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occupational contact dermatitis

irritant contact dermatitis (ICD), allergic contact dermatitis (ACD) and contact urticaria.

Dryness (involvement of the web spaces between the fingers is often the first sign)
Scaling and flaking
Splitting and cracking


Irritant contact dermatitis

Repeated exposure to water, including hand washing and scrubbing
Skin cleaners, antiseptic washes, detergents, liquid and bar soaps
Drying of the skin using paper towels
Heat from hot water
Sweating, especially when wearing occlusive gloves for extended periods of time
Glove powder
Low humidity: hands often get drier in winter


Allergic contact dermatitis

Allergic contact dermatitis (ACD) is a delayed type of allergy that causes dermatitis on areas of the skin exposed to allergens. Allergy is very individual: one person may be allergic to a substance that another person can use without problems.

ACD can occur at any time, after someone has been using the same product for many years or for just a few weeks. Dermatitis generally develops some hours or even 1-2 days after contact with the allergen, but does not occur the very first time an individual is exposed to the substance. People may not have had a history of allergies before and in fact are probably less likely to be 'allergic' types. The clinical features of ACD cannot be reliably differentiated from ICD.

ACD will often complicate pre-existing ICD, when the skin barrier has become damaged. Once an allergy to a substance has developed, it is generally lifelong.

Common causes of ACD in healthcare workers include:

Rubber glove ingredients, such as thiurams and carbamates, which are required for the elastic properties of disposable gloves.
Preservatives such as formaldehyde and formaldehyde releasing preservatives used in products such as skin cleansers.
Ingredients in hand cleansers and surgical scrubs such as coconut diethanolamide, an emulsifying agent, found in many hospital skin cleansers, especially hand washes
Antiseptics such as chlorhexidine, although fortunately this allergy is rare
Colophony (rosin) is the usual cause of sticking plaster allergies in patients
Domestic exposures to many other allergens present in skincare products and liquid soaps, including fragrances, as well as contacted through hobbies and other activities

Special note: The preservative methylisothiazolinone (MI) is currently causing very high rates of ACD. All healthcare workers with contact dermatitis should check the ingredients of their own products and avoid it where possible. Methylisothiazolinone may be found in some liquid soaps, shampoos, sunscreens, hair products, moisturisers and disposable wipes, particularly baby wipes.

Patch testing diagnostic for ACD


Contact Urticaria (including Latex Allergy)

Contact urticaria is a different type of allergic skin reaction, occurring immediately rather than being delayed. Allergy to latex, or natural rubber protein, is a form of contact urticaria and healthcare workers are exposed to latex in many brands of disposable gloves but also in other medical products.

Powdered latex gloves also increase the risk for latex allergy as the powder facilitates the transfer of the latex allergen to the skin and also aerolises it, so latex proteins that have attached to the powder can be inhaled, or enter the skin via cracks and splits in the skin.

Signs and symptoms of latex allergy:

An itchy, red rash within minutes of contacting latex
Hives or welts on the skin
Runny nose, itchy eyes, sneezing and sometimes asthma
Burning, itching, tingling and swelling from latex contact on mucous membranes

Blood tests (for allergen specific IgE, formerly known as RAST) is used to diagnose latex allergy, as well as another form of allergy testing, prick testing, which is completely different to patch testing. Prick testing is commonly used by allergists to diagnose immediate hypersensitivity reactions in the investigation of asthma, hay fever and food allergies.


The treatment is avoidance of all latex products. Nitrile gloves are a readily available latex-free alternative. Vinyl gloves are also latex-free, but may not offer adequate protection against bodily fluids. Latex-free reusable gloves are also available, made from nitrile or polyvinyl chloride (PVC), which may be useful for home.


