OBS & GYN Flashcards
(284 cards)
1
Q
What is normal menstrual bleeding?
A
Normal Menstrual Bleeding:
• Avg 30mL lost with each menstrual period
• Upper limit is 80mL
2
Q
Definition of abnormal uterine bleeding
A
- Blood loss of more than 80mL (subjective by the patient)
- Cycle length of < 24 days or > 35 days
- Intermenstrual or postcoital bleeding
3
Q
Definition of dysfunctional uterine bleeding
A
Excessive bleeding which is not due to pregnancy, pelvic pathology or systemic disease that can be cyclical (ovulatory) or non-cyclical (anovulatory). Anovulatory bleeding commonly occurs at the beginning and end of reproductive life
(adolescence and premenapause).
Diagnosis of exclusion
4
Q
Definition of menorrhagia
A
- Excessive or prolonged menstrual bleeding occurring at regular intervals
- Note: both patient and doctor are unreliable at predicting amount of blood lost
5
Q
Definition of inter-menstrual bleeding
A
Bleeding that occurs between regular menstrual cycles
6
Q
Definition of post-coital bleeding
A
Bleeding up to 24 hours after intercourse
7
Q
Definition of pre-menstrual spotting
A
Bleeding during the week prior to a period
8
Q
Definition of Metrorrhagia
A
Bleeding of normal or less than normal volumes at irregular intervals
9
Q
Definition of Menometrorrhagia
A
Prolonged or excessive bleeding at irregular intervals
10
Q
Definition of Polymenorrhoea
A
Regular bleeding that occurs at intervals < 24 days
11
Q
Aetiology of abnormal uterine bleeding
A
12
Q
What History and Examination for abnormal uterine bleeding
A
13
Q
Investigations for abnormal uterine bleeding
A
14
Q
Investigation considerations according to patient group
A
Common to consider:
- BHCG
- Bloods: iron, FBC, folate, B12, coags ,TFTs, LFTs
- Imaging: Pelvic, abdominal or transvaginal US
- STI swab
- Pap smear
- Colposcopy
- Hysteroscopy
- biopsy
15
Q
Management of abnormal uterine bleeding
A
16
Q
Uterine blood flow
A
17
Q
Causes of abnormal uterine bleeding
A
18
Q
DDx of abnormal uterine bleeding
A
- Ectopic pregnancy
- Miscarriage
- Placental abruption, placenta previa
- Breakthrough bleeding
- Benign structural abnormalities (adenomyosis, fibroids, polyps)
- Gynaecological malignancies
- Chlamydia
- Hormonal changes – menopause/perimenopause
- Prolapse
- Trauma
19
Q
Investigation for abnormal uterine bleeding (part 2)
A
20
Q
Treatment for abnormal uterine bleeding
A
21
Q
Definition of uterine fibroids (leiomyoma)
A
Benign tumours of the uterus composed of smooth muscle and fibrous connective tissue
22
Q
Epidemiology of uterine fibroids
A
Epidemiology:
• Incidence increases with age
• Affects 20-50% of women > 30 years
• Prevalence may be as high as 80%
23
Q
Aetiology and anatomical classification of uterine fibroids
A
24
Q
Clinical features of uterine fibroids
A
- Asymptomatic – most common
- Menorrhagia (caused by submucosal fibroids)
- Dysmenorrhoea (painful periods)
- Pelvic pain/pressure
- Bloating
- Enlarged uterus – firm, asymmetric, non-tender
- Usually slow growing but can be accelerated growth in pregnancy due to high oestrogen
25
**Investigations for uterine fibroids**
* Pelvic U/S
* Endometrial biopsy (via hysteroscopy)
* DDx – clinically similar to adenomyosis and uterine polyps (require biopsy)
26
**Treatment for uterine fibroids**
27
**Complications and prognosis of Uterine fibroids**
28
Anatomy of uterus
29
**Definition and epidemiology of Antepartum Haemorrhage**
**Definition:**
• Uterine bleeding that occurs after 20 weeks gestation that is unrelated to labour and delivery
**Epidemiology:**
• 6% of all pregnancies experience PV (per vagina) bleeding in the 3rd trimester
30
**Aetiology of antepartum haemorrhage**
31
**General management of antepartum haemorrhage**
32
**Definition and epidemiology of abruptio placenta (placenta abruption)**
**Definition:**
• Premature separation of a normal implanted placenta from the decidual lining of the uterus after 20 weeks gestation
**Epidemiology:**
• Occurs in 1 in 200 pregnancies
• Black women \> white women
33
**Aetiology and risk factors for placenta abruption**
Aetiology:
• Exact cause is unknown
34
**Types of placenta abruption**
Types:
• Apparent: Bleeding apparent
• Concealed: Bleeding is not-apparent
• Mixed: Bleeding with concealment
35
**Pathophysiology of placenta abruption**
**Pathophysiology:**
* **Rupture of maternal vessels** in the decidua basalis at the interface of the anchoring villi
