RCSI NB OG Flashcards
(219 cards)
1
Q
Preterm Labour (PTL) def incidence
A
before 37 weeks of gestation
11% of all live births
2
Q
Labour prior to 24 weeks =
A
threatened miscarriage
3
Q
PTL Causes
A
1/3 spontaneous PPROM
1/3 iatrogenic
1/3 idiopathic
4
Q
Iatrogenic PTL Causes
A
- Preeclampsia
- IUGR
- Maternal disease necessitating delivery
5
Q
Spontaneous Preterm Delivery Causes
A
- PTL
- PPROM
- Cervical incompetence
6
Q
PTL risk factors
Non-pregnancy related
A
- Low socio-economic group
- Extremes of age
- Poor nutritional status
- Smoking
- Drug abuse
7
Q
PTL risk factors
Pregnancy related
A
- Multiple pregnancy
- PPROM
- Uterine anomalies
- History of preterm delivery in prior pregnancy
- Placenta praevia
- Placental abruption
- Polyhydramnios
- Medical complications of pregnancy eg PET
- Intrauterine infection
8
Q
Predict Preterm Delivery with two tests
A
Fetal Fibronectin
Transvaginal ultrasound
9
Q
Tell me about Fetal Fibronectin/ Partosure
A
- Glue-like protein binding the fetal membranes
- Cervicovaginal swab at 23 and 35 weeks gestation should be negative
- Positive swab - increased risk preterm delivery
- Good negative predictive value <1% chance of delivery within a week – high specificity
10
Q
Tell me about Transvaginal ultrasound
A
Short cervix (<25mm) predicts 75% cases preterm delivery Shorter the cervix = higher the chance of preterm delivery
11
Q
Preterm Delivery Prevention
A
No proven preventative strategies
12
Q
Progesterone for Prevention of Preterm Birth
A
Weekly IM injections of 17α-hydroxyprogesteone caproate
Reduced incidence of preterm delivery by 1/3 in patients with prior preterm delivery
NEJM
13
Q
Preterm Labour – Role of Antibiotics
A
no benefit when membranes are still intact
ONLY FOR PPROM
14
Q
GBS, listeria, mycoplasma, bacteroides, ureaplasma –> 15 - 20% of PTL
Tx GBS prophylaxis
A
3g benzylpenicillin IV
THEN 1.8g 6 hourly (clindamycin if penicillin allergic)
15
Q
Cervical Cerclage
A
For high-risk cases, short cervix on transvaginal U/S
16
Q
Preterm Delivery – Prevention
prophylactic vaginal progesterone or prophylactic cervical cerclage to women:
A
- with a history of spontaneous preterm birth or mid trimester loss between 16+0 and 34+0 weeks of pregnancy and
- in whom a transvaginal ultrasound scan has been carried out between 16+0 and 24+0 weeks of pregnancy that reveals a cervical length of less than 25 mm.
17
Q
Preterm Delivery – Prevention
prophylactic vaginal progesterone to women
A
with no history of spontaneous preterm birth or mid trimester loss in whom a transvaginal ultrasound scan has been carried out between 16+0and 24+0 weeks of pregnancy that reveals a cervical length of less than 25 mm.
18
Q
Preterm Delivery – Prevention
prophylactic cervical cerclage for women
A
transvaginal ultrasound scan between 16+0 and 24+0 weeks of pregnancy that reveals a cervical length of less than 25 mm
Hx P-PROM
LLETZ
19
Q
Preterm Labour Dx
A
- Regular contractions
- Cervical change
- Cervical dilatation
20
Q
Preterm Labour – Management
A
- Administer antenatal corticosteroids
Dexamethasone 6mg 12 hourly x 4 doses
or
Betamethasone 12mg IM 24hrly x 2 doses - Tocolysis
- Transfer to tertiary level facility with NICU
21
Q
Antenatal Corticosteroids
A
24 and 36 weeks
Reduction in Respiratory Distress Syndrome, neonatal mortality, Intraventricular Haemorrhage, Necrotising Enterocolitis and PDA
22
Q
Commonly used tocolytics:
A
Atosiban: oxytocin receptor antagonist
Nifedipine: calcium channel blocker
Ritodrine or Terbutaline: beta adrenergic agonist
Magnesium Sulphate: competitive antagonist to calcium
Indomethacin: interferes with prostaglandin synthesis
23
Q
Preterm Delivery Neonatal Complications
A
- Respiratory distress syndrome (RDS)
- Necrotising enterocolitis (NEC)
- Intraventricular haemorrhage (IVH)
- Periventricular leukomalacia (PVL)
- Sepsis
- PDA
24
Q
PPROM
A
Preterm Premature Rupture of the Membranes
before 37 weeks gestation
1% to 3% of all pregnancies
25
Premature ROM
rupture of the chorioamniotic membranes prior to the onset of labour, and may occur at term
26
Prolonged ROM
ROM > 24hrs
27
PPROM Dx
Hx gush of fluid, constantly wet
Physical Exam pooling of fluid in the posterior vaginal fornix
Amnisure – for placental alpha-microglobulin 1 in cervicovaginal fluid. High sensitivity and specificity.
