Flashcards in Obstetrics and Gynaecology 2 Deck (50):
Define Post-Partum Haemorrhage
What are the RCOG classifications?
PPH is bleeding from the genital tract in excess of 500 mls within 24 hours of the birth of a baby.
Minor: 500 - 1000 ml
moderate: 1000 - 2000 ml
severe: 2000 ml
What are the main causes of Post Partum Haemorrhage?
The four T's
Uterine atony accounts for 80% of cases of major post partum haemorrhage.
Others include retained or morbidly adherent placental tissue, uterine and genital tract trauma, surgical haemorrhage, or coagulopathy secondary to abruption, sepsis, pre-eclampsia or amniotic fluid embolus.
What is primary dysmenorrhoea?
What is secondary dysmenorrhoea?
Primary Dysmenorrhoea occurs in females with no pelvic pathology (50% of women 10% severe) usually coincides with the start of menstruation
Secondary occurs in association with some form of pelvic pathology
What features make primary dysmenorrhoea likely?
1. Menstrual pain starting 6-12 months after menarche, once cycles are regular
2. Pain starts shortly before the onset of menstruation, and last for up to 72 hours, improving as the menses progresses.
3. Non-gynaecological symptoms such as:
4. Other gynaecological symptoms are not present.
5. Pelvic examination is normal.
What is the normal treatment for primary dysmenorrhoea
N.B. what is treatment pathway after initial treatment?
What is not recommended?
Offer NSAIDS such as:
ibuprofen, naproxen or mefenamic acid unless contraindicated.
Be aware mefanamic acid is more likely to cause seizures in O.D. (also be aware there is a low therapeutic window)
Paracetamol if NSAIDs not tolerated or in addition to.
If the women doesn't wish to concieve consider
3-6 months trial of hormonal contraception.
Oral - desogestrel 75 mg
Parenteral (depo-provera, nexplanon)
Intrauertine progestogen only (Mirena)
local application of heat
Transcutaneous electrical nerve stimulation - to a high frequency.
RCOG guidelines recommend that women with cyclic pain should be offered a therapeutic trial of hormonal treatment for a period of 3 to 6 months before having a diagnostic laparoscopy - to look for endometriosis.
Weak opioids are not recommended.
Neither are herbal, dietary, acupuncture, acupressure, spinal manipulation, behavioural therapy and exercise - due to lack of good quality evidence.
List some causes of secondary dysmenorrhoea and their indications
1. Endometriosis/Adenomyosis - cyclical or chronic pelvic pain, frequently occurring prior to menstruation and accompanied by heavy menstrual bleeding and deep dysparenunia. Rectal pain or bleeding may indicate recto-vaginal endometriosis.
2. Fibroids (leiomyomas) - Lower abdominal pain, frequently accompanied by heavy menstrual bleeding; a pelvic mass may be identified on examination.
3. Pelvic inflammatory disease - lower abdominal pain and tenderness that may be accompanied by dyspareunia, abnormal vaginal bleeding, and abnormal vaginal discharge. In acute infection, fever may be present
4. Intrauterine device insertion (IUD) 3 - 6 months previously usually. Pain may be accompanied by longer and heavier periods, often with intermenstrual bleeding or spotting. -Consider removal and alternative.
5. Also consider ovarian tumours.
One line description of dysmenorrhoea
Painful menstruation, associated with high prostaglandin levels in the endometrium causing contraction and uterine ischaemia.
What is endometriosis?
Where do you classically find it?
The presence and growth of endometrial-like tissue outside the uterus which induces a chronic, inflammatory reaction.
Affecting 1-2% of women
It is estrogen dependent, and therefor mostly effects their productive years.
N.B. if it is within the myometrium itself it is called adenomyosis
It can occur throughout the pelvis, particularly the uterosacral ligaments, and on or behind the ovaries. Accumulated blood is dark brown and can form a chocolate cyst or endometrioma on the ovaries.
What are the symptoms of endometriosis? How can they be classified?
Non-cyclical pelvic pain
fatigue in the presence of any of the above
Non-gynaecological cyclical symptoms:
dyschezia (difficult of painful defecation)
also consider IBS and PID
What are some investigations for use in endometriosis?