Pain management in labour

Panadol/Panadeine in early labour
Inhalation Therapy
Epidural Block


APGAR scoring

Measure at 1 minute & 5 minute (if 5 minute score is <7 do a 10minute test)
Heart rate:
Respiratory effort:
Muscle tone:
Reflex Irritabiity:



synthetic oestrogen (Ethinyloestradiol, Mestranol, oestradiol) (provide regular and predictable bleeding pattern) + progesterone


Progestogen only hormonal contraception

contraceptive implant
Injectable: DMPA
Progestogen IUD
3-month progesterone vaginal ring -> use during lactation


Derivation of progestogen

17-acetoxyprogesterone: cyproterone acetate, medroxyprogesterone acetate, nomegestrol acetate (NOMAC)
19 nor-testosterone: Norethisterone, dienogest, levonorgestrel, desogestrel, etonogestrel, gestodene
spironolactone: drospirenone



useful for anti-androgenic and diuretic properties



counter androgenic s/e





Nomegestrol acetate

mildly anti-androgenic


Progestogenic s/e

androgenicity may increase acne, hirsuitism and affect mood
increase in LDL and decrease in HDL
insulin resistance/glucose metabolism
anti-proliferative effect on endometrium -> protects endometrium and affects pattern of bleeding
Norethisterone, dienogest, nomegestrol acetate can suppress endometrium so much -> absent bleeding


Steroid receptors

high numbers in breasts and genitourinary tract
- Androgen receptors
- Oestrogen receptors
- Progesterone receptors


Progesterone (mechanism)

- suppress LH surge -> prevents ovulation
- thickens cervical mucus
- thin the endometrium making it unsuitable for implantation


Oestrogen (mechanism)

- suppress FSH -> prevent maturation of ovarian follicle
- enhance effect of progesterone
- stabilise the endometrium


Progestogens (contraindication)

steroid dependent cancers


Oestrogen (contraindication)

- previous DVT or pulmonary embolus
- stroke and heart disease (both valvular and ischaemic)
- heavy smokers over 35-years-of-age
- diabetes with associated vascular disease
- severe liver disease
- steroid dependent cancers
- migraine with aura
- pregnancy
- lactation (<6 months post-partum) as may suppress milk production


oestrogen-related symptoms: positive

no mid cycle peak/less endometrial stimulation -> results in lighter bleeding
- synthetic oestrogen induces production of sex hormone binding globulin (SHBG) in liver which binds androgens and prevents them acting on receptors: decreased acne


oestrogen-related symptoms: negative

- breast tissue proliferation may lead to discomfort, breast enlargement
- fluid retention may lead to bloating, oedema, headaches
- increase in SHBG may result in decreased libido
- effect on clotting factors = increased risk of thromboembolism and CVA


Taking Combined Pill

- immediate contraceptive cover if active pill taken on day 1-5 of bleeding (day 1 for estradiol pills)
- can be started later but will need to use additional contraceptive cover for one week
- missed pills:
- if less than 24 hrs take as soon as remembered and no need for additional cover
- if more than 24 hours remembered, additional cover required for one week
- if pills missed in last week of pack, packets should be run together and placebo pills missed


Pill failures

9% in real life (1-2% theoretical) due to missed pills
- effectiveness affected by: vomiting and diarrhoea, drugs used to treat epilepsy, TB & HIV hypericum (St Johns Wort)
- daily commitment difficult 25-50% discontinue in first 12 months


Extended use regimens: Seasonique

84 days of 30ugms ethinyloestradiol/50ugms levonorgestrel (equivalent to 4 ordinary packets) followed by one week of 10ugms of EE alone which bleeding occurs
- 4 menstrual periods a year
- irregular bleeding more common
- no need to have monthly bleeding - can run most pill packs together to avoid bleeding (but not phasic pills)


Continuous COCP use

safety = 12 months
Lybrel: 20mcgm of EE & 90mcgm of levonorgestrel


Oestradiol pills: Qlaira

- estradiol valerate (natural oestrogen) and dienogest
- multiphasic - 2 placebo pills
- less hepatic effect than LNG pills - less increase in SHBG
- lipid effects comparable to newer pills
- complex missed pill/switch regiment


Oestradiol pills: Zoely

24/4 estradiol and nomegestrol acetate pill
- nomegestrol: long half-life strong specificity for progesterone receptors, anti-androgen
- potent endometrial suppression, less effect on liver enzymes