Ferning - broad fern pattern on microscopy vs narrow fern pattern of amniotic fluid
Vaginal swab pH - Nitrazine sticks turn blue in presence of amniotic fluid
Cervico-vaginal fetal fibronectin
Intraamniotic instillation of indigo carmine dye
Ultrasound
28
PPROM causes
* Spontaneous / Idiopathic (most cases)
* Infection: Chlamydia, GBS, Bacteroides
* Smoking
* Placental abruption
* PPROM in prior pregnancy
* Incompetent Cervix
* Multiple Pregnancy (twins / triplets etc)
* Polyhydramnios
* Iatrogenic (after amniocentesis)
29
PPROM Risks
```
Risk of infection
Intrauterine infection
Placental abruption
Cord compression
Fetal demise (1% - 2% of PPROM cases)
```
30
PPROM Surveillance
```
• Maternal signs of infection
• Fetal signs of infection
• Serum markers of infection
• Ultrasound markers of fetal compromise
– Altered biophysical profile (BPP)
• CTG abnormalities
```
31
Signs of maternal infection
* Pyrexia
* Tachycardia
* Uterine tenderness
* Preterm labour
* Foul smelling vaginal fluid
32
Signs of fetal infection
```
• Fetal tachycardia
• Non-reactivity / reduced variability on CTG / variable decelerations
• Alteration in biophysical profile
– Loss of breathing movements
– Decrease in gross body movements
```
33
Amniotic fluid markers of infection
* Amniotic fluid glucose is low
* Amniotic fluid white cell count is high
* Amniotic fluid Gram stain / culture are positive
* Amniotic fluid C-reactive protein > 20 mg/l
34
Mid trimester PPROM(16-25 wks)
Pulmonary hypoplasia less than 26 weeks gestation
overall survival is 50-75%
50% deliver within a week, 20% continue for over a month after occurrence of PPROM
35
When PPROM occurs, WHAT significantly improved perinatal outcome
10 day course of Erythromycin 250mg QDS
36
All cases of PPROM should be delivered by
37 weeks
| OR immediately if fetal compromise or infection, even without evidence of fetal lung maturity
37
Outpatient management of PPROM
* patient clinically very well for the first few days after PROM (no pain, no bleeding, no signs of infection)
* no major co-morbidities in the pregnancy
* corticosteroids are complete
* lives in close proximity to the hospital
* good support at home
* the patient at home four hourly temperature monitoring
* the hospital has an appropriate day care unit where the patient can come in regularly for assessment of fetal and maternal wellbeing
38
Threatened Miscarriage -
Vaginal bleeding associated with a viable intrauterine pregnancy up to 24 weeks gestation
39
Antepartum Haemorrhage
Vaginal bleeding from 24 weeks until the onset of labour
40
Intrapartum Haemorrhage
Vaginal bleeding from the onset of labour until the end of the 2nd stage of labour
41
Postpartum Haemorrhage
Vaginal bleeding from the third stage of labour until the end of the puerperium (6 weeks postpartum)
42
APH causes
Placenta Praevia 30%
Placental Abrupti 20%
Local Causes 5%
Unclassified 45%
43
Placenta praevia
def
Incidence
partially or wholly situated in the lower uterine segment
1 in 20 at 24 weeks
1 in 200 at 40 weeks
Nulliparous 0.2% Multiparous 0.5%
44
Placenta praevia
| what do you want to know
ant or post
| ant --> accreta/percreta if Hx C-S
45
Placenta praevia
grade I
Minor
If the leading edge of the placenta is within 2cm of the internal cervical os
(low lying placenta)
46
Placenta praevia
grade II
Minor
Reaches the internal os (marginal)
| There is little if any difference between marginal and partial degree of placenta praevia
47
Placenta praevia
grade III
Major
Covers the os but asymmetrically situated
48
Placenta praevia
grade IV
Major
Covers the os, centrally located
49
Risk Factors for Placenta Praevia
```
Prior Uterine Surgery
Caesarean Section (10x risk after 3 c-sections)
Curettage
Myomectomy
Surgical TOP (2x Risk after 2 TOPs)
Increased parity
Advanced maternal age 9 x risk in >40 vs <20yrs
Multiple pregnancy
Smoking
```
50
P/C Placenta previa
Painless vaginal bleeding which can be unprovoked or occurs post coitus or following uterine contractions
First episode of haemorrhage usually not severe & typically painless
Often asymptomatic: Incidental diagnosis seen on routine obstetric ultrasound
51
Physical exam Placenta previa
1. Uterus soft and non-tender
2. Fetal heart rate is usually normal
3. Typically high presenting part or malpresentation, because head cannot descend into pelvis
52
Never do what in Placenta previa
VAGINAL EXAM
53
Dx Placenta previa
TVUS
54
risks of Placenta previa
| maternal
* Haemorrhage
* Co-existent abruption
* Placenta Accreta (15%)
* Hysterectomy
* Death
55
Risks of Placenta previa
| fetal
```
• Preterm birth
• IUGR
– Common in women with multiple bleeds.
– Overall rate 15% in praevia
• Death
```
56
Placenta previa Immediate Management
```
IV Line (14G x 2)
FBC/Coag/X-match 4 units
IV Fluids
O Negative blood
Call for senior help (obstetric and anaesthesia) NICU
```
57
Subsequent management of placenta praevia:
```
Has bleeding stopped?
Was it mild bleeding?
Was it a life-threatening bleed?
Is fetal testing non-reassuring?
What is gestational age?
