Obg Key Flashcards
1
Q
Some important contraindications for the use of COCP:
A
√ Smoking.
√ Obesity (BMI > 30 Kg/m2).
√ Hx of thromboembolism.
√ Learning difficulties (as they may forget to take the pills).
√ Post-partum (if breastfeeding: CI for 6 months) (If not: CI for 6 weeks).
√ Migraine with aura.
√ HTN (even if well-controlled HTN).
2
Q
A
3
Q
If < 20 YO → Don’t prescribe IUS (Mirena®) or Depo-Provera (IM
Medroxyprogesterone acetate).
Depo-Provera → Risk for osteoporosis in such a young age.
• Many females who recently started on Depo-Provera (Progesterone-only-
injections) or Mirena tend to initially have bleeding more days than usual and
vaginal spotting between cycles.
Most females become amenorrheic after 1 year of use.
Therefore → Reassure and advice the patient to come back if these
unscheduled bleedings become problematic
A
.
What if bleeding becomes problematic?
→ COCP for 3 months (While still on Depo-Provera)
Or: Mefenamic acid or Tranexamic acid for 5 days.
• IUS (Mirena®) and Depo-Provera are not recommended if ♀ < 20 YO
• Nexplanon® “Etonogestrel implant” is safe < 20 YO.
• COCP and POP are also safe < 20 YO.
• In females with some learning difficulties
→ Do not prescribe Pills (COCP, POP) as they may forget taking the pills.
4
Q
Intrauterine contraceptive systems (IUS) (eg, Merina) and Progesterone-
only implants (eg, Nexplanon) are used for long-term contraception
and thus
should be avoided if a woman has intentions and plans to get pregnant in the
near future (eg, within 6 months).
• After giving a birth, COCP is contraindicated in breastfeeding ♀ (for 6
months) and in non-breastfeeding ♀ (for 6 weeks).
• After Delivery:
- A - A breastfeeding non-breastfeeding ♀ can start taking COCP after 6 months of delivery.
♀ can start COCP after 6 weeks of delivery.
A
Progesterone only pills (POP) are safe in breastfeeding, they are given
orally; not injections, and they are short-term birth-control methods.
• No contraceptive method is required post-partum for 21 days after delivery.
• Depo-Provera (Medroxyprogesterone acetate) is IM injection given once
every 3 months. It is contraindicated in females < 20 YO.
However, it is first-line in females with SCA and Menorrhagia.
5
Q
√ Menorrhagia = Heavy menstruation ▐ √ Dysmenorrhea = Painful menstruation ▐
√ Metrorrhagia = Irregular menses
◙ In young ♀, Not sexually active (i.e., she doesn’t require any
contraception as she is sexually inactive)
♦ Menorrhagia only (Heavy menstruation) → First line is mirena. pregnancy is wished soon or she is < 20 YO, then → tranexa
♦ Menorrhagia + Dysmenorrhea →
Mefenamic acid
♦ Menorrhagia + Irregular menses + Does not want to get pregnant → COCPs.
♦ Metrorrhagia (irregular menses) ± Menorrhagia/ Dysmenorrhea → COCPs.
√ Once there is dysmenorrhea (painful menstruation) → Mefenamic acid
√ Once there are Metrorrhagia (irregular menses) → COCPs
A
√ Menorrhagia only → Mirena (first-line) unless if she is < 20 YO or she wishes
to be pregnant in the near future, then → Tranexamic acid
√ Menorrhagia in a female with SCD → Depo-Provera (IM progesterone).
7
Q
In a sexually active ♀ (she requires contraception) +
Menorrhagia/ ± Dysmenorrhea/ or Fibroids NOT distorting the
uterine cavity
A
The first-line → Mirena (IUS) = Levonorgestrel Intrauterine System
8
Q
Q) What if Mirena is Contraindicated (e.g., the ♀ < 20 YO or no long
contraception is wished)?
If No contraindications to COCP (e.g. smoking, obesity, Hx of thromboembolism)
COCP
(or POP or implants).
• If there is uterine cavity distortion by fibroids → → implants (e.g. Nexplanon)
A
If ♀ with SCD “Sickle cell disease” and Menorrhagia → Depo-Provera IM.
◙ Emergency Contraception (had unprotected sex and wants contraception now)
√ presented within 72 hours (within 3 days) of the unprotected sex
→ Levonelle pill.
9
Q
√ Presented within 120 hours (5 days) of the unprotected sex
or → IUD “Copper” EllaOne pill.
◙ The contraception that reduces the risk of Cervical Cancer
→ Condoms
Using condoms reduces the risk of HPV infections → thus, reduces the risk of
cervical cancer.
A
25 YO female is now 22 days after delivery and wishes a contraceptive
method that does not include needles. She would like to get pregnant after
6 months.
→ Progesterone-only pills.
√ IUS and Implants are for long-term contraception.
√ COCPs are contraindicated after delivery for 6 months in breastfeeding ♀.
√ Depo-Provera is IM injection (and she doesn’t want injections).
10
Q
18 YO with some learning difficulties using condoms and want an alternative
contraceptive method.
A
Implants)
→ Nexplanon
√ COCP is safe < 20 YO if no contraindications. However, she has learning
difficulties and thus may forget to take the pills.
√ < 20 YO: IUS (Mirena) and Depo-Prover-a are better avoided (UKMEC2).
11
Q
Example (3),
A 40 YO smoker and overweight female presents with heavy periods
(Menorrhagia).
She would like a long-term contraceptive method
A
.
→ IUS (e.g. Mirena = levonorgestrel intrauterine system).
• Remember, in a sexually active ♀ (requires contraception) with
menorrhagia/ dysmenorrhea/ or fibroids not distorting the uterine cavity
The first line → Mirena (IUS) = Levonorgestrel Intrauterine System
• Furthermore, this lady has contraindications to COCP (Obesity, Smoking).
12
Q
After initiating Depo-Provera 2 months ago, a female presents complaining
of unscheduled bleeding.
A
→ Reassure and advice to return if bleeding become problematic.
The majority of females who start Depo-Provera (Progesterone-only IM
injections taken once every 3 months “12 weeks”) tend to have
intermenstrual spotting.
This usually settles after a year of Depo-Provera use.
13
Q
Example (5),
A 16 YO female who is not sexually active presents complaining of
menorrhagia (heavy bleeding), Dysmenorrhea (Painful cycles) and Irregular
cycles.
A
→ COCP.
◙ In young ♀, Not sexually active (doesn’t requires contraception)
♦ Menorrhagia only (Heavy menstruation) → Tranexamic acid
♦ Menorrhagia + Dysmenorrhea → Mefenamic acid.
♦ Metrorrhagia (irregular menses) ± Menorrhagia/ Dysmenorrhea → COCP.
14
Q
A 31 YO lady, known case of sickle cell disease, presents complaining of
heavy menstrual bleeding (menorrhagia).
She is not sexually active and has
no plans for children in the near future. The most appropriate Rx:
A
→ Depot medroxyprogesterone acetate (DMPA) = IM Depo-Provera.
15
Q
Example (7),
A 39 YO woman who has completed her family wants a long-term
contraception. She has extensive fibroids that distort her uterine cavity
A
→ Nexplanon (progesterone-only subdermal implants,
(they are replaceable every 3 years)
If this exact female does not have fibroids or the fibroids are small
→ IUS (Mirena).
16
Q
A 16 YO fit and healthy female presents complaining of severely painful
menstrual periods.
Her cycles are regular at 28 days. She denies being
sexually active.
A
→ Mefenamic acid.
◙ In young, non-sexually active females:
√ Once dysmenorrhea (painful cycles) → Mefenamic acid (NSAIDs)
√ Once irregular menses → COCP
√ Menorrhagia only → Tranexamic acid
17
Q
Example (9),
A 33 YO female with HTN (controlled with ACE inhibitor ramipril), non-
smoker. The least appropriate contraceptive method for her is:
A
→ COCP.
HTN (even if well controlled) is a contraindication for COCPs.
◙ Some important contraindication for the use of COCP:
Smoker or ex-smoker
▐ Obesity (BMI > 30 kg/m2)
▐ Hx of
thromboembolism
▐ learning difficulties
▐ Post-partum (if breastfeeding →
CI for 6 months) (If not → 6 weeks)
▐ Migraine with aura
▐ HTN (even if
well controlled)
18
Q
31 YO female wants a reversible contraceptive method. She had C-section
one year ago.
She also complains of menorrhagia and dysmenorrhea.
A
→ Mirena (levonorgestrel intrauterine system).
◙ Note that “reversible” doesn’t mean short-term!
◙ C-section is not a contraindication for Mirena!
◙ In sexually active ♀ (requires contraception) + menorrhagia/
Dysmenorrhea/ or fibroids not distorting the uterine cavity
√ The first line → Mirena (IUS) = Levonorgestrel Intrauterine System
(See above).
19
Q
44 YO female presents asking for contraception advice.
She has completed
her family and needs no more children. US has incidentally revealed multiple
small submucosal fibroids. She is asymptomatic.
A
The most appropriate contraceptive advice → mirena (ius)
Again, small fibroids that are not distorting uterine cavity along with the need
of contraception are better manged using Mirena.
It would provide
contraception as well as could shrink the size of uterus
20
Q
Lower abdominal pain (usually unilateral) + Recent Amenorrhea (6-8
weeks) ± Vaginal spotting ± Cervical excitation
A
→ Ectopic Pregnancy.
Vaginal US → empty uterus
For the management, before jumping into laparoscopy:
√ If the patient is stable → request beta-hCG.
