obs and gynae revision lecture

8/18/2019 Obs and Gynae Revision Lecture

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OBSTETRICS



• Placenta- HCG (doubles every 48hrsunt l !" #$s%



&ntenatal care

• 've re)nancy test- &ttend GP• Re*erred *or boo$ n) at hos tal• Boo$ n) +SS scan to date re)nancy• ,ull H and boo$ n) bloods• Ident *y .O/ r s$ (Co00un ty1Green%

or HIGH r s$ (Consultant1Red%



Boo$ n) Invest )at ons

• ,BC (R t "8 #$s%• Blood )rou and abs2 (r t "8#$s%•

Rubella status• HEP B1C3 HI 3 Sy h2 I* no H ch c$en o

do ar cella• 5 ur ne

• OGTT3 Hae0o)lob no athy screen



Each v s t

• BP• 5 ur ne• ,undal he )ht (! c01#ee$%• ,etal heart # th 5o tone• Pal ate abdo0en *or

resentat on1stat on



Screen n)• C+BS -!!-!6 #$s• ,ree *etal 57&• !4-" #$s 9screen n) bloods• G ves r s$ *or tr so0y "!2 7ot

de:n t ve2 (5S ↓ 3 SB ↑ % I* ; ! n !< 3re*erred *or counsell n)

• " #$s ano0aly scan Structuralabnor0al t es1 S na B :da

• C S (=-!! #$s%1 &0n ocentes s (;!<

#$s%2 >aryoty e2 !? r s$ o*0 scarr a e2



.abour

• Pr 0 arous- !"-"4 hrs• @ult arous- A-!" hrs• +sually de:ned as the onset o*

a n*ul3 re)ular contract ons3 0orethan one every ten 0 nutes3 # th

ro)ress ve cerv cal e ace0ent andd latat on acco0 an ed by descent o*the resent n) art2



In t at on• Phys olo) cal *actors lar)ely

un$no#n2• Occurs #hen *actors #h ch nh b t

contract ons and 0a nta n a closedcerv d 0 n sh and are succeededby the act ons o* *actors #h ch do the

o os te2• Increase n ntracellular *ree calc u0

br n)s about contract on2

Prosta)land ns and o ytoc n ncrease



Sta)es n .abour• Sta)e I- Onset o* labour to *ull

d latat on2 latent and act ve hase(;6c0 d lated2%

• Sta)e II- ,ull d latat on to del very o*baby ( 4hrs n r 03 6hrs n @ult %Pass ve and act ve2

• Sta)e III- B rth o* baby to del very o*lacenta2 ( !hr% Can be act ve 9

(Syntoc non1Synto0etr ne% or

Phys olo) cal2



Pro)ress

• Con:r0 resentat on• @on tor ,H -Inter0 ttent1 Cont nuous• +ter ne 0uscle Contract ons- 6-<

)ood contract ons n ! 0 ns2• E a0 ne *or C d latat on1

e ace0ent1 stat on and os t onevery 4hrs2 E ect 0 n 0u0

ro)ress 2<-!c01hr2



Parto)ra0



,etal @on tor n)2



Presentat on



Stat on



Pos t on• Related to OCCIP+T ( oster or

*ontanelle%5 rect

5 rect

R )ht .e*t

R

R .

.

POSTERIOR

&7TERIOR

TR&7S ERSE TR&7S ERSE

Sy0 hys s Pub s

Sacru0



Pos t on• Related to OCCIP+T ( oster or

*ontanelle%

5 rect

5 rect

R )ht .e*t

R

R.

.

POSTERIOR

&7TERIOR

TR&7S ERSE TR&7S ERSE

Sy0 hys s Pub s

Sacru0



&nal)es a n labour• Breath n)1 TE7S1 Bath1 Co-coda0ol• Entono (7 trous o de1 o y)en%•

@or h ne- can cause CTG chan)es1neonatal res de ress on2• Re0 *entanyl PC&2•

E dural- .614 ( 7eeds I Du ds3Catheter3 Cont nuous CTG%• Can be to ed u * needs .+SCS2



Proble0s2

• Prolon)ed latent hase• &rrest o* d latat on• &rrest o* descent o* resent n) art2• ,etal co0 ro0 se2



