarriage

PPROM
infect
preterm
fetal malnutrition, health, lifestyle

Cocaine (vasoconstrictor)
- fetal
. effects of vasoconstriction - kidney injury + CNS impairment
- maternal
. abruptio placentae
. spont abortion
. decr delivery duration
. obst complic
. premature labour
ICE, amphetamine
- no major fetal outcomes
- psych comorbid, preterm, child at risk, foster, domestric
- incr use in women
- incr levels in breast milk tf have to discard breast milk
Breastfeeding
- marijuana is liphophilic - distributes to fat
Nictoine,
-

tobacco
spont abortion
abrutpio placentae
plaenta previa
uterine bleeding
SIDS RR = 4.5
incr risk childhood cancer
tx - nicotine patches
nicotine . crosses placenta
. breast milk
. restrict placental blood flow = reduced oxygenation
. results in lo birth weight

"I don't smoke in front of the baby"

- 1 pack / d = 20 = 20 * 5 min = 100 min per day = 2 hr from baby
- realistic claim ??
Marijuana
- THC tetrahydrocannabinol
- same impacts as tobacco
Caffeine
-

low birth weight at > 6 coffee/tea/cans coke per day

irregular fetal HR late in preg
jittery baby on withdrawal
reflux (caffeine causes LES to relax

Types of drugs causing NAS

- depressants
. opiates, hypnotics, alcohol
- stimulants
. amphetamines, cocain,e caffeine, tobacco
- hallucinogens
. cannabinoid, lsd, pcp
- inhalants

- pyschiatric agents
Onset and duration of withdrawal
- IF short t1/2 = faster onset,
DRUG
ONSET with
methadone
3 d
heroin
2 d
cocain
3 d
benzos
6 wk
etoh
immed
stim
immed aft

shorter lasting, greater withdrawal

DURATION OF WITHDRAWAL
6 mo
3 wk
6 mo
6 mo
mo's
3 wk

After birth in context of NAS

- try not to separate mother/baby
- swaddle,
- quiet environemnt
- encourage breast feeding
. less withdrawal
. fewer meds needed
.lower finnegan scores
- contra to breast feeding = HIV, recent drug use, drug affected
- mnitor for NAS
- withdrawal pharm
. opiates for NAS opiates
. phenobarbitone for NAS sedative
- home service + follow up
testing before and after birth
- urine tests
- hair of baby (detects cocain,e amphet, metahdone)
. requires follicles
. indicates maternal drug taking for entirety of pregnant
. sesntive for cacaine and opiates
. less sensitive for cannabis
- meconium from 3rd trimester
NAS
-

hyperhagia (>190 mL/kg/d)

methadone mother
no incr wt
incr loss of wt in 1st week of life
finnegan score
. head sweating
. fever
. yawning freq
. mottling marbling discoloration
. nasal stuffiness, mucous
. sneezing freq
. nasal flaring
. RR normal, 30-60 /min
. feeding probelms
- either hypotonic or hypertonic esp limbs, neck
- stiffness maybe episodic/paroxysmal
- tremors, jerking, sings of distress (baby tring to con
trol uncomfortable sensatinos)
. GIT
- water/explosive diarrhe,
- excoriation,
- gas/constpiation

- dehydration
NEED TO BE ABLE TO FINNEGAN SCORE BABY
Morphine for opiate NAS
- only used if opiate exposure confirmed
- indicated if finnegan if more then 3 scores above 8 or one score of >
10
- 0.5 mg/kg/d spread across 4 doses
- gradually incr dose until scores < 8
- ECG monitoring
- no minimum dose for discharge
- add on phenobarbitone if not adquate
Phenobarbitone for NAS
- 2.5 mg/kg PO BD
- single agent for non-opiate withdrawal
- also indicated as an add on to morphine for refractory opiate withdraw
al
- incr by 1 mg/kg/day for 3 days until infacnt settles
outpatient monitoring
- sleeping, feeding, weight gain (hyperphagia), tone, irritability
weaning meds
- drop by mL not mg
- 0.1 mL per week
~2 mo for morphine
Finnegan score valid for opiates but also used for other drugs
Lifestyle, risk taking behaviour address
drug dependent parients (risk of inflicting psych, sexual, emotional abuse on pa
rents)
- agree on mx plans and document
- inform pt of statutory obligation to inform DOCS
Common nutritional problems in mothers due to diet, alcohol, smoking, marijuana,
infection
- premature
- malnurition and small for gestational age
- low omega 3
- low b12, b1, D, Fe
Problems due to maternal drug use
- SGA
- vit def
- breast feeding problem
- feeding vs NAS
- hi infant formula use
- growth failure
D+A affects on maternal nutrtion
- suppress appetite
- decr nutrient absorption
. cannabis - zinc
. cigarettes - iron
. alcohol - thiamine
- incr metabolic requirement
. amphetamines