```
Immediate delivery OR
| Expectant management
58
Immediate delivery for placenta previa if
severe haem
non reassuring CTG
34-36 wks +/- steroids
59
Expectant management of praevia
exceptional / stable circumstances in women who have never had significant vaginal bleeding and live close to the hospital with good immediate family supports
Aim for delivery at 37 weeks
60
Mode of delivery of praevia
Elective C-section + spinal/epidural
unless type 1 and formation of lower segment has resulted in vertex passing the edge of the placenta
61
Placenta Accreta
cause?
use MRI and/or colour doppler USS
chorionic villi in contact with myometrium (80% of cases)
primary deficiency of or secondary loss of decidual elements (decidua basalis)
62
Placenta Increta
chorionic villi invade into myometrium (15% of cases)
63
Placenta Percreta
chorionic villi invade into serosa or beyond (5% of cases)
64
abnormal placentation a/w
Hx prior c section
uterine instrumentation fibroid surgery
prior placenta praevia
65
patient with suspected placenta accreta should be fully counselled before CS about possibility of
caesarean hysterectomy massive intrapartum haemorrhage
| blood transfusion
66
Placental Abruption
Incidence:
Recurrence risk in subsequent pregnancy:
Premature separation of normally sited placenta
1 in 150 deliveries
5 –15%
67
Abruption classification
Revealed haemorrhage vs Concealed haemorrhage
68
Risk factors for Placental Abruption
```
Chronic hypertension / preeclampsia
Abdominal trauma
Cocaine use
Smoking
Prolonged PROM/chronic chorioamnionitis
High parity
Abruption in prior pregnancy
Maternal thrombophilia (factor V leiden etc)
```
69
Symptoms of Abruption
Clinical Signs of abruption:
Abdominal pain
Backache
+/- Vaginal bleeding
Faint or collapse = shock
Uterus Wood-like, Irritable
Fetal parts difficult to palpate and fetal heart may be inaudible
70
Diagnosis of abruption:
clinical
| U/S to rule out placenta previa
71
Management of abruption:
IV Line: FBC, Group and x match 4 units, Coagulation screen
Continuous CTG
If baby is alive - emergency c section
If fetus already dead amniotomy & vaginal delivery
72
Complications of abruption:
Coagulopathy = decreased fibrinogen level, decreased platelets & raised fibrin degradation products
30%
DIC
Hypovolemia
73
Local Causes of APH
U/S r/o placenta praevia speculum examination r/o cervical cancer
cervical ectropion
cervicitis
foreign body
safe to take a cervical smear in pregnancy
74
Vasa Praevia
vessels of the umbilical cord run in the fetal membranes and cross the internal cervical os = velamentous insertion of the cord
Rare: 0.1%
P/C intrapartum haemorrhage at SROM or AROM
rapid fetal haemorrhage/ bradycardia/ death
emergency caesarean section
75
All rhesus negative women should receive anti-D injection
Routine Antenatal prophylaxis
Following any sensitising events (PVB/ Invasive fetal testing (Amniocentesis or CVS)/ post trauma/ cervical cerclage/management of a miscarriage or ectopic pregnancy)
Post partum if the infant is confirmed Rh Positive
76
Kleihauer test
estimates the volume of fetomaternal haemorrhage
calculate appropriate dose of anti D
77
5 Rh antigens
D; C; c; E; e.
78
Rh neg mom and first Rh pos pregnancy
Fetal Rh Antigen
| --> Anti- D IgM, which cannot cross the placenta to cause fetal haemolysis
79
Rh Tx
in utero blood transfusion
delivery
>34 weeks followed by neonatal exchange transfusion or Neonatal top- up transfusion
continuous monitoring
Cord blood should be sent for Direct antiglobulin test, heamoglobin and bilirubin levels
Neonatal observation for jaundice and /or anaemia
Regular feeds
80
rh monitoring
Maternal Anti D titres
Every 4 weeks until 28weeks gestation
Every 2 weeks until birth
Fetal Biometry and Biophysical Profile
Fetal Middle Cerebral Artery peak systolic velocities (MCA-PSV) weekly
Referral to fetal medicine
Anti-D level >4 IU/ml
MCA PSV >1.5 MoM (Multiples of Mean)
Hydrops
81
Hypertension in pregnancy
BP of at least 140mmHg systolic or 90mmHg diastolic on at least 2 occasions 6 hours apart that occurs after 20 weeks’ gestation
82
Proteinuria
Excretion of ≥ 300mg of protein in 24h
83
Pregnancy induced hypertension
Hypertension that develops as a consequence of the pregnancy and that regresses in postpartum
84
Pregnancy aggravated hypertension
Underlying hypertension worsened by pregnancy
85
PREECLAMPSIA or PET (Proteinuric pregnancy induced hypertension)
* hypertension during pregnancy
* Proteinuria
* +/- pathological oedema
86
ECLAMPSIA
Seizures + pre-eclampsia
| 25% seizures post-partum
87
Pre-eclampsia 2 theories
Vascular: reduction in placental blood flow secondary to abnormal placentation or maternal microvascular disease
poorly perfused placenta releases circulating factor's target maternal vascular endothelium
Immune: Maternal alloimmune reaction triggered by rejection of the fetal allograft
88
vascular pre-eclampsia theory
trophoblast cells migrate into the uterine wall and replace the endothelium of spiral arteries --> low-resistance arteriolar system -->
placental ischaemia
OR
excessive size = hyperplacentosis
89
The Immune Theory Of PET
Sperm exposure causes mucosal alloimmunisation --> classic inflammatory response
90
Systemic Inflammatory Response in PET BECAUSE OF
endothelial activation
91
Risk Factors For Pre-eclampsia
```
Nulliparity
Extremes of maternal age
Pre-eclampsia in a previous pregnancy
25% risk if onset < 34 weeks
50% risk if onset <28 weeks
Chronic hypertension or renal disease
Obesity
Insulin resistance / diabetes
Thrombophilia
Family Hx
Multiple pregnancy
```
92
Cardio effects of PET
Increased peripheral resistance (raised BP)
| Increased vascular permeability & reduced maternal plasma volume.
