7. high yield obs & gynae
TRANSCRIPT
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Obstetrics and
Gynecology
September 2009
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Herpes In Pregnancy
DNA virus.
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Greatest risk of primary infection after 28 weeks of gestation.
May cause miscarriage and preterm labor.
High mortality and morbidity. Asso. with mental retardation and developmental delay.
Vertical transmission during labor.
Ref:JM(1047) ,Oxford handbook (105)
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Risk factors for intra partum
infection
Primary infection.
Recurrent herpes.
Multiple lesions.
Premature rupture of membranes.
Preterm Labor.
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Management
Symptomatic.
Prophylactic anti viral like Acyclovir from 38
weeks until delivery, to prevent recurrent herpes.
Arrange caesarean – if active lesions at time of
delivery or within preceding 4 days, membranes
ruptured for more than 4 hrs.
In vaginal delivery ,acyclovir to neonate.
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Long term effects of Hormone
Replacement Therapy
Decreased risk of endometrial and bowel cancer.
Increase risk of breast cancer after more than 5 years use.
Helps primary prevention of CVS disease only if HRT is started within 4 years of menopause.
Increased risk of Stroke in all age groups.
(Ref:Therapeutic Guidelines)
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Types Of HRT Cyclical Combined HRT.
(Daily Oestrogen +Cyclical Progestin)
Use within 1 or 2 years of the last
period and in those having some
spontaneous menses. No break
thorough bleeding.
Continuous combined HRT. For those with more than 2 years of
amenorrhea or those who have only
light bleeding. Chance of break
thorough bleeding.
Unopposed estrogen Patients undergone hysterectomy.
Transdermal Oestrogen therapy In patients with H/O Venous thrombo
embolism, Hypertension, Significant Liver
disease, Smokers, Symptoms not controlled
by Oral therapy.
Oestrogen Implant therapy Hysterectomy patients, Unresponsive to
Oral or transdermal therapy
Intra vaginal Estrogen Therpy Genitourinary symptoms, Syetmic estrogen
C/I or does not produce releif
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Therapy Initiation: Start at low or
ultra low dose.
Cessation
For those with mild symptoms: Gradual tapering over 6 weeks.
For those with severe symptoms: Taper over 6 months.
Progynova – Oestradiol valerate.
Conjugated Oestrogens: Premarin.
Oral Ultra
low
dose
Low
dose
Med
dose
High
Dose
Oestra
diol
1mg
on alt
days
1 mg 2mg 4mg
Oestra
diol
valerat
e
1 mg
on alt
days
1 mg 2 mg
Conju
gated
Oestro
gens
0.3 mg
on
alterna
te
days
0.3 mg 0.625
mg
1.25
mg
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Hormone Replacement Therapy
Indications:
• Symptomatic women.
• Symptom free cases to prevent osteoporosis, atherosclerosis, CVS diseases, Urogenital atrophy, Alzheimer's.
• Special Group: Premature Ovarian Failure, Gonadal dysgenesis, Surgical or Radiation Menopause.
ContraIndication:
• Hormone dependent cancer.
• H/O recent thrombo embolism.
• Acute /Chronic liver disease.
Relative C/I :
• Past H/O venous thrombo embolism.
• Cerebrovascular disease, CVS disease.
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Rectus Sheath Haematoma
Benign but Uncommon cause of
abdominal pain.
Bleeding into rectus sheath from damage to
superior or inferior epigastric arteries or
their branches or from direct tear to rectus
muscle.
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Risk Factors:
Age: Elderly.
Sex: Females more prone.
Pregnancy: During gravid, labor, Post partum.
Anticoagulant therapy: Most common.
Coughing : URTI, Tuberculosis, Bronchitis, Asthma.
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Abdominal Surgery.
External Trauma.
Vigorous uncoordinated rectus muscle contraction : Activities with significant Valsalva effort, such as coughing, sneezing, straining from constipation, urination, and sexual intercourse, have been implicated in rectus sheath hematoma
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Signs and Symptoms.
Most Common presenting complaint is severe acute abdominal pain.
In Pregnancy , D D :
1. Uterine rupture.
2. Placental Abruption.
3. Ovarian torsion.
4. Degenerating uterine leiomyoma.
Maternal mortality is 13% and fetal mortality is 50%.