TV USS to diagnose or exclude an ovarian ednometrioma
TV USS is useful for identifying or ruling out rectal endometriosis
Laproscopy with histology
What are the treatments for endometriosis?
Remember how are they categorised?
In primary care: Depending on the women's preferences.
1. Pain relief via NSAIDS - ibuprofen, naproxen or mefenamic acid (though more dangerous in overdose)
+/- paracetamol or alone
2. If the women doesn't wish to conceive then a 3-6 month trial of hormone contraceptive
a) COCP 3 months of conventional and then tricycling or continuous use if this is in adequate (taking 3 boxes after each other to stop withdrawal bleeds)
b) oral desogestrel (POP) depot, subdermal implant (nexplanon) and IUS Mirena. after discussion of the advantages and disadvantages.
C) non-contraceptive progestogens - medroxyprogesterone or norethisterone
3. combination of the above
In secondary care:
1. Gondadotrophin-releasing hormone (GnRH) analogues - initially stimulate then inhibiti secretion due to pituitary downregulation followed by anovulation, markedly reduced oestrogen and amenorrhoea, inducing a reversible menopause
N.B. Add back HRT should be initiated to reduce post menopausal symptoms and bone mineral density loss. (otherwise only 6 months, with HRT 2 years+)
1. Excision or ablation of endometriosis deposits
- laparoscopic - diathermy, laser ablation or excision of deposits, ovarian cystectomy
- radical surgery - total abdominal hysterectomy and slapingo-oopherectomy. BSO
What is the aetiology of endometriosis?
Clinically what is good to remember?
Whats the prevalence?
The most popular theory is the retrograde menstruation theory.
Though more distant foci may result from mechanical, lymphatic or blood-borne spread.
Affected women do have an impaired immune system and evidence of neuro and angiogenic activity causing pain. Genetic linkage suggests a degree of inheritence.
Remember there is little correlation between severity of symptoms and severity of apparent disease on laparoscopy.
1 in 10 women of reproductive age in the UK.
What is chronic pelvic pain? What is important?
An intermittent or constant pain in the lower abdomen or pelvis of a woman of at least 6 months duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.
It is a symptom not a diagnosis!
N.B. CPP presents to primary care as frequently as migraine or low-back pain. Affecting approx 15% of adult women. Carrying a heavy social and economic price.
Possible causes of Chronic Pelvic Pain
- Endometriosis/Adenomyosis _ with cyclical pain
- Irritable Bowel Syndrome
- Interstitial Cystitis (painful bladder syndrome)
- Psychological factors are important as depression and sleep disorders are common. A number give history of childhood and/or ongoing sexual or physical abuse.
- Dense vascular adhesions (caused by endometriosis, previous surgery or previous infection)
- Musculoskeletal pain -trigger points and spasm of the pelvic floor - Rx botulinum injx
? Pelvic congestion syndrome or myofascial syndrome.
What is important to cover in the Chronic Pelvic Pain consultation?
the Woman's ICE
Ideas about the pain
What examinations in Chronic Pelvic Pain are important?
Abdominal and Pelvic - identify focal tenderness, enlargement, distortion or tethering or prolapse. +/- trigger points.
What investigations are important in Chronic Pelvic Pain?
1. Screen for infection - Chlamydia, Gonorrhoea, Bacterial Vaginosis and Trichomonas Vaginalis.
to idenitify and assess adnexal masses
MRI and TVS for adenomyosis
Does a positive endocervical sample diagnose PID?
No. It supports it.
Equally a negative result does not rule out the diagnosis of PID.
PID is best managed with a GUM physician.
What symptoms would prompt a CA125
More than 12 times per month of (3x per week)
- Early satiety
- Pelvic pain
- Urinary urgency or frequency
- Over 50 new symptoms of IBS
Chronic Pelvic Pain treatments?
1) if cyclical trial endometriosis treatment of 3-6 months of hormonal treatment before diagnostic laparoscopy + biopsy _ this can also be effective for non-endometriosis related cyclical pain.
2) IBS treat with antispasmodics + modify the diet.
3) offer analgesia (NSAIDS +/- paracetamol
What is the ROME III criteria for diagnosis of IBS?
