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1

Ectopic pregnancy

Developing blastocyst implants anywhere besides endometrial lining of uterine cavity

2

Where are most ectopics found

Tubal 93% (70% ampullary)

3

Risk factors for ectopic pregancy

Patient factor:
infertility
>40years

Lifestyle factors:
sexual promisquity
Past/ current smoker

Gynae/ obs
Previous tubal surgery (assisted reproductive techniques)
confirmed genital tract infection
previous miscarriage
previous ectopic
previous induced abortion
sterilization
tubal pathology (esp chlamydia) (PID)
Diethylstilbestrol exposure
Previous myomectomy

4

What are protective factors of ectopic

All contraceptives

5

Pathology of ectopic pregancy

invasion of the small blood vessels leading to extraluminal bleeding and haematoma

irregular dilatation of the fallopian tube

6

Triad of symptoms in ectopic pregnancy

Amenorrhoea
Vaginal bleeding
Abdominal Pain

The pain may be localized or diffuse. There may be a transient relief of pain following tubal rupture when stretching of the serosa ceases. (patient may feel dizzy)

7

Investigations in ectopic pregnancy

1. Ultrasound, to check if intrauterine.
(Sign of intrauterine pregnancy is gestational sac
surrounded by double echogenic ring)
-empty uterus + complex cystic mass and free fluid in
pouch of douglas = highly suggestive of ectopic.
- May see adnexal mass

8

At what B HCG level should one visualise an intrauterine pregnancy via transvag scan

>= 1500

and at a crown rump length of >7mm one should see the heart

9

Unruptured ectopic management -expectant

When no evidence of rupture in a U/S confirmed ectopic
B -hcg level < 1000IU/ L & declining within 48 hours
stable/ asymptomatic (no blood in pelvis)

Patients followed up twice weekly, until level is 50% of initial value, then weekly till level undetectable.

10

Unruptured ectopic- medical management

Methotrexate (first line) 1mg/Kg IM
Indications
-no evidence of rupture
- hemodynamically stable
-B-HCG < 3000 IU
- No fetal cardiac activity on U/S (<4cm)
- Normal FBC U&E
*repeat dose if levels don´t fall adequately

11

Unruputured ectopic- surgical management

Only if medical Rx won´t work
B HCG >3000
fetal cardiac activity
adnexal mass >4cm
*usually laparoscopy...consider salpingostomy/salpingectomy if there is contralateral tubal disease with a strong desire for future fertility.

12

Risk factors for ruptured ectopic

B HCG >10 000IU
Never used contraceptives +
Hx of tubal damage, infertility and induction of ovulation

13

How is a ruptured ectopic diagnosed

Clinical diagnosis
* no need for b hcg to diagnose...
Obviously needs a positive pregnancy test though

14

How do we predict volume of blood loss in a ruptured ectopic

The shock index:
( heart rate/ systolic blood pressure)

but.. knowing signs of hypovelemia is probably more practical (according to Dr Trip)

15

How do we define massive haemorrahage in a patient with a ruptured ectopic

acute loss of >25% of total volume

Stop bleeding, and rescus

* Rx will usually include laparotomy (salpingectomy)

16

Management of Massive bleeding (eg ruptured ectopic )

1. Preliminary diagnosis of massive bleeding
2. Obtain a quick hx, assess vitals (quick quick)
-Amenorrhoea
-Abdominal pain
-Bleeding per vagina
-Nausea and vomiting
-Dizziness and fainting
- No contraception

3. Initial intervention
-Call for help
- secure airway, give Oxygen (mask)
-Large bore (16G) x 2
-Draw blood for complete blood count, clotting profile
-crossmatch 4 units of packet red cells
-pregnancy test
-Infuse 2 litres of crystalloid rapidly, followed by basal
infusion of 200ml/hr
4. Second assessment
-Examinet pt
-reassess diagnosis
-repeat vitals, monitor urine output, o2 SATS
- prepare pt for theatre
5. Treatment goals:
-Hb 7-10
-Platelets >100 000
-INR <1.5
- Avoid hypothermia, hypocalcemia, metabolic
alkalosis and hyperkalemia.
-MAP 70-80mmHg
-Urine output of >30ml/hr