The Cullen sign, periumbilical ecchymosis, in a patient with a rectus sheath hematoma
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Diagnosis: USG or C T
scan.
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Management
In Pregnancy: Non surgical management
preferred.
Rest, Analgesics, Haematoma
compression ,Icepacks and treatment of
predisposing conditions.
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Ante Partum Haemorrhage
Bleeding any time after 20 weeks of gestation
(but before delivery of baby).
Before 20 weeks: R/O cervical causes and other
local causes.
After 20 weeks:
• Placenta praevia
• Accidental haemorrhage/Abruptio Placenta. (REF: Llewellyn jones, Oxford handbook (231) and Emedicine)
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Placenta Praevia
Implantation of placenta over the lower segment.
Painless, causeless, profuse, recurrent.
Common in Multiparous, Prev Caesearen and prev h/o PP.
Blood loss is maternal.
Diagnosis: Ultrasound. Confirmed only after 30 weeks.
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Types of Placenta Praevia.
Major: Completely covers the internal os
(Type 4) or partially covers the internal os.
(Type 3)
Minor: Approaches the border of the internal
os (Type 3) or low lying (Type 1).
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Presenting part is unengaged. Malpresentation is common.
Uterus is non tender.
Bleeding in second half of pregnancy is PP unless proven othewise.
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Management
Minor: Continue till term or labor can be induced.
Major always caesarean. Usually at 37- 38 weeks.
Mgmt:
• Admission
• Check vital signs.
• No vaginal examination.
• USG.
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If before term, Mgmt depends on severity of
bleeding.
Severe bleeding: Urgent treatment to
deliver.
Less severe : Expectant mgmt till 36
weeks.
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Placental abruption/Accidental
haemorrhage.
Premature separation of a normally situated
placenta.
Can be due to direct trauma.
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Risk Factors
Maternal hypertension
Multiple pregnancy
Multiple pregnancy
Polyhydramnios
Smoking, Substance abuse
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Presentation
Abdominal pain with or without vaginal bleeding. Pain is sudden and severe
Uterine contractions.
Fetal distress may be present.
Severe cases: S/O shock, rising fundal height.
Diagnosis is clinically. USG is not an accurate tool.
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Management
Depends on severity, asso. complication
and fetal gestational age.
In severe cases, Deliver, irrespective of
whether fetus dead or alive. Delivery by
caesarean or vaginal.
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Complications
Maternal:
1. Hypovolaemic shock,
2. DIC
3. Acute renal failure,
4. PPH
Fetal:
1. IUGR
2. Pre term delivery
3. Anemia
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Vasa Praevia
Fetal blood vessels overlying the internal os,
in front of the presenting part.
Rupture of membranes involving the
overlying vessels leads to vaginal
bleeding.
Fetal blood is lost ,leading to fetal
exsanguination and death.
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Recurrent Pregnancy Loss
Three or more successive miscarriages.
Causes:
• Unexplained (50-70%)
• Genetic cause (70%) – most seen during first trimester.
• Auto immune causes: APLA (Late second trimester) ,SLE.
• Endocrine like diabetes, luteal phase deficiency.
• Anatomical causes: Incompetent cervix. Seen in second trimester.
Ref: Emedicine, L and Jones(107)
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Incompetent cervix
Painless cervical dilatation in 2 trimester or
early 3 trimester.
Asso .with rupture of membranes.
Unless treated ,recurrent.
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Causes and Management
Causes include prev trauma to cervix like D
and C.
Mgmt:
After 14 weeks.
Not usually done after 24-26 weeks.
Reinforcement of weak cervix by sutures.
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Oral Contraception
Venous thromboembolism associated with the combined oral contraceptive pill will usually occur in the first year of its use.
Most common in women with a genetic thrombophilia. While it is not cost effective to screen all women before they start taking a combined oral contraceptive pill, women with a first degree relative who has a history of venous thromboembolism should be screened for a thrombophilia before commencing a combined oral contraceptive pill .