Ty es o* del very

• S 5• &ss sted del very• a) nal breech del very2• .+SCS (lo#er uter ne se)0ent

caesarean sect on%



S 5

• En)a)e0ent• 5escent• Internal rotat on• Cro#n n)1E tens on• Rest tut on• 5el very o* ant then ost shoulder2



Th rd sta)e

• 5el very o* lacenta2• Controlled cord tract on2• Guard uters2• Syntoc non1 Synto0etr ne2• R s$ o* PPH



E0er)enc es

• @al resentat on- Breech3 *ace3 Bro#3co0 ound- .+SCS2

• Cord rola se- Cord co0es out # thDu d2 Elevate resent n) art- Crash.+SCS

•

Shoulder dystoc a- Head del vered2Shoulders stuc$2 @anoeuvres to tryd s 0 act2



The uer er u0• A #$s ost natal• +terus shr n$s- .och a roduced•

PPH (secondary%• 5 T1PE• Hae0arrho ds1 Const at on•

Postnatal de ress on



Breast *eed n)

• Oestrogen and Progesteronest 0ulate breast rol *erat on

• Prolactin st 0ulates 0 l$ roduct onand descent nto alveol

• Oxytocin st 0ulates 0 l$ e ect on• , rst th c$ yello# Du d- Colostru0• @a nta ned by suc$l n)



Breast *eed n)



Breast *eed n)

• S$ n to s$ n contact1 Bond n)• Rece ves all reFu red nutr ents• Pass ve 00un ty o* ant bod es

• Can t breast *eed # th certa n0ed cat ons or * HI 've



Co0 l cat ons

• Crac$ed n les• @ast t s• @ l$ stas s• Poor su ly-• 5o0 er done



PRE TER@ .&BO+R



5e:n t on

• Onset o* labour be*ore 6 #ee$s

• Presence o* uter ne contract ons o*su c ent *reFuency and ntens ty tocause d lat on o* the cerv r or toter0 )estat on

• Cause lar)ely un$no#n- no cause*ound n < ? cases



R s$ ,actors• Social factors- lo# soc al class- youn) 0other- lo# 0aternal #e )ht

- s0o$ n)

• Over distension of uterus- 0ult le re)nancy

- olyhydra0n os

• Fetal anomaly



R s$ ,actor• Uterine anomaly- con)en tal- cerv cal nco0 etence

• Infection-0aternal yre al llness-chor o-a0n on t s (caused by re0ature ru ture o*

0e0branes%

• Trauma- n ury-sur)ery dur n) re)nancy



5ru) treat0ent -Tocolys s• 5esc s on to treat de ends on

)estat on and stero ds• Treat0ent does not have any bene:t

on er -natal 0ortal ty• aluable *or delay n) del very unt ltrans*er to un t # th su tableneonatal care can be rov ded

• &llo#s t 0e *or cort costero ds to be) ven to accelerate *etal lun)0atur ty2



5ru) treat0ent

• DHP Calcium channel blockers(n *ed ne%

• Inh b t uter ne 0uscle contract on• 7o roven bene:t over

beta0 0et cs3 other than *e#er s de

e ects• 5ose o* " 0) ) ven *ollo#ed by ! -

" 0) ) ven 6-4t 0es da ly

de end n) on uter ne act v ty



Tocolys s

• Oxytocin rece tor anta!onist(atos ban "

• Bloc$s act on o* o ytoc n on uterus#h ch st 0ulates contract ons

• G ven I 3 0a 0u0 durat on 48hours• . censed *or nh b t on o* re0ature

labour bet#een "4 and 66 #ee$s)estat on



POST P&RT+@

H&E@ORRH&GE



PPH

• ;< 0ls blood loss P• Pr 0ary or secondary

• Secondary- endo0etr t s1RPOC



Pr 0ary PPH

• E0er)ency• &BC

• &- tal$ to t• B- *ac al O"• C- I &ccess (" lar)e venDons% ,BC3 Coa)3 J-0atch I Du ds



Causes

• T- Tone• T- T ssue•

T- Trau0a• T- Thro0b n



Tone

• &ton c uterus = ?• Catheter se• B 0anual co0 ress on• I@ syntoc non ! u• I@ er)o0etr ne < 0c)• I Syntoc non n*us on 4 u• I@ Hae0abate (PG," α % "< 0c)