* **Accumulating blood splits the decidua**, separating a thin layer of decidua with its placental attachment from the uterus
* **The bleeding may be small and self-limited** or it can continue to separate the decidua leading to complete or near complete placental separation
* The **detached portion is no longer able to exchange gases** and nutrients
* **May lead to foetal compromise** if the remaining foeto-placental unit is unable to compensate for this loss of function
36
**Clinical features of antepartum haemorrhage**
37
**DDx for anterpartum haemorrhage**
DDx:
* Preterm labour - can co-exist/caused by placental abruption
* Placenta praevia
* Chorioamnionitis - bleeding is uncommon
38
**Diagnosis and complications of antepartum haemorrhage**
**Diagnosis:**
• Diagnosis of exclusion, based on clinical Hx and U/S
**Complications:**
• Hypovolaemic shock (medium)
• DIC
• Intra-uterine growth restriction
• Preterm birth
• Perinatal death
39
**Management of antepartum haemorrhage**
40
**Definition of Placenta Praevia**
Definition:
* The presence of placental tissue that extends over or lies proximate to the internal cervical os
* Should be suspected in any woman \> 20 weeks gestation that presents with painless vaginal bleeding
41
**Epidemiology and risk factors of placenta praevia**
**Epidemiology:**
* Uncommon in 1st pregnancies (0.2% in nulliparous)
* 0.5% in multiparous and a 4-8% recurrence
**Risk Factors:**
* Previous placenta praevia - 0.7% risk
* Infertility treatments (IVF) - 2% risk • Endometrial scarring, (previous LSCS) - 0.6%
* Impeded endometrial vascularisation e.g. HTN, diabetes, uterine tumour, drugs (cocaine) smoking and Advanced maternal age
* Increased placental mass: ⁃ Multiparity
42
**Aetiology and classification of placenta praevia**
43
**Clinical features of Placenta Praevia**
44
**DDx for placenta praevia**
DDx:
* Normal labour
* Placental abruption
* Placenta accreta
* Miscarriage (more common in early pregnancy)
45
**Investigations for placenta praevia**
**Investigations:**
* Transabdominal U/S - Assess placental position
* Transvaginal U/S - Preferred
* FBC - Assess Hb level in acute bleeds
* Type and crossmatch
46
**Management of Placenta Praevia**
47
**Complications of placenta praevia**
Complications:
* Anaemia (short-term high) - due to bleeding
* Complications of C-section
* Preterm birth
* Abnormally adherent placenta
48
**Prognosis of placenta praevia**
49
**Definition of Placenta Accreta**
50
**Epidemiology and risk factors of Placenta Accreta**
**Epidemiology**
* 5-10% risk in the presence of placenta praevia
* 10-20% risk with previous LSCS
**Risk Factors:**
* Placenta praevia
* Previous C-section or uterine surgery
* Maternal age \> 35 years
* Multiparity - increases after each childbirth
* Uterine pathology like fibroids
51
**Aetiology and pathophysiology of placenta accreta**
**Aetiology:**
* Unknown
* Abnormality to the uterine lining
**Pathophysiology:**
* Defective decidualisation (thin, poorly formed or absent decidua) related to previous surgeries or anatomical pathologies or extra-villous trophoblastic invasion
* Allows for the placenta to attach directly to the myometrium
52
**Clinical features, Investigations and Management of Placenta Accreta**
53
**For Vasa Previa what is the:**
* **Definition**
* **Epidemiology**
* **Aetiology and pathophysiology**
* **Clinical features**
* **Diagnosis**
54
Assisted reprodutive tech cards to be filled - Gobi's incomplete - might have to check in Jims
55
**Common cancer of the vulva, epidemiology and symptoms**
The female external genitalia is called the vulva. Made up of 3 main parts: labia majora, labia minora and clitoris
* Cancer of the vulva makes up around 4% of female genital tract cancers and is quite rare
* Most are SCCs
* Most commonly diagnosed in post-menopausal women, ~ 70 years
* Symptoms include ulcerative sores that do not heal, itching, unusual vaginal bleeding and/or discharge
56
**Aetiology of cancer of the vulva**
57
**Sites of vulval cancer**
58
**Symptoms of vulval cancer**
59
**Risk factors of vulval cancer**
60
**Types of vulval cancer**
61
**Diagnosis and staging of vulval cancer**
62
**Treatment of vulval cancer**
63
**Definition of cervical cancer**
* Cervical cancer is a HPV-related malignancy of the uterine cervical mucosa