Continuous or recurrent abdominal pain or discomfort on at least 3 days a month in the last 3 months with the onset at least 6 months previous, associated with at least two of:
- improvement with defecation
- onset associated with a change in frequency of stool
- onset associated with a charge in the form of stool
What are some Gynaecological red flags for pelvic pain?
- Bleeding per rectum
- New bowel symptoms over 50
- New pain after the menopause
- Pelvic mass
- Suicidal ideation
- Excessive weight loss
- Irregular vaginal bleeding over 40
- Postcoital bleeding
When would you give ferrous sulphate for anaemia and how much?
when the Hb is <105 g/L
For 3 months
At what Hb is anaemia classified in obstetrics?
Whats the normal range?
<110 g/L at booking
<105 g/L in the 2rd and 3rd trimester
<100 g/L post partum
Remember in pregnancy a disproportionate increase in plasma volume compared to red cell mass causes a drop in Hb to approximately 115 g/L
Remember that the physiological requirement of iron in pregnancy is 3x higher than the requirement increases as pregnancy advances.
The normal range of female Hb is 115-165 g/L
Define post menopausal bleeding
Bleeding >12 months after the last menstrual period
What is the vulva?
The area of sin that stretches from the labia majora laterally to the mons pubis anteriorly and the perineum posteriorly.
What type of epithelium is the vagina lined by?
What is the lymphatic drainage of the vulva?
Why this important?
Via the inguinal lymph nodes to the femoral and the external iliac nodes.
Important for metastatic spread of carcinoma of the vulva
What types of problems can affect the vulva?
Vulva pain syndromes
What are some causes of pruritis vulvae?
- Candidiasis (+/- vaginal discharge) - especially in type II DM, obese, pregnancy, after ABX and compromised immunity
- Vulval warts (condylomata acuminata (HPV virus 6 and 11)
- Public lice, scabies
- Eczema, psoriasis, lichen simplex (chronic vulval dermatitis), lichen sclerosus, lichen planus, contact dermatitis.
- Premalignant disease (vulva intraepithelial neoplasia VIN)
What is a Bartholin's gland?
Two bartholin glands are located behind the labia minora and secrete lubricating mucus for coitus.
What can blockage of a Bartholin's gland result in?
what are the symptoms?
Blockage can cause cyst formation, which if infection occurs (commonly with staph or E. Coli) an abscess forms.
Symptoms are pain, with a large tender swelling.
Incision and drainage with marsupialization, where the incision is sutured open to allow drainage.
What is VIN?
what are some risk factors?
Vulval Intraepithelial Neoplasia:
Precancerous atypia cells in the vulval epithelium. It is confirmed by a histological diagnosis.
normally affecting 35-55 for usual type
differentiated type seen in older women
It is most commonly caused by Human Papillomavirus (HPV) HPV 16 [Usual type] There is also type associated with lichen sclerosus or planus [Differentiated type], this latter has a greater risk of progression to squamous cell carcinoma.
Smoking is a risk factor
What are the signs and symptoms of VIN?
Whats the Rx?
burning and itching/irritation
clinical appearance is very variable.
Raised white, erythematous or pigmented lesions occur and these may be warty, moist or eroded
multifocal lesions are common
REFERRAL TO THE CA MDT!
Up to date cervical cytology + up to date colposcopy +/- anoscopy
imiquimod 5% cream - immune modifier (not in pregnancy)
5 fluorouracil cream
When is carcinoma of the vulva most common?
Whats the incidence?
1200 new cases a year in the UK and 400 deaths
90% are SSC, with melanomas, basal cell carcinomas, adenocarcinomas making up the rest.
Whats the aetiology of carcinoma of the vulva?
VIN, de novo, lichen slcerosis, immunosupression, smoking, paget's disease of the vuvla
signs and symptoms of vulva carcinoma?
What disease to people commonly present with?
Enlarged inguinal lymph nodes
50% of people present with stage 1 disease.
What is the staging for vulval carcinoma?