B 0anual co0 ress on



T ssue

• Chec$ lacenta• @anual re0oval



Trau0a

• Gen tal tract trau0a• Re a r



Thro0b n

• Chase Coa) result• Contact hae0atolo)y• /atch *or s )ns o* 5IC



&7TE P&RT+@

H&E@ORRH&GE



&PH

• Bleed n) *ro0 the )en tal tract a*ter"4 #$s )estat on

•

"-<? o* re)nanc es• I0 ortant cause o* 0aternal and

*etal 0orb d ty and 0ortal ty

• 5on t *or)et &nt 5 n Rh-ve #o0en



Causes

• Placenta raev a• Placental abru t on• Sho#• .ocal causes

• asa raev a



Placenta raev a

• Placenta develo s n lo#er uter nese)0ent2 2<? o* all re)nanc es

•

R s$ *actors- ncreased a)e -0ult arous - rev .+SCS

- S0o$ n) - rev h story - 0ult le re)nancy



Class :cat on



Presentat on

• " #$ +SS (= ? # ll 0 )rate%• Pa nless va) nal bleed n)-

un rovo$ed• Post co tal bleed n)• @al resentat on

• @ass ve hae0orrha)e 0ay *ollo##arn n) bleed



5 a)nos s

• E1 S eculu0 should not be carr edout * PP sus ected

•

+SS (T scan best%• @RI scann n) can hel detect accreta



@ana)e0ent (@a or%• I* sy0 to0at c- ad0 t• .ar)e cannula3 GKS• 5el very at 6 -68#$s by .+SCS

(earl er * nd cated%• Best to have blood3 cell salva)e and

ntervent onal rad olo)y ready

• I* hae0orrha)e- &BC3 stab l se0other then e0er)ency .+SCS



Placental &bru t on

• Bleed n) *ollo# n) se arat on o*nor0ally s ted lacenta2 2<-!2<? o*

all re)nanc es• R s$ *actors- Increased a)e - @ult arous

- S0o$ n) - Recreat onal dru) use - &bdo0 nal trau0a



Class :cat on

Revealed1Concealed



Presentat on

• P bleed n)- &0ount 0ay notcorrelate # th s )n :cance o*

hae0orrha)e• &bdo0 nal a n1 tens on• Shoc$1 colla se•

,etal d stress



5 a)nos s

• +sually cl n cal• +SS (only

* 0other and baby

stable%



@ana)e0ent

• &BC• Resusc tat on• 5el very * reFu red• Increased r s$ o* PPH• /atch *or s )ns o* 5IC



@ISC&RRI&GE



@ scarr a)e

• !< ? o* all con:r0ed re)nanc es• Threatened• Inev table• Co0 lete1Inco0 lete• @ ssed• Recurrent• @olar



Threatened 0 scarr a)e

• P bleed n) '1- abdo a n• @ ld• Os closed• +SS con:r0s v able re)nancy• @ay lead on to 0 scarr a)e



Inev table 0 scarr a)e

• Heavy P bleed n) and a n• O en cerv• Products n canal



Co0 lete1 Inco0 lete

• Co0 lete- roducts assed anduterus e0 ty

• Inco0 lete- 7ot all roducts assedbut no ,H on +SS and P bleed n)



@ ssed 0 scarr a)e

• Pre)nancy .oss # th no s• Can be c$ed u at boo$ n) scan• Pre)nancy s usually )one a#ay



@ana)e0ent

• E ectant- &#a t body to assre)nancy

•

Sur) cal- Evac• @ & 9 0anual vacuu0 as rat on• @ed cal- @ *e r stone and @ so rostol



Recurrent 0 scarr a)e• 6 or 0ore 0 scarr a)es• !? o* all #o0en•

Chro0oso0al abnor0al ty• Con)en tal uter ne abnor0al t es• Cerv cal nco0 etence• In*ect on• PCOS• Thro0bo h ll a



@olar re)nancy• H )h HCG3 .ar)e uterus• P Bleed n)

P#$TI#% 'O%(• /here art o* lacenta over)ro#s

( rol *erates% @ay be develo n) *etus

resent3 but s )enet cally abnor0al andcannot surv ve outs de the #o0b2 T#os er0 enter e)) and nstead o* *or0 n)t# ns *or0s an abnor0al *oetus2 Tr lo d2