* HPV is transmitted via sexual intercourse
64
**Epidemiology of cervical cancer**
**Epidemiology:**
* Cervical cancer is the 2nd most common malignancy in women worldwide
* Peak infection incidence is between 15-25 years, with the majority resolving in 12-18 months
* Prevalence of HPV at age 35 is 5%
* Effective screening programs have reduced mortality by 75% in the last 50 years
* 60% of diagnoses occur in women who have never had screening or have not been screened in the last 5 years
* Pap smears are a very successful cancer screening tool
65
**Aetiology and risk factors of cervical cancer**
66
**Pathophysiology of cervical cancer**
67
**Clinical features and staging of cervical cancer**
68
**Investigations for cervical cancer**
69
**Pap smear results in cervical cancer screening**
70
**Classification and staging of cervical cancer**
71
**Management of cervical cancer**
72
**Screening for cervical cancer**
- 25-74 years
- Every 5 years
- Test looks for HPV
73
**Prognosis for cervical cancer**
74
**Histology of the transformation zone and types of smears**
75
**Histology of cervical cancer**
76
Contraception cards - gobi's incomplete - please insert
77
**Epidemiology and factors enhancing risk of diabetes in pregnancy**
78
**Complications and maternal insulin requirements in T1DM and pregnancy**
79
**Management of T1DM in pregnancy and delivery**
80
**Considerations and management of T2DM in pregnancy**
81
**Definition and epidemiology of Gestational Diabetes Mellitus (GDM)**
**Definition:**
* Any degree of glucose intolerance with onset or first recognition in pregnancy
* Includes women that develop T1DM/T2DM during the pregnancy, hence need for retrospective classification
**Epidemiology:**
* Accounts for 70% of diabetes in pregnancy
* Higher in asian and black populations
* Rates of GDM are on the rise
82
**Aetiology of GDM**
83
**Pathophysiology of GDM**
84
**Clinical features of GDM**
85
**Investigations for GDM**
86
**Screening for GDM**
87
**Management for GDM**
88
**Complications of GDM**
89
**Prognosis for GDM**
90
**Role of prostaglandins in labour**
91
**Role of oxytocin in labour**
92
**Role of B2 agonists in labour**
93
**Role of tocolytics in labour**
94
**Induction of labour and myometrial contraction**
95
**Inhibition of labour and myometrial relaxation**
96
**Definition of ectopic pregnancy**
**Definition:**
* A pregnancy resulting from the fertilised ovum implanting in a site other than the normal uterine cavity
* Obstetric Emergency: If undiagnosed it can lead to maternal death due to rupture of the implantation site and intraperitoneal haemorrhage
**Epidemiology:**
* Incidence rate of 1-2% and rising
* Recurrence rate is 15% after 1st and 25% after the 2nd
* Accounts for 80% of 1st trimester maternal deaths. Mortality rates are declining
97
**Aetiology and risk factors of ectopic pregnancy**
98
**Classification of ectopic pregnancy**
99
**Pathophysiology of ectopic pregnancy**
100
**Clinical features of ectopic pregnancy**
101
**Investigations for ectopic pregnancy**
102
**Diagnosis of ectopic pregnancy**
**Diagnosis:**
* Elevated β-hCG with no intrauterine gestation sac (\> 5 weeks is visible on TVS)
* Detection of free-fluid in the peritoneal cavity
* Laparoscopy rarely required for diagnostic purposes
103
**Differential diagnosis for ectopic pregnancy**
**DDx:**
* Miscarriage
* Acute appendicitis
* Ovarian torsion
* Ruptured corpus luteal cyst or follicle
* Normal 1st trimester bleeding (20% of women have normal pregnancies)
* UTI/PID
104
**Management of ectopic pregnancy**
105
**Complications and management of ectopic pregnancy**
106
**Normal B-Hcg and diagnosis of interuterine/normal pregnancy**
107
**Definition and epidemiology of endometrial cancer**
**Definition:**
• Epithelial malignancy of the uterine corpus mucosa - usually adenocarcinoma
**Epidemiology:**
* Most common gynaecological malignancy in the developed world
* 7th most common cancer in women overall
* Incidence in western countries is 10x more than in developing
108
**Aetiology of endometrial cancer**
109
**Risk factors for endometrial cancer**
**Risk Factors:**
* Obesity
* Age \> 50 years
* Endometrial hyperplasia
* Unopposed exogenous/endogenous oestrogen exposure
* FHx of endometrial cancer
* FHx of breast or ovarian cancer
* HNPCC
