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Terminology
2010
By
Class of 2011
Terminology 2010
IMPORTANT
This Terminology 2010 is based on the previous edition by Dr. Edward Chu on 1st January 2004. Without
previous contributions by our seniors and collegues, this book cannot be produced so successfully.
In this edition, reference was made to:(1) Obstetrics Illustrated (6th Ed.) by Hanretty, K.P. in 2003;
(2) Gynaecology Illustrated (5th Ed.) by Hart, D.M. & Norman, J. in 2000;
(3) Protocol for Obstetrics and Gynaecology of Prince of Wales Hospital, by Department of Obstetrics and
Gynaecology of The Chinese University of Hong Kong, last retrieved by class 2010 on January 2009,
Materials from the above stated sources were incorporated into this edition. The copyright belongs to the
authors and publishers of the respective sources. This Terminology 2010 solely serves as a self-study
material for medical year four students in obstetrics and gynaecology module, which is not intended for any
sales or profit making purposes. Students should refer to standard textbooks and the most updated guidelines
in case of any doubt or discrepancies. The author shall bear no responsibility to any consequences of using
this book.
5 September 2009
I hope you will find this book useful Terminology, Protocol and Illustrated all in one.
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DEDICATION
For ladies, wives, mothers, and our future generations.
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Terminology 2010
Brief Content
GENERAL OBSTETRICS ............................................................................................................................. 18
Obstetrics................................................................................................................................................................................. 18
Foetal anatomy ........................................................................................................................................................................ 19
Maternal anatomy .................................................................................................................................................................... 24
Antepartum .............................................................................................................................................................................. 30
Malpresenation ........................................................................................................................................................................ 41
Preterm labour and PPROM .................................................................................................................................................... 47
Postpartum............................................................................................................................................................................... 53
Obstetric statistics.................................................................................................................................................................... 62
Miscellaneous topics in General Obstetrics............................................................................................................................. 65
FOETAL MEDICINE .................................................................................................................................... 70
0. Foetal medicine ....................................................................................................................................................................... 70
1. Chromosomal disorders ........................................................................................................................................................... 71
2. Congenital abnormalities ......................................................................................................................................................... 78
3. Genetic disorders ..................................................................................................................................................................... 83
4. Foetal Haemolytic Diseases .................................................................................................................................................... 85
5. Foetal diagnosis and therapy ................................................................................................................................................... 88
6. Foetal growth and Monitoring ................................................................................................................................................. 92
7. Amniotic fluid ......................................................................................................................................................................... 99
8. Foetal well-being ................................................................................................................................................................... 106
9. Multiple pregnancy................................................................................................................................................................ 108
MATERNAL MEDICINE ............................................................................................................................ 114
1. Changes in pregnancy ........................................................................................................................................................... 114
2. Diabetes mellitus ................................................................................................................................................................... 118
3. Preeclampsia.......................................................................................................................................................................... 124
4. Other maternal medical diseases ........................................................................................................................................... 133
LABOUR MANAGEMENT ......................................................................................................................... 146
0. Intrapartum management ....................................................................................................................................................... 146
1. Normal Labour ...................................................................................................................................................................... 148
2. Inducation of Labour and Failure to Progress ....................................................................................................................... 162
3. Pain relief and maternal monitoring ...................................................................................................................................... 172
4. Intrapartum foetal monitoring ............................................................................................................................................... 173
5. Operative delivery ................................................................................................................................................................. 181
GENERAL GYNAECOLOGY ...................................................................................................................... 193
0. Gynaecology.......................................................................................................................................................................... 193
1. Menstrual problems ............................................................................................................................................................... 194
2. Birth control .......................................................................................................................................................................... 214
3. Disorders of early pregnancy................................................................................................................................................. 224
4. Endometriosis and Adenomyosis .......................................................................................................................................... 237
5. Benign gynaecological tumours ............................................................................................................................................ 241
6. Gynaecological infection ....................................................................................................................................................... 246
7. Growth and Development...................................................................................................................................................... 250
8. Menopause and HRT ............................................................................................................................................................. 252
9. Gynaecological surgery & investigations .............................................................................................................................. 256
10. Miscellaneous topics in gynaecology .................................................................................................................................... 267
REPRODUCTIVE MEDICINE ................................................................................................................... 269
0. Reproductive medicine and Endocrinology .......................................................................................................................... 269
1. Anovulation and endocrinopathy .......................................................................................................................................... 270
2. Assisted reproductive procedures .......................................................................................................................................... 276
3. Male infertility....................................................................................................................................................................... 281
4. Sexual dysfunction ................................................................................................................................................................ 283
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Detailed Content
GENERAL OBSTETRICS ............................................................................................................................. 18
0.
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Obstetrics ............................................................................................................................................................................... 18
Foetal anatomy ...................................................................................................................................................................... 19
Foetal skull ................................................................................................................................................................................... 19
Fontanelle ..................................................................................................................................................................................... 19
Sagittal suture............................................................................................................................................................................... 19
Sinciput ........................................................................................................................................................................................ 19
Vertex ........................................................................................................................................................................................... 19
Lie ................................................................................................................................................................................................ 19
Presentation .................................................................................................................................................................................. 20
Position ........................................................................................................................................................................................ 20
Denominator................................................................................................................................................................................. 20
2.
Maternal anatomy ................................................................................................................................................................. 24
Levator ani ................................................................................................................................................................................... 24
Urogenital diaphragm................................................................................................................................................................... 24
Pelvis ............................................................................................................................................................................................ 24
Pelvic Inlet ................................................................................................................................................................................... 24
Pelvic Cavity ................................................................................................................................................................................ 24
Pelvic Outlet ................................................................................................................................................................................. 24
Ischial spine.................................................................................................................................................................................. 25
Pubic symphysis ........................................................................................................................................................................... 25
Subpubic arch ............................................................................................................................................................................... 25
Intertuberous diameter ................................................................................................................................................................. 25
Shape of pelvis ............................................................................................................................................................................. 26
Gynaecoid .................................................................................................................................................................................... 26
Anthropoid ................................................................................................................................................................................... 26
Android ........................................................................................................................................................................................ 27
Platypoid ...................................................................................................................................................................................... 27
Funnel pelvis ................................................................................................................................................................................ 27
Contracted pelvis.......................................................................................................................................................................... 28
Cephalopelvic disproportion ........................................................................................................................................................ 28
Pelvimetry .................................................................................................................................................................................... 28
Rickets.......................................................................................................................................................................................... 28
Lordosis........................................................................................................................................................................................ 28
Os ................................................................................................................................................................................................. 29
Lower segment ............................................................................................................................................................................. 29
Dextrorotation of uterus ............................................................................................................................................................... 29
3.
Antepartum ............................................................................................................................................................................ 30
Pre-conception counselling .......................................................................................................................................................... 30
Antepartum care ........................................................................................................................................................................... 31
Pregnancy test .............................................................................................................................................................................. 32
Dating of pregnancy ..................................................................................................................................................................... 33
Antepartum haemorrhage (APH) ................................................................................................................................................. 35
Placenta praevia ........................................................................................................................................................................... 35
Abruptio placentae ....................................................................................................................................................................... 38
Couvelaire uterus ......................................................................................................................................................................... 39
Velamentous Insertion of the Cord .............................................................................................................................................. 39
Vasa praevia ................................................................................................................................................................................. 39
APH of unknown origin ............................................................................................................................................................... 40
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Malpresenation ...................................................................................................................................................................... 41
Malpresentation ............................................................................................................................................................................ 41
Breech presentation ...................................................................................................................................................................... 41
External Cephalic Version (ECV) ................................................................................................................................................ 44
Cord prolapse ............................................................................................................................................................................... 46
Preterm labour and PPROM ............................................................................................................................................... 47
Preterm labour .............................................................................................................................................................................. 47
Braxton Hicks contractions .......................................................................................................................................................... 48
Preterm delivery ........................................................................................................................................................................... 48
Rupture of membranes ................................................................................................................................................................. 49
Amniostrix ................................................................................................................................................................................... 50
Chorioamnionitis .......................................................................................................................................................................... 50
Cervical incompetence ................................................................................................................................................................. 52
Postpartum............................................................................................................................................................................. 53
Postpartum care ............................................................................................................................................................................ 53
Postpartum fever .......................................................................................................................................................................... 54
Postpartum haemorrhage .............................................................................................................................................................. 54
Uterine atony ................................................................................................................................................................................ 55
Uterine rupture ............................................................................................................................................................................. 56
Uterine inversion .......................................................................................................................................................................... 57
Sheehan syndrome ....................................................................................................................................................................... 58
Puerperium ................................................................................................................................................................................... 59
Involution ..................................................................................................................................................................................... 59
Lochia .......................................................................................................................................................................................... 59
Engorgement of breasts ................................................................................................................................................................ 59
Colostrum ..................................................................................................................................................................................... 59
Lactation ...................................................................................................................................................................................... 60
Breast-feeding .............................................................................................................................................................................. 60
Breast milk ................................................................................................................................................................................... 60
Postpartum depression ................................................................................................................................................................. 61
Postpartum blue............................................................................................................................................................................ 61
Postpartum psychosis ................................................................................................................................................................... 61
Obstetric statistics ................................................................................................................................................................. 62
Maternal mortality........................................................................................................................................................................ 62
Perinatal mortality ........................................................................................................................................................................ 62
Stillbirth ....................................................................................................................................................................................... 62
Intrauterine death ......................................................................................................................................................................... 63
Neonatal death.............................................................................................................................................................................. 64
Miscellaneous topics in General Obstetrics......................................................................................................................... 65
Advanced maternal age ................................................................................................................................................................ 65
Fecundity...................................................................................................................................................................................... 65
Postterm ....................................................................................................................................................................................... 66
Gravid .......................................................................................................................................................................................... 67
Grand multipara ........................................................................................................................................................................... 67
Trimester ...................................................................................................................................................................................... 67
Placenta ........................................................................................................................................................................................ 67
Obstetric surgery .......................................................................................................................................................................... 67
Obstetric emergency..................................................................................................................................................................... 67
Birth trauma ................................................................................................................................................................................. 68
Subaponeurotic haematoma ......................................................................................................................................................... 68
Cerebral palsy .............................................................................................................................................................................. 68
Jehovahs witness ......................................................................................................................................................................... 69
Consanguinity .............................................................................................................................................................................. 69
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General Obstetrics
0. Obstetrics
What is Obstetrics
In Latin obstre means to stand opposite to (oba:-opposite to; stre:-stand). It originally pertained to a midwife standing opposite to
a parturiting woman and assisting in delivery. Now Obstetrics does not just concern of delivery, but a branch of medicine that
deals with pregnancy, labour and puerperium. In general, it has been subdivided into general obstetrics, maternal medicine and
foetal medicine.
Aims of obstetric care
To minimize maternal and foetal morbidities and mortalities (see maternal mortality and perinatal mortality) by early
identification of problems, actual and potential, and instituting appropriate management. To prepare, psychologically and mentally,
the mother and her husband (or partner) for pregnancy, labour and parenting, by providing them with support and education about
pregnancy and childbirth and childcare.
There are three phases of obstetric care:
1. Antepartum care
a. To detect and monitor any risk factors and manage it accordingly.
i.
Majority of women are healthy. However, they may carry some risk factors that may affect the pregnancy. Common
examples are carrier of thalassaemia genes; maternal obesity and family history of diabetes are associated with
gestational diabetes.
ii. In addition, some women may have subclinical diseases that may not reveal until during pregnancy. For example, an
asymptomatic alular heart disease may deteriorate because of increased cardiac demand during pregnancy.
iii. Many antenatal disorders are not predictable or preventable, but their complications can be reduced by early
recognition, through regular monitoring. For example, regular blood pressure measurement and urinalysis during
every antenatal visit can pick up the evolution phase of pre-eclampsia.
b. To decide the optimal time and mode of delivery.
The normal time and mode of delivery is spontaneous labour at term (37 to 41 weeks of gestation) followed by
vaginal cephalic delivery. However, maternal or foetal complications may arise and preterm delivery, either by
induction of labour or caesarean section is required. The risks of continuation pregnancy to both the mother and
foetus should always be balanced against the risks of early delivery.
2. Intrapartum care
a. To ensure maternal and foetal well-being during labour and delivery.
b. To provide adequate labour pain relief.
c. To deliver the baby in the safest way for both the mother and the baby. Sometimes operative delivery may be required.
3. Postpartum care
a. To ensure normal recovery from pregnancy and childbirth.
i.
Common early complications are postpartum haemorrhage and postpartum fever.
ii. One of the important late complications is postpartum depression.
b. To look for any problems in childcare and feeding.
c. To advise on contraception and family planning.
d. To follow up any antenatal problems and provide appropriate referral, counselling and management.
In addition to the above three parts, some couples will also be benefited from pre-conception counselling, particularly those who
have pre-existing chronic diseases, or family history of genetic disorders.
Other important topics in general obstetrics
1. Antepartum haemorrhage, postterm;
2. Besides, it is important to understand the physiological changes in pregnancy, the anatomy of the maternal pelvis and the
foetal skull.
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Terminology 2010
1. Foetal anatomy
Foetal skull
The foetal skull is made up of the vault, face and the base. The vault is formed from parts of the frontal, occipital and the pair of
temporal bones and parietal bones. Between these bones there are four membranous sutures:-sagittal, frontal, coronal and
lambdoidal sutures.
Fontanelle
The foetal skull consists of a number of bones, and there are two fontanelles on the head, each being where a number of bones
meet.
1. Fontanelles is the membranous structure between margins of cranial bones of a foetus.
2. The anterior fontanelle is where the two parietal and two frontal bones meet.
a. This is a large space, and can be identified because 4 sutures run from it.
b. The anterior fontanelle is in the centre of the head, and is the presentation when the head is in the military of deflexed
position. When the head undergoes flexion, the presentation is the vertex.
3. The posterior fontanelle is where the two parietal and the single occipital bone meet.
a. It lies at the junction of the sagittal sutured and the lambdoidal sutures between the two parietal bones and the occipital
bone.
b. Usually it cannot be felt as a space, rather where 3 sutures meet.
4. The two fontanelles define the anterior and posterior limits of the vertex. These sutures and fontanelles allow moulding
during labour, and facilitate in assessment of the position of the foetal head during vaginal examination in labour.
Sagittal suture
This is the suture on the foetal skull where the two parietal bones meet, and is between the anterior and posterior fontanelles.
Sinciput
The part of the foetal head in front of the anterior fontanelle. It is part of head between the eyebrows and hairy scalp.
Vertex
A well-defined area of the foetal skull, bounded by the anterior and posterior fontanelles, and the two parietal eminences. The
vertex presentation is the normal and the most common one. It occurs once the head has undergone flexion, when the foetal head
will present with the smallest diameter to the birth canal.
Lie
This defines how the longitudinal axis of the baby is aligned with that of the mother. (Figure 2)
1. Longitudinal lie (98%) is when the baby is up and down, so the baby is in either cephalic or breech presentation. It is the
normal lie as the uterine cavity is longitudinal in shape.
2. Transverse lie (0.2%) is when the foetal poles are on the sides of the mother's abdomen. Causes are those that distort the
shape of uterine cavity:-lower segment fibroid, placenta praevia
3. Oblique lie (0.1%) is when one of the foetal poles is over one of the iliac fossae. The causes are similar to transverse lie.
4. Unstable lie is when the foetal lies change frequently from and to longitudinal, transverse or oblique. It implies that there is
too much room for the baby, such as in polyhydramnios, or the mother has a very lax abdomen (such as in grand multipara);
or in pelvic inlet contraction where the foetal poles fail to engage.
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Terminology 2010
Presentation
Definition This is the part of the baby most easily felt by vaginal examination during labour.
Different types of presentation
1. Cephalic presentation
It is when the foetal head presents first. It is an imprecise term as it does not specify which part of the head is presenting,
and is usually used after abdominal palpation.
2. Vertex presentation (95%)
Vertex is the normal one, and occurs when the head is well flexed. Anterior fontanelle presentation is also normal,
especially in early labour before the head is fully flexed. It is also common in occipital posterior position. Presentations
other than this are malpresentations.
3. Brow presentation (0.02%)
It occurs when the head is extended. This sometimes occurs naturally, especially in multipara where the baby is not fixed
in position. More commonly it is associated with an obstruction in the birth canal such as disproportion, fibroid, ovarian
cyst, or placenta praevia. Unless the baby is very small, brow presentation makes the foetal diameters too large to deliver
vaginally. The head usually cannot enter the pelvic brim, so that when the membranes rupture, there is a high risk of cord
prolapse.
4. Face presentation (0.04%)
It is when the head is fully extended, and this occurs in very small babies, when the head enters the pelvis as a brow, but
extends into a face at the outlet and delivers. Although it can occur spontaneously, more commonly it is associated with
many loops of cords around the neck, or with thyroid goitre so the baby is forced into an extended position. Face
presentation can deliver vaginally if the head is rotated to a mentum anterior position. If rotation is to mentum posterior,
then the baby cannot bend its neck any further to fit the curvature of the pelvic canal, and so obstructed labour results.
5. Breech presentation (3%)
Breech presentation is when the baby's bottom comes out first. This can be a frank breech, flexed / complete breech or a
footling breech.
6. Other types of presentation
If the baby is in the transverse lie then the presentation would be the shoulder, elbow, or the hand. If the baby is floating
free, sometimes the umbilical cord is the presentation.
Position
The relationship of a defined area on the presenting part called the denominator, to the maternal pelvis. The most common
presenting position in cephalic presentation is occipto-anterior. Occipito-posterior position occurs in one-third of the cases.
Denominator
It is a defined area of the foetal presenting part, used to describe the position of the foetal presenting part in relation to the
maternal pelvis.
Presentation
Denominator
Vertex
Occiput
Face
Mentus
Breech
Sacrum
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Terminology 2010
Figure 1 Attitude
Figure 2 Lie
Figure 3 Position
Figure 7 Vertex
presentation
The presenting diameters of the skull
Depends on the degree of flexion of the foetal head, it may present to the birth canal (maternal pelvis) in different longitudinal
diameters and presentation:
Foetal neck
Longitudinal diameter (cm)
Presentation
Fully-flexed
suboccipito-bregmatic (9.5)
vertex
Semi-flexed
suboccipitao-frontal (10)
vertex, usually with occiputo-posterior position
Mildly-extended
occipito-frontal (11.5)
vertex, usually with occipito-posterior position
Moderately-extended mento-vertical (13)
brow
Fully-extended
submento-bregmatic (9.5)
face
Remark:
- Suboccipito-bregmatic:-from the suboccipital region to the centre of the anterior fontanelle
- Suboccipitao-frontal:-from the suboccipital region to the prominence of the forehead
- Occipito-frontal:-from the posterior fontanelle to the root of the nose
- Mento-vertical:-from the chin to the furthest point of the vertex
- Submento-bregmatic:-from below the chin to the anterior fontanelle
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Figure 11 Sutures
Figure 12 Circumferences
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2. Maternal anatomy
Levator ani
Levator ani muscles is a pair of broad flat muscles, each arises from the inner surface of the antero-lateral pelvis, passes
downwards and inwards, from the lateral sides and meet each other at the midline. The muscles together constitute the pelvic
diaphragm. Each muscle is also divided into three parts:-pubococcygeus anteriorly, ischiococcygeous and iliococcygeus
posteriorly. The nerve supply is by the pudendal nerve (S2-4) on each side.
The exact origins of the muscles are:- The lower part of the body of the os pubis
- The tendinous arch of the parietal pelvic fascia (white line)
- The pelvic surface of the ischial spine
The site of midline insertions are:- The pre-anal raphe and the central point of the perineum where one muscle meets the other on the opposite side
- The wall of the anal canal, where the fibres blend with the deep external sphincter muscle
- The postanal or anococcygeal raphe, where again one muscle meets the other on the opposite side
- The lower part of the coccyx
Clinical role of levator ani
1. The pubococcygeus muscles support the pelvic and abdominal viscera, including the bladder. Weakness of the support results
in genital prolapse.
2. The medial edge passes beneath the bladder and runs laterally to the urethra, into which some of its fibres are inserted.
Together with fibres from the opposite muscle they form a loop which maintains the angle between the posterior aspect of the
urethra and the bladder base. During micturition this loop relaxes to allow the bladder neck and upper urethra to open and
descend. Failure to maintain the angle results in urinary stress incontinence.
3. The medial borders of the pubococcygeus muscles pass on either side from the pubic bone to the pre-anal raphe. They thus
embrace the vagina, and on contraction have some sphincteric action. Spasm of the muscle results in vaginismus.
Urogenital diaphragm
It is a triangular-shaped ligament lying below the levator ani muscles, and filling the gap between the descending pubic rami. It
consists of two layers of pelvic fascia, with the deep transverse perineal muscle (compressor urethrae) lying between the layers.
The diaphragm is pierced by the urethra and the vagina.
Pelvis
It is composed of a pair of iliac bones, a pair of ischial bones, a pair of pubic bones and a sacrum. Together with the pelvic
ligaments, they form the birth canal, with an inlet, cavity and an outlet.
Pelvic Inlet
Also known as the pelvic brim, the upper limit of the true pelvis. It consists of the pubic symphysis in front, the upper edge of the
pubic bones and the iliac bones on both sides, and in the back the sacrum (usually the S1). The normal diameters of the brim are
said to be 11cm anteroposteriorly, and 12cm laterally. An AP diameter of 10 cm is usually considered to be narrowed, and 9cm
would be diagnosed to be a contracted pelvis.
Pelvic Cavity
The walls of the pelvis are partly bony and partly ligamentous. The posterior boundary is the anterior surface of the sacrum, and
the lateral limits are formed by the inner surface of the ischial bones and sacrosciatic notches and ligaments. In front the pelvis is
bounded by the pubic bones, the ascending superior rami of the ischial bones and the obturator foramina.
Pelvic Outlet
The lower end of the bony birth canal. Marked by the pubic symphysis in the front, the lower edges of the pubic rami, limited
laterally by the ischial tuberosities, and posteriorly by the coccyx. In women with android pelvis, the pelvic outlet is narrowed
from side to side, and this sometimes prevents the baby from being delivered in the second stage, resulting in a failed instrumental
delivery.
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Terminology 2010
Ischial spine
The sharp posterior-medical protrusion from the ischial bone. It is halfway between the pelvic inlet and outlet. The ischial spines
are of great obstetrical importance because the distance between them represents the shortest diameter of the pelvic cavity. They
are readily felt vaginally or rectally and therefore serve as valuable landmarks in assessing the station of the presenting part. It is
also a landmark to identify the site of pudendal nerve during pudendal anaesthesia.
Pubic symphysis
Where the two pubic rami join in the front. It forms the anterior border of the pelvic canal.
Subpubic arch
This is formed by the inferior borders of the pubic rami, ending at the ischial tuberosities. Normally this has an angle of 90
degrees. The shape of this arch is important in that it determines whether the foetal head has difficulty in coming out of the pelvic
outlet. As the baby's head is more or less round, a narrowed arch will force the baby's head backwards, so that the available
antero-posterior diameter is much less than as measured in the pelvimetry. The unavailable part of this AP diameter is called the
waste space of Morris. A good way to envisage this is to draw the pubic arch, and try to put a circle 9.5cm inside it. The distance
between the circumference and the apex of the arch is the waste space. The pubic arch is best assessed clinically, by feeling for the
arch and estimating its angle. Also, the distance between the ischial tuberosities should be about 10cm, which is usually the width
of the doctor's knuckles. A narrowed pubic arch will lead to difficulty in the second stage, and is a common cause of failed
instrumental delivery.
Intertuberous diameter
The distance between the tuberosity of the ischial bones. It is the transverse diameter of the pelvic outlet and normally measured
9cm. It can be assessed clinically by putting a fist to the perineum. The intertuberous diameter is normal when it can
accommodate 4 knuckles of fingers.
Figure 13 Levator Ani (Perineum)
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Terminology 2010
Shape of pelvis
The pelvis is classified according to different pelvic shapes and the size is assessed by clinical pelvimetry.
A normal pelvis
- The brim is round, and the sacral promontory is not prominent
- The angle of inclination is about 55 degree to the horizontal
- The cavity is shallow with straight, non-converging walls
- The sacrum is smoothly curved
- In the outlet the sacro-sciatic notches are wide and shallow
- The sacrum does not project forwards
- The ischial spines are not prominent
- The pubic arch is wide and domed
- The sub-pubic angle is about 90 degree
- The inter-tuberous diameter is wide
Pelvic shapes
Four major pelvic shapes have been described:-Gynaecoid, Anthropoid, Android and Platypoid
Gynaecoid
This is the normal and most common type of pelvis. The brim is oval in shape, with the lateral diameter larger than the
antero-posterior diameter. The sacrum is well curved, and tilted in such a manner as to render the antero-posterior diameter of the
outlet slightly larger than the inlet. The midcavity is wide, the anteroposterior diameter being generous because of a good sacral
curve, and the lateral diameters are also good, with a good distance of 3-4 cm between the ischial spines and the sacrum. The
outlet has an antero-posterior diameter larger than the lateral diameter, and the subpubic arch is more than 80 degrees. Such a
pelvis fits naturally into the diameters of foetal skull with a normal vertex presentation.
Anthropoid
This is a variant of the normal pelvis. Its shape is very similar to that of the gynaecoid pelvis, except that the inlet is ovoid shape,
with a long antero-posterior diameter, and the lateral diameter near the back is slightly larger than that in front. Such a shape tends
to encourage occipito-posterior position.
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Android
It is a male-like pelvic shape which tends to have a triangular inlet with beaking near the front. This encourages an occipital
posterior position. It is also a funnel pelvis, where the outlet is smaller than the inlet, and a side to side narrowing of the pelvic
canal. The outlet has a narrow subpubic arch. Typically women with android pelvis may have other android features, such as
having broad shoulders, are muscular, and sometimes hirsute.
Android pelvis can be diagnosed by pelvimetry, with the following features:1. The antero-posterior diameter at the outlet is smaller than that at the inlet
2. A narrowing of the distance between the ischial spines
3. A narrowed sacrosciatic notch
For this type of pelvis, the foetus tends to present with occipital posterior position, and the head has difficulty in rotating to the
anterior position as the pelvic canal is narrowed. The funnel shaped pelvis also results in obstructed labour. As the narrowest part
is at the outlet, the worst situation is the arrest at the second stage of labour. This would lead to a failed instrumental delivery with
all its disastrous consequences.
Platypoid
One of the pelvic shapes. 'Plat' is derived from a Greek word meaning flat. This type of pelvis is a result of clinical or subclinical
rickets. The pelvic brim is narrowed from front to back, so appearing flat, and this sometimes is associated with an exaggerated
lumbar lordosis. The combination of these causes the pelvic inlet to be small, and this contracted pelvis makes it difficult for the
foetal head to enter the pelvis. This is classically the situation of cephalopelvic disproportion. The softening of the bones caused
by rickets also leads to a splaying of the subpubic arch, so that the pelvis is usually only narrowed at the brim while the rest
presents no difficulty. This is responsible for the old obstetric adage that if the head will go in the brim it will come out the outlet.
Sometimes the head will angle sideways in an attempt to enter the pelvis, and this is called asynclitism.
Funnel pelvis
This describes a pelvis where the outlet diameter is smaller than the inlet, especially the antero-posterior diameters as seen on the
pelvimetry. Funnel pelvis occurs in the android pelvis. Women with funnel pelvis have difficult labours, because the birth canal
gets tighter as labour progresses, and the smallest part of the pelvis is only encountered at the second stage of labour.
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Terminology 2010
Contracted pelvis
This denotes a pelvis which is smaller than normal, to the extent that it may cause difficulties in labour. Contraction may occur at
the inlet, and this is usually associated with a platypoid pelvis. Contraction can also occur at the outlet, and this is usually
associated with the android pelvis. The android pelvis may also be contracted in midpelvis, with a side to side narrowing of the
pelvis, which can be seen as a narrowed sacral sciatic notch on pelvimetry, or as a narrowed distance between the ischial spines.
Cephalopelvic disproportion
This describes the situation where the foetal head is too big for the birth canal. Before World War II, when nutrition was poor,
many women had rickets and so developed platypoid pelvis. These lead to inlet disproportion. Women who have android features
however may have an adequate pelvic inlet, but a narrow outlet. They tend to have difficulty in delivering the baby at the second
stage, and are said to have outlet disproportion.
Pelvimetry
Definition
Measurement of the size of the pelvis, either clinically or radiographically.
Clinical pelvimetry
Clinical method is as follow:
1. Inlet assessment:
Assess the diagonal conjugate diameter by inserting the index and middle fingers to reach the sacral promontory. If the
sacral promontory can be reached, it means the inlet is small (usual length of the index finger is 10cm).
2. Mid cavity assessment:
a. Assess the sacral curvature by digital examination.
b. Assess the ischial spines.
3. Outlet assessment:
a. Assess the intertuberous diameter. It should be as wide as a normal fist (9cm)
b. Assess the subpubic arch which is normally 90 degree.
Clinical assessment of pelvic size and shape is only likely to be of benefit if the pelvis is severely contracted
Radiological pelvimetry
By X-ray, CT, MRI
CT is the most common way as it has less radiation and more accurate when compared with X-ray, but cheaper and more
available than MRI
Criteria for normality have not yet been set
Pelvimetry is of no reliable evidence of benefit for the traditional indications of primigravid breech presentation, or after
caesarean section for suspected disproportion
Rickets
A softening of the bone due to vitamin D deficiency. The weight of the upper torso then pushes the sacral promontory towards the
pubis, and the lumbar spine develops an exaggerated lordosis. As a result the pelvic inlet appears flattened, and this is called the
platypoid pelvis. Women with rickets and platypoid pelvis develop inlet disproportion. Rickets should be differentiated from
osteoporosis.
Lordosis
An exaggerated anterior curving of the lumbar spine. Often occurs in rickets.
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Terminology 2010
Os
Greek word meaning opening. In obstetrics means where the cervical canal is. The internal os is the end of the cervical canal at
the uterine end, and external os the vaginal end.
Lower segment
The thin expanded lower portion of the uterus which forms from the isthmus during the last trimester of pregnancy. It is located
between the attachment of the peritoneum of the uterovescial pouch superiorly and the level of the internal os inferiorly. It
provides the usual method of approach to the baby in the operation of caesarean section. When abdominal delivery is necessary in
a preterm pregnancy when the lower segment is not yet formed, a classical caesarean section is then the method of approach. The
lower segment is less contractile as there are fewer muscle fibres. When the placenta is located there (placenta praevia), bleeding
from the placental bed is more difficult to control.
Dextrorotation of uterus
The pregnant uterus is usually rotated towards the right side, due to the presence of the rectum and sigmoid colon on the left side.
This is relevant that to avoid injury to uterine vessels during lower segment caesarean section, the operation table should be tilted
towards the left side.
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Terminology 2010
3. Antepartum
Pre-conception counselling
Aim
1. To ensure women are in good and healthy condition before being pregnant
2. It is important as the most critical phase of foetal development is complete by the time of the first antenatal clinic attendance,
and adverse factors may have already begun to produce their effects
Elements
1. General health assessment and advice
a. Nutrition
b. Healthy behaviour:-e.g. quit smoking and alcoholism
2. General screening
a. Cervical pap smear
b. MCV for thalassemia
c. Rubella immunity
3. Control of pre-existing chronic diseases
a. Diabetes mellitus, thyroid disorders, valvular heart diseases are common in female at reproductive age.
b. Poor control of these diseases would definite causes significant maternal and foetal morbidities
4.
5.
Discussion/Something to Consider
You are a medical officer of the Family Planning Association.
1. A healthy couple has just married and come for pre-pregnancy advice. History and examination are unremarkable. What
screening tests would you perform for them?
2. Supposed the complete blood pictures of both of the couple show microcystic picture but otherwise normal result. How would
you counsel them and what further tests would you do?
3. The female partner of the couple has negative rubella antibody test. What advice would you give her?
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Terminology 2010
Antepartum care
Definition
A planned programme of observation, education, and medical management of pregnant women directed towards making
pregnancy and delivery safe and satisfying experiences
Elements
1. Screening of Risk factors
a. To regularly look for any risk factors which adversely affect the health of mother and baby
b. This is achieved through regular history taking, examination, and screening tests.
2. Counselling To advise on the nature and extent of any perceived risks, and how to minimize or eradicate them
3. Monitoring To monitor the maternal and foetal well-being in high risk cases
4. Treatment To treat any medical condition which might affect or be affected by the pregnancy (see maternal medicine)
5. Management of minor disorders See minor disorders of pregnancy
6. Education To provide advice, reassurance and support for the woman and her family, such as:a. Advice on wearing seat-belt
b. Instructions to admit to hospital when significant symptoms occur such as fever, vaginal bleeding or discharge,
abdominal pain, etc
Antepartum care consists of booking assessment; and continuing antenatal care.
Booking assessment
1. Timing
a. Optimally takes place at 8 to 10 weeks and should not later than 16 weeks
b. Important for dating of pregnancy:-to look for any date problem and confirm the estimated date of confinement (EDC)
c. Check for any pre-existing risk factors by history taking (Obs), examination (Obs) and screening tests
2.
3.
Additional screening tests such as the followings may be required if additional risk markers are present:
a. Urine culture
b. Screening for sexually transmitted diseases
c. Oral glucose tolerance test
d. Biochemical screening for neural tube defects and Down syndrome
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Terminology 2010
Subsequent assessment
1. When and where to be seen
a. Uncomplicated (low risk) pregnancy
i. Women should be seen every 4 weeks for the first 28 weeks of pregnancy, then every 2 weeks until 36 weeks, and
weekly until delivery
ii. Can be seen in maternal child health centre, by midwives or general practitioners
b. High risk pregnancy
i. Women with medical or obstetric problems require close surveillance at an interval determined by the nature and
severity of the problem.
ii. Under care of a specialist
Routine maternal assessment
Weight and notation of any change
Blood pressure with notation of any change
Urine glucose and protein
Periphera oedema
Presence of any symptoms
Routine foetal assessment
Foetal activity (from history)
Foetal size:-both the actual size and the growth rate; assessed with fundal height measurement
Foetal presentation and engagement (in late pregnancy)
Amount of amniotic fluid
Foetal heart rate, by auscultation with Pinard stethoscope or a hand-held Doppler apparatus (Doptone)
Please refer to history taking (Obs) and examination (Obs) for detail
Discussion/Something to Consider
1. A patient at 34 weeks of gestation is found to have weight gain of 2 kg over the last 1 week. Is it normal? What are the
possible causes? How would you assess her condition?
2. A patient asks you in the antenatal clinic whether it is dangerous to wear seat-belt during traveling in a car. How would you
advise her?
Pregnancy test
It is a simple bedside dipstick test for presence of human chorionic gonadotropin in urine. It is highly specific and sensitive
(detection limit of around 25-50IU/L), and produces a result in 1 to 2 minutes. The test can produce to positive result as early as
14 days post-fertilisation.
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Terminology 2010
Dating of pregnancy
Introduction
Dating is one of the most important tasks in antenatal care. 20% of pregnant women will have date problems because:1. Last menstrual period is forgotten or uncertain
2. Menstrual cycles are irregular
Some definitions
1. Last menstrual period (LMP) date of the first day of last menstrual flow
2. Estimated date of confinement (EDC):
a. The mean duration of pregnancy
b. About 40% of women will deliver within 5 days of EDC and 66% within 10 days
c. It is 280 days from the LMP provided that ovulation occurs at day 14 of the menstrual cycle
d. It is 266 days from the date of ovulation
How to calculate EDC (Nagele's rule)
1. By LMP: It is calculated by using LMP by adding 280 days (40 weeks) to it. It is assumed that ovulation occurs at or day
14 of LMP, in a normal regular 28 days cycles. To the first day of LMP add 7 days, then subtract 3 months, and then add
1 year. e.g.:-LMP:-10/10/2009 EDC:17/07/2010
2. By First positive pregnancy test (5-6 weeks of amenorrhoea)
3. By Ultrasound dating.
Some important facts:-menstrual cycles, ovulation and fertilization
In a normal regular 28-day cycle, ovulation occurs 14 days after the LMP
Ovulation may be delayed when the usual duration of menstrual cycles is longer. For example, ovulation may occur at day
21 if the menstrual cycles are 35 days
Fertilization occurs within 2 days of ovulation
Implantation occurs 7 days after ovulation, and completes 14 days after ovulation
Foetal life starts at about 14 to 15 days after LMP (if the cycles are 28 days) or even later if the menstrual cycles are longer
HCG is produced after implantation, and is detectable in the serum 1 week after implantation
HCG is detectable in urine (positive pregnancy test) since 2 weeks after fertilization (4 week after LMP, or later if ovulation
occurred later)
Therefore, if a patient has used to have long menstrual cycles, and had a negative pregnancy test at 5 week of amenorrhea,
but positive test at 6 week. Then most probably she had a date problem of 1 to 2 weeks.
Some important facts:-symptoms and signs of pregnancy
Features
Morning sickness
Breast changes
Bladder symptoms
Cervical softening
Quickening (primigravida)
Quickening (multipara)
Audible foetal heart sound with pinard
Abdominally palpable pregnant uterus
Hegar's sign
Week of pregnancy
4 to 13
start from 6 week
6 to 13 week
start from 6 week
start from 18 week
start from 16 week
start from 24 week
start from 12 week
8 to 13 week
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Terminology 2010
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Terminology 2010
Placenta praevia
Abruptio placentae
Incidence
Incidence: 2.0% 3-5% of pregnancies
Discussion/Something to Consider
What is your assessment for a woman presents with painless unprovoked vaginal bleeding of 10ml at 28 weeks of gestation?
Placenta praevia
Definition
It is defined as a low-lying placenta, when the placenta encroaches onto the lower segment.
Classification
Terminology 2010
1.
Classification with aids of Ultrasound, with the use of modern ultrasonography, the placental position can now be defined
more accurately antenatally.
Type I
low-lying placenta positioned closed to the os (within 5cm).
Type II
marginal placenta praevia located at the margin of the os.
Type III
partial placenta praevia partially covering the internal os.
Type IV
total placenta praeviacompletely covering the os.
2.
Old classification (by Dewhurst), based on clinical examination findings or findings at the time of caesarean section:Grade I
placenta extends on to the lower segment but does not reach the os.
Grade II
placenta extends to the os.
Grade III
placenta covers the os eccentrically.
Grade IV
placenta covers the os centrally.
3.
Simplest Classification
Minor
placenta encroaches on the lower segment but does not cover internal os (type I and II)
Major
placenta covers internal os (type III and IV)
Incidence
0.6% of pregnancies
Risk factors
1. Maternal factors:
a. Multiparity scarring of the endometrium due to repeated pregnancies
b. Advanced maternal age >35 defective vascularization of the decidua due to atrophic changes or inflammation, thus
decrease the blood supply to the endometrium and require a greater surface area for placental attachment to provide
adequate maternal blood flow
c. Previous C/S or surgeries Altered blood supply to the endometrium and changes in the quality of the endometrium,
due to previous incision in the lower segment
2. Foetal factors
Multiple pregnancies Decreased surface area of placental implantation, in multiple pregnancies
Clinical presentation
1. Painless vaginal bleeding
a.
Most characteristic sign of placenta praevia
b.
Can occur suddenly without warning, during rest or activity, or after coitus or pelvic examination
c.
Bleeding usually occurs for the first time early in the third trimester, when the lower segment begins to form.
d.
Bleeding is caused by the tearing of the placental attachments at or near the internal os as the cervix changes
e.
The bleeding cannot stop spontaneously because the stretched fibres of the lower uterine segment are unable to contract
and compress the torn vessels
2. Present as malpresentation
3. Incidental finding on routine ultrasound scan
Diagnosis
1. Should always be suspected in the presence of vaginal bleeding in the third trimester
2. The index of suspicion is heightened if there is co-existing malpresentation or multiple pregnancy
3. Ultrasonic examination
It is a valuable tool in confirming the diagnosis of placenta praevia Transabdominal scan (TAS) is usually adequate in
assessing the relation between the low-lying placenta and the internal os. In borderline cases or in case of posterior placenta,
transvaginal scan (TVS) is more accurate than TAS
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Terminology 2010
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Terminology 2010
Abruptio placentae
Definition
It is also called 'accidental haemorrhage. It is defined as uterine bleeding resulted from a normally implanted placenta that
prematurely detaches from the uterus, after 24 weeks of gestation and before the delivery of the foetus.
2.
3.
Revealed type
a. Peripheral detachment
b. Bleeding from cervical os
Concealed type
a. Less common
b. Central detachment
c. Blood is trapped behind the placenta and does not escape
Detachment of the placenta results in disruption of uteroplacental transfer of oxygen, leading to foetal hypoxia and death.
Clinical presentations
1.
2.
3.
Terminology 2010
Complications
1. Maternal
a. Massive haemorrhage and shock
b. Disseminated intravascular coagulopathy due to release of placental thromboplastin and other clotting factors
c. Postpartum haemorrhage due to uterine atony
d. High risk of caesarean section
2. Foetal
a. Intrauterine foetal hypoxia (distress) and death
b. Preterm delivery
Protocol, as of 22 June 2002
1.
Transfer to labour ward
2.
Assess maternal well-being and perform resuscitation for hypovolaemic shock if necessary
3.
Intravenous access with large-bore catheters
4.
Monitor vital signs closely:-BP, pulse, urine output
5.
Monitor foetal well-being by continuous foetal heart monitoring
6.
Check CBP, RFT, Clotting profile and crossmatch, make correction if necessary.
7.
Decide mode and time of delivery with midwives, by caesarean section unless the cervix is already fully dilated, or
the foetus has already died
8.
Consider steroid if <34 weeks
9.
Look for retroplacental clot of the placenta after delivery
10. Clear documentation of events
Discussion/Something to Consider
What are the differences between the management of abruptio placentae and that of placenta praevia, when each of them presents
at 30 weeks of gestation?
Couvelaire uterus
Uterine apoplexy, occurs with severe concealed type of abruptio placentae. The uterus is purple due to haemorrhage within its
musculature with retention of blood and cord. It is a phenomenon wherein the retroplacental blood may penetrate through the
thickness of the uterine wall into the peritoneal cavity. Clinically the uterus is hard and tender.
The placenta has developed some distance away from the attachment of the cord and the vessels divide in the membranes. If they
cross the lower pole of the chorion a condition arises called vasa praevia. Rupture of the membranes will then precipitate
haemorrhage which will exsanguinate the fetus.
Vasa praevia
It the placenta is developed some distance away from the attachment of cord, the connecting vessels run under the membrane. In
case a branch of the umbilical vessels passes over the internal os of the cervix, and therefore becomes the presenting part (vasa
praevia). The vessel may rupture spontaneously or during amniotomy resulting in foetal bleeding. It is a rare cause of antepartum
haemorrhage. The USG film with color-doppler below shows a vessel (colored) running over the internal os.
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Terminology 2010
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Terminology 2010
4. Malpresenation
Malpresentation
Definition
Any presentation other than vertex. They are:1. Breech presentation:-4.2% 3%
2. Cord presentation:- 1/1000 1/400
3. Face presentation:- 1/2500 1/500
4. Brow presentation:-1/10000 1/2000
5. Shoulder presentation, foetus usually in transverse lie
Medical students should know the most common malpresentation:-breech presentation
Breech presentation
Incidence
The most common type of malpresentation
Incidence deceases with maturity.
25-30% at 28 weeks.
Causes
1. The majority occurs by chance
2. Maternal
a. Uterine anomalies:-e.g. bicornuate uterus
b. Obstruction at lower pole:- Fibroids, placenta
3. Foetal
a. Multiple pregnancy
b. Preterm
c. Foetal anomalies:-e.g. hydrocephalus
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Terminology 2010
Foetal risk
1. Foetal risk related to the underlying causes
a. Foetal anomaly
b. Prematurity
2. Foetal risk related to vaginal breech delivery
a. Premature rupture of membranes
b. Cord prolapse:-risk is lowest in frank breech presentation but highest in footling
c. Birth injury:-e.g.:-Intracranial haemorrhage, rupture of viscus, dislocation of joints, fractures of long bones, peripheral
nerve injury
d. Birth asphyxia:-as a result of delayed delivery
Maternal risk
1. Maternal risk related to the underlying causes. e.g. Placenta praevia
2. Maternal risk related to breech delivery:- Higher caesarean section rate and Birth canal injury
Investigations
1. Ultrasound
a. Define the type of breech, assess foetal growth and estimate of foetal weight, and liquor volume
b. Look for any underlying causes like foetal anomalies, placenta praevia and uterine abnormalities
2. CT pelvimetry
a. Ensure adequate pelvis before allowing vaginal breech delivery
b. Rarely indicated now as vaginal breech delivery is not recommended
Decision of mode of delivery
1. External cephalic version (ECV)
2. Elective caesarean section
3. Vaginal breech delivery
Guideline
The mode of term breech delivery is controversial until recently when a large randomized controlled study comparing elective
caesarean section and vaginal breech delivery has shown that the former is associated with significantly lower perinatal mortality
and morbidity. The implication is that patients should be counselled for either elective section or ECV only. Patient who strongly
request vaginal breech delivery must fulfil the strict selection criteria (see vaginal breech delivery).
Other determining factors:
1. Gestation If occurred before 36 weeks, conservative management as spontaneous version may take place
2. Foetal malformations:a. Lethal foetal abnormalities:-vaginal delivery
b. Potential salvageable foetal abnormalities:-caesarean section
3. Foetal well-being Caesarean section if there are signs of foetal compromise such as oligohydramnios, or abnormal
cardiotocogram, etc.
4. Number of foetuses,
a. Twin pregnancy:i. Presenting twin is breech presenting:-caesarean section
ii. Non-presenting twin is breech:-can try vaginal delivery
b. Triplet or higher order pregnancy:-caesarean section
5. Uterine abnormalities Caesarean section in case of uterine anomalies, placenta praevia or other pelvic obstructions
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Terminology 2010
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Terminology 2010
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Terminology 2010
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Terminology 2010
Cord prolapse
Definition
1. Occult: intact membrane with cord alongside the presenting part but not palpable.
2. Cord presentation a loop of cord lies below the presenting part and the membranes is intact
3. Cord prolapse a loop of cord prolapsed out from the cervix with the membranes ruptured
Figure 21 Presentation of the cord (Left) ; Occult presentation of the cord (Right)
Pathology
1. This may occur if the presenting part of the baby does not fit well into the pelvic brim, and a sudden gush of amniotic fluid
when the membranes rupture.
2. As the baby descends, it presses upon the cord. More important is that the umbilical cord blood vessels undergo an
irreversible vasoconstriction when they become cooled.
Risk factors
1. Unengaged foetus:
2. Breech presentation
3. Prematurity
4. Cephalo-pelvic disproportion
5. Polyhydramnios
Complication
Sudden foetal hypoxia and death because of umbilical cord compression or cord vessels constriction
Diagnosis
1. Cord seen at vulva, or felt on vaginal examination
2. Acute foetal distress immediately after rupture of membranes
Management
1. Avoid cord compression and vasoconstriction. Put any visible cord back in the vagina as:a. Cool air will make the cord go into spasm, and
b. The vagina will keep it warm and moist and prevent spasm
c. Hold presenting part away from the cord and maintain this until delivery to prevent cord compression
d. Tilt bed head down
2. Immediate delivery if foetus is still alive
a. If cervix is not fully dilated:-emergency caesarean section
b. If cervix is fully dilated:-instrumental delivery
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Terminology 2010
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Terminology 2010
Preterm delivery
Definition
Delivery at a gestational age of less than 37 weeks
Incidence
The incidence is 6% (5.7-6.7%), with 2.5% (2.4-2.7%) before 34 week
Clinical significance
Significant foetal morbidity and mortality
Account for 75% of all perinatal death
Causes of preterm delivery
1. Preterm labour, or
2. Iatrogenic preterm delivery
Sometimes a preterm pregnancy has to be discontinued because the risk of continuing the pregnancy is higher than that of
preterm delivery. For example, in severe pre-eclampsia, abruptio placentae, foetal growth retardation (IUGR) and foetal
distress, there is a high risk of intrauterine death or maternal morbidity and mortality when the foetus is not delivered on time.
Modes of preterm delivery
1. If the foetus is viable it must be delivered by the route least likely to cause trauma or hypoxia
2. In general, aims for vaginal delivery if gestation < 26 weeks, as caesarean section at early gestation, and with infants under
1000g, can be hazardous for the mother and are not necessarily safer for the baby
3. The indications for caesarean section are stronger but not absolute in twin pregnancy and breech presentation
4. Pre-term labour is unpredictable and the woman may become fully dilated quickly and silently
5. Aims to have the presence of an experienced neonatal paediatrician at delivery
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Terminology 2010
Rupture of membranes
Definition
1. Premature/Prelabour rupture of membranes (ROM):-ROM before onset of labour
2. Preterm rupture of membranes:-ROM before 37 week
3. Prolonged rupture of membranes:-ROM for more than 24 hours
Incidence
2% (3.7-5.7%) of all pregnancies, 33% of all preterm deliveries
Risk factors for premature rupture of membranes
1. Polyhydramnios
2. Infection of genital tract
3. Cervical incompetence
4. Breech presentation
Diagnosis of rupture of membranes
1. Typical history a sudden gush of clear watery fluid passed vaginally
2. Examination watery fluid in vagina; oozing of fluid from cervical os after coughing
3. Other diagnostic tests (Usually are not required unless the diagnosis is inconclusive from the history and examination):a. Amniostrix (Nitrazine paper)
i. The orange colour of amniostrix changes to blue with contact with liquor
ii. May have false positive if the fluid is alkaline (such as mucus, blood)
b. Fern pattern
i. A swab dipped in fluid is used to make a slide and is allowed to dry thoroughly.
ii. Under microscopic examination, a characteristic fern pattern is noted, due to salt content in liquor
iii. False positive from cervical mucus
c. Ultrasonography may reveal decreased liquor volume after ROM. However, if the volume of leaking is not much, the
amniotic fluid volume would still appear normal under USG
Risk after rupture of membranes
1. Cord prolapse
2. Intrauterine infection
3. Preterm labour and delivery
Protocol, as of 5 November 2002
1. Investigation High vaginal swab to exclude infection
2. Decide mode and time of delivery, Depending on gestation and presence of infection
a. Gestation of 24-34 weeks:i.
Aim to prolong pregnancy beyond 34 week to minimise foetal complications from preterm delivery
ii.
Steroid to enhance foetal lung maturity in absence of infection
iii.
Monitor any maternal or foetal signs of infection such as maternal fever, tachycardia. uterine
tenderness, keep pads to inspect for foul vaginal discharge or MSL, and foetal tachycardia, and prompt
delivery if infection occurs. Monitor foetal growth with USG.
iv.
Avoid vaginal examination unless indicated, and should be done under aseptic technique.
v.
Start dexamethasone and antibiotics for 10 days, or till delivery, whichever occurs earlier.
Erythromycin 250 mg qid po; Treat accordingly for +ve HVS result.
If carrier ampicillin 2g load IV + amoxicillin 250 po tid;or clindamycin 900 mg IV + above.
b. Gestation between 34-37 weeks, Induction of labour if there is good neonatal support., Otherwise conservative
management till 37 weeks, when induction of labour is indicated if still not in labour after 24 hours of ROM.
(1) If re-sealing of membranes is diagnosed for >=1 week, patient can be discharged.
(2) If continuous leaking of liquor, keep patient in hospital and plan delivery at 34 weeks.
(3) If preterm labour occurs <24hrs of commencement steroid, consider tocolytic agent in the absence of intrauterine infection.
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Terminology 2010
Amniostrix
Amniostrix is made of nitrazine paper which turns from orange to blue when contacting with alkaline fluid. As amniotic fluid is
alkaline, it can be used as a test of rupture of membranes. It is not specific as other fluid such as blood, cervical mucus or urine
may give a false positive result.
Chorioamnionitis
Definition
It is an acute inflammatory process involving the chorion, its foetal blood vessels, the umbilical cord, and the amnion (by local
extension of the inflammation, as the amnion itself has no blood supply). This inflammatory process is potentially fatal to both the
mother and the foetus.
Causes
1. It is often a result of ascending infection, and prolonged rupture of membranes is a major risk factor. The common
micro-organisms are:
a. Group B streptococcus
b. Gram negative rods from bowel contamination
c. Sexually transmitted disease
d. Bacterial vaginosis e.g. Gardnerella vaginalis, E coli, enterococci
e. Others ureaplasma urealyticum, mycoplasma hominis
2. Risk factors
a. Preterm / premature rupture of membranes > 24 hours
b. Preterm labour rupture of membranes
c. Group B Streptococcus carrier
Clinical features
1. Maternal intrapartum fever (>37.8 oC)
2. Maternal tachycardia without other focus of infection identified, particularly if membranes have been ruptured
3. Uterine tenderness
4. Foul smelling discharge from the cervix
5. Maternal leukocystosis
6. Foetal tachycardia without other focus of infection identified.
7. Abnormal CTG, especially ones with decreased variability and lack of accelerations
Diagnosis
1. The diagnosis is mainly relied on the clinical features. Microscopic examination and culture of amniotic fluid are difficult and
inaccurate before delivery, and are not very helpful in an acute setting.
2. Careful clerking and examination are essential to rule out other causes of maternal fever, such as urinary tract or respiratory
tract infections
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Terminology 2010
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Cervical incompetence
Definition
Cervical incompetence means cervical dilatation in the absence of uterine contractions in second trimester or early third trimester.
Classically it is defined as a clinical syndrome characterized by painless dilatation of cervix, resulting in recurrent spontaneous
midtrimester abortions or preterm delivery (vaginal), in the absence of any associated uterine activity.
Causes
1. Previous traumatic events:
a. Mechanical cervical dilation
b. Second-trimester abortion
c. Cervical amputation, conization or laceration
2. Congenital:-rare
a. In utero diethylstilbestrol exposure
b. Spontaneous occurrence
Diagnosis
1. History
a. Typical history of painless mid-trimester cervical dilation resulting in expulsion of a nonviable foetus; or premature
labour in early third trimester
b. History of any traumatic events involving the cervix
2. Examination presence of cervical dilation may be accompanied by bulging forewater, without uterine contractions.
3. Ultrasound shows Hour glass appearance and shortened cervix.
4. Diagnostic tests in non-pregnant state, a number of methods for assessing cervical incompetence before pregnancy have been
suggested but none are reliable. These include:
a. Passage of 8mm Hegar dilator through the cervix:-no resistance suggests incompetence
b. Hysterosalpingogram:-dilation of cervix with leaking of dye under X-ray
Protocol, as of 22 June 2002
1. Cervical cerclage placement of a circumferential cervical suture that externally supports the internal os
2. Elective cervical cerclage:
a. Performed when the cervix is not yet dilated, in patients with history of cervical incompetence
b. Performed at around 13 weeks after foetal viability is confirmed
3. Emergency cervical cerclage:
a. Performed when the cervix already dilated
b. Success rate is lower
c. Risk of rupture of membranes, infection, abortion or preterm delivery because the membranes are usually
bulging out after the cervix has dilated
d. Consider waiting for 12-24 hours before deciding cerclage, to observe for signs of preterm labour, to permit uterine
quiescence to facilitate the reduction of herniated membranes and decrease risks of rupture during cerclage placement.
4. Special considerations
a. If chorioamnionitis is diagnosed, for removal of cerclage and delivery
b. If no evidence of chorioamnionitis,
i. 34 weeks / at 37 week for removal of cerclage and induction of labour in labour ward.
ii. 28 weeks to 34 weeks
Start steroid to enhance foetal lung maturity
Observe for spontaneous onset of labour
iii. <28 weeks
Start steroid to enhance foetal lung maturity
Decision by consultant concerning the removal of cerclage and delivery
5. Mirselene Tape: 5 mm thick, 400 mm long non-absorbable suture for cerclage
Discussion/Something to Consider
When a woman presents to you with a history of recurrent abortions, what information do you want to ask to diagnose a case of
cervical incompetence?
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Terminology 2010
6. Postpartum
Postpartum care
Aims
1. To ensure normal recovery from pregnancy and childbirth during puerperium
2. To follow up any antenatal problems and provide appropriate referral, counselling and management
3. To look for any problems in childcare and feeding
4. To advise on contraception and family planning
Routine care in early postpartum period
1. Look for any complications such as:
a. Postpartum haemorrhage
b. Anaemia
c. Postpartum fever
2. Provide adequate analgesia for wound pain
3. Prophylactic measures such as:
a. Encourage early mobilization to prevent thrombosis
b. Anti-D immunoglobulin for non-sensitized rhesus negative mothers
c. Rubella vaccine for non-immune mothers
4. Counselling, support and education
a. Advise on childcare
b. Encourage maternal-infant bonding
c. Promote and teach breast-feeding
d. Advise contraception and family planning
Postpartum visit at the end of puerperium
1. Usually is arranged at the end of puerperium (6 weeks post-delivery)
2. Examine for blood pressure elevations, breast masses or tenderness, uterine size, anaemia and healing of wound
3. Search for any problem in childcare, resumption of coitus and work, and any adjustment difficulty
4. Advise on contraception
5. Obtain pap smear if not screened before
6. Follow up any remaining problems such as:a. Screen for diabetes if previously diagnosed to have gestational diabetes
b. Refer to physicians if persistent proteinuria after pre-eclampsia
7. Continue to encourage healthy habits
What medical students should know?
Three major postpartum complications:
1. Postpartum haemorrhage
2. Postpartum fever
3. Postpartum depression
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Terminology 2010
Postpartum fever
Definition
Body temperature of 38 degree or higher on two occasions beyond the first hours and within the next 9 days postpartum
Incidence
5 to 10% (0.6-1.7%) of all pregnancies
Causes
1. Infectious causes
a. Intrauterine infection High risk after prolonged ruptured membranes and prolonged labour
b. Urinary tract infection High risk when multiple urinary catheterizations are performed during labour
c. Wound infection caesarean wound or episiotomy wound
d. Breast infection
i. Higher risk in breastfeeding mothers, usually cause by staphylococcus aureus
ii. Need to differentiate from breast engorgement of breasts and chemical mastitis
iii. Treat with antibiotic; may require incision and drainage
2. Non infectious causes
a. Haematoma vulval haematoma or pelvic haematoma
b. Lung atelectasis (Day 1-3)
c. Deep vein thrombosis (Day 7-10)
d. Breast problems
i. Engorgement of breasts
ii. Non-infectious mastitis
Discussion/Something to Consider
How to differentiate breast engorgement and infectious mastitis clinically?
Postpartum haemorrhage
Definition
1. Primary PPH Blood loss more than 500ml during the third stage of labour or 800ml during a caesarean section, and for
within 24 hours afterwards
2. Secondary PPH Any abnormal vaginal bleeding after the first day of delivery till the completion of the puerperium
Incidence
2.6%
Causes of primary PPH
1. Bleeding from uterus
a. Uterine atony (63.2-73.0%)
i. The most common cause
ii. May be secondary to retained placental tissue
b. Retained placenta (5.6-11.4%), may result from morbid adhesion of placenta to the uterine wall
c. Inversion of uterus, very rare (0.2-0.3%)
d. Uterine rupture or tear (0.1-0.3%)
2. Bleeding from lower genital tract injuries
a. Cervical tear (2.4-2.9%)
b. Vaginal tear (3.0-6.8%)
c. Vulval tear or haematoma (1.9-3.5%)
3. Secondary to systemic causes disseminated intravascular coagulopathy (0.8%)
Causes of secondary PPH
1. Common causes are Endometritis and retained placental tissue
2. Rare causes are delayed uterine rupture, uterine arterial-venous malformation and DIC.
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Terminology 2010
Complications
1. Shock and death
2. Sheehans syndrome (very rare)
3. Puerperial anaemia
Management of primary PPH
1. Assess the patients haemodynamic status with resuscitation by fluid and oxygen
a. Monitor blood pressure and pulse
b. Place patient in head down position
c. Assess the amount of blood loss
d. Set up large bore ivaccess with colloid or crystalloid fluid replacement
e. CBP, cross match, +/- clotting profile
f. Transfuse blood/ platelets/ FFP if inappropriate
2. Identify the cause and treat the cause
a. Examine placenta for completeness
b. Examine uterine tone
c. Examine lower genital tract for any tear and origin of bleeding
d. Examine signs of internal bleeding
e. Examination under anaesthesia and exploration of uterus may be required if retained placenta is suspected
3. Specific treatment
a. Manual removal of placenta for retained placenta
b. Oxytocic for uterine atony
c. Surgical repair and haemostatsis for genital tract injury
d. Incision and drainage for vulval haematoma
e. Hysterectomy for non-repairable uterine injury, uncontrolled bleeding, morbid adherence of placenta
4. Inform mid-call 1 if persistent bleeding or OT required
Uterine atony
Definition
It means failure of the uterus to contract post delivery. It is a common condition immediately after delivery in which the uterus
become hypotonic and loses it contractility that is the most important mechanism to control blood loss after delivery of the baby
and placenta. It is the most common cause of postpartum haemorrhage.
Risk factors
1. Uterine atony is also caused by retained placental tissue which should be ruled out first when uterine atony occurs.
2. Uterine atony is more common in:
a. High parity
b. Over-distended uterus such as multiple pregnancy, polyhydramnios
c. Abruptio placentae, placenta praevia
d. Prolonged labour, or prolonged stimulation with syntocino
e. Sepsis
Prevention of uterine atony
1. All women should be given syntometrine or syntocinon immediately after the delivery of their babies.
2. High risk cases should also be given additional syntocinon infusion to maintain the uterine tone.
Protocol, as of 22 June 2002
1. Rule out retained placental tissue
2. Resuscitation with fluid or blood replacement
3. Control blood loss with oxytocics which include syntocinon, or other prostaglandins. 40 units syntocinon infusion in
500ml Hartmanns solution/normal saline solution to run over 4 hours. Additional units may be necessary.
4. Bimanual compression of the uterus and massage with the abdominal hand
5. If still fails to control bleeding, inform midcall 1 before giving Hemabate.
6. Inform Midcall 2 if the above measures fail and arrange for EUA laparotomy hysterectomy
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Terminology 2010
Uterine rupture
Definition
1. Complete uterine rupture:- uterine cavity directly communicate with peritoneal cavity
2. Incomplete uterine rupture:- uterine and peritoneal cavities separated by visceral peritoneum
3. Uterine dehiscence:- foetal membranes are not yet ruptured
Incidence 0.01%
Causes
Uterine rupture can occur spontaneously or after traumatic events. A scarred uterus is vulnerable to rupture, but rupture can
occasionally occur in an unscarred uterus. It is not common and usually occurs because of scar from previous operations.
1. Maternal factors
a. Congenital anomaly:-undeveloped uterine horn
b. High parity
c. Previous surgery:- ECV, instrumental delivery, MROP, caesarean section, hysterotomy, myomectomy, metroplasty
d. Previous trauma:-curette, sharp or blunt trauma
2. Foetal factors Foetal anomalies distending lower segment such as hydrocephalus
3. Obstetrics factors
a. Obstructed labour
b. Uterine hyperstimulation
c. Morbid adherence of placenta
Figure 23 Causes of uterine rupture. (Left to right) Spontaneous; Classical C/S; and Lower Segment C/S.
Pathology
1. Rupture of unscarred uterus
a. Longitudinal or lateral
b. Vascular with torn vessels and heavy bleeding
c. 85% are not repairable and require hysterectomy
d. High maternal and foetal mortalities and morbidities
2. Rupture of scarred uterus
a. Rupture along old scar
b. Wound relatively avascular
c. Two-third of the ruptures are amendable
d. Lower maternal and foetal mortalities and morbidities when compared with unscarred uterine rupture
3. Rupture of uterus with previous caesarean section scar
Type of scar
Incidence
Timing
Maternal mortality
Foetal mortality
Classical
2.5%
1/3 before labour
5%
75%
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Lower Segment
0.5%
rarely before labour
0%
12%
Terminology 2010
Clinical features
1. Sudden abdominal pain
2. Vaginal or intra-abdominal bleeding
3. Uterine contractions may cease
4. Foetal distress and misplacement
Diagnosis
1. High suspicion if patient with a scared uterus presented with acute abdominal pain and bleeding with abnormal CTG
2. Some cases of uterine rupture are not diagnosed until during caesarean section
3. Differential diagnosis:
a. Abruptio placentae:- also present with acute pain and bleeding, and foetal distress
b. Uterine hyperstimulation:- also present with sudden foetal distress
c. Amniotic fluid embolism:- present with sudden shook and foetal distress
Management
1. Resuscitation
2. Immediate delivery:-by caesarean section
3. Repair of uterine rupture and hysterectomy, depends on
a. Type and extent of rupture
b. Severity of bleeding
c. Patient's past obstetric history and wish of fertility
4. Patients must be counselled for elective section next pregnancy, if the uterus is repaired and conserved
Prevention
1. Reduce prevalence of scared uterus in the population by avoiding unnecessary caesarean section
2. Avoid overstimulation of uterus by oxytocic during labour
Uterine inversion
Definition
It is a very rare complication of the third stage of labour in which the fundus is inverted into the uterine cavity.