@olar re)nancy

• CO'P%(T( 'O%(• /hole lacenta s abnor0al and

)ro#s ra dly2 7o develo n) *etus2One s er0 enters the e)) but onlyhal* o* one set o* chro0oso0es are

resent2 &neu lo d2



5 a)nosed on +SS

Sno# stor0a earance



@ana)e0ent

• Sur) cal evac• Products sent to lab *or con*or0at on• Re) ster # th @olar re)nancy un t

(5undee%- They # ll *ollo# u• Trac$ HCG to • 7o ne# re)nancy *or ! yr but need

to avo d co0b ned hor0onalcontrace t on



Can ro)ress to22222P($SIST()T *(ST#TIO)#%

T$OPHO+%#STIC DIS(#S(• Part o* the 0ole re0a ns n any art o* the

body des te n t al treat0ent -can )ro#Fu c$ly

CHO$IOC#$CI)O'#• Rare but curable *or0 o* cancer- lacenta

beco0es 0al )nant• Can s read throu)hout the body3 usually

to lun)s3 l ver and bra n2 Treat0ent sche0othera y



@+.TIP.EPREG7&7CL



@ult le re)nancy

• Inc dence o* t# ns M!1!• Tr lets M!14• Pred s os n) *actors 9Increased a)e -,a0 ly1 ersonal

H

- ,ert l tytreat0ent

-Race



Ter0s

• @ono15 Ny)ot c- 7o2 o* e0bryos• Chor on c ty- 7o2 o* lacentas• &0n on c ty- 7o2 o* a0n ot c sacs



5 Ny)ot c t# ns

• 7on dent cal• " e0bryos 0 lant• &l#ays " lacentas and " sacs



@onoNy)ot c t# ns

• Ident cal• ! e0bryo s l ts• S l t 6 days- 5C5& 4- days- @C5& 8-!" days- @C@&- rare

!6-!< days - con o ned t# ns



5 a)nos s• Boo$ n) scan• Be*ore * hy ere0es s1 *ert l ty R



&ntenatal co0 l cat ons

,ET&.• Increased re-ter0 del very and

seFualae• Increased r s$ o* ano0al es• Increased r s$ I+GR1I+5

• In @C t# ns- T# n to T# n Trans*us onsyndro0e (TTTTS%



&ntenatal co0 l cat ons

@&TER7&.• Severe hy ere0es s• Increase r s$ 0 scarr a)e• Increase r s$ o* anae0 a3 Pre-

ecla0 s a3 Pelv c a n3 &PH3

Placental raev a3 Gestat onald abetes and PPH2• Cord acc dents



&ntenatal care

• H )h R s$• @ore v s ts• &no0aly scan at !8-" #$s2 (cant

really do C+BS1&,P%• Iron tablets• Ser al Gro#th scans• 5el very M68#$s

5 l



5el very• a) nal vs .+SCS• I* t# n I s Breech or s )n :cantly

s0aller- .+SCS• I* t# n I s ce hal c- could try a) nal

del very• Cont nuous 0on tor n) (,SE on t# n

I%• I access• 5 culty s # th t# n II- Should be A

0 ns a*ter I at 0ost•



T# n to T# n Trans*us on

• @onochor on c t# ns• Placental arter ovascular

anasta0os s• +neven d str but on• 5onor t# n 9anae0 c3 I+GR3

ol )ohydra0n os• Rec ent t# n- Polycythae0 c3

Polyhydra0n os3 &sc tes and leural

e us ons



TTTS



Treat0ent

• R s$y• .aser ablat on o* anasto0os s

vessels• Early del very



S0all *or dates*etus



S0all *or 5ates

• Const tut onally s0all baby• ,etal )ro#th restr ct on (,GR%•

+sually c$ed u by 0easur n)*undal he )ht

• Con:r0ed on +SS (Gro#th scan%



,etal )ro#th chart



Const tut onally s0all

• S0all 0other• Sy00etr cally s0all2•

.ess that ! th cent le but )ro# n)a ro r ately

• 7or0al l Fuor volu0e• 7or0al u0b l cal artery do lers



I+GR

• &sy00etr cal )ro#th• .o# l Fuor volu0es1 &bnor0al

5o lers• 7ot )ro# n) alon) cent les• So0et 0es *etal d stress



Causes

• Placental nsu c ency• ,etal ano0al es•

5ru)s• In*ect on



Placental nsu c ency

• @ost Co00on• &bnor0al t es n lacental

develo 0ent• 5 abetes• Pre-ecla0 s a•

Thro0bo h l a• Connect ve t ssue d seases• Placental n*arct on1abru t on



5ru)s

• S0o$ n) ("-*old r s$%• &lcohol•

Recreat onal dru)s• Beta-Bloc$ers



@ana)e0ent

• Increased 0on tor n)• Gro#th scans3 l Fuor volu0es and

u0b l cal artery do lers every "#ee$s• Early del very



Pre- ecla0 s a

• Increased BP and rote nur a '1- oede0a• ; 6 00H) systol c or ;!<00H)