17

Diagnosis of advanced abdominal pregnancy

Abdominal pain, tenderness
N/V
Vaginal bleeding

Examination:
- abnormal lie
-easily palpable fetus
-abnormally senstive abdomen
-displaced cervix/ barely enlarged uterus

Diagnosis on ultrasound

18

Causes of abnormal uterine bleeding

PALM COEIN
-Polyps
-Adenomyosis
-Leiomyomata
-Malignancy and hyperplasia
-Coagulopathy
-Ovulatory dysfuntion
-Endometrial
-Iatrogenic
-Not yet classified

19

What is dysfunctional uterine bleeding?

Abnormal uterine bleeding without any organic pathology.
diagnosis by exclusion
either Ovulatory or Anovulatory

20

Ovulatory Dyfunctional uterine bleeding:
(pathophysiology and presentation)

Occurs due to local factors originating in the endometrium.
-Poor formation or function of corpus luteum
-Irregular shedding of the endometrium (due to
persistence of the corpus luteum)

21

Anovulatory dysfunctional uterine bleeding

Abnormality of hypothalamic- pituitary-ovarian axis.
Path: bleeding comes from an endometrium that has not been preceded by ovulation. therefore luteal secretory changes will be absent.
-Excessive oestrogen stimulation of endomentrium.
(due to graafian follicle which didn´t rupture, leading to
excessive rise in oestrogen levels. endometrium
becomes hyperplastic. Eventually oestrogen levels
fluctuate and when below critical level endometrium is
shed...heavy bleeding.
-Inadequate stimulation of endometrium
Circulating oestrogen levels are low. when oestrogen
falls below critical level, bleeding occurs. (irregular
acyclical)

22

History in abnormal uterine bleeding

How long is the cycle?
length
duration
amount
clots
symptoms of ovulation (slight cramping or pain, breast
tenderness, bloating, light spotting)

Changes in menstruation ?
Medical hx and non-gynae medication
Sexual hx and contraceptive use
Past gynae hx, pap smears and surgeries, and medications
Familial bleeding tendencies

23

What to look for on examination in abnormal uterine bleeding

General: shock, anemia, purpura and petechiae
stigmata of endo disease (goitre, obesity,
striae).
Pelvic exam: local lesions, feel adnexa.
exclude rectal & urethral bleeding.

Examine breasts

24

Special investigations in abnormal uterine bleeding

1. preganancy test
2. Hb (FBC, platelets, coagulation studies, crossmatch)
3. Pap smear

4. U/s: look @ endometrial thickness (trans vag & abdo)
5. Hysteroscopy: direct visualisation & biopsy

25

Management of abnormal uterine bleeding

Acute...stabalise, physical exam to establish cause

HORMONAL THERAPY
- Oral progestogen (converts to secretory endo), give
for 7-10 days. Bleeding occurs once drug withdrawn.
Then give ovulatory agent, or progesterone agent/
contraceptive pill.
- High dose oestrogen followed by oral progestogen:
only if bleeding is due to atrophic endometrium.
- Combination oral contraceptive pill
NON-HORMONAL: antifibrinolytic therapy (tranexamic acid- Cyclokapron)
SURGICAL Rx: D & C

26

Definitive management of abnormal uterine bleeding

Expectant (esp teenagers)
MEDICAL Mx
-Antifibrinolytic drugs
-NSAIDS (reduce prostaglandin synthesis.
Prostaglandin causes vasodilation)
-COCP
-Progestogens, for pt´s where oestrogen is
contraidicated and in anovulatory DUB
-Danazol
-GnRh analogues (inhibit FSH)

SURGICAL
-Hysterectomy and endometrial ablation.

27

side effects of transexamic acid/ cyclokapron

N/ V
dizziness
tinnitis
rashes
abdo cramps

Thrombosis (always check pt´s risk factors for thrombosis)

28

Amenorrhoea

Primary: Pt reached 16 & never menstruated
Secondary: Cessation of menstrual bleeding for at least 3 months.