Incidence
1 in 10000 deliveries (0.3% locally)
Classification
1. First degree / incomplete fundus at external os
2. Second degree / complete fundus into vagina
3. Third degree fundus out of vagina
Causes
1. Lax uterus
2. Morbid adherence of placenta
3. Inappropriate cord traction to deliver the placenta:
a. No counter pressure (controlled cord traction) to prevent fundal descent.
b. Premature traction before evidence of placental separation
c. Too vigorous fundal pressure
Clinical Presentation
1. Uterine fundus is protruding out from the cervix (in complete inversion)
2. Severe postpartum haemorrhage
3. Severe abdominal pain
4. Shock
5. Fundus is not palpable on abdominal examination and PV exam will reveal a hard mass.
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Terminology 2010
Figure 24 Uterine inversion. (Left to right) First, second and third degree
Figure 25 Manual reduction by Taxis (Left and Centre); and by laprotomy (Right)
Protocol, as of 22 June 2002
1. Resuscitation and management of haemorrhage and shock
2. Reposition of the uterus
a. Manual replacement by Taxis
i. While the adherent placenta is left undelivered, the fundus is pushed back manually vaginally.
ii. Uterine relaxants such as hexoprenaline 10mcg may be required.
iii. Once the uterus is in position, the attendant's hands should remain in endometrial cavity until a firm contraction
occurs (oxytocic may be required). Then the placenta can carefully be removed .
b. Replacement with hydrostatic pressure by OSullivan
Warm saline (up to 10L) is infused into posterior fornix of vagina, to distend the vagina and uterus so as to push
the fundus of the uterus back.
c. Laparotomy is rarely required. The uterus is cut open to release the constriction and the fundus is reverted.
3. Manual Removal of Placenta
Sheehan syndrome
This is a rare complication of postpartum haemorrhage. Severe blood loss and vascular shock at or after delivery lead to a
reduction of blood flow through the pituitary-hypothalamic circulation, resulting in thrombosis, and necrosis of the pituitary gland
with loss of its function. Patients exhibit hypogonadotropic hypogonadism (fi rst sign:-no return of menstruation after delivery) as
well as evidence of thyroid and adrenal cortex impairment. Replacement of deficient hormones is required.
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Terminology 2010
Puerperium
Definition
In Latin puer means child and parere means to bear. It is the period during which the reproductive organs return to their
pre-pregnant condition and are usually regarded as an interval of 6 weeks after delivery.
Normal physiological changes during puerperium
1. Involutionof uterus
2. Lochia
3. Lactation
Involution
Involution of uterus
Uterus regains its usual nonpregnant size within 5 to 6 weeks, shrinking from 1000g immediately postpartum to 100g. The rapid
atrophy is due to the marked decrease in size of the muscle cells rather than the decrease in their total number. Breast-feeding
accelerates involution because stimulation of nipples releases oxytocin from the neurohypophysis, and the resulting contractions
of the myometrium facilitate the involution process. In primparous women, the uterus tends to remain contracted tonically,
whereas in multiparous, the uterus contracts vigorously at interval. The uterine contraction pain that produced throughout the
period of involution is called afterpain, and is more common in multiparous women and nursing mothers.
Lochia
It is the uterine discharge that follows delivery and lasts for 3 to 4 weeks puerperium. The discharge undergoes changes during the
first few weeks:
Lochia rubia is blood-stained fluid that lasts for the first few days
Lochia serosa appears 3 to 4 days after delivery, it is paler than lochia rubra because it is admixed with serum
Lochia alba occurs after the tenth day, because of an admixture with leukocytes, the lochia assumes a white or yellow-white color.
Foul smelling lochia suggests infection. Look for signs of endometritis such as fever, tachycardia and poor involution.
Engorgement of breasts
It is a normal phenomenon with the breasts become full, red, hard and sore due to increased blood flow before milk secretion
commences. It usually occurs in the first few days post-delivery, and may cause fever. It must be differentiated from mastitis
which is usually unilateral. Other cause of postpartum fever should also be looked for before attributing the fever to breast
engorgement.
Mastitis
If infective cause is found, treat by antibiotics accordingly. Otherwise, it is usually due to the blockage off ducts. Better
positioning can be suggested so that milk can be drained with expression of milk. Analgesics may be prescribed. Its complication
is abscess.
Discussion/Something to Consider
How is engorgement of breasts differentiated from mastitis clinically?
Colostrum
Yellowish fluid expressed from the breasts during late pregnancy and before the onset of true lactation. Compared with mature
breast milk, it contains more minerals and protein, much of which is globulin, but less sugar and fat. It also contains some immune
cells. The immunoglobulin A and other host resistance factors such as complement, macrophages, lymphocytes, lactoferrin in
colostrum provide protection for the newborn against enteric pathogens. The colostrum gradually converts to mature milk a few
days after delivery.
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Terminology 2010
Lactation
Growth of mammary glands
1. Early in pregnancy, HCG, chorionic somatotropin, prolactin causes a marked increase in ductular sprouting and branching
2. Estradiol and progesterone cause the mammary gland to become richly arboized
3. Serum growth factor and insulin cause cell proliferation at the end of the ducts, which under the influence of prolactin and
corticosteroids, differentiate to form alveoli
4. Placental lactogen and prolactin stimulate the secretion of colostrum
Lactation
1. The withdrawal of oestrogen after the delivery of the placenta allows lactation to begin
2. Lactation is in large part sustained by the stimulus of nursing that causes a transient increase in prolactin and oxytocin, the
former hormone is responsible for alveoli synthesis of milk, while the latter is responsible for ejection of milk from the
alveoli into ductules
Breast-feeding
Advantages to mothers
1. Increases bonding
2. Promotes uterine involution
3. Effective post-partum contraception
4. Economical Save money on formula feeding
Contraindications
1. HIV positive (unless formula feeding confers greater risk through contaminated water supply, especially in the Third World)
2. Drug abusers
Measures to promote breast-feeding
1. Baby-friendly hospital:- promote breast-feeding since antenatal period
2. Nurse specialists to help tackle problems or misunderstanding
3. Never provide formula feeding unless really indicated
Tips
1. Early start
2. Proper positioning - baby's mouth covers the whole nipple and areola
3. Feed on demand
4. Healthy lifestyle
5. No supplements
6. No worry about engorgement - analgesics, tight bra and frequent feed
Breast milk
1.
2.
3.
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Terminology 2010
Postpartum depression
Epidemiology
12% of Hong Kong Chinese women
Usually occurs in women with previous depressive disorders or other life situations predisposing them to depression
Clinical features
Depressive symptoms:
- Low mood, tearfulness, not her normal self
- Irritability, bad temper
- Guilt, self-blame, low self-esteem
- Forgetfulness, poor concentration
- Sleep disturbance, especially early morning
- Loss of appetite
- Suicidal ideas or attempt
- Distressed by the inability to have affection towards the baby
- Lack of confidence in child care
- Excessive anxiety about baby's health
- Obsessive fear of harming the baby
Treatment
- Psychoeducation
- Pharmacotherapy:-tricyclic anti-depressant
- Psychotherapy:-discuss childcare and interpersonal problems
Prognosis
Untreated 1/3 continued to be depressed by one year, 1/10 by 2nd year
Treated Good and prompt response to treatment
Persistent stressors and personality tend to associate with poor prognosis
Future pregnancy
1/6-1/2 risk of relapse
Postpartum blue
It affects up to 70% of all mothers, and occurs during the first 2 weeks after delivery, usually 48 and 72 hours postpartum. It is
manifested by tearfulness, anxiety, mood lability, irritability, insomnia and depression. It is said to be related to physiological
changes in hormone levels after delivery, often resolves spontaneously and require no treatment. It should be differentiated from
postpartum depression.
Postpartum psychosis
Or puerperal psychosis usually occurs 2 to 3 months post-delivery. Most show symptoms of manic-depressive type, with
confusion and disorientation; delusional thoughts or expressions of suicide. It should be differentiated from postpartum
depression.
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Terminology 2010
7. Obstetric statistics
Includes maternal mortality rate, perinatal mortality rate, stillbirth rate, and neonatal death rate
Maternal mortality
Definition
Deaths of women during pregnancy or within 42 days of termination of pregnancy, from any cause related to (direct) or
aggravated by (indirect) the pregnancy or its management, but not from accidental or incidental (fortuitous) causes.
Direct
Deaths resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions,
omission, incorrect treatment, or from a chain of events resulting from any of the above.
Indirect
Deaths resulting from previous existing disease, or disease that developed during pregnancy and which was not due to direct
obstetric causes, but was aggravated by the physiological changes in pregnancy.
Fortuitous
Deaths from unrelated causes which happen to occur in pregnancy or the puerperium
Late
Deaths occurring between 42 days and 1 year after abortion, miscarriage or delivery that are due to Direct or Indirect maternal
causes
Maternal mortality in Hong Kong
Hong Kong has the one of the lowest maternal mortality rate of the world, around 10 (6.1-11.8) per 100000 pregnant women. The
most common causes of maternal death are pulmonary embolism (30%) and suicide secondary (20%) to postpartum depression.
Perinatal mortality
It includes all stillbirth and (early) neonatal death. The perinatal mortality rate is:-number of stillbirth + (early) neonatal death per
1000 total birth (all stillbirth + livebirth). It is about 4.7/1000 in Hong Kong.
Stillbirth
Definition
It is the birth of a dead foetus at or after 24 weeks of gestation. Stillbirth rate is the number of stillbirth per 1000 births (stillbirth +
livebirth). It is about 3-4/1000 (2.4-3.4) in Hong Kong.
Causes
About 50% of cases are unexplained stillbirth. The following are identifiable causes:
1. Foetal complications:
a. Chromosomal abnormalities (32.8%)
b. Complications of twins such as twin-twin transfusion syndrome
c. Intrauterine growth retardation (IUGR)
d. Congenital infections
2. Maternal complications:
a. Abruptio placentae
b. Hypertension (8.2%), Pre-eclampsia
c. Poorly controlled diabetes mellitus (6.6%)
d. Other poorly controlled maternal diseases such as hypothyroidism, SLE, antiphospholipid syndrome
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Terminology 2010
Intrauterine death
Protocol, as of 6 November 2002
1. Diagnosis and Investigation
a. Confirm diagnosis with USG.
b. Perform the following tests if the cause of IUD is not obvious:
i. Autoimmune tests:-APTT, ACA, ANA
ii. Microbiological screening:
- HVS
- VDRL for syphilis
- Parvovirus serology:-maternal IgM
- Rubella serology if rubella antibody was negative previously:-Maternal IgM
iii. Maternal disease:-intrahepatic cholestasis LFT
c. The following tests should be performed only if suspected as a cause of IUD
i. Toxoplasma serology
ii. Cytomegalovirus serology
iii. Fasting glucose
2. Management of delivery
a. If patient agrees for IOL, induce labour with:
i. <28 weeks - misoprostol or cervagem
ii. 28 weeks - PGE2 vaginal pessary followed by syntocinon infusion if the cervix is favourable
b. Avoid rupture of membranes unless in active labour
c. Provide adequate pain relief
d. Monitor patient preferably in a single room with husbands accompany
e. Manage accordingly for chorioamnionitis and abruptio placentae
3. Management after delivery
a. Record the following information by on-call medical officer with photos for documentation:
i. Body weight
ii. Maceration
iii. Congenital anomalies
iv. Umbilical cord and placental anomalies, placental weight and any retroplacental clots
v. Liquor characteristics
b. Send:
i. Dead body for post-mortem examination if patient agrees
ii. Placenta for histological examination
iii. Placental swab for microbiological examination
c. Perform the following tests only if indicated:
i. Swabs from babys throat, conjunctiva and rectum for viral study
ii. Cord blood (in heparin bottle)/foetal skin/deep placental tissue for chromosomal study if had not been performed
previously (contact Clinical Genetic Labarotary, Cheung Sha Wan 27253773 )
iii. X-ray of whole baby for skeletal abnormality
d. Complete Death documentation forms by on-call Medical officer (to be sent to the Death Certificate Clerk). Discuss
burial/ cremation
e. Maternal Care:
i. Encourage the couple to see the baby photo
ii. Consult Grief Counselling Team
iii. Transfer to Gynae ward side room
iv. Arrange postnatal follow up in LKS clinic
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Terminology 2010
Neonatal death
Definition
- Early neonatal death are all neonatal deaths within 7 days of delivery
- Late neonatal death are all neonatal deaths after first 7 days but within 28 days of delivery
- The neonatal death rate is the number of early neonatal death per 1000 livebirth. It is about 1.4(1.2-2.8)/1000 in Hong Kong
- Post-neonatal death are all neonatal deaths after 28 days but within 1 year of age
Causes
- Over 80% of cases are due to prematurity (50% <28 weeks)
- Other causes include congenital abnormalities, severe birth asphyxia
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Terminology 2010
Fecundity
A measure of the ability to produce offspring. This declines markedly with advancing maternal age, especially after 35 year old.
The fecundability rate is the monthly probability of pregnancy when the opportunity for conception exists.
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Terminology 2010
Postterm
Definition
1. Post-term pregnancy Pregnancy lasting 41/42 completed weeks (294 days) or more (WHO)
2. Post-maturity syndrome clinical syndrome with the neonate manifesting signs of:
a. Long and thin in body girth and underweight from loss of subcutaneous tissues
b. Patchy areas of desquamation and skin is stained with meconium, although rarely the latter feature may be absent
c. The ventral surfaces of the hands and feet are wrinkled and the nails are long and stained with meconium
Incidence
1.4% Varies from 3 to 10%, depending the accuracy of the dating of pregnancy
Causes
1. Most are by chance
2. Rarely it is associated with foetal abnormalities(0.1-1%):-anencephaly, foetal adrenal hypoplasia, absence of foetal pituitary,
placental sulfatase deficiency. The deficiencies of hormones in the above conditions are thought to cause the failure of
initiation of labour.
Risk of post-term pregnancy
1. Maternal risk
a. Maternal anxiety
b. Higher caesarean section rate (17.6-25.8%) resulting from macrosomia, failure of induction of labour, and foetal distress
c. Birth canal injury resulting from difficult delivery of macrosomic baby
2. Foetal risk
a. Post-maturity syndrome
b. Macrosomia (10%) and associated birth injury (0.5%) such as shoulder dystocia
c. Intrauterine growth retardation
d. Foetal compromise
e. High chance of meconium stained liquor (MSL) and therefore meconium aspiration syndrome
f. Overall 2-fold increase in perinatal mortality rate when compared to term gestation
Diagnosis
Accurate dating of pregnancy from menstrual history, early ultrasound assessment, landmarks of foetal development:-quickening,
foetal heart sound, uterine size.
Protocol, as of 28 July 2002
1. Ensure the EDC is well defined.
2. Arrange follow-up in MCH meanwhile.
3. On the day of admission at 41 weeks, perform routine examination and CTG by midwives.
4. If patient declines IOL at 41 weeks, rearrange IOL no later than 42 weeks.
Discussion/Something to Consider
What are the assessments that should be done before induction of labour for postterm?
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Terminology 2010
Gravid
Means pregnant, irrespective of outcome. A primigravida is a woman pregnant for the first time.
Grand multipara
A woman with parity 4 or more. She is likely to have powerful and coordinated uterine contractions. The labour progress is
usually quite fast. However, the chances of birth before arrival to hospital, uterine rupture and postpartum haemorrhage due to
uterine atony are higher. In addition, their babies may tend to be bigger, causing an unexpected obstructed labour or shoulder
dystocia.
Discussion/Something to Consider
How to prevent uterine rupture and postpartum haemorrhage in this group of patient?
Trimester
-
Placenta
Structure of a placenta
- Cotyledons Membranes:-see chorioamnionicity
- Umbilical cord
Disorders of placenta
- Placenta praevia
- Abruptio placentae
- Retained placenta
- Morbid adherence of placenta
- Placenta insufficiency
- Placenta tumour:-chorioangioma
- Chorioamnionitis
Obstetric surgery
Operative delivery
1. Caesarean section
2. Instrumental delivery
3. Episiotomy
4. Manual removal of placenta
5. Postpartum hysterectomy
6. Repair of tear of lower genital tract
Prenatal diagnosis and therapy
1. Chorionic villus sampling
2. Amniocentesis
3. Cordocentesis
Obstetric emergency
-
Eclampsia
Shoulder dystocia
Cord prolapse
Amniotic fluid embolism
Pulmonary embolism
Massive haemorrhage, due to placenta praevia or any causes of postpartum haemorrhage
Uterine inversion
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Terminology 2010
Birth trauma
Types of birth trauma
Incidence: 0.4-0.6%
1. Skeletal injury
a. Long bone fractures
b. Skull bone fractures
2. Bleeding
a. Cephalhaematoma
b. Subaponeurotic haematoma
3. Nerve injury
a. Brachial plexus injury (Erb palsy)
b. Facial nerve injury
Subaponeurotic haematoma
Or subgaleal haematoma is a result of birth trauma. The subaponeurotic space is a potential and expansible space between the
skull bone and the scalp, with vessels run through it. Bleeding inside it can be huge resulting in shock and high mortality (20%). It
is extremely uncommon after normal vaginal delivery, but occurs in 6/1000 vacuum extraction. The main clinical feature is a
boggy swelling of the scalp that crosses suture lines, with or without shock. It should be differentiated from other scalp swelling
such as caput succedaneum and cephalhaematoma. Early recognition is crucial in preventing complications and mortality.
Cerebral palsy
Definition
A non-progressive disorder of the brain resulting in impairment of motor function, usually of spastic rigidity type. Other types
includes dyskinetic, ataxic and mixed.
Pathology
Hypoxic ischemic injury of a developing brain, mainly of the white matter
Causes
Causes can be divided into prenatal, perinatal and postnatal. Birth asphyxia was being blamed as the major cause of cerebral palsy
until recent decades. Now it is clear that only 10% of the cases are related to intrapartum events or birth asphyxia. Majority is due
to complications of prematurity, of which the neonate are prone to intraventricular haemorrhage and hypoxic brain injury. Other
causes are chronic antepartum hypoxia, congenital brain malformations, and postpartum insults (20%) such as meningitis
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Terminology 2010
Jehovahs witness
Protocol, as of 22 June 2002
The patient may refuse whole blood or any blood products including immunoglobulins. If refusal is expressed, counselling should
be given by an obstetric doctor as well as an obstetric anaesthetist for the patient to understand the consequence of refusal of blood
products including death. Patient should sign a standard refusal form (Form A) and her wish clearly documented in the notes.
In emergency situations such as when the patient is unconsious and requires blood products, if there is no doubt that she has
previously clearly expressed a refusal to receive blood transfusion, blood transfusion cannot be given. A standard form B should
be signed by the person providing the information and the next of kin.If doubt exists whether the patient has expressed refusal of
blood products, an FHKAM should be involved in the decision of blood transfusion. All details must be recorded in the notes.
Consanguinity
A relationship by descend from the same ancestor, or having a blood relationship. It is important for genetic counselling when
there is a positive family history of genetic disorder, and a couple has blood relationship.
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Terminology 2010
Foetal Medicine
0. Foetal medicine
What is foetal medicine?
1. A subspecialty in Obstetrics.
2. Deals with high risk pregnancy with foetal diseases and complications (see below).
3. Carry out prenatal diagnosis and counselling, and foetal therapy.
4. Multi-disciplinary care involving obstetricians, paediatricians, geneticists, and paediatric surgeons.
What are the foetal diseases and complications?
1. Congenital abnormalities such as:
a. Chromosomal abnormalities
b. Genetic disorders
c. Foetal infections
d. Multifactorial malformations
2. Growth disorders:-intrauterine growth retardation (IUGR)
3. Multiple pregnancy
4. Preterm labour and delivery
What are the commonly used diagnostic tools
1. Ultrasonography (see USG (Obstetrics))
2. Chorionic villus sampling
3. Amniocentesis
4. Cordocentesis
What are the possible therapeutic tools?
1. Transplacental medication
2. Transumbilical medication and transfusion
3. Foetal surgery
4. Termination of pregnancy
Foetal diseases medical students should know
Please refer to the following individual topics:
1. Congenital abnormalities:-chromosomal abnormalities, genetic disorders, foetal infections, multifactorial malformations
2. Growth disorders:-intrauterine growth retardation (IUGR)
3. Multiple pregnancy
4. Preterm labour and delivery
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Terminology 2010
1. Chromosomal disorders
Chromosomal abnormalities
Introduction
1. Affect 7% of all conceptions, and 6 per 1000 livebirths
2. 95% of gametes with chromosomal abnormalities are not viable
3. 60% of all first trimester spontaneous abortions, 5% of all second trimester abortions, and 5% of stillbirths
4. Most are trisomies
Types of chromosomal abnormalities
1. Numerical aberrations
a. Aneuploidy
i. The number of chromosomes is not the multiple of the haploid; it can be trisomy (47) or monosomy (45)
ii. Autosomal chromosomes involved:-trisomy 21 (Down syndrome); trisomy 18 (Edward syndrome), trisomy 13 (Patau
syndrome)
iii. Sex chromosomes involved:-XO (Turner syndrome), XXY, XXX, XYY
b. Polyploidy The number of chromosomes is an exact multiple of the haploid, but greater than the diploid number (2n),
e.g. Triploidy (3n, 69XXY), or tetraploidy (4n)
2. Structural aberrations
a. Rearrangement of chromosomal structure due to chromosome breakage and inappropriate rejoining of the broken ends.
i. Translocation
ii. Deletion
iii. Duplication
iv. Inversion
v. Isochromosome
Genetic material may be lost (unbalanced) or maintained (balanced) after a rearrangement
Balanced rearrangements:- Individuals with balanced rearrangement are phenotypically normal. However, they
have an increased risk of producing unbalanced gametes, leading to reproductive loss or abnormal children
3. Other aberrations
a. Mosaic an individual with two or more cell lines derived from a single zygotes
b. Chimaera two cell lines are derived from two separate zygotes
What should medical students know?
Down syndrome, Turner syndrome, translocation
Translocation
1. Translocations of fragments between chromosomes can be:
a. Reciprocal
b. Robertsonian
c. Insertional
2. Balanced translocation:
a. Exist when the gemone contains the correct amount of genetic matter
b. Usually have no outward manifestation
c. Parental karyotyping is essential
d. If one parent has a balanced translocation, the theoretical outlook for any offspring is 1:-4 having the same balanced
translocation; 1:4 having a normal karyotype; and 1:2 having an unbalanced translocation. However, the actual risk of
having unbalanced translocation is 1:10 as most of them will abort.
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Terminology 2010
Biochemical screening
What is biochemical screening?
Biochemical screening is a screening test for Down syndrome performed at around 16 to 20 weeks of gestation. It consists of
measurement of maternal plasma level of several markers, including alpha-feto protein (AFP), human chorionic gonadotropin
(HCG) and unconjugated estriol (uE3). It is also called triple test when all three markers are tested, or dual test when only AFP
and HCG are assessed. In public hospitals of Hong Kong, dual tests are offered to pregnant women at or above 35 years old for
cost-effectiveness.
Test
aFP
hCG
uE3
Inhibin-A PAPP-A
NT
Remarks
Double Test
Y
Y
Early second trimester
Triple Test
Y
Y
Y
Quadruple Test
Y
Y
Y
Y
Combined Test
Y
Y
Y
Late first trimester; Maternal age.
Integrated Test
Y
Y
Y
Y
Y
Y
Serum
Y
Y
Y
Y
Y
Y
A variant of integrated test using
Integrated Test
serum markers only
Aim of biochemical screening
The aim is to screen women for increased risk of having a Down fetus. The test itself is not diagnostic, but it selects the high risk
cases for diagnostic amniocentesis which is an invasive procedure. Compared with screening by age alone, biochemical screening
has a higher detection rate and a lower false positive rate so that the number of subjects requiring amniocentesis is reduced.
Mechanism of biochemical screening
Compared with normal pregnancies, women with pregnancy complicated with Down syndrome have lower plasma levels of AFP
and uE3, and a higher level of HCG. (Note that in different chromosomal disorders the biochemical markers may rise or fall)
Although the differences are not very distinctive (otherwise these biochemical tests would be diagnostic), they can be used to
estimate the chance of having a Down fetus. Given the same false-positive rate, by incorporating more markers, the detection rate
can be increased at the expense of higher cost.
OSCAR
In CUHK, One-Stop-Clinic for Assessment of Risk is carried out at 11-13 weeks if the pregnant woman requested. It is a
combined test for detection of Downs syndrome and other chromosomal abnormalities. If high risk is found, women are offered
prenatal diagnosis.
Alpha-feto protein
What is alpha-feto protein (AFP)?
It is an alpha-globulin which is similar in molecular weight to albumin. It is normally synthesized during pregnancy in the yolk
sac and foetal liver. Maternal serum AFP levels rise rapidly in pregnancy as a result of the passage of foetal AFP into maternal
circulation via the placenta. AFP is present in foetal serum and cerebrospinal fluid at a concentration of about 30000 times greater
than that in maternal serum and 150 times greater than that in amniotic fluid It is also increased in non-pregnant patients with liver
diseases such as primary hepatocellular carcinoma, and malignant yolk sac tumour of ovary.
Alpha-feto protein in obstetrics
Maternal serum AFP is increased in several foetal malformations including open neural tube defects, gastroschisis and
ophalmocele. It is used in some Caucasian countries as a screening test of neural tube defects.
Maternal serum AFP is decreased in pregnancy with Down syndrome. It is used in combination with human chorionic
gonadotropin or unconjugated estriol as a biochemical screening test for Down syndrome.
Increased maternal serum AFP is also reported to be associated with poor foetal outcome such as IUGR.
Alpha-feto protein in gynaecology
Serum AFP is secreted from ovarian tumours like yolk sac tumours, and other germ cell tumours. It is a very sensitive and specific
tumour marker for yolk sac tumours, and can be used for diagnosis, monitoring and detection of recurrence.
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Terminology 2010
Nuchal translucency
It is the subcutaneous edema over the back of the foetal neck. Normally it is less than 3mm in the first trimester. It is associated
with chromosomal abnormalities when the nuchal translucency is abnormally high. It has been suggested as a screening test for
Down syndrome. The sensitivity is around 60%, and 5% of population would be screened positive. Its screening power is
therefore similar to that of biochemical screening, but it allows an earlier screening in the first trimester. The limitation of the test
is the technical difficulty in measuring the parameter and therefore a poor reproducibility. Because of that, it is still not a standard
screening test in Hong Kong. A first trimester USG would show an abnormally increased nuchal translucency.
Trisomy
This is a condition of having three copies of a given chromosome in each somatic cell rather than the normal number of two. In
majority of cases, it is resulted from non-disjunction during meiosis. The most common type is trisomy 21(Down syndrome),
trisomy X, trisomy 18 (Edward syndrome) and trisomy 13 (Patau syndrome).
Non-dysjunction
A mistake during meiosis which causes some resulting haploid cells to have only 22 chromosomes and others 24 chromosomes,
instead of the normal 23. If a gamete with 22 chromosomes fuses with one with the normal 23, a zygote with 45 chromosomes
results (monosomy). If a gamete with 24 chromosomes fuses with one with the 23, a zygote with 47 chromosomes results
(trisomy). Non-dysjunction occurs more commonly during ooytes development in women of advanced maternal age.
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Terminology 2010
Down syndrome
Definition
Trisomy 21
Presence of extra chromosome 21 or its material
Incidence
1 in 850 of all livebirths
The most common type of chromosomal abnormalities
Incidence rises markly with maternal age, with 1 in 1000 at 30 years old, to 1 in 300 at 35 and 1 in 100 at 40
Aetiology
Extra chromosome is resulted from:
1. Non-dysjunction
a.
Accounts for 95% of all down syndrome
b.
Arises in the stage of meiosis of the ovum before fertilisation
c.
Karyotype:-47XX, + 21 or 47XY, + 21
2. Unbalanced translocation
a.
Accounts for 4% of all down syndrome
b.
One of the parental karyotypes consists of a translocation with the long arm of a Chromosome 21 to the other
Chromosome (e.g. Chr 14)
c.
The translocated segment is then inherited to the offspring so that the offspring would have a long arm of Chr 21 in
addition to one pair of Chr 21 (unbalanced)
d.
Karyotype:-46, XX, der (14;21) or 46, XY, der (14;21)
3. Mosaicism
a. Accounts for 1% of all down syndrome
b. Results from mitotic non-disjunction during the early stage of embryogenesis. These patients have cells with a normal
Chromosome number and some that are aneuploid.
c. Karyotype:-46, XX / 47, XX, +21 or 46, XY / 47, XY, +21
d. Mosaic patients may exhibit variable or milder symptoms, depending on the proportion of abnormal cells.
Clinical features of Down syndrome
1. Mental retardation
a. Mean IQ is 40% of normal population
b. Only 20% has no or mild mental retardation
2. Malformation
a. Congenital heart defects (40%)
b. Malformations of the gastrointestinal tract, e.g. Duodenal atresia (10%)
c. Head and face:-Brachycephaly / microcephaly; epicanthic folds and flat facial profile;
d. Limbs:-Simian crease; gap between first and second toe
3. Other complications
a. Alzheimer's disease
b. Subfertility
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Terminology 2010
Prenatal screening
1. Maternal age Using cut-off of 35 years old at time of EDC
a. 18% of pregnant women will be screened positive
b. Only sensitive for 20% of down syndrome, as majority of down (80%) are come from mothers below 35 years old
c. Safe and inexpensive screening tool
2. Biochemical screening
a. Using serum AFP, HCG with or without unconjugated estriol
b. 5% of pregnant women are screened positive
c. Sensitivity of 60%, i.e. Pick up more down than screened by maternal age alone, and less false positive so that few
pregnant women require an invasive diagnostic procedure
d. Disadvantage is that it can only be done in 2nd trimester
3. Nuchal translucency in 1st trimester using cut-off of 3mm
a. 5% of pregnant women are screened positive
b. Sensitivity varies from 33% to 60%
c. Potential benefit of early screening followed by CVS
d. Problem of reproducibility, and further studies required to define its clinical usefulness
4. Screening by USG of Down features in 2nd trimester
a. Shortened femur length, shortened humeral length, thickened nuchal skinfold, short ear length, foetal pyelectasis, choroid
plexus cyst, duodenal atresia, congenital heart defects, abnormalities of the fifth digit, trisomy hands
b. Sensitivity 33% only
Prenatal diagnosis
1. Foetal karyotyping by chorionic villus sampling
2. Foetal karyotyping by amniocentesis
Management of pregnancy with Down syndrome
1. Counselling and support:- Discuss the prognosis and long term complications of Down syndrome, social and health support
available for Down children in the society
2. Options of continuing pregnancy and termination of pregnancy:
a. Termination of pregnancy is legal when before 24 week of gestation
b. Medical and surgical procedures of termination, and their complications.
Discussion/Something to Consider
You are seeing a patient of age 38 at 8 week of gestation of her first pregnancy in the clinic. She was anxious about Down
syndrome. How would you counsel the patient, and which investigation would you suggest?
Edward syndrome
-
Trisomy 18
Multiple foetal abnormalities.
One of the lethal chromosomal abnormality
Related to advanced maternal age
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Terminology 2010
Patau syndrome
Definition
1. Trisomy 13, or presence of extra chromosome 13 or its material
2. Karyotypes
a. Trisomy 13 type:-47, XX, +13
b. Translocation type:-46, XX, t13
c. Mosaic type:-46, XX / 47, XX, +13
Incidence
1 in 15,000 births
Clinical features
Mental retardation
Cardiac defects (80%)
Renal defects (30%)
Holoprosencephaly, failure of the prosencephalon (the forebrain of the embryo) to develop
Cleft lip and palate
Eye defects such as microphthalmia, anophthalmia and coloboma
Polydactyly
Umbilical hernia
Prognosis
It is a lethal chromosomal abnormality, second trimester abortion, stillbirth or early death after birth.
Klinefelter syndrome
Definition
A chromosomal disorder of a male with an extra X chromosome (47 XXY), usually resulted from nondisjunction during meiosis.
Incidence
1 in 1000 males
Pathology
1. The most common karyotype is 47 XXY; about 15% of cases show mosaicism
2. Male hypogonadism develops as there are two X chromosomes
Clinical features
Taller and thinner than average
Eunuchoid features, female fat distribution
Reduced facial and body hair
Gynaecomastia
Testicular atrophy
Sterility due to impaired or absent spermatogenesis
Mild degree of mental retardation (severity is correlated with the number of extra X chromosomes), some may have normal
intelligence
Mosaics show milder symptoms
Investigation
1. High FSH and LH levels
2. Low testosterone
3. Semen analysis shows azoospermia
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Terminology 2010
Turner syndrome
Definition
Monosomy X with karyotyping 45XO
Incidence
1/3000 female births
Aetiology
Non-disjunction in approximately 55% of cases
The remaining 45% of patients are either mosaics (30%) or have structural abnormalities of the X chromosome (15%)
The karyotypic heterogeneity is responsible for significant variations in the phenotype.
Clinical features
Short stature
Normal intelligence
Webbed neck
Low posterior hairline
Broad chest and widely spaced nipples
Aortic coarctation
Diffuse pigmented nevi
Cubitus valgus
Peripheral lymphoedema at birth
Renal anomalies such as horseshoe kidney
Primary amenorrhea, streak ovaries, infertility, low oestrogens with elevated gonadotropin
Poor secondary sexual characteristics
Mosaics can present with oligomenorrhea and some secondary sex characteristics
Prenatal screening
Unlike Down syndrome, there is no screening program for turner syndrome.
Turner syndrome should be suspected if routine scan shows presence of cystic hygroma or other characteristic abnormalities
Prenatal diagnosis
1. USG would show characteristic features:
a.
Cystic hygroma
b.
Renal anomalies
2. Karyotyping with chorionic villus sampling or amniocentesis
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Terminology 2010
2. Congenital abnormalities
Neural tube defect
What is a neural tube defect (NTD)?
It is a group of congenital malformations of the brain, spinal cord, skull bones and spine that occur during the development of the
neural tube. It includes anencephaly, encephalocele, spina bifida with or without meningocele. It is called a closed NTD when the
lesion is completely covered by skin or thick opaque membrane. Otherwise, it is called opened NTD. Anencephaly is invariably
an open lesion.
Causes of neural tube defect
Multifactorial. It is associated with folate deficiency.
Incidence of neural tube defect
The incidence is about 4 per 1000 birth in Caucasian countries and is higher than in Asian. It is approximately equal for
anencephaly and spina bifida (without anencephaly). Encephalocele is rare, accounting for 5% of all NTDs.
Prognosis of NTDs
1. Anencephaly is not compatible with life.
2. Open spina bifida has a poor survival (5-year:-33%) and tends to be handicapped (90%).
3. Closed spina bifida has a 5-year survival rate of 60%, and 2-third are handicapped.
Screening and diagnosis
1. Maternal serum alpha-feto protein screening (MSAFP) at 16 to 18 weeks. MSAFP is higher in pregnancies with an open NTD.
Pregnancies screened positive should be followed with a morphology scan. However, closed NTDs are likely to be missed.
2. Screening with USG. Nowadays with improved quality in USG imaging, NTD can be screened more accurately with a
morphology scan at around 18 to 20 weeks. Foetal malformations other than NTD can also be examined. However, small
closed NTD can still be missed with USG.
Prenatal management of NTDs
Patients should be counselled the prognosis of the defect, and discussed with different management options including termination
of pregnancy.
Prevention of NTDs
Folic supplement is advised to high risk group. It should be taken at least 8 weeks before pregnancy, and continued till first
trimester. It has been showed to decrease the incidence of NTD by 2-third.
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Terminology 2010
Gastroschisis
It is a kind of multifactorial congenital abnormalities with an incidence of 1 in 3000 birth. Unlike omphalocele, it is rarely related
to chromosomal abnormalities, and is usually isolated, although cardiac and other structural abnormalities co-exist in 20% of
cases. It is a total anterior abdominal wall defect (often on the right side) resulting in protrusion of abdominal viscera (usually
small bowel) into the amniotic cavity. Unlike omphalocele, the abdominal viscera is not covered by the peritoneum, and is
therefore prone to chemical irritation from amniotic fluid (which usually occurs after 30 weeks of gestation, said to be related to
changes of chemical constituents from that time onwards). This leads to bowel inflammation, ischemia, and dilatation which make
postnatal repair difficult. Besides the risk of bowel injury, there is also increased risk of intrauterine growth retardation,
intrauterine death, intrapartum foetal distress. Management should include close antepartum surveillance and elective caesarean
delivery. The recurrence risk is less than 1%.
Omphalocele
Also called exomphalos, is the extra-embryonic herniation of abdominal viscera due to failure of the gut to return to the
abdominal cavity at 8 weeks of gestation (physiological hernia), resulting in a defect of the abdominal wall. The peritoneal sac is
intact. The incidence is 1 in 5000 delivery, and 30% cases have chromosomal abnormalities, and another 20% have co-existing
malformations (usually involving the heart and kidneys).
Presentation
The defect is detectable with USG after 12 week of gestation by when physiological herniation should have been reduced.
Multiple malformations, growth retardation and polyhydramnios are common associated features. An elevation of maternal serum
alpha-feto protein may be found on biochemical screening.
Management
1. Prenatal
a. Differentiate between omphalocele and gastroschisis:
i. Presence of peritoneal sac in omphalocele
ii. Midline defect in omphalocele but lateral defect in gastroschisis
iii. Herniation of liver occurs in 40% of omphalocele but is very rare in gastroschisis
b. Rule out chromosomal abnormalities and other anomalies which are crucial prognostic factors
c. Counseling
i. Prognosis is good for neonates with surgery, without chromosomal and other structural abnormalities
ii. Survival is well in excess of 75-80%
2. Delivery Can allow vaginal delivery when it is cephalic presenting
3. Postnatal
a. Prevent heat and fluid loss and infection before surgical repair
b. Surgical repair when foetal condition is stable
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Terminology 2010
Hydrops foetalis
Hydrops foetalis is defined as a foetus with generalised edema plus collection of fluid in at least one of the body cavities (ascites,
hydrothorax, or pericardial effusion). Traditionally in the western countries, it is classified into immune and non-immune hydrops.
The former is due to rhesus isoimmunisation which is more common in the Caucasian population. Actually, the causes of hydrops
are very diverse, including foetal anaemia, primary cardiac abnormalities, extra-cardiac structural abnormalities, and
chromosomal abnormalities. The common end-point is foetal heart failure. The prognosis depends on the underlying cause. Even
the foetus is born, the cardiomegaly will cause pulmonary hypoplasia and the neonate dies soon after birth.
Causes of Hydrops foetalis
1. Foetal anaemia due to:a. Alpha-thalassemia (Haemoglobin Bart disease)
i. The most common cause of hydrops in our locality.
ii. A lethal condition in which termination of pregnancy should be considered.
b. Rhesus isoimmunisation Can be treated with repeated intrauterine transfusion or early delivery of the foetus. The
prognosis is much better nowadays.
c. Parvovirus infection The prognosis is good with repeated intrauterine transfusion until the anaemia resolved in a few
weeks time.
2. Chorioangioma
a. A rare placental tumour causing high-output heart failure due to foetal haemolysis and arterio-venous shunting
b. The prognosis is variable, depends on the size of the tumour
c. Other vascular malformation includes vascular teratoma and intracranial arterio-venous malformation.
3. Primary cardiac abnormalities
a. Arrhythmia
i. Heart block, supraventricular tachycardia
ii. Can be treated with transplacental anti-arrhythmic agents
b. Major structural abnormalities of heart
4. Extra-cardiac abnormalities
Some structural abnormalities may compress on the foetal heart or obstruct its outflow resulting poor cardiac function,
like chylothorax, diaphragmatic hernia, primary pleural effusion and Congenital cystic adenomatoid malformation of the
lung (CCAML).
Diagnosis
1. Early sign is cardiomegaly by USG at week 16. If it is normal, the chance of hydrop fetalis will be low.
2. Concommitent features e.g. MCA peak systolic flow and placenta size.
Complication
1. Severe pre-eclampsia due to formation of a large placenta.
2. Birth injury due to big baby.
3. Early diagnosis is important for sake of the mother as this condition is untreatable.
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Terminology 2010
Renal agenesis
Definition
Bilateral absence of the kidneys, usually associated with the oligohydramnios sequence.
Synonyms
Potter syndrome (no longer used).
Incidence
1-2:10,000
Etiology
Usually sporadic occurrence but 20-36% of bilateral renal agenesis (BRA) present a familial recurrence (possibly autosomal
dominant with incomplete penetrance and variable expression).
Pathogenesis
Results from a lack of induction of the metanephric blastema by the ureteral bud. The absence of kidney results in the absence of
amniotic fluid after 12-13 weeks (before fluid is an exsudate or an extension of the intercellular fluid of the foetus). The
oligohydramnios causes the pulmonary hypoplasia. In rare cases of monozygotic twin discordant for the renal agenesis, the
pulmonary hypoplasia does not occur.
Diagnosis
The diagnosis is first suggested by the absence of amniotic fluid then by the absence of the bladder and the lack of kidneys.
Colour Doppler has been found useful in those difficult exams to identify the lack of renal arteries. Before a final diagnosis is
made one should think and if possible exclude the possibility of pelvic or ectopic kidneys that could compress the bladder and
exclude the possibility of ectopic ureter that could explain the absence of bladder.
Genetic anomalies
Unknown.
Differential diagnosis
Bilateral renal medullary cystic dysplasia and bilateral renal hypoplasia may appear as BRA. Further normal but non-functioning
kidneys anormal placental implantation (on a uterine septum for instance) can lead to the same presentation of severe
oligohydramnios. This information is important to convey during patient's counseling:-The concern is not only the renal agenesis
(which may be absent) but the oligohydramnios that will lead to pulmonary hypoplasia.
Associated anomalies
Since this is a common anomaly, many different associations have been described (Vacterl, Meckel, chromosome 22
malformations#). In practice most of these are difficult to identify by ultrasound because of the oligohydramnios.
Prognosis
Lethal.
Management
Many authors have suggested the use of amnioinfusion or even intraabdominal infusion of saline in order to better visualize the
anatomy. Although there might be indications for such aggressive approach in a non-viable foetuses, these are quite uncommon,
and not justified in the majority of cases. Termination of pregnancy can be offered before viability. Standard prenatal care is not
altered when continuation the pregnancy is opted for. Confirmation of diagnosis after birth is important for genetic counseling.
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Terminology 2010
Potter syndrome
Several entities use the eponym Potter:
1. Potter syndrome, now renamed either oligohydramnios sequence or bilateral renal agenesis (BRA) depending on whether the
cause of the syndrome (BRA) or the mechanism is referred to.
2. Potter syndrome Type I is now referred to as Autosomal recessive polycystic kidney disease
3. Potter syndrome Type II is now referred to as Renal dysplasia
4. Potter syndrome Type III is now referred to as Autosomal dominant polycystic kidney disease
Teratogen
Definition
It is an agent extrinsic to the embryo or foetus that causes an increased risk of the following:
- Malformation-physical malformation
- Carcinogenesis- increased risk of cancer
- Mutagenesis-increased risk of genetic disease
- Altered function (e.g. Mental retardation)
- Growth deficiency (intrauterine growth retardation)
- Pregnancy wastage (i.e. Abortion or stillbirth)
- Teratogens may produce no effect at all in exposed pregnancies; only the most potent human teratogens typically affect 20 to
70% of exposed foetuses
Classes of teratogenic agents
1. Microbiological
a. Virus:-rubella
b. Bacteria:-syphilis
c. Parasites:-toxoplasmosis
2. Chemical drugs, smoking, alcohol
3. Physical Irradiation
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Terminology 2010
3. Genetic disorders
Genetic disorder
Introduction
There are more than 1000 known Mendelian disorders, which may be either dominant or recessive and may involve either
autosomal or sex chromosomes
Autosomal disorders
Both sex are equally affected
1. Dominant
a. Expression may be variable from one individual to another (expressivity).
b. Affected individual will produce offspring who are either normal or affected, in a 1:1 ratio
c. Affected individual either has an affected parent or represents a new mutation
d. Obstetric presentation-these disorders confront the obstetrician in several ways:
i. Affected parent:-50% risk
ii. Previously affected child born to unaffected parents means that the child represents a new mutation:-no increase in
recurrent risk
e. Examples:-Achondroplasia, Osteogenesis Imperfecta (type I, II, IV,V), Marfan syndrome, Neurofibromatosis (Type I),
Huntingtons disease, Polycystic Kidneys
2. Recessive
a. Both parents of affected infant must be carriers
b. Offspring of carrier parents will be normal, carriers, or affected in 1:2:1 ratio
c. Siblings may be affected, but other affected relatives are uncommon unless there is consanguinity in the pedigree
d. Example:-thalassemia, sickle cell disease, cystic fibrosis.
X-linked disorders
No father-to-son transmission
1. Dominant
a.
Males and females may both be affected
b.
An affected male will have all normal sons and all daughters will be affected
c.
Offspring of an affected female will be normal or affected, in a 1:1 ratio
d.
Examples:-Vitamin D-resistant rickets
2. Recessive
a.
Only males are affected (there is the possibility of a rare homozygous female)
b.
An affected male will have all normal sons, and all his daughters will be carriers
c.
Examples:-G6PD deficiency, Haemophilia, Duchenne's muscular dystrophy, Fragile X syndrome.
Haemophilia
Introduction
A group of X-linked recessive hereditary disorder of blood coagulation
Subdivided into Haemophilia A and Haemophilia B
Pathology
1. Haemophilia A
a. Caused by a reduced amount or activity of factor VIII
b. Two-thirds of the cases are inherited as a X-linked recessive condition, and the remaining cases are resulted from
spontaneous mutations and hence do not have a family history
c. The gene for factor VIII is located at Xq2.8
d. Genetic defects include deletions and point mutations (CGA to TGA)
2. Haemophilia B (Christmas diseae)
a. Low Factor IX
b. Inheritance and clinical features are same as Hemophilia A
c. The gene for factor IX is located at Xq2.6
d. Incidence is one-fifth that of Hemophilia A (1:10000 for Haemophilia A and 1:50000 for Haemophilia B)
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Terminology 2010
Carrier detection
1. Haemophilia A
a. By positive family history
b. Laboratory tests:
i. Factor VIII < 50%
ii. Factor VIIIc/VWF < 0.7
c. Genetic analysis:-gene tracking or identification of direct genetic lesions, e.g. RFLP
2. Haemophilia B
a. By positive family history
b. Genetic analysis:-RFLP
Prenatal diagnosis
1. Sex determination
a. Haemophilia is ruled out if foetus is a female
b. By ultrasound (USG) examination of foetal genitalia
c. Foetal sex may not be identified by USG until in second trimester
2. Genetic study
a. Foetal cells are obtained by chorionic villous sampling (CVS) in first trimester or amniocentesis in second trimester
b. Gene tracking by RFLP or VNTR with extended family members
c. Direct probing for known genetic lesions by PCR, SB techniques, etc. (mutations or deletions)
3. Clotting factor assay More than 18 weeks' gestation, foetal blood can be obtained by cordocentesis can for factor VIII assay.
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Terminology 2010
d.
e.
2.
genotype
features
+-thalassaemia
Asymptomatic with low or near normal MCV
0-thalassaemia
Asymptomatic with low MCV
-SEA
-thalassaemia
3
Hb H (4)
Anaemiabut viable, low MCV
4
Hb Bart's (4)
Hydrops foetalis, non-viable
Depends on the pattern and number of gene deletion of parents, the newborn has a chance of acquiring major
(homozygous) alpha-thalassemia ranging from zero to 25%.
In Hong Kong, the -SEA carrier rate is 4.5%. The chance of getting Hb Barts is 25% for an - couple.
Beta-thalassemia
a. 3.4% are carriers in Hong Kong.
b. A normal human has 1 pairs of beta genes. Beta-thalaessemia is due to gene mutation, which results in absence (0) or
reduced beta globin chain synthesis (+), with a relative excess of alpha chains. The end result is haemolysis similar to
that in alpha-thalassemia.
c. Heterozygous carriers are asymptomatic with low MCV and increased HBA2, while homozygous patients suffer from
anaemia requiring regular blood transfusions.
d. If both parents are carriers of beta-thalassemia, the newborn has a 1 in 4 chance of acquiring major (homozygous)
beta-thalassemia.
e. As foetal haemoglobin synthesis does not require beta component, the disease does not reveal until about 6th month of
neonatal life when haemoglobin synthesis switches from gamma chain to beta chain
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Prenatal diagnosis
1. Alpha-thalassemia
Hb Bart's disease can be diagnosed by following ways:a. Ultrasound
i. Look for signs of hydrops foetalis including thickened placenta, cardiomegaly, hydrothorax, ascites and skin edema
ii. The advantages are non-invasive and sensitive
iii. Disadvantage is that the onset of hydrops varies and may not be diagnosed until in second trimester
b. Genetic study
i. Look for presence of alpha gene in foetal cells
ii. Foetal cells are obtained by chorionic villus sampling (CVS) or amniocentesis
iii. The advantages are accurate and early diagnosis is possible with CVS
iv. The disadvantage is invasive and risk of foetal loss
c. Haemoglobin study
i. Look for foetal anaemia and haemoglobin pattern in foetal red blood cells
ii. Foetal red blood cells are obtained by cordocentesis
iii. Advantages are that the diagnosis is accurate and quick
iv. Disadvantages are that cordocentesis is invasive and difficult to perform before 16 weeks
v. It is usually reserved for confirmation of diagnosis when hydrops foetalis has already been present, in which case
quick result is required to guide the subsequent management
2. Beta-thalassemia` As beta-thalassemia is not revealed during foetal life, the only method of diagnosis is by genetic study
3. In conclusion,
a.
- couple CVS, amniocentesis and serial USG
b.
- couple DNA studies of couple DNA
c.
- couple Study partner for mutation as 7% of them may have trait. Manage as - couple if present.
Other Antepartum Management
Women who are carriers of thalassemia should be given folate 5mg once daily and obimin 1 Tab once daily as the demand of the
vitamin is increased during pregnancy. Consider transfusion if Hb < 8g/dL.
Discussion/Something to Consider
If on haemoglobin pattern analysis, one of the couple is found to be an alpha-thalassemia carrier while the other is a beta carrier,
what would be the prenatal counselling and diagnosis?
Rhesus
Rhesus blood group system consists of C, D, E antigens. The genes coded for these antigens are inherited as autosomal dominance,
i.e. the phenotype of DD and Dd is D positive, while dd is D negative. Among thee three rhesus antigens, rhesus D
iso-immunisation is the most common and also most severe type. 99% of Hong Kong Chinese are Rhesus D positive while 85%
Caucasian are D positive.
Rhesus D iso-immunisation
Introduction
Rhesus D iso-immunisation was a common foetal haemolytic disease in the Caucasian population resulting in high foetal morbidy
and mortality. It has now been under control with effective prophylactic therapy.
Pathogenesis
When the mother is rhesus D negative but the foetus is rhesus D positive, the mother may be sensitized when the foetal red cells
enter the maternal circulation. This can occur during labour, abortion, antepartum haemorrhage, or some obstetric procedures such
as chorionic villus sampling. The sensitized mother will then develop IgM against the rhesus antigen. Subsequent sensitisation
will trigger the synthesis of IgG. While the IgM molecules are too big to cross the placenta, IgG can do so, and attack the foetal
red cells, resulting in foetal haemolytic anaemia. In severe case, hydrops foetalis develops.
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Discussion/Something to Consider
Can you explain why rhesus D iso-immunisation is more commonly affect the subsequent pregnancies than the first one?
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Advantages
1. Accurate and sensitive
2. Can be done in the first trimester (10 to 13 weeks) so that intervention such as termination of pregnancy for abnormal cases
can be performed earlier during when the operative risk is lower
3. Results can be obtained in shorter time.
Disadvantages
1. Foetal loss rate is slightly higher when compared to amniocentesis
2. Rate of mosaicism is slightly higher among trophoblastic cells, and the karyotype of trophoblasts may not reflect the actual
karyotype of the foetus
Cordocentesis
What is cordocentesis?
It is an invasive procedure in which the umbilical cord is punctured in utero. It is indicated when foetal blood sampling is required
for foetal diagnosis, or transfusion of blood and drugs are required for foetal therapy.
Indications
1. Diagnostic purpose:a. Foetal white cells for karyotyping
It is a much quicker method for foetal karyotyping than amniocentesis and chorionic villi sampling. A quick diagnosis is
particularly required in highly suspected cases, or if time to decide for termination of pregnancy is limited before 24
week of gestation.
b. Foetal haemoglobin and haemoglobin pattern To assess foetal anaemia, and confirm Haemoglobin Bart's disease
(alpha-thalassemia major)
c. Foetal blood for other genetic diagnosis
d. Assessment of foetal well-being To assess blood gas value (rarely done)
2. Therapeutic purpose:For blood transfusion, which is the most common therapeutic indication. Foetal anaemia resulted from Rhesus
iso-immunisation, parvovirus infection
Risk
It is associated with 2% foetal loss rate. It may cause foetal bleeding, tamponade of umbilical cord due to haematoma formation.
For all of the above procedures, Rhesus status must be known and anti-D prophylaxis is indicated if mother is Rhesus
negative while the foetus is Rhesus positive.
Genetic counselling
Definition
The process whereby patients or relatives at risk of a disorder that may be hereditary are advised of:1. The consequences of the disorder,
2. The probability of developing and transmitting it, and
3. The ways in which this may be prevented or ameliorated.
The risks of having a child with a genetic disorder or congenital malformations are estimated, and the parents are assisted in
making a decision regarding contraception, sterilization, adoption, artificial insemination, carrier detection, referrals to agencies
concerned with handicapped children, prenatal diagnosis and options regarding pregnancy termination.
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Ultrasound (Obstetrics)
Two ways to perform obstetric USG
1. Transabdominal (TAS)
2. Transvaginal (TVS)
Advantages of TVS over TAS
1. As TVS probe is closer to pelvic organs, requirement for penetration is lower, allowing higher frequency of ultrasound wave
to be used. The result is a better resolution of images
2. Full bladder is not required during TVS
Advantages of TAS over TVS
1. Because of the limited penetration of TVS, TVS may not be able to detect organs that are beyond the pelvis, such as
pregnancy beyond 1st trimester, and a large pelvic tumour which has been displaced up to the lower abdominal cavity
2. Some patients may feel discomfort towards vaginal examination
Three Targets in obstetric USG
1. Foetus
a.
Viability:-see viable
b.
Number of foetus
c.
Identify multiple pregnancy and determine chorioamnionicity
d.
Dating of pregnancySize and growth
e.
Common foetal USG parameters are crown-rump length, biparietal diameter, femur length, and abdominal
circumference
f.
Morphology
g.
Well-being monitoring assessed by Doppler studies of foetal arterial blood flow, biophysical profile and amniotic
fluid volume
2. Placenta and amniotic fluid placenta praevia, placental tumour, amniotic fluid volume etc
3. Uterus and adnexa co-existing fibroids, uterine anomaly, ovarian tumour
Four uses of USG in obstetric
1. Screening such as:
a. Screening of Down syndrome with nuchal translucency during first trimester
b. Routine dating scan
c. Routine morphology scan
2. Diagnosis of abortion, ectopic pregnancy, multiple pregnancy, foetal malformations, placenta praevia etc.
3. Monitoring foetal growth, foetal well-being
4. Assisting other invasive procedures such as chorionic villi sampling, amniocentesis and cordocentesis
Role of USG in modern obstetrics
1. Definite Various diagnostic roles
2. Limited amniotic fluid volume assessment, estimation of foetal weight, diagnosis of IUGR, 1st trimester screening of Down
syndrome
3. Controversial Routine 18-22 week USG scan (see below)
Indications of USG during 1st trimester
1. Confirm viability of pregnancy
2. Date gestational age (by crown-rump length)
3. Confirm the location of pregnancy (exclude ectopic pregnancy)
4. Diagnose multiple pregnancy
5. Diagnose abnormal uterine or ovarian tumour / pathology
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Doppler effect
Doppler Effect and use in medicine
Doppler effect is a physical principle named after Doppler, Christian Johann, an Austrian physicist and mathematician who first
discovered in 1842. It is an 'apparent' change in the frequency of waves, as of light or sound (including ultrasound), occurring
when the source and observer are in motion relative to each other. The frequency increases when the source and observer
approach each other, and decreases when they move apart. It can therefore, be used to estimate the velocity of the moving object
by measuring the changes of frequency of waves. In medicine, human blood flow can be examined by applying ultrasound waves
which are then reflected back by the moving red blood cells in the circulation, and analysed with electronic means. See Doppler
studies for application in Obstetrics.
Doppler studies
Doppler studies of blood flow in medicine
Using the principle of Doppler effect, the blood flow in human circulation can be assessed with ultrasound. The changes in
frequency of reflected waves are analysed and displayed as a pattern of waveforms across time. Various ratios using values at the
systolic and the diastolic phase of blood flow are calculated to reflect the degree of blood flow:A/B ratio (or S/D ratio) = systolic/diastolic
Pulsatity index
Resistance index
Ratios rather than the actual velocity are calculated because the calculation of the later required the knowledge of the angle
between the path of the wave and the path of the moving object, which is not possible in practice. This factor can be
eliminated using the ratios.
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Asymmetric
a. Slowing or arrest of foetal abdominal circumference only
b. Supply of nutrients to the foetus is inadequate to support growth
c. Usually presents in later pregnancy when foetal needs are increasing
d. The vital organs are protected and there is sparing of head growth initially. Therefore it appears 'asymmetric', with the
growth of the abdomen more affected than that of the head
e. Mainly due to maternal causes, e.g. placental insufficiency
3.
Remark
a. Differentiation of symmetric and asymmetric growth retardation is not always clear cut
b. Some causes will lead to both symmetric and asymmetric pattern, depending on the onset of problem:-e.g. Maternal
malnutrition may result in symmetric growth retardation if the onset of the problem is in early pregnancy, but may lead to
asymmetric pattern if malnutrition only occurs in the late pregnancy
c. The head growth will eventually be affected in the late stage of asymmetric growth retardation.
d. Some disorders may cause asymmetry of growth but is not actually growth retarded:-e.g. Hypochrondroplasia
Diagnosis
1. Rule out date problem and constitutionally small baby.
2. Clinical suspicion from inappropriate small fundal height.
3. Ultrasound diagnosis with small foetal abdominal circumference (AC) (below 3rd centile), or slowing or arrest growth of AC.
4. The biparietal diameter and femur length may also be small. There may also be signs of foetal compromise such as
oligohydramnios.
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Macrosomia
Definition
There is no universal definition for macrosomia. Some define it by the body weight at or more than 4.0 kg or 4.2 kg, while some
define it by body weight more than 97% for the gestation.
Incidence
About 3% of newborns in Hong Kong are at or above 4.0 kg
Causes
In majority of cases no specific cause can be identified. It is associated with:
Postterm
Maternal diabetes mellitus, gestational or established
Rarely congenital syndromes
Risks
1. Maternal risks
a. Higher risk of operative delivery including caesarean section and instrumental delivery
b. Higher risk of birth canal injury, such as perineal tear, particularly when shoulder dystocia occurs.
2. Foetal risks
a. Higher risk of shoulder dystocia and related birth injury and birth asphyxia, particularly in diabetic patients
b. Foetal risks associated with postterm and poorly controlled maternal diabetes mellitus
Antepartum management
1. Suspect macrosomia when the uterus is large for date. Ultrasound foetal parameters (biparietal diameter, abdominal
circumference, and femur length) are larger than normal. Foetal weight can be estimated from a formula using the above
parameters.
2. Screen for gestational diabetes mellitus and treat accordingly
3. Counsel for risk of macrosomia and mode of delivery. Consider caesarean section if the estimated foetal weight is 4kg
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Crown-rump length
Definition
Crown-rump length is defined as the distance between the topmost part of the foetal head and the buttock, and is the single most
important parameter of foetal size in the first trimester.
Abdominal circumference
Definition
Foetal abdominal circumference (AC) is one of the commonest parameters for size and growth. It reflects the liver size and
volume of subcutaneous fat. It is the most sensitive indicator of intrauterine growth restriction (IUGR).
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Biparietal diameter
Definition
Biparietal diameter (BPD) is the longest distance between the two parietal eminences. It reflects the brain growth, and is one of
the commonest parameters of foetal size and growth. It is also the greatest presenting diameter in vertex presentation. The average
size of BPD in a term foetus is 9.5cm.
Measuring biparietal diameter with USG
1. The foetal head should be in lateral position
2. An accurate plane with the following landmarks is identified:
a. The midline falx
b. The thalami are symmetrically positioned on either side of the falx
c. Visualization of the septum pellucidum at one third of the fronto-occipital distance.
3. The measurement is made between the outer plate of one parietal eminence and the inner plate of the other, and is
perpendicular to the midline falx.
Uses of biparietal diameter measurement
1. For dating in the second trimester
2. For monitoring of foetal growth
3. For estimation of foetal weight
Factors affecting the biparietal diameter
1. Dolicocephaly
a. It is a condition is which the foetal skull is moulded and compressed laterally, so that the fronto-occiputal length is
elongated and the BPD is shortened. However, the head circumference should not be changed.
b. It is a normal condition and is commonly seen in breech presentation and transverse lie.
2. IUGR
BPD is the last parameter to be affected in case of asymmetric IUGR because of brain sparing effect. However, it can be
affected early in symmetric IUGR.
3. Brain abnormalities Hydrocephaly and Microcephaly
4. Skull bone abnormalities Thanatophoric dwarfism
Femur length
Definition
Foetal femur length is one of the commonly used parameters of foetal size and growth. It is defined as the distance between the
ends of metaphysis and can be measured with ultrasound. It reflects the crown-heel length (longitudinal growth).
Measuring femur length
1. The femur image is at an angle of less than 30 degrees to the horizontal.
2. Two blunted ends of the femur are clearly visualised.
3. The extension to the greater trochanter and the head of femur is not included.
Uses of femur length measurement
1. For dating in the second trimester.
2. For monitoring of intrauterine growth.
3. For estimation of foetal weight.
Factors affecting the femur length
1. Intrauterine growth retardation (IUGR) It is affected early in symmetric IUGR but late in asymmetric IUGR.
2. Down syndrome In general foetuses with Down syndrome have a shorter femur. Femur length was once suggested as a
screening test for Down syndrome, but was found to be less effective.
3. Congenital dwarfism n various bone disorders are associated with short long bones including thanatophoric dwarfism.
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7. Amniotic fluid
Amniotic fluid
Definition
Also called 'liquor', is the fluid normally inside the amniotic cavity. It is foetal urine.
Volume
Normal range varies from 300ml to 1500ml
Normal range depends on gestation, with the peak at 34 to 36 weeks
Composition
1. Electrolytes
2. pH:-slightly alkaline, changes amniostrix from orange to blue, a test for rupture of membranes
3. Foetal cells:-amniocytes can be collected with amniocentesis and cultured for foetal karyotyping
Production and removal
1. Production
a. Foetal urine
i. The major source of liquor
ii. Urine production starts from 12 week
iii. Anhydramnios in case of absent foetal kidneys or infantile type of polycystic kidneys
b. Foetal lung fluid Constitutes small portion of liquor production as most of the fluid is swallowed by the foetus
2. Removal
a. Foetal swallowing and absorption via GI tract
Polyhydramnios when there is pathology affecting the mechanism such as anencephaly, esophageal atresia and duodenal
atresia.
b. Transmembranous and intramembranous:-account for small percentage of amniotic fluid circulation.
How is amniotic fluid volume measured?
1. Subjective method
Relative amount of echo-free fluid areas are subjectively compared with the space occupied by the foetus and placenta
2. Greatest pocket method
a. The vertical length of the deepest pocket of liquor is measured
b. When it is less than 1cm, oligohydramnios is diagnosed; when more than 8cm, polyhydramnios is diagnosed
3. Amniotic fluid index The most common method used
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Oligohydramnios
Definition
Oligohydramnios is an inadequate volume of amniotic fluid
Anhydramnios is the complete absence of amniotic fluid.