d astol c above boo$ n) BP or• Systol c ;!< 00H)• Only " ? o* at ents # th ncreased BP n

re)nancy have re-ecla0 sa (8 ? are

PIH- re)nancy nduced hy ertens on



Severe

5e:ned severe *• 6' rote n or 0ore n ur nalys s• BP ;! 1!!•

sual d sturbances1headache1 a lloede0a• R+Q1E )astr c a n1tenderness• Clonus• Ol )ur a1 Renal *a lure•

HE..P syndro0e ( H ae0olys s3 ( levated % verenNy0es3 %o# P latelets%• &ll above su))est ecla0 s a could be 00 nent2



&et olo)y

• .ar)ely un$no#n• I00unolo) cal d sturbance decreased

nvas on o* 0aternal s ral arter es ntolacenta decreased lacental *unct on

• Endothel al cell da0a)e , br n *ra)0ents#h ch brea$ a#ay and de os t n-

•

$ dney Renal *a lure3 rote nur a• C7S convuls ons



R s$ *actors

• Pr 0 )rav da• " yrs a)e and ;6<yrs a)e2•

,a0 ly1 Personal h story o* Pre-ecla0s a• @ult le re)nancy• Obes ty• 7on s0o$ers• Pre-e st n) hy ertens on or renal

d sease



R s$s to 0other

• Renal1He at c *a lure• HE..P•

Stro$e• 5 sse0 nated ntravascularcoa)ulo athy (5IC%

• Pul0onary oede0a• Convuls ons• 5eath



R s$s to baby

• I+GR ()ro#th restr ct on%• Placental abru t on•

Pre0atur ty• Hy o c da0a)e• 5eath



Invest )at ons

• H story• E a0 ( nc ando e a03 reDe es3

*undosco y%• 5 ur ne3 re)ular BP s• Bloods (.ar)e cannula3 ,BC3 .,T s +rate3

+KE s3 Coa) and Gr and save%• I* severe- +r nary catheter- 0on tor

out ut22 Invas ve 0on tor n)- central l ne3

ECG2



Trea0ent

• Treat0ent does not cure re-ecla0 s a3 t s a 0 sto revent ecla0 s a

• Only cure s to 5E.I ER B&BL•

'ild, &nt hy ertens ves (.abetalol " 0) 6 dayor @ethyldo a orally%• I* 6<#$s )estat on- stero ds2 !"0)

beta0ethasone I@2• Severe - I .abetalol1hydralaN ne - I @a)nes u0 sul hate 4) bolus and