* Tamoxifen use (oestrogen receptors antagonist) for Rx of breast Ca (7x)
* DM
* HTN
110
**Classification of endometrial cancer**
**Classification:**
* Adenocarcinoma (90%)
* SCC
* Transitional cell carcinoma
* Small cell
* Undifferentiated
111
**Clinical features of endometrial cancer**
112
**Investigations for endometrial cancer**
113
**Differential diagnosis for endometrial cancer**
**DDx:**
* Endometrial hyperplasia - commonly presents with abnormal uterine bleeding, irregular or heavy periods
* Endometrial polyp - usually asymptomatic, but if symptomatic presents similarly
* Endometriosis - More common in younger pre-menopausal women
* Cervical cancer - Typically younger women; PV bleeding usually provoked (post-coital)
114
**Spread and management of endometrial cancer**
115
**Complications and prognosis of endometrial cancer**
116
**Definition and epidemiology of endometriosis**
**Definition:**
• Ectopic endometrial glands and stroma growing outside the endometrial cavity and uterine musculature
**Epidemiology:**
* 3-10% of women aged 20-50 (women of reproductive age usually)
* Average age at diagnosis is 25-28 years
* Account for 25-35% of infertility
* Severity of symptoms increases with age and peaks at 40yrs • Prevalence higher in white women and women with Lower BMIs • Adolescent endometriosis exists
117
**Aetiology + risk factors for endometriosis**
**Aetiology:**
• Several theories exist + Genetic predisposition
**Risk Factors:**
* Reproductive Age
* Family Hx
* Nulliparity
* Mullerian anomolies
* Others: White, Low BMI, Autoimmune disease, Smoking
118
**Pathogenesis of endometriosis**
**1. Retrograde menstruation theory:** ⁃ Retrograde menstruation seeds in the abdominal cavity ⁃ Occurs in 70-90% of women
**2. Coelomic metaplasia:** ⁃ Peritoneal mesothelium undergoes metaplastic transformation into endometrial tissue
**3. Induction theory:** ⁃ Unknown biochemical substance induce undifferentiated peritoneal cells to form endometrial tissue
**4. Immunological theory:** ⁃ Alterations in cell-mediated immunity leads to abnormal clearance of endometrial cells
119
**Pathophysiology of endometriosis**
1. Endometriosis and sub-fertility: Altered anatomy with tube/ovarian involvement and scarring and PG overproduction can also interfere with fertilisation
2. Dysmenorrhoea occurs due to reactive hormonal-tissue in the abdomen
3. Chronic pain may be due to fibrosis that occurs with chronic inflammation
120
**Types of lesions in endometriosis**
Three types of lesions in endometriosis:
* superficial peritoneal endometriosis – powder burn lesions on ovaries, serosa and peritoneum, may also appear as white plaques, scarring, red implants, serous vesicles
* ovarian cysts (endometrioma) – ‘chocolate cysts’ forming from menstrual bleeding in the ovaries
* deep infiltrative endometriosis – nodules extending more than 5mm beneath the peritoneum involving the uterosacral ligaments, vagina, bowel, bladder, or ureters
121
**Signs and symptoms of endometriosis**
122
**Staging of endometriosis**
123
**Clinical presentation of endometriosis**
124
**Differential diagnosis of endometriosis**
* Adenomyosis – hyperplasia leading to growth of endometrial tissue within the myometrium, symptoms may be identical, and endometriosis is often concurrent
* Pelvic inflammatory disease
* Malignancy – ovarian, uterine, endometrial
* Ovarian cyst
* Irritable bowel syndrome
125
**Investigations and diagnosis of endometriosis**
**Investigations:**
* TVS - may show ovarian endometrioma or deep pelvic endometriosis
* Diagnostic laparoscopy
**Diagnosis:**
* Laparoscopy - _Gold Standard_. Finding of extra-uterine endometrial tissue on visualization and biopsy (histopathology)
* Examination - Pouch of Douglas Pain with nodularity of the uterosacral ligament. Fixed in retroversion
* TVS: Especially for endometrioma
126
**Management of endometriosis**
127
**Complications and prognosis of endometriosis**
128
**Definition of foetal malpresentation**
**Definitions:**
* In normal pregnancies the foetus assumes a normal longitudinal (vertical) lie with a cephalic presentation and the head well flexed
* 5% of all term pregnancies have a deviation from this lie
129
**Causative factors for foetal malpresentation**
130
**Types of foetal malpresentations**
Types of Malpresentations:
1. Unstable lie
2. Face presentation
3. Brow presentation