Causes
1. Leaking of amniotic fluid after rupture of membranes
a. The most common cause of oligohydramnios
b. however, the amniotic fluid volume may still appear normal after rupture of membranes if the leaked volume is not much
2. Foetal malformations resulting in decreased production of urine:
a. Bilateral renal agenesis (Potter's syndrome) no functional foetal kidneys and therefore completely no foetal urine
production and anhydramnios
b. Infantile type of polycystic kidneys
i. Dysgenesis of kidneys which become non-functional
ii. Autosomal recessive inheritance
c. Posterior urethral valve
i. Urine production is present but excretion is impaired because of urethral obstruction
ii. Bladder is therefore distended and there is secondary dilated renal pelvis. Renal function may be eventually impaired
3. Foetal compromise resulting in decrease production:
Intrauterine hypoxia or growth retardation (IUGR) Renal blood flow decreases and hence the urine production
Foetal Risks
Depends on underlying causes and time of occurrence:
1. Rupture of membranes:-intrauterine infection, preterm labour, cord prolapse
2. Foetal malformations:-may not be viable such as Potter's syndrome and infantile type of polycystic kidneys
3. Foetal compromise:-intrauterine death
4. Pulmonary hypoplasia, when severe oligohydramnios occurs before 20 weeks of gestation during when development of lung
is critical
5. Postural deformities:-various degree of limbs and facial deformities
Diagnosis
1. Clinically, the uterus small for date and foetal parts can be easily felt
2. Ultrasonical:-Decreased amniotic fluid volume demonstrated e.g. by amniotic fluid index measurement
a. AFI < 8cm or Greatest pocket <2cm
b. Anhydramnios if complete absence of liquor
Protocol, as of 15 January 2008
1. Antenatal Management
a. Investigate for the underlying cause:
i. Rule out rupture of membranes from history and physical examination.
ii. Rule out foetal growth restriction
iii. Morphology scan for abnormalities of foetal kidneys and bladder in case of anhydramnios
iv. Assessment of foetal growth and well-being
b. For isolated primary oligohyramnios:-Monitor foetal growth, liquor volume and umbilical arterial flow bi-weekly
2. Intrapartum Management of isolated oligohydramnios
a. Aim at delivery at 38 weeks
b. Aim at vaginal delivery if there is no other contra-indications
c. Induction of labour with PGE2 can be considered in antenatal ward if there is no other signs of foetal compromise
d. Consider early delivery if case of foetal compromise
3. Treatment depends on the underlying causes:
a. Termination of pregnancy for lethal malformations
b. Amnioinfusion to replenish amniotic fluid to avoid pulmonary hypoplasia and postural deformities.
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Oligohydramnios sequence
The oligohydramnios sequence is a set of related conditions resulting from marked decreased in amniotic fluid. This typically
results from bilateral renal agenesis (34%), or chronic leakage of fluid. Other conditions such as bilateral multicystic renal
dysplasia (34%), unilateral renal agenesis and contralateral multicystic renal dysplasia (9%), renal tubular dysgenesis, autosomal
recessive (infantile) polycystic disease, non-functioning but morphologically normal renal tracts (3%), abherrant placental
implantation (on a uterine septum for instance) can lead to the same set of findings. 50% of these foetuses have anomalies that are
not part of the oligohydramnios sequence. In the oligohydramnios sequence, the decrease of fluid causes lung hypoplasia and
foetal compression. The foetal compression results in abnormal limb positions with dislocations and an abnormal face (flat with
low set ears). After delivery these newborn die of pulmonary insufficiency (via pneumothoraces).
Polyhydramnios
Definition
It is an excess of amniotic fluid, in contrast to oligohydramnios where there is a decrease in amniotic fluid (Norm: 500-1500 ml).
Ultrasound would reveal a Single packet > 8cm or AFI >2 standard deviation on chart.
Causes
It is related to the increase in production or decrease in removal of the amniotic fluid. In one-third of cases the cause is idiopathic,
but some are due to foetal, maternal or placental disorders:
1. Foetal causes
a. Anencephaly
b. Oesophgeal atresia, duodenal atresia
c. Gastroschisis and omphalocele
d. Foetal hydrops
2. Maternal causes poorly controlled diabetes
3. Placental causes rarely due to placental tumour such as choriangioma
Risks
1. Foetal
a. Preterm labour
b. Unstable lie
c. Premature rupture of membranes and cord prolapse
d. Foetal abnormalities leading to polyhydramnios
e. Cord prolapse
2. Maternal
a. Discomforts secondary to pressure effects
b. Dyspnea, indigestion, abdominal pain, edema and varicose veins
c. High risk of operative delivery
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Differential diagnosis
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Amnioinfusion
What is amnioinfusion?
Amnioinfusion is a procedure by which normal saline is infused into the amniotic cavity. It can be done transcervically using an
intrauterine catheter during intrapartum period, or abdominally during antepartum period.
Indication
1. Intrapartum:
a. Meconium stained liquor (MSL)
Heavily meconium stained liquor increases the risk of meconium aspiration syndrome. The aim of amnioinfusion is to
dilute the MSL and hence reduce the risk.
b. Umbilical cord compression
Cord compression may occur during labour. It may result in variable decelerations of foetal heart rate, particularly
when the liquor volume is reduced. It has been suggested that amnioinfusion may help to prevent the event. However,
no control trials have yet proven its role in preventing intrapartum foetal distress.
2. Antepartum - Severe oligohydramnios
a. For diagnostic purpose, Ultrasound images are suboptimal as transmission of ultrasound wave is poor in case of
oligohydramnios. Replenishment of liquor helps to improve ultrasound imaging and allow better assessment of foetal
morphology that may be abnormal in case of severe oligohydramnios
b. For therapeutic purpose, Replenishment of liquor may help to reduce the complications of oligohydramnios such as
postural deformities or pulmonary hypoplasia. In order to prevent pulmonary hypoplasia, the procedure must be
performed before mid-gestation because it is the critical period of bronchial and alveolar differentiation.
Protocol, as of 22 June 2002
1. Insert intrauterine catheter under aseptic technique.
2. Infuse 1L of normal saline at room temperature (rate:-10-15 ml per minute).
3. Repeat every 4 hours until the second stage of labour.
Amnioreduction
What is amnioreduction?
It is a procedure by which excessive amniotic fluid is drained, usually via a needle inserted abdominally.
What are the indications?
1. Severe polyhydramnios
When the uterus is over distended, there may be maternal discomfort and an increased risk of preterm labour and cord
prolapse. Amnioreduction would be required to relieve pressure symptoms. To avoid cord prolapsed during rupture of
membranes in a case with severe polyhydramnios going into labour; reduction of the liquor volume abdominally beforehand
is also suggested. The role of amnioreduction in prevention of preterm labour is not well-defined.
2. Twin-twin transfusion syndrome
As the recipient twin is polyhydramnic, repeated amnioreduction on the recipient may help to improve the prognosis of the
disease and prolong the pregnancy.
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8. Foetal well-being
Foetal well-being
Definition
1. Foetal compromise:
a. Poorly defined
b. Usually means conditions in which the normal growth and neurological development are not optimal
c. Points to a relatively chronic problem, distinguished from foetal distress
2. Foetal distress:
a. Also poorly defined
b. Usually means a acute hypoxic state of foetus that may result in foetal damage or death if it is not reversed or the foetus
is not delivered urgently
3. Ultimately, foetal compromise can lead to distress
Physiological changes associated with foetal compromise
Sequential changes occur when the foetus is undergoing chronic hypoxia and conservation of oxygen and energy for foetal brain
will occur in expense of peripheral organs.
1. Redistribution of blood flow Increase cerebral blood flow and decrease peripheral blood flow
2. Growth discrimination
a. Depletion of storage of liver glycogen, reflected by slowing down of growth of abdominal circumference
b. Slowing down of growth of femur
c. Growth of brain, reflected by the biparietal diameter maintained until at the very late stage
3. Further decrease in peripheral blood flow Decrease in renal blood flow, resulting in reduction of foetal urine, and hence
liquor volume (oligohydramnios)
4. Conservation of energy and oxygen
a. Foetal movements decrease
b. Foetal breathing movements decrease
c. Foetal tones decrease
5. Anaerobic metabolism
a. Metabolic acidosis, resulting in abnormal cardiac function
b. Abnormal heart rate regulation:-decreased baseline variability, late decelerations and bradycardia, as shown in
cardiotocogram
6. Ultimate outcome if not treated Foetal death
How to assess foetal well-being
1. Foetal movements
2. Non-stress test or contraction stress test using cardiotocogram
3. Liquor volume assessment (see amniotic fluid and amniotic fluid index)
4. Biophysical profile
5. Doppler studies of foetal blood flow
The most commonly used are cardiotocogram, amniotic fluid index, Doppler studies
Management
1. Aim is to maximize the chance of survival of the foetus
2. Balance the risk of continuing pregnancy and risk of termination of pregnancy which would usually mean a preterm delivery
3. Decide the time and mode of delivery, determining factors are
a. Degree of foetal compromise
b. Gestation age
i. When there are signs of foetal distress such as abnormal non-stress test:-immediate delivery
ii. When there are signs of foetal compromise but the foetus is not in acute danger, and the foetus is immature:-close
monitoring of foetal well-being
iii. When there are signs of foetal compromise and the foetus is mature, delivery.
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Biophysical profile
It is one of the methods to assess foetal well-being during antepartum period, using the combination of ultrasound and electronic
foetal heart monitoring. It consists of 5 parameters:
Parameters
Heart reactivity
Amniotic fluid volume
Tone
Movement
Breathing movements
1.
2.
Assessment
2 accelerations of 15bpm for 15s in 40 min
A pocket 1cm in 2 perpendicular planes
1 episode of limb movement from flexion to extension then back to flexion
3 gross body movements in 30 min
Sustained foetal breathing movements 30s in 30 min
Foetal movement
Counting of foetal movements
1. A daily count of perceived foetal movements from 28 weeks' gestation is a simple and inexpensive routine screening device
for monitoring of foetal well-being
2. Advice should be sought if fewer than 10 movements are perceived within 12 hours or if the mother feels that the baby is not
moving
3. Other tests of foetal welfare such as foetal cardiotocogram can then be applied
Advantages
1. Simple, safe and inexpensive
2. Can be initiated by mother herself at home
3. No sophisticated equipment is required
Limitations
1. A large number of foetal movements may not be perceived
2. There are great variations in the number of foetal movements from day to day in individual women and from woman to
woman
3. The sensitivity and specificity of the method are low
4. One randomized trial suggests a clear benefit, but another does not
5. Less than 1/1000 women might benefit from formal foetal movement counting, using later foetal death as an outcome
6. Formal counting provokes anxiety in about 25% of women. Another 50% are reassured by it.
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9. Multiple pregnancy
Multiple pregnancy
Incidence
1% of all pregnancies
Most are twin pregnancy (10-15/1000 incidence for twin; 1-4/1000 incidence for triplet)
What medical students should know?
For medical students, they should know twin pregnancy. They will not be examined on higher order pregnancy except twin, but
they should understand and apply the principles of twin pregnancy in the management of other multiple pregnancy.
Twin pregnancy
Types of twin pregnancy
Twin pregnancyis classified according to:
1. Zygosity Monozygotic and Dizygotic. (M:D = 1:3)
a.
Monozygotic: 20% of twin pregnancy (3-4/1000), constant across whole world.
b.
Dizygotic: 80% of twin pregnancy, varies among different races. (West African > Japan)
2. Chorioamnionicity
a. All dizygotic twins are dichorionic diamniotic
b. Depends on the time of cleavage, monozygotic twins may be dichorionic diamniotic, monochorionic diamniotic,
monochorionic monoamniotic
Incidence
1% of all pregnancies incidence increases with positive family history, use of ovulation induction, or assisted reproductive
technology (ART). Thus in Hong Kong, the rate of multiple pregnancy increased recently.
Diagnosis of multiple pregnancies
1. History Multiple pregnancy must be suspected if the pregnancy is resulted from ovulation induction or assisted reproductive
technology
2. Physical Examination
a. Uterus large for date
b. More than 2 foetal poles palpable (late)
c. Foetal heart pulsations, which are of different rate (at least 15bpm), are heard simultaneously
3. Ultrasound
a. The only reliable method.
b. Confirm twin pregnancy
c. Also assess the zygosity and chorioamnionicity
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Antepartum management
1. Frequent visits:- from booking to week 28 once monthly; from week 28-36 biweekly.
2. Determination of chorioamnionicity It is best assessed with USG in the first or early second trimester as soon as possible.
3. Close maternal surveillances:a. Regular monitoring of blood pressure and urine protein to detect early pre-eclampsia
b. OGTT at 26 to 28 week to exclude gestational diabetes
4. Close foetal surveillances:a. Regular monitoring of foetal growth and liquor by USG, as fundal height cannot reflect the growth of individual twins.
b. It is important to detect discordant growth and liquor volume in monochorionic twins which is a sign of twin-twin
transfusion syndrome
c. Morphology scan at 20 week
5. Nutrition supplement Iron, folate and vitamins to prevent nutritional anaemia
6. Prevention of preterm labour At present no effective preventive measure
7. Time of delivery:a. Studies have shown that the foetal risks are higher when twin go beyond 38 week of gestation. This may relate to the
accelerated aging of placenta when compared to singleton pregnancy
b. Therefore, twin pregnancy should have induction of labour, or caesarean at 38 week
8. Mode of delivery:a. Vaginal delivery if the presenting twin is in cephalic presentation, otherwise for elective caesarean section
b. Caesarean section should also be performed (at 34 week or not later than 37 week) for monochorionic monoamniotic
twins pregnancy to avoid cord entanglement in late pregnancy or during labour
Intrapartum management
1. Foetal monitoring
During labour, both foetuses should be monitored with continuous cardiotogram. The first twin is monitored with a foetal
scalp electrode and the second one with external Doppler apparatus.
2. Pain relief epidural anaglesia is recommended.
3. Delivery of the second twin
a. After vaginal delivery of the first twin, the presentation of the second twin may remain high or altered; uterine
contractions are diminished (uterine inertia); cervix may begin to close. There may also be cord prolapse, diminished
placental function, abruptio placentae resulting in hypoxic injury.
b. USG may be helpful to assess the presentation; if not, perform ECV.
c. Oxytocin augmentation should be considered when uterine inertia occurs.
d. Membranes of the second twin should not be ruptured until the foetal head is well engaged.
e. When foetus remains high in presentation after 30 minutes or when there is foetal distress, operative delivery (including
caesarean section) should be considered.
4. Third stage
a.
Give syntometine.
b.
Oxytocvin infusion to prevent atony.
c.
Check placenta and membranes for chorioamnionicity.
Postpartum management
Prophylactic oxytocic to prevent postpartum haemorrhage. This includes a single bolus of oxytocin or syntometrine followed
by oxytocin infusion.
Discussion/Something to Consider
1. Ultrasound shows a discordant growth of a twin pregnancy at 20 week of gestation, what are the possible diagnoses and how
can we differentiate them?
2. A woman of age 37 has a twin pregnancy. She is at 10 weeks of gestation asking for prenatal diagnosis of Down syndrome.
How would you counsel her?
3. A woman with a twin pregnancy is found to have a twin died in utero at 28 week of gestation. How would you manage her?
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Terminology 2010
Chorioamnionicity
1.
Singleton pregnancy must be monochorionic monoamniotic (MCMA). However, chorioamnionicity may be multiple in case
of multiple pregnancy, depends on the zygosity and the time of division of the embryo. Take twin pregnancy as an example,
dizygotic twins must be dichorionic diamniotic (DCDA). Monozygotictwins may be DCDA, MCDA or MCMA depends on
the timing of cleavage as follow:
Time of Cleavage
Day 0 to 3
Day 4 to 8
Day 9 to 12
After day 12
Stage of embryo
Morula
Embryonic disk
Blasticyst
Foetus
Chorioamnionicity
DCDA
MCDA
MCMA
Conjoint twin
2.
Determination of chorioamnionicity is very important in management of twin pregnancy because the lower the chorionicity
and amnionicity, the higher is the foetal and maternal risks. Chorioamnionicity is most easily and accurately determined by
USG in the first trimester:
a. DCDA:-the twins are separated by a thick chorionic septum between the gestation sac.
b. MCDA:-each of the twins is contained inside a thin amniotic sac, which in turn, is contained in the same chorionic
membrane.
c. MCMA:-no membranes are seen between the twins
3.
During the second trimester, chorioamnionicity can also be accurately assessed:a. If they are of different sex, it must be dizygotic. The external genitalia can be determined with USG since early second
trimester
b. If the membrane septum is thick or there is lamda sign, it is DCDA, and the pregnancy can be dizygotic or monozygotic.
c. If there is no membrane septum between the twins, placenta must be MCMA, and the pregnancy must be monozygotic
d. If the membrane septum is thin or there is absence of lamda sign, it is MCDA, and the pregnancy must be monozygotic
Figure 29 Chorioamnionicity.
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Terminology 2010
Conjoint twin
Conjoint twins are a rare form of monochorionic monoamniotic twin pregnancy (see chorioamnionicity), resulted when the
splitting of the embryonic mass after day 12 of fertilisation. Conjoint twins are classified according to the dominant site of
interfoetal body part connection, into five major types:1. Thoracopagus (thorax, 30-40%)
2. Omphalopagus (abdomen, 25-30%)
3. Pygopagus (sacrum, 10-20%)
4. Ischiopagus (pelvis, 6-20%)
5. Craniopagus (head, 2-16%)
The prognosis of conjoint twins is in general poor, and depends on the site and extent of conjoining. Half of them are intrauterine
deaths and one-third of the remaining livebirths have severe defects for which surgery is not possible. Conjoint twins are
suspected under ultrasound, when both foetuses are always facing to each other with the same lie and presentation, with no
membranes separating them. Detail ultrasonic examination will identify the site of conjoining.
Twin-twin transfusion
What is Twin-twin transfusion?
Twin-twin transfusion is a disorder specific to monochorionic twin pregnancy. Normally there are vascular channels between the
twins through the placenta, and the blood flow between the twins is balanced. However, for some reasons that are still uncertain,
unbalanced blood flow sometimes occurs. Consequently, one twin becomes the donor while the other becomes the recipient of
blood.
The donor becomes anaemic, hypoxic and malnutrited, resulting in growth retardation and oligohydramnios. On the other hand,
the recipient becomes volume overload and with hyperviscosity of blood (increase in haematocrit). High-output heart failure
develops, and the foetus becomes hydropic with polyhdyramnios. This condition usually occurs during the second trimester. The
mortality is high without any intervention.
Prenatal diagnosis
Prenatal ultrasonography plays an important role in diagnosing twin-twin transfusion. There is discordance of growth and
oligohydramnios in the growth-deficient twin (donor twin) and polyhydramnios in the other (recipient twin). The bladder of the
donor twin may not been seen at all. Sometimes, the donar twin become a "struck twin" when he has no liquor at all and is
compressed against the uterine wall by the gestation sac of the recipient. The recipient twin may show features of hydrops foetalis
in the latter stage.
Treatment
The most popular treatments are repeated amnioreduction, and devascularisation of the anastomosis with laser.
The prognosis improves to 50 to 70%.
Lamda sign
It is an ultrasonic feature used to diagnose the chorioamnionicity of a twin pregnancy. The presence of a lamda sign suggests a
dichorionic diamniotic (DCDA) placenta. In a DCDA twin pregnancy, there is a thick septum consisting of two layers of amnion
and two layers of chorion between the gestational sacs. After 9 weeks of gestation, this septum becomes progressive thinner, but
remains thick at the base as a triangular tissue projection, which is called lamda sign.
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Terminology 2010
Maternal Medicine
1. Changes in pregnancy
Physiological changes in pregnancy
Why do we need to study the physiological changes?
1. Understand how human adapt to pregnancy
2. Some medical diseases may become worse during pregnancy, for examples:a. Valvular heart diseases, and
b. Diabetes mellitus.
3. Some physiological changes may mimic symptoms and signs of medical disorders, for examples:a. Palpitations, ejection murmur are common in normal pregnancy that may mimic heart disorders
b. Pregnant women often have physiological goitre
4. Some normal ranges may alter in pregnancy, for example, mild proteinuria of <0.3g per day is normal in pregnancy (<0.1g
per day in non-pregnant adult)
5. Some changes may alter the pharmacokinetics of drugs
What are the important physiological changes?
The changes are mediated by increased production of progesterone, oestrogens, hCG and hPL.
1. Cardiovascular system
a. Cardiac size increases by 12%
b. Stroke volume increases by 25 to 30%, reaches its maximum at 12 to 24 weeks of gestation
c. Cardiac output increases by 40% and reaches maximum at 20 to 24 weeks
d. Decrease in blood pressure and peripheral vascular resistance
e. Ejection systolic murmur
f. Normal S3 gallop
g. Reversible changes in the ST, T or Q waves in ECG due to the left and upward displacement of the heart
2.
Respiratory system
a.
Incfease in respiratory rate due to progesterone production.
b.
Functional residual capacity, residual volume, and expiratory reserve volume all decrease by 20%
c.
Dead space and tidal volume increase by 30 to 50%
d.
Marked increase in alveolar ventilation by 65%
e.
Minute ventilation increases by 50%
f.Oxygen consumption increases by 15 to 20%
g.
Alveolar CO2 decreases due to increased respiratory rate
3.
Glucose metabolism
a. During pregnancy, the production of various diabetogenic hormones including human placental lactogen, progesterone,
prolactin and cortisol are increased.
b. Their actions on glucose metabolism are counterbalanced by an increase in insulin concentrations which reaches almost
twice of non-pregnant levels.
c. The vast majority of pregnant women (96-98%) manage to maintain their blood glucose within normal limits, but the rest
of them fail to do so and become hyperglycemic (gestational diabetes).
4.
Thyroid gland
a. During the first trimester, human chorionic gonadotropin (which structurally mimics TSH) produced from the placenta
stimulates the secretion of thyroxine from the thyroid glands. The TSH level decreases. There may also be a transient
increase in free T4 level. These changes are associated with hyperemesis gravidarum
b. As the pregnancy goes on, the TSH and free T4 levels return to normal.
c. Total T4 increases as the level of thyroxine binding protein increases because of oestrogen stimulating effect on the liver
production of the binding protein.
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Terminology 2010
5.
Haematologic system
a. Increase in plasma volume up to 50% by term
b. Increase in blood volume up to 50% by term
c. Increase in RBC volume by 30% by term
d. Increase in WBC, mainly polymorphonuclear cells
e. Increase in platelet production
f. Increase in production of clotting factors, particularly factor I (fibrinogen) and III due to oestrogen stimulation.
g. Pegnant women are therefore more prone to develop thromboembolic diseases.
6.
Renal system
a. GFR increases by 50% and renal plasma flow increases by 25% to 50%
b. Relative decrease in serum creatinine due to:i. increased GFR
ii. Dila;tation of ureters from 10 weeks onward
iii. Secondary to progesterone effect, and
iv. Pressure effect, by uterine compression (right > left)
Discussion/Something to Consider
A liver function and a renal function test are performed in a pregnant woman. Is the result normal? why?
Result
Normal range
Na
140mmol/L
134-145mmol/L
K
3.5mmol/L
3.5-5.1mmol/L
Urea
2.5mmol/L
3.4-8.9mmol/L
Creatinine
40umol/L
44-107umol/L
Albumin
28g/L
36-48g/L
Bilirubin
3umol/L
0-15umol/L
ALT
30IU/L
<58IU/L
ALP
200IU/L
30-90IU/L
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Terminology 2010
Pharmacology in pregnancy
Effect of pregnancy on pharmacokinetic
1. Drug absorption form GI tract
a. reduction in gastrointestinal motility may increase absorption of some poorly soluble drugs such as digoxin, or decrease
absorption of some drugs that undergo metabolism in gut wall, such as chlorpromazine
b. vomiting in early pregnancy may reduce absorption of orally administrated drugs
2. Drug distribution
a. Increase of plasma volume and extracellular fluid volume may decrease the steady state concentration of drugs with a
small volume of distribution
b. Decrease in albumin concentration may alter the free fraction of protein-bound drugs
3. Drug elimination
a. increase renal blood flow and GFR increase renal excretion of polar drugs
b. increase in hepatic microsomal oxidase system induced by pregnancy increase the metabolism of certain drugs
particularly anticonvulsants
Effect of drug on foetus
1. Fertilisation and implantation
Mifepristone (RU486), an anti-progesterone that antagonize the endogenous progesterone effects on endometrium, is used as
an abortive agent
2. Organogenesis
a. Diethylstilboestrol (DES):-adenocarcinoma of vagina in teenage years
b. Androgens:-virilization, limb reduction, esophageal anomalies, cardiac defects
c. Tetracyclines:-inhibition of bone growth, discoloration of teeth
d. Anticonvulsants:-neural tube defects
e. Warfarin
3. Growth, development and physiology
a.
Anti-thyroid drugs cross placenta and may result in foetal and neonatal hypothyroidism
b.
Prostaglandin synthetase inhibitors can cause premature closure or the ductus arteriosus
c.
CNS depressants such as opiates cause neonatal respiratory depression
d.
Drugs with dependence potential such as opiates taken regularly during pregnancy can result in withdrawal symptoms
in the neonate
Drugs in breastfeeding
1. Most drugs enter breast milk to a greater or lesser extent but, because the concentration has been greatly reduced by
distribution throughout the mother's body, the amount of drug actually received by the breast-fed baby is usually clinical
insignificant
2. Drugs that can safely be given to breast-feeding mothers include:
a. Penicillins, cephalosporins
b. Theophylline, salbutamol by inhaler, prednisolone
c. Valproate, carbamazepine, phenytoin
d. Beta blockers, methyldopa, hydralazine
e. Warfarin, heparin
f. Tricyclic antidepressants
g. Haloperidol, chlorpromazine
3. Certain drugs achieve sufficient concentration in breast milk, and they are sufficiently potent that their use in breast feeding
mothers should be avoided
a. Sulphonamides, chloramphenical, isoniazid, tetracyclines
b. Narcotic analgesics
c. Benzodiazepines
d. Lithium
e. Phenindione
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Terminology 2010
Maternal medicine
What is maternal medicine
1.
Also called medical Obstetrics, is a subspecialty in Obstetrics.
2.
Study of physiological changes in pregnancy.
3.
Deals with medical diseases and complications of the mothers during pregnancy.
4.
Also handles other high risk pregnancies e.g. Surgical diseases.
5.
Team-care multi disciplinary approach (obstetricians, midwives, nurse specialists, paediatricians, physicians, surgeons,
anaesthetists, intensive care specialists.) Is important.
Three kinds of medical diseases
1. Medical diseases present before pregnancy (pre-existing) e.g. heart diseases, epilepsy
2. Medical diseases caused by pregnancy (pregnancy specific) e.g. pre-eclampsia, gestational diabetes mellitus
3. Medical diseases occurring for the first time in pregnancy which may be the predisposing factor (co-incidental).
How to study maternal medicine
1. Firstly, understand how a disease and its therapy (which are usually medication) affects the pregnancy (both the mother and
the baby), e.g. poorly controlled diabetes mellitus increases risks of foetal macrosomia, intrauterine death
2. Secondly, understand how a therapy (which are usually medication) affects the pregnancy (both the mother and the baby), e.g.
anti-convulsants increase foetal risk of neural tube defects
3. Conversely, how the pregnancy affects the disease, e.g. pregnancy is diabetogenic and control of diabetes mellitus may
require adjustment of insulin therapy. It is important to understand the physiological changes in pregnancy
4. Finally, how the pregnancy affects the treatment
Which medical diseases a medical student should know
1. Hypertensionin pregnancy
2. Diabetes mellitus
3. Heart diseases in pregnancy
4. Thromboembolic diseases
5. Thyroid disorders
6. Epilepsy
7. Appendicitis
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Terminology 2010
2. Diabetes mellitus
Diabetes mellitus
Introduction
Diabetes mellitus is one of the most common medical disorders in pregnancy. Pregnant women may have diabetes before
pregnancy (pre-existing), or develop glucose intolerance during pregnancy (gestational diabetes). In both conditions, the glucose
intolerance may be so severe that insulin control is required (insulin-dependent diabetes). During pregnancy, women require more
energy intake. On the other hand, as pregnancy is diabetogenic (see physiological changes in pregnancy), glucose control becomes
more difficult. Poor control of glucose level may result in various maternal and foetal complications. Nephropathy and retinopathy
is more severe during pregnancy.
Foetal Complications
1. Macrosomia
Hyperinsulinemia and hyperglycemia not only result in excessive growth but also an increase in fat deposition over
shoulder, resulting in high risk of shoulder dystocia, birth injuries and operative deliveries
2. Intrauterine growth retardation
IUGR is uncommon but can occur in severe chronic cases of diabetes with vasculopathy. Uteroplacental blood flow is
affected resulting in foetal growth restriction.
3. Foetal malformations
a. CVS-the most common system involved; VSD, ASD, TGA, situs inversus, hypolastic left ventricle
b. CNS:-anencephaly, encephalocele, holoprosencephaly
c. Others:-caudal regression syndrome, bowel atresia, etc
d. Teratogenicity is associated with poorly controlled diabetes during embryogenesis (first trimester).
e. The exact mechanism is unknown, maternal hyperglycemia, hyperketonemia and hypoglycemia have been suggested.
4. Intrauterine death
Sudden intrauterine death can be resulted from poor control of hyperglycemia, or secondary to IUGR. It was the major
cause of perinatal mortality in diabetic patients in the past, before the use of insulin.
Neonatal complications:
1. Hypoglycemia:-poor maternal glucose control can result in foetal beta-cell hyperplasia, leading to exaggerated insulin release
following delivery.
2. Respiratory distress syndrome:-hyperglycemia and hyperinsulinemia affect biosynthesis of pulmonary surfactant.
Maternal complications
1. Pre-eclampsia
2. High risk of operative deliveries
3. Pre-existing nephropathy and retinopathy may be worsen during pregnancy
Principles of management
1. Prepregnancy Pre-conception counselling is very important. Tight glucose control is emphasized to miminize risk of
teratogenicity. Complications such as nephropathy and retinopathy should be looked for.
2. Antenatal
a. Refer to dietitian for diet adjustment (30kcal/kg body weight) to provide adequate energy during pregnancy.
b. Hypoglycemic agents should be changed to insulin for better control.
c. Regular glucose monitoring H'trix (Fasting, Post-breakfast, lunch, supper), blood sugar series, multistix and HbA1c
d. Monitoring of maternal complications Blood pressure, urine albumin/creatinine ratio, RFT, refer to ophthalmologist.
e. Monitoring of foetal condition
i. Morphological assessment at around 20 weeks
ii. USG for growth and liquor volume when uterus is large for date every 4 weeks.
3. Intrapartum
a. Time of delivery While the pregnancies of well controlled cases can be continued till 40-41 weeks, poorly controlled
cases should have induction of labour earlier in 37 weeks to prevent sudden intrauterine death
b. Mode of delivery Pregnancy with macrosomic babies should be counselled for elective caesarean section
4. Postpartum Change to pre-pregnant diet and drug regime and discuss contraception
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Terminology 2010
Gestational diabetes
Definition
It is defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy.
The definition does not differentiate those pre-existing diabetes mellitus which are not picked up until the patient becomes
pregnant, from those genuine gestational in origin (due to exaggerated physiological changes in glucose metabolism).
The definition applies irrespective of whether or not insulin is used for treatment or the condition persists after pregnancy.
There have been controversies for long time in the subjects of gestational diabetes on the best method for screening, the diagnostic
criteria and the management of identified gestational diabetes.
Incidence
Total incidence 6.3% - (IGT 4.6%; GDM 1.5%; Pre-existing DM 0.2%)
Antenatal screening
1. Gestational glucose intolerance can be screened by various ways:
a. Presence of clinical risk factors:
i. In previous pregnancies:- history of gestational diabetes, macrosomia, unexplained stillbirth
ii. In current pregnancy:- persistent or significant glycosuria, macrosomia, maternal obesity, advanced maternal age
iii. Other risk factor:- positive family history of diabetes in first-degree relatives
b. Biochemical:- spot glucose level, fasting glucose level
3. A positive screening result should be followed by a diagnostic oral glucose tolerance test
Diagnosis
Oral glucose tolerance test
It is usually performed around 26 to 28 weeks of gestation when the pregnancy-induced diabetogenic effects are most
prominent. It may be performed earlier when there is clinical suspicion.
It is the only diagnostic test of gestational diabetes. However, the glucose load and the cut-off levels vary among centres. In
PWH, 50g glucose load is used. The fasting plasma level of more than 5.5mmol level, or the second hour level of more than
8 is diagnostic.
Complications
1. Foetal complications
a. Macrosomia, neonatal hypoglycemia, polycythaemia, hyperbilirubinaemia
b. Risk of congenital malformation is not increased unless the onset of gestational diabetes is at the first trimester
2. Maternal complications Increased risk of pre-eclampsia, operative deliveries (46.4%), and increased chance of development
of diabetes mellitus in future.
Management
The antenatal and intrapartum management is similar to that of pre-existing diabetes mellitus:
1. Maternal diabetes control
a. Refer DM nurse for education
b. Refer dietitian for diet control
c. Admit for blood sugar series after diet control for 3 days (admit soon if FG>7 or 2 hour >11, suspect pre-existing DM)
d. Insulin if poor control
2. Fetal Monitoring
Serial USG for fetal growth parameters and liquor volume
3. Post-Partum
a. Resume normal diet
b. Check Hstix at fasting and postprandial for 1 day
c. A 75g oral glucose tolerance test (WHO criteria) should be repeated 6 weeks postpartum to rule out pre-existing disease.
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Terminology 2010
2.
1st trimester
1500kcal/day
1500kcal/day
2nd trimester
1800kcal/day
2000kcal/day
Borderline
> 5 - 5.5
> 7 - 7.5
Abnormal
> 5.5
> 7.5
3.
4.
Terminology 2010
5.
Timing of delivery
a. GDM on diet with good control: await spontaneous labour and induction at 41 weeks gestation
b. GDM requiring insulin or pre-existing DM/IGT with normal H'sitx: consider induction at 40 weeks
c. GDM or pre-existing DM/IGT with poor glycaemic control and/or any complication: consider induction at 38 weeks or
earlier if indicated
6.
Mode of delivery
a. Discuss elective caesarean delivery if the EFW > 4 kg
b. Take precaution of shoulder dystocia if mother with a macrosomic fetus (AC > 97 centile) undergoes vaginal delivery:
c. Doctor standby at foetal head delivery
d. Mid-call doctor assess before instrumental delivery
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Terminology 2010
2.
Actrapid (unit/hr)
0
0
1
2
3
4
6
Action
/
/
/
/
Inform MO & consult endocrinologist
Inform MO & midcall 1,consult endocrinologist
Inform MO & midcall 1,consult endocrinologist
Remark:
a. Insulin should be given through a syringe pump.
b. Actrapid should be used and diluted with isomolar Haemaccel/gelofusin to a concentration of 1U per ml (49.5 ml
isomolar Haemaccel/gelofusin + 0.5 ml Actrapid).
3.
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Terminology 2010
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Terminology 2010
3. Preeclampsia
Hypertension in pregnancy
Definition of hypertension in pregnancy
1. Arterial diastolic pressure:
a. 110mmHg on any occasion, or
b. 90mmHg on 2 or more occasions at least 4 hours apart
2. Definition of proteinuria in pregnancy
a. Daily urine protein output of 300mg, or
b. Spot urine protein/creatine ratio of > 30mg/mmol
c. 2 clean-catch mid-stream or catheter specimens of urine collected at least 4 hours apart with
i. 1g albumin/l or2+ on reagent strip, or
ii. 0.3g albumin/l or >= 1+ on reagent strip if urine pH is <8 or specific gravity is < 1.030
Causes of hypertension during pregnancy
1. Transient elevation:- also called white-coat hypertension, related to stress and anxiety
2. Pregnancy induced hypertensive disorders:
a. It can be pregnancy induced hypertension, pre-eclampsia or eclampsia
b. This group of disorders may be superimposed with pre-existing hypertension
c. Hypertension induced by pregnancy almost always occurs after 20 week, except in rare cases such as molar pregnancy.
3. Pre-existing hypertension:
a. Also called chronic hypertension
b. Most are primary (or essential) but occasionally it may be secondary to:
i. Renal disorders such as lupus glomerunephritis
ii. Endocrine disorders such as phaemochromocytoma or cushing syndrome
iii. Vascular disorders such as co-arctation of aorta
c. the diagnosis of pre-existing hypertension is made usually because there is history before pregnancy, or the hypertension
is noted at the first in pregnancy, but before 20 week when pre-eclampsia is unlikely
4. Unclassified hypertension:
a. In some situation it may be difficult to differentiate whether the hypertension is due to pre-existing disease or induced by
pregnancy, therefore it is said to be unclassified
b. For example, when a patient comes to the first booking at 25 week of gestation, and is noted to have hypertension, we are
not certain whether it is pre-existing or pregnancy induced, as there is no record of the preceding blood pressure. It is
then belonged to unclassified group
c. Management of this group of patient depends on the clinical symptoms and signs, and may be treated as pre-eclampsia if
it progresses
Discussion/Something to Consider
1. How to differentiate transient hypertension from pre-eclampsia clinically?
2. When a patient comes to you at 28 weeks of gestation for the booking visit, and is noted to have blood pressure of 150/95.
What is your management?
Protocol, as of March 2006
1. Diagnostic criteria for hypertension in pregnancy
SBP 140 mm Hg
or
DBP 90 mm Hg on 2 occasions at 4 hours apart, or
SBP 160 mm Hg
or
DBP 110 mm Hg at any occasion
2. Diagnostic criteria for significant proteinuria in pregnancy
a. Urine protein 0.3 g/d (24-hour urine collection should always be used for the diagnosis of significant proteinuria unless
the clinical urgency dictates immediate delivery)
b. Spot urine Protein to creatinine ratio 30 mg/mmol which usually equivalent to > to 0.3 g proteinuria / 24 hours can be
used as an alternative
c. Urine albustix 2+ usually suggest significant proteinuria but should always be confirmed by 24 hour urine or spot urine
protein to creatinine ratio
d. Urinary tract infection should be excluded by MSU
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Terminology 2010
Preeclampsia
Introduction
It is a common disorder, peculiar to pregnancy, characterized by hypertension and proteinuria (see hypertension in pregnancy for
definition of hypertension and proteinuria). It is a multisystem disorder involving CNS, hepatorenal system, and coagulation. It
invariably progresses as pregnancy advances, and can only be cured by delivery.
Definition
1. Gestation onset after 20 weeks; and
2. Arterial pressure
a.
170/110 mmHg or more on any 1 occasion; or
b.
140/90 mmHg or more on 2 occasions at least 4 hours apart; and
3. Proteinuria
a.
300 mg or more in 24 hours; or
b.
Spot urine protein/creatinine ratio 30mg/mmol or more.
Incidence
6% in Caucasian
2% in Hong Kong Chinese
Risk factors (RR:-relative risk)
1. Pre-existing medical diseases
a.
Renal diseases (RR 20:1)
b.
Chronic hypertension (RR 10:1)
c.
Antiphospholipid syndrome (RR 10:1)
d.
Diabetes mellitus (RR 2:1)
2. History of
a.
Previous pre-eclampsia
b.
Pre-eclampsia in family (RR 5:1)
3. Pregnancy associated
a.
Twin pregnancy (RR 4:1)
b.
Nulliparity (RR 3:1)
c.
Maternal age < 15 or > 40 years
d.
Hydrop foetalis (Rhesus iso-immunisation, alpha-thalassaemia major)
e.
Pregnancy by a new partner
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Terminology 2010
Pathophysiology
The exact mechanism is unknown. It is characterized by:1. Generalized vasoconstriction, leading to hypertension and reduction in blood volume.
2. Widespread endothelial damage, leading to:a. Capillary leaking of protein and proteinuria
b. leaking of fluid to extravascular space resulting in peripheral edema and pulmonary edema, and reduction in
intravascular volume
These pathological changes probably start in the early second trimester as follow:
1. Stage 1:-starts before 20 weeks and causes no symptoms
a. Failure of trophoblastic invasion of spiral arterioles which normally results to vasodilatation of vessels walls
b. Placenta is perfused under high pressure because of the vasoconstriction effect
c. Local endothelial damage causes aggregation of platelets, fibrin and lipid-laden macrophages (acute atherosis) and
microthrombi formation. Spiral arterioles become further occluded
2. Stage 2:-Manifestation of disease
a. Ischaemic placenta releases an unknown but apparently blood-borne substance, which leads to widespread endothelial
cell damage, causing generalised vasoconstriction, increased vascular permeability, and clotting dysfunction
b. Because of the high resistance, the uteroplacental blood flow decreases, resulting in malnutrition and hypoxia of foetus
Clinical manifestation
1. Onset
a. At any time after 20 week, but most commonly in the third trimester near term.
b. In practice it seldom occurs before week 24.
2. Symptoms
a. Usually asymptomatic with detection of high blood pressure and proteinuria on routine check up
b. Minority would present with symptoms of impending eclampsia
c. Occasionally present with complications of PET such as convulsion and abruptio placentae
Symptoms of impending eclampsia
1.
Hypertension: arterial pressure 160 mmHg systolic or
110 mmHg diastolic on two occasions at least 6 hours
apart with the patient at bed rest
2.
Proteinuria: 5g in 24 hour urine collection or 3+ on
dipstick in at least two random clean catch samples at
least 4 hours apart
3.
Oliguria (500 ml in 24 hours)
4.
Cerebral signs: headache, papilloedema, blurred vision
or altered consciousness
5.
Hyper-reflexia and sustained ankle clonus
6.
Epigastric pain due to subcapsular haemorrhage
7.
Pulmonary oedema or cyanosis
8.
Thrombocytopenia
9.
Impaired liver function
10. Intrauterine growth restriction or fetal growth restriction
Comlications of PET
Maternal
1. DIC / HELLP syndrome (10-20%)
2. Pulmonary edema / aspiration (2-5%)
3. Liver failure or haemorrhage (<1%)
4. Acute renal failure (1-5%)
5. Eclampsia (<1%)
Foetal
1.
IUGR
2.
Preterm delivery
3.
Abruptio placentae
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Management
1. Principles
a. The disease can only be cured by delivery.
b. Aims to minimise risk of prematurity, and avoid maternal and foetal complications of pre-eclampsia
c. Depends on severity of disease and maturity of the pregnancy:
i. If the pregnancy is >34 weeks, deliver the pregnancy to prevent progression of the disease
ii. If the pregnancy is premature and disease is mild, try to prolong the pregnancy to reduce the risk of preterm delivery
iii. If maternal and foetal complications already occur, should consider delivery regardless of maturity, or it will end up
with maternal or foetal mortalities.
Maturity Mild
Severe
< 34
Steroid to enhance fetal lung maturity
X match for blood, platelet, FFP
Correct the coagulopathy: platelet transfusion, FFP
weeks
Close monitoring of BP in hospital
Monitoring of albuminuria and Input/output chart
Control BP: IV antihypertensive
Monitoring of biochemistry and haematological
Magnesium sulphate: prophylactic for eclampsia
parameters : CBP, RFT, LFT, PT/APTT (twice
Monitor CTG for fetal well being
Arrange emergency CS when the mother is
weekly)
USG for foetal growth (every 2 weeks) and liquor
stabilized
volume (weekly)
Monitor CTG for fetal well being (twice weekly)
Cross-match
Delivery if maternal deterioration or foetal
compromise
>34
Assess cervical status for induction of labour
Give MgSO4 and arrange emergency CS as soon as
weeks
Investigation: CBP, RFT, LFT, PT/APTT
possible
CTG monitoring for fetal well being
Cross match
2.
3.
4.
5.
Surveillance
a. Aim to look for any deterioration of maternal or foetal condition that may require prompt delivery
b. Maternal surveillance
i. Blood pressure
ii. Urine protein
iii. Liver and renal function
iv. Clotting profile
c. Foetal surveillance
i. Foetal growth with USG
ii. Foetal well-being with CTG, Doppler studies and liquor volume
Control of blood pressure
a. Aim
i. To control blood pressure to prevent CVA
ii. Would not alter the progress of disease
b. Drugs
i. Hydralazine
ii. Methyldopa
Control of convulsion
a. Aim To prevent and recurrence of convulsion and stop acute convulsion
b. Drugs
i. Magnesium sulphate
ii. Diazepam
Fluid management
a. To maintain adequate intravascular volume and perfusion pressure
b. To prevent fluid overload which would result in pulmonary edema, and under-replacement would result in renal failure.
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Eclampsia
Definition
Presence of convulsions in addition to pre-eclampsia, probably resulted from cerebrovascular vasospasm, or cerebral oedema.
Incidence
About 0.1% of all pregnancies
Clinical presentation
1.
Onset:
a. In vast majority of cases it is preceded by several days and often weeks of clinically evident PET
b. In a very few cases an unheralded fulminant onset occurs
c. 50% occur antepartum, 25% intrapartum, 25% postpartum
d. Most of the postpartum convulsions occur within 1 day of delivery but seldom beyond 3 weeks
2.
Symptoms:
a. Prior to convulsions, patients usually have restlessness, tremulousness and facial twitching
b. Grand mal seizures with loss of consciousness
3.
Signs: Prior to convulsions, there may be hyper-reflexia and sustained clonus, with Papilloedema
Differential diagnoses of convulsions during pregnancy
Pre-existing epilepsy
Cerebral lupus
Meningitis
Space occupying lesions
Protocol, as of 14 January 2008
1.
General measure
a.
Call for help, inform medical officer, mid-call, senior call and anaesthetist.
b.
Lie patient in left lateral position, Maintain airway and give 100% O2
c.
Documentation of the event and duration of convulsion
2.
Anti-convulsants
a.
Diazepam is used to terminate any ongoing convulsion. Regimen: 5-10 mg slow IV bolus (given over about 1 min.)
b.
MgSO4 is used to prevent further recurrent convulsion
i.
If eclampsia occurs before commencement of MgSO4, start loading dose infusion over 5 min
ii.
If eclampsia occurs during initial loading dose, complete the loading dose over 5 min
iii. If eclampsia occurs during MgSO4 maintenance infusion, additional 2 gram bolus of MgSO4 (4 ml of 50%
MgSO4 diluted with normal saline into 10 ml) given over 5 minutes
c.
Recurrent eclampsia can be managed with a further 2 gram bolus of MgSO4 but alternative anti-convulsant or
intubation should be considered if a total 10 gram of bolus has been given
3.
A consultant or specialist in maternal medicine should be involved in case of eclampsia
4.
Investigate for underlying cause if the case is an early onset pre-eclampsia
5.
Oral antihypertensive can be used as to control BP if indicated
a.
Use Adalat Retard: 20 mg - 40 mg bd and/or labetalol 200 mg bd - 400 mg tid
b.
Avoid methyldopa as it may increase the risk of postpartum depression. Consult physician for refractory case
6.
At discharge from postnatal ward, antihypertensive drugs can be tailed off gradually over 2-4 weeks with dose revision at
weekly to biweekly interval with BP monitored at ward follow up.
7.
Postnatal follow up in General clinic at 6 to 8 weeks to review blood pressure and proteinuria by urine albustix
a.
Renal function and 24 hour urine collection are not required routinely except renal impairment at the diagnosis of
pre-eclampsia or persistent positive albustix at postnatal follow up
b.
CBP and LFT at 1 week before follow up as indicated in case of HELLP syndrome
8.
Refer patient to physician if hypertension or proteinuria still persists after puerperium
9.
Delivery
Baby should be delivered immediately after stabilisation of the mother. Caesarean section is usually the choice, unless
the second stage of labour is reached and instrumental delivery can be attempted.
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Discussion/Something to Consider
1. How to differentiate eclampsia from epilepsy clinically?
2. You are the junior on-call obstetrician and are informed that a 24 years old lady at 30 week of gestation was brought to the
A&E Department by her husband. She was noticed by her husband at home that she suddenly collapsed and convulsed for 2
minutes. The patient is now awake. What are you going to do?
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HELLP syndrome
Definition
It is an acronym formed from Haemolysis, Elevated Liver enzymes, and Low Platelets (thrombocytopenia). It is a disorder
specific to pregnancy, and is thought to be one of the complications or variants of pre-eclampsia.
Clinical features
1. Features of pre-eclampsia
2. Features of HELLP:
a. Complete blood picture
i. Anaemia
ii. Thrombocytopenia
b. Liver function test
i. Elevated bilirubin
ii. Elevated ALT
3. Other features Impaired clotting profile
Management
1. Immediate delivery of pregnancy
2. See management of pre-eclampsia
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Mitral stenosis
This is a good example to illustrate the various ways how a heart disease can affect a pregnancy.
Effect of pregnancy on the disease
1. Left atrial outflow obstruction results in:
a. Reduction in ventricular filling and hence reduction in cardiac output (risk of heart failure).
b. Elevation of left atrial, pulmonary venous and pulmonary capillary wedge pressure (risk of pulmonary oedema).
c. Abnormally increase in left atrial size which may affect the atrial condition (risk of atrial fibrillation).
d. The risk is higher during pregnancy because:
i. During antepartum:-there is an increase in cardiac demand; the increase in heart rate further impairs ventricular filling;
increase in blood volume further exaggerates pulmonary oedema.
ii. During intrapartum:-cardiac demand further increases because of pain and pushing in second stage.
iii. During postpartum:-about 500ml of blood volume returns from the uterus to the circulation as the uterine volume
shrinks after delivery (autotransfusion).
2. In addition, the damaged mitral valve or the replaced valve is associated with increased risk of endocarditis.
3. There is also an increased risk of thromboembolism secondary to atrial fibrillation and a mechanic valve replacement.
Effect of disease on pregnancy
1.
Patient with significant disease will have increased risk of intrauterine growth restriction.
2.
It can cause atrial fibrillation, with increased risk of DVT / PE especially during pregnancy.
Pre-conceptional counselling
Patient should be assessed for the physical and physiological fitness of bearing a pregnancy, and counselled on the risk of
undergoing pregnancy.
The functional class status is assessed with symptoms and signs of cardiac failure and atrial fibrillation.
Echocardiogram to determine the severity of the disease, ventricular function and diameter of mitral valve.
Patient with severe disease may become suitable for pregnancy after valvotomy or valvular replacement.
Management during pregnancy
Monitor maternal cardiac status by the functional class, cardiac symptoms, and echocardiogram assessment.
Monitor foetal growth and foetal well-being by serial ultrasound scan for growth parameters and liquor volume, and CTG.
Management in labour
Antibiotic cover at the onset of labour or rupture of membranes in order to prevent bacterial endocarditis.
Close monitoring of maternal vital sign, fluid input and output. Severe cases will require arterial line (monitor systemic
blood pressure), CVP line (monitor the central venous pressure) or even Swan Ganz catheter (monitor the pulmonary
pressure).
Continuous monitoring of foetal heart tracing with CTG.
Avoid fluid overload.
Prophylactic instrumental delivery to avoid strenuous effort during the bear down.
Avoid syntometrine as the drug will increase the afterload; slow intravenous syntocinon at third stage (too rapid injection
will lead to a drop in the systemic blood pressure and hence reduce the venous return).
IV diuretics (frusemide) at the third stage to reduce fluid overload from autotransfusion of blood from the uterine circulation
after the delivery.
Continue to monitor input and output after the delivery as the patient will be at risk of pulmonary oedema within 48 hours
postdelivery.
Other Management
Adjust the dosage of anti-coagulants to prevent thromboembolism
Anti-arrhythmic agents to control atrial fibrillation.
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Anaemia
Common types of maternal anaemia during pregnancy
1. Physiological anaemia
a. Low haemoglobin due to dilution effect in pregnancy, because the increase in plasma volume is relatively higher than the
increase in red cell volume (see physiological changes in pregnancy)
b. Haemoglobin level is usually not less than 10g/dL
2. Nutritional anaemia
a. Synthesis of haemoglobin is inadequate because of nutritional deficiency in iron, folate, and vitamin B12
b. Increase risk in multiple pregnancy, maternal malnutrition
3. Inherited anaemia
Deficient synthesis of haemoglobin because of inherited diseases such as thalassemia and sickle cell anaemia
4. Post-haemorrhagic anaemia
It is common to have anaemia after heavy postpartum haemorrhage or antepartum haemorrhage
Protocol, as of 22 June 2002
1. Investigations
a. Check peripheral blood smear and Fe / TIBC
b. If MCV >100 fL, refer to Macrocytosis
c. If MCV <= 80 fL, check Hb pattern, husband"s CBP and Hb pattern
2. Refer to Thalassemia, Iron deficiency, or Macrocytosis for specific treatment.
3. Give iron supplement for NCMC anaemia of unknown cause, unless there is known history of iron overload.
4. If Hb 8 g/dL:
a. Follow up in midwife clinic 4 weeks after supplement with CBP taken 1 day before the appointment
b. Discharge patient to MCHC if Hb > 10 g/dL and continue supplement
c. Refer back to doctor if Hb does not rise despite supplement
5. If Hb < 8 g/dL:
a. Consider transfusion if symptomatic
b. Admit as soon as possible for investigation and treatment if Hb < 6g/dL
c. Follow up in medical obstetrics clinic 2 weeks after treatment with CBP taken 1 day before the appointment
Macrocytosis
Protocol, as of 7 May 2001
1. Investigations
a. Mild macrocytosis (MCV between 100 fL and 110 fL)
i. Check peripheral blood smear
ii. No need for further investigation unless
Smear show features of megaloblastic anaemia
e.g. hypersegmented neutrophils and oval macrocytes on the blood film, then check Vit B12 and folate status.
Clinically suspicious of thyroid or hepatic disorder, then check TFT or LFT.
b. Moderate to severe macrocytosis (MCV > 110 fL)
i. Check peripheral blood smear, serum vitamin B12, serum and red blood cell folate
ii. Check TFT or LFT according to clinical suspicion
2. Diagnosis
a. Vitamin B12 deficiency:
Serum vitamin B12 level below the laboratory normal range in the presence of hypersegmented neutrophils and oval
macrocytes.
b. Folate deficiency:
RBC folate level below the laboratory normal range in presence of hypersegmented neutrophils and oval macrocytes.
c. Serum vitamin B12 or RBC folate slightly below the laboratory reference range in the absence of hypersegmented
neutrophils and oval macrocytes should not be regarded as genuine deficiency.
3. Treatment Admit patients under medical obstetrics team and consult haematologist. Vitamin B12 supplement should only
be commenced after haematologists assessment.
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Iron deficiency
Protocol, as of 7 May 2001
1. Diagnosis
a. Low serum iron and high TIBC, or
b. Low serum ferritin
2. Investigation
a. No need to check faecal occult blood or parasite unless clinically suspicious
b. Admit patient and consult physician immediately if patient complains melena
3. Treatment FeSO4 200mg tds or fortifer 1 tab qd if intolerant to FeSO4
Asymptomatic bacteriuria
It is bacterial growth in a concentration of 10,000 or more per ml of urine without symptoms. This is present in about 8% of
pregnant women, and about half of them will develop signs of urinary tract infection during pregnancy if untreated.
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Thrombocytopenia
Definition:-Low platelet count
Protocol, as of 7 May 2009
1. Classification
a. Gestational thrombocytopenia
b. Idiopathic thrombocytopenic purpura (ITP)
c. Thromboctyopenia due to other autoimmune disease
d. Thrombocytopenia due to HELLP, pre-eclampsia and acute fatty liver of pregnancy
2. Diagnostic criteria for gestational thrombocytopenia and ITP
a. Gestational thrombocytopenia
i. Platelet 100*109/L, and
ii. in the absence of underlying pre-eclampsia or HELLP, autoimmune diseases, or history of thrombocytopenia
outside pregnancy
b. Idiopathic thrombocytopenia purpura
i. Platelet < 100 *10E9/L, or
ii. Known history of thrombocytopenia before pregnancy, and
iii. In the absence of underlying pre-eclampsia or HELLP and autoimmune diseases
c. Remarks:
i. No need to screen for auto-immune diseases unless clinically suspicious
ii. Definite diagnosis of gestational thrombocytopenia and ITP can only be made retrospectively after pregnancy.
3. Out-patient management for gestational thrombocytopenia
No need for monitoring platelet count if there is no bleeding tendency and initial platelet >=100*10E9/L,
4. Out-patient management for ITP
a. Mild thrombocytopenia (Plt = 100-140*109/L) Monitor Plt at 28 and 36 weeks in general obstetric clinic
b. Moderate thrombocytopenia (plt = 50-100*109/L) Monitor Plt every 4 weeks in general obstetric clinic
c. Severe thrombocytopenia (plt < 50*109/L)
i. Admit patient and consult haematologist.
ii. Discharge to medical obstetrics clinic when Plt >= 50*10E9/L after treatment.
iii. Monitor Plt every 2 weeks in medical obstetrics clinic.
iv. Arrange anaesthetic consultation
5. Intrapartum management for all thrombocytopenic patients
a. Check CBP on admission
b. Notify anaesthetist early in labour ward if Plt <100*109/L
c. Intramuscular injection is contraindicated if Plt <80*109/L (Consider intravenous pethidine vs. IMI pethidine)
d. Reserve platelet concentrate if platelet < 50*109/L
e. Give hydrocortisone cover if patient has been on long term steroid.
6. Postpartum management
a. For gestational thrombocytopenia
i. Check platelet at 6 weeks after delivery in postnatal ward
ii. Follow up in midwife clinic at 8 weeks to review platelet result while routine postnatal care should be in MCH
iii. Refer to haematologist clinic if platelet still <140*10E9/L
b.
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Thromboembolism
Epidemiology:
Less common in Chinese than in Caucasian, incidence around 1 in 300 in PWH, majority in postnatal period, predominantly calf
vein DVT, above knee DVT less than 1 in 1000 pregnancy.
Risk factors of deep vein thrombosis:
Constitutional factors:
Advanced age (>40)
Gross obesity
Smoker
Previous history of DVT
Charcots Triad
Stasis:- Caesarean section, Immobilisation (for > 4 days)
Endothelial injury:- antiphospholipid syndrome, pre-eclampsia.
Hypercoagulability:- pregnancy itself (due to oestrogen), Thrombophilia (protein C/S deficiency, anti-thrombin deficiency)
Clinical features:
Calf and leg swelling, pain
Leg swelling
Homans' sign may be present (active or passive dorsiflexion of the foot associated with pain incomplete dorsiflexion or
flexion of the knee to release tension. This sign may be absent in about 50% of cases of DVT
Dyspnoea, respiratory distress, desaturation and chest pain are features of pulmonary embolism
Diagnosis:
High index of suspicion when a pregnant woman complains of unilateral calf pain and swelling, in particular within a few days
after caesarean section.
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Management:
1. Medical treatment - current treatment is either subcutaneous low molecular weight heparin (predominantly used in
antenatal DVT) or warfarin (predominantly used in puerperium)
a. Enoxaparin till post-delivery
b. Start warfarin at day 3 post-delivery (provided that there is no excess bleeding)
c. Then stop Enoxaparin when INR is between 2 to 2.5
2. General management
a. Above knee DVT - Slightly elevate the legs and bed rest for 1 or 2 days until calf pain resolves after medical
treatment, then encourage mobilisation, apply elastic stocking
b. Below knee DVT- Encourage mobilisation and elastic stocking.
3. Follow up
a. Patient can be discharged when she has been on the same dose of warfarin for 2 consecutive days.
b. It has been agreed with haematologist that patient will be seen in 1 weeks time in warfarin clinic
c. Follow up in medical obstetric clinic at 6 weeks postpartum
Prophylaxis
Protocol, as in 22 June 2002
1. Indicated in patients with previous history of
a. DVT, PE or thrombophilia;
b. Anti-phospholipid syndrome
c. Mitral stenosis with atrial fibrillation
d. Peripartum cardiomyopathy
e. Immobilisation such as observation in labour ward for a long period and after long operation
2. Physical measures:-elastic stocking, intermittent pneumatic compression during labour, caesarean section and early
puerperium
3. Medical:-subcutaneous low molecular weight heparin (Enoxaparin and Fraxiparine)
Pulmonary embolism
Embolism involving pulmonary vasculature with high mortality and needs intensive care support
Clinical Features
Asymptomatic
Dyspnoea, respiratory distress.
Haemoptysis
Desaturation and chest pain
Loss of consciousness.
Investigations
D-dimer
Doppler USG
V/Q Scan
Venography
Treatment
Urgent open embolectomy may be needed to clear the blood clots. Usually associated with deep vein thrombosis, especially
bilaterally
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Antiphospholipid syndrome
Definition
Antiphospholipid syndrome (APS) is an uncommon autoimmune disorder characterised by:
1. Presence of one or both of the following auto-antibodies:-anticardiolipin antibodies (aCL) and lupus anticoagulant (LA), and
2. Presence of thromboembolic disorders, recurrent pregnancy loss, thrombocytopenia, or haemolytic anaemia; and
3. Less commonly, systemic or pulmonary hypertension.
Diagnosis
The diagnostic criteria include:
1. Two positive readings for LA and / or aCL at least 3 months apart, plus
2. At least one of the clinical criteria
3. The presence of auto-antibodies alone without clinical complications may not require treatment. Antiphospholipid syndrome
should also be differentiated from systemic lupus erythematosus (SLE), although they both have aCL and similar clinical
features.
Management
1. High-dose steroid and immunosuppression used for treating SLE are not recommended in APS.
2. Positive history of thromboembolism:- Patients are at high risk of recurrence of thromboembolism during pregnancy and
should be given heparin prophylaxis
3. Positive history of recurrent pregnancy loss alone:- Combination of low-dose aspirin and heparin (low molecular weight)
decreases the risk of recurrent loss.
Epilepsy
Introduction
Epilepsy affects 0.5% of women of child-bearing age and is the most common chronic neurological disorder complicating
pregnancy. The cause of majority of epilepsy is primary, but some are secondary to previous medical events like cranial surgery or
meningitis. The important points in obstetrics are:
1.
Epilepsy should be differentiated from other pregnancy-related causes of convulsions such as eclampsia
2.
Anti-convulsants are potentially teratogenic
3.
It may be difficult to control the disease during pregnancy because:
a. The physioloigical changes during pregnancy may affect the pharmacokinetic of anti-convulsants
b. Patients may be fear of the foetal side effects and not compliant to treatment
Effect of pregnancy on epilepsy
Risk of relapse of convulsions
1. While half of the pregnant women have no changes in the frequency of convulsion, one-quarter of women have increased
frequency of convulsions, due to the reasons mentioned above.
2. Those women who have been fit-free for many years are unlikely to fit in pregnancy unless she discontinues her medication.
Effect of epilepsy on pregnancy
1. There is no direct effect on pregnancy in epileptics.
2. Indirect effects include:
a. Acute convulsions may result in physical trauma;
b. Status epilepticus may lead to hypoxic damage of both the mother and the foetus.
c. The baby has risk of developing epilepsy:
i.
4% when either parents has primary epilepsy
ii. 10% when there is a previously affected sibling
iii. 20% when both parents have epilepsy
d. Teratogenicity of anti-convulsants
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Intrapartum management
a. Continue anti-epileptics, if any.
b. Time and mode of delivery not affected, manage as normal labour and delivery
c. Inform paediatrician for assessment at delivery
d. Vitamin K1 intramuscular injection to neonate as routine
e. If require anti-convulsant for prevention of eclampsia, consult neurologist if patient is on anti-convulsant already. In
general, the guidelines for pre-eclamptic anti-convulsants still apply.
4. Postnatal management
a. The neonate should be given vitamin K prophylaxis.
b. There is no contraindication to breast-feeding, caution if mother is on diazepam or high-dose phenobarbitone
c. When patients want hormonal contraception, higher dose of combined oral contraceptive or progestogen-only
pills should be advised.
d. Educate about safe child care in the context of possibility of fitting episode e.g. during bathing of baby
e. Consult neurologist for adjustment of anticonvulsant dosage after delivery if dosage has been increased during
pregnancy, otherwise early out-patient follow up would be adequate.
f. Advise on contraception:-efficacy of OCP may be reduced. High dose (50mcg E2) preparations should be
recommended if used.
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Appendicitis
Incidence
It is a common acute surgical condition during pregnancy:-1:1500 to 1:2000
Clinical features
1. It is more frequent in the first two trimesters
2. It is more difficult to diagnose as the clinical symptoms and signs are more vague than in non-pregnant women.
3. Delayed diagnosis and treatment are not uncommon in pregnancy and account for the high maternal and foetal morbidities
and mortalities.
4. Patients usually present with fever, nausea and vomiting, right-sided abdominal pain and tenderness. The site of the pain
changes with the position of the appendix which is pushed upwards by the gravid uterus. Signs of peritonitis may be masked
by the gravid uterus. White cells count is usually raised.
Complications
1. Maternal Peritonitis and maternal death (potentially fatal if delay in diagnosis)
2. Foetal Preterm labour, foetal distress, intrauterine death
Differential diagnoses
1. Related to genital organs:
a. Ectopic pregnancy (during the first trimester)
b. Torsion ovarian cyst
c. Red degeneration of fibroid
d. Abruptio placentae
e. Chorioamnionitis
2. Other surgical diseases:- Acute cholecystitis, pancreatitis
Management
1. Appendicectomy
2. Antibiotics
3. Monitor foetal well-being and maternal vital sign during the peri-operative period.
Discussion/Something to Consider
A 29-year-old lady at 30 weeks of gestation presented with one-day history of severe right lower quadrant pain preceded by
epigastric pain. It was associated with nausea, vomiting and fever. What are the differential diagnosis and how to make diagnosis?
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Thyroid disorder
Introduction
Thyroid disorders are common endocrine disorders affecting women at reproductive age. It may complicate pregnancy or cause
various gynaecological disorders.