• If B-hCG is > 1400 → LaparoScopy. (ectopic pregnancy)
• If < 1400 → wait, observe and repeat vaginal US later. (it might be a normal
pregnancy but the fetus is so tiny to be observed by US now).
√ If the patient is unstable from the start (e.g. SBP <90) → LaparotOmy.
21
Q
◙ A pregnant with Hx of Caesarean Section develops profuse vaginal bleeding
+ Severe Abdominal Pain + Going into Shock (Hypotension and Tachycardia).
A
→ Uterine rupture.
22
Q
◙ In the late weeks of pregnancy, painless vaginal bleeding
A
→ suspect placenta previa (do Transvaginal US).
23
Q
painless vaginal bleeding and placenta is high (ie, not placenta previa)
→ suspect cervical ectropion.
Endometrial Carcinoma
◙ For any female > 51 YO presents with Postmenopausal vaginal bleeding
(spotting)
√ Suspect → ( emdometrial carcinoma)
Request initially If thick → Hysteroscopy + Biopsy).
transvaginal ultrasound to check endometrial thickness.
However, if the question asks about the (most likely Dx), atrophic vaginitis
and vulvovaginal atrophy are the commonest causes of postmenopausal
bleeding. However, the most worrisome diagnosis that need investigation by
US ± hysteroscopy and biopsy is endometrial carcinoma.
This is why our next
step would always be transvaginal US to R/O endometrial carcinoma.
A
◙ In the late weeks of pregnancy, painful vaginal bleeding (constant abd pain),
Tender, hard abdomen
→ suspect placenta abruption (do CTG)
◙ A pregnant lady in her third trimester presents with tachycardia ± fever + Hx
of PROM ± Vaginal discharge (often offensive and yellow)
→ suspect Chorioamnionitis.
◙ Lower abdominal pain, Fever, Deep dyspareunia, Dysuria, menstrual
irregularities, Vaginal or cervical discharge, Cervical excitation
→ PID (Pelvic Inflammatory Disease)
◙ Dyspareunia ± dysuria + frequency in > 51 YO
→ suspect (Give topical estrogen)
Atrophic vaginitis
◙ Dyspareunia ± dysuria, frequency + Hot flushes + Night sweats in > 51 YO
→ suspect (Give HRT: Hormonal Replacement).
If she is a smoker → Transdermal HRT instead of oral HRT (safer).
Postmenopausal syndrome
◙ 2ry amenorrhea after chemotherapy
→ suspect Premature ovarian failure.
24
Q
♀ in child-bearing age, Chronic pelvic pain, Dysmenorrhoea, Deep
dyspareunia ± dysuria, dyschezia
→
Suspect (give NSAIDs and Paracetamol → a trial of COCP → Laparoscopy “definitive”).
Endometriosis
◙ lower abdominal pain and tenderness with High Fever + NO DISCHARGE.
Additional hints → (tubo ovarian abscess)
Sexually active and doesn’t use barriers).
(perform Pelvic US).
A
SUDDEN severe unilateral iliac fossa pain + Nausea + Vomiting
± Tender mobile mass
→ Ovarian Torsion (Refer her to Gynaecology to take her to the theatre!)
◙ African + Bloating + heavy regular periods + enlarged uterus
→ suspect (do transvaginal US)
fibroids → Polycystic ovarian syndrome ◙ Inability to conceive (infertility) + Obesity + Acne + ↑ LH
PCOS (request pelvis ultrasound)
(Other features: ↑ insulin “acanthosis nigricans”, ↑ androgens, menstrual
irregularities: amenorrhea/ oligomenorrhea).
◙ Chronic pelvic pain, worsens by standing, worsens premenstrually ± Post-
coital ache (deep dyspareunia).
→ Pelvic congestion syndrome
(it is non-organic; thus, laparoscopy is unremarkable)
◙ Primary amenorrhea + Cyclical pain ± mass at lower abdomen
→ Hematometra. (Accumulation of blood within uterus).
25
Q
• When to give Varicella-Zoster Immunoglobulin (VZIG)?
Almost never used now (not recommended after the newest 2022 update).
1 ◙ 2 ◙ 3 ◙ • When to give oral Acyclovir? In the following cases:
Immunocompromised patients who develop Chicken Pox rash.
Pregnant ♀ who develop Chicken Pox
rash. (If severe rash → IV aciclovir).
Immunocompromised patients who are exposed (get in contact with) a
person with chicken pox but in 2 conditions:
1) If the exposure happened within the infectivity period (ie, 2 days before the
appearance of the rash on the person up until 5 days after rash appearance).
2) If their immunity to varicella is unknown or negative. Ie, if their serology for
varicella zoster immunity is negative. (If it is negative, this means they are not
immune to chicken pox).
A
4) pregnant ♀ who get in contact with a person with chicken pox but in 2
conditions:
1) If the contact happened within the infectivity period (ie, 2 days before the
appearance of the rash on the person up until 5 days after rash appearance).
2) If their immunity to varicella is unknown or negative. Ie, if they have not
had varicella (chicken pox) before, or their serology for varicella zoster is
negative. (If it is negative, this means they are not immune to chicken pox)
26
Notes:
◘ Oral Aciclovir is effective if given up to 14 days after contact.
◘ The infectious period of Varicella Zoster is 2 days before rash appearance till
5 days after rash or when vesicles dried out and crusted.
◘ Incubation period of VZ can be up to 21 days after exposure.
◘ In chicken pox, if there is superadded infection (eg, indicated by vesicular
discharge and high fever) → Give antibiotics.
27
The Steps:
Pregnant women or Immunocompromised Patients
Exposed (came
in contact with) a Person who Has Chicken Pox + There is no rash
appeared on them yet:
[Step 1]: Check the Time of Exposure:
Check if the exposure (contact) occurred within the infectious period (2 days
before rash till 5 days after the rash appearance on the person who she got in
contact with). We mean the rash appearance on the contact, not the pregnant
or the immunocompromised.
These two if the rash appeared on them, we
directly start oral aciclovir (or IV aciclovir if severe).
- If yes, the exposure was within the infectious period → go for step 2.
- If no, the exposure was not within the infectious period → Reassure.
[Step 2]: Checking Immunity to Varicella Zoster:
Perform serum antibodies for varicella zoster (this step is omitted if the
pregnant woman has had chicken pox in the past, she is immune → reassure).
28
The Steps:
Pregnant women or Immunocompromised Patients Exposed (came
in contact with) a Person who Has Chicken Pox + There is no rash
appeared on them yet:
TAKE CARE, in the immunocompromised people (eg, Chemotherapy, DM,
Chronic corticosteroids, Cancer, heavy smokers), we perform serology for
varicella immunity REGARDLESS of chicken pox history, ie, even if they had
chicken pox in the past, we still perform VZ serology.
On the other hand, in the exposed pregnant, if there was a history of chicken
pox, reassure, if no or unsure → perform VZ serology.
[Step 3]: Decide
- If within infectious period + VZ serology is -ve (not immune) → oral aciclovir.
- If the serology is +ve (VZ antibodies detected) (immune) → Reassure.
29
pregnant in the 2nd trimester was in significant contact with a child with
chickenpox 7 days ago. The child developed chicken pox rash the following
day after he met her. She has never had Varicella zoster infection.
A stored
blood sample is tested negative (not detected antibodies) for varicella zoster
virus IgG. Now, she has no rash. What is the most appropriate management?
The best management → Oral Acyclovir.
• Was the exposure within the infectious period?
Yes, he developed the rash the following day after meeting her, this means he
was infectious (2 days before rash until 5 days after rash).
• Is she immune to VZ?
No, she has no history of chicken pox + Her serology for VZ is negative
→ Give oral aciclovir.
If any of the above 2 points was a (NO), → Reassure.
In the past, the answer to this question was to give varicella zoster
immunoglobulin (VZIG). This has changed in 2022.
Now, for pregnant women who get in contact with a person with chickenpox,
we break it down:
30
Chickenpox mng
If the contact was within the period of infectivity (ie, 2 days before rash
appearance up until 5 days after the rash appearance in the contact) and the
immunity status to VZ is negative, → Give aciclovir.
More Elaboration:
• If she has never had Chicken pox (she is not immune to it) or if the immunity
status is unknown, next step → Check serum Varicella zoster Ab (IgG).
→ If +ve (immune) → Reassure (as she is immune).
→ If -ve (not immune) → Give Oral Aciclovir.
• Aciclovir is effective if given within 14 days after exposure.
• If she develops rash → Give oral Acyclovir within 24 hours (IV if severe).
• If the serum varicella zoster virus IgG had come back Positive (immune)
→ the answer would have been: Reassure.
31
Example 2,
What if she was in contact with someone 8 days ago.
And after
these 8 days have passed, he developed chickenpox rash?
→ Reassure
(The infective period of chickenpox is 2 days before the appearance of the
rash up until 5 days after rash appearance.
Here, 8 days have passed and then
he developed the rash. So, when she was in contact with him, he wasn’t
infectious).
32
Example 3,
A 31-year-old pregnant woman in her 36 gestation developed red itchy
papules on her back, face and trunk. Over a period of 1 day, these papules
turned into vesicles that are widespread.
2 days before the rash appeared, she
had body aches, fever, and headache (prodromal symptoms).
Her body
temperature is 39.1 degrees. What is the most appropriate action?
→ Give oral aciclovir (or IV aciclovir if severe).
If these are not in the options → Admission into the hospital.
She already has chicken pox, no reason for chicken serum varicella IgG
antibodies. Treat.