93
Resp effects of PET
pulm oedema
94
Renal effects of PET
Glomerular damage leads to proteinuria, hypoproteinaemia, reduced oncotic pressure.
95
coag effects of PET
Hypercoagulability
| DIC
96
liver effects of PET
HELLP syndrome
| Hepatic rupture.
97
CNS effects of PET
Thrombosis of cerebral arterioles.
Eclampsia,
cerebral haemorrhage, cerebral oedema
98
Fetal effects of PET
Impaired uteroplacental circulation
IUGR
hypoxaemia
IUFD.
99
Criteria For Severe Pre-eclampsia
| Clinical signs of severity:
BP ≥ 160 mmHg systolic and/or ≥ 110 mmHg diastolic
CNS symptoms (headache/ blurred vision/ blindness)
Hyperreflexia/ clonus
Pulmonary oedema
Epigastric / RUQ pain
100
Criteria For Severe Pre-eclampsia
| Biological signs of severity:
```
Oliguria (≤ 500 ml in 24 hours)
Proteinuria ≥ 5g in 24 hours
Thrombocytopaenia (plt count < 150 000/μL)
Haemolysis
Liver cytolysis / abnormal liver enzymes
```
101
Umbilical Doppler
velocity of umbilical artery blood flow
```
Normal = low resistance blood flow
Preeclampsia = increased placental resistance leads to abnormal diastolic flow ranging from simply reduced to reversed
```
102
Cerebral Doppler in case of fetal hypoxia
the cerebral doppler will be the last to become abnormal & predictive of short-term poor fetal outcome hypoxia, acidosis, death…
103
PET MATERNAL COMPLICATIONS:
* Placental abruption (1-4%)
* DIC/ HELLP (10-20%)
* Pulmonary oedema
* Acute renal failure
* Eclampsia (<1%)
* Liver failure or haemorrhage
* Death
104
PET FETAL COMPLICATIONS:
* Preterm delivery
* Fetal intrauterine growth restriction (IUGR)
* Hypoxia- neurologic injury
* Perinatal death
105
HELLP Syndrome
| Complication of severe preeclampsia
Haemolysis (H)
Elevated Liver enzymes (EL)
Low Platelets (LP)
Steroids improve platelet levels
106
PET Evaluation of the severity:
BP
Clinical examination: clinical signs of severity
FBC, Coagulation screen, Liver Function Tests, Uric Acid
24 hour urine collection to quantify proteinurea
107
PET Evaluation of fetal well-being:
```
CTG
US scan
fetal biometry and weight
amniotic fluid quantity
Umbilical and cerebral doppler
fetal movements
```
108
Treatment Of Pre-eclampsia
Delivery of the fetus and the placenta OVER 37 WKS
| Below 34 wks if severe PET or fetal compromise
109
PET monitoring pre-delivery
4-hourly BP
Twice weekly monitoring of bloods (liver enzymes, uric acid, platelets
CTG, Biophysical Profile
110
Indications For Delivery in Pre-eclampsia
Term gestation (>37 weeks)
Uncontrollable hypertension
Thrombocytopaenia (Plt count <150)
Liver dysfunction (↑AST/ALT)
Symptomatic preeclampsia (headaches, visual disturbance, epigastric pain)
Hyperreflexia/ clonus
Fetal compromise (severe growth restriction/ oligohydramnios/ abnormal umbilical artery Dopplers)
Any complication of severe PET (Abruption, HELLP, renal failure, eclampsia etc.)
111
Drugs used to control acute severe hypertension: (>160mmHg systolic and / or > 110 mmHg diastolic)
IV hydralazine
IV labetolol
Short-acting oral nifedipine
112
Drugs used to control chronic hypertension in pregnancy
Oral methyldopa
Oral labetolol
Oral sustained-release nifedipine
113
BEWARE of hypotension in pregnancy
under 130/80 mmHg --> fetal hypoxia
114
MgSO4
during labour and immediately postpartum in women with severe PET
Infusion should be continued for 24 hours after delivery of the baby.