Thyroid disorders in gynaecology
1. Hypothyroidism
a. Menorrhagia
b. Infertility
2. Hyperthyroidism
a. Amenorrhea
b. Infertility
Thyroid disorders in obstetrics
1. Hyperthyroidism
a. Causes
i. Due to the effect of human chorionic gonadotropin, there is usually transient hyperthyroidism during the first
trimester (see physiological changes in pregnancy). It is usually self-limiting but may be associated with hyperemesis
gravidarum.
ii. The most common cause of hyperthyroidism during pregnancy is Graves disease (95%), in which auto-immune TSH
receptor-stimulating antibodies (an IgG) can cross the placenta leading to foetal hyperthyroidism.
b. Complications
i. Uncontrolled hyperthyroidism results in various foetal complications:-abortion, IUGR, preterm labour, foetal
thyrotoxicosis (in Graves disease only). Rarely a foetal gotire may cause hypertension of the foetal neck, leading to
malpresentation.
ii. Maternal complications are thyroid storm, tracheal obstruction due to a retrosternal gotire.
c. Treatment
i. The mainstay of treatment is by antithyroid agents such as propylthiouracil and carbimazole.
ii. Beta-blockers may be required to control the cardiac symptoms before the hyperthyroidism is under controlled.
iii. Carbimazole is not used as the drug crosses placenta and may cause fetal hypothyroidism.
Protocol, as of 22 July 2002
1. Newly diagnosed hyperthyroidism
a. Admit patient for endocrinologist's assessment
b. Propylthiouracil (PTU) is the preferred antithyroid drug
c. Check:
i. ATG antithyroglobulin antibody
ii. AMC antimicrosomal antibody
iii. If suspected transient gestational hyperthyroidism:-check red cell zinc
2. Transient gestational hyperthyroidism
a. Diagnosis (1) No feature of Graves' disease, (2) Normal red cell zinc; and (3) Clinically euthyroid
b. Monitoring Check TFT every 4 weeks in general obstetrics clinic until result returns to normal
3. Hyperthyroidism in remission
a. Check TSH, ATG and AMC (only if not checked in recent years) to predict postpartum thyroid dysfunction
b. If raised antibody, make sure patient has a follow up with the endocrinologist post delivery
c. If normal TSH, routine antenatal care
4. Hyperthyroidism on treatment
a. Review fT4 result and current treatment
b. Regular FU in medical obstetrics clinic (every 4 weeks if stable) and general obstetrics clinic
c. Monitor fT4 every 4-8 weeks during pregnancy, no need to check TSH unless suspicious of over-treatment.
5. If inadequate treatment
a. Admit to ward to consult endocrinologist
b. USG for foetal growth and CTG are recommended for uncontrolled hyperthyroidism
c. Inform paediatrician post delivery for neonatal assessment
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2.
Hypothyroidism
a. Causes
Hypothyroidism can be resulted from iodine deficiency in endemic area, thyroiditis or post-surgical or radiation therapy
for previous hyperthyroidism.
b. Complications
Abortion, IUGR decreased intelligence quotient of the offspirngs.
c. Treatment
The treatment is by thyroxine replacement which does not cross the placenta.
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Labour Management
0. Intrapartum management
Intrapartum management is one of the most important area in Obstetrics. The aims are to ensure that the foetus is delivered in the
most optimal condition for gestation, while the potential hazards of childbirth and any underlying pathology to the mother are
minimised. It consists of the following aspects:
1. Maternal monitoring:-to ensure maternal well-being during labour and delivery, relief stress and anxiety.
2. Labour pain relief:-provides adequate and safe analgesia to the mother.
3. Intrapartum foetal monitoring:-to ensure foetal well-being during labour and delivery.
4. Monitoring the progress of labour:-to ensure the progress of labour is normal, look for any obstruction of labour and take
prompt actions.
5. Decision of mode of delivery:-to decide the most optimal time and the safest way of delivery which may involve instrumental
delivery or caesarean section.
6. All the above monitoring can be summarised in a partogram that facilitate the intrapartum management.
Management of first and second stage of labour
Protocol, as of 7 May 2001
1.
General Nursing
a.
Nurse patient in semi-recumbent position during first stage, and prop-up during second stage of labour, unless
condition allows ambulation.
b.
Keep nil by mouth unless specified by medical officer.
c.
No need for routine cross-matching for all patients.
d.
Provide adequate analgesia.
e.
Record intrapartum monitoring on partogram.
f.
Routine intrapartum monitoring
2.
Progress of labour:
a.
Vaginal examination(V.E.)
i.
Q4H in the latent phase
ii.
Q2H in the active phase
b.
Inform medical officer if
iii. Cervical dilatation less than 1cm/h in the active phase
iv. Prolonged second stage (1 hour for nullipara, 30min for multipara)
3.
4.
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Partogram
The partogram is a graphic display of progress in labour, with complete collection of information on the cervical dilatation,
presentation, station (descend) and position of the presenting part. There are also recordings of the intrapartum monitoring of the
maternal and foetal well-being, and administration of any drugs. The partogram facilitates the monitoring of the progress of labour,
diagnosis of dystocia, and continuation of intrapartum management and decision making.
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1. Normal Labour
Labour
Definition of labour
Onset of regular painful uterine contractions accompanied by
1. Effacement of the cervis
2.
3.
Show.
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Initiation of labour
It is not fully understood
The main trigger is probably foetal rather than maternal
It may involve foetal cortisol, and prostaglandins
Once initiated, labour appears to be self-perpetuating
Three stages of labour
The labour process is divided into three stages:
1. First stage
a. It starts from the diagnosis of labour until the cervix is fully dilated (10cm for term pregnancy)
b. The foetal head engages, descends gradually into the pelvis and rotates
c. The cervix often dilates slowly for the first 3cm and is called the latent phase
d. Thereafter, average cervical dilatation is at the rate of 1cm/hour in nulliparous, and about 2cm/hour in multiparous
e. It normally would not last longer than 12 hours
2. Second stage
a. It starts from full dilatation of the cervix to the delivery of the foetus
b. Descent, flexion, and internal rotation of the foetal head are completed
c. Followed by extension and restitution (external rotation)
d. Maternal pushing is essential
e. It usually takes 40 minutes for nulliparous and 20 minute for multiparous.
3. Third stage
a. It starts from delivery of the foetus to delivery of the placenta
b. It normally lasts about 15 minutes
c. Normal blood loss is up to 500ml
Mechanism of vaginal cepahlic delivery
1. Engagement
The ovoid-shaped head normally enters the pelvis in the occipito-transverse position, because the transverse diameter of
the inlet is greater than the antero-posterior diameter
2. Descend
a. The foetal head descends further into the birth canal.
b. The degree of descent is measured by station.
c. During the descend, the foetal skull may change shape to adapt the maternal pelvis (moulding). Caput succedaneum is
usually formed by compression.
3. Flexion
The head also flexes as it descends further, so that the its vertex becomes the presenting part
4. Rotation (internal rotation)
a. The foetal head rotates 90 degree so that the face is facing the sacrum; the occiput is anterior, below the symphysis pubis
b. This enables it to pass through the pelvic outlet which has a wider antero-posterior than transverse diameter
c. In 5% of cases, the head rotates to occipito-posterior position
5. Extension
The foetal head extends and distends the perineum (crowning), and finally is delivered
6. Restitution (external rotation)
The foetal head then rotates 90 degree back to the same position in which it enters the inlet, facing either right or left, to
enable delivery of the shoulders
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Caput succedaneum
Foetal scalp edema resulted from obstructed venous return caused by pressure of the head against the rim of the cervix during
labour. While it is quite common during a normal labour, severe edema may signify an obstructed labour. On vaginal examination,
the edema also makes the foetal head felt at a lower station. However, the foetal head is actually high in the birth canal, and
difficulty may be encountered when instrumental delivery is wrongly attempted.
Moulding
The alternation in shape and diameters of the foetal skull during labour. The fontanelles and sutures permit the force of
contractions to compress the head against the bony pelvis and adapt its shape to that of the birth canal. Moulding is divided into 3
degrees:
1. First degree closure of the suture lines
2. Second degree reducible overlapping of the skull bones over suture lines
3. Third degree Irreducible overlapping of the skull bones over suture lines
While moulding is a normal phenomenon during labour, severe moulding signifies obstructed labour.
Engage
A term applied when the greatest diameter of the baby's presenting part has passed through the pelvic inlet of themother. The
greatest diameter is biparietal diameter in cephalic presentation, and bi-iliac diameter for breech presentation. Engagement is
particularly important when the mother has a platypoid pelvis, as when the head is engaged, the rest of the labour should present
no difficulty. As disproportion becomes less of a problem nowadays, engagement becomes less important. The descent of the head,
as measured by the number of fifths of the head still palpableabdominally, becomes more important.
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Station
Definition
It denotes the level of descent of the presenting part as assessed on vaginal examination, similar to engagement which is assessed
abdominally. Station is defined by the distance in centimeters between the leading portion of the foetal presenting part, and the
plane of the maternal ischial spines (which is arbitrarily set as zero level). For example, it is S+2 if the leading bony portion of the
foetal skull is 2cm below the ischial spines but is S-1 if it is 1cm above them.
Clinical importance
When the presenting part reaches the ischial spines (station 0), it is often engaged. Station is one of the five parameters making up
the bishop score. It is also used to define the level of instrumental delivery. Station may be incorrectly assessed when there is
significant caput succedaneum which gives a wrong impression that the presenting part is low.
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Neonatal Resuscitation
Protocol, as of 22 June 2002
1. Take cord blood for blood gas assay (arterial and venous), thyroid function and G6PD.
2. Give newborns injection:
a. Vitamin K1 to all newborns.
b. Hyperhep(hepatitis immunoglobulin) to newborns of hepatitis B carrier mother.
3. Routine Resuscitation
a. Apply gentle suction confining to the oral cavity, oropharynx, and the nasal cavity.
b. Dry the baby thoroughly and wrap in a warm blanket.
c. Stimulate the baby by flicking the feet or by rubbing the skin with towel if the baby is not active.
d. Record Apgar score, cord arterial and venous blood gases results.
4. Use of Nalaxone
a. Give naloxone intramuscular injection to the baby if and only if
i. The mother has received narcotic injection within 6 hours of delivery, and
ii. The baby shows evidence of respiratory depression at birth.
b. The baby should be reassessed by neonatologist before being discharged from the labour ward.
c. If the baby does not respond to naloxone, inform neonatologist.
5. Resuscitation of Extremely Preterm Delivery
a. Before delivery, arrange neonatalogical consultation for counselling of the patient
b. Inform neonatal MO for resuscitation in the following conditions:
i. Preterm deliveries with working gestation >=24 weeks irrespective of birth weight
ii. Cases of working gestation around 22-24 weeks but:
- Baby weight >500g and shows evidence of life at birth, or
- Patient has decided for resuscitation after counselling by neonatologist, or
- Patient has not been counselled by neonatologist
c. Do NOT resuscitate babies from termination of pregnancies irrespective of birth weight.
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2.
3.
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Retained placenta
It is a condition in which the whole placenta or part of it is retained inside the uterine cavity after the delivery of the baby. It may
be due to morbid adherence of placenta to the myometrium. Complications include:
1. Postpartum haemorrhage
2. Uterine inversion when excessive cord traction is attempted to deliver the placenta
It is managed by manual removal of placenta (MROP).
Protocol, as of 22 June 2002
1. Inform the intern and obstetric call medical officer.
2. Assess and treat postpartum haemorrhage
3. Set drip, CBP and X-match.
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Neonatological consultation
Protocol, as of 22 June 2002
1. Conditions requiring neonatal medical officer to stand-by at delivery
a. Antenatal conditions
i. Preterm delivery (gestation< 37 completed week)
ii. Estimated foetal weight < 2kg or significant intrauterine growth retardation
iii. Multiple pregnancies
iv. Oligohydramnois
b. Perinatal conditions
i. Suspected foetal distress
ii. Meconium stained liquor
iii. Babies with known or suspected malformations that may require immediate medical attention at birth.
c. Placental conditions
i. Suspected chorioamnionitis
ii. Prolapsed cord
iii. Abrutpio placentae
iv. Placenta praevia
d. Difficult deliveries
i. All Caesarean deliveries
ii. Vaginal breech deliveries
iii. Difficult deliveries e.g. shoulder dystocia
e. Other conditions in which the obstetricians anticipate adverse neonatal outcome.
2.
3.
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Postnatal discharge
Protocol, as of 6 November 2004
1. Time of discharge
Usual length of stay after term delivery (calculated from the time of birth of the baby):
a. Uncomplicated labour and vaginal delivery (included instrumental):
i. 3 days for parity 1 patients,
ii. 2 days for patients of parity 2 or above
b. Complicated labour and vaginal delivery:-3 days or more.
c. Caesarean section:-4 days or more
2. Patient's request for early discharge within 48 hours after birth
a. Early discharge is allowed only if the following criteria are fulfilled:
i. Uncomplicated vaginal delivery
ii. Patient should have been observed for at least 24 hours after birth
iii. Midwife has assessed the following:
- Patient is mobile with adequate pain control.
- Bladder and bowel functions are adequate.
- No problem in feeding baby.
- Stable emotion.
- Advice on perineal care has been given.
- Advice on postnatal follow-up and health check for both the mother and the baby has been given.
- Patient is accessible to medical and social support including MCH, postnatal ward hotline, postnatal clinic at
Li Ka Shing Outpatient Clinic, community nursing service, medical social worker when needed.
- Patient can be contacted for follow-up.
iv. Doctor or intern has assessed the following:
- Perineal wound is normal.
- No postpartum haemorrhage or ongoing bleeding.
- No fever (> 38 degrees for two or more readings of at least one hour apart) within 24 hours before discharge.
- Rh immunoglobulin has been given if indicated.
- No intrapartum or postpartum complications that require inpatient medical treatment or observation.
- Follow up plan has been drawn for any antepartum, intrapartum or postpartum problems or complications.
- Contraceptive advice has been given.
b. For cases not fulfilling the above criteria:
i. Decision should be made by a medical officer on individual basis (or agreed by a medical officer after assessment
by an intern).
ii. If patient insists early discharge against medical advice, she should sign the "Discharge with acknowledgement of
medical advice" (DAMA).
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Bishop score
The score used to assess the ripening of the cervix for induction of labour. Scores are assigned to each of the five cervical features
and the total score is obtained by summation. With a low score (0-3), there is a higher risk of failed induction, resulting in
caesarean section (over 20%) compared with a score of eight or more, where the failed induction rate is less than 3%. With a high
score the cervix is said to be ripe.
Bishop's score
Dilatation (cm)
Length (cm)
Consistency
Position
Station
0
<1
4
firm
posterior
-3
1
1-2
2-4
medium
central
-2
2
3-4
1-2
soft
anterior
-1, 0
3
>4
<1
/
1
Amniotomy
Amniotomy or artificial rupture of membranes is a common intrapartum procedure, performed with an amnihook (or with a
Drew-Smythe cannula in hindwater amniotomy).
Indication
1. Augmentation of labour in spontaneous rupture of membrane, and Induction of labour. The procedure would stimulate
production of endogenous prostaglandins which brings about uterine contractions as well as cervical softening.
2. Application of foetal scalp electrode or blood sampling;
3. Instrumental delivery.
Risk
1. Compression of foetal head during labour, thus it should be avoided in vaginal delivery of preterm foetuses as the forewater
protects the vulnerable foetal head
2. Cord prolapse, particularly if there is polyhydramnios.
3. In the management of intrauterine death, amniotomy should be avoided until the late stage of labour, in order to prevent
intrauterine infection.
Amnihook
It is a simple instrument with a small hook at the tip for amniotomy. Under aseptic technique, amnihook slides between index and
middle fingers, which are already in contact with membrane. Amnihook is then turned upward to rupture the membranes. Fingers
should withdraw after cord prolapse excluded. If liquor not seen, treat as Meconium Stained Liqour.
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Uterine hyperstimulation
It is an iatrogenic complication due to the excessive use of oxytocics, resulting in too frequent or too strong uterine contractions.
The uteroplacental blood flow is jeopardised, resulting in foetal hypoxia and foetal distress. The cardiotocogram typically shows
frequent uterine contractions (>4 in 10 minutes) and recurrent foetal decelerations or bradycardia. The other risk is uterine rupture.
Prevention
Titrate the rate of infusion of syntocinon and avoid using prostaglandins in multiparous women or when women already in labour.
Protocol, as of 7 May 2001
1. Definition More than 4 painful uterine contractions in 10 minutes induced by prostaglandins or syntocinon
2. Inform Medical Officer.
3. Uterine hyperstimulation with normal foetal heart rate
a. Hyperstimulation induced by PGE2
i. Abandon further PGE2 and remove any residual PGE2 from vagina.
ii. NPO, X-match.
iii. To labour ward for continuous foetal heart monitoring.
iv. For combined induction after hyperstimulation subsides.
b. Hyperstimulation induced by syntocinon Titrate oxytocin to keep contractions less than 4 in 10 minutes.
4. Uterine hyperstimulation with abnormal foetal heart rate
a. Hyperstimulation induced by PGE2
i. NPO, X-match.
ii. Immediate delivery.
b. Hyperstmulation induced by syntocinon
i. Stop syntocinon.
ii. Immediate delivery if no improvement in foetal heart rate.
5. Tocolytic treatment for hyperstimulation
a. Not recommended unless there is persistent bradycardia when arranging emergency Caesarean section.
b. Beware of hypotension particularly if epidural anaesthesia, and beware of uterine atony after delivery.
c. Hexoprenaline is the only choice. Give IV bolus 5 mg. Can only repeat once if no improvement after 2 mins.
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Failure to progress
Definition of failure of progress of labour
It is defined as the labour progress fails to reach an acceptable rate. The criteria are different depending on parity.
1. Prolong latent phase
During latent phase, there is cervical effacement, dilation may not be apparent and appears prolonged. It is common in
primgravida and usually idiopathic. Management is wat and supportive including sufficient pain relief. As cervix may dilate
rapid later, therefore syntocinon is not indicated.
2. Prolonged active phase:
Cervical dilatation:-less than 1.2cm/hr in a primigravida; less than 1.5cm in a multipara
3. Prolonged descend:
Descend of the presenting part:-less than 1.0cm/hr in a primigravida; less than 2.0cm in a multipara
4. Secondary arrest of dilatation:
Cervical dilatation ceases during active phase of labour for 2 or more hours
5. Prolonged second stage:
Second stage last more than 1 hour in a primigravida; 30 minutes in a multipara
6. Failed induction Fail to achieve active phase in 12 hours.
Causes of failure of progress
1. Insufficient power:
a. Incoordinate or inadequate uterine contractions
b. Poor maternal efforts during second stage
2. Obstructed labour due to disproportion of sizes of the passenger and the pathway:
a. True Cephalopelvic disproportion
i.
Abnormally large presenting part:-hydrocephaly
ii. Contracted pelvis
b. False: malpresentation or malposition of the head.
Principle of management
1. It is essential to differentiate insufficient power from obstructed labour. The former is managed with syntocinon augmentation
or instrumental delivery in the second stage, while caesarean section should be performed in obstructed labour.
2. Mismanagement of obstructed labour with syntocinon or instrumental delivery causes significant maternal (e.g. uterine
hyperstimulation, uterine rupture) and foetal complications (foetal distress, birth injuries)
3. Mismanagement of insufficient power with caesarean section puts patients to unnecessary risk of operation.
Trial of labour
It implies that the outcome of labour is uncertain because of mechanical difficulty and that particularly vigilant monitoring of
progress and of foetal well-being is required.
Obstructed labour
-
Obstructed labour occurs when the the birth canal (pelvis) is relatively small for the presenting part (usually the foetal head)
to pass through. It is usually a 'relative' condition in a pair of normal woman and foetus, but can also be due to an
abnormally contracted pelvis or the presenting part is abnormally large such as hydrocephaly.
labour presents with failure to progress, with cessation of cervical dilatation or descend of foetal head, and prominent caput
succedaneum and moulding. The station of foetal head may be high or even not engaged.
The pelvis may appear small on vaginal examination (see pelvimetry). Obstructed labour should be differentiated from
insufficient power when there is failure of progress. The treatment should be caesarean section.
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Dystocia
From Greeks words dys means (bad) and os means opening. It is a vague term meaning some sorts of difficulty in labour.
Originally it was used to describe obstructed labour when there was disproportion between the size of the presenting part and that
of the birth canal, results in in failure of progress of labour. The causes of dystocia were then classified as due to the passage (birth
canal), the passenger (baby), or power (uterine contractions and maternal effort):
Problems of Passage
Abnormal shape and dimensions of pelvis resulting in obstruction of labour. The pelvis can be assessed with pelvimetry.
Problems of Passenger
1. Malpresentation such as breech presentation
2. Malposition such as Occipito-posterior position
3. Macrosomia
4. Shoulder dystocia
5. Abnormal size of presenting part such as hydrocephaly
Problem of Power
1. Dysfunctional uterine contractions which can be:
a.
Too irregular, or
b.
Too infrequent, or
c.
Incoordinate
d.
Too weak (hypotonic)
2. Inadequate maternal effort during second stage of labour which can be due to:
a. Maternal exhaustion
b. Effect of epidural analgesia
c. Maternal paralysis due to pre-existing neurological diseases
d. Incooperative patients
Implication
It is important to differentiate the underlying causes of dystocia. While problems with the passage and passenger would result in
obstructed labour that require caesarean delivery, dysfunctional uterine contractions are treated with syntocinon augmentation, and
inadequate maternal effort can be managed with instrumental delivery.
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Shoulder dystocia
Definition
This is an obstetric emergency and is defined as difficult delivery of shoulders that
(1) Requires additional manoeuvres besides usual downward traction and episiotomy, or
(2) Results in foetal birth asphyxia or trauma such as fractures and neural plexus injuries.
Pathology
The pathology lies in the pelvic inlet. While the foetal head is delivered, one or both shoulders are struck above the inlet. Usually,
the anterior shoulder remains hooked behind the symphysis pubis and fails to rotate into a larger pelvic diameter.
Incidence
The incidence is about 0.2%, and is more common in foetal macrosomia and maternal diabetes.
Risk Factors
1. Antepartum risk factors:
a. Maternal obesity >81kg:-increase 8 fold
b. Maternal diabetes:-increase >2 fold for same birth weight
c. Post-term:-<40 week, 0.7%; .42 week 1.3%
d. Macrosomia:-<4kg incidence 0.3%; >4kg 3-10%; >4.5kg >22%
2. Intrapartum risk factors:
a. Secondary arrest of labour
b. Instrumental delivery
3. Remark 23% of shoulder dystocia do not exhibit any of the classical risk factors
Foetal complications
1.
2.
3.
4.
Birth asphyxia
Brachial plexus injury
a. Erb's 6- 16%, usually transient and mild
b. Klumpke's, phrenic palsy, rare but serious
Skeletal injury fracture of clavicle 15%, humerus 26%
Perinatal mortality
Maternal complications
1. Birth canal injury
2. Postpartum haemorrhage
HELPERR for Shoulder Dystocia
H: Help seeking
E: Episiostomy: Extend or perform a large one.
L: Leg: McRoberts manoeuvre
P: Pressure on suprapubis.
E: Enter the vagina for rotational manoeuvre
R: Remove posterior arm
R: Roll over
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Asynclitism
A sideway tilting of the head, so that the sagittal suture of the foetal skull does not lie midway between the maternal sacral
promontory and pubic symphysis. It is usually due to uneven pressure on the foetal head during its descent through the pelvis.
Asynclitism can occur before the head is engaged, or when the head is in the pelvic cavity.
Occipito-posterior
The foetus with vertex presentation begins labour usually in the occipito-lateral position because its slightly longer anteroposterior
diameter fits best into the slightly longer lateral diameter of the pelvic brim. When labour progresses, the head rotates so the baby
faces the back of the mother, occipito-anterior position. Occipito-posterior position commonly occurs if the maternal pelvis is of
the anthropoid or the android shape. It is associated with dystocia and incoordinate uterine contractions. Occipito-posterior
position usually resolves in one of following three ways:1. Most commonly, after a longish and difficult labour, the head rotates to the occipito-anterior position, and the baby delivers
normally.
2. Sometimes, the head stays persistently occipito-posterior (POP), and the head is delivered in this position. The head tends to
act like a battering ram on the perineum, and usually severe trauma to the perineum results. Occasionally a third degree
perineal tears results.
3. Occasionally, during the rotation, the head is held up by the sacrum. The part of the head near the back of the mother fails to
descend while the part near the front continues to descend, and the baby's head therefore tilts sideways (asynclitism). As the
head tilts, it becomes more obstructed, and eventually the head cannot descend anymore. This is called deep transverse arrest.
Usually, a Caesarean section is necessary. However, delivery can sometimes be affected by the use of Kielland's forceps, the
vacuum extraction, or in the old days by manual rotation of the head.
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Loveset maneuver
A maneuver originally described to deliver the shoulder in a breech presentation. The principle is that the pelvic canal is curved,
so that its anterior wall (pubic symphysis) is much shorter than the posterior wall (the sacrum). It is most likely therefore when the
foetal part is obstructed anteriorly by the pubic symphysis, the posterior part is already below the sacral promontory. Given that
the baby is held firmly by pelvic tissue, a rotation of the baby will cause the posterior part of the baby to come to the front, and as
this is already below the inlet, the baby descends. In other words, the pelvis acts like a screw, and any rotation of the baby will
bring it lower. The maneuver is very useful to deliver the shoulders of the baby after the breech is delivered. The principle is also
used when there is shoulder dystocia after cephalic delivery. Sometimes, if the baby can be rotated, the shoulder will slip under
the pelvic inlet and can be delivered.
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Entonox
Entonox is a gas mixture of oxygen and nitrous oxide with 50% each. It is an inhalational analgesic commonly used for labour
pain relief. It can be self-administered, is fasting acting, and has minimal maternal and foetal side effects. The effect is peak at
20-30 seconds, and offset in 1 minute. The efficacy is variable, and 85% of women find it helpful. In order to get maximal
analgesic effect, patients should be instructed to inhale when uterus is starting to contract, and continue inhalation until the
contraction begins to subside. Side effects are hypocarpia, dizziness, tetany and foetal hypoxia after prolonged use. Midwives can
prescribe Entonox to parturiting patients according to departmental standing order. Patients should be advised with other forms of
analgesia when labour is expected to be long, in order to avoid side effects of Entonox.
Narcotic analgesia
The most commonly used narcotic analgesic is pethidine. It is often used for labour pain relief, and post-operative analgesia. It can
be administered intramuscularly or intravenously. The former route is contraindicated in patients with clotting disorders or
thrombocytopenia. The intravenous route can be used for patient-control-analgesia. For labour pain relief, its efficacy is variable
with 50% reported good analgesic effect. The maternal side effects are vomiting and drowsiness. Since it can cross the placenta,
the major foetal risk is neonatal respiratory depression which is readily reversible with naloxone.
Pethidine
It is indicated for labour and postoperative pain relief, in the regimen of 75mg (body weight <80kg) or 100mg (body weight
80kg) Q4H prn IMI. Never give IV >25 mg at any one time. Midwives can administer the first pethidine injection for and only
for labour pain control. Doctors should be consulted when repeated injections are required. Pethidine is not contraindicated in
advanced first stage of labour. Maxolon may also be given to relieve GI upset caused by pethidine.
Epidural anaesthesia
Contraindications
1. Bleeding disorder, thrombocytopenia or on anticoagulants
2. Infection in area of epidural injection
The Pros of Epidural:
1. Excellent labour pain relief
2. Allows time for rest
3. Reduces hyperventilation and serum catecholamines
4. Great for PIH (pregnancy induced hypertension) and Caesarean sections
The Cons:-(possible spin-off problems)
1. Major
a.
Hypotension (requires IV fluids)
b.
Nerve injuries
2. Mild
a. May hamper 'push-ability' and increase need for vacuum/forceps extraction for prolonged second stage
b. Headache after accidental dural puncture (1/100); Backache; Fever
c. Postpartum urinary retention;
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Intermittent auscultation
It is a basic method of intrapartum foetal monitoring that has been used for a long period of time before the introduction of
cardiotocogram. It is still being used in many centres. During labour, the foetal heart rate is listened with Pinard stethoscope or a
Doppler apparatus (doptone) immediately after a contraction for 1 minute in a 15-minute interval. Any changes in foetal heart rate
such as decelerations are examined. Intermittent auscultation has often been compared with routine continuous foetal heart
monitoring with cardiotocogram, which has become the standard in many centres (including our unit). The former method is
simple and requires no sophisticated machines and equipments, and is less expensive. Its potential disadvantage is that it may not
be as sensitive as cardiotocogram in detecting foetal hypoxia. The latter has been shown to reduce the incidence of neonatal
seizures. However, it also has a high false-positive rate, leading to unnecessary intervention (high operative delivery rate).
Cardiotocogram (CTG)
Definition
It is an electronic monitoring method which presents graphically the status of the foetal heart rate pattern (cardio), and the uterine
activities (toco). Foetal movements can also be recorded.
Mechanism
The foetal heart rate is picked up with an external detector using Doppler effect, or during labour, with a foetal scalp electrode.
The uterine activities are usually picked up with a transducer applied on the maternal abdomen. The transducer cannot pick up the
exact intrauterine pressure, but it detects the changes of contour of the abdominal wall, which can reflect the frequency and
duration of the uterine contractions. If absolute intrauterine pressure monitoring is required during labour, an intrauterine catheter
can be inserted to the uterine cavity and connected to a transducer.
Function
Cardiotocogram is a valuable method of assessment of foetal well-being during antenatal period, as well as intrapartum period, in
modern obstetrics. It is also called non-stress test when used for antenatal monitoring. When it is used under artificial induction of
uterine contractions, it is called a contraction stress test. Contraction stress test is seldom used nowadays because of foetal risk and
inaccuracy of the test.
Mechanism
1. External cardiography
a. Doppler effect to detect cardiac movements
b. Heart rate is computed using the interval between each cardiac contraction
c. Can also detect maternal pulses
d. Auto-correlation to filter noises
2. Fetal Scalp Electrodes
a. Detect the fetal ECG
b. Heart rate is computed using the RR interval
c. Can also detect maternal ECG
d. Require rupture of membranes
Interpretation of CTG
Always remember the 3 components
1. Uterine Contractions
2. Fetal movements
3. Fetal Heart Rate Tracing
a. Baseline heart rate
b. Baseline variability
c. Accelerations
d. Decelerations
A maternal heart tracing can be added by attaching the mother to pulse oximeter to distinguish fetal bradycardia and maternal
heart rate
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Figure 33 Early onset. These may be normal in late labour but should not be ignored if persistent or severe.
Figure 35 Variable onset. These are thought to be due to cord compression. They are quite common and may be related to the
mother's position. They should not however be ignored if persistent or associated with other adverse features.
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Royal College of Obstetricians and Gynaecologists (RCOG) Categorisation of Foetal Heart Rate features
1. Normal: All features fall into the reassuring category.
2. Suspicious: 1 feature falls into the non-reassuring category.
3. Pathological: 2 or more features fall into the non-reassuring category; OR 1 or more features fall into abnormal category.
Features
Reassuring
Non-reassuring
Baseline
110-160
100-109
Variability
5
<5 for 40-90 mins
Abnormal
1.
2.
3.
<100
>180
Sinusoidal
pattern > 10
mins
Decelerations
None
1.
Early
deceleration
2.
Variable
deceleration
3.
Single
prolonged
deceleration
up to 3 mins
1.
Atypical
variable
decelerations.
2.
Late
decelerations
3.
Single
prolonged
deceleration
for > 3 mins
Accelerations
Present
Absence for >40 mins.
The absence of
acceleration with an
otherwise normal CTG
is of uncertain
significance
Uterine contractions
1.
It is recorded by external tocography: a strain gauge device detecting forward movement and change in the abdominal wall
contour on account of the contractions. It cannot measure the actual intrauterine pressure and hence not accurate. Note that
Itis also not accurate in obese or restless patients.
2.
Intrauterine pressure catheter can measure the actual intrauterine pressure with risk of infection and trauma and hence
limited clinical use.
Frequency
Duration
Peak
Basel tone
Optimal
3-4/10 min
40-90 sec
50-75 mmHg
8-12 mmHg
hypertonus
>4 /10 min
> 90 sec
>80mmHg
>15mmHg
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Foetal bradycardia
Protocol, as of 6 January 2005
1. Foetal bradycardia for 1 minute and not yet recovered
a.
Inform medical officer
b.
Look for any possible causes and manage accordingly:i.
Uterine hyperstimulation: stop any oxytocic administer hexoprenaline
ii.
Hypotension due to regional anaesthesia:Fluid replacement
Inform anaesthetist
Prepare vasopression which may be needed by anaesthetist
iii. Hypotension due to aorto-caval compression: lateral tilting of patient
iv. Placental abruption, uterine rutpure, cord prolapse: immediate delivery
c.
If 'bradycardia' is suspected to be maternal pulse, rule out the possibility either by maternal oxymetry, USG Foetal
heart or Foetal scalp electrode
d.
Take blood for cross-matching / set-up IV line if not yet done
e.
Enquiry of time of last food / fluid intake if not yet done
2. Foetal bradycardia persists for 3 minutes and not yet recovered
a.
Start preparing operation theatre for caesarean section
b.
Inform anaesthetist to stand-by
c.
Inform health care assistant to stand-by
d.
Check cervical status if vaginal delivery is feasible
e.
Prepare patient by explaining the following:i.
The current foetal condition
ii.
If foetal bradycardia persists, immediate delivery (caearean or instrumental) may be required
iii. Possible complications of operative delivery
3. Foetal bradycardia persists for 5 minutes and not yet recovered
a.
Decide caesarean section and get consent from patient immediately
b.
Aim at decision-to-delivery interval of less than 15 minutes
c.
Transfer to theatre as quick as possible, perform urinary bladder catheterisation and stripping of pubic hair in the
theatre
d.
Put the patient under anaesthesia whichever way is the fastest (which is general anaesthesia in most of the cases)
e.
Foetal heart rate would not be monitored in the theatre unless requested by the doctors
4. Foetal bradycardia recovers before decision of caesarean Depends on the foetal condition and the underlying cause of
bradycardia, foetal scalp blood sampling or early delivery may be indicated
5. Remark Decision for delivery could be made earlier depending on the actual situation and presence of any other risk
factors
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Action
Delivery indicated
Repeat FBS within 30 minutes or consider delivery if rapid fall since last sample
FBS should be repeated if the CTG abnormality persists
Procedure
a.
Need rupture of membrane
b.
Underseptic techniquie, insert amnioscope
c.
Scalp is dried with sponge or swab on long sponge-holders
d.
Scalp sprayed with ethyl chloride to induce hyperaemia and the area is covered with a think layer of paraffin jelly so that the
blood will not run down along the scalp
e.
A blade is used to make a small incision
f.
The blob of blood is touched with capillary tube
Protocol, as of 23 February 2004.
1. Preferably perform with patient in left lateral position.
2. Should not perform if breech presentation.
3. Repeat procedure (within 30-60 min of the first sample) if:
a. Initial scalp pH 7.20-7.25 or
b. persistent CTG abnormality
c. Inform Midcall-1 if repeated sampling is considered
Amnioscope
This is a set of instruments for performing foetal scalp blood sampling. It includes:1. Hollow tube that is put into the vagina for the examiner to see through and perform the procedure.
2. A blade on a long handle to make a small incision on the foetal scalp.
3. A light source.
4. A capillary tube to aspirate blood from the foetal scalp.
Foetal distress
Definition
This is a clinical diagnosis made antenatally or intrapartumly signifying an adverse foetal condition that requires an immediate
delivery, otherwise foetal hypoxic damage or birth asphyxia may follow.
Diagnosis
The clinical suspicion of foetal distress is usually based on foetal heart rate pattern on the cardiotocogram (CTG). Although CTG
is sensitive, it is not specific for foetal hypoxia and acidosis. Correct interpretation of CTG is very important in making the
diagnosis, and foetal scalp blood sampling should be performed whenever possible to assess the foetal blood pH. Finding of
acidosis (less than 7.2 during labour) confirms the diagnosis and the foetus should then be delivered immediately by caesarean
section or by instrumental delivery.
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Apgar score
Introduction
A numerical scoring system for neonatal assessment usually applied at 1 and 5 minutes after birth to evaluate the condition of the
baby, based on heart rate, respiration, muscle tone, reflexes and colour:
Sign/Score
Heart rate per minute
Respiratory effort
Muscle tone
Reflex response
Colour
0
Absent
Absent
Limp
None
Blue or pale
1
<100
Weak
Some flexion
Weak
Body pink, extremities blue
2
>100
Strong
Well flexed
Strong
Pink
Birth asphyxia
Asphyxos in Greek means without pulse. Birth asphyxia is a poorly defined term. Originally it means depression at birth, which is
assessed by Apgar scoreIn the past, depression at birth was always assumed to be associated with hypoxia and acidosis. However,
it is now clear that depression at birth can be due to various causes, such as congenital abnormalities, drugs or trauma. Therefore,
it has been proposed that birth asphyxia should be defined biochemically as the presence of hypoxia, hypercarbia and acidosis, by
blood gas analysis using umbilical arterial blood.
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5. Operative delivery
Episiotomy
Definition and aim of episiotomy
It is a surgical incision of the perineum and vagina in order to prevent perineal tear during vaginal delivery.
Types of episiotomy
1. Posterolateral incision
It is the most common method. The incision starts from the posterior forchette of vagina and then goes postero-laterally, at 45
degrees from the midline. The main advantage is that it provides the best protection against anal sphincter damage. However,
it is more difficult to repair as the edges may retract unequally.
2. Median incision
It is a midline incision from the posterior forchette downwards. It may cause anal sphincter damage, although it is relatively
easier to repair (provided that there is no anal tear).
3. J-shaped incision
The incision starts from posterior forchette, initially in downward direction and then goes laterally. It is a theoretical
compromise of the above two.
Indications of episiotomy
1. The usual practice in Hong Kong is routine episiotomy. All nulliparous and almost all primiparous women would have an
episiotomy at delivery. Selective episiotomy is advocated in many Western countries. It is argued that episiotomy is not
necessary in majority of pregnant women, and the incision may even result in more perineal tear. The experience in Chinese
favours a routine episiotomy.
2. Episiotomy should be performed in instrumental delivery, delivery of macrosomic babies, vaginal breech delivery, and
delivery in occipito-posterior position.
3. In the vaginal delivery of a premature foetus, episiotomy may be needed to protect the foetal head from being forced
repeatedly against an unyielding perineum.
4. Other indications include shoulder dystocia, previous third degree perineal tear and any other conditions when considered
necessary by the attendant.
Procedures of episiotomy repair
1.
Examine for any vaginal and cervical tear before repair.
2.
Apply adequate local anaesthetics (10ml of 1% ligocaine infitration).
3.
Repair with absorbable stitch such as 2-0 Dexon or Vircyl.
4.
Repair vaginal wound with continuous stitch.
5.
Repair perineal wound with interrupted stitches, followed by a superficial continuous subcuticular stitch.
6.
At the end of the repair:
a. Perform digital vaginal examination to ensure an adequate vaginal opening.
b. Perform digital rectal examination to exclude any suture penetrated through the anorectal mucosa.
c. Remove any gauze packed inside the vagina.
Complications of improper episiotomy repair
Ano-vaginal fistula
Vaginal and vulval haematoma
Wound infection and dehiscence
Dyspareunia
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Cervical Tear
Cervical lacerations up to 2 cm are common and do not require suturing if there is no active bleeding.
Deep cervical laceration should be repaired or supervised by Mid-call-1. This may require general or regional anaesthesia,
especially when there is extension into the vaginal vault
Perineal tear
Classification
1. First degree tear, when only skin and mucosa are involved.
2. Second degree tear, when the muscles and the perineal body are involved.
3. Third degree tear, when the anal sphincter or rectum is involved.
Figure 36 Different degrees of perineal tear. (Left to Right) First, second and third.
Complications
1. Postpartum haemorrhage
2. Anal sphincter damage resulting in faecal incontinence
3. Poor healing of the wound resulting in ano-vaginal fistula
Terminology 2010
Operative delivery
1.
2.
3.
Instrumental delivery
What is instrumental delivery?
There are two types of instrument delivery:
1. Vacuum extraction
2. Forceps delivery
These allow the use of traction if delivery needs to be expedited in the second stage of labour. The overall instrumental delivery
rate is around 10.6% 15% in PWH
Level of instrumental delivery
Outlet
The foetal head is at or on the perineum
Scalp is visible at the introitus without separating the labia
Foetal skull has reached the pelvic floor
Sagittal suture is in anteroposterior diameter or right or left occiput anterior or posterior position
Rotation does not exceed 45
Low-cavity
The leading point of the foetal skull is at station +2 cm, but not on the pelvic floor rotation 45 (left or right
occiput anterior to occiput anterior, or left or right occiput posterior to occiput posterior rotation > 45
Mid-cavity
High-cavity
Not included in classification and any instrumental delivery for level higher than mid-cavity should be
abandoned because of significant risk
Level
Outlet
Head Descend
Foetal head reaches pelvic floor and at
the perineum.
Low
Mid
Below S+2 cm
Engaged
S to S+2 cm
Unengaged head
High
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Head position
Sagittal suture is in anteroposterior
diameter.
Direct OA or OP.
Direct OA or OP
Rotation > 45o
OT position
Any position
Terminology 2010
Indications
1.
2.
Maternal indications
a. Maternal exhaustion
b. Neurological disorder where voluntary efforts are contraindicated or impossible.
c. Avoid maternal exertion which may be dangerous to the mother, such as:
i. Severe cardiac diseases
ii. Hypertensive disorders, pre-eclampsia
iii. Liver cirrhosis with oesophageal varices:-risk of bleeding
Foetal indication
a. Foetal distress
i. Abnormal heart rate pattern
ii. Abnormal scalp pH
iii. Meconium stained Liqour
b. Cord prolapse
c. Vaginal breech delivery (use piper forceps only for after coming head)
Terminology 2010
Forceps
What are Forceps?
It is a pair of instrument designed for vaginal instrumental delivery. A forceps is divided into following parts:
1. Handle Is to produce a compression force on the impacted head and to facilitate traction
2. Lock Is where the pair articulates to each other. There are three types of lock:-sliding (in Kielland's forcep), crossover (in
most of the forceps), and fixed pivot.
3. Shank forceps with long shank is designed for delivery of foetal head at higher station (such as in mid and low-cavity).
Forceps with short shank (Wrigley's forceps) are used in outlet instrumentation. The longer shank increases maternal
discomfort and risk of soft tissue trauma.
4. Blade consists of a cephalic curve which is ovoid in shape designed for a moulded foetal head, and a pelvic curve to fit the
maternal pelvis
5. The axis of the blades and that of the handles can be parallel (in Kielland), or angled (in most of other forceps)
6. The variation in the design of the different parts are made for use in different situation:
a. Kielland's forceps are designed for rotation of head in mid to high-cavity instrumental delivery. Besides a long shank, the
pelvic curves are reduced to facilitate rotation inside the pelvic cavity. They have a sliding lock that facilitates correction
of asynclitism.
b. Wrigley's forceps are used for outlet delivery, and have a short shank and handle
c. Piper's forceps are designed for delivery of after-coming head in vaginal breech delivery. It has a long shank as well as an
angle between the axis of the blades and that of the shank.
Indications and prerequisites
See instrumental delivery
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Complications
1.
2.
Foetal injury
a. Facial bruising
b. Facial nerve palsy
c. Depression fracture of foetal skull
Maternal injury
a. Perineal, vaginal and cervical tears
b. Postpartum haemorrhage Complication rate is higher with higher-cavity forceps delivery and malposition of the forceps.
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Vacuum extraction
What is vacuum extraction?
It is a form of instrumental delivery and the instrument consists of the following parts:
1. Cup:-to be applied over the vertex area of the foetal head. It can be made of metal, or silastic material
2. Vacuum pump:-a electric pump to create a vacuum pressure
3. Rubber tubing connecting the vacuum pump and the cup
Figure 40 (Left to right) Vacuum cups for OA and OP position respectively; vacuum tubing; and vacuum machine.
Indications and prerequisites
See instrumental delivery
Procedure
1. Informed consent
2. Anaesthesia by local infiltration.
3. Insertion of the vacuum cup and apply it to the vertex.
4. Apply negative pressure to 60 cmH2O.
5. Apply traction synchronise to maternal effort.
6. Adequate episiostomy.
Complications
1. Foetal injury
a. Cephalhaematoma
b. subaponeurotic haematoma
2. Maternal injury
a. Tear of lower genital tract
b. Postpartum haemorrhage
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Terminology 2010
Caesarean section
Definition
A surgical procedure that involves the delivery of the foetus through an abdominal incision. It accounts for about 20% of all
births.
Classification
1. Lower segment CS (99.6%)
a. It is a transverse incision over the lower segment of the uterus
b. It is the most common incision used nowadays
c. Compared with classical incision, it is associated with less operative blood loss, more ease to repair, and the scar is less
likely to rupture (0.5%, see uterine rupture).
2. Classical CS (0.4%)
a. It is a midline longitudinal incision over the anterior wall starting from the fundus
b. It allows larger space for delivery
c. It is an old type of incision but is still used in modern obstetrics in some situations:i.
In preterm delivery when lower segment has not been formed yet
ii. In placenta praevia where lower segment is covered with placenta and delivery may be difficult or cause severe
bleeding
iii. In transverse lie
iv. In delivery of conjoint twins
Indications
1. When vaginal delivery is not possible or at high risk because of mechanical factors:
a. Contracted pelvis
b. Cephalo-pelvic disproportion
c. Failure to progress of labour
d. Failed induction of labour
e. Failed instrumental delivery
f. Macrosomia
g. Malpresentation such as:
i. Breech presentation, in particular footling breech
ii. Transverse lie
h. Placenta praevia
2. When immediate or early delivery is required before cervix is fully dilated:
a. Foetal distress
b. Maternal distress or complications such as pre-eclampsia, eclampsia
c. Intrauterine infection
3. When the labour progress is associated with foetal or maternal risk
a. IUGR foetus:-may be in distress when undergoing the stress of labour
b. Previous uterine scar or injury
i. Risk of uterine rupture during labour
ii. High risk in classical scar, myomectomy scar and previous history of uterine tear
Procedure
1.
Epidural anaesthesia.
2.
Abdominal incision:-usually Pfannenstiel incision is performed
3.
Dissection of urinary bladder to expose the lower segment of uterus
4.
Incision of the lower segment
5.
Delivery of the baby; followed by delivery of the placenta
6.
Repair of the lower segment, usually in two layers, with haemostasis
7.
Closure of the abdominal wall (parietal peritoneum, rectus sheath, skin). Usually a rediac drain is inserted into the subrectus
space to prevent haematoma formation.
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Maternal Complications
-
Excessive bleeding
Infection:-endometritis, wound infection
Uterine injury:-uterine tear
Visceral injury:-most common:-bladder
Complications related to anaesthesia
Deep vein thrombosis and thromboembolism
The maternal death rate is three times higher than with natural delivery
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Terminology 2010
Trial of scar
Protocol, as of 7 May 2001
Incidence: 17.2% of patients with one previous uterine scar.
1.
All patients with previous caesarean section are strongly encouraged to have trial of scar (TOS) unless:
a. More than 1 previous sections;
b. Previous classical Caesarean section;
c. Previous major uterine tear in which TOS was not recommended by the attending obstetricians;
d. Previous myomectomy with entry into endometrial cavity;
e. Previous hysterotomy;
f. Other obstetric indications for Caesarean section.
2.
Antepartum Management
a.
During the first antenatal clinic, counsel patient for TOS. Arrange admission at 41 weeks for uncomplicated
pregnancy (see postdate pregnancy).
b.
For those cases that require a repeat Caesarean section, arrange elective Caesarean section at 37-38 weeks.
c.
Meanwhile, arrange follow up in MCH.
d.
There is no need for radiological pelvimetry.
e.
If a written documentation of the nature of the scar is not available, the mode of delivery should be determined by
MRCOG.
f.
If the patient strongly refuses TOS despite explanation despite counselling by MRCOG, arrange elective Caesarean
section at 37-38 weeks.
3.
Intrapartum Management
a.
Inform MRCOG if vaginal PGE2 or syntocinon is needed for induction or augmentation of labour.
b.
To labour ward once there are regular contractions or the cervix is effaced.
c.
X-match and insert iv line
d.
Monitor progress, maternal and fetal well-being
e.
Intrauterine pressure monitoring is NOT mandatory
f.
Epidural analgesia is not contraindicated.
g.
Suspect scar rupture if abnormal fetal heart rate, abnormal abdominal pain, vaginal bleeding or high presenting parts.
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Terminology 2010
General Gynaecology
0. Gynaecology
Gynae means women. Gynaecology is a branch of medicine dealing with the diagnosis and treatment of disorders affecting the
female reproductive organs. It is subdivided into:
1. General gynaecology
2. Gynae-oncology
3. Reproductive medicine and Endocrinology
4. Urogynaecology
General gynaecology
1. Menstrual disorders
2. Menopause and Hormone replament therapy
3. Birth control (contraception and sterilisation)
4. Early pregnancy complications
5. Benign tumours of ovaries and uterus
6. Endometriosis and adenomyosis
7. Infections
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Terminology 2010
1. Menstrual problems
Menstrual disorders
Menstrual cycle
Menstruation resulted from the changes in endometrium in response to sex hormones which are under the regulation of the
hypothalamic-pituitary-ovarian axis. During the first half of the cycle, oestrogenic effect is dominant and causes proliferation of
the endometrial glands (proliferative phase). After ovulation, progestogenic effect becomes dominant, inhibits proliferative
changes and stimulates the secretary function of the endometrial glands (secretary phase). Decidualisation is irreversible. When
serum concentrations of these hormones decline, endometrial shedding is initiated and the menstrual loss consists of endometrial
glands and secretions as well as blood. The first day of the onset of the menstruation of the preceding cycle is defined as the last
menstrual period (LMP).
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Terminology 2010
Amenorrhea
Definition
1. Primary amenorrhea
a.
No menstruation by the age of 14 accompanied by failure to grow properly or develop secondary sexual
characteristics, or
b.
No menstruation by the age of 16 when growth and sexual development are normal
2. Secondary amenorrhea
Absence of menses in a woman who has menses before for:(1) 6 months, or
(2) 3 consecutive cycles,.
3. Oligomenorrhea
Occurrence of menses of:(1) 5 or less occasions per year, or
(2) more than 6 weeks in most of the cycles
Causes
To have normal cyclic menstruation, one must have:
1. An intact hypothalamus-pituitary-ovarian axis producing normal ovarian cycles
2. A normal endometrium that respond to ovarian hormones
3. A normal outflow tract:-cervix, vagina and vulva
Therefore amenorrhea occurs when there are:
1. Physiological:- Pregnancy, lactation, menopause.
2. Failure of hypothalamus-pituitary-ovarian axis: (WHO Type II)
a.
Hypothalamus:-anorexia nervosa, Kallman syndrome, etc
b.
Pituitary:- Stress, Anorexia nervosa, antipsychotics, prolactinoma
c.
Ovary:i.
Ovarian failure (WHO Type III) [Hypergonadotrophic amenorrhoea]:- Turner syndrome, Testicular feminisation
syndrome, ovarian dysgenesis, resistant ovarian syndrome, premature menopause
ii.
Ovarian hormone dysfunction (WHO Type I)[Normogonadotropic amenorrhoea]:- Polycystic ovarian disease
3. Absence of normal endometrium:
a.
Uterine agenesis, Mullerian tract abnormality, androgen insensitivity syndrome
b.
Asherman syndrome, TB endometritis.
4. Obstruction of outflow tract:
a.
Vaginal:-transverse vaginal septum, vaginal agenesis or hypoplasia
b.
Vulval:-Imperforate hymen
5. Other endocrinopathy
a.
Hyperthyroidism
b.
Cushings syndrome
Remarks
1. Endocrinopathologies usually cause secondary amenorrhea except primary ovarian failure such as Turner Syndrome and
ovarian dysgenesis.
2. Structural abnormalities of uterus and outflow tract often result in primary amenorrhea except in Asherman syndrome.
3. Pregnancy and natural menopause are two physiological causes of amenorrhea that should be considered in women at
reproductive age and perimenopausal age respectively.
4. Amenorrhoea is related to a spectrum of pathologies, and it is not the only but one of the different manifestations. Patients can
present with absent secondary sexual maturation, infertility or long term compications, e.g. endometrial cancer, osteroporosis,
cardiovascular diseases, etc.
Clinical evaluation
1. General examination
2. Body weight, height and growth
3. Secondary sexual characteristic, breasts and body hair
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Terminology 2010
Investigations
Depends on the clinical suspicion, the following investigations are required:
1. Karyotyping:-Turner syndrome, testicular feminisation syndrome
2. Hormonal profile:-FSH for ovarian failure, LH/FSH ratio for PCOD, prolactin for hyperprolactinemia
3. Radiological examination for structural abnormalities of genital tract such as uterine agenesis.
4. Radiological examination of urinary tract may also be required in case of abnormal genital tract as both systems are related in
embryonic development
Primary amenorrhoea
More focus on growth and development
History
- Family history of menarche
- Growth and sexual development
- Medical and Drug history
Physical Examination
- Height, weight, body form (? Turner syndrome), growth
- Secondary sexual characteristics: (Breast beware of AIS,
axillary and pubic hair, external genetalia ? signs of
virilism)
Secondary amenorrhoea
More focus on endocrine pathologies
History
- Menstrual History
- Medical & Drug History
- Symptoms related to aetiology:
- Stress, weight loss, exercise
- Galactorrhea, headache, visual disturbances
- Hirsutism, hotflush
Physical Examination
- BMI
- Stigmata of other endocrine diseases
- Goiter
- Galactorrhea, bitemporal hemianopia
- Hirsutism, virilism
- Stigmata of hypo-estrogenism
- Atrophic genetalia
* Fertility wishes
1. Karotyping: 46XX = Pure Gonadal Dysgenesis; 46X = Turner Syndrome; 46XY = AIS
2. Hormone assay: FSH, LH, E2, PRL, TFT, androgens; mid-luteal progesterone (confirm ovulation); hCG
3. Radiological examination
4. USG Pelvis (presence of uterus / other structural abnormalities), Ovary (PCO),
5. MRI pituatary
6. Others:
Hysteroscopy: Asherman, TB
Laparoscopy and EUA: for Gonad, Uterine abnormalities, Vaginal or vulval abnormalities
Autoimmune (premature ovarian failure)
Treatment
1. Treat underlying causes if possible
2. Restore fertility:
a.
Endocrinopathologies are always associated with anovulation and infertility, and may require ovulation induction or in
vitro fertilisation.
b.
Patients with ovarian failure or absence of uterus or normal endometrium, are infertile. Oocyte donation and surrogacy
are the alternatives.
3. Restore sexual function Vaginal malformations (septum, hypoplasia, agenesis) require surgical correction
4. Restore growth and development Patients with Turner syndrome are short and with poor breasts development. Early
hormonal replacement therapy is required.
5. Protect against any long-term complication
a.
WHO Type I Protect against chronic unopposed E2 stimulation (CA Breast, CA endometrium) by OCP.
b.
WHO Type II & III Protect agains hypoestrogenism (Osteoporosis and cardiovascular disease) by HRT.
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Terminology 2010
FSH & LH
Prolactin
High
(>1000IU/L)
Normogonadotrophic Normal
Normal
Normal
Hypergonadotrophic High
(>20IU/L)
Low
Normal
-ve Karyotyping
Hypogonadotrophic Low
Low
Normal
-ve ---
Anatomical
Normal
Normal
Normal
E2
Terminology 2010
Oligomenorrhea
Defined as in Amenorrhea. It is common among teenagers as well as perimenopausal women, and is usually associated with
anovulation as a result of underlying endocrine disorders such as polycystic ovarian disease (PCOD) and hyperprolactinemia.
Cryptomenorrhea
Cryptomenorrhea means hidden menstruation. This occurs when endometrial shedding takes place but the menstrual loss cannot
escape due to blockage of parts of the lower genital tract, usually as a result of congenital malformations:-e.g. In vaginal atresia,
transverse vaginal septum, and imperforate hymen. The uterus or vagina is distended with menstrual blood. Patients present with
primary amenorrhea, cyclic lower abdominal pain, and abdominal distension, and urinary retention (due to distended uterus).
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Terminology 2010
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Terminology 2010
Complications
1. Reproductive disorders
a.
Infertility
b.
Recurrent abortion
c.
High risk of ovarian hyperstimulation syndrome (OHSS) when undergoing
ovulation induction
2. Metabolic disorders Risk of insulin resistance, hypertension.
3. Long term risk of cancer Risk of endometrial hyperplasia and endometrial carcinoma
Biochemical features
1. Increased LH levels
2. Elevated (early follicular) LH/FSH ratio > 3
3. Increased sex-hormone-binding-protein
4. Increased androgen secretion
5. Associations with hyperprolactinemia and hyperinsulinemia
Ultrasound features
1. Bilateral enlarged ovaries
2. Multiple (>10 each side) small cysts of size 1-5mm arranged at the periphery of the ovaries (necklace appearance)
3. Thickened stroma
Diagnosis
1. Biochemical:a.
More specific
b.
High LH to FSH ratio >3
2. Ultrasonic:a.
Less specific as it may occur in other endocrinopathologies that result in anovulation
b.
Features as described above
Management
1. General measures
a.
Weight reduction
b.
Counsel for the risk of diabetes, endometrial carcinoma
c.
OGTT, endometrial sampling may be indicated
2. Treatment of menstrual problems
a.
Aim to regulate cycles as well as to protect against endometrial hyperplasia
b.
Can use combined oral contraceptives or progestogen if pregnancy is not wished
c.
Can use clomiphene citrate if pregnancy is wished
3. Treatment of infertility See ovulation induction
4. Treatment of hirsutism See hirsutism
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Terminology 2010
iii.
iv.
v.
Infertility
Refer to infertility clinic
Check metabolic profile in 9F (OGTT, fasting glucose/insulin & lipid)
Exclude other co-existing infertility problem
Medical ovulation induction if confirm anovulation
z
1st line treatment: clomiphene citrate
z
2nd line treatment: metformin, ovulation induction by gonadotropins, laparoscopic ovarian
drilling
Co-existing metabolic syndrome (glucose intolerance, hyperlipidaemia etc Refer to COMBINED
gynae-endocrinology clinic
With evidence of endometrial hyperplasia,
Correct endometrial hyperplasia before any plan for pregnancy
Follow protocol Endometrial hyperplasia for the management
Kallman syndrome
1.
2.
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Terminology 2010
Anorexia nervosa
Introduction
Anorexia nervosa is one of the underlying causes of secondary amenorrhea in young women. Because of significant weight
reduction, the hypothalamus-pituitary-ovarian axis is suppressed, resulting in hypogonadotropic hypogonadism. It is a potentially
fatal disorder if not treated.
Epidemiology
1. 1% of young females
2. Predominant age group:-10-20+ years old
3. Male to female ratio:-at least 1:10
Subtypes restrictive and bulimic.
Clinical features
1. History
a.
Marked weight loss (of more than 15% of standard weight or BMI less than 16.5kg/m2), in the absence of any
primary medical disorder
b.
Food refusal attributed to fat-phobia, stomach bloating, no hunger, no appetite, fear of food.
c.
Weight controlling behaviour:-dieting, exercise, use of anorectics, laxatives or diuretics
d.
Self-induced or spontaneous vomiting, especially in fat-phobia
e.
Delusion of self body image
f.
Stunted growth (pre-pubertal)
g.
Amenorrhea
2. Physical signs
a.
Hypotension
b.
Bradycardia
c.
Lanugo
d.
Hypothermia
e.
Varying degrees of dysphoria, obsessionality, perfectionism or low self-esteem
f.
Biochemical disturbances
Aetiology
- Personal:-personality
- Family:-enmeshed or conflicting
- Environment:-stress, peers, relationships, losses
- Socio-cultural:-media publicity, gender role conflict, disempowerment
- Biological:-genetics? Neuroendocrine?
Management
Multi-disciplinary approach.
1. Assessment:
a.
Physical condition, e.g., degree of weight loss
b.
Psychosocial factors:- Suicidal risk and co-morbid psychiatric disorders
2. Treatment:
a.
Nutritional counselling, gradual weight gain, treat any physical condition if needed
b.
Psychological treatment:- Individual motivation enhancement therapy and family therapy
c.
No medication is proven to be effective
Poor prognostic factors
1. Significant weight loss
2. Chronicity
3. Presence of purging or bulimia
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Terminology 2010
Prolactin
A hormone secreted from the anterior pituitary gland, responsible for glandular proliferation of breasts and establishment of
lactation. It can also reduce gonadal activity by decreasing the pulsatile secretion of gonadotropin releasing hormone from the
hypothalamus, and blocks the action of luteinising hormone on the ovary. Normally the secretion of prolactin is under the
inhibition of dopamine secretion from the hypothalamus. Physiological hyperprolactinemia occurs during pregnancy, after
childbirth and continuation of lactation, and during stress. Pathological hyperprolactinemia can be resulted from prolactinoma,
other pituitary gland tumours that block the dopaminergic tract from the hypothalamus, anti-dopaminergic agents such as
anti-psychotic agents. Prolactin level may also rise in case of polyscytic ovarian disease and hypothyroidism. Hyperprolactinemia
results in amenorrhea, anovulation, and galactorrhea.
Hyperprolactinaemia
Causes of hyperprolactinemia
1. Physiological
a.
Prolactin levels are influenced by the time of day when blood is collected, and are also increased by stress
b.
Transient rises can occur at ovulation
c.
During pregnancy and lactation
2. Pathological
a.
Prolactinoma or other pituitary gland tumour
b.
Other pituitary gland tumours that block the dopaminergic inhibitory tract from the hypothalamus
c.
Drug induced:-anti-dopamingeric
d.
Association with polycystic ovarian disease (PCOD)
Clinical presentation
- Oligo-amenorrhea
- Galactorrhea
Further investigation
- Mild hyperprolactinemia can be a transient `physiological change (see above) and may require no further investigation, or a
repetition of the test.
- Significant hyperprolactinemia requires radiological investigation to rule out prolactinoma or other pituitary gland tumours.
Principle of treatment
- Dopaminergic agent:-bromocriptine
- Surgery for macro-prolactinoma or other pituitary gland tumours
Protocol, as of 9 May 2005
1. Work up
a.
Detailed drug history To exclude drug-induced hyperprolactinaemia (e.g. anti-psychotics)
b.
Pregnancy test To exclude pregnancy
c.
sTSH To exclude hypothyroidism
d.
Repeat prolactin if prolactin < 1000 IU/L
e.
Arrange MRI pituitary to look for pituitary adenoma or space-occupying lesion if
i.
Patient is symptomatic (e.g. menstrual disturbance, galactorrhoea & infertility) and there is persistent
hyperprolactinemia (regardless to the level of prolactin)
ii.
Prolactin > 1000 IU/L, regardless of symptoms
iii. There is evidence of pituitary insufficiency (e.g. hypogonadism, hypothyroidism, delayed puberty or growth
failure), even with modest elevations of prolactin. Non-functioning pituitary tumor may present with only
mildly elevated prolactin level due to the compression of the hypothalamus-pituitary stalk.
iv. There are neurological symptoms
f.
Screening for macroprolactinaemia
i.
Automatically performed in our hospital if hyperprolactinaemia is detected
ii.
If positive, the test will automatically be repeated with a more specific assay
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Terminology 2010
2.
3.
4.
5.
6.
7.
8.
Treatment
a.
If repeat prolactin confirmed hyperprolactinaemia but < 1000 IU/L and
i.
Patient is asymptomatic (no galactorrhoea / menstrual disturbance)
Discharge from gynae-endocrinology clinic
Refer to medical endocrine clinic for assessment of persistent hyperprolactinaemia
ii.
Patient is symptomatic (galactorrhoea / menstrual disturbance)
Give bromocriptine (Follow the protocol Bromocriptine)
Arrange MRI pituitary
b.
If MRI result is not available and prolactin 1000 IU/L, give bromocriptine regardless of symptoms
c.
If MRI shows pituitary microadenoma (<10mm), in the presence of hyperprolactinemia, give bromocriptine
regardless of the symptoms
d.
If MRI shows pituitary macroadenoma (10mm) or other CNS tumours
i.
Give bromocriptine regardless of symptoms
ii.
Urgent referral to neurosurgery clinic and medical endocrine clinic
e.
If hypothyroidism (elevated sTSH) is detected, refer to combined gynae-endocrinology clinic for treatment plan
Long term management
a.
If the main problem is infertility, work up for other infertility cause and refer to infertility clinic
b.
Otherwise
i.
Follow up in gynae-endocrinology clinic
ii.
Review symptoms and prolactin level (check PRL two weeks before follow up)
When gynaecological symptoms have resolved and PRL has been normalized with bromocriptine,
If MRI has shown pituitary microadenoma,
Refer to combined gynae-endocrinology clinic for decision on long term management as long term treatment is anticipated,
refer out to Integrated Family Medicine clinic for continuation of bromocriptine therapy will be considered.
If MRI has shown no pituitary adenoma, stop bromocriptine and follow-up for symptoms and prolactin level
a.
If symptoms or hyperprolactinaemia recur
i.
Resume bromocriptine
ii.
Refer to combined gynae-endocrinology clinic for decision on long term management
b.
If asymptomatic and prolactin remains normal after treatment stopped
i.