33
Example 4,
If a person develops chicken pox in a maternity hospital
→ Offer oral aciclovir to all pregnant women who came in contact with the
person and
have a negative varicella zoster virus antibody level (not immune)
34
Causes of Primary Post-Partum Hemorrhage (1ry PPH) → √ [Tone]: Uterine Atony “Atonic Uterus” (The most common cause).
4 Ts:
[Tone]: Uterine Atony “Atonic Uterus” (The most common cause)
√ [Trauma]: Lacerations, incisions, uterine rupture.
√ [Thrombin]: Coagulopathy.
√ [Tissues]: Retained products of conception.
35
Example 1,
Prolonged (Protracted) labour + Uterus is still palpable above the umbilicus
after delivery with postpartum hemorrhage.
The likely cause of postpartum hemorrhage → Atonic Uterus.
Rx → Uterine massage + Oxytocin (Uterotonic agent)
36
Example 2,
A primiparous diabetic Asian lady has just delivered a 4.5 Kg baby. The
delivery was done by the aid of forceps.
The placenta was removed with
continuous cord traction and her uterus is well contracted. However, she
continues to bleed excessively.
The likely cause of postpartum hemorrhage → Cervical/ Vaginal Trauma.
The most common cause of postpartum hemorrhage in general is Uterine
Atony
. However, here, the uterus is well contracted.
Big baby in a Diabetic mother are RFs of tear/ trauma at delivery.
37
Example 3,
Prolonged labour + Uterus is felt boggy and relaxed above the umbilicus after
delivery with postpartum hemorrhage.
The next immediate step in management
Uterine massage
→ (Uterine atony).
38
Intrauterine contraceptive systems (e.g. Mirena) and Progesterone-only
implants are used for long-term contraception and thus should be avoided if
a ♀ intends to get pregnant in the near future (e.g. after 6 months).
• After delivery, COCP is contraindicated in breastfeeding ♀ (for 6 months)
and non-breastfeeding ♀ (for 6 weeks).
• After Delivery:
- A breastfeeding ♀ can start taking COCP after 6 months.
- A non-breastfeeding ♀ can start COCP after 6 weeks.
Note, No Contraceptive method is required post-partum for 21 days after
delivery.
• IUS can be used within 48 hours of delivery or after 4 weeks (28 days) of
delivery (for fear of uterine perforation 2-28 days after birth).
However, it
should not be used if a woman intends to get pregnant in the near future as it
provides long term contraception.
• Depo-Provera (Medroxyprogesterone acetate) is IM injection given once
every 3 months.
• Progesterone only pills are safe in breastfeeding, not injections, and short-
term birth-control methods.
39
Example,
21-day post-partum ♀ desires not long-term contraception (wants to get
pregnant after 6 months) and prefers no injections. She is breastfeeding.
The most appropriate → Progesterone-only pill.
♦ COCP is contraindicated after delivery in breastfeeding mothers until 6
months of delivery.
♦ Depo-Provera “Medroxyprogesterone acetate” is IM injection (given deep
in gluteal or deltoid muscle once every 3 months).
She does not want
injections.
♦ Intrauterine system Progesterone-only implants and are not suitable here
as they provide prolonged birth-control while she wants to get pregnant after
6 months.
♦ Progesterone only pills are safe in breastfeeding, not injections, and short-
term birth-control methods.
40
For any female in childbearing age presenting with abdominal pain
→ Always check Urine Pregnancy Test
This is because of the fear of Ectopic pregnancy as “ruptured ectopic
pregnancy is life-threatening”!
41
Ectopic Pregnancy features
√ Lower abdominal pain and tenderness (could be unilateral). “The first
symptom”
√ A missed period (recent amenorrhea) = no menstruation for 6-8 weeks from
the beginning of the last period.
√ Vaginal bleeding.
√ Shoulder tip pain “due to peritoneal bleeding” + Peritonism [Indicate ectopic
tubal rupture]
√ Cervical motion tenderness “Cervical Excitation”.
◙ The initial Investigation
→ Urine pregnancy test
◙ If +ve → Transvaginal Ultrasound (to look for intrauterine pregnancy)
◙ If U/S shows empty uterus, we have 2 paths:
♦ If the patient is hemodynamically “stable”
→ Check Human chorionic gonadotropin (b-hCG)
♦ If the patient is hemodynamically “unstable” - If b-hCG < 1400 → Wait and Observe (unlikely ectopic pregnancy). The
fetus may be so small to be observed by US.
- If b-hCG > 1400 → Proceed to Laparoscopy (confirmed ectopic pregnancy)
(Important note: if hCG is not that high, and -repeats hCG after 48 hrs first- is
among the options, and the patient is stable, pick it.
As it might be a tubal
miscarriage that needs no Rx. If it is tubal miscarriage, the hCG will be falling).
(e.g., Hypotensive SBP < 90)
→ Urgent Laparotomy (Open Salpingectomy or Salpingostomy)
42
A pregnant ♀ in the 38th gestation with Hx of Caesarean Section develops
profuse vaginal bleeding + Severe Abdominal Pain + Going into Shock
(Hypotension and Tachycardia).
CTG (Cardiotocography) shows distressed fetus “Reduced Variability and Late
decelerations).
The likely Dx → Ruptured uterus
The Rx → Urgent Laparotomy (to deliver the fetus and to repair the uterus).
◙ RFx of Uterine rupture:
√ Previous CS or uterine surgery (it weakens the uterus).
√ Excessive oxytocin (Uterotonic agents)
√ Obstructed labour that is not recognised.
Remember,
♦ Placenta previa → PAINLESS vaginal bleeding.
♦ Placental abruption → painful.
♦ Uterine rupture → painful.
43
44
In suspected placental abruption in “the 3rd trimester” ± Fetal distress)
(Severe abdominal pain + Vaginal bleeding
(Cardiotocography) ◙ Firstly, perform → CTG (Not US)!
♦ If it shows fetal distress → Urgent C-Section.
♦ If it is normal → Perform vaginal ultrasound (to R/O placenta previa).
Note, ultrasound has minimal rule in placental abruption (clinically
diagnosis) but it is important in placenta previa.
45
What if CTG is not among the options?
→ Pick “to R/O Placenta Previa”
Ultrasound Important, never perform speculum or digital examination until placenta
previa is ruled out (by Ultrasound).
In Summary,
√ Placenta abruption → initially → √ Placenta Previa
→ Initially → CTG “Cardiotocography”
Ultrasound (Preferably Transvaginal US)
46
◙ Postmenopausal symptoms (e.g. hot flushes, night sweats,
Irritability, Vaginal Dryness, Dyspareunia)
♣ If there is uterus → Combined Hormone Replacement Therapy (HRT) with
estrogen and progesterone.
Another possible answer → Transdermal Estradiol and Progesterone patches
If she is a smoker → Transdermal HRT instead of oral HRT (safer). Transdermal
HRT has a lower risk for thromboembolic events and stroke compared to oral.
Thus, it is a safer option particularly if there is a risk factor eg, smoking.
♣ If No uterus (e.g. Hx of hysterectomy) or if there is IUS in place
→ Oestrogen-only Hormone Replacement Therapy.
This is because progesterone
is given with the estrogen to protect the uterus against endometrial carcinoma. If
no uterus, why to give progesterone?
♠ Dyspareunia → difficult or painful sexual intercourse.
• Menopause “Cessation of menstruation” is the time after a woman has her last
menstrual period. Because her final periods can be irregular, menopause is
confirmed 12 months after her last period.
• The menopause is a natural part of ageing that usually occurs between 45 and 55
years of age, as a woman’s oestrogen levels decline. In the UK, the average age for
a woman to reach the menopause is 51.
• The time of a woman’s life following menopause is called postmenopause.
• Women in postmenopause may develop “Postmenopausal Vasomotor
symptoms” such as Hot flushes, Night sweats.
(HRT) • To manage these Vasomotor symptoms → after evaluating pros and cons.
47
√ If she has had hysterectomy (No uterus), or if there is Intrauterine
system “IUS” in situ → Oestrogen-only HRT.
√ Otherwise → Combined HRT.
♦ Note, if a postmenopausal ♀ is a smoker, the HRT is given “Transdermal” as the
oral route has a higher risk for Venous Thromboembolism (VTE).
♦ Note, Combined HRT (Hormone Replacement Therapy) has 2 types:
- Sequential “Cyclical” combined HRT → used in the first 12 months of
menopause or in perimenopause “still menstruating”.
Oestrogen is taken daily
while Progesterone is taken Cyclically “for the last 14 days of a menstrual
cycle”
Continuous combined HRT → used in menopausal women (women who have
had their last menstrual cycle 12 months ago).
Both Oestrogen and
Progesterone are taken daily
48
Example (1),
A ♀ at her 39 weeks gestation had passed clear viscous fluid per vagina 4 days
ago. Now, she is feverish, sweaty and with suprapubic tenderness.
The
symphysis-fundal height (SFH) is 35 cm. There is fetal tachycardia of 175 bpm.
WBCs and CRP are ↑.
The likely Dx → Chorioamnionitis.
Chorioamnionitis → Inflammation of the fetal amnion and chorion
membranes typically due to ascending bacterial vaginal infection when there
is rupture of membranes.
• PROM “Premature Rupture of Membrane” is a major risk factor for
Chorioamnionitis (ascending vaginal bacteria)
• Fever, sweaty, high WBCs and CRP → inflammation (itis)
• The SFH is small for date (as she had PROM and lost amniotic fluid).
(Oligohydramnios is one of the known causes of small for date uterus).