Magnesium Sulphate 4g IV bolus followed by 1g/hr IV infusion used in the acute treatment of eclamptic seizures
115
Monitoring while on MgS04
HDU / LW : 1 to 1 care
Continuous CTG if antenatal
Hourly urinary catheter
Strict input / output
116
Signs of magnesium toxicity
Respiratory depression
Loss of deep tendon reflexes
If signs of toxicity : stop the infusion + check serum levels
117
What is better for invasive monitoring in PET than CVP
PCWP pulmonary capillary wedge pressure
118
PET management
```
Admit
IV line +/- urinary catheter (if severe)
Evaluation of the severity
Delivery (C section) or expectant management
+/- antihypertensive treatment
PO (BP >150/100)
IV (BP >160/110)
+/- magnesium sulfate
+/- steroids if < 34 weeks of gestation (risk of prematurity)
```
Maternal and fetal monitoring:
– BP
– Fetal monitoring daily
– Repeated US / fetal dopplers
119
aspirin and heparin reduces recurrent pre-eclampsia in women with
Thrombophilias
Low-dose aspirin inhibits biosynthesis of platelet thromboxane A2 --> prostacyclin and preventing development of PET
120
Diagnostic Gyn Op Procedures
Colposcopy
Diagnostic laparoscopy ± Tubal Patency Testing
Hysteroscopy ± Endometrial Biopsy
121
What is Laparoscopy?
The passage of a telescope into the abdominal cavity to allow inspection of pelvic and abdominal organs.
122
Laparoscopy Diagnostic Indications:
```
Unexplained pelvic pain.
Sub fertility
Investigation of adnexal masses.
Staging of endometriosis.
Dx ectopic
```
123
Chromopertubation is?
Dye is instilled per vaginum into the uterus to assess tubal patency
124
Laparoscopy Therapeutic Indications:
Sterilisation
Adhesiolysis
Treatment of endometriosis
Ovarian cystectomy (Benign lesions)
Ectopic pregnancy (salpingectomy/salpingotomy)
Salpingo-oophorectomy (Adnexal Mass, Prophylaxis)
Hysterectomy (TLH, LAVH)
Myomectomy
Tubal surgery ((Salpingostomy, reanastamosis)
Advanced Prolapse Surgery
125
Laparoscopy absolute and relative contraindications
```
Mechanical or paralytic bowel obstruction
Generalized peritonitis
Diapharagmatic hernia
Severe cardiorespiratory disease
Inflammatory bowel disease
Massive obesity
Large abdominal mass
Advanced pregnancy
Irreducible external hernia
Multiple abdominal incisions
```
126
Laparoscopy: Procedure
```
General anaesthesia
Semi-lithotomy position and bladder emptied (to avoid injury)
Cervix cannulated
Skin incision in umbilical base.
Verres needle
CO2 20-25 mmHg.
Primary trocar is then inserted at umbilicus
Secondary ports
Gas expelled and instruments withdrawn
```
127
Laparoscopy: Entry
| Different techniques to achieve a pneumoperitoneum
Closed
Verres Needle
Direct Trocar Insertion
Optical Trocar
Open
Hasson Technique
128
Complications Of Laparoscopy
```
Failed entry
Pre-peritoneal insufflation of gas --> surgical emphysema
Visceral injury- 3/1000
obese and very thin women and adhesions
Conversion to laparotomy
Infection
Port site hernia
VTE
Risk of vascular injury
```
129
what kind of vascular injury is possible during laparoscopy?
```
Major vessels (aorta/IVC) from Verres needle/ umbilical trocar
Abdominal wall vessels from lateral port insertion
```
130
Hysteroscopy And Curettage
Passage of a telescope per vaginam through the cervix to allow visualization of the endometrial cavity
Curettage of the cavity provides endometrial tissue for diagnostic purposes
131
Hysteroscopy Diagnostic Indications:
```
Postmenopausal bleeding.
Abnormal uterine bleeding
Uterine structural abnormalities
Intermenstrual/post coital bleeding despite normal cervical smear
Abnormal pelvic ultrasound findings (endometrial polyps, submucous fibroids)
Subfertility
Recurrent miscarriages
Lost intrauterine contraceptive device
```
132
Hysteroscopy Therapeutic Indications:
Removal of an endometrial polyp / retained intrauterine device
Resection of a submucosal fibroid/intrauterine adhesions/septum
First generation endometrial ablation (TCRE, Rollerball)
133
Contra-indications to Hysteroscopy
Pelvic infection
Pregnancy
Cervical cancer (heavy uterine bleeding)
134
Complications of Hysteroscopy
```
Cervical trauma
Creation of a false passage
Uterine Perforation
Hemorrhage
Infection
Failed entry into uterine cavity
Visceral injury
```
135
List of Surgical Abdominal Procedures:
```
Laparoscopy
Hysterectomy
Salpingo-oophorectomy (removal of Fallopian tubes/ ovaries).
Myomectomy
Tubal reconstructive surgery.
Ovarian cystectomy
```
136
List of Surgical Vaginal Procedures:
```
Vaginal hysterectomy
Anterior/ Posterior colporrhaphy
Sacrospinous Ligament Fixation
Hysteroscopy (Diagnostic/Operative)
Endometrial Ablation
Cervical Treatment (LLETZ, Polypectomy, McDonald/Shirodkar Suture)
```
137
Total hysterectomy
removal of uterus and cervix
138
Subtotal hysterectomy
cervix is conserved
139
Abdominal hysterectomy indications
Uterine cancer. (TAH is combined with bilateral salpingoophorectomy (BSO) ± pelvic lymph node dissection)
Ovarian cancer (TAH + BSO + omentectomy ± lymphadenectomy)
Menorrhagia refractory to medical or more conservative surgical therapy
Symptomatic uterine fibroids
Endometriosis refractory
140
Abdominal hysterectomy
| procedure
Suprapubic transverse/ Pfannenstiel incision.