Discharge from clinic
ii.
Advise self surveillance with regular monitoring of prolactin
If drug-induced hyperprolactinaemia (e.g. anti-psychotics) is suspected, follow the protocol Antipsychotic
Antipsychotic-induced hyperprolactinaemia
Protocol, as of 9 May 2005
1. Pituitary adenoma has not yet been ruled out work up for other causes of hyperprolactinaemia and start treatment as
described in the protocol hyperprolactinaemia.
2. If MRI shows no evidence of pituitary adenoma and
a.
Patient is asymptomatic
i.
Stop bromocriptine
ii.
Reassure and discharge from clinic
iii. Advise to attend if symptoms (galactorrhoea / menstrual disturbance) occur
b.
Patient is symptomatic
i.
Consult psychiatrists for dose reduction or change of the antipsychotic drugs if applicable
ii.
Treatment is based on symptoms
Menstrual disturbance change from bromocriptine to Nordette
Galactorrhoea / infertility continue bromocriptine
iii. # Nordette is not contraindicated once pituitary adenoma has been excluded
3. If MRI shows pituitary adenoma Refer to combined gynae-endocrinology clinic for decision on long term management
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Terminology 2010
Galactorrhoea
It is the spontaneous milk secretion from breasts not associated with childbirth or the lactation. It is associated with
hyperprolactinemia.
Protocol, as of 1 November 2004
1. Exclude pregnancy, exclude local causes, check prolactin level.
2. If prolactin level is elevated Follow the protocol hyperprolactinaemia
3. If prolactin level is normal, reassurance if symptoms are not disturbing
a.
Give bromocriptine if symptoms are disturbing
b.
Step-up dosing as described in the protocol Bromocriptine Titrate the dose according to the amount of galactorrhoea.
Tail off bromocriptine (stepwise reduction of the dosage by 50%) if symptoms resolve
Bromocriptine
Protocol, as of 9 May 2005
1. Initial treatment
a.
Step-up dosing
i.
1.25 mg nocte for 1 week then
ii.
2.5 mg nocte for 9 weeks
b.
Follow up in Intern Clinic 10 weeks & Gynae-endocrinology Clinic as routine
i.
Check prolactin level two weeks before each follow up
ii.
See follow-up plan on next session
iii. # The intern should consult doctors in gynae-endocrinology clinic on the same day if dose adjustment for
bromocriptine is necessary
2. Follow up treatment
a.
Review side effects (e.g. drowiness), symptoms improvement and prolactin level to adjust the dose accordingly:b.
If symptoms resolved, prolactin normalized and no side effect from drug maintain bromocriptine at 2.5mg nocte till
next FU
c.
If symptoms resolved, prolactin normalized but side effects from drug
i.
Bromocriptine can be reduced to the lowest maintenance dose of 1.25mg daily
ii.
Follow up 10 weeks in gynae-endocrinology clinic after dose adjustment (check prolactin two weeks before FU)
d.
If symptoms and/or hyperprolactinemia persist or recur,
i.
Increase the dosage
ii.
Follow up 10 weeks in gynae-endocrinology clinic after dose adjustment (check prolactin two weeks before FU)
e.
If patient is refractory to bromocriptine (total daily dose of 10mg) or cannot tolerate it,
i.
Change from bromocriptine to cabergoline (0.5mg once/week for the first week & then twice/week)
ii.
Follow up 10 weeks in combined gynae-endocrinology clinic (check prolactin two weeks before FU)
iii. Adjust the dosage according to symptoms and prolactin
Asherman syndrome
The partial or complete obliteration of the uterine cavity by adhesions (synechiae) caused by endometrial infection (such as
tuberculosis), or over-vigorous curettage after miscarriage or abortion. Depending on the severity of adhesions, amenorrhea,
hypomenorrhea, spontaneous abortion or infertility may occur. Endometrial ablation is a surgical procedure aiming at reduction or
complete cessation of menstrual flow by iatrogenically inducing Asherman syndrome, through electrical cauterization of the
endometrial cavity.
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Terminology 2010
Menorrhagia
Definition
1. Subjective complaint of excessive cyclical menstrual bleeding
2. Objective measurement
a.
Defined as >80 ml of menstrual loss.
b.
The mean menstrual blood loss per menstruation in a healthy woman ranges between 37-43ml.
i.
Menstrual blood loss of more than 80ml is regarded as excessive, and this occurs in 9-14% of women. However,
it is very difficult to document the volume of blood loss clinically
ii.
Only about 50% of women presenting with menorrhagia actually have a loss outside the normal range (>80ml).
iii. About 60% of these women would become anaemic.
iv. There is also a poor correlation between subjective and objective assessment of blood loss.
Incidence
Hong Kong incidence 3.2% in 2004.
Causes
1. Primary:- Dysfunctional uterine bleeding (DUB)
a.
It is the most common cause of menorrhagia
b.
By the name implies, there is no underlying organic cause
c.
The diagnosis is made on clinical basis, after excluding other possible organic causes (see below)
2. Local:a.
Uterine cavity:- IUCD
b.
Endometrium:- Endometritis, polyp, hyperplasia and carcinoma
c.
Myometrium:- Uterine fibroid (epsically submucosal), adenomyosis
3. Systemic:a.
Endocrine:- Hypothyroidism, Cushings disease, Exogenous steroids
b.
Bleeding tendency:-Von Willebrand's disease, idiopathic thrombocytopenia, anticoagulants.
Assessment
1. History taking
a.
Routine gynaecological history, especially focus on menstrual history
b.
When does the menstrual problem start
c.
Volume of loss each period
i.
How many and how frequent does the patient change pad each day
ii.
Any flooding of blood clots
iii. How long does each period last
d.
Any anemic symptoms and sign
e.
How is the social life affected
2. Physical Examination
a.
General: pallor, goitre, tachycardia
b.
CVS: tachycardia
c.
Abdominal: pelvic masses
d.
Pelvic for polyp, inspection of cervix, etc.
3. Investigations
a.
Blood: CBC, Fe profile; Other if suspected
b.
Radiological: USG only indicated if any abnormalities detected or fail medical treatment
c.
Endometrial assessment / Hysteroscopy for Age > 40; Long standing symptoms; Irregular bleeding or No response to
previous medical treatment
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Terminology 2010
Treatment
Depends on the cause of menorrhagia, age of patients, and wish of patients to preserve fertility:
1. Medical Treamtments:a.
General (Fertility desired)
i.
Mefenamic acid (Ponstan): 30% decrease, for dysmenorrhea
ii.
Tranexamic acid (Transamin): 40-50% decrease, commenced during bleeding
b.
Hormonal (Fertility not desired)
i.
Combined oral contraceptives: effective, for irregular cycles
ii.
Levo-norgestrel IUCD (LNG-IUS, Mirena)
iii. Danazol (A mild testosterone.)
iv. Cyclical Progestogens: No contraceptive effects
v.
GnRH Analogues
2. Surgical Treatments:a.
Endometrial ablation
b.
Myomectomy
c.
Hysterectomy
3. Remarks
a.
In general, medical therapy should be attempted for DUB. Surgical treatment is considered if medical treatment is
failed, or in severe case of DUB.
b.
Medical treatment is less useful for fibroids and adenomyosis1
c.
Myomectomy is only for treatment of fibroids if patients want to conserve uterus, otherwise fibroids and adenomyosis
are better dealt with hysterectomy.
d.
Complex atypical endometrial hyperplasia and endometrial carcinoma should be treated with hysterectomy1
Discussion/Something to Consider
Do you know any methods to estimate the menstrual blood loss clinically?
Metropathia haemorrhagia
A term to describe a very heavy menstruation after several weeks of amenorrhea which is associated with anovulation cycles.
Follicular development occurs and continues as ovulation fails to take place. This results in high circulating oestrogen levels
which continue to stimulate endometrial development in the absence of antagonism of progesterone. The consequence is cystic
glandular endometrial hyperplasia. Eventually, after several weeks the endometrium breaks down and prolonged heavy bleeding
occurs.
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Terminology 2010
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Terminology 2010
Follow up visit
1. Responded to first-line medical treatment
a.
If no anaemia Discharge from clinic with medication
b.
If iron deficiency anaemia
i.
Optimise medical treatment
ii.
Prescribe iron sulphate 300 mg tds for 4-6 weeks
iii. Follow up in routine appointment, recheck CBP 1 week before appointment
2. Failed first-line medical treatment
a.
Arrange USG, preferrably transvaginal, to assess for structural intrauterine lesion, like submucosal fibroid or
endometrial polyp
b.
If high suspicion of structural intrauterine pathology, refer for OPH directly
c.
Discuss with patient about second-line management
i.
If patient needs to preserve fertility Levonorgestrel IUCD
ii.
If fertility is not desired Consider Levonorgestrel IUCD or endometrial ablation
d.
Levonorgestrel IUCD (Mirena)
i.
This is particularly preferred for those aged less than 40
ii.
This should be considered if patient is dependent on oral Norethisterone
iii. Pre-insertion OPH to rule out intrauterine structural lesion is preferable
e.
Advise surgery especially if anaemia persists:i.
Endometrial ablation if absence of large uterine fibroid or co-existing symptomatic adenomyosis or
endometriosis Refer to guidelines on booking of second generation endometrial ablation
ii.
Hysterectomy if presence of large or multiple uterine fibroid, or co-existing symptomatic adenomyosis or
endometriosis
iii. Hysteroscopic surgery
If endometrial polyp or submucosal fibroid is confirmed on OPH, consider arranging endometrial
ablation at the time of hysteroscopic surgery if the patient aged > 40 and had complete family,
especially for those with documented anaemia.
For submucosal fibroid > 3 cm, consider giving preoperative GnRHa for 3 months to shrink it before
operation.
GnRHa should be given 6 to 8 weeks before operation if concurrent endometrial ablation is to be
performed.
Discharge
In general, patient can be discharged from clinic if there is no active management which can only be offered in gynaecology
specialists clinic. Patient can be discharged from clinic if she has no active menstrual problem, even on first visit. Patient can
be discharged from clinic if the response to procedure for menorrhagia is satisfactory. Patient can be referred back to their
family doctor if her menstrual problem has been solved by simple medication.
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Terminology 2010
Postcoital bleeding
It is a vaginal bleeding after coitus. An acute onset can be due to trauma secondary to intercourse. Tear of hymen is common after
the first coitus, and tear of vagina sometimes occurs after a vigorous intercourse. Postcoital bleeding is also a symptom of cervical
lesions such as cervical cancer, cervical polyps, cervicitis, or occasionally endometrial polyps.
Postmenopausal bleeding
It is any vaginal bleeding occurs after menopause. It is always abnormal and investigation should not be delayed. There are many
possible causes and genital malignancies should be ruled out in the menopausal age group of patients.
Causes
1. Uterine pathology:
a.
Atrophic endometritis It is the most common cause and the diagnosis is made after excluding other pathologies
b.
Endometrial polyp
c.
Endometrial carcinoma
d.
Uterine sarcoma:-rare
e.
Endometrial glands activation following hormonal replacement therapy or stimulation by endogenous oestrogen from
ovarian stromal tumours
2. Cervical pathology:
a.
Cervical polyp
b.
Cervical cancer
c.
Cervicitis
3. Fallopian tube pathology: Fallopian tube cancer. Very rare but postmenopausal bleeding may be the sole symptom
4. Vaginal pathology:
a.
Vaginal cancer
b.
Vaginal infection and ulcer:-particularly decubitus ulcer following genital prolapse
5. Vulval pathology:
a.
Vulval cancer
b.
Vulval infection and ulcer
Assessment
1. Any lower genital tract pathologies are usually picked up by speculum and digital examination.
2. Diagnosis of endometrial pathologies requires a hysteroscopy or endometrial sampling.
Remark
Sometimes per rectal bleeding or haematuria may be mistaken as vaginal bleeding. Clinical assessment should be able to
differentiate these conditions.
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Terminology 2010
Dysmenorrhoea
Definition
1. Primary (idiopathic) dysmenorrhoea Painful periods for which no organic or psychological cause can be found
2. Secondary dysmenorrhoea ainful periods for which an organic or psychosexual cause can be demonstrated
3. Remark The uses of the terms 'primary' and 'secondary' are different from that in infertility
Causes of primary dysmenorrhea
1. Primary dysmenorrhoea
a.
The cause is unknown but there is a familial tendency, with a strong likelihood that the attitude of the mother may
influence the response of the daughter
b.
It occurs in ovulatory cycles during when prostaglandins production may cause vasoconstriction or myometrial
contraction, resulting in pain.
2.
Secondary dysmenorrhea
a. Endometriosis, Chronic pelvic inflammatory disease
b. Adenomyosis, Submucosal fibroid
c. Uterine cavity and outflow tract: Ashermans syndrome
Mittelschmerz
It means pain in the middle. It is the lower abdominal pain in women which occurs at the mid-menstrual cycle and is generally
assumed to be related to ovulation. It is suggested that the pain is due to peritoneal irritation by follicular fluid and blood
following rupture of the follicle. However, the relation of the pain to the exact time of ovulation and to the side on which
ovulation has occurred is variable.
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Terminology 2010
Premenstrual syndrome
Definition
1. Primary premenstrual syndrome (primary PMS)
a.
A disorder of non-specific somatic, psychological or behavioural symptoms that recur in the premenstrual phase of the
menstrual cycle, but resolve completely by the end of menstruation, leaving a symptom-free period. The symptoms
are of sufficient severity to produce social, familial, or occupational disruption.
b.
Symptoms must have occurred in at least four of the six previous menstrual cycles.
2. Secondary premenstrual syndrome (secondary PMS)
Similar to primary premenstrual syndrome except that the symptoms do not completely resolve when the menstruation
ceases (i.e. Not symptom-free period), but does significantly improve for at least 1 week after menstruation.
3. Remark:
The implication of these definitions is that in secondary PMS there is an underlying psychological disorder whose
aetiology is similar to that of common psychiatric disorders such as depression or anxiety. Both primary PMS and the
cyclical component of secondary PMS are presumed to be related to the endocrine changes of the ovarian cycle.
Clinical features
1. Common somatic symptoms:-Breast pain, pelvic pain, abdominal bloatedness, lethargy and tiredness
2. Common psychological symptoms:-Depressive mood, decreased libido, anorexia, insomnia
3. Common behavioural symptoms:-Loss of self-control, loss of judgment, impulsive behaviour
Aetiology
Unknown. It may be due to variations in sex steoid levels and low serotonin levels.
Diagnosis
1. Many women will have some forms of discomfort during or before menstruation. To make a diagnosis of PMS, the symptoms
must fulfill the definition of PMS:-occur cyclically; be severe enough to cause disruption of women daily living, and occur
for at least 4 out of 6 cycles.
2. Rule out underlying psychiatric disorder such as depression, anxiety and psychosexual problems, and endocrine causes such
as menopause, hyperthyroidism, and organic causes such as endometriosis, pelvic inflammatory disease.
3. There is no specific test to confirm PMS. In difficult case, GnRHa depot for 3 months may be indicated to suppress
menstruation. Total cessation of the symptoms after the menstruation has suppressed is a support of the diagnosis of PMS.
Treatment
1. There are various forms of medications proposed but none of them are well proven to be effective with randomized controlled
trials.
2. Oral contraceptive pills, progestogens, vitamin B6 may be tried. Danazol and GnRHa can effectively suppress menstruation
but also have side-effects. In severe cases refractory to medical treatment, oophorectomy is the last resort.
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Terminology 2010
2. Birth control
Contraception
Methods of contraception
1. Natural methods
a.
Periodic abstinence (rhythm or calendar method)
i.
It means the avoidance of intercourse during the fertile period of the cycle.
ii.
There are different methods to predict the fertile period, such as calendar method, mucus method or by basal
body temperature
b.
Coitus interruptus
i.
It means the withdrawal of the penis in time, before ejaculation, ensuring that all sperms are deposited outside
the vagina. However, there are few sperms in the pre-ejaculate.
ii.
The failure rate is high (Pearl index = 10/100 women yr), mainly due to conscious rule breaking
c.
Lactational amenorrhoea
i.
3 criteria must be met: (1) Within 6 months postpartum; (2) Exclusive breastfeeding; and (3) Amenorrhoeic.
ii.
98% effective.
2. Barrier methods
a.
The method failure rate is low (4%) but the user failure rate is high (Pearl index = 10/100 women yr), mainly due to
inconsistent or improper use. It is sometimes used together with spermaticides to increase the effectiveness.
b.
It consists of Male condom, Female condom, Diaphragm and Cervical cap with or without spermicides.
3. Hormonal methods
a.
Combined oral contraceptives (COC)
b.
Progestogen-only pills (mini pills)
c.
Progestogen injectable
4. Intrauterine contraceptive devices (IUCD)
a.
Non-medicated / Inert IUCD
b.
Copper-containing IUCD
c.
Hormone-containing IUCD
Factors in choosing different kinds of contraception
1. Failure rate:
a.
Can be due to method failure and user failure
b.
Assessed in term of Pearl index or life table analysis
2. Reversibility How fast and how effective of recovery of fertility after stopping use of the contraceptive method
3. Side effects:
a.
Sexual satisfaction
b.
Menstrual disturbance
4. Non-contraceptive benefits:
a.
COC can also treat dysmenorrhea and menorrhagia
b.
Condoms can also prevent sexually transmitted diseases
5. Patient's past medical history:
a.
COC is contraindicated in case of history of thromboembolism
b.
Patient's acceptability and compliance
c.
Progestogen injectable requiring 4 injections a year while COC has to be taken every day.
Postcoital contraception
See postcoital contraception
Pearl index
It is a measurement of the effectiveness of a method of contraception. It is defined as number of failure per 100 women years of
exposure. The denominator is the total months (or menstrual cycles) exposed from onset of method until completion of study or an
unintended pregnancy, or discontinuation of the method by the users. The nominator is the number of unintended pregnancy. It
measures method and user failure.
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Terminology 2010
Method
Lowest expected
Norplant
0.05
0.05
Male sterilisation
0.15
0.1
Female sterilisation
0.5
0.5
0.05
Depo-provera injection
0.3
0.8
0.6
LNG-IUS
0.1
0.1
0.3
0.3
0.3
0.3
15
21
Coitus interruptus
27
16
Natural methods
25
1-9
Sponge
- nulliparous
16
- parous
32
20
- nulliparous
16
- parous
32
26
85
85
Cervical cap
No method
Typical means user effectiveness was taken into account while Lowest rules out user factor by highly motivated subjects and
medical support.
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Terminology 2010
Calendar method
It is a way of contraception by means of periodic abstinence from coitus. It is based on the fact that :1. Viability of sperms in female reproductive tract is about 2 to 7 days,;
2. Lifespan of an ovum is only 1 day; and
3. Ovulation occurs at day 14
Therefore, the fertile period starts from 7 days before ovulation, and ends 1 day after ovulation. In a normal regular 28-day cycle
(ovulation at day 14), the fertile period starts at day 7 and ends at day 15.
If there is a variation of menstrual cycle length in a woman, then
1. The beginning of the fertile period should be calculated by subtracting 21 (14+7) days from the length of the shortest cycle;
2. The end should be calculated by subtracting 13 (14-1) days from the longest cycle.
Couples are advised to avoid coitus within the estimated fertile period. This method has a high failure rate (Pearl index 40 per 100
women year). It is not suitable for women with irregular cycles, need of frequent sex, and forgettable women.
Other methods to predict ovulation includes:1. Basal body temperature
2. Cervical mucus:- becomes clear, thin, stretchy and slippery around the time of ovulation
3. Syptothermal:- combination of the above two
4. Over the counter LH kits (to detect for the LH surge in ovulation)
5. Microscopic examination of saliva for ferning.
Figure 42 Basal body temperature (left) and cervical mucus (right) method
Condom
Male condom
It is a latex (rubber) sleeve that fits snugly over the penis for contraception. It is also effective against sexually transmitted
diseases such as AIDS, hepatitis and chlamydia. It is the most popular contraceptive method in Hong Kong. The advantages are:
1. Cheap
5. Free from medical risks
2. Widely available
6. No medical supervision needed
3. Convenient and only use when needed.
7. Protection against sexually transmitted diseases
4. Highly effective if used consistently and correctly
8. Possible protection against cervical neoplasia
Figure 43 Condom (Left two); Diaphragm (Right three) and Cervical Cap (Below)
Female condom, Diaphragm and Cervical cap
It is not popular in Hong Kong because:
1. Low patients' acceptance due to the need of handling her own genitalia
2. Need fitting by trained personnel and training in use
3. Less effective than other female contraception like hormonal methods or IUCD
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Terminology 2010
Synthetic oestrogen
The only synthetic oestrogen used is ethinyloestradiol, with dose ranging from:
1. 20-30 mcg (low dose; e.g. Nordette):-most commonly used
2. 50 mcg (median dose; e.g. Duoluton)
3. 75-100 mcg (high dose):-seldom used now because of side effects
Synthetic progestogen
4 generations of synthetic progestogen including:
1. 1st generation:-norethisterone 5mg:-low potency, seldom used now
2. 2nd generation:-levonorgestrel 150-250 mcg:
3. 3rd generation:-desogestrel 150 mcg; gestodene, highly specific progestogenic effect.
a.
Advantages:- less androgenic and so less adverse effect on serum lipids.
b.
Disadvantages:- is shown in some studies to be associated with a higher risk of non-fatal venous thromboembolic
disease
th
4. 4 genereation:- clamed to have spirolactone-like effect, thus can maintain slimness.
Types of COC
1. Everyday COC:a.
Each package consists of 21 pills of COC and 7 pills of placebo.
b.
Advantage of reduction in risk that user will forget to restart her next packet on time a potent cause of pill failure.
2. Non-everyday COC
a.
Each package consists of 21 pills of COC without placebo
b.
With or without phasic changes of hormones content
3. Monophasic every pill of COC consists of same amount of oestrogen and progestogen
4. Biphasic or triphasic
a.
Pills consist of different amount of oestrogen and progestogen in different phase of the cycle
b.
Designed to minimize the dose of progestogen and hence its side effect
c.
The clinical benefits are modest and are replaced by monophasic COC with 3rd generation of progestogen/
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Terminology 2010
Terminology 2010
Seven-day rule
It is an easily remembered rule to guide the prescription of combined oral contraceptives:1. Ovulation is successfully suppressed after taking COC for 7 days continuously
2. Up to seven pills can be omitted without ovulation, as indeed is regularly the case in the pill-free week
3. More than seven pills missed in total risks ovulation
Progestogen-only pill
Nature
Also called mini-pill. Consist of daily low dose synthetic progestogen, e.g.:
1. Norethisterone 350 microgram
2. Levonorgestrel 30 microgram
Mode of action
To antagonize the endogenous oestrogenic effect on cervical mucus, making it thick, hostile and impermeable to sperms, and also
causes endometrial atrophy. Disordered luteal phase in 40 to 50% of cycles
Efficacy
1. Pearl index of 3/100
2. Increased efficacy when combined with breastfeeding
Remark
1. Similar to COC but not coagulation side effects
2. Does not protect against endometrial and ovarian cancer.
Side effects
Irregular menstrual cycles, unpredictable bleeding, amenorrhea and spotting
Advantages
No increased risk of ectopic pregnancy
No metabolic effects
No coagulation effects
Use in special groups
Lactating women
Age> 40
Smoker, history of thomboembolism
Progestogen injectable
It is one form of contraception consisting of progestogen (e.g. depomedroxyprogesterone acetate 150mg) given intramuscularly
every 12 weeks. It acts by inhibiting the ovulation.
1. The advantages are:
a.
Highly effective (Pearl index= 1/100)
b.
Highly convenient
c.
Low reliance on compliance, need only 4 injections per year.
d.
Reversible though with some delay in fertility
2. Side effects:
a.
Menstrual disturbance (After one year use, 40% of user a amenorrhea, 40% scanty infrequent period, 20% prolonged
irregular bleeding)
b.
Weight gain
c.
Delay in resumption of fertility
d.
Possible reduction in bone mineral density osteoporosis in users with long term amenorrhea
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Sterilisation
It is a long term irreversible contraception by which the fallopian tubes are excised or ligated (female sterilisation), or the vas
deferens are excised (vasectomy in male sterilisation)
Female sterilisation
Methods
1.
Route:-Via laparotomy (e.g. in the same session of Caesarean section), mini-laparotomy or laparoscopy
2.
Method:-By ligation, Falope rings or clips
3.
Time:-In the post-partum period or interval period
Assessment before the decision
1.
Age of patients
2.
Number, ages and health of her children
3.
Previous and current contraception, in particular any problems with them
4.
Reason for the request of sterilization
5.
Stability of marriage
6.
Gynaecological, obstetric & medical history
Counseling after the assessment
1.
Irreversibility
2.
Regret rate
3.
Failure rate (1%)
4.
Risk of ectopic pregnancy if failure
5.
Operative procedure and risks, such as bleeding, infection and visceral injury
6.
Alternative contraceptive methods including male sterilisation
Male sterilisation
See vasectomy.
Vasectomy
It is the excision of a small piece of the vas deferens and is a kind of male sterilisation. It is performed under local anaesthesia on
an out-patient basis. Since sperm are produced 72 days prior to ejaculation and stored in the proximal collecting ducts, a
vasectomy is not immediately effective. Azoospermia should be confirmed with semen analysis before a couple relies on a
vasectomy for contraception. The failure rate is 0.15%. Complications are uncommon, including bleeding, infection and
haematoma. Sometimes the patients may develop anti-sperm antibodies following the operation, and this accounts for the male
infertility even after anastomosis of the vas deferens.
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Terminology 2010
Termination of pregnancy
What is termination of pregnancy
It is also called induced abortion, is a procedure to discontinue a life pregnancy by evacuation of the uterus before 24 weeks of
gestation. It should only be performed under the Abortion Act, and patients should be counselled properly before the procedure.
Abortion Act (1967)
Abortion can be performed if 2 registered medical practitioners agree that the pregnancy should be terminated on the one or more
of the following grounds:1.
Risks of continuance of pregnancy to the life of the pregnant woman are greater than that of termination of pregnancy
2.
Risks of continuance of pregnancy to the physical or mental health of the pregnant woman or her existing children are
greater than that of termination of pregnancy AND the pregnancy is less than 24 weeks
3.
There is a substantial risk that if the child were born it would be seriously handicapped
Pre-abortion counselling
Why is the pregnancy unwanted?
Whether the woman is absolutely certain about her decision?
Has the woman think about the other options like continuing the pregnancy and adoption?
Methods and risks of abortion
Future contraceptive plans
Methods of abortion The choice of the method of termination depends on gestational age:
1.
Early first trimester (up to 9 weeks)
a.
Medical:-anti-progesterone mifepristone (but it is not licensed in Hong Kong)
b.
Surgical:-vacuum (or suction) evacuation of uterus
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2.
3.
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Abortion
Definition of abortion
In Hong Kong and the United Kingdom, abortion is defined as a pregnancy loss occurring before 24 completed weeks of
gestation.
The WHO definition is 'the loss of a foetus or embryo weighing 500g or less which corresponds to a gestation age of 20-22
weeks, the irreducible age for foetal well-being'.
Threatened abortion
A very common condition (15%) in early pregnancy, presents with painless vaginal bleeding. The cervical os is closed and the
intrauterine pregnancy is viable.
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Inevitable abortion
The product of gestation has not been passed out yet, but there is increasing contraction pain and vaginal bleeding, and the
cervical os is dilating. The products of gestation may sometimes be felt through the open internal os.
Remark
The above terms were defined clinically in the old days when ultrasound (USG) was not in use. The use of these terms has
changed slightly with the introduction of USG. For example, the diagnosis of missed abortion is now commonly referred to
pregnant women present with vaginal bleeding and has identified a 'non-viable' foetus. Complete abortion is diagnosed according
to ultrasound finding as described above.
Septic abortion
Septic abortion is an infected abortion. It is associated with high maternal morbidity and mortality when treatment is delayed. It is
often due to illegal abortion under unsterilized condition.
Recurrent abortion
Also called habitual abortion, recurrent abortion is defined as three or more consecutive losses of pregnancy. The incidence is 1%
which is higher than when it occurs by chance. Therefore investigations for the underlying cause are needed.
Management of abortion
1.
Principles
a.
Rule out other causes of vaginal bleeding or pain complicating early pregnancy such as ectopic pregnancy
b.
Confirm foetal viability (see viable) with USG
c.
Counselling and evacuation of uterus when required
d.
The diagnosis and management is often easy nowadays with USG, but history and examination are still essential,
particularly when the USG finding is inconclusive
2.
Counselling
a.
Explain the cause of abortion, the chance of abortion and successful pregnancy next time.
b.
Investigate further in case of recurrent abortion, or second trimester abortion.
Evacuation of uterus
1. Owing to the advances in ultrasound and medicine, treatment of abortion has been changed in the recent decades.
2. In the past, almost all women with abortion required surgical treatment to ascertain complete evacuation. With the improved
resolution with transvaginal scan, uterine cavity is much more accurately assessed. Women with diagnosis of complete
abortion by USG can then be managed conservatively. Secondly, prostaglandin analogues, such as misoprostol, have effect of
cervical softening and oxytocic effects. When misoprostol is taken orally, it causes a complete evacuation of uterus in 70% of
cases in 24 hours. It has the advantages of minimizing operative complications such as perforation of uterus and introduction
of intrauterine infection. The side effects are mild and well tolerated, including diarrhea, vomiting and abdominal pain.
Occasionally, it may cause severe vaginal bleeding which requires an emergency surgical evacuation.
3. Therefore, options of surgical and medical treatment should be offered to patients with abortion.
Discussion/Something to Consider
How would you counsel a patient who is diagnosed to have threatened abortion at 6 week of gestation? How would you explain
the treatment of uterine evacuation to a patient with incomplete abortion?
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Terminology 2010
Recurrent abortion
Definition
Recurrent abortion or habitual abortion is defined as 3 or more consecutive abortion.
Incidence
The incidence is about 1% of all women and is greater than the rate expected by chance alone, suggesting that there is a specific
underlying cause in many cases.
Figure 49 Anatomical factors:-Fibroid (Left) and arcuate uterus with septum (Right).
Causes
In majority of cases, the causes are unknown. The following pathologies are identified causes:1. Chromosomal abnormalities
One of the couple may have some forms of chromosomal abnormalities that may be transmissable, resulting in
recurrent abortion. They themselves, however, may be phenotypically normal. A typical example is translocation
(reciprocal or robertsonian). The abortion usually present with absent foetal heart in-utero, in the first or sometimes
second trimester. Structural abnormalities may be present.
2. Uterine anomalies
a.
Congenital anomalies of uterus are associated with recurrent abortions. Implantation to the site of underdeveloped
uterine body, or hypoplastic and hypovascular area of uterus may result in restriction of foetal growth and abortion.
b.
Cervical incompetence typically presents with painless mid-trimester miscarriage
3. Endocrine disorders
a.
Poorly controlled diabetes is associated with early pregnancy failure. However, well-controlled DM, asymptomatic or
mild glucose intolerance are unlikely to cause pregnancy failure. OGTT to rule out occult diabetes in case of recurrent
abortion is therefore not necessary.
b.
Similarly clinical hypothyroidism is also a risk factor for recurrent abortion but subclinical disease is not. Screening of
thyroid disease is again not indicated.
c.
Hypersecretion of luteinizing hormone:-It has been showed that polycystic ovarian disease (PCOD) with high LH
level is associated with recurrent pregnancy loss, usually in the first trimester.
4. Immunological disorders Autoimmune diseases such as antiphospholipid syndrome and systemic lupus erythematosus are
associated with foetal loss.
5. Other risk factors
a.
Environmental factors such as heavy alcohol consumption and smoking may contribute to recurrent pregnancy loss.
b.
Congenital infections Congenital infections are unlikely to cause recurrent foetal loss, although they can result in
sporadic loss. Patients can develop immunity after primary infection such as in rubella, chickenpox.
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3.
Septic abortion
Definition
It is a condition in which the abortion is associated with an ascending intrauterine infection.
Causes
It can be a result of surgical evacuation of uterus under inadequate aseptic technique. It commonly occurs in the setting of illegal
termination of pregnancy where sterilisation of instruments is poor. Septic abortion can also follow incomplete abortion or
prolonged rupture of membranes before 24 weeks of gestation.
Clinical features
Fever and tachycardia
Pelvic pain and tenderness
Vaginal bleeding or pusty discharge
Cervical os may be opened
There may be evidence of retained product of gestation (POG) under USG
Complications
Septic shock
Disseminated intravascular coagulopathy (DIC)
Management
Antibiotics
Evacuation of uterus if there is evidence of retained POG
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Ectopic pregnancy
Definition
A pregnancy with implantation outside the normal uterine cavity. The ectopic site can be:
Fallopian tubes:-the most common site
Ovary:-uncommon
Cornus of uterus:-uncommon
Cervix of uterus:-uncommon
Peritoneal or omental surface:-very rare
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Terminology 2010
d.
4.
5.
6.
Disadvantages:
i.
Persistent ectopic pregnancy because of incomplete removal of POG:-5%
ii.
Risk of recurrence of ectopic at the same site in subsequent pregnancy:-5%
Medical Treatment
a.
Consists of systemic injection of methrotrexate which is a cytotoxic agent that kills the proliferating foetal and
trophoblastic tissue. Direct injection of methrotrexate or KCl into the site of ectopic pregnancy is not shown to be
effective.
b.
Success of treatment is confirmed by gradual reduction and disappearance of serum HCG.
c.
Medical treatment is rarely used in Hong Kong and is only indicated when:i.
Cervical ectopic pregnancy where surgical excision is difficult and associated with heavy bleeding.
ii.
There is persistent ectopic pregnancy after conservative surgical treatment
iii. There is persistently detectable HCG but the site of ectopic is unknown
iv. Patient refuses surgery
Chance of success is low when the initial HCG level is high, or the ectopic pregnancy is big.
Complications of medical treatment are those of side effects of cytotoxic:-nausea, vomiting, liver function derangement, etc.
Discussion/Something to Consider
Which kinds of patients are contraindications for conservative surgery for tubal pregnancy?
Protocol, as of 21 April 2008
1. Use of methotrexate
a.
Not for primary treatment of tubal ectopic pregnancy
b.
Usage need to be endorsed by FHKAM
i.
Ectopic pregnancy with hCG > 5,000iu/L, ectopic mass over 3cm, cardiac activity documented
ii.
Patient unlikely to comply with follow up and repeated hCG assay
iii. Deranged LFT, RFT or neutropenia or thrombocytopenia
c.
Advice to patients
i.
Refrain from use of alcohol, vitamins with folic acid
ii.
Refrain from sexual intercourse until hCG return to normal
iii. Avoid pregnancy for 6 months from last injection
d.
Dosage regime, follow up and monitoring
i.
Single dose:-50mg/m2 SA IM Check hCG on D4 and D7, repeat same dose if D7 decline < 15% of D4
ii.
Multiple doses may be used:-1mg/kg IM on alternate day; folinic acid 0.1mg/kg IM on other days Check
hCG on D1, 3, 5 and 7 every 48 hours, stop further dose if 4 doses given or until hCG decline by > 15% on 2
consecutive readings
e.
Consent from patient needed
2. Operative treatment
a.
Laparoscopic approach preferred, laparotomy acceptable if patient hemodynamic status not stable or surgical
expertise not available
b.
Milking or aspiration of ectopic content as treatment is not recommended
c.
Salpingostomy:i.
Contra-indicated if:Ectopic site over 4cm, cardiac activity documented, tube ruptured already
Patient not reliable for monitoring and follow up or not acceptable to secondary treatment
ii.
Not recommended if:Family completed
Diseased tube
iii. Check hCG on D1, give single dose of MTX if <50% drop in hCG level.
iv. Repeat hCG weekly till normal.
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Hyperemesis gravidarum
Definition
Excessive vomiting during early pregnancy, to the extent of dehydration, weight loss, electrolyte imbalance and acid-base
disturbance.
Causes and pathophysiology
1. Vomiting is one of the commonest early pregnancy complications, and is thought to be related to the production of HCG
which stimulates the chemoreceptor in the hypothalamus. The risk is higher in:
a.
Multiple pregnancy
b.
Gestational trophoblastic disease
c.
Hyperthyroidism
d.
Urinary tract infection
2. The symptoms usually subside after the first trimester when the HCG level starts to decrease from the peak.
3. Remark:-Vomiting can be due to co-existing pathology of other systems, such as GI and CNS system. Careful clerking and
examination are very important not to miss the diagnosis.
Complications
Hypokalemia
Malnutrition
Wernicke syndrome (due to deficiency of thiamine)
Mallory-Weiss syndrome
Clinical features
1. Onset of symptoms:-in the first trimester, around 6 to 8 weeks
2. Common features:
a.
Nausea and vomiting
b.
Loss of appetite
c.
Weight loss
d.
Signs of dehydrations
Investigation
1. To assess severity:
a.
Renal and liver function tests
b.
complete blood picture
2. To rule out underlying causes:
a.
USG to look for multiple pregnancy and gestational trophoblastic disease
b.
Thyroid function test
c.
Mid-stream urine for culture
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Treatment
1. Regular monitoring
a.
Blood pressure and pulse
b.
Fluid input and urine output
c.
Urine ketone
d.
Body weight
2. Fluid electrolytes correction
a.
Rehydration with intravenous fluid
b.
Potassium supplement
3. Nutrition support
a.
Dry food
b.
Vitamin supplement
4. Antiemetics Metroclopramide
Although they seldom cause any dangers to the mother and foetus, they are common and often cause discomforts to the
mother and sometimes annoying.
The symptoms may also mimic those of severe disorders.
Medical students are required to know how to explain, advise and manage these minor disorders for pregnant women, and to
differentiate them from major disorders.
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Backache
1. A common symptom and results from increased joint laxity in the lumbar spine and the exaggerated lordosis which occurs in
pregnancy.
2. Management is conservative, with rest, analgesia, and improvement in posture
Breast soreness
1. Commonest in early pregnancy as the breasts increase in size.
2. Reassurance and symptomatic relief with a brassiere that provides adequate support are all that is needed
Peripheral paraesthesiae
1. Numbness and tingling occur due to compression of peripheral nerves because of fluid retention, most commonly the median
nerve (carpal tunnel syndrome)
2. No treatment is usually required when the cause has been explained to the patient
Headache
1. Usually a typical tension headache and is best treated by rest and mild analgesia
2. Migraine often improves but may deteriorate, stay the same or occur de novo, in pregnancy
Postural hypotension
1. More likely to occur in pregnancy because of venous pooling in the lower limbs
2. It is best prevented by avoiding precipitating factors:-standing up quickly, hot bath, standing in hot weather for long time
Pruritus
1. Generalized
a.
Generalized itching (pruritus gravidarum) usually begins in the third trimester and may be associated with cholestasis
in pregnancy
b.
Treat with topical antipruritus
2. Pruritus vulva
a.
Usually due to candidiasis
b.
Treat with topical anti-fungal agent
Frequency of micturition
1. Symptoms of early pregnancy when it may be due to increased renal filtration
2. Also in late pregnancy when it is due to pressure from the enlarged uterus
3. Urinary tract infection has to be excluded when there is also dysuria or urgency
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Clinical features
1. Subclinical
a.
Some women are asymptomatic and the diagnoses are made incidentally on routine examination or during surgery for
other reasons
b.
Signs and symptoms are caused by:i.
Proliferation,inflammation and bleeding at different sites;
ii.
Adhesions at different sites.
2. Pelvic pain
a.
Dysmenorrhea, dyspareunia, chronic pelvic pain that may be progressive, and not relieved by simple analgesics
b.
Pain arises because of:i.
Prostaglandins production
ii.
Local inflammation
iii. Adhesion and scarring
iv. Stretching of nerves after scarring
c.
Remark:-severity of endometriosis is not correlated to the degree of pain
3. Infertility
Possible mechanisms of infertility in endometriosis include:Problem area
Ovarian function
Coital function
Tubal function
Sperm function
Endometrium
Early pregnancy failure
4.
5.
Mechanism
Anovulation, luteolysis
Dyspareunia causing reduced penetration and coital frequency
Altered tubal and cilial motility, impaired fimbrial oocytes pick-up
Inactivation or destruction by inflammative changes
Luteal phase deficiency, endometrial interference
Increased abortion
Endometrioma
a.
Presents with acute abdominal pain related to rupture or haemorrhage, or
b.
Presents with pelvic mass under physical or ultrasonic examination
Others
a.
Gastreointestinal system:- dyschezia, cyclical GI bleed, intestinal obstruction and tenesmus
b.
Urinary system:- cyclical dysuria and haematuria
c.
Lung: cyclical haemoptysis, haemopneumothorax
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Terminology 2010
Diagnosis
1. Diagnostic laparoscopy
a.
Gold stsandard in diagnosis but may miss lesions because of difficulty in visualising the whole pelvis and there are
variable appearances of deposits.
b.
Indications:
i.
Patients with chronic pelvic pain, secondary dysmenorrhea or dyspareunia not responsive to simple analgesic
ii.
Patients with infertility with above symptoms
c.
Look for peritoneal deposits, endometrioma and pelvic adhesions (features as mentioned above)
2. Ultrasound
a.
While endometrioma can be picked up by USG, peritoneal deposits are not visible by USG
b.
USG features of endometrioma
i.
Variable with homogenous or heterogeneous echogenic content
ii.
Usually around 3 to 7cm in diameter
iii. Can be bilateral
iv. No papillary growth
3. Biopsy
a.
Seldom required to diagnose peritoneal deposits as the gross features are obvious
b.
May be needed to confirm diagnosis when the endometriosis is found in atypical sites such as in bladder or skin
Management
Principle
1. Endometriosis is a chronic disease that is difficult to be eradicated, without radical surgery
2. The disease may present without causing significant symptoms
3. High recurrent rate after medical or conservative surgical treatment
4. Choices of treatment depends on the severity and type of symptoms, and desire of fertility, and are introduced as follows.
Expectant management
Indications:-asymptomatic or mildly symptomatic
NSAID prn for pain relief
Hormonal treatment
1. Indications severe pain, want to preserve fertility
2. Mechanisms suppress oestrogen that stimulates the proliferation of endometirum.
3. Choices:
a.
Gonadotropin releasing hormone analogue (GnRHa)
i.
Mechanism:-suppresses ovarian function and hence endogenous oestrogen production which supports the
growth of endometriosis
ii.
Advantages:-effective pain relief (90%), no androgenic effects compared with danazol
iii. Disadvantages:-side effects of hypoestrogenism, delay fertility
b.
Danazol
i.
Mechanism:-Androgen that suppresses hypothalamic-pituitary-ovarian axis and therefore decreases endogenous
oestrogen production
ii.
Advantages:-effective pain relief (90%), no hypoestrogenic effects compared with GnRHa
iii. Disadvantages:-androgenic side effects; delay fertility
Conservative surgery
Aims at pain relief and restoration of fertility
Choices vary from cystectomy (for endometrioma), adhesiolysis, ablation of endometriotic spots
Radical surgery
Consists of bilateral salpingo-oophorectomy and total hysterectomy
Aims at pain relief and complete eradication of the disease
Fertility is not preserved
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Terminology 2010
Adenomyosis
Definition
The presence of tissue resembling endometrial glands and stroma within the myometrium of the uterus
Pathology
1. Macroscopic
a.
Grossly enlargement of uterus, usually globally
b.
Spongy appearance with no cleavage plane
2. Microscopic
a.
Endometrial glands and stroma embedded in the myometrium
b.
Focally or uniformly
Clinical features
1. History
a.
Asymptomatic
b.
Menorrhagia
c.
Secondary dysmenorrhea
d.
Deep dyspareunia
2. Examination Enlarged tender uterus, especially during perimenstrual period
Diagnosis
1. Can only be confirmed by histology
2. Ultrasound to rule out fibroids
3. Endometrial biopsy to rule out other causes of menorrhagia
Treatment
Hysterectomy if symptomatic
Discussion/Something to Consider
What are the similarities and differences between the clinical presentation and management of adenomyosis and that of fibroid?
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Terminology 2010
Physiological cysts
See follicular cyst.
Follicular cyst
It is a common physiological ovarian cyst. Sometimes a developing follicle may not ovulate and become persistent. It is
associated with the use of progestogen contraceptive and ovulation induction agents. It has a thin wall and clear content under
ultrasound and often less than 5cm in diameter. Majority of them are asymptomatic but in few occasions they present with acute
lower abdominal pain as a result of haemorrhage or rupture.
Ovarian cystadenoma
The two most common types are serous cystadenoma and mucinous cystadenoma. The former tends to be unilateral and unicystic,
while the later is more likely to be bilateral and multicystic.
Serous cystadenoma may take any one of the following three forms:(1) A simple cystic form with smooth surface and smooth lining.
(2) A cystic structure with intracystic papillary formations, which may be sessile buttons or pedunculated frond like projections.
(3) An adenomatous form where many of the loculi are small and papillary structures are solid and complex.
Sometimes they can be very large with diameter more than 10cm. USG features are similar with thin wall and clear content. They
are different from their malignant counterparts as they do not have solid element or papillary growth, and there is no ascites.
Treatment is cystectomy or oophorectomy, by laparoscopy or laparotomy method.
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Terminology 2010
Dermoid cyst
It is a benign teratoma which consists of mainly skin tissue, with sebaceous material and hair, and is the reason for its name.
Sometimes it may contain teeth or bone tissues. Rarely, active thyroid tissue (stromal ovarii) may be present. It is one of the
commonest benign ovarian tumours occurring in in reproductive age. It is often bilateral (10%), with size ranged from a few
centimetres to up to 10 cm. It is ovoid and unilocular in shape. The wall consists of dense fibrous tissue lined by stratified
squamous epithelium. The eminence may contain sebaceous glands, teeth, hair, nervous tissues, cartilage, bone, respiratory and
intestinal epithelium and thyroid gland tissue. Thick yellow sebaceous material fills the cyst. It is very mobile and therefore
commonly presents with torsion. Patients usually present with on and off colicky lower abdominal pain signifying a process of
intermittent torsion. They then suddenly experience acute colicky abdominal pain that changes to constant sharp pain, signifying
an acute torsion with ischemic necrosis and peritoneal inflammation. On physical examination, peritoneal signs with pelvic mass
and tenderness can be found. Under USG, a dermoid cyst is well-circumscribed with homogenous content. A hyperechogenic
shadow signifies a bone or a tooth. The treatment is cystectomy or oophorectomy which can be done under laparoscopy or
laparotomy.
Figure 55 The macroscopic (left) and microscopic (right) appearance of dermoid cyst.
Teratoma
Ovarian teratoma is one of the commonest germ cell tumours. It develops from a totipotential germ cell (a primaryoocyte) of the
ovary, and therefore can give rise to all kinds of cells and tissues. The commonest tissue types are skin with hair follicles and
sebaceous glands, bone, teeth, and neural tissues. Depending on the maturity of the neural component, teratoma is divided into
mature (benign) and immature (malignant) type.
1. For mature teratoma,
a.
The tissues of a mature teratoma are well differentiated. It is also often called dermoid cyst as it contains skin tissue,
hair and sebaceous material.
b.
Uncommonly a benign tetratoma may contain functional thyroid gland tissue (stromal ovarii) that secrets thyroxine,
resulting in hyperthyroidism.
2. For imature teratoma,
a.
2% of teratoma consist of immature or undifferentiated tissue, and is called immature teratoma, or malignant teratoma.
As in other germ cell tumours, the treatment of malignant teratoma is surgery followed by chemotherapy.
b.
Unilateral oophorectomy is adequate provided that the other ovary is not involved. Fertility can be preserved.
Hysterectomy and bilateral oophorectomy is suggested if patients have completed family.
Nabothian cyst
It is a small cyst beneath the epithelium of the uterine cervix of no clinical significance. It can be multiple and the size is not more
than 10mm. See transformation zone for the formation of Nabothian cyst.
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Terminology 2010
Fibroid
Definition
fibre:-connective tissue; oid:-like. It is actually a benign smooth muscle tumour (leiomyoma) of uterus.
Incidence
20-25% of women in reproductive age
Pathology
1.
2.
Sites:
a.
Intramural most common site
b.
Submucosal
i.
5% of all fibroids
ii.
Most commonly cause symptoms
c.
Subserosal pedunculated may sometimes undergo torsion
d.
Cervical
i.
Uncommon but can cause urinary problems such as urinary retention and ureteric obstruction, and
ii.
Surgical difficulty because of close proximity to ureters and accessibility
e.
Within broad ligament extremely rare but can cause diagnostic and surgical difficulties
Histology:
a.
b.
c.
3.
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Terminology 2010
Clinical presentation
1. Clinical presentation depends on sites and size of fibroids, 50% of women are asymptomatic
2. Menorrhagia
a.
Menorrhagia is more common with submucosal and intramural fibroids
b.
Mechanism:
i.
Increases total surface area of the uterine cavity
ii.
Disordered uterine motility
iii. Ulceration and haemorrhage overlying submucosal fibroids
iv. Disordered prostaglandin synthesis
3. Pressure symptoms
a.
Abdominal distension and discomfort, especially with rapid growing fibroids
b.
Symptoms of urinary retention, especially with cervical fibroids
4.
5.
6.
7.
Pain
a.
Uterine camping:-attempted expulsion of submucosal fibroids
b.
Acute torsion of pedunculated fibroids
c.
Red degeneration (usually during pregnancy)
Sub-fertility
a.
An uncommon presentation, accounts for only 3% of all infertile women
b.
Possible mechanisms:
i.
Mechanical cornual occlusion
ii.
Distortion of uterine cavity resulting in failure of implantation
iii. Alternation of local blood flow
Sarcomatous change very rare:-0.1%
Specific complications during pregnancy
a.
Red degeneration of fibroid
i.
Presents as acute localised uterine pain, usually in the second or third trimester
ii.
Occasionally there is fever and leucocytosis
iii. Treatment is conservative with adequate anaglesia
b.
Malpresentation occurs when a large fibroid occupying the cervical or lower pole of the uterus
Diagnosis
1. Diagnosis is usually obvious on physical examination
a.
Enlarged uterus, usually of irregular shape
b.
Submucosal fibroid protruding out from cervix
2. Ultrasound
a.
Is usually not required unless clinical examination is not definite
b.
Identifies the sites and number of fibroids that may help to plan of management
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Terminology 2010
Management
1. Principle
a.
Choice of treatment depends on degree of symptoms, desire to preserve fertility, and site and size of fibroids
b.
Expetect management
c.
Medical treatment
i.
Only for temporary symptomatic relief, during waiting for surgery, and correction of anaemia
ii.
Symptoms usually return and fibroid re-grow after stopping medication
d.
Myomectomy
i.
Only for symptomatic women who want to preserve fertility
ii.
Can be performed via laparotomy, laparoscopy, or hysteroscopy, depends on the site of fibroids
iii. Recurrence of fibroids and symptoms:-15%; 10% require re-operation
iv. Risk of unplanned hysterectomy (for large intramural fibroids) because of uncontrolled bleeding
v.
Post-operative pelvic adhesions that may affect tubal patency, if posterior uterine wall is cut
e.
Hysterectomy definite treatment for symptomatic women who do not want to preserve fertility
Discussion/Something to Consider
A 30 year-old single woman is referred to you because of incidental finding of a 3cm diameter intramural fibroid on routine
check-up. How would you manage her?
Protocol, as of 23 May 2005
1. Antenatal management
a.
Counsel the patient:i.
It is a bengin lesion and would not cause any risk to the mother and the fetus in most of the cases
ii.
Small chance of red degeneration that may lead to abdominal pain
iii. May cause fetal malpresentation if the fibroid is situated at the lower pole of the uterus
b.
No need to arrange serial ultrasound examination routinely throughout the antenatal period, unless there is difficulty
in monitoring fetal growth by fundal height measurement.
c.
For fibroid locating at the lower pole of the uterus, arrange follow-up at 37 weeks of gestation (+/- USG) to assess
the fetal presentation and engagement and decide mode of delivery:
d.
Allow vaginal delivery unless the uterine fibroid is situating at the lower segment AND affect engagment of fetal
head or cause malpresentation.
2. Intrapartum management
a.
If Caesaerean section is indicated for any reason, DO NOT perform myomectomy at the same time.
b.
After delivery, no need for routine prophylactic syntocinon infusion unless the uterine fibroid larger than 5 cm. Give
syntocinon infusion (40 units in 500 ml of cystalloid solution over 4 hours) if it is required.
3. Postnatal follow up
a.
For patients who are asymptomatic before the pregnancy (no menorrhagia or pressure symptoms):i.
It is not necessary to give gynaecology follow-up after delivery
ii.
Advise patient to seek medical advice when she has symptoms
b.
For patients who has symptoms before the pregnancy:i.
Arrange a follow-up appointment at Pelvic Mass Clinic in 6 months with pictorial chart given to patient to
document the menstrual pattern
ii.
It may be necessary to postpone the follow-up appointment if the patient would have long period of breast
feeding and remains amenorrhoea.
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6. Gynaecological infection
Pelvic inflammatory disease
Definition
The strict definition of pelvic inflammatory disease (PID) is the clinical syndrome attributed to the ascending spread of
microorganisms (unrelated to abdominal surgery or pregnancy) from the vagina and cervix to the endometrium, fallopian
tube and / or the contiguous structures.
It implies sexual transmission as the main source of infection, or secondary to some procedures such as uterine curetting. It
is distinguished from pelvic infections resulted from other sources such as appendicitis, diverticulitis, and pelvic
tuberculosis from haematological spread.
It is a clinical diagnosis and does not specify the exact location of infection. An anatomical terminology such as
endometritis, salpingitis, parametritis, or tub-ovarian abscess is more specific and preferred if the site of infection can be
identified via laparoscopy.
It is subdivided into acute and chronic PID
Acute PID
Pathogenesis
Ascending infection:-common organisms are gonorrhea and chlamydia
Secondary anaerobic invasion after the genital tract is infected and damaged
Clinical features
Acute or subacute pelvic pain, usually bilateral
Purulent vaginal discharge
Fever
History of recent coitus
Cervical excitation pain
Acute appendicitis is the most common differential diagnosis
Complications of acute PID
Tubo-ovarian abscess
Septicemia
Long term
Terminology 2010
Chronic PID
Recurrent or chronic symptoms of pelvic pain resulted from chronic pelvic inflammatory changes, fibrosis and adhesion which are
consequences of previously partially treated acute PID
Clinical features
Chronic pelvic pain
Dysmenorrhea
Acute exacerbation may superimpose on a chronic PID
There is usually but not always a history of acute PID because sometimes a diagnosis of acute PID may have been missed in
the past
Differential diagnosis is endometriosis
Diagnosis
Diagnostic laparoscopy
Treatment
1. No curative treatment as damage has already occurred
2. Aim to relief symptoms or treat infertility
3. Pain relief By NSAID; and hysterectomy in case of intractable pain and fertility is not required
4. Fertility tubal surgery or assisted reproductive procedure
Discussion/Something to Consider
1. How to differentiate acute PID and acute appendicitis when a young women presents to the A&E department complaining of
acute lower abdominal pain?
2. Are there any differences between the clinical presentations of acute PID caused by gonorrhea and that of chlamydia?
Protocol, as of 9 May 2008
1. Diagnosis
a.
Minimal criteria:i.
Uterine/adnexal tenderness or
ii.
Cervical motion tenderness
b.
Additional criteria (to enhance specficity):i.
Oral temperature > 38.3oC (tympanic > 38.8 oC)
ii.
Abnormal cervical or vaginal mucopurulent discharge
iii. Elevated erythrocyte sedimentation rate (ESR)
iv. Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis
v.
Elevated C-reactive protein (C-RP)
vi. Presence of abundant numbers of WBCs on saline microscopy of vaginal secretions
c.
Specific criteria:i.
Endometrial biopsy with histopathologic evidence of endometritis
ii.
Transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes
with or without free pelvic fluid or tubo-ovarian complex
iii. Laparoscopic abnormalities consistent with PID
2. Investigation
a.
HVS, ECS for N. gonorrhoeae or C. trachomatis
b.
CBC with differential count
c.
ESR, C-RP (for patients who are clinically suspicious of having PID, but having normal white cell count)
d.
VDRL and HIV testing
e.
Pregnancy test
f.
TVS
g.
Endometrial biopsy (warranted in woman who has undergone laparoscopy, but no visual evidence of salpingitis)
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3.
4.
5.
6.
7.
Treatment
a.
Outpatient care For mild to moderate PID not requiring hospitalisation
b.
Antibiotic regime:i.
Ceftibuten 400mg orally for single dose (to cover gonorrhea) AND
ii.
Metronidazole 400mg TDS orally for two weeks (to cover anaerobes) AND
iii. Doxycycline 100mg BD orally for two weeks (to cover chlamydia)
iv. Patients should be reviewed at 72 hours for assessment of clinical response. If there is no clinical
improvement, patient should be hospitalised and evaluated on the diagnosis and the need for laparoscopy. The
antibiotics should then be changed to parental regime.
c.
Alternative antibiotic regime for patient with beta-lactam allergy or tetracycline allergy
i.
Low risk for sexually transmitted disease (STD)
Ciprofloxacin 500mg BD for one week AND
Metronidazole (Flagyl) 400mg TDS orally for two weeks
ii.
High risk for STD
Azithromycin 2g orally for single dose AND
Metronidazole (Flagyl) 400mg TDS orally for two weeks
In-patient care
a.
Indications
i.
Surgical emergencies (eg appendicitis / ectopic pregnancy) cannot be excluded.
ii.
Pregnant women
iii. Unreliable patients
iv. No response, severe symptoms, or not tolerating out-patient treatment
v.
Increased risk of anaerobic infection as suggested by prior IU instrumentation, IUCD in-situ, suspected
tubo-ovarian abscess
b.
Antibiotic regimes (from local hospital data)
i.
Cefuroxime (Zinacef) 750mg Q8H IV AND
500mg BD orally (one week in total) AND
ii.
Metronidazole (Flagyl) 500mg Q8H IV AND 400mg TDS orally (two weeks in total) AND
iii. Doxycycline 100mg BD orally
100mg BO orally (two weeks in total)
c.
Alternative regimefor patient with beta-lactam allergy, tetracycline allergy, or high operative risk
i.
Gentamicin 2 mg/kg of body weight i.v. or i.m. as loading dose, followed by 1.5 mg/kg of body weight Q8H
i.v. or i.m. as maintenance dose, until 24 hours after clinical improvement (The response rate is higher when
Gentamicin is included.) AND
ii.
Clindamycin 900mg Q8H i.v. (can be switched to 450mg QID orally when there is adequate clinical response
for over 24 hours, for a total of 2 weeks)
Operative management
a.
Indicated for:i.
Exclusion of other surgical emergencies
ii.
Tubo-ovarian abscess with no response (review in 24 hours for decision on operation)
iii. Failed medical treatment (review in 24-48 hours for decision on operation)
b.
Laparoscopy preferable.
c.
Procedure:- Lysis of adhesion when limiting access to tubo-ovarian complex / abscess or which tether bowel.
Salpingotomy for drainage of pyosalpinges. Dissect and drain loculations of pus. Irrigate pelvic and abdominal
cavity liberally. Avoid blunt dissection OR excision of tubo-ovarian mass. Insertion of wide bore drain after
drainage of tubo-ovarian abscess
IUCD
No evidence suggests that IUCD should be removed in women diagnosed with acute PID, however, close clinical
follow-up is mandatory if the IUCD remains in place. The rate of treatment failure and recurrent PID in women
continuing to use an IUCD is unknown. IUCD may be left in situ in women with clinically mild PID. In severe PID,
IUCD shall be removed shortly after commencement of antibiotics
Male sex partners
Refer to Social Hygiene Clinic all the sexual partners with sexual contact occurred within 60 days preceding the patient's
onset of symptoms. If last sexual contact beyond 60 days, refer the last sexual partner to Social Hygiene Clinic.
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Bartholins Gland
Figure 56 (Left to Right) Bartholin's cyst and its differential diagnoses, sebaceous cyst, and lipoma.
Bartholin's gland is a pea-sized mucus-secreting gland situated in the lower part of each labium majus. It is connected to the
vaginal entrance by a duct. Its secretion contributes to vaginal lubrication. Obstruction of the duct causes a Bartholin cyst.
Inflammation may lead to abscess formation (Bartholin abscess). The treatment is marsupialisation. It should be differentiated
from other lesions of the perineum, such as sebaceous cysts, lipoma, as the treatment is different.
Pyometra
It is a collection of pus inside endometrial cavity. It is usually due to outflow obstruction such as cervical stenosis secondary to
menopause, previous surgery, or cervical cancers. The obstruction results in stasis of endometrial secretion and secondary
infection. It may be asymptomatic, or presents with purulent vaginal discharge, or symptoms of primary causes such as
postmenopausal bleeding in case of cervical cancers. Pyometra should be drained with Vabra aspiration and the collection should
be sent for histological and microbiological examination. Hysteroscopy is contraindicated as it may spread the infection.
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Puberty
Definition
It encompasses physiological changes leading to the development of adult reproductive capacity. It is different from adolescence.
Normal puberty
A normal puberty consists of following stages:
1. Adrenache the beginning of pubic hair development
2. Thearche the beginning of breast development
3. Menarche the beginning of first menstrual period
Abnormal puberty
Precocious puberty
Precocious puberty
Definition
Features of puberty develop too early with:
1. Breast development before 8 years of age; or
2. Menarche before 10 years (or more than 2 standard deviations before the mean ages of onset).
It is further classified according to the underlying pathophysiology:
1. True or central due to gonadotrophin production driving the ovaries
2. False or peripheral due to autonomous adrenal or ovary production of sex hormones
Tanner staging
Tanner staging of breast development at puberty:
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
Infantile stage
Bud stage:The breasts and papillae are elevated as a small mound and there is an increase in the diameter of the areola
Small adult breast:The breasts and areola are further enlarged with a continuous round contour
Secondary mound:The areola and papilla enlarge to form a secondary mound projecting above the contour of the remainder of the breast
Typical adult breast:The secondary mound disappear so that the breasts have smooth rounded contour
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Hirsutism
Virilism
It is the presence of one or more of the following:-clitoral hypertrophy, breast atrophy, male-type baldness and deepening of voice.
It is different from hirsutism. It is invariably due to excessive endogenous androgen production, such as congenital adrenal
hyperplasia and androgen-secreting ovarian stromal cell tumour.
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Intermediate
Physical
Urinary:
Frequency
Urgency
Incontinence
Reproductive:
Vaginal Dryness
Dyspareunia
Atrophic vaginitis
Discharge
Long term
Asymptomatic
Osteoporosis
Cardiovascular disesaes
Climacteric
1.
2.
3.
4.
In Greek 'klimakter' means the rung of a ladder. It is a 'critical' period of time around menopause when ovarian function is
gradually compromised.
This is a time of decreasing fertility, decreasing oestrogen level and the appearance of the typical symptoms of menopausal
syndrome, although the menstrual periods will still be present.
The earliest endocrine change at the climacteric period is hypothalamic-pituitary hyperactivity due to lack of negative
feedback by follicular hormone. Therefore, elevated FSH is a early endocrine marker of climacteric period.
The menopausal symptoms include:
a.
Vasomotor symptoms:-hot flushes, palpitation, 80% of patients
b.
Psychological symptoms; anxiety, depression, irritability, liability of mood, lack of concentration; in 30% of patients
c.
Atrophic symptoms:-vaginal dryness, urgency and frequency of micturition.
Osteoporosis
Bone disease characterised by low bone mass, micro-architectural deterioration of bone tissue leading to enhancement of bone
fragility and a consequent increase in fracture risk. It is different from osteomalacia. Women after menopause or with chronic
hypoestrogenemia are at risk of development of osteoporosis. Bone fractures secondary to osteoporosis causes significant
morbidity and mortality in this group of patients, as well as medical cost of the society. Hormonal replacement therapy effectively
prevents bone loss in these high risk patients. A T-score of BMD >-1 = normal; -1 to -2.5 = osteopenia; and <-2.5 = osteoporosis.
Women are more prone to osteoporosis because they have a lower pealk bone mass, a longer life, and they are easier to fall.
Treamtment would incluie hormonal replacement therapy, biphosphonates, vitamin D, Calcitonin, SERM and Tibolone.
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Hormonalreplacementtherapy
Definition
Replacement of natural oestrogen (with or without progestogen) to patients with deficiency of endogenous oestrogen due to
ovarian failure in order to minimize the risk of lack of oestrogen such as osteoporosis and atherosclerotic heart diseases
Type of natural oestrogen
1. Estradiol
2. Estradiol valerate
3. Equilin
Different preparation of oestrogen
1. Oral oestrogens
a.
First pass effect of liver leads to conversion of 1/3 of oestrogen to weak estrone glucoronide which is excreted quickly
b.
Estrone to estradiol of 2:1 instead of natural ratio of 1:2
c.
Also cause increase in sex hormone binding globulin, cortisol binding globulin, rennin substrate and HD and a
depressant effect on anti-thrombin III, and therefore theoretically contraindicated in women with a history of clotting
disorders or hypertension
2. Vaginal oestrogen cream for local treatment as well a systemic treatment
3. Percutaneous oestrogen cream
a.