49
Chorioamnionitis Features: (Important √)
▐ Maternal tachycardia (followed by) fever
▐ Fetal tachycardia
▐ Abdominal pain and uterine contractions (Suprapubic tenderness)
▐ Hx of PROM
▐ The amniotic fluid could be purulent, offensive, foul smelling,
yellow or brown.
• Note, sometimes there won’t be fever as maternal tachycardia often
occurs before pyrexia (fever).
i.e. Tachycardia (Then) → Fever
50
Example (2),
A lady at her 24 weeks gestation admitted for preterm premature rupture of
membrane (PPROM).
She does not have fever. However, she is tachycardic at
122 bpm and has abdominal pains, uterine contractions and suprapubic
tenderness.
Speculum examination reveals a foul-smelling discharge
originating from the cervix with the cervix being slightly open.
The likely Dx → Chorioamnionitis.
All manifestations are toward chorioamnionitis (as mentioned above).
She is not feverish as Maternal Tachycardia often precedes maternal fever.
e. fever may develop later.
51
Additional points for your knowledge:
♦ Premature rupture of membranes (PROM) is the rupture of the fetal
membranes before the onset of labour
.
♦ Preterm premature rupture of membranes (PPROM) is ROM prior to 37
weeks’ gestation.
♦ Prolonged rupture of membrane (Prolonged ROM) is any rupture of
membrane that persists for more than 24 hours and prior to the onset of
labour.
SFH (Symphysis Fundal Height)
Gestational age Fundal height landmark
12 weeks Pubic symphysis
20 weeks It reaches the Umbilicus
20-36 weeks GA (in weeks) ± 2 = …. Cm
36-40 weeks Xiphoid process of sternum
A pregnant lady at 37 weeks gestation presents with lower abdominal pain +
small amounts vaginal bleeding.
CTG ♦ First step →
♦ If not among the options → (suspected placental abruption).
Ultrasound (to rule out placenta previa).
52
In any a female (especially < 25 YO) who uses IUS (e.g. Mirena) and develops
lower abdominal pain + Irregular menstrual cycles
Suspect → Pelvic inflammatory disease (PID)
Quick Notes:
• Intrauterine contraceptives are a major risk factor for PID.
• Presence of IUS (e.g. Mirena) → Alleviates the symptoms of endometriosis,
adenomyosis and fibroids.
√ Note, Adenomyosis = ectopic endometrial tissue within the myometrium
itself (endometriosis within myometrium).
• Asherman syndrome → endometrial adhesions usually following D&C
“Dilatation and Curettage” of the uterine cavity. It presents with abdominal
pain and menstrual irregularities and causes infertility.
• IUD “Device” e.g. Copper T
• IUS “System” e.g. Mirena (levonorgestrel-releasing IUS)
ABCD (C → D) = (Copper → Device)
53
After Broad-spectrum antibiotic course → death of vaginal normal flora
→ a good chance for the development of bacterial vaginosis and/or vaginal
candidiasis.
Trichomoniasis
(Trichomonas
Vaginalis)
√ Frothy, yellowish-greenish
smelly vaginal discharge.
√ Vaginal itching is common.
√ Strawberry Cervix.
√ Vaginal pH: > 4.5
Rx → Oral
Metronidazole
Bacterial
Vaginosis
(Gardnerella
Vaginalis)
√ Thin, grey-white, fishy
(VERY offensive) smelling
discharge.
√ Vaginal itching is
uncommon.
√ Positive Whiff test
(Potassium Hydroxide).
√ Vaginal pH: > 4.5
Rx → Metronidazole
+ Clindamycin
54
Vulvovaginal
Candidiasis
“Vaginal Thrush”
√ Thick white (Cheese-like)
odourless vaginal discharge.
√ Vaginal pH: 4-4.5
Rx → Local
Clotrimazole
(Anti-fungal)
(Candida
Albicans)
Note, normal vaginal pH is 3.8 to 4.5.
To Recap,
♣ White Thick discharge → candida (Vaginal Thrush).
♣ Yellow-greenish offensive discharge + vaginal itching ± Strawberry Cervix ±
pH > 4.5 → Trichomonas Vaginalis (Trichomoniasis).
♣ Offensive discharge Without itching ± fishy smell ± pH > 4.5
→ Bacterial Vaginosis (Gardnerella Vaginalis).
55
Example (1)
A pregnant woman has taken antibiotic for her dental abscess. On the 3rd day,
she developed thick white vaginal discharge.
◙ The likely diagnosis → ◙ The Likely causative organism →
Vulvovaginal Candidiasis “Vaginal Thrush”.
Candida Albicans.
56
Example (2)
A young lady presents with offensive vaginal discharge. She is sexually active
with a single partner. Her vaginal pH is 5.5. High vaginal swabs are taken for
culture.
The likely organism → Treatment → Gardnerella Vaginalis. (Bacterial Vaginosis).
Metronidazole.
Both Bacterial Vaginosis (Gardnerella Vaginalis) and Trichomoniasis
(Trichomonas Vaginalis)
can cause offensive vaginal discharge and pH >4.5.
♦ Bacterial Vaginosis “Gardnerella Vaginalis” is more common.
♦ Trichomoniasis “Trichomonas Vaginalis” has yellow-greenish offensive
vaginal discharge + it usually causes vaginal itching.
Note:
Although Bacterial Vaginosis
“Gardnerella Vaginalis” is not a sexually-
transmitted disease, it is the most common cause of abnormal vaginal
discharge in ♀ in childbearing age.
◙ Amsel’s Criteria: 3 of 4 criteria are diagnostic for Bacterial Vaginosis:
√ Homogenous grey-white discharge.
√ When adding Potassium Hydroxide 10% (KOH) to the discharge → fishy
smell (Whiff test).
√ “Clue Cells” under microscopy.
√ Vaginal pH > 4.5
57
A 40 YO ♀ presents with an offensive malodorous vaginal discharge that is
clear in colour. Its pH is 5.1. There is no vaginal itching, abdominal pain or
dyspareunia.
The likely causative organism → Gardnerella Vaginosis.
No vaginal itching + Not yellow-greenish + pH > 4.5
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A 30 YO ♀ presents with a very strong foul-smelling vaginal discharge. Which
of these organisms is likely responsible?
(Chlamydia / N. Gonorrhea / Gardnerella / or All of them)?
The answer is → Gardnerella.
Do not get tricked!
Chlamydia and N. Gonorrhea do not usually present with Foul-smelling
discharge.
59
Again,
→ Transvaginal Ultrasound In Placenta previa (Painless Vaginal bleeding in the 3rd trimester)
(preferred over Abdominal U/S).
The presence of a fetus in a transverse lie in a primigravid ♀ is a clue that
there is a mass in the way.
If [+] painless vaginal bleeding → this mass is most likely the placenta
occluding the cervical os (Placenta previa).
60
Cessation of menstruation (Prolonged Amenorrhea) in ♀ < 40 YO
→ Suspect → (POF).
→ Request → (↑ FSH > 25 IU/L in two occasions 4 weeks apart is diagnostic).
→ Rx → Serum FSH.
Hormone Replacement Therapy (HRT) Until the age of 51 YO.
• Amenorrhea in ♀ aged 40-45 YO → ovarian failure. They are different). Others: hot flushes, sweating…
Request → Early menopause Serum FSH & Ultrasound.
(not Premature
Presentations of Premature Ovarian Failure:
♦ Amenorrhea/ Oligomenorrhea is commonest presentation. (√)
♦ Postmenopausal features (e.g. hot flushes, night sweats, vaginal dryness,
dyspareunia, irritability).
♦ Infertility.
◙ Important Note:
Although the most common cause of Premature Ovarian Failure is Idiopathic,
it can occur after Chemotherapy or Irradiation as well!
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Presentations of Premature Ovarian Failure:
♦ Amenorrhea/ Oligomenorrhea is commonest presentation. (√)
♦ Postmenopausal features (e.g. hot flushes, night sweats, vaginal dryness,
dyspareunia, irritability).
♦ Infertility.
Although the most common cause of Premature Ovarian Failure is Idiopathic,
it can occur after Chemotherapy or Irradiation as well
62
63
Atrophic vaginitis = vulvovaginal atrophy
= genitourinary syndrome of menopause (GSM)
• Presentation →
Urinary manifestations (Dysuria, Frequency, incontinence, nocturia)
[±]
Vaginal Atrophy manifestations (e.g., Dyspareunia/ vaginal itching/
dryness/ burning) in a ♀ in the menopause age (usually > 50).
♠ Dyspareunia → difficult or painful sexual intercourse.
• Occurs due to → Estrogen deficiency after menopause.
• Rx → Topical Estrogen “Intravaginal estrogen”. “Oestrogen cream”.
♦ If a female presents with only atrophic vaginitis (dyspareunia, dysuria,
vaginal dryness) → “Oestrogen Cream”.
Local oestrogen
♦ If associated with recurrent UTIs:
→ Vaginal oestrogen tablets (pessary).
64
♦ If + other menopausal symptoms (e.g., hot flushes)
→ Hormonal replacement therapy (HRT).
Another possible answer → Transdermal Estradiol and Progesterone patches
65
Cancer Screening Programmes available in the UK
• Colorectal Cancer Screening:
√ Fecal Immunochemical Test (FIT).
√ 60-74 YO every 2 years.
• Breast Cancer Screening:
√ (Mammogram).
√ ♀ 50-70 YO every 3 years.
√ Those with high risk → 40-70 YO annually.
• Cervical (Cervix) Cancer Screening:
√ (Pap smear – Cervical smear: Cytology, HPV)
√ 25-49 YO → every 3 years.