- delayed gastric empyting - opiates

RF assessment materal
- low bmi
- low weight gain
- N/V/constipation
- SGA
- veiled, dark skinned women
- vegetarians
- eating disorders
EXAM
- how to ask history
- down to ther level, nonjudgemental
- symptoms of withdrawl
1. what going to happen to my baby (methadone baby)
. changes, mood, GIT, baby
2. will my baby withdrawal
. yes - controlled
3. sx of withdrawal
. tone, feeding, mood
4. what does score of 8 mean
. finnegans withdrawal scale indicating use of morphine
5. are you gong to use morphine ? methadone ?
6. can I breastfeed my baby
. we encourage breastfeeding for mothers not on drugs
. not compatible with maternal methadone use
7. can i go visit the baby in the nursery
. encourage you to spend as much time as possible with them
8. how long will the baby be on morphine for ?
. about 2 mo
9. can I learn to give the medicine ?
. yes
10. will DOCS be involved
. It is just a notification so that we can offer you more support
11. will they take the baby away from me
. only if the baby is at risk
12. can i breastfeed and take drugs
. not recommended, since it can be expressed thru bnreast mil and harm b
aby
13. i've heard about buprenorphine - what about it
. used for non opiate withdrawal OR as adjunct to morphine to refractory
opiate withdrawal
14. my baby is on morphine and I spilt it - can I have more please ?
. how did you spill it ?
. only give you enough for a daily supply
. it won't be enough to have any effect on the mother - no point in them
taking it
15. my baby is Nauseous but is sucking a lot - I have Hep C, my nipples are blle
ding
. try to use formula until nipples have stopped bleeding
16.
------------------------------PWH - hypoglycemia
_______________________________
fetal BG
- closely related to maternal BGL
- umbilical venous blood glucose is 2/3 value fo mothers BG level
- maintained by diffusion across placenta

- fetal gluconeogenesis and glycogenolysis are not active before deliver

y
Neonatal BG
- abrupt cessation of glucose diffusion across placenta
- trigger of gluconeogenesis and glycogenolysis
- normal to get a transient fall in BG for 2 hr post birth = ketone body
and lactate utilised for glucose
- it stabilises after 4 hr when counter regulatory hormones (glucagon, e
pi, GH, cortisol) induce glucose production
- persistent hypoglycemia = neurologic sequelae
Maternal factors affecting neonatal BG
- time since last food
- duration of labour
- IV glucose to mum
- diabetes, insulin therapy
4 things resulting in decr ability to respond to low blood sugars by utilising g
luconeogenesis and glycogenolysis - resulting in hypoglyc
1. lack of glycogen store
. stores in liver, muscle, fat
. reduced in pre-term,
. intra uterine growth restriction
. SGA
. < 2.5 kg
2. incr level of circulating insulin
. diabetic mothers
. growth restricted
.
3. XS utilisation of glycogen store
. hypothermic
. hyperthyroid
. tachycardic
. tachypnoeic
. sepsis
. encephalopathic
. macrosomia - > 4.5 kg
4. inadequate provision of susbtrate
. vomiting
. diarrhoea
babies of poorly control diabetes
- maternal hyperglycemia
- fetal hyperglycemia
- premature maturation of fetal pancreatic islets
- hypertorophy of beta cells
- neonatal hyperinsulinemia
- hi insuline but food stopped = hypoglycemia after interruption of intr
auterine glcuose supply from mother
preterm infants
- low fat, sepsis, asphyixated, unwell
- substrate deficiency secondary to immaturity of enzyme pathways
SGA, IUGR
mones may

babies
scrawny, low fat, low glycogen,
lack of substrate (adipose and lgycogen)
incr insulin
after delivery a poorly coordinated response of counter-regulatory hor
contribute to hypoglycemia in some infants.

Normal BG ~down to 2.6 mmol/L

Complications with BSL
- glucose essential nutrtient for brain
- accounts for 90% of O2 consumption
- occpital lobe is most sensitive to O2 deficit
- neurologic sequelae
Screen for HIGH RISK infants
- RF
. maternal DM
. SGA
. unwell
. premature
. big babies > 2.5
. small babies << 2.5
- non specific hypoglycemic sx
. jittery
. irritable
. poor feeding
. lethargy
. apnoea, cyanosis
. hypotonia
. convulsions
- Ix
. enzyme strip method - dexrostix
. poor accuracy below 2 mmol/L
. confirm with blood gas or formal blood sugar
Mx of asymptomatic hypoglycemia
- BSL < 2.6 mmol/L
- feed ASAP (within 2 hr)
- repeat 4 hrly
- supplementary feed with bottle/formula
- aim to raise glucose level > 2.6
- repeat BSL 30 min after feed
Mx symptomatic (apnoea, cyanosis, seizure, lethargy)
- transfer to NICU
- IV 10% dextrose first
- frequent BSL monitor
If BSL bw 2-2.5 mmol/L
- feed every 3-4 hrs
- monitor BSL bf feed for at least 24 hr and until2 consecutive BSL are
> 2.6 mmol/L
If BSL < 1.2 mmol/L
- establish IV access
. if unable - IM glucagon
- bolus 2mL/kg 10% dextrose first
- then IV fluids of 10% dextrose at 60 mL/kg/day
- recheck bsl 30 min after bolus
- if needed, give additional bolus
Persistent hypoglycemia
- collect insulin, cortisol, GH, ammonia, lactate, pyruvate, formal BSL
BEFORE hydrocortisone
. only can be interpreted if BSL is low ie to see what is causin