Consists of 3mg estradiol in each daily 5g applicator of cream
b.
Bypasses liver and achieves a 1:2 estrone to estradiol ratio
4. Transdermal patches
a.
Consist of a thin multi-layered unit containing a drug reservoir, a rate-controlled ,membrane and an adhesive layer
b.
Patches have surface area of 5 to 20cm2 and administer estradiol at a controlled rate of 25 to 100mcg/day in vivo
c.
Need to change twice weekly
d.
Troublesome skin reactions ranging from hyperaemia to blistering, now little since new patches are used.
5. Subcutaneous implants
a.
Consist of 50mg estradiol pellet implanted subcutaneously in lower abdomen
b.
Estradiol level peaks at 2 to 3 months and declines to pretreatment level after 6 months
Progestogen
1. Is used with oestrogen in case of intact uterus
2. Aims to oppose oestrogen stimulation on endometrium and hence prevents endometrial cancer
3. On its own it is not a good HRT to control climacteric symptoms or prevent osteoporosis and atherosclerotic heart disease
4. Side effects:- mastalgia, bloating, pre-menstrual syndrome like symptoms.
Different forms of combination of oestrogen and progestogen
1. Unopposed (without progestogen) For those without uterus
2. Opposed (with progestogen)
a.
Cyclic:-for those with uterus and want regular withdrawal bleeding
b.
Continuous:-for those with uterus and want complete amenorrhea
Indications of HRT
1. Prolonged hypoestrogenism
2. Physiological menopause
3. Surgical menopause
4. Premature ovarian failure
5. Hypogonadotrophic hypogonadism
6. Symptomatic relief of climacteric discomforts
7. Prophylaxis against osteoporosis
8. Prophylaxis against atherosclerotic cardiovascular diseases
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Contra-indications of HRT
1. Absolute
a.
Oestrogen dependent cancers:- Endometrial cancer, Breast cancer
b.
Venous thromboembolism
c.
Active liver disease
d.
Undiagnosed abnormal vaginal bleeding
2. Relative
a.
Past history of thromboembolism
b.
Chronic liver diseases
c.
Hypertension and diabetes are not contraindications for HRT, provided that they are under good control.
Side effects
1. Most are mild and well-tolerated:
a.
Breast bloating and tenderness
b.
Weight gain
c.
Breakthrough bleeding:-need to rule out underlying endometrial pathology when abnormal vaginal bleeding occurs
2. Risk of breast cancer no firm evidence of increased risk. Possible long term (>5 years) risk.
Discussion/Something to Consider
1. Should all menopausal women be given hormonal replacement therapy routinely?
2. A postmenopausal woman of age 55 who has been put on opposed HRT for 3 years, presents to you with persistent vaginal
bleeding for 2 week. What is your management and counselling?
Protocol, as of 1 November 2004
1. Regimens
a.
Estrogen only therapy
i.
For women with no uterus
ii.
Oral regimens
Progynova 1 mg daily PO (low dose regime)
Premarin 0.625 mg daily PO
Premarin 0.3 mg daily PO (low dose regime)
iii. Non-oral regimens
Estreva (topical gel 0.5 mg / dose) 3 doses daily LA
Estraderm (transdermal patch 50 mcg / 24 hour) 1 piece once, 2 days /week LA
b.
Combined estrogen + progestin therapy
i.
For women with intact uterus
ii.
Continuous regimens:-No withdrawal bleeding
Kliogest 1 tab daily PO
Premelle 1 tab daily PO
Activelle 1 tab daily PO (low dose regime)
iii. Cyclical regimens:-With monthly withdrawal bleeding
iv. (For women with premature ovarian failure or recent menopause < 2 year)
Femoston 1 tab daily PO
Premelle cycle 1 tab daily PO
c.
Second line postmenopausal hormone therapy
Consult FHKAM for initial commencement (Prescriptions need authorization)
Evista (Raloxifene) 60 mg daily PO
Livial (Tibolone) 2.5 mg daily PO
2. Follow up (FU) Plan 6 months intern clinic & FU 12 months HRT clinic
a.
Assess side effects (e.g. irregular vaginal bleeding, breast discomfort)
b.
Assess drug compliance
c.
Assess efficacy of HRT (e.g. relief of menopausal symptoms)
d.
Review benefit-risk profile & justification of HRT use every year
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Curettage
Definition
Uterine curettage is a minor gynaecological surgery in which part of the endometrial lining of the uterus is removed by means of a
hollow spoon-shaped instrument (curette). Dilatation of the cervix is required to admit all but the smallest curette.
Hysterotomy
It is a gynaecological surgery for termination of pregnancy in the early second trimester. The uterus is cut open longitudinally and
the products of gestation are removed. The procedure is essentially the same as that of a classical caesarean section which is for
delivery of babies after 24 weeks of gestation. Hysterotomy is rarely done nowadays because of very effective and much safer
medical methods of termination of pregnancy (with prostaglandins). The risks of hysterotomy are haemorrhage, and uterine
rupture in subsequent pregnancy.
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Endometrial ablation
It is a relative minor gynaecological operation in which the endometrial lining down to the basal layer is destroyed, so that no
more or only minimal endometrial glands will be responsive to oestrogen. It is used to treat dysfunctional uterine bleeding (DUB).
Incidence
Endoscopic endometrial ablation:- 176 admissions in 2004.
Hysteroscopic endometrial ablation:- 187 admissions in 2004.
Methods of ablation
There are various ways of ablating the endometrium including microwave, thermal balloon, and electrocautery via hysteroscopy.
The former two methods can be performed under local anaesthesia in an out-patient setting.
Efficacy
About75-90% of patient will become amenorrhea after the treatment, 15% will still have menstruation but the flow is much
reduced, 5% have no improvement and require further treatment.
Advantages
Endometrial ablation has advantages over medical therapy of DUB:
No hormonal side-effects
No problem of drug compliance
Avoids the need of hysterectomy and subsequent morbidity and mortality. It can be done as a minor surgery in a day-case
setting, allowing quick recovery.
Disadvantages
It cannot treat dysmenorrhoea.
Long term effects for DUB is not satisfactory. Many patient may need repeat ablation or hysterectomy.
Contraception is not guaranteed - patients have to continue practising contraception
High risk of miscarriage, intrauterine growth restriction, abnormal placental adherence (e.g. Placenta accreta) if pregnancy
occurs.
Protocol, as of 1 December 2008
1. Novasure endometrial ablation is available within NTEC:2. The Second generation endometrial ablation can be offered to the following women:a.
DUB or menorrhagia refractory to medical treatment
b.
No fertility wish
c.
Women > 40 years old
3. If you want to book the Novasure endometrial ablation, please make sure the followings is available:a.
A recent normal endometrial sampling
b.
A recent normal cervical smear
c.
Relatively normal endometrial cavity, without the presence of the followings:i.
Congenital uterine abnormalities, such as bicornuate uterus, uterine septum
ii.
Submucosal fibroid or intramural fibroid that severely distorting the endometrial cavity
iii. Large endometrial polyp
iv. The assessment of the endometrial cavity can be done by TVS or OPH
d.
Uterine size less than 12 weeks, preferably with uterine length 4-12cm. (due to the limitation of device, the ablation
cannot be performed if uterine length less than 4cm and more than 12 cm)
4. Advise contraception till the date of the operation
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Myomectomy
What is myomectomy?
It is the excision of uterine fibroids. It is indicated when the fibroids become symptomatic or too large, and the patient Wants to
preserve the uterus for fertility. Otherwise, hysterectomy is the preferred choice. Depends on the site of the Fibroids, it can be
performed via laparotomy (for intramural fibroids), laparoscopy (for pedunculated fibroids), or hysteroscopy (for submucosal
fibroids).
Open myomectomy (via laparotomy) (65%)
The uterus is cut over the greatest diameter of the fibroid which is then enucleated. The uterine wound is finally repaired with the
dead space closed. The complications are excessive bleeding from the wound, and adhesion formation. Pre-operative GnRHa or
danazol may be used to decrease the size and vascularity of the fibroid.
Laparoscopic myomectomy (15%)
It is for pedunculated fibroids. The stalk of the fibroid is ligated or diathermized and cut. The fibroid is the morcelated and
removed in pieces via the small laparoscopic wound.
Hysteroscopic myomectomy (20%)
It is for small submucosal fibroid. A loop diathermy is used to cut the stalk, or the fibroid into pieces which are the removed
vaginally.
Outcome of myomectomy
Recurrence of fibroids (10%)
Recurrence of symptoms (10%)
Improvement of fertility in patient having fibroids as the sole cause of infertility (30%)
Discussion/Something to Consider
You are the house officer going to obtain the consent of a 26 years old patient with a 6cm intramural fibroid causing menorrhagia.
What would you explain to the patient about the operation?
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Terminology 2010
Hysterectomy
What is hysterectomy?
Excision of uterus. It can be divided into:1. Total (or simple) hysterectomy (95%)
a.
Both the corpus and cervix of the uterus are excised
b.
It is the most common form of hysterectomy for benign uterine lesion
2. Subtotal hysterectomy (1.5%)
a.
Only the corpus uterus is removed. Uncommon in Hong Kong
b.
Cervix is sometimes preserved for the following reasons:i.
Patient's wish because of the belief of the role of cervix in sexual satisfaction
ii.
Surgical difficulty in case of dense adhesion around the cervix
iii. Potential advantage in reducing ureteric and bladder injury
iv. Potential advantage in maintaining pelvic floor support
3. Extended hysterectomy (0.5%)
a.
The whole uterus together with the upper vagina are excised
b.
It is indicated when the pathology involves the vagina such as VAIN
4. Radical hysterectomy (3%)
a.
Choice for treatment of cervical cancer and uterine cancer with secondary involvement of the cervix.
b.
The whole uterus, upper vagina, together with the parametrium are excised.
c.
It is extensive and operative morbidity and mortality is higher when compared to other forms of hysterectomy.
Methods of hysterectomy
1. Laparotomy
a.
The traditional method of both benign and malignant lesions
b.
In general operative mortality is low but various morbidities are common (8%)
2. Vaginal hysterectomy
a.
Method of choice for treatment of uterine prolapse
b.
Operative morbidity and mortality are generally lower compared to laparotomy (7%) because:
i.
Abdominal wound is avoided
ii.
Technically easier as patient selected for vaginal hysterectomy usually has a small, atrophic, prolapsed uterus
and less pelvic adhesion
c.
The drawback is that other pelvic pathology such as ovarian lesion may not be assessed in vaginal hysterectomy
3. Laparoscopic method
a.
Aims to minimise the operative complications of laparotomy by converting it to a vaginal hysterectomy (LAVH), or
take the corpus uterus out via laparoscopic wound after morcelation (LASH)
b.
Two common types:
i.
Laparoscopic assisted vaginal hysterectomy (LAVH)
ii.
Laparoscopic assisted subtotal hysterectomy (LASH)
c.
Case selection:
i.
Benign uterine pathologies
ii.
Vaginal hysterectomy alone is not feasible
iii. Uterine size less than 14 week
iv. No severe pelvic adhesion
Complications of hysterectomy
1. General complications
a.
Febrile morbidity
b.
Haemorrhage
c.
Infection
2. Visceral injury
a.
Ureteric and bladder injury
b.
Bowel injury
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SUBTOTAL HYSTERECTOMY
VAGINAL HYSTECTOMY
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Hysteroscopy
What is hysteroscopy?
It is a kind of minimal invasive gynaecological operation in which an instrument (hysteroscope) with lumination is inserted
through the cervix to allow have direct visualization of the uterine cavity, which should be distended with CO2, normal saline or
glycine. It allows visual diagnosis of any endometrial pathologies, guides biopsy, and other surgical procedures.
Indications
1. Diagnostic:-can be performed as a day-case under no anaesthesia or paracervical block
a.
Abnormal vaginal bleeding such as
b.
Intermenstrual bleeding and menorrhagia refractory to medical therapy which may be due to endometrialPolyps or
submucosal fibroid)
c.
Postmenopausal bleeding (to rule out endometrial carcinoma)
d.
Suspected congenital uterine abnormality such as septated uterus
2. Therapeutic:
a.
Endometrial ablation
b.
Resection of submucosal fiborids or endometrial polyps
Contraindication
Pyometra (risk of spreading infection to peritoneal cavity)
Complications
1. Infection
2. Haemorrhage
3. Uterine perforation
4. Cervical laceration
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Cryotherapy
Cryotherapy is also called cryocautery and cryosurgery, and is commonly used to treat CIN. It involves the use of a metal probe
cooled through isotropic expansion of a compressed gas released from a tank through a small orifice under pressure. The gases
mostly used are nitrous oxide and CO2. This allows destruction of affected tissue to a depth of 3 mm. It is quick and sufficiently
painless to be used in the conscious patient. The destructive effect in the tissue depends on the rapid lowering of the temperature,
resulting in crystallization of cell water and disruption of cell membranes and organelles. The success rate of the treatment is
80-90%.
Figure 60 Cryotherapy
Figure 61 Electrocautery
Electrocautery
It is also called electrocoagulation, hot cautery or diathermy. It is commonly used to treat CIN, and for haemostasis during
operation. The device consisted of a heating instrument of high resistance similar to the soldering iron heated to a dull red. The
device delivers electric current from the generators. The procedure is very painful and usually requires general anaesthesia. It will
destroy tissue to a depth of 7-8 mm
Cold coagulation
It is commonly used method to treat CIN. The apparatus generates a probe temperature of 100 to 120 degree Celsius which is
'cold' in comparison to electrocautery or electrocoagulation diathermy, hence the name "cold coagulation". The heat is conveyed
to the tissues via thermosounds, which are held against the lesion in several overlapping applications, each lasting 20 to 30
seconds.
Marsupialisation
It is a surgical procedure in which a cyst is everted rather than excised. This is particularly used in the treatment of Bartholin's
cysts and makes the operation quicker and more bloodless than excision of the gland. It also reduces the incidence of recurrence.
The cyst or abscess is widely opened within the labium minus and drained and its walls sutured to the skin leaving a large orifice
which it is hoped will form a new duct orifice and allow conservation of the gland. A ribbon-gauze pack is inserted for 48 hours
by some operators.
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Endometrial sampling
Indications
It is the biopsy of the endometrial tissue for histological examination. It is mainly indicated for investigation of abnormal uterine
bleeding, in which case endometrial hyperplasia or endometrial carcinoma is suspected. Occasionally it is indicated for
investigation of infertility. It may help to diagnose ovulation and luteal phase insufficiency by the presence of secretary phase
changes. Endometrial tuberculosis can be diagnosed by the presence of caseous granuloma or culture of the tissue.
Methods
1. Uterine curetting
a.
It is the traditional method that has to be performed under general anaesthesia, and is therefore much replaced by the
following methods nowadays.
b.
It is supposed that it provides the greatest yield of tissue
2. Aspiration technique, with endometrial sampler or Vabra aspirator
A rapid and simple out-patient procedure, and provides a reasonable good yield of tissue for histological examination.
3. Hysteroscopically directed biopsy
The endometrial cavity is also examined at the same time via hysteroscopy. Localised suspicious lesions can be
targeted. The yield however is very limited due to because of the small-sized biopsy forceps.
In general, sampling by both uterine curetting and aspiration methods provide comparative good sensitivity for histological
diagnosis of endometrial pathologies. Hysteroscopic assessment allows visualisation of structural abnormalities such as
submucosal fibroids or endometrial polyps that can be missed by the other two methods. However, it has to be supplemented with
endometrial sampling by other methods.
Complications
1. Perforation of uterus
2. Introduction of infection
Endometrial sampler
A simple narrow plastic tube inserted into the uterine cavity for endometrial sampling. It provides reasonable good yield of tissue
for histological assessment.
1.
Pipelle de Cornier
The Pipelle is inserted into the uterine cavity and the plunger withdrawn to produce a vacuum. The endometrium is thereby
sucked into the tube and subsequently expelled into fixative. This procedure is better tolerated than the Vabra curette but does
not always produce sufficient tissue to evaluate histologically.
2.
Vabra Curettage
This method of obtaining material for histological examination can be done in the out-patient clinic. Adequate specimens can
be obtained, but the procedure is painful. If out-patient methods of examining endometrium do not provide reliable
information, conventional curettage must be carried out.
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Hysterosalpingogram
What is Hysterosalpingogram?
Hysterosalpingogram (HSG) is an X-ray examination of the genital tract after contrast injection into the uterine cavity, by which
contour of the uterine cavity, fallopian tubes and endocervical canal are visualized. It is normally performed within the first ten
days of menstruation in order to avoid inadvertent exposure of the early embryo to irradiation
This is a normal salpingogram. Note:
1: The antevered uterus is foreshortened.
2: The long thin tubal outline.
3: The ill-defined shadow of peritoneal spill.
4: Cervico-vaginal leakage
Indications
Investigations of the following:
1. Patency of fallopian tubes (to investigate infertility)
HSG is less invasive when compared with laparoscopy and chromotubation for the investigation of the tubal patency.
However, it has false positive result as the injected contrast may cause tubal spasm that transiently blocks the tubes. In
addition, laparoscopy allows assessment of any pelvic pathology such as endometriosis, chronic pelvic inflammatory
disease, and pelvic adhesion, which is not possible with HSG.
2. Structural abnormalities of uterus:-congenital uterine anomalies such as bicornuate uterus and septate
Sometimes submucosal fibroids and endometrial polyps can be identified incidentally with HSG but HSG is not the
primary diagnostic method of these lesions
3. Cervical incompetence
Leaking of contrast from the internal os the cervix may be seen in case of cervical incompetence. However, the
diagnostic accuracy is still limited. See cervical incompetence for detail.
Contra-indications
Allergy reaction to contrast
Active pelvic inflammatory disease
Pregnancy
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Imperforate hymen
It is a congenital disorder in which the hymen membrane remains intact. When patients start menarche, menstrual blood flow is
blocked and the blood accumulates and distends the vagina. Usually patients present at early teenage with amenorrhea
(cryptomenorrhea), cyclic abdominal pain, abdominal distension and urinary retention. On examination, the hymen membrane is
bulging out and appears blue because of the blood collection behind the membrane. Ultrasound shows a distended vagina beneath
the bladder. The treatment is excision and drainage.
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Reproductive medicine
0. Reproductive medicine and Endocrinology
Introduction
It is a branch of gynaecology dealing with various kinds of hormonal disorders directly or indirectly involving the hypothalamicpituitary-ovarian axis, resulting in anovulation, infertility or ovarian failure (menopause), or sometimes disorders of puberty. The
management of these kinds of disorders is usually medical therapy, with ovulation induction, or hormonal replacement therapy. It
may also involve sophisticated bio-technicology when assisted reproductive technology (ART) is used to treat infertility.
What medical students should know
Common disorders:
1. Polycystic ovarian disease (PCOD)
2. Hyperprolactinemia
3. Various causes of infertility and the investigations
4. Problems associated with menopause
Common treatments:
1. Ovulation induction
2. Hormonal replacement therapy
3. Some ideas about ART
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Treatment
1. Principle:
a.
Correct underlying causes if possible
b.
Try appropriate method with the least risk first
2. Treatment modalities include:
a.
Ovulation induction (OI)
b.
In utero insemination (IUI) with or without ovulation induction
c.
Assisted reproductive procedure
i.
In vitro fertilisation (IVF)
ii.
In vitro fertilisation with intracytoplasmic sperm injection (ICSI)
d.
Besides medical treatment, adoption should also be discussed
Treatment of anovulation
Treat with ovulation induction
1. Clomid is the first line
2. HMG or FSH if clomid is failed or contraindicated
3. Ovarian drilling only for PCOD
Treatment of endometriosis
1. Risk of infertility increases with severity of endometriosis
2. Medical treatments relieve pelvic pain but not improve fertility
3. Surgical treatments including cystectomy, ablation of endometriosis improve chance of fertility
4. IVF should be considered if surgical treatment failed, or in case of severe endometriosis which is not easily treated by surgery
Treatment of tubal blockage
Can be treated with tubal surgery or with in vitro fertilisation (IVF):
1. Tubal reanastomosis for previous sterilisation
2. Salpingostomy for simple and small hydrosalpinges
3. Severe tubal blockage is managed with IVF
Treatment of male infertility
1. In utero insemination for mild impairment of semen quality
2. In vitro fertilisation with ICSI for severe impairment
3. Sperm donation:-insemination of donor sperm
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Anovulation
Definition
It means absence of ovulation. Two different conditions occur in anovulation:
1. Defective follicular phase and follicular development that result in hypoestrogenemia
2. Apparently normal follicular phase but defective luteal phase, leading to normal or increased level of oestrogens, but deficient
progesterone. It may result in endometrial hyperplasia
Causes
1. Endocrine disorders involving the hypothalamo-pituitary-ovarian axis
a.
Ovary:i.
Polycystic ovarian disease (PCOD), the most common cause
ii.
Turner syndrome
b.
Pituitary:i.
Congenital absence of FSH or LH-secreting cells
ii.
Sheehan syndrome
iii. Damage by surgery or radiotherapy
iv. Hyperprolactinaemia
c.
Hypothalamus:i.
Anorexia neurosa
ii.
Weight and stress related causes of hypogonadotropism
iii. Kallman syndrome:-rare
iv. Compression or destruction by intracranial tumour:-uncommon
d.
Other endocrine disorders that indirectly affect the hypothalamo-pituitary-ovarian axis:i.
Hyper or hypothyroidism
ii.
Hyperandrogenaemia
iii. Cushing disease,
iv. Menopause
2. Most of the causes (except PCOD) result in hypoestrogenic type of anovulation
Clinical features
1. Features of anovulation:
a.
Oligomenorrhea or amenorrhea
b.
Infertility
c.
Absence of biphasic changes of basal body temperature, etc
2. Features of underlying causes:-Features of Turner syndrome, PCOD, menopause, thyroid disorders etc
Investigation
Confirm anovulation:1. Low progesterone at the middle of the supposed luteal phase (i.e. Day 21 of 28-day menstrual cycle)
2. Look for underlying causes, such as:
3. FSH and LHtaken at the follicular phase
a.
LH:-FSH ratio >3 or high LH level is diagnostic of PCOD
b.
High FSH suggests menopause
4. Prolactin levels, etc
Management
1. Treat underlying causes
2. Treat infertility with ovulation induction
3. Prevent endometrial hyperplasia which is a complication of chronic anovulation associated with hyperestrogenemia
4. Prevent complications of hypoestrogenemia, usually with hormonal replacement therapy
Discussion/Something to Consider
How do different causes of anovulation affect the choice of ovulation induction?
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Ovulation
Definition
Ovulation is the process during which a Graafian follicle ruptures to release a mature oocyte with its surrounding cumulus
oophorus. This is initiated by a luteinizng hormone (LH) surge (a brief rise in LH started 36 to 38 hours before ovulation), which
precipitates the final changes in the follicular wall, follicular fluid volume and the oocytes which are the necessary precursors to
ovulation. The first meiotic division is completed at this stage and half of the chromosome complement discarded as the first polar
body.
How can we know the timing of ovulation?
1. It is sometimes necessary to know the time of ovulation for purpose of conception, treatment of fertility (such as correct
timing of artificial insemination or the transfer of previously frozen embryos.) and as well as contraception (rhythmic
method)
2. Clinical
a.
Ovulation usually occurs 14 days before the next expected menstruation (i.e. around day 14 in a 28 day cycle).
b.
In longer cycles, ovulation occurs later.
c.
Ovulation may be associated with temporary discomfort or pain (see Mittelschmerz).
d.
Soon after its occurrence there is a rise in the basal body temperature due to progesterone production.
e.
There are changes in cervical mucous before ovulation (spinnbarkeit sign and ferning)
3. USG monitoring:- serial ultrasound scans to monitor the growth of ovarian follicles and rupture
4. Measuring the LH:- The onset of the LH surge can be determined by measuring LH concentrations in blood and urine.
5. Measuring the progesterone:- Blood taken at the expected mid-luteal phase (i.e. day 21 in a normal 28-day cycle) shows a rise
in progesterone level.
Ovulation Induction
1. Some women fail to ovulate (see anovulation) and become infertile, because of various endocrinopathologies.
2. Ovulation induction is required
3. l In assisted reproductive technology (ART), the administration of hCG is used to trigger ovulation and time oocyte collection
(to simulate a LH Surge), particularly if spontaneous LH surges are suppressed by GnRHa.
Spinnbarkeit
The ability of cervical mucus to be drawn into threads. This is maximal a day or so before ovulation due to the oestrogen surge for
the Graafian follicle. After ovulation this quality is lost and cervical mucus becomes thick (tacky) due to the effect of progesterone.
It is one of a bedside method to assess timing of ovulation
.
Ferning
Ferning of cervical mucus
When cervical mucus obtained just before ovulation is dried and allowed to crystallize, a pattern resembling fern leaves can be
observed under microscope. This property of cervical mucus is resulted from the influence of estrogens which makes the mucus
more profuse and fluid just before ovulation. This is a favourable sign in the assessment of quality of cervical mucus.
Ferning of amniotic fluid
A ferning pattern can also be observed under microscope after drying and crystallization of amniotic fluid. It can be used as a test
to confirm rupture of membranes when a specimen of fluid is obtained from the vagina (not from the cervix). However, it is not
very practical and is seldom applied clinically now.
Fertilisation
The process by which the male and female gametes unite to form a zygote. This begins when the spermatozoon first contacts the
oolemma (the oocyte surface membrane) and lasts until the genetic material of sperm and oocyte have mixed and reduplicated as
the zygote initiates its first division into two cells. In vivo, fertilisation occurs in the fallopian tube, usually within one day of
ovulation, and is completed in approximately 24 hours.
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Conception
The process from fusion of the gametes through the early development of the conceptus, to implantation of the blastocyst. The
intervention of conception in order to prevent pregnancy to occur is called contraception.
Luteal phase
A phase of an ovarian cycle starting from ovulation to the next menstruation. It usually lasts 14 days. During this period, the
corpus luteum secrets progesterone which turns the endometrium into secretary state, becomes thicker, more vascular and
receptive to a blastocyst. The cervical mucus also becomes thicker and impenetrable to spermatozoa. Luteal phase insufficiency
may occur resulting in failure of a blastocyst to implant.
Follicular phase
The period of development of the dominant follicle (with its oocyte and theca and granulosa cells) to become a fully formed
Graafian follicle, which will be responsive to the pre-ovulatory LH surge. The follicular phase usually lasts for 14 days.
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Postcoital test
What is a postcoital test (PCT)?
It assesses the quality of the cervical mucus which may be one of the causes of infertility. Inflammation of cervix, presence of
antisperm antibodies in the cervical mucus may cause death or inactivation of sperm.
How to perform postcoital test
Timing:-6 to 12 hours after a normal unprotected intercourse, performed just before the estimated date of ovulation.
Procedure:-After passage of a speculum, a small amount of cervical mucus is aspirated and immediately examined
microscopically. The viability and mobility of sperms are assessed.
Assessment:
The test is considered adequate if 5 to 10 freely mobile sperms are seen per high power field.
Their motility is assessed:-it may vary from highly active progressive movement to sluggish, or no, motility.
Clumping, shaking or agglutination (head to head or taito tail) may suggest the presence of antisperm antibodies.
How to interpret postcoital test result
A good PCT indicates that intercourse is adequate, the male is likely to be fertile and the woman is normal up to the level or
the cervix. The prognosis for conception is good in the presence of good PCT.
On the other hand, a single unsatisfactory test may not be of any significance as most commonly, the poor cervical mucus is
due to inappropriate timing of the test. When performed too early, it may not be fully oestrogenic; when performed too late,
it may have become highly viscous under the influence of progesterone.
The test may need to be repeated.
A gross deficiency of mucus (dry cervix) may result from amputation of the cervix and certain other operations which
destroy cervical glands. The presence of white blood cells may indicate inflammatory condition, prejudicial to conception.
If sperms are not present in repeated PCT despite a normasemen analysis, a coital problem should be suspected.
It is still controversial whether post-coital test should be a routine investigation in the management of infertile couple. Due
to the poor reproducibility and diagnostic and prognostic performance of postcoital test, it is not routinely performed in
PWH.
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Ovulation induction
What is ovulation induction?
It is a procedure or treatment to induce ovulation artificially for patients suffering from infertility due to anovulation.
Methods of induction
1. Medical
a.
Clomiphene citrate:- as an anti-oestrogen to raise LH and FSH level, therefore promotes follicular development.
b.
Gonadotropin therapy:- for WHO type I and II.
c.
Pulsatile gonadotropin releasing hormone (GnRH):- for WHO type I and II.
d.
Dopamine agonists:-bromocriptine (only for hyperprolactinemia)
2. Surgical
a.
For medical therapy resistant PCOS
b.
Beneficial for ovulation than hirsutism
c.
Different surgical approach:- Wedge resection, laparoscopic ovarian drilling.
3. No remedy for WHO Type III hypergonadotropic hypoonadism (primary ovarian failure), consider donor oocyte and
adoption.
Two main complications of ovulation induction
1. Multiple pregnancy
2. Ovarian hyperstimulation syndrome (OHSS)
Confirmation of ovulation
1.
2.
3.
Biphasic BBT
Elevated Luteal phase progesterone (Measure 7 days before menstruation)
Others: LH surge, serial ultrasound
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Clomiphene
Nature
1. An oranon-steroidaanti-estrogen
2. Racemic mixture of its 2 sterochemical isomers zuclomiphene (weak oestrogen) &enclomiphene citrate (potent antiestrogen)
Mechanism of action
1. Its anti-estrogenic activities diminish the negative feedback and increase the release of endogenousgonadotropin.
2. An intact hypothalamic-pituitary axis and presence of endogenous oestrogen are essential for its effectiveness
Regime
1. Start with a daily dose of 50mg, taken for 5 days from day 2 to 6 of the menstruacycle (some may start from day 5)
2. Confirm ovulation by basabody temperature chart or mid luteaprogesterone
3. Adjust the dosage according to the ovulation response. The maximum dose is 200mg daily
4. The couple is advised to have intercourse on alternate days for 1 week around the time of ovulation
Efficacy
1. Ovulation rate:- 40-60% per cycle
2. Conception rate:-15-20% per ovulatory cycle
3. Cumulative 6-month conception rate:-60-75%
4. Remark:-alternative method of ovulation induction should be consider if the patient is anovulatory even on maximum dose of
clomid or fail to conceive after 6 to 12 ovulatory cycles
Complications
1. Usually safe with mild side effects
2. Vasomotor flushes (10%), abdominal bloating (5%), breast discomfort (2%), headache (1%), visual symptoms
3. Multiple pregnancy rate:-5% (mostly twin); higher multiple pregnancies rare
4. Ovarian hyperstimulation is very rare
Advantages
1. Simple, safe and cheap
2. Orally active
3. Worth trying as the first line agent in those cases with intact hypothalamic-pituitary-ovarian axis
Protocol, as of10 May 2003
1.
Usual starting dose of clomid is 50mg daily from D2 to D6 each cycle
2.
Increase the dose by a monthly increment of 50 mg daily until ovulation occurs or a maximum dose of 200 mg daily has
reached
3.
Check response by BBT
4.
Confirm ovulation by mid-luteal (D21 in 28-days-cycle) progesterone
5.
If remained anovulatory on maximum dose of clomid, refer for OI (with gonadotropins) after confirmation of tubal
patency
6.
If failed to conceive after 12 cycles of successful clomid treatment with confirmation of ovulation, refer for further
assessment infertility clinic
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In vitro fertilisation(IVF)
What is in vitro fertilisation?
1. It is a 4-stage assisted reproductive procedure which includes:
a.
Controlled ovarian hyperstimulation,
b.
Oocyte retrieval under transvaginal ultrasound guidance,
c.
Fertilization with sperm in vitro, and
d.
Embryo replacement into the uterus.
2. Main indications
a.
Tubal infertility
b.
Moderate-to-severe endometriosis
c.
Male infertility
d.
Failure of other infertility treatments.
3. Efficacy
a.
Conception rate:-10-30% per cycle (success rate decreases with increasing female age)
b.
Cumulative conception rate:-40-60% after five cycles (success rate decreases with increasing female age)
4. Complication
a.
Multiple pregnancy rate:-20-30%
b.
Ovarian hyperstimulation syndrome (1% risk of severe OHSS)
c.
Potential risks during oocyte retrieval. E.g. Haemorrhage, infection, visceral injuries to vessels, bowels etc.
d.
Recent studies have suggested that it may be associated with a higher risk of carcinoma of ovary. This has not be
confirmed yet
Insemination
Intra-uterine insemination is an assisted reproduction technique (ART) in which a prepared specimen of semen is injected by
means of a cannula through the cervical canal, directly into the uterine cavity. The semen can be prepared from husband or from
donor if it is a case of male infertility. The insemination is performed at the time of ovulation as determined by ultrasound or
hormone measurements, and is usually preceded by ovarian stimulation.
Complications of insemination itself are very low but ovarian hyperstimulation and multiple pregnancy may be resulted from
concurrent ovarian stimulation. Intra-uterine insemination is particularly useful in women with deficient cervical mucus. It is
widely used for unexplained infertility and mild endometriosis before resorting to in vitro fertilisation (IVF). Success in men with
impaired sperm concentration or motility and those with antisperm antibodies is doubtful. The technique is simpler and cheaper
than IVF and less objectionable in those who, on religious or personal grounds, may not wish to undergo IVF.
Intra-cytoplasmic sperm injection (ICSI) is one of the ART procedures to treat male infertility. A single spermatozoon is injected
into the cytoplasm of the oocyte using a microinjection pipette. It overcomes the problem of severe oligospermia because only a
few sperms are required, as compared to millions in conventional in vitro fertilisation. It also helps in sperm dysfunction such as
immotility and penetration failure, since the sperm is injected directly into the oocyte. Provided that the injected sperm is viable,
the chance of fertilisation is good. The risk of the treatment is that as severe oligospermia or azospermia is associated with
chromosomal abnormalities, there is a higher chance of transmission of abnormal karyotype to the offsprings.
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Clinical features
Clinically, there are abdominal distension, nausea, vomiting, and diarrhea, dyspnea, oligouria.
Treatment
1. For mild cases, treatment is conservative:
a.
Monitoring of haemodynamic status, urine output, weight gain, electrolytes
b.
Fluid support which may consist of albumin or other kinds of colloid infusion
c.
Prevent deep vein thrombosis with elastic stocking
2. For severe cases, surgical intervention may be required:
a.
Pleural effusion:-pleural drainage
b.
Massive ascites:-paracentesis
c.
Laparotomy or laparoscopy for ruptured or bleeding ovarian cysts
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3. Male infertility
Spermatogenesis
-
Male infertility
Male factor accounts of 30% of all cases of infertility. There are two major mechanisms for male infertility:
1. Abnormalities in spermatogenesis
2. Abnormalities in the delivery system of semen:
a.
Blockage at vas deferens
b.
Retrograde ejaculation
Abnormalities in spermatogenesis
1. Spermatogenesis can be affected by:
a.
General environmental factors:- Such as chronic smoking, alcoholism, toxin or heavy metal, hot environment
b.
Primary testicular failure resulted from:
i.
Chromosomal abnormalities such as Klinefelter syndrome
ii.
Irradiation, chemotherapy, surgery, tuberculosis and mump infections
c.
Endocrine disorders such as:
i.
Deficiency of hormones of pituitary gland and hypothalamus such as in Kallman syndrome
ii.
Hyperprolactinemia
d.
Miscellaneous:
i.
Y-chromosome microdeletion is found in 10% of severe male infertility
ii.
Varicoele which may result in a higher testicular temperature, is said to be associated with poor spermatogenesis
Diagnosis of male infertility
Male infertility is screened with semen analysis. More sophisticated tests for sperm functions are not very useful clinically.
Treatment of male infertility
1. General measures Improvement of general health including stopping smoking and alcohol intake may improve semen
quality in patients with mild impairment of semen quality
2. Hormones Only for correction of endocrine disorders
3. Intrauterine insemination For mild impairment of semen analysis
4. In vitro fertilisation and ICSI For severe impairment of semen quality
5. Surgery For correction of blocking, retrograde ejaculation, and varicocele
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Semen analysis
What is semen analysis (SA)
A laboratory test of seminal fluid carried out to investigate male fertility or the effectiveness of vasectomy. The technique and
range of normal values have been standardized by the World Health Organisation (WHO).
How to perform semen analysis
1. Timing:-the male have ejaculated at least once within the week prior to the test but not within the previous 2 days
2. Collection:-all semen samples should be obtained by masturbation into a clean, wide-mouthed nontoxic plastic container and
delivered to the laboratory as soon as possible, preferably within one hour
3. Assessment:-volume and liquefaction time of the semen, sperm count, motility and morphology
WHO criteria for normal semen characteristics:
Parameter
Normal value
Volume
2ml or more
Concentration
20 million/ml
Motility
50% or more sperms have progressive motility
Morphology
30% or more sperms have normal form
Liquefication
Complete in 30 min
White Blood Cell <1 x 106/L
Diagnosis
The diagnosis is made when two or semen analysis on separated occasion at least 3 months apart is abnormal.
How to interpret a SA report
1. The most common reason for abnormal SA is the inaccurate collection of the specimen, or history of recent illness (in 3
months) that may affect the production of sperm. Therefore, it is advisable to repeat the SA after a 3-month interval
2. If the SA is grossly abnormal, further investigation should be taken to look for the underlying causes.
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4. Sexual dysfunction
Sexual dysfunction
Sexual functioning involves a unique combination of physical, psychological and social expression. It allows a couple to
reproduce, bond and enjoy each other. Sexual dysfunction accounts for 5% of all cases of infertility. Both male and female can be
affected.
Female sexual dysfunction
Vaginismus
Dyspareunia
Male sexual dysfunction
Erectile or ejaculatory dysfunction
Libido
Sexual drive or desire. The intensity of libido varies from person to person, and may also vary in women in relation to the
menstrual cycle, pregnancy or menopause. Libido generally decreases in both sexes with advancing age. The term must not be
confused with orgasm.
Vaginismus
It is a kind of sexual dysfunction. It is involuntary painful spasm of the pubococcygeus muscle (see levator ani) leading to closure
of the vaginal introitus, preventing penetration. It is different from dyspareunia. The cause is psychological rather than organic.
Treatment is by gradual desensitization.
Dyspareunia
It means painful sexual intercourse. Pain on penetration may be superficial or deep. Deep dyspareunia often has underlying
pathologies such as pelvic endometriosis and chronic pelvic inflammatory disease. Superficial dyspareunia usually has a
psychological element and lack of lubrication during intercourse. Sometimes superficial dyspareunia of acute onset is related to
local pathologies such as vaginitis, vulval herpes and ulcer.
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Oncology
0. Gynae-oncology
Introduction
It is a subspecialty of gynaecology deals with malignant and pre-malignant lesion of the genital tract
Female genital cancer in Hong Kong
Hospital Authority 2006 Report:Cancer
Incidence
Death
Ca Cervix
459 (9.6, 5th) 133 (2.4, 9th)
Ca Ovary
450 (9.7, 6th) 136 (2.6, 8th)
Ca Corpus
570 (11.7, 4th) 49 (1.0, 15th)
Cervical cancers and ovarian cancers are the 4th and 10th most common cancers in female population in Hong Kong
Topics
1. Premalignant lesion of genital tract
a.
Cervical intraepithelial neoplasm (CIN)
b.
Vaginal intraepithelial neoplasm (VAIN)
c.
Vulval intraepithelial neoplasm (VIN)
d.
Endometrial hyperplasia
2. Cervical cancers
a.
Majority is squamous cell carcinoma
b.
Rarely adenocarcinoma
3. Ovarian cancers
a.
Majority is epithelial cancer
b.
The rest is non-epithelial cancer including:-germ cell tumours and stromal cell tumours
4. Cancers of corpus uterus
a.
Most are endometrial carcinoma
b.
Rarely sarcoma arise from the smooth muscle tissue
5. Vaginal cancers
a.
Most are squamous cell cancer
b.
Very rarely adenocarcinoma related to in utero exposure to DES
6. Vulval cancers Most are squamous cell cancer and rarely melanoma
7. Gestational trophoblastic diseases more common in Asian than in Caucasian
Modalities of treatment
1. Surgery mainstay of curative treatment for epithelial type of cancers:-endometrial, ovarian, and cervical cancer
2. Chemotherapy mainstay of treatment for trophoblastic disease and germ cell ovarian tumours
3. Radiotherapy
a.
Mainstay of treatment for cervical cancer
b.
Adjuvant therapy for high-stage endometrial cancer
What should medical students know?
Students should know cervical cancer, endometrial carcinoma, ovarian cancer, gestational trophoblastic disease and premalignant
lesions:-CIN and endometrial hyperplasia as they are relatively common.
Sarcoma, vaginal and vulval premalignant lesions and cancers are very uncommon.
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Incidence
Primary growths of the vagina are rare and the average gynaecologist will see only one such tumour for 30 of the cervix.
Pre-invasive lesions (VAIN) are now more frequently diagnosed. They may proceed to cancer. There is little evidence for
radiotherapy as a cause and intrauterine exposure to di-ethyl stilboestrol (DES) in fact carried a very low risk of causing vaginal
cancer as opposed to vaginal adenosis. Secondary growths are more common, especially extension from cervical cancer, and
metastatic deposits may appear from disease elsewhere in the body.
Histology
85% are squamous carcinomas, occurring in women over 60. The remainder include melanoma, sarcoma, adenocarcinoma and
clear cell carcinoma, all of which tend to be associated with middle-aged or even young women
Clinical Features
The patient is usually menopausal and most commonly complains of bleeding (60%). Discharge (15%) and pelvic pain (<10%)
may be present. If the bladder is involved, she will experience pain and dysuria. The tumour is not at first painful and unless it
appears in a woman who is still sexually active, it is not likely to present until it has penetrated the vaginal wall and caused
bleeding. Old women often believe or affect to believe that all bleeding is from haemorrhoids.
Diagnosis
An early tumour can easily be missed if it is obscured by the blade of a metal
speculum. The whole vagina should always be inspected, and cytological smears
taken from any lesion at all unusual. Colposcopy, cystoscopy and
proctosigmoidoscopy are indicated to detect spread.
Site and Spread
Tumours of the lower third (25-30% of cases) have a much poorer prognosis than those of the upper and middle thirds, partly
because spread to the inguinal nodes is quicker and because of the danger to the bladder. Prognosis depends on the stage, which
depends on when the patient goes to her doctor, and on the position in the vagina. The lower third with its much quicker lymphatic
spread is the least favourable.
Treatment
In stage 0 growths, good results have been obtained with local application of 5-fluorouracil cream, but for stage I onwards,
radiotherapy is the usual treatment.
1. It can be applied at any stage.
2. It is more readily available than skilled radical surgery.
3. The patients are often elderly and poor surgical risks.
Radical surgery (radical hysterectomy, vaginectomy, lymphadenectomy) is claimed to give good results in experienced hands, and
a cure rate of over 80% has been achieved for stage I. In stage IV where radiotherapy is only palliative, surgery which includes
some form of exenteration is the better treatment if the patient is fit and the gynaecologist has the necessary experience. Vaginal
melanoma is almost always fatal, with poor results from radiotherapy and no appropriate chemotherapy available. Sarcoma
botrioides is a rare tumour of young children, presenting as grape-like masses with bleeding. Chemotherapy with vincristine,
actinomycin D and cyclophosphamide gives good results.
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Staging of CA vulva
Staging CA vulva FIGO 2009
Stage I
Tumor confined to the vulva
Stage II
Tumor of any size with extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with
negative nodes
Stage III Tumor of any size with or without extension to adjacent perineal structures with positive inguino-femoral lymph
nodes
Stage IV Tumor invades other regional (2/3 upper urethra, 2/3 upper vagina), or distant structures
Incidence:-3 per 100 000 (UK); 1.3 per 100 000 (HK) per year
Aetiology
The aetiology of vulval cancer is unknown. Some vulval cancers contain viral antigens
(e.g. HSV 2), but the importance of these in the aetiology of the disease is uncertain.
Histology
Squamous carcinoma:-85%
Melanoma:-5%
Clinical features
The majority of patients with vulval cancer are over 60. The presenting features include vulval irritation and pruritus (70%), a
vulval mass (60%) and bleeding (30%). The diagnosis is often delayed, partly due to the patient's reluctance to seek medical help,
and partly due to delay in performing a clinical examination once the patient presents. Any lump on the vulva must be examined
and biopsied. The inguinal lymph nodes may be enlarged, but absence of enlargement does not guarantee absence of lymphatic
spread.
Protocol of this disease is too lengthly and unnecessary to be included.
Surgical treatment
1. Radical vulvectomy is the optimum treatment for vulval cancer. The conventional operation is radical vulvectomy with
dissection of the superficial and deep inguinal glands and the external iliac glands. Such surgery has increased the five year
survival for the disease which is now 75%. The whole vulva, skin and subcutaneous tissue are excised down to the
periosteum. The wound should be closed completely if possible, undercutting and mobilizing skin if necessary. Radical
vulvectomy with en bloc dissection and removal of the inguinal and iliac lymph glands is associated with significant
morbidity. The following variations in technique have been introduced to reduce morbidity.
2. In vuval cancer, lymphatic metastases develop initially by embolisation. In early disease there is no need to remove the
lymphatic channels between the tumour and the groin nodes. Therefore, three separate incisions can be used to remove the
tumour and the nodes on each side. Such an approach is associated with lower morbidity than conventional surgery.
3. If the primary tumour is small, and confined to one area, a more limited operation may be as effective as radical vulvectomy.
In modified radical vulvectomy, the lesion and surrounding area is removed, leaving the reminder of the perineum intact. A
2-3 cm margin of healthy tissue should be removed along with the tumour.
Figure 66 Conventional radical vulvectomy (Leftmost two), Separate groin incision(third) and modified radical vulvetomy(right).
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Tumour grossly limited to the true pelvis with negative nodes but with histologically confirme microscopic seeding of
abdominal peritoneal surfaces
Tumour involving one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces none
exceeding 2cm in daimeter; nodes are negative
Abdominal implants >2cm in diameter and/or positive retroperitoneal or inguinal nodes
Stage 4 Growth involving one or both ovaries with distant metastasis. If pleural effusion present, there must be positive
positive cytology to allot a case to stage 4; parenchymal liver metastasis equals stage 4
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2.
3.
Preoperative Investigations
a.
Haematological Investigations:
i.
CBP
ii.
RFT and LFT
iii. Tumour markers
AFP, BHCG, CEA for suspected germ cell tumours
CA125 for suspected epithelial cell carcinoma
iv. Serum for blood grouping and cross match
b.
ECG
c.
Chest X-ray
d.
Abdominal and pelvic ultrasound scans to look for distant metastasis especially over the lymphatic areas of the
groin and pelvis
e.
CT and MRI To be performed as clinically indicated
f.
Pleural or peritoneal tapping
i.
This is performed for symptomatic relief
ii.
Fluid would be sent for cytology to look for malignant cells
g.
Sigmoidoscopy/colonoscopy For patients with bowel symptoms or raised CEA
Preoperative Preparation
a.
Inform the possibility of losing reproductive function if the patient has not completed her family
b.
Bowel preparation
i.
Fluid diet for 48 hours before OT
ii.
Phosposoda 24 hours before OT
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Dysgerminoma
It is the most common malignant germ cell tumours of the ovary, and also account for 2-5% of all primary ovarian cancers. It
mainly affects the young women (< 30 year old). It is similar to seminoma of men. It is solid, loculated, moderate in size, and
usually has a long ovarian pedicle which is at risk of torsion. It is bilateral in 10% of cases, and is spread through lymphatic
channels to para-aortic, mediastinal and supraclavicular lymph nodes. It does not produce hormones, but may contain elements of
yolk sac tumour and choriocarcinoma, and their presence may make the prognosis worse. Therefore, testing for serum level of
alpha-feto protein and human chorionic gonadotropin are important. Dysgeminoma is very sensitive to both chemotherapy and
radiotherapy. Treatment is usually oophorectomy followed by chemotherapy. The contralateral ovary and uterus can be preserved
for fertility.
Discussion/Something to Consider
As dysgeminoma is also radiosensitive, what is the reason that chemotherapy is preferably to radiotheray as a post-surgical
adjuvant treatment?
Krukenberg tumour
It is a secondary ovarian cancer with characteristic histological picture of mucin-ladin, signet-ring cells infiltrating a hypoplastic
ovarian stroma of spindle shaped cells, and is usually metastasized from stomach, colon, breast, pancreas. It is usually bilateral,
and most are lobulated, of moderate size, rapid growing, and retained the normal shape of ovary.
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Pap smear
Definition
It is a cytological investigation of the cervical cells designed for screening of cervical intraepithelial neoplasia (CIN), as a
preventive measure against cervical cancer.
Who should be screened?
All women aged 20 to 64 who are or ever have been sexually active.
When should be screening stopped
At age 65
However, women aged 65 or above should be encouraged to have a smear if they have not been screened previously
How often should smears be taken?
1. Every 3 to 5 years
2. in HK, yearly in the first 2 years, then every 3 years
Frequency of screening
Reduction in risk of developing invasive diseases
Every 5 year
84%
Every 3 year
93%
Every year
95%
3. As there is only 2% reduction of risk of invasive cancer by yearly screening when compared to 3-yearly screening, the later is
more cost-effective
How to take a Pap smear
1. Patient relaxes in the dorsal position. Perform speculum examination to visualise the whole cervix.
2. Use a small amount of water-based lubricant so that it would not affect the smear. Swab away any blood or discharge.
3. If the squamo-columar junction can be seen, take a smear from the transformation zone by 360 degree firm surface sweep
with a suitable spatula
4. If the squamo-columar junction is sited within the endocervical canal then take a smear by rotating a cytobrush in the canal.
5. Spread the smear evenly over a labelled glass slide. Fix it rapidly with ethanol to avoid drying artifact.
How to examine a pap smear under microscope
1. The cytological features of individual cervical cells are examined. The degree of dyskaryosis depends on the nuclear features
and nuclear to cytoplasmic ratio, and is classified to mild, moderate and severe. Koilocytosis, a feature of human
papillomavirus infection may also be picked up.
2. Because of the difficulties in differentiate the grading; an alternative classification system called Bethesda is also commonly
used. In the Bethesda system, CIN II and III are combined into high grade squamous intraepithelial lesion (HGSIL), while
CIN I and koilocyotosis are combined into low grade SIL. The Bethesda system also includes 'atypical squamous cells of
unknown origin' (ASCUS) of which cervical cells show mild dyskaryosis but do not fit in low grade SIL. They are usually
due to reactive changes toward inflammation.
3. Besides, lower genital tract infection may sometimes be picked up from a smear:-trichomonas vaginalis, candidiasis, clue
cells of bacterial vaginosis.
How good is a Pap smear?
False negative rate of 15% in detection of histologically confirmed CIN.
Management of abnormal pap smear
1. For HGSI(CIN II and III):-Refer to colposcopy with early appointment
2. For LGSI(CIN I and koilocyotosis):-Refer to colposcopy
3. For ASCUS:-Repeat smear after 6 months
Discussion/Something to Consider
1. What features of cervical cancer and Pap smear fit the WHO criteria of screening?
2. Which factors account for the false negative of a Pap smear?
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Spatula
An implantment with a broad, flat, blunt blade, used especially for mixing or spreading. The Aryes spaula is designed to take a
Pap smear from the cervical os. For postmenopausal women who usually have a tight stenotic cervical cos, it would be more
appropriate to use a cytobrush.
Cyutobrush
An instryument designed to take Pap smear from a stenotic os which is more commonly encountered in postmenopausal women.
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Bethesda
What is Bethesda system?
It is a reporting system for Pap smear result as follows:
1. Adequacy of the specimen
2. Satisfactory for evaluation
3. Satisfactory for evaluation but limited by... (specific
reason)
4. Unsatisfactory for evaluation (specific reason)
5.
6.
7.
8.
Descriptive Diagnoses
1. Benign cellular changes
a.
Infection
i.
Trichomonas vaginalis
ii.
Fungal organisms morphologically consistent with Candida spp
iii. Predominance of coccobacilli consistent with shift in vaginal flora
iv. Bacteria morphologically consistent with Actinomyces spp
v.
Cellular changes associated with Herpes simplex virus
vi. Others
b.
Reactive changes
i.
Reactive cellular changes associated with:
ii.
Inflammation (includes typical repair)
iii. Atrophy with inflammation ("atrophic vaginitis")
iv. Radiation
v.
Intrauterine contraceptive device
vi. Others
2. Epithelial cell abnormalities
a.
Squamous cell
i.
Atypical squamous cells of undetermined significance (ASCUS):-Qualify*
ii.
Low-grade squamous intraepithelial lesion encompassing:- HPV** mild dysplasia/ CIN 1
iii. High-grade squamous intraepithelial lesion encompassing:- Moderate and severe dysplasia. CIS/CIN I & II
iv. Squamous cell carcinoma
b.
Glandular cell
i.
Endometrial cells, cytologically benign, in postmenopausal women
ii.
Atypical glandular cells of undetermined significance (ASGUS):-Qualify*
iii. Endocervical adenocarcinoma
iv. Endometrial adenocarcinoma
v.
Extrauterine adenocarcinoma
vi. Adenocarcinoma, NOS (not otherwise specify)
c.
Other malignant neoplasms:-Specify
d.
Hormonal
i.
Hormonal evaluation (applies to vaginal smears only)
ii.
Hormonal pattern compatible with age and history
iii. Hormonal pattern incompatible with age and history:-Specify
iv. Hormonal pattern not possible due to:-Specify
3. Remark:
a.
*Atypical squamous or glandular cells of undetermined significance should be further qualified as to whether a
reactive or a premalignant/malignant process is favoured.
b.
**Cellular changes of human papillomavirus (HPV), previously termed koilocytosis, koilocytotic atypia, or
condylomatous atypia, are included in the category of low-grade squamous intraepithelial lesion.
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Colposcopy
Definition
Colpo:-vagina; scopy:-view. A detail examination of the female lower genital tract with the aids of low-power (magnification of 5
to 20 times) illuminated binocular microscope.
Indications
1. Diagnostic:- To examine and guide biopsy when there are abnormal pap smears or lesions of lower genital tract suspicious of
intraepithelial neoplasms (such as CIN, viand VAIN)
2. Therapeutic:- To excise or destroy benign or premalignant lesions by means of loop electrosurgical excisional procedure
(LEEP), cryotherapy, electrocautery or laser therapy
How to perform colposcopy
1. Bimanual examination and taking pap smear (if indicated):
a.
Essential to aid detection of frank invasive disease of cervix, an uterine or an ovarian mass
b.
Deferring the smear until after colposcopic inspection may provide a less satisfactory sample for cytological
examination
c.
After that, the cervix is examined under a microscope.
2. Examination with saline:a.
Remove any discharge with normal saline
b.
Look for any leukoplakia, viral condyloma and any evidence of invasive disease such as ulcerated or rrregular surface,
and atypical vessels.
3. Examination with acetic acid:
a.
Apply 5% acetic acid
b.
Acetic acid causes tissue to swell, especially abnormal epithelium, which has a higher nuclear density, high protein
concentration. This results in change of refraction of light, and therefore the abnormal epithelial tissue appears white
(acetowhite lesion)
c.
Identify the squamo-columnar junction (SCJ) which is defined by the lower limit of normal columnar epithelium.
Failure to identify the SCJ correctly is one of the main pitfalls in colposcopy.
d.
Determine the nature of the lesion by assessing the colour, the margins and vascular markings of the lesions:
i.
CIN lesions are acetowhite with distinct margin. They often show a mosaic vascular pattern with patches of
acetowhite separated by red vessels. Punctations are vessels running perpendicular to the surface. In general, the
more quickly and strongly the acetowhite changes develop, the clearer and more regular the margins of the
lesion, and the more pronounced the mosaic or punctation, the more severe is the CIN lesion is.
ii.
Flat warts usually present as acetowhite lesions of faint and very irregular margins. There are usually isolated,
satellite lesions.
iii. See acetowhite for other causes of acetowhite changes.
iv. Invasive lesions have very marked mosaic pattern or coarse punctation. There are atypical vessels which run a
bizarre course and are often corkscrew or comma-shaped, with large diameter, abruptly appearing on and
disappearing from the surface, and do not branch dichotomously like normal vessels.
4. Examination with Lugol solution (Schiller test):- Normal squamous epithelium (which contains glycogen) stains dark brown
by Lugol solution (iodine and potassium iodine). Whereas columnar or abnormal squamous epithelium do not.
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Dyskaryosis
A cytological term used to describe cells compatible with origin from epithelium with dysplasia. In cervical intraepithelial
neoplasia, dyskaryosis is classified as mild, moderate, or severe according to appearances suggesting origin from CIN I, II, or III.
The distinction between changes compatible with human papillomavirus (HPV) infection or CIn I is particularly difficult to make.
Cytological grading correlates poorly with subsequent histological diagnosis. This correlation can be substantially improved if the
three cytological grades are merged to two. Bethesda system divides abnormal smears into those showing high and low grade
squamous intraepithelial lesions (HGSIL and LGSIL)
Koilocyte
It represents the diagnostic cytopathic effect of human papillomavirus (HPV). Koilcytes are HPV-infected epithelial cells with
enlarged, wrinkled and sometimes hyperchromatic nuclei, which are surrounded by a clear space or halo. Koilocytes are usually
seen in the intermediate and superficial layers of the epithelium.
Acetowhite
It is a term used during colposcopy to describe any lesion that changes to white in colour after being treated with acetic acid.
Lesions that typically show acetowhite change include cervical intraepithelial neoplasm (CIN) and wart (human papillomavirus
infection). The intracellular protein content is high in these lesions and therefore the abnormal cells swell after being treated with
acetic acid. This results in change of refraction of light and hence the lesion appears white.
Sometimes normal columnar epithelium will also blanch briefly after exposure to acetic acid. It can be identified by its villous or
furrowed surface. Squamous metaplasia has a glassy white appearance but it is hard to distinguish from CIN I. Subepithelial
fibrosis secondary to previous cervical excision or destruction surgery may also appear white. This can be recognised by the radial
arrangement of lines of fine punctations.
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Cervical cancer
Introduction
1. Squamous cell carcinoma is the most common type of cervical cancer. Only 5% belong to adenocarcinoma.
2. Medical students are not required to know the detail of adenocarcinoma except the following:a.
Adenocarcinoma is different from squamous cell type in the following aspects:
i.
It affects women of younger age
ii.
It is difficult to be screened or diagnosed as it arises in the endocervical canal
b.
Adenocarcinoma is similar to squamous cell type in that there is a premalignant stage, and spread, staging and
treatment are the same.
3. The rest of the content refers to squamous cell carcinoma.
Epidemiology
1. Second most common gynaecological cancer in Hong Kong. Incidence in 2007 is 400.
2. Median age of onset:
a.
CIN:-35-40
b.
Cancer:-45-50
c.
Trends toward younger age group
3. Drastic reduction of mortality by pap smear screening (24.7 in 1983; 7.7 in 2007)
Aetiology and pathogenesis
Abnormal squamous metaplasia of the cervical epithelium in the transformation zone associated with human papillomavirus 16
and 18, resulting in cervical intraepithelial neoplasia (CIN) which progresses to carcinoma.
Risk factors
- Lower social class
- Cigarette smoking (more than 20 cigarettes/ day)
- Coitus at young age
- Compromised immune status
- Multiple sexual partners , Prostitution
- Multipara, age at first pregnancy
- Sexually transmitted diseases especially HPV type 16 and 18
- Male partner with STD, penile CA
- History of cervical dysplasia (CIN)
Clinical features
1. Asymptomatic in some patients Screened by smear
2. Present with local symptoms:
a.
Abnormal vaginal bleeding:-Postcoital bleeding, Intermenstrual bleeding
b.
Vaginal discharge:-blood-stained, unpleasant smell
3. Rarely with symptoms associated with advanced disease Bowel or urinary symptoms, bone pain, cachexia, weakness, SOB
4. Local signs:
a.
Hard, friable, irregular, enlarged, fixed, contact bleeding
b.
Vaginal and parametrial involvement, pelvic side wall involvement
5. Systemic signs are uncommon:
a.
Anaemia
b.
Inguinal lymphadenopathy
c.
Pulmonary involvement, hydronephosis, hepatomegaly, ascites
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Spread
Mainly direct spread:-upper and lower vagina, parametrium, pelvic side wall
Lymphatic:-obturator, hypogastric, external iliac, common iliac, para-aortic, rarely retrograde to inguinal
Rarely through blood to:-liver, lung, bone, brain
Staging
Staging of CA cervix remains on clinical assessment (see staging of CA cervix)
Diagnosis
Confirmed with cervical biopsy, which can be assisted with colposcopy. Pap smear is not a diagnostic tool.
Staging procedure
1. Plan for option of treatment
2. Provide information of prognosis
a.
Cystoscopy and examination under general anaesthesia
b.
USG, CT scan or MRI:-assess liver, kidneys, lymph nodes involvement
c.
Proctoscopy, Barium enema:-if rectal involvement is suspected
d.
IVU:-look for urinary tract involvement, replaced with good USG
e.
Lymphangiography:-limited role because of inaccuracy in assessing lymph node involvement
Protocol, Preoperative Investigations, as of 16 April 2004
1.
Haematological Investigations:
a.
CBP
b.
RFT and LFT
c.
TA4 for squamous cell carcinoma
d.
CA125 for adenocarcinoma
e.
Serum for blood grouping and cross match
2.
ECG
3.
Chest X-ray
4.
Abdominal and pelvic ultrasound scan to look for distant metastasis especially over the lymphatic areas of the groin and.
pelvis
5.
CT and MRI to be performed as clinically indicated
6.
Examination under Anaesthesia and Cystoscopy
a.
Can be omitted if satisfactory assessment can be accomplished without anaesthesia or when the patients medical
condition is poor
b.
If there is a difference in opinion, the lower stage should be awarded
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Treatment
1. Principle
a.
Radical surgery and radiotherapy are the mainstay of treatment
b.
Choice of treatment depends on staging, age, and medical fitness of patients
2. Stage vs Treatment
a.
Ia1
Simple hysterectomy
b.
Ia2-IIa
Radical hysterectomy and bilateral pelvic lymhadenectomy or RT
(Both achieve similar good cure rate but have advantages and disadvantages compared to each others)
c.
IIb-IV
Radiotherapy
3.
4.
5.
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Exenteration
It is an ultra major gynaecological surgery in which the midline pelvic organs including the uterus, rectum, and bladder are
excised. Urinary diversion and colostomy are required after exenteration. It is subclassified into:
1. Anterior exenteration radical hysterectomy together with total cystectomy
2. Posterior exenteration radical hysterectomy plus excision of rectum and rectosigmoid
3. Total exenteration anterior and posterior exenteration
It is indicated in and only in advanced primary or recurrent malignancy of the uterine cervix (or rarely uterine corpus) that has
invaded the bladder and/or rectum, but still confined to the pelvis, so that excision of these major pelvic organs may result in cure.
It is of high operative morbidity and mortality and patient selection for this surgery is very important.
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Staging of CA cervix
I
Ia
Ia1
Ia2
Ib
Ib1
Ib2
II
IIa
IIa1
IIa2
IIb
The tumour extends to the pelvic wall and/or involves lower third of the vagina
and/or causes hydronephrosis or non-functioning kidney
III
IIIa
Tumor involves lower third of the vagina, with no extension to the pelvic wall
IIIb
The carcinoma has extended beyond the true pelvis or has involved (biopsy
proven) the mucosa of the bladder or rectum.
IV
IVa
IVb
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2.
3.
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Endometrial carcinoma
Incidence
1. Most common gynaecological malignancy in USA and Hong Kong, which is higher than cervical cancer. .
2. 600 new cases in Hong Kong, with an average rate of 11.8 in 100,000 in 2007.
3. Median age of onset:-55
Risk factors
Mainly related to chronic exposure of endogenous or exogenous oestrogen:- Early menarche and late menopause
- Nulliparity and infertility
- Exogenous oestrogens Oestrogen used alone without progestogen:-increases risk of CA endometrium by 4-9 time
- Polycystic ovary disease (PCOD) Chronic anovulation develops CA endometrium at an earlier age, accounts for most of
cases diagnosed before age 40
- Obesity Conversion of androstenedione to oestrone by fat cells, with subsequent conversion to oestradiol
- Hypertension
- DM 20% incidence of DM in patients with CA endometrium
Protective factors
Pregnancy
Oral contraceptive pills
Pathology
1. Histology type:
a.
Majority (60%) is endometrioid adenocarcinoma which is the least aggressive type
b.
Other types are papillary, clear cell adenocarcinoma, adenosquamous and squamous type which are in general more
aggressive
Figure 72 (Left to Right) Adenoacanthoma (Grade I); Adenosquamous carcinoma (Grade II); Clear cell carcinoma.
2.