√ 50-64 → every 5 years.
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Important:
If the ectropion is symptomatic (e.g., it causes bleeds on touch)
→ Refer for
Otherwise
→ colposcopy.
Reassure.
◙ Cervical ectropion that causes NO bleeding or pain during or after sexual
intercourse should be left alone (Reassurance). It is not even a risk factor for
cervical carcinoma.
◙ Cervical ectropion: (Red ring around the os)
The stratified squamous epithelium that lines the Ectocervix (Vaginal part of
cervix) is replaced by Columnar epithelium (that lines the endocervix)
(Migration of the epithelium of the endocervix onto the epithelium of the
ectocervix)
In short
→ (the stratified Squamous Ectocervix is replaced by Columnar epithelium).
“In high oestrogen states (e.g. pregnancy, COCP), the endocervix columnar
epithelium comes further down “migrates”. This is friable and thus bleeds.
√ This occurs due to ↑ Oestrogen (e.g. Pregnancy, Puberty, using COCP).
√ It is generally asymptomatic but can present with painless vaginal bleeding
or non-purulent watery discharge post-coital (after intercourse).
√ No Rx is required unless symptoms are annoying → Cervical smear (if
normal) → Cryotherapy/ Diathermy/ Cautery with silver nitrate.
67
Barretts oesophagus
Just for memory refreshing, in the Barret’s oesophagus:
[Squamous epithelium of the lower 1/3 of the oesophagus turns to Columnar
epithelium with goblet cells → RF for Adenocarcinoma]
This is called (METAPLASIA) “important √”
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Example (1)
A 31 YO ♀ presents enquiring about vaginal spotting 2 days ago. She is on
COCP. Last cervical smear was 1 year ago and reported normal
. O/E, cervical
ectropion is diagnosed. There is no bleeding on touch.
The next step → Reassurance.
√ If the cervical ectropion bleeds on touch and the cervical smear is normal
→ Refer for colposcopy.
√ If smear was done > 3 years ago → order cervical smear.
Cervical smear is required once every 3 years in ♀ aged 25-49 YO. Thus, no
need to repeat it as it was normal only 1 year back.
√ If no bothersome symptoms (no bleeding on touch) → leave the ectropion
alone (Reassure).
√ Please note that if there is post coital bleeding + Hx of new partner/ vaginal
discharge/ abdominal pain, we suspect cervicitis and order endocervical swab.
69
Example (2)
A 29 YO female presents complaining of post-coital painless vaginal bleeding.
U/S shows placenta anterior and high.
Fetal movements and heart are seen
on the U/S. Her abdomen is soft, lax and non-tender.
◙ The likely Dx → Cervical ectropion
(Remember, RFs of cervical ectropion includes pregnancy, using COCP).
♦ When reading “Painless vaginal bleeding”, the first thing that comes to
mind is (Placenta Previa). However, the U/S here revealed that the placenta is
normally situated (Anterior and High), whereas in placenta previa, it would be
down/ low (occluding the cervical os).
♦ What other benign condition in such a young “pregnant” lady that can
cause painless vaginal bleeding “after sexual intercourse”?
Yes, cervical ectropion. Nonetheless, further investigations are needed to
confirm it such as local speculum examinations ± cervical smear.
♦ Note, as fetal heart is seen on the U/S → It is not missed miscarriage.
♦ Remember, in placenta abruption, the abdomen would be TENDER, hard
(painful vaginal bleeding).
“Bleeding is not always existing in placental abruption as it might be
concealed bleeding”
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Preeclampsia:
It is a condition seen after the 20th week of gestation, characterized by:
√ BP >140/90 (Pregnancy-induced Hypertension) + one of the following:
√ - Protein in urine (proteinuria ≥ 0.3 g/24 hr ie, ≥ 300 mg/24 hr), or
- Protein/Creatinine ratio (PCR) ≥ 30 mg/mmol, or
- Albumin/Creatinine ratio (ACR) ≥ 8 mg/mmol.
In short:
> 20 weeks gestation (+) HTN (+) Proteinuria → Think: Preeclampsia.
◙ Risk Factors of Preeclampsia include:
First pregnancy, Pregnant Teens or Women over 40 YO, Pre-existing HTN in
pregnancy, DM, CKD, Chronic HTN, Pregnancy interval > 10 years, FHx.
◙ Symptoms occur in severe preeclampsia (ie, BP ≥ 160/110):
Headaches, Visual disturbance (flashing lights),
Epigastric or upper right quadrant pain, Rapid edema (especially in face).
71
Management of Pre-eclampsia (important) √:
• First-line antihypertensive (if BP >140/90) in preeclampsia pregnant women
→ Oral labetalol.
Other safe antihypertensives → Hydralazine, Methyldopa, Nifedipine.
• Women at risk factors of preeclampsia are advised to take aspirin 75-150 mg
daily from the 12th week gestation until the delivery.
◙ Important points on the management of -severe- preeclampsia:
If the patient is having a (severe) preeclampsia (ie, BP ≥ 160/110 with
symptoms such as headaches, visual disturbance, epigastric pain)
AND
1 or > of the following: (Brisk reflexes -hyperreflexia), clonus, eclamptic fits
In addition to labetalol (which is the first-line antihypertensive in pregnancy),
Give → a prophylactic dose of IV magnesium sulphate (to prevent eclampsia).
Then → Plan for the delivery of the baby once the patient is stabilised.
This is because the delivery of placenta (induction of labour) is the only cure
for preeclampsia.
However, one should balance out the risk of too
prematurity of a baby against the preeclampsia complications. In all cases,
stabilise the patient first (eg, if severe preeclampsia → IV MgSO4 first).
72
Additional Notes on Preeclampsia:
◙ There is no cure for preeclampsia except for The delivery of the baby.
◙ Women with mild preeclampsia may be treated conservatively to allow the
baby to mature, as long as they are closely monitored.
They may be given
corticosteroids to help the baby’s lungs mature and magnesium sulfate to
prevent seizures. Sometimes, medications to lower blood pressure (eg,
Labetalol) are needed.
◙ Fetal complications of preeclampsia include the risk of preterm
delivery, oligohydramnios (low fluid volume within the uterus), and sub-
optimal fetal growth.
◙ Maternal complications of preeclampsia and eclampsia include liver
and kidney failure, bleeding and clotting disorders, and HELLP syndrome.
73
Eclampsia
It is the development of severe Tonic-clonic (grand-mal) seizures in a woman with
preeclampsia.
It has a 2% mortality (death) rate.
Preeclampsia (HTN, significant proteinuria, ≥ 20 weeks gestation)
+ Seizures
= Eclampsia.
◙ Management of Eclampsia (Important) √:
√ To control/ prevent seizure→ √ If another fit? → MgSO4 (Magnesium sulphate).
A further bolus of IV MgSO4.
MgSO4 regimen (important √)
√ Loading dose of MGSO4:
→ 4 g in 100 ml 0.9% NS by infusion pump over 5-10 min. (important)
√ Followed by 1 g/hour (maintenance) for 24 hours after the last seizure.
√ Recurrent seizure?
Either give a further 2 g MgSO4 bolus or ↑ the infusion rate to 1.5-2 g/hour
(instead of 1 g/hour).
◙ What if MgSO4 overdose develops (eg, loss of deep tendon
reflexes, Nausea, Vomiting, Confusion)?
1) Stop the MgSO4.
2) Request serum MgSO4 levels urgently.
3) Give Diazepam (only if there is still ongoing seizure).
4) Give Calcium gluconate (as an antidote for MgSO4).
♦ After you have managed the seizure and the patient is stable
► Delivery of the baby (Induce labour).
Important note,
Eclamptic fits “Seizures” can occur in the postpartum periods (rarely without
a Hx of preeclampsia – HTN and Proteinuria- However, it is possible)!
74
• HELLP Syndrome
→ Hemolysis (low Hb), Elevated Liver enzymes, Low Platelets.
♦ Features: Epigastric or RUQ pain & tenderness ± Nausea and Vomiting ±
dark or tea coloured urine “due to hemolysis” ± HTN and other features of
preeclampsia
Rx → Delivery of the baby ▐ MgSO4 if seizures (eclampsia)
• Acute Fatty Liver of Pregnancy (AFLP)
→ ELLP (without Hemolysis) + (↓) Glucose ± (↑) Ammonia
• Disseminated Intravascular Coagulation (DIC)
→ High PT, High PTT, High Bleeding Time, Low Platelets, Low Fibrinogen
75
Example (1),
A pregnant woman in her 35 weeks pregnancy developed sudden severe
(acute) abdominal pain and is taken for emergency C-Section.
Her BP 110/60.
Labs:
Hb: 101 ▐ WBC 9.5 (Normal) ▐ Platelets 65 (Low) ▐ PT 28 sec (high) ▐ PTT 67
sec (high) ▐ Fibrinogen 0.7 (low) ▐ Bilirubin 23 (high)
The likely Dx → Disseminated Intravascular Coagulation (DIC).
High PT, PTT
Low Platelets, Fibrinogen
→ DIC (see the comparison above)
◙ Remember: DIC Triggers→ sepsis, surgery, major trauma, cancer,
and complications of pregnancy
This lady might have developed Placenta abruption which has led to DIC.
76
Example (2),
A 32 YO pregnant lady at her 38 weeks gestation presents feeling unwell with
sudden onset epigastric pain associated with nausea and vomiting. Her
temperature is 36.8 C.
Her blood pressure is 150/100. Her Labs show raised
liver enzymes and: Hb 8.6 (low), WBC 5 (Normal), Platelets 90 (low).