Stage 1a: confined to the vulva <2 cm negative nodes
1b confined to the vulva >2 cm negative nodes
Stage 2: any size with adjacent spread negative nodes
stage 3: any size with inguinofemoral nodes
stage 4a: invading upper uretha, vagina, rectum, bladder, bones
stage 4b: distant mets
What investigates are needed and whats the treatment for vulval carcinoma?
assess fitness for surgery
stage 1: local excision
stage 2+ wide local excision +/- lympadenectomy (triple incision radical vulvectomy)
survival is >90% in stage one 40% in stage 3-4
What is the most common cause of vaginal discharge?
Bacterial Vaginosis in women of reproductive age - caused by Gardnerella Vaginalis
It is associated with loss of lcatobacilli and an increase in anaerobic and highly specific fastitidous BV associated bacteria in the vagina. Which produce enzymes that breakdown the vaginal peptides into volatile, malodorous amines.
A grey-white discharge is present with a classic fishy odour, but no vulvovaginitis
Rx is with metronidazole or clindamycin cream.
BV is associated with preterm labour (before 37 weeks)
What is Pelvic Inflammatory Disease?
What are the common aetiological agents?
Is it the result of ascending infection from the endocervix causing:
- tuboovarian abcess
- pelvic peritonitis
- Perihepatits (Fitz- Hugh-Curtis syndrome 10%)
Can be caused be descending infection from the appendix.
spread of asymptomatic STIs:
Uterine instrumentation - termination of pregancy, ERPC, lap and dye, intrauterine devices. Complications of child birth
What are the risk factors for PID?
Risk factors for STI.
- Young age <20
- multiple sexual partners
- recent partner change
- non-use of condoms
- symptomatic partner
PID almost never occurs in the presence of a viable pregnancy.
Signs and Symptoms of Pelvic Inflammatory Disease?
1 - Lower abdominal pain which is typically bilateral
2 - deep dyspareunia
3 - abnormal vaginal bleeding, including post coital, inter-menstrual and menorrhagia
4 - abnormal vaginal or cervical discharge which is often purulent
1 - lower abdominal tenderness which is usually bilateral
2 - adnexal tenderness on bimanual vaginal examination
3 - cervical motion tender on bimanual vaginal examination
4 - fever > 38oC
A diagnosis of PID and empirical ABX treatment should be considered and usually offered in any <25 sexually active women who has the above symptoms AND PREGNANCY HAS BEEN EXCLUDED.
Guidelines from British Association for Sexual Health and HIV
What is the differential diagnosis of lower abdominal pain in a young woman?
Ectopic pregnancy - pregnancy should be excluded in all woman suspected of PID
Acute appendicitis - nausea and vomiting occurs in most patients with appendicitis but only 50% of those with PID. Cervical movement pain with occur in about a quarter of women with appendicitis
Endometriosis - relationship between menses and symptoms may help
Complications of an ovarian cyst - e.g. torsion or rupture - often of sudden on set
Urinary Tract Infection - often associated with dysuria and/or urinary frequency
Functional pain - maybe associated with longstanding symptoms (Chronic Pelvic Pain?)
What does the patient need to be counselled on when being treated for PID?
- An explanation of the treatment and possible side effects
- Following treatment fertility is usually maintained but their remains a future risk of infertility, chronic pelvic pain or ectopic pregnancy
- clinically more severe disease is associated with a greater risk of sequelae
- repeat episodes of PID are associated with exponential increase in the risk of infertility
- the earlier the treatment is given the lower the risk of future fertility problems
- future use of barrier contraception with significantly reduce the risk of PID
- the need to screen her sexual contacts for infection to prevent her becoming reinfected
What is a common reason to admit patients to hospital?
Outpatient regime for the treatment of PID?
Ceftriaxone 500 mg single IM dose
oral doxycylcine 100 mg BDS
Metronidazole 400 mg BDS
for 2 weeks (14 days)
When should a lady with PID undergoing treatment be reviewed?
AT 72 hours (3 days) there should be a substantial improvement in clinical symptoms and signs.
Review then at 2 - 4 weeks is ideal
What are the complications of PID?
- Formation of abscess of pyoslaphinx
- tubal obstruction and subfertility
- Chronic pelvic infection or pain
- Ectopic pregnancy is 6x more common after pelvic infection
- risk of tubal damange after one episode is 12%