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Spread
1. Local Myometrium, Cervix and Adnexa
2. Lymphatic Pelvic and Para-aortic lymph nodes
3. Distant:-rare, to lungs.
Clinical features
1. Most cases present with abnormal vaginal bleeding:-Postmenopausal bleed, irregular short menstrual periods, menorrhagia
2. Rarely present with secondary symptoms:-Urinary or bowel symptoms
3. Physical examination:-Local signs are uncommon until it metastasis to cervix or beyond. Uterus may be enlarged
Diagnosis
Confirm with endometrial biopsy which can be obtained by:
1. Endometrial sampler
2. Vabra aspiration
3. Dilatation and curettage
Staging procedure
1. Surgical staging is used. Following preoperative assessments provide some ideas about the extent of the tumour:
a.
USG, CT scan, or MRI of abdomen for liver, pelvic and paraaortic Lenlargement
b.
Hysteroscopy to assess any cervical involvement; it replaces the old fashion method:-fractional curettage
c.
Grading from histological examination
d.
Cystoscopy, proctoscopy and examination under general anaesthesia if local spread is suspected
2. Surgical staging procedure:
a.
Peritoneal cytology
b.
LN Biopsy
c.
Cut open the uterus after hysterectomy to look for the depth of myometrial invasion and the cervical invasion
d.
See Staging of CA endometrium
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Management
1. Stage I Grade 1
a.
TAHBSO
b.
No need for lymhadenectomy (only 2 % involvement in stage I grade 1 disease)
c.
Myometrial involvement >1/2, whole pelvic RT
2. Stage I Grade 2, 3
a.
TAHBSO + LN sampling
i.
10% of LN involvement in grade 2
ii.
25-30% LN involvement in grade 3
If pelvic LN +ve, need whole pelvic irradiation
If para-aortic LN +ve, need progestogen or chemotherapy
b.
If peritoneal cytology + ve
i.
At risk of peritoneal recurrence
ii.
Progestational agent
iii. Chemotherapy
iv. Intraperitoneal P32
3. Stage II
a.
Radical hysterectomy; or
b.
Whole pelvic irradiation followed by intracavity Cesium, followed by TAHBSO
4. Stage III and IV TAHBSO pre-op RT
Recurrence
Treat by progestational agents (effective in 1/3 recurrence) or chemotherapy
Prognostic factors
1. Histologic grading
2. Staging
3. Depth of myometrial invasion
4. Metastasis of lymph nodes
5. Peritoneal cytology
6. Cervical involvement
7. Adnexal involvement
8. (Uterine size is not a significant prognostic factor)
Prognosis
Stage
I
II
III
IV
5-year survival
75%
50%
25%
5%
Discussion/Something to Consider
Why the surgical treatment of early stage CA endometrium is is different from that of CA cervix?
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Staging of CA endometrium
Staging CA Endometrium FIGO 2006
I
Ib
II
Tumour invades cervical stroma, but does not extend beyond the uterus
III
IIIb
IIIc
IIIc1
IIIc2
IV
IVb
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5. Trophoblastic diseases
Gestational trophoblastic disease (Molar Pregnancy)
This is a group of disorders involving benign and malignant growth of trophoblastic tissue, and
is classified into:
Hydatiform mole which is subclassifed into complete and partial
Invasive mole
Choriocarcinoma:-a rare but severe disease
Placentasite tumour:-very rare
Residual trophoblastic disease may follow a mole
Hydatiform mole
Also called molar pregnancy, is one form of gestational trophoblastic diseases and is further
subclassified into complete and partial mole.
Complete mole
It is an abnormaconception without an embryo or foetus, but solely cytotrophoblastic and syncytotrophoblastic hyperplasia,
with loss of villous vascularity, causing gross hydropic swelling and centracistern formation.
The karyotyping of the conception is usually 46XX
Incomplete mole
It is an abnormaconception with presence of embryonic or foetaelement, and a mixture of normaappearing villi and
focavillous swelling and trophoblastic hyperplasia.
The karyotyping of the conception is usually 69XXY or 69XXX, as a result of fertilisation of an ovum by two sperms or a
sperm that has duplicated chromosomes.
Epidemiology
Common in Asian:-Asian to West ratio:-8:1
1 in 350 (HK); 1 in 82 (Taiwan); 1 in 1500 (USA)
Higher risk < 20 and > 40 years of age
Clinical presentation
Usually present between 8 and 24 weeks of gestation with peak at 14 weeks
Vaginal bleeding (occurs between 6-16 weeks, 95%)
Passed vesicular tissue vaginally
Uterus large for date (50%)
Hyperemesis gravidarum (30%)
Bilateral thecal-luteacyst (15%)
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Complications
Anaemia (due to massive haemorrhage)
Uterine perforation (due to invasion or surgicaevacuation)
Pelvic sepsis
Clinical hyperthyroidism (10%, related to high HCG level)
Residuatrophoblastic disease
Pre-eclampsia
Disseminated intravascular coagulopathy (DIC)
Trophoblastic pulmonary embolisation (rare)
Remark:-clinical presentation is less severe and complications are less common in case of partial mole
Diagnosis
1. USG A complete mole has typical intrauterine vesicular features without foetal element. The differential diagnosis would
be cystic degeneration of an abortion. A partial mole may be difficult to detect under USG.
2. Biochemical There is a very high serum level of HCG in complete mole. The elevation of HCG level in partial mole is less.
Management
The mainstay of treatment is suction evacuation of uterus. The HCG level should be monitored post-operatively until it returns to
normal because of the risk of residual trophoblastic disease. Chemotherapy may be required if there is a persistent elevation of
HCG.
Protocol, as of 16 April 2004
1.
2.
3.
Terminology 2010
4.
5.
6.
7.
8.
Follow Up
a. Serial monitoring of plasma beta HCG is used to detect any residual trophoblastic disease
b. The follow up plan is as follow:
i. Weekly beta HCG is measured until the level has returned to normal.
ii. For those patients who have suboptimal fall in HCG, HCG would be checked weekly
iii. Monthly follow up is carried out in the first 12 months after evacuation of uterus
iv. Oral contraception is not recommended until beta HCG levels has returned to normal
v. Practice contraception for 1 year after the beta HCG has returned to normal is required to ensure complete cure.
vi. Beta HCG needed to be measured 6 weeks after any future delivery or abortion
Indications for Systemic Treatment in GTD
a. Histological evidence of choriocarcinoma
b. An abnormal regression pattern of HCG in terms of rising of by >10% or plateauing for three consecutive times
c. HCG level > 20,000 IU/ml noticed > 4 weeks after the evacuation
d. Persistently elevated HCG 6 onths after evacuation
e. Rising HCG in the absence of another pregnancy
f. Evidence of metastases
A histological diagnosis of GTD is not required for chemotherapy treatment.
Pre-Chemotherapy Work Up
a. Serum
i. CBP
ii. LFT
iii. RFT
iv. Beta HCG
b. Chest X ray
c. Ultrasound of the abdomen and pelvis
d. Lumbar puncture to collect cerebral spinal fluid for beta HCG, culture and sensitivity test, microscopy and biochemical
study. A CSF to serum level beta-HCG ratio exceeds 1:60 indicates CNS involvement
Subsequent Monitoring
While on chemotherapy, patients need weekly plasma beta HCG, CBP, LFT and RFT
Scoring of Risk Factors
a. Patients are classified as low, medium or high risk using the WHO Scoring system
b. Multiple agents chemotherapy is used for patients at medium or high risk
Prognosis
1. Complete mole (malignant:-15-20%)
2. Partial mole (smaller risk)
Terminology 2010
Choriocarcinoma
This is a rare but highly malignant tumour and can arise from:Product of gestation:-gestational choriocarcinoma, a kind of gestational trophoblastic disease)
Ovaries (a kind of germ cell tumour of ovary)
Gestational choriocarcinoma
Incidence
1. 1 in 40,000 in the West and 1 in 13000 in the East
2. 50% arise from complete mole; 25% from abortion/ tubal pregnancy; and 25% from term gestation
Pathology
1.
2.
3.
Treatment
Chemotherapy
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Bagshawe score
The Bagshawe score is designed to classify patients with gestational trophoblastic diseases into low risk, medium and high risk
according to the prognostic factors. Each prognostic factor is assumed to act as an independent variable and the effects of the
factors are additive. It helps to guide the clinical management:
1. Low risk:-methrotrexate
2. Medium risk:-etoposide or actinomyocin D
3. High risk:-EMA/CO regimen
Prognostic factors
Age (years)
Antecedent pregnancy
Interval between end of antecedent pregnancy
and start of chemotherapy (months)
HCG (iu/L)
ABO group (female X male)
Largest tumour
Site of metastases
Number of metastases identified
Previous use of chemotherapy
score 0
<39
Mole
score 1
>39
Abortion
score 2
/
Term
score 4
/
/
4
<103
/
/
/
/
/
4-6
103-104
O X A or A X O
3-5cm
Spleen, kidney
1-4
/
7-12
104-105
B or AB
>5cm
GI tract, liver
4-8
single drug
12
>105
/
/
Brain
>8
2 or more
The total score for a patient is obtained by adding the individual scores for each prognostic factor.
Total score:-<4=low risk; 5-7= medium risk; >8= high risk
Staging of GTD
FIGO staging of gestational trophoblastic diseases
Stage
Disease development
0
Molar pregnancy
I
Persistently elevated HCG titres (i.e. 6 months or more after evacuation) and tumour confined to body of uterus
II
Pelvic and / or vaginal metastasis
III
Pulmonary metastasis
IV
All other distance metastases
Remark:-This staging system is not used by most major centres for trophoblastic diseases as it does not help in treatment planning.
The Bagshawe score which guides the use of chemotherapy is used more often.
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CA125
It is a kind of tumour-associated antigens, uses as a tumour marker for ovarian epithelial carcinoma. It has several limitations:1. Although its level is elevated in 90% of advanced stage, it is only elevated in 50% of stage I disease and therefore is not a
good screening test for early disease.
2. It is also found in many benign gynaecological conditions such as endometriosis, uterine fibroid, adenomyosis, as well as
other malignant lesions of endometrium, endocervix, fallopian tube, pancreas. Therefore it is not specific.
3. It is not sensitive for mucinous type and borderline ovarian epithelial cancer.
4. The clinical use of CA125 is therefore mainly as a monitoring of the disease and effectiveness of treatment. The decline of
the level after chemotherapy implies good chemo-response, while an increase in level suggests recurrence of the disease.
Chemotherapy
Chemotherapy plays a major role in treatment of various gynaecological malignancies especially gestational trophoblastic disease,
ovarian germ cell tumour and ovarian epithelial carcinoma. It may also used to treat some cases of ectopic pregnancy (such as
cervical or residual ectopic pregnancy). The following discussion will concentrate on the role of chemotherapy in gynae-oncology.
Role of Chemotherapy
1. Curative role
a.
Gestational trophoblastic diseases
i.
Chemotherapy is the primary treatment in residual gestational trophoblastic diseases. The rapidly growing
trophoblastic cells are very sensitive to chemotherapy.
ii.
The advantages over surgical treatment are:Surgical morbidities are avoided. In particular, haemorrhage as the uterus would be very vascular.
Distant spread of the disease can also be controlled with chemotherapy
Uterus is preserved for future fertility.
iii. Usually a single cytotoxic agent, methrotrexate is used. It is very effective and has less side-effects. Other
cytotoxic drugs may be used depending on the Bagshawe score.
b.
Ovarian germ cell tumours Ovarian germ cell tumours, such as dysgerminoma, malignant teratoma, yolk sac tumour
are very aggressive. However, because of good responses to chemotherapy, these kinds of tumours can be treated with
unilateral oophorectomy followed by chemotherapy. The remaining ovary can be preserved if not involved.
Dysgeminoma are sensitive to radiotherapy, yet chemotherapy is still the preferred choice because of less side-effects.
c.
Other gynaecological tumours Cervical cancers, endometrial cancers, vulval and vaginal cancers are NOT
chemosensitive.
2. Adjuvant role Ovarian epithelial cancers are less chemosensitive to the germ cells counterparts. Chemotherapy is used as an
adjuvant treatment to surgical excision.
3. Palliative role Chemotherapy is seldom use for palliative treatment in gynae-oncology. Tamoxifen or progestogens may be
used for advanced stage of endometrial cancers.
4. Commonly used cytotoxic agents are Methrotrexate for gestational trophoblastic disease and platinum group for ovarian
epithelial carcinoma
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Radiotherapy
Radiotherapy plays critical therapeutic role in gynae-oncology, especially squamous cell carcinoma of cervix. It is applied in two
major ways:-internal (bradytherapy) and external (teletherapy).
1. Bradytherapy:a.
Radioactive substances are inserted into vagina, targeting at the cervix, parametrium, and vagina. It is used to treat
carcinoma of the lower genital tract
b.
Complications are local skin effects, vaginal stenosis, cystitis and proctitis
2. Teletherapy:a.
External beam of irradiation targeting at the pelvic and aortic lymph nodes where bradytherapy cannot reach
b.
Complications are damages from small bowel and ovarian irradiation,
It is used as a primary curative treatment, adjuvant or palliative therapy, and can be either used alone or integrated with surgery
and cytotoxic chemotherapy:
1. Curative:- As a primary treatment for cancinomas of cervix, vagina and vulva.
2. Adjuvant:- After radical surgical treatment for cervical cancers (when risk of distant metastasis is high) and endometrial
carcinoma (beyond stage I)
3. Palliative:- For bone metastasis and pain control
Palliative
Palliative treatment in malignant diseases does not aim to cure but to improve a problem or condition such as symptomatic relief.
For example, radiotherapy or narcotic injection to relieve bone pain due to metastasis.
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Urogynaecology
0. Urogynaecology
Introduction
Urogynaecology is a subspecialty of gynaecology dealing with disorders of pelvic floor that result in two major problems:-genital
prolapse and urinary incontinence. It also deals with other lower urinary tract problems such as voiding disorder The diagnosis of
urinary disorders usually requires urodynamic study.
What medical students should know?
4. The physical examination and management of various types of genital prolapse which are usually vaginal hysterectomy with
pelvic floor repair (colporrhaphy), or conservatively with ring pessary.
5. The two main causes of urinary incontinence in female:-genuine stress incontinence and detrusor instability, and how to
differentiate them clinically and with urodynamic study.
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1. Genital prolapse
Genital prolapse
Definition
It is a group of disorders caused by weakness of the pelvic floor resulting in abnormal descend of various pelvic structures through
the vagina. These include:
1. Cystocele Backward descend of the urinary bladder into the vagina and beyond. It appears as a protrusion of the anterior
vaginal wall
2. Urethrocele Backward descend of the urethra into the vagina and beyond. It appears as a small protrusion of the distal end
of anterior vaginal wall
3. Rectocele Forward descend of the rectum into the posterior vagina. It appears a protrusion of the posterior vaginal wall into
the vagina and beyond
4. Enterocele Herniation of the pouch of Douglas which often contains loops of small bowel, through the upper part of the
posterior vagina.
5. Uterine prolapse
a.
Downward displacement of the uterus towards or through the introitus
b.
Divided into three degrees:
i.
1st degree:-descend of the cervix within the vagina and not through the introitus
ii.
2nd degree:-descend of the cervix, but not the whole uterus, through the introitus
iii. 3rd degree (or procidentia):-descend of the cervix and the whole uterus through the introitus, usually bringing
with it the cystocoele, enterocele and rectocele
6. Vault prolapse Prolapse of the vaginal cuff in the hysterectomized patient.
Incidence
Genital prolapse usually occurs after middle age, and affects 10% of multiparous women, and is very rare among nulliparous.
Aetiology
The above pelvic organs are normally supported by the pelvic floor, which consists of levator ani and pelvic fascia. Its
weakness results in genital prolapse. The main factors leading to the deficiency are trauma (often as a result of childbirth),
and ageing (collagen lack of oestrogen support).
Failure to support the vaginal vault by plicating it to the cardinal ligaments during hysterectomy may precipitate vault
prolapse subsequently, and colposuspension may also lead to enterocele or rectocele.
Rarely, some genetic disorders associated with congenital weakness of collagen may contribute in a minority of patients.
Clinical features
All kinds of genital prolapse may present with a mass protruding out of the vagina spontaneously, or after coughing or straining. It
is usually reducible. The protruded mass causes dragging pain, discomfort during walking or standing, and may bleed secondary
to rubbing or laceration. Depends on the site and degree of prolapse, urinary, bowel or sexual problems may result:1. Cystocele and urethrole:
a.
Stress incontinence, frequency of micturition, voiding difficulty
b.
Rarely in severe case of cystocele, there are kinking at the ureterovesical junction, leading to bilateral hydronephrosis
2. Rectocele:- difficulty on defaecation
3. Uterine prolapse, vault prolapse:- discomfort during coitus, dyspareunia
4. Enterocele:- usually asymptomatic but rarely the enterocele may be performated leading to exposure of prolapsed small
bowel and consequently bowel injury
History
1. Assess the degree of prolapse and severity of symptoms
2. Look for any precipitating factors:-childbirth history and birth injury; chronic cough, etc
3. Ask for any medical illness and assess the physical fitness of patients
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Physical examination
1. General examination and examination after other systems:-important as majority of patients are old and have some form of
medical illness. It help to assess whether patients are fit for surgery
2. Examination of genital prolapse
Diagnosis and Investigations
1. Investigate with urodynamic study when there are multiple urinary symptoms
2. Investigate for fitness if patients also have medical disorders
3. Decide the mode of treatment according to the type of prolapse, physical fitness and wish of patients
Treatment
1. Definite surgical correction is the mainstay of treatment which include:
a.
Vaginal hysterectomy (for uterine prolapse)
b.
Colporrhaphy (pelvic floor repair):-anterior colporrhaphy for cystocele & urethrocele; posterior colporrhaphy for
rectocele
c.
Repair of enterocele
d.
Sacrocolpopexy for vault prolapse
2. Conservative management with vaginal ring pessary may be considered when:
a.
Patients are physically unfit for surgery
b.
Patients refuse surgery
c.
Temporary relief while patients are waiting for surgery
d.
Patients are pregnant or want to preserve uterus for fertility (rare)
Differential diagnosis
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Cystocele
Figure 73 Cystocele
Urethrocele
Figure 74 Urethrocele
Rectocele
Figure 75 Rectocele
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Enterocele
Figure 76 Enterocele
Uterine prolapse
Vault prolapse
See genital prolapse for detail
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Sims speculum
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Pad test
Pad test is a simple bedside assessment to verify and quantify urine loss. The patient wears a preweighed sanitary towel, drinks
500ml of water and rests for 15 minutes. After a series of defined manoeuvers the pad is reweighed. A urine loss of more than 1g
is considered significant.
Protocol, as of 20 April 2004
1. The pad test (test) is performed when the patient has a full bladder, which is usually at the end of the filling cystometry
(after filling up the bladder with normal saline).
2. The patient should not be menstruating or having excessive vaginal secretion.
3. Test duration normally lasts for 10 minutes.
4. The test is performed in a separate room outside the urodynamics room.
5. The same electronic weighing machine should be used throughout the test.
6. Two gynae pads (pads) and one square white linen (linen) are to be used for the test.
7. Weigh pads and linen before test. Record the total weight in grammes (g).
8. Give the pads to the patient to put inside her underpants / panties, and the pads should be secured against the perineum.
9. Perform standardised exercise in area covered by pre-weighed linen:
a.
Walk for 50 metres on level ground at usual pace. This can be done by asking the patient to walk a 5-metre distance
to-and-fro 10 times.
b.
Climb 5 steps.
c.
Cough for 5 times.
d.
Perform heel-bounce for 5 times.
e.
Perform sit-and-stand for 5 times.
f.
Place hands in running tap water at comfortable temperature for 1 minute.
10. Pads and linen (if soiling occurs during test) are weighed at completion of the test. Record the total weight in grammes (g).
Ring pessary
A device made of silicon or plastic used as a conservative management for genital prolapse. It is put into the vagina so that it rests
in the posterior fornix and sits over the symphysis pubis. It is indicated when the patients are unfit or refuse surgical treatment,
want to preserve fertility, or as a temporary relief while waiting for surgery. However, it is ineffective in severe degree of genital
prolapse. There are various sizes of ring pessaries in reference the diameter of the ring in minimetre. The size should fit the patient,
as it would fall out when it is too small, or cause voiding difficulty, laceration or pressure necrosis, and infection of vagina when it
is too big. The appropriate size is the one with a diameter equal to the distance between the posterior fornix and the symphysis
pubis (can be assess by digital vaginal examination). After it is inserted, the patient should be asked to walk around and void to
see if any discomfort. The patient should also be followed every 6 months for changing the pessaries, and look for any
complications.
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Terminology 2010
Colporrhaphy
It is the vaginal surgical repair of the pelvic floor as the treatment of genital prolapse. It is often performed together with vaginal
hysterectomy.
Anterior colporrhaphy is the plication of the pubocervical fascia (a part of the pelvic fascia between the bladder and the vagina) so
that the descended bladder (cystocele) is elevated with the support of the fascia. It is however not a effective treatment for genuine
stress incontinence (50% success rate). The risk of the operation is perforation of the bladder.
Posterior colporrhaphy is the plication of the part of levator ani muscle between the posterior vaginal wall and the anterior rectal
wall, so that the herniated rectum (rectocele) is reduced by the reinforced muscle. It is often performed together with the repair of
the perineum (perinorrhaphy). The risks of the procedure are perforation of rectum, dyspareunia secondary to tight vaginal
opening after repair.
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ANTERIOR COLPORRHAPHY
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POSTERIOR COLPOPERINEORRHAPHY
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REPAIRMENT OF ENTEROCELE
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2. Urinary incontinence
Urgency
Urgency is the complaint of a sudden compelling desire to pass urine which is difficult to defer. Motor urgency is associated with
uninhibited detrusor contractions. The most common cause is detrusor instability. Sensory urgency is due to irritable lesions such
as cystitis, calculus in which the detrusor is stable.
Incontinence
See urinary incontinence
Urinary incontinence
Introduction
Urinary incontinence is defined as an involuntary loss of urine which is objectively demonstrable and cause a social or hygienic
problem (definition of International Continence Society). It is reported to be very common in reproductive aged women and
postmenopausal women (20%). It is subdivided into various types (see below). Majority are belonging to stress incontinence and
urge incontinence.
Types of urinary incontinence
1. Stress incontinence Involuntary loss of urine when the intra-abdominal pressure is increased, such as during exercise,
coughing, and sneezing. It is most commonly due to genuine stress incontinence. Sometimes detrusor instability may present
as stress incontinence, and urodynamic study may be required to differentiate them.
2. Urge incontinence Inability to withhold the passage of urine with a sudden strong desire to micturate (urgency), due to
hyperexcitability of the bladder detrusor muscle. Hyperexcitability can be primary or secondary to infection or irritation of
the bladder wall.
3. Overflow incontinence Involuntary loss of urine due to when the intravesical pressure exceeds maximum urethral pressure
due to bladder distension and in the absence of detrusor activity. It is secondary to bladder outflow obstruction.
4. True incontinence Involuntary loss of urine due to a defect in the anatomical integrity of the urinary tract, such as
vesicovaginal fistula
What medical students should know
Definitions of various urinary symptoms
Genuine stress incontinence and detrusor instability, and how to differentiate them clinically and with urodynamic study.
Principles of treatment of the above diseases
Stress incontinence
Involuntary loss of urine when the intra-abdominal pressure is increased, such as during exercise, coughing, and sneezing. It is
most commonly due to genuine stress incontinence or detrusor instability. See urinary incontinence for detail.
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Terminology 2010
Urge incontinence
See urinary incontinence
Overflow incontinence
The involuntary loss of urine when the intravesical pressure exceeds maximum urethral pressure due to bladder distension and in
the absence of detrusor activity.
True incontinence
See urinary incontinence
Reflex incontinence
The involuntary loss of urine due to abnormal spinal reflex activity in the absence of the sensation to micturate.
Colposuspension
Colpo means vagina. Each side of the vaginal vault are 'suspended' by stitching it to the ipsilateral iliopectineal ligament. The
bladder neck is therefore elevated. It is one of the most effective continence surgery (90%). The surgical complications are de
novo detrusor instability (5%), voiding disorder (5%), development of enterocele or rectocele.
Urethropexy
The bladder neck is approached through a suprapubic incision and elevated by suturing
the paraurethral tissues to adjacent structures such as the rectus sheath or the
ilio-pectinealligament. These operations are more difficult than vaginal urethroplasty,
especially in obese women. Some operators employ a laparoscopic technique
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Nocturia
Being woken twice or more for voiding at night whilst asleep. See also frequency of micturition for causes of nocturia and
frequency.
Dysuria
Pain during micturition. It is a symptom of urethritis or cystitis.
Interstitial cystitis
A chronic condition which presents with severe frequency of micturition, urgency, lower abdominal pain, dysuria and haematuria
in the absence of bacterial cystitis. At cystoscopy, ulcers with a granulomatous base and surrounding hyperaemia are found.
Biopsy of the lesion shows chronic non-specific ulceration.
Voiding disorder
Causes
Urinary voiding disorder is less common in female than in male. It is either due to outflow obstruction, or inadequate
detrusor contractions. Sometimes it may be too painful to void in situations such as post-vaginal surgery, or urethritis.
The causes of obstruction in female include:-large fibroids, or other pelvic masses, severe cystocele.
Inadequate detrusor pressure can be due to various kinds of neurological disorders involving the central nervous system, or
the sacral plexus (neuropathic bladder). After regional anaesthesia, patients may also lose the sensation of bladder filling as
well as the motor function.
Clinical features
Patient with chronic voiding difficulty usually complain of hesitancy, frequency of micturition, nocturia, poor stream of urine,
incomplete emptying, straining to void. Acute urinary retention may develop. On examination during acute episode, a full bladder
is demonstrated, and a large volume of residual urine is drained on catheterization. There are also complications such as recurrent
urinary tract infection.
Investigation
Uroflowmetry would show a low peak flow rate with a prolonged voiding time. There is also residual urine.
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Detrusor instability
Definition
Abnormal contractions of the bladder muscle (detrusor) occur spontaneously or in response to a stimulus (e.g. Filling of bladder,
coughing, sound of running water, etc), when the individual is attempting to inhibit micturition.
Aetiology
It can either be primary (idiopathic) or secondary to cystitis, urinary stones, atrophy, neuropathy, or post-surgery (de novo DI).
Clinical features
Urinary symptoms including:-urgency, frequency of micturition, urge incontinence, stress incontinence.
Diagnosis
Cystometry is diagnostic. It shows detrusor activities on provocation during the filling phase of the cystometry. Other features
are:-gradually increased of baseline deterusor pressure during filling. Early occurrence of the first sensation of urgency. It is
essential to differentiate detrusor instability from genuine stress incontinence because the treatments are different from each other.
Incorrect diagnosis and consequently wrong treatment will even make the problem worse.
Treatment
1. Bladder retraining, biofeedback, hypnotherapy:-successful in 60% of cases
2. Medicine
a.
Anti-cholinergices (oxybutynin)
b.
Amitriptylline (imipramine)
3. Surgery (Last resort)
Discussion/Something to Consider
As both detrusor instability and genuine stress incontinence can present with stress incontinence. Are there any differences
between the two in term of symptomatology?
Urodynamic study
The two most commonly performed urodynamic studies are: (1) Cystometry; and (2) Uroflowmetry. Occasionally video
cystourethrography or urethral pressure profilometry may be indicated.
Uroflowmetry
It is a simple non-invasive urodynamic study in urogynaecology, used to investigate voiding disorder. It is usually performed
together with cystometry. The patient is asked to void to a toilet which is sensitive to the change of volume over time, from which
the urine flow rate is estimated. The peak flow rate should be more than 15ml/s, and the normal flow curve is bell-shaped and
duration of voiding. should not be prolonged. The urine volume should be at least 150ml as flow rates with a small volume are not
reliable. Low peak flow rate, prolonged flow indicates a voiding disorder, which can be due to obstruction, or a neuropathic
bladder.
Cystoscopy
An endoscope is inserted via the urethra into the urinary bladder allowing examination of the interior wall. Biopsy and excision
surgery can be performed during cystocopy. It is indicated for:
1. Multiple irritable bladder symptoms such as urgency, dysuria, frequency of micturition, haematuria, in which case chronic
cystitis (e.g. Interstitial cystitis), bladder stones are suspected
2. Investigation of urinary fistula
3. Staging of cervical cancer
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Terminology 2010
Cystometry
It is one of the most commonly performed urodynamic study in urogynaecology, in which the detrusor activity during filling of
the bladder and a series of provocation is assessed. The detrusor pressure (the pressure generated by the detrusor contractions)
cannot be measured directly but is calculated by subtracting intraabdominal pressure from intracystic pressure. It is mainly used to
differentiate detrusor instability from genuine stress incontinence. The indications are:1. Multiple urinary symptoms:- urge incontinence, urgency, frequency of micturition, stress incontinence are suggestive of
detrusor instability and cystometry is indicated to confirm the diagnosis. Isolated stress incontinence is almost always due to
genuine stress incontinence and cystometry is not essential.
2. Previous unsuccessful continence surgery:- to assess the severity of residual urinary problem and diagnosis of de novo
detrusor instability
3. Pre-continence surgery assessment:- Occasionally cystometry may be indicated before corrective surgery for genuine stress
incontinence to detect any subclinical pre-existing detrusor instability and voiding disorder which may get worse after surgery
4. Other conditions:-voiding disorder, neuropathic bladder
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Drugs
0. Drugs
The following groups of drugs are commonly used in O&G:
1. Oxytocics
2. Tocolytics
3. Anti-hypertensives
4. Anti-convulsants
5. Steroid and Hormonal replacement therapy
6. Antibiotics
7. Anticoagulants
The followings drugs are discussed in previous chapers.
1. Analgesics during labour
2. Insulin
3. Contraceptives
a.
Combined oral contraceptives
b.
Rogestogen-only pills (mini pills)
c.
Progestogen injectable
4. Ovulation induction agents clomiphene citrate
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Terminology 2010
1. Oxytocics
Definition
1. From Greek:-oxys:-sharp, quick; tokos:-childbirth (from tiktein:-to bear); meaning hastening labour.
2. It is a group of agents that are able to stimulate myometrial contractions.
3. Common oxytocics include:
a.
Oxytocin or syntocinon
b.
Prostaglandins and their analogue
c.
Ergometrine
Indication of oxytocics
1. In Obstetrics
a.
Induction of labour and augmentation of labour
b.
Prophylaxis and treatment of uterine atony
2. In Gynaecology:- Evacuation of uterus in abortion, and termination of pregnancy
Complications of oxytocics
1. Uterine hyperstimulation, resulting in uterine rupture and severe bleeding
2. Water intoxication with oxytocin
3. Gastrointestinal and cardiorespiratory complications with prostaglandins
4. Hypertension with ergometrine
Oxytocin
What is oxytocin
It is a peptide hormone secreted from the hypothalamus and transported to the posterior lobe of the pituitary where it is eventually
released.
What are the effects of oxytocin
It has two major actions in human:1. Firstly, it stimulates smooth muscle contraction in uterus (oxytocic)
a.
It is essential for the initiation and progression of labour
b.
It binds to oxytocin receptors of myometrial cells and activate the contractile protein
c.
The number of oxytocin receptors increases gradually as pregnancy go on, and exponentially before onset of labour.
The production of receptors is stimulated by prostaglandins
d.
A positive feedback loop acts on the pituitary secretion of oxytocin. More oxytocin is secreted as uterine contractions
are stimulated and continued
2. Secondly, it stimulates contractions of myoepithelial cells of mammary glands. It facilitates lactation
3. Besides, as its biochemical structure is similar to that of vasopressin (antidiuretic hormone also secreted from the posterior
pituitary gland), it also has weak antidiruetic effect.
How is oxytocin metabolised
The peptide is rapidly broken down into amnio acid by oxytocinase in blood. The half-life of oxytocin is therefore 3-4 minutes.
What are the clinical uses of oxytocin
See syntocinon for clinical uses.
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Syntocinon
Syntocinon is a synthetic oxytocin, and has the same biochemical structure, pharmacokinetic and pharmacodynamic
characteristics as oxytocin. It is given intravenously, as a bolus injection or infusion.
Clinical use of syntocinon
1. Intrapartum use:a.
For induction of labour and augmentation of labour. Syntocinon is given as intravenous infusion. The rate of infusion
is titrated against the frequency of uterine contractions. The optimal frequency is 3 to 4 contractions in 10 minutes.
Care must be taken to avoid uterine hyperstimulation.
b.
To overcome uterine inertia in the second stage delivery of twin pregnancy. Uterine contractions may diminish after
the first twin is delivered, and the second twin may not descend. Augmentation is required to hasten the delivery of
the second twin
2. Postpartum use:a.
As an alternative of routine syntometrine in the third stage of labour against uterine atony. It is given as a bolus
injection.
b.
As a prevention or maintenance treatment against uterine atony in high risk cases such as placenta praevia, abruptio
placentae, twin pregnancy. It is given by continuous infusion
3. Other uses:a.
As an adjuvant agent for evacuation of uterus in treatment of abortions
b.
As an oxytocic in a stress test:- Syntocinon was used to stimulate uterine contractions in a stress test for foetal
well-being. This test is rarely required nowadays as less invasive tests for foetal well-being are now available.
Protocol, as of 25 March 2004
1. Regimen
a. For induction and augmentation of labour:
i. Start infusion using either infusion drip set or syringe pump (see table 1), and titrate the infusion rate accordingly.
ii. Maintain the infusion rate if adequate contractions (3 to 4 contractions per 10 minutes) are achieved, till the next
cervical assessment.
iii. Inform medical officer if more than 20 mu/min of oxytocin is required to achieve optimal uterine contractions.
b. For intrapartum managment third stage of labour:
i. IV bolus 5 units over 1-2 minutes, or
ii. IM bolus 10 units if no IV access available and in absolute emergency (unlicensed route). Patients with cardiac
disease or those particularly at risk of hypotension should have the IV bolus 5 units given slower i.e. over 5
minutes
iii. iv infusion 40 units in 500ml crystalloid solution Q4H once
2. Midwives can administer syntocinon bolus injection at third stage of labour according to departmental standing order.
Risks of syntocinon
The major risk is uterine hyperstimulation, which would result in foetal distress and uterine rupture. The other risks are less
common and mild, and include hypotension (related to direct peripheral vasodilatation), water intoxication (related to anti-diuretic
effect).
Syntometrine
It is a combined drug consisting of 5 mg of syntocinon and 0.5mg of ergometrine. It is commonly given intramuscularly during
the third stage of labour routinely as a prophylaxis against uterine atony and postpartum haemorrhage. It is given as a regimen of 1
ampoule IMI. The syntocinon component acts quickly in 2 minutes and produces clonic uterine contractions while the ergometrine
component stimulates sustained tonic contractions. It is contraindicated in cardiac diseases, hypertension and asthma because of
vasocontrictive effects of ergometrine. Midwives can administer routine syntometrine injection at third stage of labour according
to standing order.
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Ergometrine
A compound oxytocic consisting of syntocinon and ergometrine used for prophylaxis or treatment of uterine atony in the third
stage of labour. It is given intramuscularly. It has the advantages of both syntocinon and ergometrine. It is contraindicated in
hypertension because of vasoconstrictive effect of ergometrine.
Prostaglandin
What are Prostaglandins
They are groups of compounds derived from unsaturated 20 carbon fatty acids, primarily arachidonic acid, via the cyclooxygenase
pathway. It was thought to be come from the prostate gland from which its name originated. It is now well known that
prostaglandins are found in many organs with diverse physiological effects in human. The most important groups of
prostaglandins in obstetrics and gynaecology are prostaglandin E (PGE) and prostaglandin F (PGF). They are involved in the
process of ovulation, initiation of labour, and pathogenesis of dysmenorrhea and menorrhagia. Synthetic PGE and PGF are also
used in various obstetric situation including cervical ripening for induction of labour, treatment of uterine atony, and in
gynaecological conditions such as termination of pregnancy and treatment of abortion.
Misoprostol
Introduction
A prostaglandin E1 analogue. Originally used for prevention and treatment of gastric ulcers associated with the use of
nonsteroidal anti-inflammatory drugs.
Has become an important drug in obstetrics and gynaecology because of its uterotonic and cervical ripening actions.
Pharmacology
1. Administration and absorption:a.
Can be given orally or vaginally.
b.
After oral administration, misoprostol is rapidly absorbed and converted to its pharmacologically active metabolite,
misoprostol acid. Plasma concentrations of misoprostol acid peak in 30 minutes and decline rapidly thereafter.
c.
After vaginal administration, plasma concentrations peak in 1 to 2 hours and then decline slowly, resulting in slower
increases and lower peak plasma levels, but overall exposure to the drug is increased.
d.
Uterine contractility becomes plateaued 1 hour after oral administration. When given vaginally, uterine contractility
increases continuously for 4 hours and reaches a maximum level higher than that when given orally.
2. Metabolism and excretion:- It is primarily metabolised in the liver and less than 1% of it is excreted in urine.
Side effects
1. Side effects are dose-dependent and less severe when the drug is administered vaginally.
2. Fever, chills and shivering.
3. Gastrointestinal upset:-Nausea, vomiting, diarrhea, abdominal pain.
4. Unlike prostaglandin E2 and F2, it would not cause bronchospasm or myocardial infarction.
5. Teratogenicity:-limbs defects, ring-shaped constrictions of the extremities, arthrogryposis, hydrocephalus, holoprosencephaly,
Mobius syndrome (congenital facial paralysis) are reported.
Obstetric and gynaecological Indications
1. Medical termination of pregnancy
a.
When combined with mifepristone, can be used for termination of pregnancy at a gestation less than 9 weeks.
i.
Oral mifepristone 600mg followed 48 hours by oral misoprostol 400mcg, or
ii.
Oral mifepristone 200mg followed 48 hours by oral misoprostol 600mcg
b.
Efficacy:
i.
95% complete abortion rate when used before 7 completed weeks
ii.
90% complete abortion rate when used between 8 to 9 completed weeks
2. Treatment of miscarriage
3. Cervical ripening before surgical abortion
4. Induction of labour
5. Postpartum haemorrhage
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Misoprostol (Cytotec)
Protocol, as of 31 October 2002
1. Nature A PGE-1 analogue of the prostaglandin group
2. Indications
First line treatment for:a. First and second trimester miscarriages to evacuate the uterus
b. Second trimester medical induced abortion
c. Cervical ripening prior to mechanical cervical dilatation for first trimester suction termination of pregnancy
3. Caution Patients with high risk for uterine rupture, hypersensitivity, severe cardiac disease.
4. Adverse reactions Uterine rupture
5. Side effects GI upset, vomiting, diarrhoea, pyrexia
6. Route of administration Oral or vaginal
7. Regimen
a. For medical evacuation of the uterus for first trimester miscarriage, 400micrograms every 4 hours for 3 doses orally.
b. For medical evacuation of the uterus for second trimester abortion (spontaneous or induced), 400micrograms every 3
hours vaginally for 5 doses. May repeat the course if necessary. If 2 courses fail, consider change to gemeprost.
c. For cervical ripening prior to mechanical cervical dilatation for first trimester suction termination of pregnancy,
200micrograms single dose vaginally 3 hours before the procedure
8.
Discussion / Justification
a. Vaginal Misoprostol is more effective than Gemeprost in second trimester TOP.
b. Vaginal route of Misoprostol is more effective than oral Misoprostol in second trimester induced abortion
c. For cervical priming, oral Misoprostol is better than vaginal Gemeprost with greater baseline cervical dilatation and
easier dilatation.
d. For cervical priming, 200mcg vaginally is as effective as 400mcg vaginally
e. For cervical priming, vaginal Misoprostol is more effective if given 2-4hrs prior to surgery than oral Misoprostol given
8-12 hrs prior to surgery.
Gemeprost (Cervagem)
1.
2.
3.
4.
5.
6.
7.
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Terminology 2010
Prostaglandin E2 (Dinoprostone)
Protocol, as of 22 June 2002
1. Nature A PGE-2 analogue of the prostaglandin group
2. Indications
a. Induction of labour
b. Softening and dilatation of cervix before induction of labour
3. Caution Patients with high risk for uiterine rupture, hypersensitivity
4. Adverse reactions Uterine hyperstimulation, foetal distress, uterine rupture
5. Side effects GI upset, vomiting, pyrexia
6. Route of administration Vaginal pessary inserted high into the posterior vaginal fornix
7. Regimen a. 1 tablet every 4-6 hours
b. Maximum dosage 3 tablets
Sulprostone
Protocol, as of 22 June 2002
1. Nature A PGE2-analogue (c.f. dinoprostone)
2. Indication for induction of abortion or induction of labour after intra-uterine death when other treatment has failed
3. Contraindications
a. Asthma
b. Cardiac disease
c. Hepatic or renal failure
4. Regimen
a. Add 500mcg to 250ml of NS for infusion
b. Infuse at 100mcg per hour
c. May infuse continuously for 10 hours
d. Never exceed infusion rate of 500mcg per hour
e. Maximum total dosage of 1500mcg
5. Side effects:- Nausea, vomiting, diarrhoea, headache, fever
Hemabate (Carboprost)
Protocol, as of 22 June 2002
1. Nature Carboprost tromethamine (PGF2-alpha)
2. Indication Severe postpartum haemorrhage due to uterine atony
3. Regimen
a. 250 ug imi. NOT for IVI.
b. Same dose may be repeated after 15 minutes, for at most 8 doses.
4. Side effects
a. Common side effects include diarrhea, vomiting, fever, and hypertension.
b. Serious side effects such as asthma and pulmonary oedema are rare.
5. Contraindications
a. Heart failure or severe heart diseases
b. Chronic lung disease with respiratory failure
c. Renal or liver impairment
d. Hypersensitivity to Hemabate
6. Monitoring Continuous SaO2 monitoring
7. Remark
a. Hemabate is stored in the freezer compartment of the fridge in labour ward.
b. Concurrent administration of Maxolon is advised to relief GI upset.
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Terminology 2010
2. Tocolytic
Definition
In Greek toco means labour; lysis means dissolve; It is a group of agents that cause relaxation of uterine muscle and hence
dissolution of labour. It is opposite to oxytocic
Common tocolytic agents
1. Beta-sympathomimetic
a.
Ritodrine
i.
It is administered by continuous intravenous infusion, usually indicated for suppression of preterm labour.
ii.
The rate of infusion is titrated against the frequency of uterine contractions.
iii. Maternal side effects are:
Tachycardia and hypotension
Heart failure and pulmonary edema
Hypokalemia and hyerglycemia
iv. Foetal side effects are:
Foetal tachycardia
Foetal distress secondary to maternal hypotension
b.
Hexoprenaline
i.
It is usually given in bolus intravenous injection
ii.
It is a short acting agent used mainly for uterine relaxation during external cephalic version (ECV) and relief of
uterine hyperstimulation
iii. Types of side effects are similar to ritodrine but severity is much less because it is short-acting, and often
adminstered in a single bolus rather than by continuous infusion
2. Prostaglandin inhibitors Sulindac
a.
It is a kind of non-steroidal anti-inflammatory drugs (NSAID) that inhibit cyclooxygenase in the synthesis of
prostaglandin from arachidonic acid.
b.
It is administered orally
c.
Maternal side effects are not pronounced; foetal side effects not common but include oligohydramnios, patent ductus
arteriosus
3. Calcium channel blocker Nifedipine
a.
It is administered orally
b.
Maternal side effects are headache, flushing, hypotension and tachycardia
Indications of tocolytics
1. Preterm labour
a.
The main aim of tocolytics is to allow more time for glucocortiocord to effect on lung maturation, in order to prevent
neonatal respiratory disease (RDS) and other complications of prematurity
b.
The first line treatment has been ritodrine until recently nifedipine has been proven to be as effective but less side
effects than ritodrine
2. External cephalic version Short-acting agents like hexoprenaline improve the chance of success by relaxing the uterus
3. Uterine hyperstimulation Short-acting hexoprenaline may also help to relax the uterus rapidly and relieve foetal distress
during uterine hyperstimulation
Contraindications
1. When continuation of pregnancy is of higher risk than inhibition of labour:
a.
Chorioamnionitis
b.
Abruptio placentae
2. When the pregnancy has reached a maturity of low neonatal mortality or morbidity:- at 34 or more weeks of gestation
3. When there are co-existing maternal disorders that may be worsen with the tocolytics:a.
Beta-sympathomimetic are contraindicated in thyrotoxicosis and major heart diseases
b.
Prostaglandin inhibitors are contraindicated in thrombocytopenia and peptic ulcer diseases
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Terminology 2010
General Guideline
Protocol, as of 2 March 2004
1. Types
a. Calcium channel blockers:-nifidepine
b. Beta-adrenergic agonists:-salbutamol, ritodrine, hexoprenaline
c. Oxytocin antagonists:-atosiban
d. Prostaglandin antagonists:-sulindac
2. Indications
a. Suppression of preterm labour before 34 weeks
Nifidepine > Ritodrine > Sulindac
b. Prophylaxis against preterm labour eg. after laparotomy, cervical cerclage
Nifidepine
c. Prior to external cephalic version
Hexoprenaline
d. Uterine hyperstimulation
Hexoprenaline
e. Uterine inversion
Hexoprenaline
3. Contraindications
a. Obstetric complications:- Antepartum haemorrhage, abruptio placentae, chorioamnionitis
b. Maternal complications:- Pre-eclampsia
c. Foetal complications:-IUGR, foetal compromise
d. Medical diseases of which the condition may be exacerbated by side effects of certain tocolytics:
i. Beta-adrenergic agonists:- (Ritodrine and Hexoprenaline)
- Severe cardiac diseases (e.g.heart failure, aortic stenosis or arrhythmia)
- Poorly controlled hyperthyroidism or taking beta-blocker for control of tachycardia
- Poorly controlled diabetes mellitus
ii. Prostaglandin antagonists:- (Sulindac)
- Asthma
- Drug allergy
- Thrombocytopenia
- Renal, cardiac, hepatic impairment
- Peptic ulcer
4. Special precautions
Discuss with Mid-call 2 if tocolytics are used in:
a. Rupture of membranes
b. Cervical dilatation of > 4 cm
c. Multiple pregnancy
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Sulindac
Protocol, as of 7 May 2001
1. Nature NSAID.
2. Indication
As third line treatment of preterm labour when both Nifedipineand Ritodrine are contraindicated
3.
Regimen
200mg po Q12H for 4 doses
4.
Contraindications
a. Asthma
b. Drug allergy
c. Renal, cardiac, hepatic impairment
d. Peptic ulcer
e. Thrombocytopenia
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Terminology 2010
Atosiban
1.
2.
3.
4.
5.
5.
6.
7.
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Terminology 2010
Salbutamol
Protocol, as of 1 August 2002
1. Indication
Beta-agonist as second line treatment of preterm labour.
2. Regimen
a. Prepare infusion solution of 50 microgram/ml by adding 25 mg of salbutamol solution into 500 ml NS
b. If fluid restriction is necessary, can give higher concentration at 200 ug/ml by adding 10mg of salbutamol into 40 ml
NS and administer through syringe driver
c. Start infusion rate at 10 ug/min.
d. Increment at 15 minute-interval by 5ug/min until:i. Uterine contractions are suppressed
ii. Maximun dosage attained (45ug/min)
iii. Complications arise
3. Caution
a. Stop or reduce infusion if:i. Maternal pulse >140 bpm or BP<90/60mmHg
ii. Hypokalemia (serum level< 2.8mmol/L)
iii. Foetal tachycardia > 180 bpm
iv. Remark:-mild degree of hyperglycemia can be tolerated. Consult medical obstetrics team for any problem of
glucose control.
b. Stop infusion and inform mid-call 2 if pulmonary oedema
c. Maintain dosage for 1 hour after uterine contractions have subsided, then reduce by 50% decrements at six-hourly
interval. Aim to give Salbutamol for steroid to work
d. Consider third line tocolytic agent with midcall-1 if:
i. The above complications arise, or intolerable side effects
ii. Contractions not suppressed despite maximum dosage of ssalbutamol
4. Monitoring in labour ward
a. NPO
b. Intravenous fluid add up to 83ml/hr
c. BP/pulse Q15min
d. Respiratory rate Q1H
e. Haemoglucostix/serum glucose/electrolytes Q4H (Q1H in case of DM requiring insulin treatment)
f. I/O chart
g. SaO2 as required
h. Continuous foetal heart monitoring
i. Note adverse effects:-palpitations, chest pain, dyspnoea, hypotension, pulmonary oedema
5. Contraindications
a. See general contradindications for tocolytic agent
b. Severe cardiac diseases and arrhythmia
c. Poorly controlled hyperthyroidism or taking beta-blocker for control of tachycardia
d. Poorly controlled diabetes mellitus
e. Consult medical obstetrics team for concern in the use of ritodrine in patients with the above medical disease.
Hexoprenaline
Protocol, as of 7 May 2001
1. Indications
a. Uterine relaxation for ECV
b. Uterine relaxation in uterine hyperstimulation
c. Uterine relaxation in uterine inversion
2. Regimen
a. In ECV or uterine inversion IV bolus 10ug given in 3 equally divided doses every 2 minutes.
b. In uterine hyperstimulation IV bolus 5ug. Can only repeat once if no improvement after 2 minutes.
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Ritodrine
Protocol, as of 30 January 2002
1. Indication
Beta-agonist as second line treatment of preterm labour.
2. Regimen
a. Effective dosage:-150-350ug/min.
b. Start with 50ug/min, increment at 15 minute-interval by 50ug/min until:i. Uterine contractions are suppressed, or
ii. Maximun dosage attained (350ug/min), or
iii. Complications arise
3. Caution
a. Stop or reduce infusion if:
i. Maternal pulse >140 bpm or BP<90/60mmHg
ii. Hypokalemia (serum level< 2.8mmol/L)
iii. Foetal tachycardia > 180 bpm
iv. Remark:-mild degree of hyperglycemia can be tolerated. consult medical obstetrics team for any problem of glucose
control.
b. Stop infusion and inform mid-call 2 if pulmonary oedema
c. Maintain infusion rate for at least 6 hours after contractions have ceased, and up to 24 hours for steroid to work
d. Consider third line tocolytic agent with midcall-1 if:
i. The above complications arise, or intolerable side effects
ii. Contractions not suppressed despite maximum dosage of ritodrine
4. Monitoring in labour ward
a. NPO
b. Intravenous fluid add up to 83ml/hr
c. BP/P Q15min
d. Respiratory rate Q1H
e. Haemoglucostix/serum glucose/electrolytes Q4H (Q1H in case of DM requiring insulin treatment)
f. I/O chart
g. SaO2 as required
h. Continuous foetal heart monitoring
i. Note adverse effects:-palpitations, chest pain, dyspnoea, hypotension, pulmonary oedema
5. Contraindications
a. See general contraindications for tocolytic agent
b. Severe cardiac diseases and arrhythmia
c. Poorly controlled hyperthyroidism or taking beta-blocker for control of tachycardia
d. Poorly controlled diabetes mellitus
e. Consult medical obstetrics team for concern in the use of ritodrine in patients with the above medical disease.
Discussion/Something to Consider
1.
Can you explain why prenatal use of NSAID is associated with oligohydramnios and neonatal patent ductus arteriosus?
2.
Can you explain why ritodrine is associated with hypokalemia and hyperglycemia?
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Terminology 2010
3. Anti-hypertensives
The role of anti-hypertensives in obstetrics is to prevent complications of hypertension such as stroke. It is indicated In patients
with pre-existing hypertension, or severe pre-eclampsia. However, it cannot alter the progress of pre-eclampsia, which would only
be resolved after delivery. The commonly used anti-hypertensives in obstetrics are:
Methyldopa
It is a centrally acting agent that causes peripheral vasodilatation given orally, and requiring a high loading dose because of long
half life, therefore not for acute control. It is very safe in pregnancy, and is therefore the first choice for long term treatment during
antenatal period. Side effects include depression, nightmares and postural hypotension.
Hydralazine
It is a potent direct smooth muscle relaxant leading to vasodilatation, usually given in bolus intravenously for acute control, and
also for maintenance therapy when given as infusion. Side effects include headache, nausea and palpitation
Protocol, as of 2 August 2001
1. Indication
a. As second-line treatment for intrapartum anti-hypertensive treatment in pre-eclampsia
b. May be used in postpartum
2. Regimen
a. Bolus
i. 5 mg IV slowly in 1 min.
ii. Observe for effect over 20 minutes. Repeat if BP remains high (i.e. SBP > 160 or DBP > 100) after 20 minutes
iii. Consider giving pre-load crystalloid fluid such as 250ml Hartmann solution over 30 minutes if repeated doses of
hydralazine are given, particularly if there is haemoconcentration.
iv. If fail to control the BP with 2 bolus doses, for infusion regime.
b. Infusion:i. Consult medical obstetrics team before starting hydralazine infusion
ii. Start with 5 mg/h (i.e. 5 ml/h ) (Dilute 100 mg of hydrallazine into 100 ml with normal saline).
iii. Titrate against BP with an increment of 5 mg/h every 20 minutes.
3. Caution:- Action of IV hydralazine peaks at 20 minutes, therefore less than 20 minute interval of increment or repeated
dosage is not recommended
Nifedipine
Acts quickly when given orally or sublingually, effective for acute control. Slow releasing form is effective as maintenance. The
main side effect is headache
Protocol, as of 28 July 2002
1. For postpartum use only.
a. Oral Adalat 5 mg as an alternative to IV hydralazine if SBP> 160 or DBP > 100.
b. Repeat after 15 minutes if blood pressure is not controlled
2. Adalat Retard (slow release):- Start with 20mg bd, can increase up to 40mg bd
3. Caution if used with MgSO4, as interaction may cause severe hypotension.
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Labetolol
It is an alpha and beta-adrenergic blocker that causes peripheral vasodilatation. It is mainly used postnatally because of the risk of
IUGR after long term use. It can be given orally for maintenance, or intravenously for acute control. It is contraindicated in heart
failure.
1. Nature Alpha and Beta-blocker
2. Indications
a. For intrapartum blood pressure control, if hydralazine causes maternal tachycardia >120, or other significant side
effects.
b. For postpartum blood pressure control as first line if being given MgSO4. (Since Nifedipine cannot be given.)
3. Regimen:
a. Infusion:
i. Start with 20 mg/h (i.e. 20 ml/h) (Dilute 100 mg of labetalol into 100 ml with normal saline).
ii. Titrate against the BP with an increment or reduction by 5-10 mg/h (i.e. 5-10 ml/h) at 15-30 min interval.
iii. Maximum rate should not exceed 100 mg/h.
iv. Stop infusion if maternal heart rate < 70/min, and restart at a lower infusion rate when heart rate > 70/min.
b. Bolus regime:
i. Only used for malignant hypertension.
ii. Instruction to be given by consultant or anaesthetist.
c. Oral regime:
i. For postpartum use only, as first-line if MgSO4 is being used.
ii. Start with 200 mg bd.
iii. Should not be used in the presence of pulmonary edema and heart failure.
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Terminology 2010
4. Anticonvulsants
1.
2.
3.
4.
Indications
a. Prophylaxis in pre-eclampsia and eclampsia
b. Treatment of eclampsia and epilepsy.
Drugs used in pre-eclampsia and eclampsia
a. Magnesium sulphate MgSO4
b. Diazepam
c. Phenytoin for patients with epilepsy who has been on long-term phenytoin
d. Thiopentone to be prescribed by anaesthetist
Drugs used in epilepsy should be decide by physician/ neurologist
Antenatal patients should receive oral vitamin K 10mg once daily from 36 weeks onwards
Diazepam
Diazepam is used as an anticonvulsant to stop acute seizure in eclampsic patients. It is given as an intravenous bolus. It may also
be used as a prophylactic agent but it would require continuous intravenous infusion. It is less effective than MgSO4 as a
prophylaxis, and sedation of mother and neonatal depression are the concerns.
Protocol, as of 22 December 2007
1. Indications
a. As immediate treatment for the convulsing eclamptic patient
b. As second-line anticonvulsant prophylaxis in severe pre-eclampsia and eclampsia if MgSO4 is contraindicated or fails
to control convulsions, or causes significant toxicity.
2. Regimen for the convulsing patient:
a. 5-10 mg slow IV bolus injection over 1 minute.
b. Total bolus dose preferably does not exceed 30 mg before delivery.
3. Prophylaxis regimen:
a. Loading dose:
IV bolus of 10 mg over 2 min (if diazepam has just been given to stop convulsion, decrease the loading dose by the
amount that was given)
b. Maintenance dose:
i. Start at 3 mg/h (18 ml/h, 80 mg of diazepam into 500 ml with 5% dextrose).
ii. Titrate at hourly interval so that patient is sedated but arousable, by increment of 2 mg/h until maximum rate of 10
mg/h (62 ml/h) is reached.
iii. Maximum daily dose is 3 mg/kg/ 24h.
iv. Continue till 24 hours after delivery or 24 hours after the last convulsion, whichever occurs later.
4. Monitoring and management of toxicity:
Conscious state and respiratory rate hourly.
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Terminology 2010
Phenytoin
Protocol, as of 22 June 2002
1. Indications
a. As prophylaxis for eclampsia in severe pre-eclamptic patients in circumstances where phenytoin is decided by midcall
2 and neurologist to be the preferred agent
b. As treatment for epilepsy as prescribed by neurologist
2. Remarks
a. Should liase with neurologist and decide by midcall 2 before commencement
b. Generally, MgSO4 is still the first line prophylactic and treatment drug for severe PET/eclampsia in epileptic patients.
3. Regimen as prophylaxis for PET patients
a. Loading dose
i. At time 0 hour, give 10mg/kg made up to 50ml with Hartmann"s solution as intravenous infusion over 20 minutes
ii. At time 2 hours, give 5mg/kg made up to 50ml with Hartmann"s solution as intravenous infusion over 20 minutes
b. Maintenance dose At time 12 hours and every 8 hours thereafter for 4 days, given as 200mg i.v. or oral
4. Monitoring
a. Phenytoin level should be checked on day 1-2 before the morning dose (day of delivery counts as day 0) to avoid
toxicity
b. Inadequate phenytoin level without convulsion does not necessarily require increase in dosage
c. Cardiac monitoring if patient has cardiac disease
Magnesium Sulphate
Indication of Magnesium sulphate
It is an anticonvulsant for prophylaxis against development of eclampsia, or prevention of recurrent convulsions. It has been
shown to be more effective than diazepam in preventing recurrence of convulsions. It does not have side effect of neonatal
depression.
Administration of Magnesium sulphate
It is administered by bolus injection intramuscularly, followed by intravenous infusion for maintenance.
Side effects of Magnesium sulphate
Magnesium sulphate antagonizes calcium in the muscle contractility and nerve conduction. The side effects are therefore muscle
paralysis and cardiac arrest. The therapeutic range is narrow:Plasma level (mmol/l)
2-4
>5
>6
>7.5
>12
Effect
Therapeutic
Loss of patella reflex
Prolonged AV conduction
Respiratory arrest
Cardiac arrest
Therefore, it is important to monitor the reflex, respiration, ECG for sign of toxicity during administration of MgSO4. As
magnesium is excreted via the renal system, the dosage have to be decreased when the urine output is diminished.
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Steroid Cover
Protocol, as of 23 May 2005
1. Indications for steroid cover during labour, delivery and surgery
a. Patients on long-term oral corticosteroids > 10 mg prednisolone daily (or equivalent) or have received this dose in the
last three months.
b. Dosage of various kinds of steroid that is equivalent to 10mg prednisolone:i. Dexamethasone or Betamethasone 1.5mg
ii. Methylprednisolone
8mg
iii. Hydrocortisone
40mg
iv. Cortisone acetate
50mg
2. Steroid cover is not indicated when:a. Oral daily prednisolone intake is 10mg or less or the last dose of steroid is more than 3 months ago.
b. Short course of steroids for 1 - 2 week.
3. Regimen
a. Labour and intrapartum caesarean section
i. Give usual dose of steroid before labour
ii. Give 25mg IV hydrocortisone Q6H at onset of labour till delivery
iii. Resume usual steroid dose post-delivery
iv. In case of complicated instrumental delivery or emergency caesarean section, continue IV hydrocortisone 25 mg
Q6H till 24 hour after delivery or longer till oral intake is resumed
b. Minor surgery
i. For example: cervical cerclage, fetoscopic surgery, first trimester surgical TOP, operation for ectopic pregnancy.
ii. Give usual dose of steroid pre-operatively
iii. Give stat 25mg IV hydrocortisone on-call to OT
iv. After uneventful surgery, resume usual steroid dose on resumption of oral intake
c. Intermediate surgery
i. For example: elective or pre-labour emergency caesarean section, appendicectomy, cholecystectomy, ovarian
cystectomy complicating pregnancy
ii. Give usual dose of steroid pre-operatively
iii. Give stat 25mg IV hydrocortisone on-call to OT, then
iv. 25mg IV hydrocortisone Q6H for 24 hours post-operatively or longer till oral intake is resumed
v. After uneventful surgery, resume usual steroid dose on resumption of oral intake
d. Major surgery or complications
i. For example: internal iliac artery ligation, uterine artery embolization or caesarean hysterectomy; septicaemia; DIC
ii. Increase to IV hydrocortisone dose to 50 mg Q6H and gradually wean off at 48-72 hrs post-op/post-delivery
iii. Maintain this regimen until light diet started and usual steroid dose is resumed.
Tibolone
It is a synthetic steroid which exhibits all oestrogenic, progestogenic and androgenic activity. It is used as a kind of hormonal
replacement therapy and is effective in suppressing climacteric symptoms as well as preventing bone loss. The side effects are
mainly androgenic, and is usually mild and well-tolerated.
Danazol
It is a synthetic androgen frequently prescribed in gynaecology. The pharmacodynamic effect is the suppression of the
hypothalamic-pituitary-ovarian axis, resulting in hypoestrogenemia. It is used to control symptoms of endometriosis, menorrhagia
due to dysfunctional uterine bleeding, and as a pre-myomectomy treatment to reduce size and vascularity of fibroids. It is as
effective as GnRHa, but the androgenic side effects (deepening of voice, acnes, weight gain and cramping) may not be as
acceptable as that of GnRHa to women. Some of these changes may not be reversible. Prolonged use may also result in
osteoporosis, so that the use of the drug is limited to 6 months.
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GnRHa
What is Gonadotropin releasing hormone analogue (GnRHa)
GnRHa are synthetic substances in which one or more of the amino acids in GnRH are substituted by a different amino acid, so
that the activity and binding ability to receptors are altered. Their affinity to GnRH receptors is usually higher than that of GnRH,
and is more resistant to metabolism. Therefore, they produce a down-regulatory effect on the pituitary glands. In long term use, it
will result in hypogonadotropic hypogonadism. This mechanism accounts for its therapeutic effects as well as its side effects.
What are the clinical uses of GnRHa
1. Treatment of endometriosis:- Hypogonadotropic hypogonadism leads to the lack of endogenous oestrogen stimulation on
the growth of endometriosis. The progress of the disease is arrested and symptoms are relieved.
2. Treatment of fibroids and menorrhagia:- The size of fibroids is decreased because of lack of oestrogen stimulation. Menstrual
flow is stopped or diminished. It is however cannot be used as a definite treatment of fibroids or menorrhagia because the
problems often recur after stopping the treatment. It can be used before hysterectomy or myomectomy, as a temporary relief
of symptoms, or to shrink the size of the fibroids in order to facilitate surgery.
3. Use in assisted reproductive technology:- GnRHa is used as a pre-treatment before ovarian stimulation. The ovaries are first
suppressed with GnRHa before undergoing stimulation. This helps to synchronize the growth of oocytes. The endogenous
premature surge of LH is also suppressed.
Side effects of GnRHa
They are mainly related to hypoestrogenism and therefore patients will experience discomforts similar to that of climacteric.
Osteoporosis is the major long term complication. The duration of GnRHa should not exceed 6 months.
Protocol, as of 10 May 2003
1. Management of Endometriosis
a.
Aims
i.
To reduce or alleviate severe symptoms pelvic pain, dyspareunia
ii.
To eradicate any remaining disease and reduce recurrence
iii. To preserve fertility
b.
Indications (For asymptomatic women who have completed their family, treatment is generally not necessary)
i.
Women with severe symptoms
ii.
Women with visible residual or spillage at operation, especially if fertility is a concern
c.
Duration of treatment 6 months
d.
Alternatives Danazol 200 mg tds; Nordette; Depo-povera 150 mg IMI 3 monthly; and Provera 100mg QD
2. Management of Fibroid
a.
Indications
In general, GnRHa is not necessary for management of uterine fibroids. The role of GnRHa in the
management of fibroid is mainly of facilitate surgery or to avoid surgery in special circumstance. The decision
must be made or approved by specialists. The followings are possible indications:i.
Large fibroid for myomectomy
ii.
Large cervical fibroid for hysterectomy
iii. Symptomatic fibroid in patients with high surgical risk
b.
Duration of treatment
i.
For pre-operative shrinkage of fibroid no more than 3 months
ii.
For temporary relief of symptoms and await menopause generally no more than 6-12 months. If the drug
needs to be used for longer period of time, consult doctors with specialist qualification.
3. Preparation for endometrial ablation
a.