g the hypoglycemia (eg if hi insulin = hyperinsulinemia is causing the hypoglyce

mia)
- insuline level of > 10 mU/L when BG is < 2.6 mmol/L is diagnostic of h
yperinsulinism
How much glucose is required
- greater glucose requirement per kg then adults (larger brain / body ra
tio)
- normal production of glucose for baby is 4-8 mg/kg/min (6 times adult)
If persistnet (up to 4 hr) hypoglycemia after giving IV lfuids of 10% dex
- graded incr in volume or conetration of dextrose until 2.6 reached
- consider glucagon IM (but need glycogen in liver tf not good for small
baby) or hydrocortisone (incr BSL), or somatostatin, surgery to remove pancreas
- blood tests
Glucagon
-

0.1 mg/kg IM or IV
incr BSL
good for IDDM
not good fo SGA, premature - low glycogen stores
rebound hypoglycemia after 2 hr
need to follow by continous IV dextrose therapy

Hydrocortisone
- 10 mg/kg/d IV between 2 doses until BSL stable
- BEFORE administration - take, cortisol, GH, insulin, BSL levels
Diazoxide
- 15 mg/kg/d across 8 hr
- only for hyperinsulinism
Eti hypogly
- Hyperinsulinism
.IDDM (transient hyperinsulinism)
. Persistent hyperinsulinemic hypoglycaemia of infancy (beta cel
l hyperplasia)
. Beckwith Weideman Syndrome
- Inborn errors of metabolism
. Glycogen storage disorder
. Fatty acid oxidation defects
. Organic acidemias
- Other causes
. Congenital hypopituitarism
. Congenital adrenal hypoplasia
------------------------------PWH - ethics in neonatology
_______________________________
right of fetus - no rights under australian law
Four areas that are Intrinsic to every clinical encounter
1. Medical indications: Diagnosis, treatment
2. Patient preferences: wants, capacity to decide, informed
3. Quality of life
4. context social, legal, economic, institutional
The principles of medical ethics
1. Knowledge = information -> Guidance for choices that are made
2. Beneficence: doing good - Do all to benefit the patient is the primary

goal of health care - Patient-oriented-Value Human Life

3. Autonomy: - respect beliefs <5 values of others - Do not interfere w
ith the choices of others
4. Quality of life
5. Legal rights
6. Infants best i nterest'
7. Justice: Persons should be treated equally
Code of ethics:
Australia:
- late term abortion is severely restricted
- treatment to newborns may be withdrawn.
- Full moral and legal status is granted to newborns
- No moral and legal status given to a fetus.
- Information concerning survival and likely outcome should be readily available.
- if born at 24 wk
. 60% survive
. QoL - 1/5 will have neurodevelopment disability (cerebral palsy, glass
es, bilateral hearing aids, reduced IQ)
Ethical principles pertaining to the newborn baby
- Baby's best interest is primary - legally and ethically
- Every baby has the right to:
- life (sanctity of life)
- optimal treatment & care
- love & protection
- a family
- However...a babies interest may be best served by discon inuing or for
egoing treatment
- Not in the best interests of the baby to insist on the imposition or co
ntinuance of treatment to prolong life....when doing so imposes an intolerable b
urden
- There are some circumstances in which im osing or continuing treatment
to sustain a babies life results in a level of irredeemable suffering such hat
there is no ethical obligation to act to preserve that life"
- When we cannot obtain direct consent for Rx and procedures, clinicians
& parents must decide which Rx option the patient would choose
- Based on:
. Severity of medical condition
. Reversibility of life threatening condition with Rx
. Presence of serious neurological impairment
. Presence of pain
. Patients perspective of an intolerable life
. Rx related benefit v burden to the patient
Ethical principles pertaining to parents of a newborn baby
- ' A right To be involved in all decisions '
- A legal & moral aufhority To make decisions for their child - However the interests of parents are secondary
Societal ethical principles pertaining to a newborn baby
- Interests of society are secondary - except where parents refuse life
saving Rx
- Society concerns about cost for NICU need to be addressed at the poli
cy level, not individual or case by case basis
TYpe of care
- ordinary - morally incumbent on clinicians
- extra-ordinary or futile - treatment no longer accomplishs its intende

d purpose
. 1. Physiological futility: no chance
. 2. Intensive care treatment with very poor prognosis: no purpo
se

. 3. Stable baby with very poor prognosis, not dependent on tec

hnology: unbearable