◙ The likely Dx → ◙ Rx → HELLP Syndrome
Delivery of the baby.
♦ HELLP syndrome is a complication of preeclampsia. She might be having
preeclampsia as she is hypertensive and after the 20th week of gestation.
However, proteinuria needs to be investigated.
♦ HELLP:
Hemolysis (low Hb) ▐ Elevated Liver enzymes ▐ Low Platelets
All are seen here.
The presentation is also compatible with HELLP syndrome “epigastric pain
with nausea and vomiting”.
77
29 YO female had pre-eclampsia and was delivered by C-section. She is now
complaining of right upper quadrant pain.
The next appropriate investigation → Liver function tests.
√ She might have developed HELLP syndrome. We need to check liver
enzymes to help in Dx as they are elevated in HELLP syndrome.
• Pre-eclampsia (RF of HELLP syndrome).
• RUQ pain (one manifestation of HELLP syndrome).
78
For any female > 51 YO presents with Postmenopausal vaginal bleeding
√ Suspect → endometrial ca
√ Order →
√ If Endometrial Thickness is > 4 mm → Transvaginal Ultrasound (To check the endometrial thickness)
Hysteroscopy with endometrial biopsy.
Again,
In any woman in postmenopausal age presents with vaginal bleeding (even if
post-coital), if the question asks about the initial (next) test
→ Transvaginal US
If it asks about the diagnostic/ most definitive test
→ Hysteroscopy with endometrial biopsy.
However, if the question asks about the (most likely Dx), atrophic vaginitis
and vulvovaginal atrophy are the commonest causes of postmenopausal
bleeding.
However, the most worrisome diagnosis that need investigation by
US ± hysteroscopy and biopsy is endometrial carcinoma. This is why our next
step would always be transvaginal US to R/O endometrial carcinoma.
Notes,
♦ Progesterone (e.g. in combined HRT) reduces the risk for endometrial
carcinoma.
79
RFs of Endometrial Carcinoma:
Obesity/ Nulliparity/ Unopposed estrogen (estrogen given alone without
progesterone)/ PCOS/ Tamoxifen/ Early menarche/ Late menopause/ DM
(i.e. anything the increase the duration of the exposure of the endometrium
to more and more estrogen)
80
◙ Antiphospholipid antibodies include:
√ Lupus anticoagulants.
√ Anti-cardiolipin antibodies.
√ Anti-B2 glycoprotein-1 antibodies.
◙ Antiphospholipid syndrome is associated with recurrent miscarriages.
To avoid future miscarriage:
→ Give Aspirin + Low Molecular Weight Heparin
◙ All females with recurrent abortions (≥ 3 miscarriages) in the first trimester
(≤ 13-week gestation) +
those with one or more abortions in the 2nd trimester should be screened for
→ Antiphospholipid antibodies.
81
Endometriosis
Endometriosis is a common condition characterised by the growth of ectopic
endometrial tissue outside of the uterine cavity.
Around 10% of women of a
reproductive age have a degree of endometriosis.
◙ Clinical features
• Chronic pelvic pain (may be cyclic -with periods-).
• Dysmenorrhoea (Painful periods) – pain often starts days before bleeding.
• Deep dyspareunia (Painful intercourse).
• Subfertility.
• ± Non-gynaecological: urinary symptoms e.g., dysuria, urgency, haematuria,
dyschezia (painful bowel movements).
◙ Investigation
Laparoscopy and dye test is the gold-standard (most definitive) investigation
Not Hysteroscopy (remember,
the tissues are outside the uterine cavity!).
Laparoscopy may show small powder burn lesions/ Gunshot lesions especially
in Douglas Pouch which is a common site for endometriosis (
that is why
patients may suffer from dyschezia which is painful defecation).
◙ Management
√ NSAIDs and/or paracetamol are the recommended first-line treatment for
symptomatic relief.
√ If analgesia does not help, then hormonal treatments such as the
or progestogens e.g.
→ A trial of combined oral contraceptive pill medroxyprogesterone acetate should be tried.
Note,
Treat suspected endometriosis empirically with COCPs or Progesterone as a
trial for 3-6 months before laparoscopy as long as the fertility is not an issue.
Surgery:
• Laparoscopic ablation and excision of endometrioid lesions help reduce
endometriosis-associated pain.
• Laparoscopic ablation and excision of endometriotic ovarian cysts may
improve fertility.
(Remember, surgical intervention is done at the same time as the laparoscopy
for diagnosis).
82
A 40 YO lady presents with painful periods. The pain is worse on the first day
of the cycle and continues for 5 days. She has regular 28-days cycles.
She is
sterilised (she had a laparoscopic tubal sterilisation in the past). She is sexually
active with one regular partner. She takes NSAIDs and paracetamol for pain
relief during the first few days of the pelvic pain.
Endometriosis is suspected.
The most appropriate action → The most definitive test for Dx → A trial of COCP
Laparoscopy
Treat a suspected endometriosis empirically with COCP or Progesterone as a
trial for 3-6 months before laparoscopy as long as the fertility is not an issue.
It is important to note that this lady is already fertile.
Thus, managing her pain
is the priority here → COCP.
If the management is directed towards saving her fertility, we would go for
laparoscopy first
83
84
Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is a term used to describe infection and
inflammation of the female pelvic organs including the uterus, fallopian tubes,
ovaries and the surrounding peritoneum.
It is usually the result of ascending
infection from the endocervix
Causative organisms
√ Chlamydia trachomatis – the most common cause.
√ Neisseria gonorrhoeae.
Features
• Lower abdominal (pelvic) pain
• Fever
• Deep dyspareunia (Painful sexual intercourse)
• Dysuria and menstrual irregularities may occur
• Vaginal or cervical discharge
• Cervical excitation (Cervical motion tenderness).
• Abnormal vaginal bleeding (e.g. post-coital)
85
Investigation
screen for Chlamydia and Gonorrhoea
Remember that IUS and multiple partners are common risk factors for PID
Risk Factors of PID
♀ < 25 YO ▐ IUS and IUD ▐ New or multiple sexual partners ▐ Previous STIs
▐ Uterine instrumentation (e.g. surgical termination of pregnancy)
Complications
• Infertility – the risk may be as high as 10-20% after a single episode
• Chronic pelvic pain
• Ectopic pregnancy
• Tubo-ovarian abscess (important √). If left untreated or if ineffective Rx.
♦ Tubo-ovarian abscess should be suspected if a female presents with:
lower abdominal pain and tenderness with High Fever + NO DISCHARGE.
♦ Additional hints:
(Sexually active and doesn’t use barriers) → risk for chlamydia/ Gonorrhea →
cervicitis, ascends → PID, untreated→ Tubo-Ovarian Abscess.
Pelvic Ultrasound.
If Tubo-ovarian abscess is suspected → Note that cervical/ high vaginal swabs would take days to return, whereas
pelvic ultrasound can be immediately performed and may show the abscess.
86
Management of PID has different regiments based on local guidelines.
Remember that Cervicitis alone is different from PID.
Remember the following lines of treatment:
87
◙ Antibiotic Regimens for Cervicitis:
♦ Chlamydia
◙ 1st line → Doxycycline 100 mg BID for 7 Days.
◙ Another line:
Azithromycin 1-gram PO ▐ Followed by 500 mg PO OD for 2 days.
♦ Neisseria Gonorrhea: (C or C) both are single doses
◙ Ceftriaxone 1 gm IM (single dose). Or:
◙ Ciprofloxacin 500 mg PO (Single dose).
88
◙ In PID “Pelvic Inflammatory Disease” → CDM
◙ Outpatient → (OM)
• Oral Ofloxacin + oral Metronidazole
or
• Intramuscular ceftriaxone + oral doxycycline + oral metronidazole
◙ Inpatient → (CDM)
Ceftriaxone + Doxycycline + Metronidazole
(This is just an example of a regimen; the guidelines are variable)
♠ Note:
Cervicitis “presents with Vaginal Discharge” does not ascend upwards to the pelvic
structures.
So, there is usually no pelvic pain.
In contrast, PID involves Adnexa and other genital structure; hence, pelvic pain,
deep dyspareunia, cervical motion tenderness.
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90
91
92
93
94
95
5 Ds of Endometriosis
• Dysmenorrhea (Painful Periods).
• Dyspareunia (Painful intercourse).
• Dyschezia (Painful Defecation).
• Dysuria.
• Dull chronic pelvic pain.
- NSAIDs/ Paracetamol → First-line for pain.
- A trial of COCPs is given if the fertility is not an issue.
- Laparoscopy is the investigation of choice.
If similar (not exact) presentation with fever, ↑ WBCs, Cervical excitation
→ Think of PID “Pelvic inflammatory disease).
→ (CDM for Rx: Ceftriaxone + Doxycycline + Metronidazole)
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After initiating Depo-Provera 2 months ago, a female presents
complaining of unscheduled bleeding
.
→ Reassure and advice to return if bleeding become problematic.
The majority of females who start Depo-Provera (Progesterone-only IM
injections taken once every 3 months “12 weeks”) tend to have
intermenstrual spotting.
This usually settles after a year of Depo-Provera use.
If bleeding becomes bothersome
→ COCP “for 3 months” or Mefenamic acid “for 5 days” (while she is still on
Depo-Provera)
Remember,
• Depo-Provera should be avoided in females < 20 YO.
• Depo-Provera is the first-line in females with SCA and Menorrhagia.
• Depo-Provera does not prevent STDs “Sexually transmitted disease”.