29

Menorrhagia

excessive bleeding

30

Polymenorrhagia:

occurs over <21 days

more frequent bleeds, shortened cycle length

31

Oligomenorrhagia:

scanty menstruation/ long cycles over 35 days. associated with anovulation.

32

Menorrhagia

>80ml/ cycle. Increased cycle duration
cycle regular
(66% have Fe def anemia )

Metrorrhagia: irregular bleeding at any time between menstrual periods...

33

What is pelvic inflammatory disease:

Acute infection of the upper genital tract structures involving any/‘ all of uterus, tubes and ovaries.
Neighboring organs may also be affected. (endometritis, salpingitis, oophoritis, peritonitis, tubo-ovarian abscess)
Usually sexually transmitted

34

Risk factors for pelvic inflammatory disease.

Early sexual debut
<25years
Previous PID
Multiple partners, or new partner, symptomatic partner
Other STD´s
Sex during menses
Bacterial vaginosis

35

What is bacterial vaginosis:

Polymicrobial condition where normal lactobacilli are replaced by aerobic/ anaerobic bacilli. Presents with discharge.
Causative agent often gardnerella vaginalis.

36

Protective factors in PID

Barrier contraception
Oral contraception
Tubal ligation
Pregnancy

37

What is the normal dominant bacteria in the female genital tract

hydrogen peroxide producing lactobacillus acidophilus

38

Causitive agents in PID

chlamydia and gonorrhoea. Gardnerella vaginalis

Secondary invaders: anaerobes or gram negatives
-Streptococci
-e.Coli
-h.Influenza
-pseudomonas
-Klebsiella

39

Pathology: Mild PID

tubes swollen, tubes freely mobile
Tubal ostea patent
sticky seropurulent exudate us present at fimbrial end

40

Pathology of Moderately severe PID

Fibrin deposits cover serosal surfaces of the tubes
Tubes not mobile, may adhere to overies, broad ligament and bowel

41

Pathology of sever PID

Pelvic peritoneum involved
Tubal ostea sealed
Pelvic anatomy distorted
Abscess...rupture...peritonitis
Hydrosalpinx (when pus of an abscess replaced by serous fluid, walls of tube become thin and flattened, tube filled with clearwatery fluid)

42

Diagnosis of PID

Lower abdo pain (worse during coitus)
Cervical excitation tenderness
Abnormal uterine bleeding (30%)
Discharge

Normal signs of infection:
hypotension
dehydration/ pyrexia
tachypnoae/ tachycardia

43

How do patients with an aerobic infection (PID) present

usually older patients, presents with repetitive episodes of infection,
Pyrexia and demonstrable palpable adnexal mass

44

PID Staging system

Stage 1: early salpingitis
Stage 2: Late salpingitis & pelvic peritonitis
Stage 3: Pyosalpinx, or tubo ovarian mass, or tubal
occlusion
ESR >60ml/hr
Stage 4: Adult respiratory distress syndrome (generalised peritonitis)

45

What system do we use to stage PID

Gainesville classification

46

Triad PID

lower abdo pain/ tenderness
cervical excitation tenderness
adnexal & uterine tenderness/ discharge
+
>38degrees
abundant WCC
mucupurulent dischagre
ESR >15ml/hr
Elevated CRP

47

Confiremed cases of PID =

pelvic pain and tenderness
acute/ chronic endometritis (histology)

the 2 above, plus 1 below

Demonstration of chlamydia or gono
Gross salpingitis (visualised@ laparot/ laparosc)
Isolation of pathogenic bacteria from upper genital tract
Purulent pelvic fluid

48

Investigations in PID

Pregnancy test Micro tests:
FBC Urine microscopy &
culture
ESR Look @ vag discharg
CRP Endocervical swabs
HIV (chlamydia/ gono)
STD screen Imaging
Pap smear Transvag US
Doppler transvag
US
mri/ct