- plastic vaginal ring, release constant dose of oestrogen to the vaginal skin over three weeks, removed for one week = bleeding
- very low dose of oestrogen (15mcgm) but excellent cycle control
- extended use possible - more irregular bleeding


Contraceptive patch: EVRA

20mcgms oestrogen and 150mcgms norelgestromin
- 3 weeks of patch (weekly) and week free for bleeding
- extended use possible
- adherence and aesthetic is the problem


Combined injectable contraception: Lunelle

inject every 30 days
- mid injection = bleeding (15 days)
- rapid return of fertility when ceased
- self-injected systems available.


Non-contraceptive benefits of combined hormonal contraception

- shorter, lighter less painful periods - 40-80% reduction in blood loss
- less PMS (Yaz - 20mcg EE/3mg drosperinone has been approved for treatment of severe symptoms)
- less functional ovarian cysts
- less benign breast disease
- protects against pelvic infection - 50% reduction
- 50-60% reduction in uterine and ovarian cancer -> persists upto 30 years after ceasing
- improvement in acne


Emergency contraception

- Used after unprotected sex (up to 72 hours)
- obtained without script
- Postinor-1: single tablet 1.5mg LNG -> take a tablet ASAP after unprotected sex
- works by delaying ovulation - does not impede implantation, does not dislodge or damage established pregnancy


EllaOne: Ulipristal acetate-selective progestogen receptor modulator

30mgs single dose
- more effective LNG ECP on days 3-5 after USI
- directly inhibits follicle rupture
- Must delay start/restart of hormonal contraception for 5 days after taking or efficacy of ECP will be affected
- not indicated while breastfeeding


Progestogen-only contraception

- unpredictable bleeding
- useful for those who can't use oestrogen
- higher fail rate than COCP
- strictly taken within 3hrs of usual time
- effective in older women and breastfeeding mothers


Depo-medroxyprogesterone acetate (DMPA)

- 150mg by IMI every 12 weeks (-2,+4 weeks)
- bleeding disturbance - 60-80% light or no bleeding at 12 months
- delayed return to fertility - 10-11 months
- some concerns regarding bone density with long term use



- Plastic implant inserted into upper inner part of non-dominant arm
- effective
- lasts for 3 years
- removal = immediate return to fertility
- low dose, few hormonal side effects
- irregular bleeding a real problem - 20% removal rate
- insertion problems


Progestogen IUD - Mirena

- Inserted inside uterus during minor surgical procedure
- 5 years effective
- irregular bleeding almost universal in first 3-5 months until uterine lining thins - then light or no bleeding most common pattern
- PBS: $38


Male Hormonal Contraception

double dose DMPA/implants
- suppress sperm count and reduce testosterone hence needs to be combined with "add-back" via injection or implants
- side effects rare


copper IUD

- effective and convenient (up to 10 years)
- requires minor surgical procedure
- tend to make periods heavier, longer and more painful - 50 % increase in loss
- best form of emergency contraception
- hard to acquire in Australia in 5 days


Natural methods

Charting symptoms, hand-held personal computer which monitor temp and LH levels



- latex and plastic (SKYN)
- cheap-though non-latex more expensive



- inserted into vagina as mechanical barrier to sperm
- 'one-size-fits most' device (CAYA) available over web and through Family Planning Clinics
- must be left in for 6 hours after sex
- failure rate 15%