Aims To cuase atrophy of endometrium so as to shorten reduce operative time, reduce complication and
subsequent recurrence.
b.
Regime Decapeptydul 3.75 mg SC
c.
Arrange operation 6-8 weeks after starting treatment
d.
Alternative Danazol 200mg tds for 6-8 weeks
4. Precocious Puberty Discuss with doctors with specialist qualification and liaise with Paediactricians
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GnRH
Gonadotropin releasing hormone (GnRH) is a peptide hormone secreted from the hypothalamus in a pulsatile Manner. It
stimulates pituitary gonadotropins secretion, and its secretion is inhibited by oestrogen. They form the hypothalamuspituitary-ovarian axis for the control mechanism of ovulation. The beginning of pulsatile GnRH secretion in teenage initiates the
development of puberty. Psychological stress, Excessive exercise, significant weight reduction such as in anorexia neurosa result
in suppression of GnRH secretion. Synthetic GnRH can be used as a ovulation induction when given in a pulsatile manner. GnRH
analogue (GnRHa), having a similar chemical structure, are used to treat various gynaecological disorders.
Gonadotropin
There are two kinds of pituitary gonadotropins:-follicular stimulating hormone (FSH) and luteinizing hormone (LH). They are
glycoprotein hormones secreted from the anterior pituitary glands, under the stimulation of gonadotropin releasing hormone
(GnRH, which is secreted from the hypothalamus). They form the hypothalamus-pituitary-ovarian system that controls the
mechanism of folliculogenesis and ovulation. Absence of gonadotropins results in anovulation or failure to reach puberty such as
in Kallman syndrome. On the other hand, premature secretion results in precocious puberty. Another gonadotropin is human
chorionic gonadotropin secreted from the placenta. Gonadotropins can be extracted from human (e.g Human menopausal
gonadotropin (HMG), highly-purified urinary follicular stimulating hormone (hpFSH)) or synthesized by genetic engineering
technology (Recombinant FSH) They are powerful agents for ovulation induction. See gonadotropin therapy
Gonadotropin therapy
Nature
Gonadotropins are extracted from human or synthesized, and used as very effective ovulation induction agents:Human menopausal gonadotropin (HMG)
Highly-purified urinary follicular stimulating hormone (FSH)
Recombinant FSH
Mechanism of action
Act directly on ovaries to stimulate folliculogenesis
Efficacy
Ovulation rate:->95% per cycle
Conception rate:-20% per ovulatory cycle
Cumulative conception rate (6-month):-90%
Complications
Multiple pregnancy rate 10-30%, higher order pregnancy:-5%
Ovarian hyperstimulation syndrome (OHSS)
Remark:-Intensive monitoring in specialist clinic is necessary because of the higher risk of multiple pregnancies and OHSS
Advantages Most powerful
Disadvantages
Narrow therapeutic range, intensive monitoring necessary
High risks of multiple pregnancy and ovarian hyperstimulation syndrome (OHSS)
Expensive
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6. Antibiotics
Augmentin is useful in those organisms resistant to penicillin. E. coli is one of the most common organism causing urinary tract
infection and now over half of them is resistant to penicillin, but not Augmentin. It also covers the anaerobes. It is used as
prophylactic antibiotics in emergency Caesarean section Prophylactic antibiotics in vaginal surgery (e.g. Vaginal hysterectomy)
5.
Remark
a. Gentamicin infusion
i. Dilute in 50 ml NS, infuse over 30 min
ii. Dose not exceed 120 mg
b. Vancomycin infusion
i. Reconstitute in 20 ml water, and dilute with 200 ml NS
ii. Infuse over at least 100 min
c. If both ampicillin and vancomycin are contraindicated, consult physician for opinion
d. In case of renal impairment, consult physician for gentamicin and vancomycin dosage
Drug removal
a. Gentamycin has replaced netromycin which is no longer available.
b. Parenteral Erythromycin is no longer available.
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7. Anticoagulants
1.
2.
3.
Subcutaneous injection
a. Enoxaparin:-first choice
b. Fraxiparine:-alternative
Oral tablets:-Warfarin
There is inadequate experience in the use of Tinzaparin in obstetrics patient and is therefore not recommended.
Enoxaparin
Protocol, as of 22 June 2002
1. Nature
Low molecular weight heparin
2. Indication
a. Prophylaxis and treatment of thrombo-embolism
b. First-line drug for obstetrics patients
3. Route of administration Subcutaneous injection
4. Regimen
a. Prophylaxis 40mg daily SC
b. Treatment 1mg/kg body weight q12H SC
Fraxiparine (Nadroparin)
Protocol, as of 22 June 2002
1. Nature
Low molecular weight heparin
2. Indication
a. Prophylaxis and treatment of thrombo-embolism
b. Second line drug, used when enoxaparin is not available
3. Route of administration Subcutaneous injection
4. Regimen
a. Prophylaxis regimen
i. 75 kg
0.4 ml daily SC
ii. >75 kg
0.5 ml daily SC
b. Treatment regimen
i. 75 kg
0.4 ml Q12h SC
ii. > 75 kg
0.5 ml Q12h SC
Warfarin
Protocol, as of 2 August 2001
INR
Warfarin dosage
1. Indication
<=1.5
5 mg
Treatment and prophylaxis of:
>
1.5
2.0
4
mg
a. Deep vein thrombosis
> 2.0 - 2.5 3 mg
b. Thromboemobism related to heart diseases
> 2.5 - 3.0 2 mg
c. Pulmonary thromboembolism
> 3.0 - 3.5 1.5 mg
2. Regimen
> 3.5
0 mg
a. At least one baseline INR result should be available before starting
b. Day 1 and day 2:-Oral Warfarin 5 mg in the evening daily.
c. Day 3 onwards:-Warfarin dosage (which is given in the afternoon) titrated according to INR which should be checked
every morning.
3. Remarks:
The warfarin sliding scale is just a guideline and it varies with individual patients. Medical officers should not adjust the
dosage or discharge patient without discussion with seniors. Patient can be discharged when she has been on the same dose of
warfarin for 2 consecutive days. Arrange warfarin clinic 1 week
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8. Others
HyperHep (Hepatitis B Immune Globulin)
Protocol, as of 7 May 2001
1. Nature Human hepatitis B immunoglobin
2. Indication Prophylaxis for newborns whose mothers are HBsAg carriers
3. Regimen 0.5ml imi once after delivery
4. Remark Hyperhep can be administered by midwives according to departmental standing order.
Naloxone
Protocol, as of 7 May 2001
1. Indication Treatment of neonatal respiratory depression resulted from narcotic overdose.
2. Regimen 0.3mg imi
3. Remark Midwives can administer naloxone injection according to departmental standing order, while waiting for
paediatricians resuscitation.
Vitamin K
Protocol, as of 7 May 2001
1.
Indications
a. Neonatal prophylaxis against haemorrhagic disorders
b. For mothers who are on anti-epileptic drugs
2.
Regimen for neonatal prophylaxis against haemorrhagic disorders
a. Mothers who agree for neonatal IMI vitamin K1 1 mg IMI at birth
b. If mothers refuse IMI vitamin K1 for the baby, give vitamin K orally to the baby:
i.
500ug PO at birth by midwife
ii. 500ug PO at 4 weeks by mother
3.
Remark
a. Vitamin K oral preparation is different from Vitamin K1
b. Vitamin K1 can be administered by midwives according to departmental standing order.
4.
Regimen for mothers who are on anti-epileptic drugs Oral vitamin K daily from 36 weeks of gestation till delivery.
Methrotrexate
Anti-metabolites used as a chemotherapuetic agent for residual trophoblastic disease or ectopic pregnancy
Can be used alone or in combination with other agents
Side effects
Alopeccia
Nausea and vomiting
Myelosuppression
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Miscellaneous
1. English usage
English usage
1.
2.
3.
4.
Parity O Nullipartiy is commonly said to be parity 'O'. It should be more correct to say parity 'zero'.
Sure LMP It is common to say 'LMP is sure', or 'She has a sure LMP'. The correct way is 'She is sure of her LMP'.
Rupture of membranes It should be in plural form as there are two membranous layers:-amnion and chorion.
Large > date We use symbols '<' or '>' in the medical notes to denote whether the uterine size is normal for date for
convenience. However, we should not say 'uterus is larger than date' or 'smaller than date', as 'size' and 'date' are two different
parameters and are not comparable. It is correct to say 'uterus is large (small) for date', or 'uterus is larger (smaller) than
expected (from date)'
Acronym
A word formed from the initial letters of a name, or by combining initial letters or parts of a series of words, such as:
1. HELLP for Haemolysis, Elevated Liver enzymes, Low Platelets
2. TORCH for Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes
3. OHSS for Ovarian Hyper-Stimulation Syndrome
Eponym
Epi means on or upon, onyma means name. An eponym is one for whom or which something is named or supposed named, for
example, Down syndrome named after Down; Apgar score named after Virginia Apgar (1909-1974), anaesthesiologist.
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Symptomatology (Obstetrics)
Vaginal bleeding
During pregnancy, any vaginal bleeding occurred after 24 weeks is defined as antepartum haemorrhage. Any bleeding comes from
the upper genital tract before that period is diagnosed as threatened abortion.
Abdominal pain
1. Uterine origin Uterine contraction pain
a.
It is usually related to the onset of labour.
b.
Sometimes it may just be a false labour or Braxton Hicks contractions
c.
Abruptio placentae, chorioamnionitis, uterine rupture give rise to constant severe pain
d.
Other causes:-red degeneration of fibroids
2. Ovarian origin:- Co-existing ovarian pathologies such as tumour or cysts may bleed, rupture or undergo torsion resulting in
acute abdominal pain.
3. Non-gynaecological origin:- Various kinds of surgical disorders such as appendicitis, cholecystitis, peptic ulcer diseases,
pancreatitis, etc.
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Examination (Obstetrics)
On every antenatal visit
The following examination should be performed:
1. Check for anaemia
2. Maternal weight
3. Blood pressure measurement
4. Urinalysis (urine protein and sugar)
5. Abdominal examination (see obstetric abdominal exam)
On first booking
In addition to above, the following examinations should be performed at the booking visit:1. Measurement of maternal height
2. Examination of thyroid glands and signs of thyroid disorders
3. Examination of breasts
4. Examination of heart
5. Examination of perineum and lower genital tract (with speculum) for any pre-existing lesions. The cervix should be examined
for:a.
Warts, polyps and tumours
b.
Length and dilatation (the cervix is dilated and shortened in case of cervical incompetence)
c.
Pap smear to screen for cervical intra-epithelial neoplasia (CIN)
Digital vaginal examination
1. Digital examination is performed in the following conditions:a.
Before induction of labour, assess the bishop score for the favourability (ripening) of cervix
b.
During labour, assess the cervical dilatation and effacement, station and position of the foetal presenting part
c.
Assess the size of the pelvis (see clinical pelvimetry).
Discussion/something to consider
1. You may notice in the antenatal clinic that the obstetricians often do a bimanual examination of the pelvis when pregnant
women come at the first trimester of pregnancy, but they seldom do so when the their patients come at a later gestation. Do
you know why?
2. You have found a 2cm cervical wart in a woman at her booking visit at 12 weeks. What are your management and advice?
Terminology 2010
Palpation of uterus
1. Palpate the outline and contour of the uterus
2. Irregular if there are fibroids or uterine anomalies
3. Palpate for any uterine tenderness tender if abruptio placentae or intrauterine infection
4. Assess the size of the uterus
a.
12 week:-just palpable over the abdomen
b.
14 week:-a quarter-way from symphysis to umbilicus
c.
16 week:-midway between the symphysis and umbilicus
d.
18 week:-three-quarter-way from symphysis to umbilicus
e.
20 week:-uterus fundus at the umbilical level
5. Measurement of symphysial-fundal height
a.
Search for the fundus by palpating from above downward with the left hand
b.
Locate the fundus with the ulnar border of the left hand
c.
Put one end of the measure tape at the fundus
d.
Locate the pubic symphysis with the right hand by sliding downward along the uterine body until the upper border of
the pubis bone is felt
e.
Measure the distance between the fundus and the symphysis pubis
f.
After 20 week, the fundal height in centimetre correlates to gestation in week:-e.g. The fundal height at 30 week
should be around 30 2cm
6. Palpation of foetus
a.
Number of foetus:- suspect multiple pregnancy if more than two foetal poles are identified
b.
Foetal lie:i.
Search for the foetal poles at the fundus and over the suprapubic region. If present, then it is longitudinal lie;
ii.
Otherwise, search carefully at the frank region (transverse lie) or iliac fossa (oblique lie)
c.
Foetal presentation:
i.
Cephalic:-hard round well-defined border
ii.
Breech:-soft, bulky
d.
Engagement:- some degree of engagement is common when gestation is near term. High floating presenting part
should lead to the suspicion of pelvic inlet obstruction or placenta praevia
e.
Foetal back:- if it is longitudinal lie, push the foetus to the other size of the uterus and feel the foetus with the other
hand, and vice versa. The back is round and soft while the limbs are irregular, and moving
f.
Liquor volume:
i.
Foetal parts are difficult to define when there is significant polyhydramnios. The fundal height is large for date.
Fluid thrill may also be demonstrated.
ii.
In oligohydramnios, the foetal parts are easily felt and prominent. The fundal height is also small for date.
g.
Foetal parts are usually not palpable before 24 week
Auscultation of foetal heart sound
1. Site:a.
Best heard over the shoulder (back) of the foetus
b.
In cephalic presentation, it is at the level midway between the maternal umbilicus and the anterior superior spine of
the ilium
c.
In breech presentation, it is at or slightly above the level of the umbilicus
2. Instruments:- use a pinard stethoscope or a doptone
3. Foetal heart sounds are usually not audiable with a pinard stethoscope before 24 week
Discussion/something to consider
1. A patient comes at 30 week of gestation is found to have a fundal height of 35cm. Is it normal? What are the possibilities
accounts for the finding? How would you assess the case further?
2. A patient comes at 34 week of gestation is found to have a fundal height of 30cm. Is it normal? What are the possibilities
accounts for the finding? How would you assess the case further?
3. You have picked up a pulsative sound of rate 120bpm over the abdomen of a pregnant patient during an antenatal clinic. Is it
normal for foetal heart rate? Can it be maternal origin? How can you differentiate a maternal pulse from a foetal pulse?
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Terminology 2010
OBSTETRICS PALPATION
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Terminology 2010
Fundal height
Full name is symphysial-fundal height. It is the distance between the top of the uterus and the upper border of the pubic symphysis
at the midline. It is an objective method of monitoring uterine size which in term reflects foetal growth. The fundal height in
centimetre is correlated with gestation age in week, starting from 20 week of maturity. For example, at 30 week, the fundal height
is around 302cm. After 37 week, the fundal height may decrease, due to the engagement of the foetus, as well as the reduction of
amniotic fluid.
Doptone
It is a hand-held electrical apparatus used for detection of foetal heart pulsation by Doppler effect.
It has several advantages over the Pinard stethoscope:1. The foetal heart sounds are audible as early as 12 weeks of gestation
2. It is more sensitive in picking up heart sounds, even though it is not placed exactly over the foetal back
3. The mother can also hear the heart sounds at the same time
The disadvantages are:1. It requires battery to work
2. Interference may occur when more than one doptone are used at the same time for multiple pregnancies
3. Maternal pulse can be picked up easily and may be mistaken as the foetal pulse
Discussion/Something to Consider
What are the advantages and disadvantages of using a doptone when compared to a Pinard stethoscope?
Pinard stethoscope
The pinard stethoscope is a simple instrument designed for auscultation of low-pitch foetal heart sounds transabdominally. It is
pressed firmly over the site of the maternal abdomen where the back of the foetus is supposed to be. The foetal heart sound is
usually audible with the pinard stethoscope after 24 weeks of gestation.
Discussion/Something to Consider
What are the advantages and disadvantages of using a doptone when compared to a Pinard stethoscope?
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Symptomatology (Gynaecology)
Menstrual symptoms
1. It is the most common group of symptoms in gynaecology.
2. It may be abnormal in volume of flow, regularity, onset and cessation, or with associated pain and discomforts.
Abnormal vaginal bleeding
1. Related to menstruation (see menstrual disorders for details)
2. In early pregnancy:-various kinds of abortions and ectopic pregnancy
3. Benign tumours or cancers of the genital tract, presented with:a.
Postcoital bleeding
b.
Postmenopausal bleeding
Vaginal discharges
1. Abnormal in colour and odour
2. Usually due to infections, occasionally related to fistula formation between the urinary tract and genital tract
Abdominal and pelvic pain
1. Pain related to menstruation (see menstrual disorders)
2. Pain related to coitus:-dyspareunia
3. Acute pelvic pain
4. Chronic pelvic pain
Urinary symptoms
1. Urinary incontinence:- stress incontinence, urge incontinence, overflow incontinence, etc
2. Abnormal frequency
3. Frequency of micturition, nocturia
4. Discomfort
5. Dysuria, urgency
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Examination (Gynaecology)
Attitude
Be gentle, considerate and courteous.
Pre-requisites
1. Good light
2. Chaperone
3. Full exposure
4. Empty bladder immediately prior to examination
5. Gloves
Positioning of patient
1. Lithotomy position Supine + knees drawn up & fall apart + heels together
2. Sim position For examination of genital prolapse
Procedure
1. Inspection of external genitalia
2. Speculum (bivalve) examination
3. Bimanual palpation
4. Rectal examination
Examination of external genitalia
1. Pubic hair:-presence, distribution and hygiene
2. Labia majora and labia minora:-swelling, mass, ulcer
3. Urethra
4. Anus
5. Remark:-good exposure by separating the labia
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Bimanual examination
To palpate pelvic organs between both hands
1. Use lubrication
2. Insert the right index and middle fingers into vagina, with the thumb upwards and away from the urethral orifice
3. Place the left hand over suprapubic region and press downwards, while the right index and middle fingers and press upwards
4. Palpate the uterus and bilateral adnexae between both hands
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Assess:
1. Cervix:- size, consistency, tenderness (cervical excitation)
2. Uterus:- size, position (anteversion or retroversion of uterus), shape, mobility, consistency
3. Adnexal region:- mass:-size, shape, consistency, mobility, tenderness
4. Pouch of Douglas:- mass, tenderness
Examination of genital prolapse
See Examination of genital prolapse
Discussion/Something to Consider
1. How to differentiate the origin of a pelvic mass, whether it is from uterus or from ovary on examination?
2. As we have high resolution ultrasound scanning which can visualise the pelvic organs clearly, what is the value of clinical
examination?
3. How to differentiate rectocoele from enterocoele, and what is the clinical importance of differentiation between these two
lesions?
Lithotomy
A term derived from one of the oldest known surgical operations, i.e. cutting for (bladder) stone (lith means stone, tomy means
cut). It is now used to refer to the position of the patient on the operating table used for many gynaecological procedures. The
patient is placed on the operating table on their back; the hips are flexed with the thighs opened outwards and the legs supported
by strrups attached to poles on the operating table, so that the operator has easy access to the genital tract.
Speculum
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Terminology 2010
3. Infections
Foetal infection
Introduction
Foetus can acquire infection in the following ways:1. Placental transmission
2. Ascending infection from lower genital tract
3. Majority is sexually transmitted diseases
4. Infection acquired during labour when the foetus passing through the birth canal
Micro-organisms
The followings are common or important micro-organisms:
Viral:- rubella, herpes-varicella (chickenpox), HIV. Hepatitis B
Bacterial:- syphilis, group B streptococcus, gonorrhea, chlamydia
Protozal:- Toxoplasmosis
Foetal complications resulted from infection
Foetus can be damaged by infections in the following ways:
1. Congenital infection:a.
Infection can be teratogenic and cause multiple malformations
b.
High risk when infection is acquired in the first trimester
c.
Examples are Rubella and Syphilis infection
2. Neonatal infection:a.
Infection is acquired around the time of labour or delivery, often from the lower genital tract
b.
Causes localised neonatal infections
c.
Examples are
i.
Gonorrhea and chlamydia cause neonatal eye infection
ii.
Group B streptococcus causes neonatal pneumonia or meningitis
iii. Chickenpox infection through placental transmission causes neonatal pneumonia
3. Neonates become the carriers of the disease:
a.
Foetus acquires the micro-organism and becomes a carrier
b.
The micro-organism does not cause any harm to the foetus or neonate immediately, but will cause significant health
problems in the later life.
c.
Examples are
i.
Hepatitis B:-the child has high chance of developing CA liver in their later life
ii.
Indirect foetal complications
iii. Foetal health is also affected indirectly because of preterm labour and delivery secondary to intrauterine
infection or preterm rupture of membranes. Organisms such as group B streptococcus, chlamydia are associated
with preterm delivery
Common foetal infections that medical students should know
The following are chosen because they are relatively common, cause significant foetal morbidity and mortality, and illustrate
various ways how foetus or neonate are affected
1. Rubella
2. Herpes-zoster (chickenpox)
3. Syphilis
4. Gonorrhea and chlamydia
5. Group B streptococcus
6. Listeriosis
7. Hepatitis B
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Hepatitis
Viral hepatitis
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis B
Introduction
Hepatitis B infection is an important topic in Obstetrics because:1. Acute hepatitis may mimic liver disorder specific to pregnancy, such as acute fatty liver and HELLP syndrome. The
differentiation of these diseases is important in the obstetric management.
2. Vertical transmission is the main cause of endemicity in Hong Kong and perinatal infection is the major predisposing factor
of primary hepatocellular carcinoma. Neonatal prophylactic programme has been implemented.
Epidemiology
In Hong Kong, 10% adults are HBV carriers
Vertical transmission results in >90% chronic carriage
Virology
1. Double-stranded DNA virus (circular DNA with single stranded regions)
2. Family:-Hepadnaviridae; genus:-Hepadnavirus
3. Transmission via:
a.
Blood:-transfusions, sharing of needles or razors, tattooing acupuncture, renal dialysis or organ donation
b.
Sexual intercourse
c.
Close personal contact in horizontal transmission in children within families
d.
Vertical transmission:-perinatal infection at delivery, or rarely transplacental
Complications
1. Acute hepatitis
2. Fulminant hepatitis (rare; 1%)
3. Persistent infection (5%):-chronic persistent hepatitis or chronic active hepatitis
4. Risk of hepatocellular carcinoma in chronic carrier in future:-in Hong Kong, 80% of hepatocellular carcinoma cases are
caused by HBV infection
Perinatal infection
1. Vertical transmission usually occurs at delivery from maternal blood or body fluids, and transplacental transmission is very
rare
2. Vertical transmission rate depends on the level of maternal viraemia. For HBsAg positive mothers, perinatal infection occurs
in 10-20%. For women who are positive for both HBsAg and hbeag, the transmission rate is 90%.
3. Acute maternal infection during the first or second trimesters rarely leads to vertical transmission, while maternal infections
during the third trimester or chronic carriers increase the risk of vertical transmission.
4. Effect on neonates
a.
Neonates would become hepatitis B carriers. Over 90% of chronic carriers are a result of vertical transmission.
b.
Some of the infected neonates may develop hepatitis which is often mild. Rarely, fulminant hepatitis may occur.
c.
Teratogenic effects have not been reported.
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Hepatitis C
Epidemiology
In Hong Kong, <0.5% of the general population are HCV carriers.
Vertical transmission rate depends on the level of viraemia and the overall risk appears to be 5-10% and increased to 36% if
the woman is co-infected with HIV.
No effective way of preventing vertical transmission of HCV.
Virology
Single-stranded (+ve) RNA virus
Family:-Flaviviridae; genus:-Hepacavirus
Enveloped
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HIV
Virology
1. Single-stranded(+ve) RNA virus:-retroviridae
2. Several types; type 1 is the most common and type 2 is similar to type 1, which is confined to West Africa and Less virulent
Epidemiology
1. Worldwide distribution; Africa is the most prevalent area.
2. In the USA and Europe, AIDS is mainly caused by HIV-1; HIV-2 is responsible for a proportion of infections in Africa.
3. Hong Kong (in July 1999):-1255 HIV positive cases have been reported, the male-to-female ratio of new cases is around 6:1
with an increasing trend for females, 9 cases of vertical transmission were found.
4. Parenteral transmission through blood and body fluids, sexual intercourse or from mother to the child.
5. Risk factors of infection:
a.
Multiple sexual partners
b.
Bisexual activity
c.
Sexually transmitted diseases (previous or current)
d.
IV drug addicts
e.
Transfusion of blood or blood productsz
f.
Originating from an endemic area.
Maternal infection
1. Asymptomatic in early stage
2. Some women may have early diseases like vulvovaginal candidiasis, pelvic inflammatory disease (PID) and cervical
dysplasia
3. Anaemia, thrombocytopenia or neutropenia may occur
4. Women with thrombocytopenia may have epistaxis, petechiae and menorrhagia
5. Some may have non-specific symptoms like fever, arthralgias, myalgias and fatigue
6. Advanced cases:-at increased risk of opportunistic infections, such as Pneumocystis carinii pneumonia, toxoplasmosis,
lymphoma, cryptococcal meningitis
Perinatal infection
1. The transmission rate of HIV-1 to foetus was estimated to be 15-35%. Infections occur either in utero (13-33%) or at
delivery.
2. The rate of transmission to infants by infected mothers increases with the clinical severity of maternal disease and is inversely
proportional to the maternal CD4+ T-lymphocyte count.
3. The progress of the disease in these infants varies directly with the disease severity in the mother at the time of delivery.
4. Antenatal and intrapartum antiviral therapy decreases the transmission by 60-70%.
5. Breast-feeding is associated with an additional 14% risk of transmission.
Clinical features
1. No added risk of malformation
2. Most infected infants develop symptoms within the first 2 years of life.
3. Common clinical manifestations include bacterial infections, chronic parotitis, fever, lymphadenopathy, hepatosplenomegaly,
chronic or recurrent diarrhea, failure to thrive, and recurrent or persistent candidiasis.
Screening
Serological screening of HIV status should be considered in high risk patients (see above). Consent is required
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Diagnosis
1. Maternal diagnosis
a.
PCR assays for HIV cDNA in serum
b.
Virus isolation (expensive and slow)
2. Neonatal diagnosis of perinatal infection
a.
Conventional serological assays are difficult to interpret as passively transferred maternal antibodies may take up 18
months to disappear
b.
Other diagnostic tests include:i.
PCR assays for HIV cdna
ii.
p24 antigen detection (ELISA)
iii. Virus isolation
iv. IgA class-specific antibody detection (EIA)
v.
Early diagnosis allows prophylaxis against opportunistic infections
Management of for HIV-positive carriers
1. Pre-conception counselling:
a.
Counselling of risks and prognosis of the child.
b.
Consider avoiding pregnancy.
2. Antenatal:
a.
Monitoring of CD4+ counts.
b.
Extensive and ongoing counselling.
c.
Zidovudine (azidothymidine, AZT) treatment is offered to the mother during pregnancy, labour and delivery, and to
the newborn. This reduces the risk of perinatal transmission.
d.
Looking for any development of opportunistic infections or AIDS.
3. Intrapartum:- Elective caesarean section may reduce the risk of perinatal transmission.
4. Postnatal:a.
The newborn's skin should be cleansed of all maternal secretions before being punctured by a needle.
b.
Breast-feeding is avoided if possible.
c.
Prevent the baby from contacting with maternal secretions.
Pre-test counselling and testing
Protocol, as of 22 June 2002
1.
Antenatal Clinic
a.
Post posters
b.
Patients attending first visit :
i.
Give information pamphlets
ii.
Show a video.
iii. Counseling:- By midwife HIV co-ordinators; to enquire about patient"s objections; and further individual
counselling by midwife HIV co-ordinators, if patients are undecided,wish to opt-out or have questions
iv. Verbal consent before blood taking for HIV testing and other routine antenatal blood tests.
v.
If patient is still undecided, refer to AN general / MC-General / MC clinics and enquire for decision in the next
clinic follow up. Other antenatal routine blood tests should be taken first.
c.
Repeat HIV test after 3 months if patients have high risk behaviour
d.
Inform patients of the result of HIV testing in the next clinic visit.
e.
If refer to MCHC for shared antenatal care, patients will be called back if result is abnormal.
2.
Antenatal / Labour / Postnatal wards
a.
Post posters
b.
For non-booked cases with no prior testing
i.
Arrange HIV testing and/or other antenatal routine blood tests
ii.
If patient is in labour or condition not allows for HIV counselling, delay testing till condition allows or till after
delivery in postnatal wards
iii. Perform other antenatal routine blood tests as indicated
c.
Trace results if tests done elsewhere.
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3.
4.
5.
6.
7.
8.
9.
Gynaecological wards
a.
Antenatal routine blood testing including HIV is NOT a routine.
b.
HIV testing can be performed during antenatal care in the clinics
Booked courtesy / private obstetric patients
a.
Video and pamphlets will be shown before doctor"s consultation.
b.
Counselling and blood testing will be performed during consultation.
Sending blood specimens
a.
Same blood sample used for hbsag / Rubella Ab testing.
b.
Order test through the CMS laboratory request system.
Documentation of testing status / results
a.
Enter status of HIV testing into CMS:
i.
HIV test done with result : + or - or indeterminate
ii.
Repeat test result : +, -, indeterminate
iii. Opt-out
iv. Undecided
b.
Enter HIV testing status in a separate Record Book by designated midwifery staff.
c.
HIV results should be tracked for, if still not available by 2 weeks after the tests are requested, by contacting Dr. Paul
Chan, virologist of PWH.
d.
The Obstetrics SCIS can be entered with these results
Reporting of HIV results
a.
Currently under liaison, through the CMS if agreed by the Department of Microbiology
b.
Before reporting via CMS is implemented, test results are reported under the existing mechanism :
i.
Negative results sent via sealed envelopes in batches to the designated midwifery co-ordinator of the clinical
areas from where the blood specimens are sent.
ii.
Positive / Indeterminate results
Laboratory staff will inform the doctor requesting the test by phone and to arrange for repeat testing from the
patient
If positive result is confirmed, laboratory staff will inform the requesting doctor by phone, followed by a formal
report in a sealed envelope.
The requesting doctor should inform the Obstetrics HIV co-ordinator or deputy (Dr. C Y Li / Prof W H Tam) of
all positive and indeterminate results and seek advice for further management.
c.
Central reporting A monthly return on the numbers of cases screened, opt-out, and positive / indeterminate cases
will be prepared and sent to Dr. H K Wong, the central HIV co-ordinator.
Management of HIV positive cases
a.
For cases first referred to the antenatal clinic / on-call obstetric medical staff, the Obstetrics HIV co-ordinator or
deputy should be notified for advice on subsequent arrangement
b.
Early antenatal clinic appointment or admission to antenatal ward for post-test counselling of the patient
c.
Confidentiality maintained
d.
Obstetrics care in PWH by medical obstetrics team
e.
Patients will be referred to SMS (QEH) or SPP (DH) for medical care of HIV infection
f.
Paediatrician will be informed for paediatric counselling and stocking of anti-retroviral drugs for neonatal treatment.
g.
Pharmacy staff will be notified for stocking of anti-retroviral drugs for antenatal / intrapartum / postnatal use.
h.
Anti-retroviral drugs will also be stocked in the labour ward for emergency use for unanticipated HIV positive
nonbooked cases admitted in labour.For the drugs regimen, please refer to HIV-antenatal screening at AHNH/NDH.
Tracing of HIV positive patients who default follow up
a.
For MCHC referred cases who fail to turn up in the first antenatal clinic / admission appointment in PWH, MCH HIV
co-ordinator will be informed for tracing.
b.
For cases first diagnosed in the postnatal period, discharged patients will be called back for joint post-test counselling
with paediatrician. Patients will be referred to DH / QEH for long term medical follow up while their babies will be
referred to the paediatrician for assessment.
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Lamivudine therapy
Protocol, as of 6 November 2002
1.
Nature A nucleoside reverse transcriptase inhibitor of retrovirus including HIV.
2.
Indication
a.
To reduce the risk of vertical transmission of HIV from HIV-positive mothers who have not received antenatal
Zidovudine therapy.
b.
Not routinely given, but individualized treatment.
3.
Regimen
a.
Intrapartum maternal therapy
i.
Orally 150mg every 12 hours till delivery
ii.
Combined with oral Zidovudine
b.
Neonatal therapy by paediatrician
Nevirapine
Protocol, as of 6 November 2002
1.
Nature A non-nucleoside reverse transcriptase inhibitor of HIV-1.
2.
Indication
a.
To reduce the risk of vertical transmission of HIV from HIV-positive mothers to their babies.
b.
Not routinely given, but individualized treatment.
3.
Regimen
a.
Intrapartum maternal therapy:- 200mg po single dose 1 hour prior to Caesarean section or at the onset of labour
b.
Neonatal therapy:- To be decided by paediatrician.
4.
Contra-indication Hypersensitivity
5.
Toxicity
a.
Rash
b.
Deranged liver function (reported with multiple doses in non-pregnant patients)
Zidovudine
Protocol, as of 1 November 2002
1.
Nature A nucleoside reverse transcriptase inhibitor of retrovirus including HIV.
2.
Indication To reduce the risk of vertical transmission of HIV from HIV-positive mothers to their babies
3.
Regimen
a.
Antenatal maternal therapy:
i.
300mg b.d. orally
ii.
Specialist from QEH(SMS)/DH(SPP) may give the dosage differently in order to improve compliance
b.
Intrapartum maternal therapy
i.
If patient had antenatal Zidovudine therapy
2mg/kg iv loading dose over 30-60min, then 1mg/kg per hour iv till clamping of cord
ii.
If patient had not received antenatal Zidovudine therapy
300mg oral therapy for loading following by 300mg q3h till delivery
Combined with Lamivudine
c.
Neonatal therapy
i.
Give Zidovudine syrup 2mg/kg po 4 doses/day for 6 weeks
ii.
or if not tolerate orally,give iv 1.5mg/kg over 30min Q6H
iii. start therapy within 8 to 12 hours of birth
iv. if no intrapartum therapy was given, start therapy immediately after delivery
4.
Monitoring of Zidovudine therapy
a.
To be performed by specialist from QEH(SMS)/DH(SPP)
b.
baseline CBP, LFT, CPK then
c.
CBP Q2weeks for 1 month, then Q4 weeks
d.
LFT, CPK Q4 weeks
e.
Consider discontinuation if:- Hb<8g/dl; Platelet<100x109/L; WCC<75x109/L
f.
ALT/AST >5X normal
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Group B streptococcus
Organism
Group B streptococcus (GBS); Gram positive aerobic coccus
Epidemiology
1. In UK, 15-20% of women carry GBS in the vagina at delivery
2. 40-70% of infants of mothers colonised antenatally with GBS are themselves colonised, but only 1% develop evidence of
infection affected by it
3. Nevertheless GBS infections are one of the commonest infective causes of neonatal morbidity and mortality in the developed
world with an incidence of 1-4/1000 birth
4. The mortality rate for perinatal infection can be as high as 80% despite early recognition and prompt treatment
Foetal Risk
Neonatal pneumonia
Neonatal meningitis
Preterm rupture of membranes, preterm labour and delivery
Maternal Risk
Patients are usually carriers and asymptomatic
May cause vaginitis, and intrauterine infection after rupture of membranes
Screening and prevention
1. Routine screening for maternal colonisation and treatment
2. Controversial
3. GBS is only temporarily eradicated by short-term antibiotic therapy during pregnancy
4. If treatment is based on a positive culture at 28 week up to 50% will be negative at delivery, and up to 15% of
culture-negative women at 28 weeks will be culture-positive by delivery. Thus some women would be overtreated while
others would be undertreated.
Management
Intrapartum antibiotic (ampicillin) prophylaxis to prevent perinatal infection
Protocol, as of 6 November 2004
1. At onset of labour, ROM or induction of labour, give:a. Ampicillin 2g IV bolus then 1g Q6h till delivery; or
b. Clindamycin 900mg IV (diluted in 100ml NS infusion over 90min) q8h till delivery, if allergic to penicillin.
c. Request bacterial sensitivity to clindamycin whenever possible. If bacteria is resistant to clindamycin, give other
antibiotics according to sensitivity, or vancomycin 1g q12h (reconstitute in 20 ml of water and dilute with 200ml
normal saline, infusion over at least 100mins)
2. It is not necessary to give antibiotics for group B streptococcus if patient is going to have elective Caesarean section
without rupture of membranes.
3. Post-delivery
a. Inform neonatologist the result at delivery or whenever a positive result is available.
b. If the positive result is available during the postnatal period and the patient remains asymptomatic, it is not necessary to
give antibiotics to the patient.
c. Inform patient that she is a carrier and intrapartum antibiotic prophylaxis is required in future pregnancy.
d. Give a memo to the patient stating the result of positive group B streptococcus on discharge.
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Rubella
Virology
1. Family:-Togaviridae; genus:-Rubivirus
2. Single-stranded RNA virus
3. With haemagglutinin antigens
4.
5.
6.
Clinical features
1. 25% are subclinical
2. Usually present with mild febrile illness with macular rash and lymphadenopathy which lasts for 5 to 7 days
3. Macular rash first appears on the face and behind the ears before spreading down the trunk and the limbs.
4. The contagious period (i.e. Viral shedding) extends from 8 days before to 8 days after the onset of the rash.
5. Rubella antibodies are present by the time rash appears.
Foetal Risk of Congenital rubella syndrome
1. Chance
Gestation at infection
Chance of infection
Abnormalities
< 8 week
up to 85%
All infected foetuses will develop complications
< 12 week
50 - 80%
65 - 85% of infected foetuses have clinical defects
13 - 16 week
30%
30% will suffer sensorineural deafness
16 week
10%
Clinical manifestation rare
2. Features of congenital rubella syndrome
a.
Bilateral cataracts, microphthalmia
b.
Sensorineural deafness
c.
Congenital heart disease especially patent ductus arteriosus
d.
Mental retardation
e.
Intrauterine growth retardation
f.
Abortion, intrauterine death
Diagnosis of maternal rubella
1. As 25% are subclinical, diagnosis should not be based on clinical presentation alone
2. Serologic confirmation is essential:
a.
Four-fold rise in IgG titres
b.
Rubella-specific IgM antibody (false positive occurs with rheumatic factor)
Diagnosis of congenital rubella after delivery
Virus isolated from infant's pharynx, urine and cerebrospinal fluid in the first three months of life
Igm rubella-specific antibody present in cord blood
Persistence of rubella antibodies after 6 months
Screening
Immunity is screened with rubella antibody (IgG) at booking, or before pregnancy
IgG ELISA test, latex agglutination test and radial immune haemolysis test can be used
Prevention
1. Vaccination before pregnancy. This is a live attenuated virus vaccine
2. Contraception is advised for 3 months post-vaccination although the chance of congenital rubella infection caused by the live
vaccine is very rare.
Discussion/Something to Consider
1. During the booking visit at 9 weeks of gestation, a patient tells you that her child got a rubella rash 2 weeks ago. How would
you manage this case?
2. A subsequent test confirmed that she had recent rubella infection. How would you counsel and manage this pregnancy?
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Chickenpox
Virology
1. Herpes varicella-zoster causes chickenpox in a primary infection, and shingles on reactivation.
2. Incubation period:-10 - 21 days after initial contact (delayed up to 28 days if vzig immunization is given)
3. Infectious period:-2 days before onset of skin rash until cropping have ceased and crusted over (usually takes about 5 days)
Varicella-zoster virus
1. Epidemiology
a.
Primary infection (chicken pox) is common in childhood
b.
In Hong Kong, >90% of adults are seropositive, reactivation (herpes zoster) does not usually cause problem in
pregnancy as the foetus is protected by maternal antibodies
2. Virology
a.
Double-stranded DNA virus
b.
Family:-Herpesviridae; genera:-alphaherpesvirinae; HHV-3
c.
Cubic, icosahedral symmetry
d.
Morphology:-monomorphic, enveloped
3. Clinical features of primary infection (chickenpox)
a.
Symptoms like fever, malaise and a vesicular rash develop 10-20 days after exposure
b.
The rash usually begins on the face and scalp which then spreads to the trunk
c.
Contagious period from 2 days before the appearance of rash to all ruptured vesicles become crusted
d.
Highly infectious but mild in children
e.
More severe in adults and may associated with complications like encephalitis, myocarditis, pericarditis, pneumonia,
superinfection of skin lesions and adrenal insufficiency
f.
In pregnant women, the disease is more severe, pulmonary complications with initial symptoms such as cough,
tachypnoea, dyspnoea and chest pain. Gradually, the disease becomes disseminated, oral lesions and higher fever
develop, and finally respiratory insufficiency, pneumothorax, pulmonary parenchymal fibrosis and bacterial
superinfection may occur and lead to death.
Chickenpox
1. The name was meant to distinguish this weak form of the pox from smallpox (chicken being used, as in chickenhearted, to
mean weak or timid).
2. It is a febrile disease with generalised skin rash, starts as an eruption of red papules (bumps) which become vesicles (blisters)
than pustules. Other symptoms include malaise, weakness, sore throat, cough and fever.
3. Maternal risk Complications including pneumonia and encephalitis are uncommon but can be severe in adults.
4. Foetal risk
a.
When infected during pregnancy, there is a risk of congenital varicella syndrome:
i.
1% risk before 12 week of gestation
ii.
2% between 13 and 20 week
iii. Minimal after 20 week
iv. Syndrome consists of:-mental retardation, microcephaly, neurological and visual deficit, IUGR and deformity
b.
When infected during perinatal period, there is a risk of neonatal varicella
i.
Risk is 20 to 30% when mothers develop chickenpox within 5 days before and 2 days after delivery
ii.
Neonatal mortality is 30%
Diagnosis
Unlike rubella infection, chickenpox is always symptomatic, and diagnosis can often be made based on clinical features. Serology
is not required to confirm the diagnosis
Treatment of active chickenpox infection during pregnancy
1. Give acyclovir to reduce severity and duration of disease.
2. Varicella-zoster immunoglobulin is not useful for established infection.
3. Delay delivery, whenever practical, until at least 5 days after onset of skin rash, to allow passive placental transfer of maternal
antibodies.
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Significant contact
1. Definition of significant contact with Chickenpox
a. Time of exposure
i. Chickenpox/ disseminated zoster:-2 days before onset of rash till cropping has crusted
ii. Localised zoster:-day of onset of rash till crusting
b. Closeness /duration of contact
i. Continuous home contact
ii. In the same room for 15min
iii. Face to face contact e.g. conversation
iv. Large and open wards
c. Susceptible patients are potentially infectious from 10 days after the first contact, to 21 days after the last contact (or to
28 days after the last contact if VZIg is given).
2. Management of susceptible patients with significant contact
When patient is identified in out-patient
a. Refer patient to A&E Dept for obstetric follow-up by Gynae on call medical officer, until
i. Infection is excluded, or
ii. Infectious period has passed, or
iii. Patient is confirmed immune.
b. Advise patient to avoid further contact with index cases until the latter becomes non-infectious
c. Earmark patients file
d. Check patients immune status by VZIgG test
e. Ward Manager of the antenatal clinic should:
i. Liaise with A&E staff and virologist for the urgent serology test
ii. Keep track of the test result and inform Rm1 doctor when result is available
f.Manage according to VZIgG test result
3. Interpretation of and VZIgG test result and Management
a. First VZIg titre taken within 10 days of first exposure
i. Negative/ Equivocal:-treat as susceptible
- If patient is asymptomatic, give chickenpox-VZIg immunoglobulin in A&E Dept as soon as possible
- No need to check second titre.
ii. Positive:-treat as immune
b. First VZIg titre taken after 10 days of first exposure
i. Negative/ Equivocal:- Treat as susceptible
- Check second titre at least 3 days after incubation period has passed
- Not for chickenpox-VZIg immunoglobulin
ii. Positive:- Likely to be due to past infection
- observe for symptoms and check second titre to exclude recent infection at least 3 days after incubation period
has passed
- no change in titre in paired samples implies immunity; slight rise may occur in immune patients after contact;
consult virologist if in doubt
4. Admission of patients during potentially infectious period
a. Do NOT admit patient to O&G wards whenever possible.
b. Decision should be made by FHKAM
c. Alert antenatal ward staff before admission by nursing staff in clinic
d. Isolate the patient
e. Check her immune status and give chickenpox-VZIg immunoglobulin if appropriate
5. Susceptible staff should stay away from patients with active chickenpox infection, or patients who had contact with chicken
pox and are within the infectious period.
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Toxoplasmosis
A systemic infection caused by the protozoon Toxoplasma gondii. It is either asymptomatic or confused with 'flu' or other
pregnancy symptoms
Incidence
It is extremely uncommon in Hong Kong. The best estimate of the incidence in pregnant women in the UK is about 2/1000.
Congenital toxoplasmosis
Toxoplasma gondii can cause significant congenital abnormality of foetus:1. During the first trimester, transmission to the foetus occurs in about 10% of maternal infection. Foetal death or severe
sequelae are likely.
2. During the second trimester, transmission is frequent with a high risk of congenital infection.
3. During the third trimester, transmission is very frequent but the risk of problems at birth is low. However, as many as 80% of
children may develop chorioretinitis in later years.
Prevention
The best policy is prevention by avoiding undercooked meat, unpasterurised milk, and contact with cat litter; washing all garden
produce well and washing hands after gardening.
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Cytomegalovirus
Virology
Double-stranded DNA virus belongs to Herpesviridae
Epidemiology of CMV infection
1. Common; worldwide distribution
2. Most infections occur subclinically in childhood
3. In Hong Kong, about 95% of women at their childbearing age are seropositive
4. In some European countries like the UK, 40% of adults are susceptible
5. Seropositivity depends on age, socioeconomic class and country
6. Congenital infection has a high incidence:-0.2-2.2% of live births
Pathogenesis
1. Transmission via close contact with CMV-infected secretions (blood/marrow transfusion, sexual contact, close contact in
institutions)
2. A replication in the nucleus of infected cells producing the characteristic nuclear inclusions
3. Viraemia results in risk of transplacental transmission to the foetus
Clinical features
1. Primary CMV infection
a.
Usually asymptomatic except in immunosuppressed patients, but glandular fever-like illness may occur.
b.
During pregnancy, primary infection carries a foetal infection rate of 40%. The chance of foetal infection is not
affected by the gestational age, but the severity is higher in the first half of the pregnancy.
2. Reactivation of latent CMV infection
a.
Common in pregnancy
b.
Almost always asymptomatic
c.
CMV may also be transmitted to the foetus, but the maternal antibodies can reduce the severity of foetal infection
when it occurs
3. Congenital CMV infection
a.
Resulted from transplacental transmission
b.
5-10% of the infected infants are symptomatic at birth, of which 15% have classic cytomegalic inclusion syndrome
(CID)
c.
15-20% of symptomatic infants die and 90% of survivors have sequelae like hearing loss and mental retardation
d.
5-15% of asymptomatic newborns also develop sequelae
e.
The prognosis of infants who are symptomatic at birth is poor
Cytomegalic inclusion syndrome (CID)
1. Congenital infection
a.
Intrauterine growth retardation (IUGR)
b.
Central nervous system:-microcephaly, intracerebral calcifications, encephalitis, chorioretinitis
c.
Hematological:-anemia, thrombocytopenia, petechial hemorrhage
d.
Hepatic hepatosplenomegaly, elevated liver enzymes, jaundice
2. Perinatal infection
a.
Resulted from transmission via maternal secretions
b.
Common in infancy but does not harm the infant
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Terminology 2010
Diagnosis
1. Screening of primary infection using serologic testing, e.g. ELISA
a.
CMV-specific IgM can only be detected in around 60% of primary infection
b.
CMV-specific IgM may reappear in about 20% of cases of reactivation
c.
Confirmatory results:-seroconversion/igg is negative and igm is positive when first tested with a subsequent
seroconversion in IgG
2. Foetal
a.
Ultrasound examination
b.
Virus isolation from amniotic fluid
c.
Pathologic examination of the aborted tissue
3. Postnatal
a.
Congenitally infected infants may excrete virus for up to 5-7 years
b.
Congenital infection can be confirmed by virus isolation from urine and saliva taken within 3 weeks after birth
Management
1. Pre-pregnancy Discuss risks for women working in high-risk environment (e.g. Nurseries, institutions)
2. Prenatal
a.
No treatment for acute maternal infection
b.
Counseling about foetal risks
c.
Monitoring of the foetus
d.
Termination of pregnancy is considered at early gestational age
3. At delivery Infection control
4. Postnatal
a.
Confirm the diagnosis
b.
Pediatric follow-up if infection is confirmed
Parvovirus
Virology
Single-stranded DNA virus
Family:-Parvoviridae; genera:-Parvovirus
Infects only humans
Transmission via respiratory route (aerosolized droplets)
Viraemia develops 7-8 days after inoculation and ends when rash appears
The contagious period lasts from inoculation to eruption of rash, and is increased during the 1-4 days of mild fever and
myalgias which precede the rash in up to 60% of patients.
Infection
Parvovirus causes erythema infectiosum or fifth disease which is a common viral infection among children. 25% of adult
infections are asymptomatic. Patients usually have rash or/and acute symmetrical peripheral polyarthralgia that usually resolves
within 2 weeks. Occasionally it may cause bone marrow suppression, anaemia and thrombocytopenia. When a pregnant woman
acquires the infection (B19), the foetus may be infected transplacentally (33%), resulting in foetal anaemia and hydrops foetalis.
Prenatal diagnosis and management
1. Any pregnant woman who has been exposed to B19 infection or develops symptoms suggestive of B19 infection should be
investigated serologically. The presence of igm confirms recent primary infection (appears >14 days after inoculation and is
present for 3-4 months) IgG appears in the third week and persists life-long, conferring immunity
2. If the mother is found to be infected, the foetus should be monitored by ultrasonography. Hydropic changes may manifest
4-12 weeks after maternal infection
3. When signs of hydrops develop, foetal anaemia should be confirmed by cordocentesis. The presence of viral infection can be
confirmed with detection of B19 antigen or nucleic acid in foetal blood, or viral detection using electron microscopy.
4. Treatment is repeated intrauterine blood transfusion until the foetus is recovered from the viral infection. The prognosis is
good provided that prompt treatment is given.
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Terminology 2010
Listeriosis
Epidemiology
About 1 in 10000 birth in the UK
About 25% of cases are pregnancy-related
Bacteriology
Listeria monocytogenes
1. Gram-positive aerobic
2. Non-spore forming bacilli
3. Grows well at 4C (Can grow in refrigerated food)
4. An animal pathogen which is widely distributed in nature:-present in faeces of infected animals, soil, water or sewage
5. Pasteurisation may not eradicate the organism
6. Human acquire the bacteria through:a.
direct contact with infected animal
b.
handling raw meat
c.
outbreaks may occur by ingestion of diary products made from unpasturized milk or drinking infected milk
Clinical features
1. Maternal:a.
Asymptomatic or flu-like illness and fever in healthy individuals
b.
Can result in preterm labour and meconium-stained amniotic fluid (MSL)
c.
Septicemia, pyrexia of unknown origin (PUO), pneumonia or meningitis in immunosuppressed patients
d.
Haematogenous spread of Listeria may result in intrauterine infection of foetus
2. Foetal:a.
Infections in early in pregnancy:-abortion
b.
Infections later in pregnancy:-multi-organ morbidity, e.g., intraventricular hemorrhage, pneumonia, hepatitis,
neurological handicap and intrauterine death
c.
Foetal mortality may exceed 75%
3. Neonatal:a.
Early-onset manifestations due to transplacental transmission:-premature, congenital granulomatous pneumonia or
respiratory distress
b.
Late-onset manifestations due to infection at delivery:-meningitis
Maternal diagnosis
1. Pregnant women who have flu-like illness, pyrexia, uterine irritability and bloody vaginal discharge should be investigated
2. Blood, vaginal and amniotic fluid cultures
3. Demonstration of Listeria confirms the diagnosis
Management
1. A combination of ampicillin and gentamicin (or tobramycin) for 3-6 weeks
2. Gentamicin should be avoided in the absence of foetal infection since it has potential foetal ototoxicity
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Gonorrhea
Organism
Neisseria gonorrheae, a gram-negative diplococci
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Syphilis
Bacteriology
Treponema pallidium (a spirchaete)
1. Slender, tightly coiled, helical cells, 6-14 fine spirals, often flexed in centre
2. Cannot grow in vitro
3. Requires special stains, silver, immunofluorescence or dark ground illumination to visualize it
4. Transmission by:
a.
Sexual contact
b.
Intrauterine infection
c.
Transfusion of infected blood or blood products
d.
Direct inoculation
Incidence
0.05% of all pregnancies in PWH
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Trichomonas vaginalis
Trichomonas vaginalis is a motile protozoa with four unipolar flagellae. It is one of the common sexually transmitted diseases.
Clinical features:
1.
Foul smelling mucopurulent vaginal discharge
2.
Dysuria
3.
Vulval soreness
4.
Physical examination often reveals severe vulvovaginitis, with perivulval intertrigo and petechial hemorrhage on the vaginal
wall and ectocervix ('strawberry cervix')
Diagnosis:
A wet film will demonstrate the motile organisms, but the diagnosis may be confirmed by culture.
Treatment:
1.
Antibiotic - Metronidazole (Flagyl)
2.
STD screening
3.
Contact tracing
Bacterial vaginosis
It is also known as non-specific vaginitis, Gardnerella vaginitis and anaerobic vaginosis as a mixture of these kinds of bacteria is
usually identified. Gardnerella vaginalis is an anaerobic gram-negative rod anaerobe normally found in the vagina. During
infection, the number of the bacteria increases enormously to produce the characteristic grey vaginal discharge with a fishy odour.
True itching does not occur but there may be vulval soreness. It is one of the commonest causes of vaginal discharge in sexually
active women. Diagnosis is usually made clinically, with typical discharge, raised vaginal pH, and positive KOH amine ("sniff")
test. Examination of a stained vaginal smear shows the presence of 'clue cells' and culture on human blood agar shows
beta-haemolysis by Gardnerella vaginalis. The treatment is oral metronidazole or clindamycin vaginal cream. Recent data
suggests that the infection may be associated with preterm delivery.
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Chlamydia
It is a kind of atypical bacteria that replicate in cytoplasmic vacuoles within susceptible eukaryotic cells. Chlamydia trachomatis
is one of the commonest sexually transmitted diseases that causes many complications in Obstetrics and Gynaecology.
Chlamydial infection in gynaecology
Urethritis
Cervicitis
Pelvic inflammatory disease
Chlamydial infection in obstetrics
Is associated with preterm labour and preterm rupture of membranes
Causes neonatal conjunctivitis acquired from the birth canal during vaginal delivery
Diagnosis
1.
Immunofluorescence test for Chlamydial antigen
2.
Uses smear from endocervix, urethra, conjunctivae, rectum and pus from pelvic cavity. etc
3.
Fast and sensitive test
4.
Tissue culture special transport medium and prompt delivery are required
5.
Serology not useful clinically
Treatment
A 2-week course of antibiotic
Tetracycline group:-is the first line but is contraindicated in pregnancy because of tetratogenic effect
Erythromycin:-second line when tetracycline is contraindicated
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Index
Breast-feeding ............................................................................... 60
Breech presentation....................................................................... 41
Bromocriptine ............................................................................. 206
Brow presentation ......................................................................... 20
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Cytomegalovirus......................................................................... 389
Cytotec ....................................................................................... 342
Cyutobrush ................................................................................. 294
Danazol....................................................................................... 356
Dating of pregnancy ..................................................................... 33
Deep transverse arrest ................................................................. 166
Denominator ................................................................................. 20
Dermoid cyst .............................................................................. 242
Descend ...................................................................................... 149
Destructive mole ......................................................................... 312
Detrusor instability ..................................................................... 334
Detrusor Overactivity ................................................................. 333
Detrusor Overactivity Incontinence ............................................ 333
Dexamethasone........................................................................... 355
Dextrorotation of uterus................................................................ 29
Diabetes mellitus ........................................................................ 118
Diazepam .................................................................................... 352
Dinoprostone .............................................................................. 343
Disorders of early pregnancy ...................................................... 224
Disseminated intravascular coagulopathy................................... 136
Doppler effect ............................................................................... 91
Doppler studies ............................................................................. 91
Doptone ...................................................................................... 368
Down syndrome............................................................................ 74
Drinking during labour ............................................................... 152
Dysfunctional uterine bleeding ................................................... 208
Dysgerminoma ........................................................................... 290
Dyskaryosis ................................................................................ 297
Dysmenorrhoea........................................................................... 212
Dyspareunia ................................................................................ 283
Dystocia ...................................................................................... 166
Dysuria ....................................................................................... 333
Gastroschisis ................................................................................. 79
GBS(Group B streptococcus)..................................................... 381
Gemeprost ................................................................................... 342
Genetic counselling....................................................................... 89
Genetic disorder ............................................................................ 83
Genital prolapse .......................................................................... 318
Genuine stress incontinence ........................................................ 329
Germ cell tumour ........................................................................ 289
Gestational diabetes .................................................................... 119
Gestational trophoblastic disease ................................................ 310
GnRH (Gonadotropin releasing hormone) .................................. 358
GnRHa (Gonadotropin releasing hormone analogue) ................. 357
Gonadotropin .............................................................................. 358
Gonadotropin releasing hormone (GnRH) ................................. 358
Gonadotropin releasing hormone analogue (GnRHa) ................ 357
Gonadotropin therapy ................................................................. 358
Gonorrhea ................................................................................... 392
Grand multipara ............................................................................ 67
Gravid ........................................................................................... 67
Group B streptococcus ................................................................ 381
Gynaecoid ..................................................................................... 26
Gynaecological surgery .............................................................. 256
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Haemophilia ................................................................................. 83
Haemophilia A ............................................................................. 83
Haemophilia B .............................................................................. 83
HCG (Human chorionic gonadotropin) ........................................ 73
HELLP syndrome ....................................................................... 132
Hemabate .................................................................................... 343
Hepatitis ..................................................................................... 374
Hepatitis B .................................................................................. 374
Hepatitis B Immune Globulin ..................................................... 362
Hepatitis C .................................................................................. 375
Hexoprenaline ............................................................................ 348
History taking (Gynaecology) .................................................... 369
History taking (Obstetrics) ......................................................... 364
HIV (Human Immunodeficiency Virus) ..................................... 376
Hormonal replacement therapy (HRT) ....................................... 254
HPV (Human papillomavirus) .................................................... 394
HRT (Hormone Replacement Therapy) .................................... 254
Human chorionic gonadotropin (HCG) ........................................ 73
Human Immunodeficiency Virus (HIV) ..................................... 376
Human papillomavirus (HPV) .................................................... 394
Hydatiform mole ........................................................................ 310
Hydralazine ................................................................................ 350
Hydrops foetalis............................................................................ 80
Hyperemesis gravidarum ............................................................ 234
Hyperhep .................................................................................... 362
Hyperprolactinaemia .................................................................. 204
Hypertension .............................................................................. 124
Hysterectomy.............................................................................. 260
Hysterosalpingogram .................................................................. 266
Hysteroscopy .............................................................................. 263
Hysterotomy ............................................................................... 257
Macrosomia .................................................................................. 96
Magnesium Sulphate (MgSO4)................................................... 353
Malignant neoplasms of ovary .................................................... 288
Malignant neoplasms of uterine cervix ....................................... 291
Malignant neoplasms of uterine corpus ...................................... 304
Malignant neoplasms of vagina and vulva .................................. 285
Malpresenation.............................................................................. 41
Manual removal of placenta (MROP) ......................................... 159
Marsupialisation.......................................................................... 264
Maternal anatomy ......................................................................... 24
Maternal medicine ...................................................................... 117
Maternal mortality ........................................................................ 62
Meconium stained liquor (MSL)................................................. 104
Menopause .................................................................................. 252
Menorrhagia ................................................................................ 207
Menstrual cycle ........................................................................... 194
Menstrual disorders..................................................................... 194
Methrotrexate .............................................................................. 362
Methyldopa ................................................................................. 350
Metropathia haemorrhagia .......................................................... 208
MgSO4 (Magnesium Sulphate)................................................... 353
Minor disorders of pregnancy ..................................................... 235
Misoprostol ................................................................................. 341
Mitral stenosis ............................................................................. 134
Mittelschmerz ............................................................................. 212
Molar pregnancy ......................................................................... 310
Morbid adherence of placenta ..................................................... 158
Moulding .................................................................................... 153
MROP (Manual removal of placenta) ......................................... 159
MSL(Meconium stained liquor).................................................. 104
Multiple pregnancy ..................................................................... 108
Myomectomy .............................................................................. 259
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Teratogen ...................................................................................... 82
Teratoma..................................................................................... 242
Termination of pregnancy........................................................... 224
Testicular feminisation syndrome ............................................... 206
Thalassemia .................................................................................. 85
Third stage of labour................................................................... 155
Thrombocytopenia ...................................................................... 137
Thromboembolism ..................................................................... 138
Thyroid disorder ......................................................................... 144
Tibolone ..................................................................................... 356
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Figure Legend
Figure 1 Attitude ............................................................................................................................................................................... 21
Figure 2 Lie....................................................................................................................................................................................... 21
Figure 3 Position ............................................................................................................................................................................... 21
Figure 4 Breech and Cephalic Presentation ...................................................................................................................................... 21
Figure 5 Brow Presentation .............................................................................................................................................................. 21
Figure 6 Shoulder Presentation ......................................................................................................................................................... 21
Figure 7 Vertex Presentation ............................................................................................................................................................. 21
Figure 8 Face Presentaton ................................................................................................................................................................. 21
Figure 9 Foetal Skull......................................................................................................................................................................... 22
Figure 10 Measurements of Foetal Skull .......................................................................................................................................... 22
Figure 11 Sutures .............................................................................................................................................................................. 23
Figure 12 Circumferences ................................................................................................................................................................. 23
Figure 13 Levator Ani (Perineum) .................................................................................................................................................... 25
Figure 14 Pelvic Floor ...................................................................................................................................................................... 25
Figure 15 Pelvic Brim; Pelvic Inlet................................................................................................................................................... 26
Figure 16 Gynaecoid (Left) and Anthropoid (Right) ........................................................................................................................ 27
Figure 17 Android (Left) and Platypoid (Right) ............................................................................................................................... 27
Figure 18 Symptoms, Signs and Tests of Pregnancy ........................................................................................................................ 34
Figure 19 Classification of Placenta Praevia .................................................................................................................................... 35
Figure 20 External Cephalic Version. ............................................................................................................................................... 45
Figure 21 Presentation of the Cord (Left) ; Occult Presentation of the Cord (Right) ....................................................................... 46
Figure 22 Prolapsed Cord ................................................................................................................................................................. 46
Figure 23 Causes of Uterine Rupture. (Left To Right) Spontaneous; Classical C/S; and Lower Segment C/S. ............................... 56
Figure 24 Uterine Inversion. (Left To Right) First, Second and Third Degree ................................................................................. 58
Figure 25 Manual Reduction by Taxis (Left and Centre); and by Laprotomy (Right) ...................................................................... 58
Figure 26 Fluid Thrill (Left) ........................................................................................................................................................... 102
Figure 27 Uterus Large-for-Date. ................................................................................................................................................... 108
Figure 28 More than 2 Foetal Poles are Palpable............................................................................................................................ 108
Figure 29 Chorioamnionicity. ......................................................................................................................................................... 112
Figure 30 Caput Succedaneum ....................................................................................................................................................... 153
Figure 31 Controlled Cord Traction ................................................................................................................................................ 156
Figure 32 Placenta Examined ......................................................................................................................................................... 157
Figure 33 Early Onset.. ................................................................................................................................................................... 176
Figure 34 Late Onset....................................................................................................................................................................... 176
Figure 35 Variable Onset................................................................................................................................................................. 176
Figure 36 Different Degrees of Perineal Tear. (Left To Right) First, Second and Third. ................................................................ 182
Figure 37 Wrigley's Forceps ........................................................................................................................................................... 185
Figure 38 Anderson's / Simpsons Forceps ..................................................................................................................................... 185
Figure 39 Kielland's Forceps .......................................................................................................................................................... 185
Figure 40 (Left To Right) Vacuum Cups for OA and OP Position respectively; Vacuum Tubing; and Vacuum Machine. ............. 188
Figure 41 Macroscopic (Left) and Microscopic (Right) Appearance of Polycystic Ovaries. ......................................................... 199
Figure 42 Basal Body Temperature (Left) and Cervical Mucus (Right) Method ............................................................................ 216
Figure 43 Condom (Left Two); Diaphragm (Right Three) and Cervical Cap (Below) ................................................................... 216
Figure 44 Procedure of IUCD Insertion. ......................................................................................................................................... 221
Figure 45 Medical Abortion for Early First Trimester. ................................................................................................................... 224
Figure 46 Vacuum Suction Evacuation of the Uterus. .................................................................................................................... 224
Figure 47 Dilation and Evacuation. ................................................................................................................................................ 225
Figure 48 Different Types of Abortion. ........................................................................................................................................... 226
Figure 49 Anatomical Factors:-Fibroid (Left) and Arcuate Uterus With Septum (Right). .............................................................. 228
Figure 50 Fallopian Tube (Left) and Uterine Cornus (Right) Implantation. ................................................................................... 231
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