4. Compound presenation
5. Breech presentation
131
**Unstable or abnormal lie of foetal malpresentations**
132
Face presentation of foetal malpresentation
133
**Brow position of foetal malpresentation**
134
**Compound presentation of foetal malpresentation**
135
**Breech presentation of foetal malpresentation**
136
**Definition of gestational trophoblastic disease**
137
**Epidemiology and aetiology of gestational trophoblastic disease**
138
**Pathophysiology of gestational trophoblastic disease**
139
**Classification of gestational trophoblastic disease**
140
**Clinical features of gestational trophoblastic disease**
141
**Differential diagnosis of larger than stated uterus**
DDx of larger than stated uterus:
* Wrong dates for LMP
* Multiple gestation (twins)
* Other intrauterine pathology (e.g. fibroids)
* GTD
142
**Investigations for gestational trophoblastic disease**
143
**Differential diagnosis for gestational trophoblastic disease**
DDx:
* Spontaneous abortion - can be differentiated on U/S
* Multiple gestation - larger than normal uterus and elevated hCG
* Pelvic tumour - may present with enlarged uterus, painless bleeding and adnexal mass
144
**Management of gestational trophoblastic disease**
145
**Complications and prognosis of gestational trophoblastic disease**
146
**Gynae Hx Taking**
147
**Abdomen and vaginal exam**
Antenal exam"
- BP
- void bladder and urine analysis
- general inspection
- Check for ankle oedema
- fundal height
- Foetal lie
- Foetal doppler
148
**Vaginal examination**
149
**Definition of pre-eclampsia**
150
**Epidemiology, aetiology and risk factors for pre-eclampsia**
151
**Pathophysiology and types of pre-eclampsia**
152
**Clinical features of pre-eclampsia**
153
**Investigations for pre-eclampsia**
154
**Management of pre-eclampsia**
155
**Complications and prognosis of pre-eclampsia**
156
**Definition of eclampsia**
Definition:
• Onset of convulsions during pregnancy or postpartum unrelated to other cerebral pathologies in women with pre-eclampsia
157
**Epidemiology of eclampsia**
158
**Clinical features of eclampsia**
159
**Management of eclampsia**
160
**Definition of induction of labour**
Definition:
* The planned initiation of labour prior to its spontaneous onset.
* It is an intervention designed to artificially initiate uterine contractions, resulting in progressive effacement and dilation of the cervix leading to birth of the baby
* It is performed when the benefits of delivery outweigh the risks of continuing the pregnancy
* Should be performed if the risk of the process to the mother and/or foetus is acceptable, otherwise proceed to a C-section
* Occurs in 1 in 5 deliveries
161
**Aims for induction of labour**
**Aims:**
* To stimulate regular uterine contractions
* To generate progressive cervical dilation
* To facilitate a subsequent vaginal delivery
162
**Indication for Induction of Labour**
**Indication for IOL: “When the benefits of delivery outweigh the potential risks of continuing pregnancy”**
* Prolonged pregnancy (post-date pregnancy) \*\* most common cause
* Foetal growth restriction
* Pre-eclampsia or other maternal HTN disorders
* Prelabour rupture of membranes
* Chorioamnionitis - inflammation of the foetal membranes
* Unexplained antepartum haemorrhage
* Maternal medical problems - diabetes or renal disease
* Logistics - distance from hospital
163
**Contraindications for induction of labour**
Contraindications:
* Placenta previa or Vasa previa (placental cord running close to the os)
* Transverse foetal lie
* Previous classical uterine incision
* Active genital herpes infection
* Pelvic structural abnormalities
164
**Pre-induction of labour scoring system**
165
**Steps/Process involved in induction of labour**
166
**Complications and special cases in IOL**
167
Questions
168
**Definition of infertility**
169
Epidemiology and risk factors for infertility
**Epidemiology:**
• Affects 1 in 12 couples
**Risk Factors:**
* Age \> 35 years
* Hx of STIs
* Very high BMI
* Very low BMI
* Cigarette smoking ⁃ Related to accelerated menopause and decreased cilia function in uterine tubes
170
**Aetiology of infertility**
171
**Pathophysiology of infertility**
172
**Fecundity to consider in infertility**
173
**History taking in infertility**
174
**Examination for infertility**
**Females:**
⁃ General Exam
⁃ Pelvic Exam