• We should consider STIs as one of the DDx if there is intermenstrual
bleeding (spotting between cycles).
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Urinary Incontinence Management (Important √)
Incontinence → Involuntary leakage of urine.
◙ Stress incontinence
♦ Leakage of urine during activity (sneezing, coughing, laughing).
♦ The cause → The bladder outlet is weak (weak tone) and cannot counter-act
the raised intra-abdominal pressure during activity. Also, with multiple vaginal
deliveries → Pelvic floor muscles become weak.
◘ Treatment:
Pelvic floor exercise √ The initial Rx of choice → contractions, 3 times a day, for at least 3 months).
(at least 8 pelvic
√ If failed → Surgical retropubic mid-urethral tape = (Free-tension vaginal tape)
√ If surgery is not possible → Duloxetine.
Note: Another use of pelvic floor muscle training
→ symptomatic Pelvic Organ Prolapse stage 1 (e.g., uterine prolapse above
the introitus level) or stage 2 (e.g., uterine prolapse until the level of
introitus). It is tried first. Then: vaginal pessary insertion.
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Urge incontinence
♦ Leakage of urine with extreme sensation of need to void.
When I feel the desire to pee, I have to go and pee!
Or:
When I feel a desire to pee, sometimes I slightly wet myself “Leakage” before
making it to the bathroom!
♦ The cause → the bladder muscle loss of urine.
(Detrusor) is overactive and thus leads to
◘ Treatment:
√ Bladder drill (Retraining) Antimuscarinic Oxybutynin)
→ gradually increase the periods between voiding.
(for 6 weeks). + Behavioral “avoid coffee, alcohol”.
√ If drugs are needed → (oxybutynin e.g., immediate release Another important antimuscarinic drug to remember → tolterodine
Both medications were targeted int the exa
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Important Notes on Tamoxifen
√ It is a [Selective estrogen receptor modulator -SERM-].
While tamoxifen acts like an anti-estrogen in breast cells, it acts like an
estrogen in other tissues, like the uterus and the bones. Because of this, it is
called a selective estrogen receptor modulator (SERM).
√ It is used in the treatment of Breast cancer.
√ It is helpful after breast cancer in men who have positive estrogen
receptors (around 90% of men with breast cancer).
√ It increases the risk of Endometrial carcinoma.
It prevents bone loss (guards against osteoporosis).
♦ Some studies support that when giving tamoxifen to a breast cancer patient,
giving (Bisphosphonates) helps reduce the risk of bone metastasis.
♦ In patients who take Tamoxifen, the most important alarming symptom
would be → (as it ↑ risk of endometrial carcinoma).
Vaginal bleeding NOTE:
Post-menopausal women with breast cancer who have high risk of recurrence
OR those with Lymph Node metastasise are given →
Bisphosphonates as an
adjunctive therapy after surgery.
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Types of Miscarriage (Abortion) (important √)
◙ Threatened Vaginal Bleeding + Closed Cervical os + Visible fetal heart
◙ Inevitable Vaginal Bleeding + Opened Cervical os
◙ Missed (delayed) The fetus is dead before 20-week gestation. Cervical os
is closed. (±) Vaginal bleeding. US → no fetal heart.
◙ Incomplete Not all products of conception have been expelled
◙ Complete Everything has been expelled
√ Threatened, there is vaginal bleeding but the os is closed (the visible fetal
heart is threatened, expulsion may or may not occur)
√ Inevitable, no way to save it, the os is opened “ready” and the bleeding is
ongoing.
√ Delayed (missed), the fetus is dead silently (before 20 weeks of gestation).
The os is closed as nothing has happened. The vaginal bleeding is not always a
feature.
√ Incomplete, on US, there are still products of conception inside uterus.
√ Compete, on US, the uterus is empty.
♦ For knowledge, dead fetus:
- Before 24 weeks gestation → Miscarriage.
- After 24 weeks gestation → still-birth.
♦ For knowledge, in normal pregnancy, the fetal heart is seen at 6 weeks.
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◙ Sometimes, after cessation of COCP, amenorrhea continues,
normally, for 3-6 months.
♦ This is called → Post-pill Amenorrhea.
However,
If the amenorrhea persists for > 6 months, check FSH (especially if
the female is < 40 YO).
If FSH is > 25 IU/L, suspect → → order another FSH after 4 weeks to confirm the Dx of POF.
Premature Ovarian Failure (POF)
• Note, In Premature Ovarian Failure:
FSH, LH ↑ ▐ Estradiol ↓ (<50) ▐ prolactin is normal.
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Note,
Salpingitis (PID), Endometriosis, Ovarian torsions and ovarian tumours are not
associated with Amenorrhea (cessation of menstrual cycles).
For any female in childbearing age presenting with abdominal pain
→ Always check Urine Pregnancy Test
This is because of the fear of Ectopic pregnancy as “ruptured ectopic
pregnancy is life-threatening”!
◙ Lower abdominal pain (usually unilateral) + Recent Amenorrhea
(6-8 weeks) ± Vaginal spotting ± Cervical excitation
→ Ectopic Pregnancy.
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Example 1,
A 30 YO woman who had a normal vaginal delivery 3 weeks ago presents
complaining of feeling tired. Hb is 9.4 mg/dl. MCV 79 fL (low).
The Rx → Ferrous sulphate (iron supplement). Even if asymptomatic!
Post-partum Hb of < 10 g/dl → Anemia.
With low MCV → Iron deficiency anemi
Example 2,
A 29 YO female presents to antenatal care for a check-up. Her 28-week
gestation Hb is 107 g/L. MCV 91 fL.
The Rx → No treatment is required.
√ She is in the third trimester (≤ 10.5 is considered anemia)
Note that her MCV is normal (normal range of MCV: 76-96 fL.
Kindly note that 107 (g/L) is the same as 10.7 (mg/dl) with unit differences.
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Remember,
♦ Preeclampsia
= HTN + Proteinuria (> 0.3 g/24 hr) after the 20th week of gestation.
Labetalol √ To control HTN → (first-line).
** If Asthmatic (even if well controlled asthma), avoid labetalol (as beta
blockers are contraindicated in asthma).
Instead, give → nifedipine. Imp √
♦ Eclampsia = Tonic-clonic (grand-mal) seizure + Preeclampsia.
√ To control/ prevent seizure→ √ If another fit? → MgSO4 (Magnesium sulphate).
a further IV bolus of MgSO4.
MgSO4 regimen (important √)
√ Loading dose of MGSO4:
→ 4 g in 100 ml 0.9% NS by infusion pump over 5-10 min. (important).
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On delivering a baby, with every retraction, the fetal head emerges then
retracts immediately. This is called (Turtle signs) and it is seen in
→ (Shoulder dystocia).
Call for help → Episiotomy (can be delayed) → Rotation manoeuvres.
Shoulder Dystocia usually occurs due to impaction of the anterior fetal
shoulder on the maternal pubic symphysis.
An additional help should be
called as soon as shoulder dystocia is identified and McRoberts’ manoeuvre
should be performed.
This manoeuvre entails flexion and abduction of the
maternal hips, bringing the mother’s thighs towards her abdomen.
This is
followed by applying Suprapubic pressure.
episiotomy An will not relieve the bony obstruction but is sometimes used to
allow better access for internal manoeuvres.
Oxytocin administration is not indicated in shoulder dystocia.
Some RFs of Shoulder dystocia
√ Fetal Macrosomia (> 4.5 kg).
√ Maternal BMI > 30.
√ Maternal DM.
√ Previous shoulder dystocia.
√ Prolonged labour.
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Hyperemesis Gravidarum
♦ Severe/ prolonged Nausea and Vomiting in a pregnant woman between the
weeks 8-12 of gestation (may continue up to 20 weeks).
♦ We fear → Dehydration (dehydration could lead to acute kidney injury).
(Therefore → IV fluid -normal saline 0.9% NaCl- is the first initial step).
♦ Look for → Ketonuria, Tachycardia, weight loss, Sunken eyes, ↓ skin
turgor, ↑” prolonged” capillary refill
♦ Possible complications
√ Wernicke’s encephalopathy (thus, we add thiamine later in the management).
√ Remember, with severe vomiting, Mallory Weiss tear may occur leading to
hematemesis.
◙ Management of Hyperemesis Gravidarum (Important √)
F.A.S.T
Fluid → Antiemetics → Steroids → Thiamine
♣ First step → IV fluid (rehydration) top options: 0.9% NaCl, Hartman’s solution.
Imp: if low K+ (<3.5) → Give NaCl 0.9% + 20-40 mmol/L potassium chloride (KCl).
We first need to care about correcting dehydration and electrolyte imbalance.
This includes correcting the low potassium also by giving IV potassium chloride
along with sodium chloride 0.9%.
♣ Second step → Antiemetics:
√ 1st line: “zine” family eg, Cyclizine, Promethazine
√ 2nd line: IV Metoclopramide, Ondansetron
√ 3rd line: Steroids (IV hydrocortisone).
♣ Thiamine should be then considered to prevent Wernicke’s encephalopathy.
Important Note (Recently Asked):
If hyperemesis gravidarum has led to a low serum potassium, we would add
potassium to the normal saline
Give → IV sodium chloride 0.9% + potassium chloride.
We first need to care about correcting dehydration and electrolyte imbalance.
The next step if antiemetics failed to stop vomiting is to give thiamine.
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◙ It is recommended in the UK that pregnant women receive
IP Vaccines → “Whooping cough”
Influenza + Pertussis (Cough and Sneeze vaccine = Whooping cough (pertussis) and Influenza)
√ Note, Pertussis vaccine is not available alone, it comes as a part of the DPT
vaccine (Diphtheria, Tetanus, Pertussis).