Ref:Therapeutic guidelines
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Contraindications for COCS
Absolute:
1. Pregnancy
2. First 2 weeks post partum
3. H/o thromboembolic disease.
4. CVS disease
5. Estrogen dependent tumor.
6. Recently impaired liver function.
7. Migraines with aura
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Relative
Heavy smoking
More than 35 years, Smoking and other risk of CAD.
Breast feeding
4 weeks before surgery and 2 weeks after.
Gall bladder or Liver disease.
DM, HT,Complicated valvular disease, Hyperlipidaemia
Sever depression.
Undiagnosed vaginal bleeding.
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Contraception
Failure rates:
No method : 85%
Barrier:
Female – Diaphragm 16%
Condoms 21%.
Male – Condom 15%
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IUCD -0.1- 0.8%
OC pills – 0.3 % (perfect use).
Injectable or Implantable – 0.05- 0.3%.
Sterilization:
Male: 0.15-0.1%
Female: 0.5%.
Withdrawal – 27%.
Breast feeding 2-3%. (Ref Therapeutic guidelines)
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Benefits
Menstrual disorders
PID
Benign Breast disease and tumors.
Functional ovarian cysts.
Endometrial and Ovarian Ca.
Rheumatoid Arthritis.
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Risks
DVT
Stroke
Myocardial infarction
May be asso. cervical cancer.
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Missed Pills.
If less than 24 hrs
Take the pill ASAP
If the pill is missed in the first week,use additional protection for next 7 days. .
If more than 24 hrs
Take active pills ASAP. Use protection for next 7 days.
If the missed pill is in the third week or the pill free week, start the new packet.
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If the missed pill was an active pill and
was missed in the first week of a new
packet, and the woman had intercourse at
or after this time, she will need to use
Emergency contraception.
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Emergency Contraception
Also called ‘Morning after pill’
Ideally to be taken ASAP after unprotected
sex.
Protection is till 5 days.
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Methods
Levonorgestrel :Only method of emergency contraception registered for use in Australia.
Single dose of levonorgestrel 1.5 mg given within 72 hours of unprotected sexual intercourse, or levonorgestrel 750 micrograms with the same dose repeated 12 hours later
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Yuzpe Method
Four tablets of ethinyloestradiol
30 micrograms + levonorgestrel
150 micrograms within 72 hours of
unprotected sexual intercourse, and
repeating this 12 hours later.
Used only if no alternative.
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Protection of 85%.
Side Effects:
Nausea ,Vomitting, Dizziness and fatigue.
Headache, Breast tenderness.
No adverse effects on fetal development.
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Vulval Cancer: Elderly Women. 3% of all
genital cancers.
Vulval itching for months and years.
Hard nodule or an ulcer.
Mgmt : Vulvectomy with dissection of the inguino femoral lymph nodes.
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Cyclic Vulvitis Characterised by vulvar pain, which occurred in a cyclic
fashion, generally in concert with the menstrual cycle.
The pain could arise spontaneously or could be provoked by touch, pressure or friction.
Redness might or might not be present on examination.
Intermittent, low-grade candidiasis (usually without the typical physical findings of vulvovaginal candidiasis) is the cause.
The problem often improved when chronic, suppressive oral or topical anticandidal agents were used.
Ref: The Terminology and Classification of Vulvar Pain International Society for the Study of Vulvovaginal Disease
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Vaginal Bleeding in I trimester
Differential Diagnosis
1. Implantation Bleeding
2. Miscarriage
3. Ectopic Pregnancy
4. Molar pregnancy
5. Local causes unrelated to pregnancy
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Abortion Clinical Features Management
Threatened
•Vag Bleeding, may or may not be asso
with pain.
•OS closed. No passage of POC.
Close
Monitoring
Inevitable
•Vaginal bleeding with cramps.
•Dilatation of Cx bt no POC passed.
Evacuation
Incomplete
•Vag bleeding
•Dilatation of Cx
•Passage of some POC. Severe pain.
Evacuation
Complete
H/0 vag bleeding, abdo pain, and
passage of POC.
Aftr POC passed,pain , vag bleeding
.
OS closed.
USG - empty uterus.
Expectant
Mgmt
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Missed Abortion
Nonviable intrauterine pregnancy that has been retained within the uterus without spontaneous abortion.