Round ligaments, Tubo-ovarian, uterine artery, uterosacral pedicles and vaginal angles clamped, cut and ligated.
If the patient is younger than 45 years, ovaries are usually conserved
141
Abdominal hysterectomy lower midline vertical incision only if
more extensive exposure is required (e.g. ovarian cancer/ large fibroids).
142
Abdominal hysterectomy complications
Haemorrhage , transfusion
Visceral injury (bladder, ureter, bowel)
Infection.
DVT/ PE
Acute menopausal symptoms if ovaries removed
143
Myomectomy
Removal of fibroids individually if a woman wishes to conserve her uterus
greater blood loss than hysterectomy
transfusion risk = 5-10%
Risk of hysterectomy
144
Tubal Reconstructive Surgery
Tubal occlusion = salpingitis, endometriosis or previous sterilisation
Poor results reflect both the tendency for inflamed tubes to become blocked again = microscopic tubal damage, and impaired cilial motility
Risk of ectopic pregnancy following tubal surgery
145
Vaginal Hysterectomy
| preferable to abdominal hysterectomy
For
2nd or 3rd degree uterine prolapse.
Any other benign indication for hysterectomy
146
Vaginal Hysterectomy Contraindications:
Genital tract malignancy.
Uncertain ovarian pathology.
Large uterine fibroids.
Previous abdominal surgery leading to adhesions.
147
Vaginal Hysterectomy procedure
General/spinal anesthesia.
Circumferential incision made on cervix.
Bladder freed and dissected upwards.
Peritoneal cavity is opened anteriorly (uterovesical pouch) and posteriorly (Pouch of Douglas).
Uterosacral, uterine artery and tubo-ovarian pedicles clamped, cut and ligated.
Uterus removed and ovaries inspected to exclude significant ovarian pathology.
Associated vaginal wall prolapse repaired.
Vaginal vault closed.
Vaginal pack and urinary catheter inserted
148
Vaginal Hysterectomy complications
```
Hemorrhage.
Vault hematoma infected
Urinary tract injury (bladder/ ureter).
Vaginal shortening (particularly if pelvic floor repair performed --> dyspareunia
conversion to abdominal hysterectomy
```
149
Anterior Colporrhaphy (anterior repair) for cystocoele +/- stress incontinence
excision of a portion of vaginal skin and placement of support sutures to pubocervical fascia.
Excess vaginal skin excised & vaginal wall closed.
Urinary catheter placed for 24-48 hours postop
150
Anterior Colporrhaphy Complications:
Urinary retention.
Vaginal shortening.
Bladder/ urethral injury.
151
Posterior Colporrhaphy for rectocoele
Portion of posterior vaginal wall excised.
| Underlying levator ani muscles exposed and joined with interrupted sutures in midline.
152
Posterior Colporrhaphy Complications:
Dyspareunia
| Due to over-enthusiastic closure of levator ani muscles and removal of excess posterior vaginal wall skin
153
Menorrhagia definition
regularly excessive menstrual blood loss that affects the physical, social, emotional or material quality of life of the patient.
154
Menorrhagia Hx
Amount, duration of bleeding ,h/o flooding or passage of clots, regularity of periods
Associated symptoms
Dysmenorrhea, intermenstrual or post coital bleeding, pelvic pain
Impact on quality of life
Time off work/school, effect on social life
Other factors that may effect treatment options
Co-morbidities or previous treatments
Past medical history / surgical history
e.g coagulation disorders
155
Menorrhagia Clinical Examination
Vital signs, height and weight
General examination, anaemia?
bruising or petechiae
Palpate abdomen for enlarged liver, pelvic masses, pelvic nodes
Speculum examination – visualise cervix, smear if indicated
Bimanual palpation – is uterus mobile or fixed (if fixed could indicate endometriosis)
156
Menorrhagia Investigations
```
FBC
B-Hcg
Coagulation profile
Thyroid Function Test
Trans vaginal ultrasound CT/MRI for endometrial thickness, exclude fibroids and polyps
Endometrial Biopsy
Hysteroscopy/D & C
```
157
Endometrial Biopsy
To exclude atypical hyperplasia or endometrial carcinoma
Rarely indicated in woman < 40
Method
– Outpatient biopsy - e.g. Pipelle
– Hysteroscopy - outpatient or GA
– D&C - a diagnostic, not a therapeutic procedure
158
Causes Of Abnormal Uterine Bleeding
Figo Classification
PALM
P Polyp
A Adenomyosis
L Leiomyoma (Fibroid)
M Malignancy / Hyperplasia
159
Causes Of Abnormal Uterine Bleeding
Figo Classification
COEIN
non-structural causes
```
C Coagulation disorder
O Ovulatory dysfunction
E Endometrial (primary disorder of mechanisms regulating haemostasis)
I Infection / Iatrogenic (medications)
N Not yet known
```
160
Dysfunctional Uterine Bleeding (DUB)
Abnormal bleeding in the absence of organic pathology
extremes of reproductive life
A/W anovulatory cycles
161
Menorrhagia Tx
| Non hormonal
NSAIDs Mefenamic acid
| Antifibrinolytics Tranexemic acid
162
Menorrhagia Tx
| Hormonal
```
LNG-IUS 20 mcg/ day for 5 yrs
COCP
Norethisterone
Injectable long acting progestogens
GnRH analogues
```
163
Non hysterectomy surgical treatments for menorrhagia
Endometrial Ablation
– impedence-controlled bipolar radiofrequency ablation
– thermal balloon endometrial ablation
– Myomectomy
– Uterine artery embolisation (UAE)
164
Fibroids can be
```
pedunculated
intramural
intracavitary
submucous
subserous
```
165
Hysterectomy types
Abdominal
• Total or subtotal
• Transverse or midline incision
• ± bilateral salpingo-oophorectomy
Laparoscopic
• LAVH: Laparoscopic Assisted Vaginal Hysterectomy
• TLH: Total Laparoscopic Hysterectomy
Vaginal
166
definitive treatment for menorrhagia?