⁃ Cervical Smear
⁃ Swabs as appropriate
**Male:**
⁃ General Exam
⁃ Testes, vas, varicocele
⁃ Prostate
175
**Investigations for infertility**
176
**Management of infertility**
177
**Prognosis for infertility**
178
**Notes on IVF**
179
**Infertility advice for couples**
180
**Definition of labour**
181
**Foetal and maternal anatomy in labour**
182
**The process of labour**
183
**Mechanism of labour**
184
Factors affecting the outcome of labour
185
Factors affecting the duration of labour
186
**Management of labour**
187
Investigations prior to hospital booking for antenatal care
188
**Schedule of routine visits for normal antenatal care**
**Schedule of Routine Visits:**
* 11-12 weeks - booking Hx by hospital staff
* 12-14 weeks - appointment with specialist & allocated a model of AN care
* 16-24 weeks - 4 weekly appointments
* 28-36 weeks - 2 weekly appointments
* 36+ weeks - weekly appointments
189
**Checks on each visit for normal antenatal care**
190
**Dietary advice for normal antenatal care**
191
**Additional investigations in normal antenatal care**
192
**Post delivery date women in antenatal care**
193
Ovarian cancer epidemiology and introduction
* Ovarian cancer is the 2nd most common gynaecological malignancy and the major cause of death from gynaecological cancers
* Mean age of presentation is 63 years
* Patients with early-stage ovarian cancer are asymptomatic or have vague/non-specific symptoms
* In late disease, patients present with abdominal pain or swelling
* Survival rates for ovarian cancer remains poor due to late presentation of the disease
194
**Aetiology and risk factors for ovarian cancer**
195
Symptoms of Ovarian cancer
196
**Metastatic spread of ovarian cancer**
Metastatic Spread:
* Direct: Spread to surrounding structures
* Lymphatic: Spread to the pelvic and para-aortic nodes is common
* Haematoganous: Distant mets are uncommon
197
**Types of ovarian cancer**
198
**Staging of ovarian cancer**
**Staging:**
* _Stage 1_: Growth limited to the ovaries -
* _Stage 2:_ Growth involving one or both ovaries with pelvic extension
* _Stage 3_: Growth involving one or both ovaries with peritoneal implants outside the pelvis or positive retroperitoneal or inguinal nodes
* _Stage 4_: Growth with distant metastases
199
**Investigations for ovarian cancer**
200
**Blood tests and markers for ovarian cancer**
201
**Management of ovarian cancer**
202
**Definition of pelvic mass**
**Definition:**
* A mass arising from a pelvic organ
* May originate from female reproductive organs (ovaries, uterus) or other pelvic organs (bladder, rectum, blood vessels)
203
**Clinical features of pelvic mass**
204
**Definition of pelvic organ prolapse**
205
**Epidemiology, risk factors and aetiology of pelvic organ prolapse**
206
**Pelvic anatomy and support in pelvic organ prolapse**
3 levels of pelvic support:
- Level I has long mesenteric attachments (cardinal and uterosacral ligaments),
- Level II has more direct connections to the pelvic walls (e.g. paravaginal attachments),
- Level III has a direct fusion of the vagina with the levator ani muscles, perineal membrane and body
207
**Cystocele types, grading and treatment in pelvic organ prolapse**
208
**Rectocele and Enterocele description and treatment in pelvic organ prolapse**
209
**Uterine and vaginal wall description and treatment in pelvic organ prolapse**
210
**Staging and clinical features of pelvic organ prolapse**
211
**Investigations and complications of pelvic organ prolapse**
212
**Perineal tears description**
213
**Risk factors for 3rd and 4th degree perineal tears**
**Risk Factors for 3rd and 4th Degree Tears:**
* Birth weight \> 4kg
* Persistant occipitoposterior position
* Nulliparity
* Induction of labour
* Epidural anaesthesia
* 2nd stage labour \> 1 hour
* Shoulder dystocia
* Midline episiotomy
* Forceps delivery
214
**Anatomy of perineum and classification of perineal tears**
215
Description of an episiotomy in perineal tears
216
**Perineal repair and prognosis**
217
**Definition of Polycystic Ovarian Syndrome**
According to the Rotterdam consensus,1 polycystic ovarian syndrome (PCOS) is defined by the presence of two of three of the following criteria:
- oligo‐anovulation,
- hyperandrogenism and
polycystic ovaries (≥ 12 follicles measuring 2‐9 mm in diameter and/or an ovarian volume > 10 mL in at least one ovary).