Typically, no symptoms exist besides amenorrhea No vaginal bleeding, abdominal pain, passage of tissue, or cervical changes are present.
Detected when a fetal heartbeat is not observed or heard at the appropriate time.
An ultrasound usually confirms the diagnosis. (Ref: Emedicine, L and Jones).
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Parvovirus B19 in Pregnancy Non Immune at risk.
Risk of transplacental
infection throughout
pregnancy.
Screen By Immunoglobins.
Miscarriage is 4% < 20 weeks.
If Infected : Fetal Monitoring
by USG.
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Fetal Parvovirus syndrome: Anaemia,
Hydrops fetalis with cardiac failure.
If Hydrops ,Consider Early blood
transfusion.
(Ref: JM 1047)
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Drugs and Pregnancy (Ref: Therapeutic Guidelines ,RWH)
Amphetamines
During Ante natal
• Miscarriage
• Prematurity
• Still birth
Developmental Defects:
• Small head size.
• Eye problems
• Cleft lip and palate.
• Limb defects.
• Heart Defects
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Cannabis/Marijuana
Not Asso.with Birth defects.
Asso with reduced growth and development.
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Heroin
Not asso with physical abnormalities.
Crosses placenta,asso with withdrawal
symptoms and miscarriages.
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Benzodiazepines
Usually safe.
In late pregnancy – Neonatal drowsiness. Floppy infant syndrome.
Oxazepam ,ortemazepam preferred over diazepam.
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PCOS
Diagnostic criteria - Two of the following three criteria.
Menstrual irregularity.
Hyperandrogenism.
Polycystic appearance of the ovaries: 10 or more
follicles in at least 1 ovary measuring 2-9 mm in
diameter or a total ovarian volume of >10cm3
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Presentation
Oligomenorrhea ,Secondary Amenorrhea.
Hyperandrogenism : Hirsutism, Acne,Male pattern baldness.
Infertility- Chronic Anovulation.
Obesity.
Diabetes Mellitus- Impaired glucose tolerance.
Acanthosis nigricans and High Blood pressure.
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Daignosis
Lab Findings:
LH:FSH – 2-3 : 1
LH > 10 IU/L
Testosterone and androstenedione
SHBG
Insulin
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USG
Echodense stroma or
hyperechoic stroma
String of pearls
appearance.
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Management
Life style modifications: Weight loss, Exercise.
For PCOS and impaired glucose tolerance, or
with PCOS and type 2 diabetes – Metformin.
Sub fertility – Clomiphene /Tamoxifene,
Metformin.
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Secondary Amenorrhoea
Cessation of menstruation for more than 6 months
in normal female, not due to pregnancy.
Unless organic disease is suspected or the women
is desperate for trmt of infertility, investigation is
delayed till 6 -12 months ,as most women start
menstruating during this time.
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Primary gonadal (Ovarian) failure
Unknown cause.
Menopause before age of 40.
An FSH level above normal range of lab, confirmed by
repeating the measurement indicates primary ovarian
failure.
A level of more than 40 IU/l indicates menopause.
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Common Causes {Ref:L AND JONES (224)}
Weight loss 20-40 %
Polycystic Ovaries 15- 30%
Post Pill 10-20%
Hyper prolactinaemia 10-20 %
Primary Ovarian Failure 5-10 %
Asherman’s Syndrome 1-2 %
Hypothyrodism 1-2 %
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Pre Eclampsia
(Ref :Ten Teachers , Williams, RWH,L and Jones)
Min Criteria:
• B P ≥ 140/90 mm Hg after 20 weeks of
gestation.
• Proteinuria of more than 300 mg / 24 hrs.
Severe PE : ≥ 160 /110 + Proteinuria ( > 300mg/l)
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Imminent Eclampsia
Severe PE +
• Severe Headache
• Blurring of Vision
• Epigastric pain
• Exaggerated reflexes
• Oliguria
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Risk Factors
Primigravida (young and elderly).
Family H/O
Placental Abnormality.
Multiple pregnancy
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Complications
Maternal
• Ecclampsia
• Abruptio placentae.
• Oligohydramnios
• Preterm labor
• HELPP
• PPH
Fetal
• IUD
• IUGR
• Prematurity
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Indications for admission
B P ≥ 150/100 mm Hg on 2 occasions.