49

Indications for laparotomy in PID

Generalized peritonitis
pt> 40 years
Recurrent PID attacks
Hx of tubal ligation

50

Differential when suspecting PID

Obstetric/gynae
ectopic
dysmenorrhoea
intrauterine preganancy complication
ovarian cyst
ovarian torsion/ tumour
Gastro
appendicitis
cholecystitis
gastroenteritis
Tb ABDOMEN
IBD
Renal
cystitis
Pyelonephritis

51

Primary prevention of PID

Counsil on sexually transmitted nature of disease
contraceptive advice
contact and treat partner

52

Treatment of PID

Principles include: controlling infefction and preserving fertility

53

Outpatient treatement In PID

Ceftriaxone of cefoxitin or other 3rd generation ceph
+
Doxycycline
Add metronidazole for anaerobes (bacterial vaginosis)
Up to 14 days for Chlamydia

54

Inpatient Rx in PID

Hydration, analgesia, vitals
Cefoxitin (2g IV 6 hrly) + doxy (100mg IV or oral 12hrly)

or
Clindamycin + gentamycin

Change to oral meds after 24 hours if better (decrease temp, decrease size in tubo ovarian abscess

55

Indications for surgery in PID

1. Peritonitis
2.Tubo-ovarian abscess (not repsonding to A/Bs in 48hr
3.Pelvic abscess, pointing into vag, rectum or abdo wall
4.uncertain diagnosis

56

Sequelae of PID

Recurrence (25%), higher in HIV+
infertility
ectopics
chronic pelvic pain
psychological
mortality

57

What is miscarriage?

Ending of pregnancy before fetus is viable (26wks)

58

First trimester miscarriage is up to how many weeks

13

59

Second trimester miscarriage is up to how many weeks

13-20wks

60

Define recurrent miscarriage

3 consecutive miscarriages before 20weeks gestation
or 3 miscarriages at any time

61

Causes of early spontaneous miscarriages

CHANCE
investigate after 3
chromosomal anomalies 60%
environmental factors, toxins, viral, infections, smoking

POOR PLACENTATION
Uterine septum
autoimmune diseases (collagen diseases)
human lymphocyte antigen status.. if both partners
genetically similar, thromboblast disgarded

62

Causes of late spontaneous miscarriages

BAD UTERUS
inability to hold pregancy
congenital anomalies
uterus didelphys
incompetent cervix
submucous myomata
POOR PLACENTATION
Inadequate trophoblast invasion of uterine spiral
arterioles (leads to poor placental function with severe
IUGR....death)

63

Investigations for second trimester miscarriage

RPR
Lupus anticoagulant
Antinuclear factor
Hysterosonography

64

Miscellaneous causes of spontaneous miscarriages

Syph
CMV, Rubella, toxo
Chlamydia, mycoplasma
Hypothyroidism

65

Causes of recurrent miscarriage

Genetic abnormalities
Structural abnormalities
infection
antiphospholipid syndrome
Thrombophilic disorders (factor V leiden, activated protein c resistence )

66

WHat is antiphospholipid syndrome

Antiphospholipid antibodies are directed against phospholipid binding plasma proteins
presence of 2 or more of the antibodies @ 2 occasions, 12 weeks apart + 1 of the clinical criteria is diagnostic

67

clinical criteria of antiphospholipid syndrome

>= 3 consecutive unexplained miscarriages before 10 week
1 or more unexplained death of morphologically normal fetus older than 10 weeks
1 or more prem births of morphologically n fetus younger than 34 weeks + severe pre eclampsia or placental insufficiency
thrombosis in organ

68

Primary infertility

Never conceived before

69

Secondary infertility

conceived at least once before

70

Infertility

Inability to achieve pregnancy after one year of adequate sexual exposure

71

Reproductive failure

Repeated failure to carry pregnancy to viability

72

Top 3 causes of invertility

1. Tubal damage
2. Abnormal semen (commonly teratozoospermia)
3. Anovulation

73

Which lifestyle and environmental factors have an effect on fertility

1. BMI >25 (overweight)
-abnormalities in GnRH and pituitary gonadotropin
secretion are common
2. Smoking..lower fertility in men and women
3. Cannabis, inhibits secretion of GnRH
4. Cocaine, tubal damage
5. Alcohol use is associated with lower pregnancy rates
6. Exposure: perclorethylene, toluence as well as herbicides and fungicides.