Ovcon 35

chewable, spearmint flavoured OCPs, for those who can't swallow



OCP and folic acid combination: for those who fall pregnant immediately after stopping pill



using implants and dissolvable polymers


STI syndromes

- Urethral discharge, persistent or recurrent
- genital ulcers, hiv infection, inguinal bubo
- scrotal swelling
- vaginal discharge (cervical & vaginal infection)
- lower abdominal pain
- neonatal conjunctivitis


round ligament of the uterus

originates at uterine horns


laparoscopic procedure

manipulator inserted into the uterus part


Pouch of douglas (rectouterine pouch)

extension of peritoneal cavity between rectum and uterus


Pouch of Dunn (vesicouterine pouch)

pouch between uterus and bladder


Uterosacral ligaments

The uterosacral ligament (Rectouterine ligament; posterior ligament) consists of the rectovaginal fold of peritoneum, which is reflected from the back of the posterior fornix of the vagina on to the front of the rectum. It forms the bottom of a deep pouch called the rectouterine excavation, which is bounded in front by the posterior wall of the uterus, the supravaginal cervix, and the posterior fornix of the vagina; behind, by the rectum; and laterally by two crescentic folds of peritoneum which pass backward from the cervix uteri on either side of the rectum to the posterior wall of the pelvis. These folds are named the sacrogenital or rectouterine folds. They contain a considerable amount of fibrous tissue and non-striped muscular fibers which are attached to the front of the sacrum.


Tubal dye flush

can see if the fallopian tubes are patent



named by the site of the fibroid
- can cause constipation, urinary urgency,



- presence of the endometrial lining outside the uterus
very common
- pain during menstruation, intercourse
- heavier periods
- inability to conceive
Diagnosis: excise endometrial tissue


cervical polyp

99% benign, asymptomatic, vaginal discharge, bleeding between periods, or heavy periods


Cervical cancer

Common cause: viral infection (HPV)


HPV testing

every 5 years, can be done at home, clinic etc


Imperforate hymen

Usually during puberty: menstruation collects in the uterus
- a year or two, blood will accumulate and increase pressure by pressing on bladder or urethra
- bulging membrane (bluish in colour)
- blood will flow out if incision is created (treatment) -> higher risk of endometriosis
failure of the canalisation of the urogenital sinus


Double vagina - uterus didelphys

incomplete fusion of Mullerian ducts


Kallman's syndrome

anosmia (can't smell), infantile look (no puberty), hypogonadotropic hypogondism


Testicular feminisation, androgen insensitivity syndrome

testicles need to be removed (within the body) as it can change to a malignancy


5alpha reductase deficiency

Born with male gonads, testicles and Wolffian structures


absent vagina

MRKH, Mullerian agenesis (absence of a uterus, cervix, upper part of vagina)


Antenatal Screening

First antenatal visit before 8 weeks
- FBC (Hb level), blood group (rhesus important), Rubella, Hep B & C serology, HIV, Syphilis and Vitamin D, varicella zoster, HSV

12-14 weeks: ultrasound
- NIPT (non-invasive prenatal test) (10.5 weeks)
- analyses DNA sample in blood -> trisomy 21, Edwards syndrome (trisomy 18), Patau syndrome (trisomy 13), (when selected) DiGeorge Syndrome (22q11.2 deletion)
- can also test for Turner syndrome & Klinefelter's syndrome
- structural (12.5 weeks)
- test for aneuploidy
- MCS for microscopy & culture
- cervical cytology, haemoglobinopathies

19-20 weeks: morphology ultrasound
- fetal heart beating, multiple pregnancies, fetal size, position of placenta, volume of amniotic fluid, fetal abnormalities

- requires a full bladder to provide clear 'window' to pregnancy & make uterus rise up from behind pubic bone

26-28weeks: Full blood count, Hb & platelet count, ferritin, rhesus antibody presence, haemolytic disease, glucose challenge test (urine glucose no value in detecting of gestation DM)

Triple test: measures for alpha-fetoprotein (AFP), hCG, unconjugated estriol (UE3)
low AFP, low UE3, high hCG = down syndrome
low everything = trisomy 18 (Edward's syndrome)
high AFP, n/a others = neural tube defects (spina bifida, that may have associated increased levels of acetylcholinesterase in amniotic fluid), omphalocele, gastroschisis, multiple gestation


Edward's syndrome

trisomy 18, often born small, heart defects, small head & jaw, clenched fists with overlapping fingers, intellectual disability
- kidney malformations, omphalocele, esophageal atresia, growth deficiency, feeding & breathing difficulties, arthrogryposis