**Definition:**
• Complex endocrine disorder characterised by hyper-androgenism, symptoms of hyper-androgenism, oligo/ anovulation, and polycycstic ovarian morphology on U/S
218
**Epidemiology, risk factors and aetiology of polycystic ovarian syndrome**
219
**Pathophysiology of polycystic ovarian syndrome**
220
**Clinical features of polycystic ovarian syndrome**
221
**Investigations for polycystic ovarian syndrome**
222
**Differential diagnosis for polycystic ovarian syndrome**
**DDx:**
* 21-hydroxylase deficiency - Leads to accumulation of androgen precursors
* Thyroid dysfunction - May lead to irregular menstruation but hyper-androgenism is absent
* Hyperprolactinaemia - May lead to infrequent or absent menses. Galactorrhoea is usually present
* Cushingʼs syndrome - Cortisol excess leading to obesity, HTN, hirsutism, acne and menstrual irregularities
* Androgen secreting neoplasms - Of the adrenal gland or ovaries
223
**Diagnosis of polycystic ovarian syndrome**
Diagnosis:
* Clinical features, elevated androgens and polycystic ovarian morphology on U/S
* NOTE: Up to 25% of women have polycystic ovarian morphology, but do not have PCOS without symptoms
224
**Management of polycystic ovarian syndrome**
225
Complications and prognosis of polycystic ovarian syndrome
226
**Definition of post partum haemorrhage**
227
**Epidemiology of post partum haemorrhage**
228
**Aetiology of post partum haemorrhage**
229
**Antepartum risk factors for post partum haemorrhage**
230
**Intrapartum and post partum risk factors for post partum haemorrhage**
231
**Management of post partum haemorrhage**
232
**Reasons for foetal HR monitoring**
233
**CTG interpretations in foetal HR monitoring**
234
**Deceleration in detail on CTG for foetal HR monitoring**
235
**Management of Foetal HR in context of CTG readings**
236
**Interpret CTG**
237
**Interpret CTG**
238
**Interpret CTG**
239
**Interpret CTG**
240
**Interpret CTG**
241
**Interpret CTG**
242
**Interpret CTG**
243
**Interpret CTG**
244
**Interpret CTG**
245
**Definition of pre-term labour**
Definition:
* Pre-term Labour = Labour that occurs between 20 weeks and 36 + 6 weeks
* Term Labour = Labour that occurs between 37 weeks and 41 + 6 weeks
246
**Epidemiology of pre-term labour**
Epidemiology:
* Leading cause of perinatal morbidity/mortality in developed countries
* Morbidity/mortality inversely proportional to gestational age
* Morbidity/mortality is uncommon \> 32 weeks getation
* Incidence of 5-25%
* 12.7% in Australia with \< 2% below 32 weeks
* Increasing incidence (IVF, multiple pregnancies, elective)
247
**Aetiology of pre-term labour**
**Multifactorial:**
⁃ 50% - Spontaneous
⁃ 30% - PPROM (Pre-term prelabour rupture of membranes) = Rupture of membranes \< 37 weeks
⁃ 20% - Iatrogenic
⁃ \< 1% - Cervical incompetence
248
**Pathophysiology and classification of pre-term labour**
- inflammation (infection or autoimmune)
- uterine stretch + cervical incompetence
- antepartum hemorrhage
- premature desidual activation
- social stress
- Genetics
249
**Risk factors of pre-term labour**
250
**Clinical features of pre-term labour**
251
**Management of pre-term labour**
252
**Definition of rhesus haemolytic disease**
253
**Causes of foetal anaemia**
**Causes of Foetal Anaemia:**
* Rhesus disease
* Transplacental viral infection (Parvovirus B16)
* Placental foetal vessel rupture
* Twin-twin transfusion
254
**Epidemiology of Rhesus Haemolytic Disease**
255
**Aetiology of foetal haemolytic disease**
256
**Pathophysiology of foetal haemolytic disease**
257
**Signs of foetal aneamia**
**Signs of Foetal Anaemia:**
* Polyhydramnios
* Enlarged foetal heart
* Ascites and pericardial effusion
* Hyperdynamic foetal circulation (detected on MCA flow doppler)
* Reduced foetal movements
* Abnormal CTG with reduced variability, eventually leading to a _sinusoidal trace_
258
**Investigations for foetal haemolytic disease**
259