Hysterectomy
167
Uterine Artery Embolization (UAE)
treat single or small numbers of fibroids
alternative to myomectomy
via catheter in femoral vein
Causes avascular necrosis of the fibroid(s) = pain
168
UI Predisposing Factors
* Age - especially postmenopausal
* Obesity
* Parity – risk increases with parity, especially vaginal deliveries, caesarean not protective
* Family History
* Decreased mobility
* Cognitive impairment/dementia
* Comorbidities – diabetes, stroke, depression
* Drugs (diuretics, hypnotics)
* Caffeine intake, smoking
169
Types of Urinary Incontinence (UI)
```
Stress UI
Urgency UI [mixed – stress and urgency]
Overflow Incontinence
Anatomical
• Fistula
• Congenital abnormalities
```
170
Physiology of Micturition
Parasympathetic fibers (S2-S4) signal the detrusor muscles to contract (anticholinergic drugs oppose this!)
Sympathetic fibers (T10-L2) signal the detrusor to relax and the bladder neck and urethra to contract
Pudendal nerve (S2-S4) provides motor innervation to urethral sphincter
171
Assessment of Incontinence
```
History
Physical/pelvic exam
Urinalysis and other basic tests
Urodynamic testing
Cystourethroscopy
```
172
Incontinence History
* Relevant urinary symptoms include: frequency, volume, severity, hesitancy, precipitating triggers, nocturia, enuresis, intermittent or slow stream, incomplete emptying, continuous urine leakage, and straining to void
* Precipitating triggers: cough, exercise, medications, childbirth, surgery
* Lower genital tract symptoms: pelvic pressure/pain, vaginal dryness, dyspareunia
* Medications: Diuretics, anti-hypertensives (-blockers)
* Previous treatments
173
During the last week, how many times did you accidentally leak urine with:
Physical activity
Feeling of strong, sudden need to pass urine that did not allow you to get to the toilet fast enough
restricting her normal daily activities?
toilet mapping incontinence pads
174
Voiding Diary
```
Fluid intake: time, type, amount
Urine output: time, amount
Urine leakage
Triggers - cough, sneeze, exercise, sex
urgency, dysuria, frequency
Pad
Excess intake or output
```
175
Absent perineal sensation with decreased rectal tone =
cauda equina syndrome
176
Weakness with hyperreflexia of the lower extremity =
upper motor neuron lesion
177
Rectal Examination
```
mass
Anal sphincter resting tone
Voluntary contraction
Perineal sensation
Fecal impaction
```
178
Urinalysis
```
Bacteriuria
Haematuria
Pyuria
Glycosuria
Proteinuria
```
179
other bladder tests
```
Postvoid Residual (PVR) > 50mL
Bladder Stress Test (Cough Test)
Filling urodynamic assessment = Cystometry
Voiding urodynamic assessment = uroflowmetry
```
180
Cystometry
| Stress Incontinence
leaking of urine in the presence of raised intra-abdominal pressure and the absence of detrusor activity, the total bladder pressure will be raised at the moment of incontinence but the detrusor pressure is stable
181
Cystometry
| Urgency Incontinence
the total bladder pressure and the detrusor pressure will be equally elevated at the time of incontinence
182
Voiding urodynamic assessment = uroflowmetry
| Dx
```
outflow obstruction (cystocele)
weak detrusor (neurological)
```
183
leaking during physical activity, but can reach the toilet in time
Stress incontinence
184
leaking during physical activity, but can reach the toilet in time
Stress incontinence
185
leaking during physical activity, can't reach the toilet in time, urgency, nocturia
urge incontinence
186
Stress incontinence causes
Urethral Hypermobility - obesity cough trauma
Intrinsic Sphincteric Deficiency - post menopause
187
Stress incontinence management
```
lifestyle
contributing factors
Pelvic Floor Exercises
Bladder training
Topical vaginal oestrogen
Duloxetine (SNRI)
Sling Procedures: TVT, TOT
Urethral bulking agents
Burch Colposuspension
```
188
TVT (Tension-free Vaginal Tape)
• Prolene mesh is inserted transvaginally at the level of the mid-urethra using 2 trocars and passed through the retropubic space exiting the abdominal wall
189
Complications of incontinence surgery
```
vascular injury
bowel/bladder injury
voiding difficulties
erosion of tape through urethra/vagina
urinary retention
urgency incontinence
```
190
TOT (Transobturator Tape)
Prolene mesh is also inserted transvaginally at the level of the mid-urethra but pass instead through the obturator foramina and exit through the skin of the groin area
191
Burch Colposuspension
low transverse incision OR laparoscopically
Non-absorbable sutures are placed retropubically to approximate the paravaginal tissues to the ileopectineal ligament
Complications: voiding difficulties, prolapse, detrusor over activity
192
Urgency Urinary Incontinence (UUI) causes
detrusor overactivity