Maternal Symptoms.
Concern for Fetal Well being.
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Deliver
Gestation > 37 weeks
B P uncontrolled.
Deterioration LFT/RFT
Neurological symptoms /Eclampsia
Abruptio
Fetal welfare.
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Management
Mainstay – Deliver the fetus.
PE before 32 weeks: Continue preg till 35 weeks or longer.
Steroids for fetal maturity.
Daily DFMC / 3 weekly CTG.
PE btwn 32 – 35 : Same mgmt.
After 35 Weeks: Terminate by Caesarean or induction.
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Potential PE : See patient in 7 days.
Mild PE : See pat in 3 days.
Severe PE : Admission.
Drug of choice: Alpha Methyl Dopa.
Other drugs: Labetalol,Atenolol/
Acute Crisis : I V hydrallazine.
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Eclampsia
Severe P E + Convulsions.
Drug of choice : Mag Sulphate.
• Anti convulsant.
• Not to treat hypertension.
• Acts on cerebral cortex.
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Intoxication Avoided by maintaining urine output.
Signs:
Patellar and biceps reflex – disappear first.
Respiration depression
Respiratory paralysis.
Rx – Stop Mag sulphate.
Antidote : Ca Gluconate.
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Down Syndrome Screening. (Ref:
Therapeutic Guidelines)
Nuchal Translucency: 10 -13 weeks.
Serum levels:
• Triple test : 15-18 weeks .serum
chorionic gonadotrophin , - feto
protein, unconjugated serum oestriol.
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Diagnosis
Chorionic Villus sampling: 10 weeks -13
weeks. Fetal loss is1.5%.
Amniocentesis: 15-20 weeks. Fetal loss is
0.8%.
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Risk
Age in years Risk
25 1:1376
35 1:424
40 1:126
45 1:31
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PAP SMEAR
• In case of unsatisfactory smear, repeat the pap
test in 6-12 weeks after correcting the factor
responsible for the smear to be unsatisfactory.
• If your result shows signs of inflammation, but
the smear is otherwise satisfactory, you do not
need a repeat smear sooner than the usual two
years between Pap smears .
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PUPP (Pruritic urticarial papules
and plaques of pregnancy)
Rashes that itch strongly.
Never involve the face.
Usually appears in 3 trimester.
No harm to baby.
Disappears after delivery.
Rx: Topical steroids (Betamethasone cream ).
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Malformation of Female
Reproductive system. (Ref:Emedicine)
Malformations asso. with renal (50%)and bony anomalies.
Uterus Didelphys.
Investigation:
i. Pelvic USG.
ii. HSG- For uterine cavity and fallopian tubes.
iii. MRI- Best.
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Infertility (Ref:Therapeutic Guidelines)
Severe oligospermia :< 5 million motile sperm/ml.
For men with very low numbers of functional sperm, intracytoplasmic sperm injection techniques.
Empirical or nonspecific therapies -Include hormones and hormone antagonists (Gonadotrophins, androgens, antioestrogens), nutritional supplements, anti-inflammatory drugs, antibiotics and physical therapies (testicular cooling, varicocele ablation).
Systematic reviews (using conception rate as a measure) have shown that none of these therapies consistently improves fertility.
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Group B Streptococcal Infection. (AMC Clinical Assessment pg432)
Routine Screening 34-36 weeks.
Antibiotics given to mother only when she presents in labor.
No risk to mother with the organism, may affect baby.
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Treatment with parenteral Penicillin in labor or if membrane rupture before labor.
If allergic to Penicillin, Use Erythromycin.
Parenteral Penicillin to baby after birth is optional unless signs of infection or High risk cases (Prolonged ROM)
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Ectopic Pregnancy
Sites and frequencies of ectopic pregnancy.
Fallopian tube is the commonest site.
A. Ampullary, 80%;
B. Isthmic, 12%;
C. Fimbrial, 5%;
D. Cornual/Interstitial, 2%;
E. Abdominal, 1.4%;
F. Ovarian, 0.2%;
G. Cervical, 0.2%.
Ref: Emedicine
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Signs/Symptoms
Amenorrhea
Vaginal Bleeding
Abdominal pain.