√ So, pregnant women in the UK are advised to receive Influenza and DPT
vaccines (between 20-32 weeks of gestation).
(Remember from the infectious disease chapter:
HIV patients should avoid: BCG and Yellow fever vaccines
And if CD4 is < 200, also avoid MMR vaccine).
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Stages of Labour
◙ Stage 1: From the onset of true labour to when the cervix is fully dilated.
√ In a primigravida, it typically lasts 10-16 hours. It has 2 phases:
= 0-3 cm dilation, normally takes 6 hours.
= 3-10 cm dilation, normally 1 cm/hr (Acceleration of cervical
♣ Latent phase ♣ Active phase dilatation)
◙ Stage 2: From full dilation to delivery of the fetus.
◙ Stage 3: From delivery of fetus to when the placenta and membranes have
been completely delivered.
√ Presentation → 90% of babies are vertex.
√ Head enters pelvis in occipito-lateral position.
√ The head normally delivers in an occipito-anterior position.
♣ Signs of labour include:
♦ Regular and painful uterine contractions.
♦ A show (shedding of mucous plug).
♦ Rupture of the membranes (not always).
♦ Shortening and dilation of the cervix.
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Example 1,
A 28 YO pregnant ♀ at 39-week gestation presents with regular painful
uterine contractions.
Her waters broke 2 hours ago. Her cervix is 4 cm dilated.
The stage of labour → Stage 1 (active phase since the dilatation is > 3cm).
Example 2,
A 28 YO pregnant ♀ at 39-week gestation presents with regular painful
uterine contractions. Her waters broke 2 hours ago. Her cervix is 10 cm dilated
and started pushing now
The stage of labour → Stage 2
Stage 2: From full dilation (10 cm) to delivery of the fetus.
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Failure to progress
◘ Important,
If the labour is stuck (prolonged) at the first stage -latent phase- “when the
cervix is 3 cm dilated with no further dilatation” “poor or no further progress”:
→ perform “if the waters have not been broken yet”
→ give Amniotomy IV drip Oxytocin “Syntocinon”
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◙ Bilateral cystic masses on Pelvis US (+) Vaginal Bleeding in 1st trimester (+)
Large for date uterus (± Hyperemesis = morning sickness)
→ think of Hydatidiform mole “Molar pregnancy”
♦ Also, “snowstorm” appearance of mixed echogenicity → Bilateral cystic masses = Large theca lutein cysts.
molar pregnancy.
Hydatidiform mole might be “complete” or “partial”.
If complete, the serum beta human chorionic gonadotropic (B-hCG) will be
extremely high. This ↑↑↑ hCG can lead to hyperemesis.
Management of complete hydatidiform mole.
√ Surgical evacuation (Suction Curettage). The products of conception have to
be histologically examined to confirm the diagnosis.
√ Check hCG every 2 weeks. (No Pregnancy is allowed until hCG is back to
normal; therefore, strict contraception “barrier/ oral” is required.
◙ So, after surgical evacuation of hydatidiform mole
→ measure b-hCG
Note, Hydatidiform mole is one type of what’s called GTD [Gestational
Trophoblastic Disease].
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Types of GTD [Gestational Trophoblastic Disease].
√ Complete hydatidiform mole.
√ Partial hydatidiform mole.
√ Gestational trophoblastic neoplasia (e.g. invasive mole, choriocarcinoma). As
this type is malignant, chemotherapy is required.
♣ Again, the US findings in hydatidiform mole:
√ Bilateral cystic masses → represent large theca lutein cysts.
√ Snowstorm appearance of mixed echogenicity → represent hydropic villi
and intrauterine hemorrhage.
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Tubo-ovarian abscess (important √).
♦ It is an advanced complication of Salpingitis (PID).
♦ Tubo-ovarian abscess should be suspected if a female presents with:
lower abdominal pain and tenderness with High Fever + NO DISCHARGE.
♦ Additional hints:
(Sexually active and doesn’t use barriers) → risk for chlamydia/ Gonorrhea →
Cervicitis → PID → Tubo-Ovarian Abscess.
If Tubo-ovarian abscess is suspected → Pelvic Ultrasound.
Note that the results of endocervical/ high vaginal swabs would take days to
return, whereas pelvic ultrasound can be immediately performed and may
show the abscess.
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The vitamin that, if given during pregnancy, would reduce the risk of having a
baby with teratogenic effects (neural tube defect) is
Folic acid
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Folic acid dose in pregnancy
The usual dose → 0.4 mg (400 ug) a day for 12 weeks of pregnancy.
◙ 5 mg a day for 12 weeks of pregnancy if any of the following:
√ DM.
√ BMI > 30.
√ A pregnant woman taking antiepileptics.
√ Family history of NTD (Neural Tube Defect).
√ Previous pregnancy with NTD.
◙ 5 mg for the entire length of pregnancy if:
√ Thalassemia or thalassemia trait.
√ Sickle Cell Disease (SCD).
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pregnant female on antiepileptic medication:
→ Give folic acid 5 mg daily for 12 weeks of pregnancy.
A woman with DM planning to get pregnant:
→ Give folic acid 5 mg daily for 12 weeks of pregnancy.
woman with sickle cell anemia is planning to get pregnant:
→ Give folic acid 5 mg daily for the entire length of pregnancy.
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Rarely, hysteroscopy can cause uterine or tubal perforation. The patient
would present with Abdominal pain/ Rigidity, Hypotension and Tachycardia
due to intra-abdominal bleed. If this is the case, the “initial” next step would
be
→ Ultrasound abdomen and pelvis. (Not CT! we cannot wait as Laparoscopy/
laparotomy might be the next step after Us
Painless vaginal bleeding after sexual intercourse in the third trimester
gestation ♀ + everything else is normal
→ Placenta Previa.
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Rhesus negative pregnancy
√ A basic understanding of the pathophysiology is essential to understand the
management of Rhesus negative pregnancies.
√ Along with the ABO system, the Rhesus system is the most important
antigen found on red blood cells. The D antigen is the most important antigen
of the rhesus system.
√ Around 15% of mothers are rhesus negative (Rh -ve)
√ If a Rh -ve mother is pregnant with a Rh +ve child, a leak of fetal red blood
cells may occur → this causes anti-D IgG antibodies to form in mother. This is
called (Rhesus Isoimmunisation) “this ♀ has become sensitised”.
√ In upcoming pregnancies, these Anti-D antibodies can cross the placenta
and cause the baby to develop haemolysis (Anemia) due to [Rhesus
incompatibility], and Hydrops Fetalis (Oedema).
√ That’s why in the next pregnancies, the mothers are given prophylaxis
Anti-D injections
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Important Note to Recall:
In a rhesus negative woman who has delivered a rhesus positive baby, it is
crucial to → (even if she had received it during
Administer anti-D immunoglobulin as soon as possible and
always within 72 hours of delivery pregnancy).
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◙ Example 1:
A pregnant mother with Rh -ve has been found to have Rhesus
Isoimmunisation (Anti-D Antibodies) developed due to her pregnancy with a
Rh +ve baby in the past, we need to
→ [Assess the fetal Middle Cerebral Artery “MCA” on Ultrasound].
This allows us to estimate the fetal Hb (The severity of Anemia).
there is a risk that this new baby is now having hemolysis “i.e. low Hb”. Thus,
we estimate the Hb by US of the middle cerebral artery).
√ If MCA assessment is abnormal
→ Fetal cord blood sampling (to quantify the Hb).
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Example 2:
A mother with (A -ve) blood group has just delivered her second baby who
soon develops severe jaundice. She has never received any IM injections
during her previous pregnancy.
The baby’s cause of jaundice is likely → Rhesus incompatibility
(Rhesus isoimmunisation “Anti-D Antibodies” → Hemolysis → Jaundice).
This rhesus -ve mother has likely developed Anti-D antibodies (from the
previous pregnancy with a rhesus +ve baby)
and she did not receive IM
prophylactic Anti-D immunoglobulins.
So, the Anti-D antibodies crossed the
placenta and attacked the fetal blood causing hemolysis and thus jaundice.
Important
Anti-D immunoglobulin should be given as soon as possible (but always
within 72 hours) of giving birth (sensitizing event).
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◙ Causes of jaundice in the first 24 hrs
√ Rhesus haemolytic disease (Rh incompatibility)
√ ABO haemolytic disease (ABO incompatibility)
√ Hereditary spherocytosis
√ Glucose-6-phosphodehydrogenase (G6PD) deficiency.
** The Rest is for Reading (For general medical knowledge) **
Prevention
♦ Test for D antibodies in all Rh -ve mothers at booking.
♦ Give anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks.
♦ Anti-D is prophylaxis – once sensitization has occurred, it is irreversible.
Anti-D immunoglobulin should be given as soon as possible (but always
within 72 hours) in the following situations:
• delivery of a Rh +ve infant, whether live or stillborn
• any termination of pregnancy
• miscarriage if gestation is > 12 weeks
• ectopic pregnancy
• antepartum haemorrhage
• amniocentesis, chorionic villus sampling, fetal blood sampling
• abdominal trauma
Tests
All babies born to Rh -ve mother should have cord blood taken at delivery for
FBC, blood group & direct Coombs test
Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
Affected fetus
oedematous (hydrops fetalis, as liver devoted to RBC production, albumin
falls)
jaundice, anaemia, hepatosplenomegaly
heart failure
kernicterus
Treatment: transfusions, UV phototherapy
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