**Management of Foetal Haemolytic Disease**
260
**Complications and prognosis of foetal haemolytic disease**
261
**Red cell Antigens**
262
**Definition of twin gestation**
**Definition:**
* Multiple Gestation: Consists of two or more foetuses (twins make up 99% of this)
* Monozygotic Twins: Arising from a single fertilised egg that divides
* Dizygotic Twins: Arising from two separately fertilised eggs
263
**Epidemiology of twin gestation**
**Epidemiology:**
* 1-2% of pregnancies have more than one foetus
* The chance of miscarriage, foetal abnormalities, poor growth, preterm delivery and intrauterine or neonatal death are considerably higher in twin than singleton pregnancies
* 2/3rds of twins are dizygotic (non-identical) & 1/3rd are monozygotic (identical)
* Incidence is on the rise
264
**Risk factors of multiple gestations**
**Risk Factors for Multiple Gestations:**
* Assisted reproduction techniques (ovulation induction and IVF)
* ↑Maternal Age (35-39 years)
* High parity
* Black race
* Maternal family Hx
265
**Aetiology of twin gestation**
266
**Classification of multiple gestations**
267
**Types of twin gestation**
268
Maternal physiological changes of twin gestation
269
**Complications of twin gestation**
270
**Medical management of twin gestation**
271
**Twin to twin transfusion syndrome:**
* **Pathophysiology**
* **Management**
* **Complications**
* **Prognosis**
272
**Twin Reversed Arterial Perfusion sequence:**
* **Description**
* **Management**
* **Prognosis**
273
**Multifoetal reduction**
274
**Description/definition of vaginal cancer**
The vagina is a muscular canal ~7.5cm long that extends from the vulva to the cervix
* Primary cancer of the vagina is one of the rarest gynaecological cancers (makes up around 2%)
* Most commonly diagnosed in women \> 50 years who were exposed to the drug Diethylstilbestrol (DES) in the womb
* Symptoms include abnormal vaginal bleeding, postcoital bleeding, vaginal discharge & pelvic pain
* Most cases are detected in advanced stages and require radiation therapy or chemoradiation for treatment
275
**Aetiology of vaginal cancer**
276
**Symptoms of vaginal cancer**
**Symptoms of Vaginal Cancer:**
* Early stages are asymptomatic
* Painless vaginal bleeding not associated with menstruation
* Postcoital bleeding
* Smelly discharge
* Pain on urinating or passing bowel motions (may indicate local spread) • Constant pelvic pain
277
**Metastatic spread of vaginal cancer**
278
**Risk factors for vaginal cancer**
**Risk Factors:**
* Age - usually occurs in women \> 50 years
* Previous Hx of gynaecological cancers
* Previous treatment of dysplastic cells
* HPV infection
* Smoking
* Prenatal exposure to DES
* Vaginal adenosis (almost all DES daughters have vaginal adenosis)
279
**Types of vaginal cancers**
**Types of Vulval Cancers:**
* Vaginal SCC - Accounts for 95%
* Vaginal Adenocarcinoma - most are clear-cell carcinomas arising from DES daughters
* Vaginal Melanoma - rare
* Vaginal Sarcoma - arising from connective tissue or muscle cells of the vagina (rare)
280
**DES-related vaginal cancers**
**DES-related Vaginal Cancers:**
* Diethylstilbestrol was used from 1938-1971 as a synthetic hormone that was mistakenly used to prevent miscarriage
* DES exposure in utero alters the shape of the cervix and uterus and up to 30% have vaginal adenosis
* There is a small risk (1 in 1000) of vaginal adenosis in DES-exposed women to develop into a clear-cell carcinoma of the vagina
* Mean age of diagnosis is 19 years
281
**Investigations for vaginal cancer**
Investigations:
* Colposcopy
* Biopsy and staging
* CXR, CT abdomen and pelvis or MRI/PET for mets
282
**Treatment for vaginal cancer**
283
**Other complications of vaginal cancer**
Other complications:
• Rectovaginal or vesicovaginal fistula formation, which can be hard to treat palliatively
284
**Shoulder dystocia**