neuropathy MS or bladder neck obstruction
spinal cord injury
bladder abnormalities, increased/altered bladder microflora
193
UUI Dx
Filling Urodynamic Contraction of the detrusor muscle during bladder filling = detrusor overactivity
194
UUI Tx
Lifestyle modifications, pelvic floor exercises +/- biofeedback, and bladder training
Anticholinergic agents (oxybutynin, tolteridine, fesoterodine)
beta 3 agonist (Mirebegron)
Tricyclic antidepressants
Local oestrogen
Cystoscopy + intravesical Botox injections
Clam Ileocystoplasty
195
Anterior Vaginal Prolapse eg
Cystourethrocele
| Cystocele
196
Apical Vaginal Prolapse eg
```
Uterovaginal
Vaginal vault (post-hysterectomy)
```
197
Posterior Vaginal Prolapse eg
Rectocele
| Enterocele
198
POP aetiology
```
long 2nd stage of labour
instrumental
large/ many babies
menopause
COPD
obesity
ascites
weight lifting
constipation
```
199
Pelvic Floor Muscles
Levator ani muscle complex
Puborectalis, pubococcygeus, ileococcygeus
Coccygeus + levator ani = pelvic diaphragm
Perineal muscles
Superficial and deep transverse perineal muscles, ischiocavernosus, bulbospongiosus
200
Pelvic Ligaments
1. Cardinal and uterosacral ligaments
2. Paravaginal attachments along the length of the vagina to the superior fascia of the levator ani muscle
upper two thirds of vaginal
3. Perineal body, perineal membrane, and superficial and deep perineal muscles
distal one third of the vagina
4. Broad Ligament
201
Anterior Vaginal Prolapse Sx
stress urinary incontinence from urethral hypermobility or urinary retention from urethral kinking that causes obstruction
feeling of incomplete emptying with voiding, a slow urinary stream, or urinary urgency
202
Cystocele
bulging or descent of the bladder into the upper vaginal wall
203
Urethrocoele
descent of the urethra and bladder neck
204
Apical Vaginal Prolapse
(Uterovaginal & Vaginal vault)
POPQ criteria
Stage 1
Prolapse remains > 1 cm above hymenal remnants
205
Apical Vaginal Prolapse
(Uterovaginal & Vaginal vault)
POPQ criteria
Stage 2 =
Prolapse descends to the introitus
| defined as an area extending from 1 cm above to 1 cm below the hymenal remnants
206
Apical Vaginal Prolapse
(Uterovaginal & Vaginal vault)
POPQ criteria
Stage 3 =
Descends > 1 cm past the hymenal remnants
| but does not represent complete uterine procidentia or complete vaginal vault eversion
207
Apical Vaginal Prolapse
(Uterovaginal & Vaginal vault)
POPQ criteria
Stage 4 =
complete uterine procidentia
| the vagina and/or uterus are maximally prolapsed with essentially the entire vaginal mucosa everted
208
Vaginal Vault Prolapse may occur following
abdominal or vaginal hysterectomy
209
Vaginal Vault Prolapse
| Abdominal repair
Sacrocolpopexy via laparotomy or laparascopy
210
Vaginal Vault Prolapse Vaginal repair
Sacrospinous or uterosacral ligament fixation
211
Rectocele =
prolapse of lower posterior vaginal wall usually containing the rectum
212
Enterocele =
prolapse of the upper posterior vaginal wall, usually involving the pouch of Douglas and loops of bowel
213
posterior vaginal prolapse
| Sx
Splinting = need to splint, or place manual pressure on the vagina, rectum, or perineum, to defecate
Constipation or feeling of incomplete emptying
Fecal incontinence
214
Symptoms of POP
```
Vaginal or pelvic pressure and/or sensation of “something coming down”
Lower back or pelvic pain
worse with prolonged standing
relieved by lying down
Stress/urge incontinence; nocturia incomplete voiding; splinting or positional changes may be required for urination
rarely retention
constipation/ incomplete voiding
fecal urgency
fecal incontinence obstructive symptoms
Bleeding or chronic vaginal discharge
Sexual dysfunction
```
215
Clinical exam for POP
patient bearing down
Use of Sims speculum to identify uterovaginal or vault prolapse
retractor to splint the opposite vaginal wall
Stress incontinence with coughing
ulceration or vaginal atrophy if postmenopausal
pelvic or abdominal masses
General examination
216
POP Investigations
```
MSU
Blood Glucose
+/- Urodynamics
+/- IVP (procidentia)
Anaesthetic assessment
```
217
Conservative measures for POP
```
weight loss
Physiotherapy - pelvic floor exercises!
bladder training
treat chronic cough
stop smoking
avoid heavy lifting
local oestrogen if postmenopausal
```
218
Vaginal pessary for POP if...
Review every 6 months and change pessary
```
Unfit for surgery
declines surgery
Pregnant
Family not complete
let ulcer healing before surgery
```
219
Surgery options for POP
Vaginal
Abdominal
```
Anterior colporrhaphy
Posterior colpoperineorrhaphy
Manchester (Fothergill) repair
Vaginal hysterectomy
Sacrospinous Ligament Fixation
Mesh/Tape procedures
```
Burch colposuspension
Colposacropexy