74

History for infertility patient

INFERTILITY RELATED
Age of partner
Primary or secondary
Previous marital or reproductive hx (live births, abortions, ectopics, puerperal infections.
Menstrual hx: age of menarche, regularity and length of cycle, dysmenorrhoea
Previous contraception and any complications
Previous infections
Breasts: thelarche, development, galactorrhoea, and premenstrual tenderness
Skin abnormalities: acne, abnormal hair growth
Mass: sudden increase or decrease

General, social and family hx

75

Evaluation of pt with infertility

ANATOMICAL FACTORS

SYSTEMIC FACTORS

IMMUNOLOGICAL FACTORS

PHARMACOLOGICAL FACTORS

ENVIRONMENTAL FACTORS

76

Anatomical factors in infertility

Vagina
-anatomical defects
- infections
- lubricants
-psychosomatic manifestations

Cervix
-Anatomical defects
-infections
-absent or excessive mucus production
- Surgery

Uterus
- Anatomical defects
- infections
- surgery

Fallopian tubes ( big factor in infertility)
- Anatomical defects
-Infections
- Surgery

Ovaries
-Functional disorders
-Infection
- Surgery
-Endometriosis

77

Systemic factors in infertility

Pathological conditions of:
Hypothalamus
pituitary gland
thyroid
adrenal glands
cardiovascular system
liver & kidney

78

Pharmacological factors in infertility

Opiods
antiprostaglandins
chemotherapy
antidepressents
clomiphene citrate
Look out for drugs that cause hyperprolactinemia

79

Environmental factors in infertility

smoking
drugs
previous surgery (intrabdominal, pelvic)
sexual history (dyspareunia, frigidity)
Vaginal lubricants

80

What should one focus on in physical examination of infertile pt

Assess stature, length, mass
Secondary sexual characteristics and hair distribution
Breast development, exclude galactorrhoea

Abdo exam: scars, masses, tenderness
Gynae exam
Rectovaginal examination to exclude endometriosis

81

what is one of the first things one must do before further investigation infertility

Culture menstrual fluid for mycobacterium tuberculosis

82

How do we classify patients with females infertility

ovulatory and anovulatory

83

How to tell if patient is ovulatory

Ovulatory cycles:
Regular (length between 26 to 32 days)
Mid cycle pain
Biphasic basal body temp chart
Adequate mid -cycle mucus secretion

Lab investigations:
#Progesterone on day 21 (>30nmol/L= ovulation)
#E2 (oestradiol) on day 12-14, 700-1200 pmol/ L is
normal)
#Endometrial biopsy, day 24-26: should show a secretory pattern
#LH and FSH (>30 IU on two differnt occasions indicates ovarian insuffiencency)

84

Evaluating mid-cycle mucus

Charecteristics of adequate mucus
-Adequate amount
-Ability of mucus to stretch 8-10cm or more
-Macroscopic appearance: watery, thin, clear and transparent
- When dried on slide, should have ferning pattern on microscopy

* poor mucus production is physical barrier to sperm. may require a procedure to achieve fertilasation.

85

Chronic Anoovulation:

1. Obesity
2. Hyperprolactinemia
3. Serum TSH to exclude hypothyroid
4.Male factor
5. Polycystic ovarian syndrome
6. Clomiphene therapy (may be repeated 3 times)
dosage 25mg/day for 5 days (day 5-9 of cycle)
Pt usually ovulates between 5th day and 8th day after
last tablet, during periovulatory period (day 13 to 16) patient must be monitored for adequate mucus production.

*Hysterosalpingogram & laparoscopy can be done to evaluate tubal motility and patency

86

Surgeries done for tubal pathology in infertility

Fimbrioplasty = lysis of adhesions

Neosalpingostomy = creation of new tubal opening in fallopian tube with distal occlusion.

Mircosurgical reanastomosis of fallopian tubes after sterilization.

87

Indications for in vitro fertilization

1.Absent or irreparably damaged fallopian tubes
2.Idiopathic infertility
3. Endometriosis causing infertility
4.Male factor
5.Female antisperm antibodies

88

Oligozoospermia

sperm count less than 10 million/ml

89

Asthenozoospermia

less than 30% motile spermatozoa

90

Teratozoospermia

Less than 5% spermatozoa with normal morphology

91

Azoospermia

no spermatozoa in ejaculate

92

Aspermia

No ejaculate

93

Causes of male infertility

*Pretesticular or pregerminal causes
*Testicular causes
*Post-testicular causes
*Genitourinary infections
*Immunological causes

94

What do you do if there is one abnormal semen analysis

you do another one

95

Normal semen analysis (fertile ):

Concentration: >15
Motility (%): >30
Forward progression: >2
Motility index: >50

96

Subfertile

Concentration: <15
Motility: <30
Forward progression: 1.0-1.9

Concentration: <15
Motility: <30
Forward progression: 1.0-1.9

97

Infertile

Concentration: <2.0
Motility (%): <10
Forward progression: <1.0
Motility index: <20.0


98

Causes of male infertility:

• Pretesticular or pregerminal causes
o Central gonadotropin deficiency
o Endocrine excess syndromes
o Other
 Hypothyroidism
 DM
• Testicular causes
o Chromosomal
o Cryptorchidism
o Radiation/ chemo
o Mumps, viral orchidis
o Trauma
o Sertoli-cell-only syndrome
• Post testicular causes
o Congenital duct obstruction
o Aquired ductal block (tb, gonorrhoea)
o Impaired motility
• Genitourinary infections
• Immunological causes

99


Approach to causes of male infertility:

1. Pretesticular or pregerminal
2. Testicular
3. Post testicular
4. Genitourinary infections
5. Immunological

100

Main cause for endometrial Carcinoma:

Unopposed oestrogen (exogenous or endogenous), leads to continued stimulation and proliferation of the endomentrium…with eventual carcinoma

101

Risk factors for endometrial carcinoma:

1. Obesity: Increased peripheral fat conversion of androgens to oestrogens. + anovulation.
2. Parity: infertility due to anovulation increases exposure time unopposed oestrogen.
3. Family history: positive family history leads to an increased risk.
4. Delayed menopause
5. Exogenous oestrogen: Postmenopausal oestrogen hormone replacement therapy increases risk. This must be opposed with progesterone for 11 days out of the cycle.
a. The oral contraceptive pill is protective due to progesterone.
6. Endogenous oestrogen: women with PCOS are anovulatory
7. Medical disorders: previous pelvic irradiation, in hypertensive or dm

102

Types of endometrial Ca (histo)

Adenocarcinoma
Adenocarcinoma with squamous metaplasia
Adenosquamous carcinoma
clear cell carcinoma
Uterine papillary serous adenocarcinoma

103

how do we stage uterine carcinoma

FIGO staging

104

Clinical presentation of endometrial Ca

Symptoms
Postmenopausal bleeding
vaginal discharge
Pain

Signs
Hypertension/ obesity
Vaginal atrophy
Vaginal lesions

*Pelvirectal exam to rule out parametrial invasion

105

What special investigations to do in Endometrial Ca

1. Cytology
Cannot be used for cases of suspected endometrial adenocarcinoma ( poor positive predictive value, of limited use)

2.Ultrasound (screening test )
Those with postmeno bleeding, require transvaginal US
Endometrial thickness is measures, those >5mm require tissue diagnosis

3. Endometrial sampling with cannula with vacuum aspiration

4. Hysteroscopy and dilatation and curettage

106

How is endometrial carcinoma staged

Surgical staging

107

Rx for endometrial Ca

SURGERY. (TAH, BSO +peritoneal lavage )
1. staging
2.debulk the disease
3. palliation

*severe cases require radical hysterectomy and pelvic node dissection (stage2b)

108

What changes staging in endometrial Ca, to need for chemotherapy and radiotherapy

Lymph node mets