!)1hr• @on tor BP3 +r ne out ut3 ReDe es3 Res rate and

@a) levels * To c ty



Cont22

• CTG- *or *etal #ellbe n)• 5ec de #hen sa*e to del ver baby2 (can be

C-sect on or Induct on o* labour%• There s an ncreased r s$ o* PPH2 (Post

artu0 hae0orrha)e%• Cont nue 0ana)e0ent *or "4hrs ost

del very• I* has ecla0 t c se Nure- treat # th @)SO4

) 2



,uture re)nanc es2

• Pro hylaxis n *uture re)nanc es-.o# dose as r n ( <0)%

•

Care*ul BP 0on tor n)• Gro#th scans



5 abetes n

re)nancy

5 b



5 abetes

• Pre e st n) 5 abetes• Gestat onal 5 abetes

• Pre)nancy s state o* Insul nres stance2

•

Placenta roduces ant nsul nhor0ones (hP.3 cort sol and)ulca)on%

G l 5 b



Gestat onal 5 abetes

• Onset # th re)nancy• &ssess cl n cal r s$ and cons der

Hb&!c at boo$ n) and OGTT at "8#$s• Re*er to 5 abet c Obstetr c cl n c2•

@ lder r s$s than I55@• Can ro)ress to Ty e II 5@

ostnatally•

5 et controlled vs @et*or0 n1 Insul n

Ho# re)nancy e ects



) y5 abetes• Insul n reFu re0ents r se• 5ecrease n Renal *unct on

( rote nur a%• Increased e sodes o* hy o)lycae0 a• /orsen n) o* Ret no athy•

Hy er)lycae0 a n Stero d use

Ho# 5 abetes e ects



re)nancy• Increased r s$ o* con)en tal

abnor0al t es•

Increases r s$ I+517eonatal death• Increased r s$ Pre-ecla0 s a• Polyhydra0n os•

@acroso0 a1I+GR• Pre0atur ty• Postnatal hy o)ycae0 a and

aund ce2

& l



&ntenatal care

• Pre-conce t on counsell n)• @ult -d sc l nary a roach•

Str ct 5 abet c control• 5eta led &no0aly scan• &7C every " #ee$s at 0 n 0u0 # th

)ro#th scans• Induct on at 68 #$s

b



.abour

• Cont nuous GTG• Sl d n) scale n certa n cases- Hal* as

soon as lacental del vered• A #$ *ollo# u - GTT



BRE&>



GL7&ECO.OG L7or0al

@enstruat on

7 0 l @ t t



7or0al @enstruat on

• Cycle ""-6< days• 5urat on o* bleed n) days•

Blood loss 8 0ls• @enstrual Phase- endo0etr u0 shed• 5 schar)ed throu)h C by uter ne

contract ons

7 0 l l



7or0al cycle

Prol *erat ve (,oll cular%



(hase

• 5ay <-!6• Ovar an *oll cular )ro#th•

Increas n) oestro)en• Gro#th and vascular sat on o*

endo0etr u0•

Ovulat on occurs day !4• Ovulat on occurs !4 days r or to

ne t er od n a cycle that s not "8

days

Secretory (luteal% hase



Secretory (luteal% hase

• 5ay !<-"8• Pro)esterone ncreases2 Produced by

cor us luteu0• @a nta ns endo0etr al th c$ness3re ar n) *or 0 lantat on

•

Ends # th de0 se o* cor us luteu0

@enstrual hase



@enstrual hase

• 5ay !-<• 5ecl ne o* oestro)en and

ro)esterone• Brea$do#n o* endo0etr u0- sheds



Heavy

@enstrualBleed n)

Heavy @enstrual bleed n)



Heavy @enstrual bleed n)

• 5e:ned as ; 8 0ls blood loss10onth

•

Heavy 0enstrual blood loss a ect n)QO. or caus n) anae0 a• ! ? o* all #o0en•

@ost co00on )ynaecolo)y re*erral

Causes



Causes

• P&.@ COEI7Poly Coa)ulo athy

&de0o0yos s Ovulatory5ys*unct on.e o0yo0a Endo0etr al

@al )nancy Iatro)en c7ot yet class :ed

&ssess0ent



&ssess0ent

History • @enstrual cycle len)th3 durat on• Heavy clots3 Dood n)3 ta0 ons1 ads• I@B3 PCB• &ssoc ated a n

Examination• &bdo0 nal• P• S eculu0- s0ear1s#abs

Invest )at ons



Invest )at ons

• Pelv c +SS• ,BC3 clott n)3 T,T s

In older #o0en (;4 yrs%• P elle b o sy• Hysterosco y '1- b o sy

Causes



Causes

• 5ys*unct onal +ter ne bleed n)• , bro ds•

Poly s• Endo0etr al ca

bro ds (le o0yo0a%



, bro ds (le o0yo0a%

• Ben )n tu0ours o* 0yo0etr u0• " ? nc dence n #o0en ;4 yrs old

@ana)e0ent



@ana)e0ent

Medical• 7on-hor0onal•

Hor0onal

Surgical• @ nor• @a or

@ed cal



@ed cal

Non- hormonal • @e*ena0 c ac d (7S&I5%•

Trane a0 c ac d (ant :br nolyt c% Both ta$en dur n) er od only

@ed cal



@ed cal

Hormonal • Pro)esto)ens- 7oreth sterone

- Provera - POP (CeraNette%• @ rena co l• COC3 5e o rovera3 GnRH analo)ues• Es0ya

Rad olo) cal



Rad olo) cal

• , bro ds• +ter ne artery e0bol sat on•

ReFu res @RI

Sur) cal (@ nor%



Sur) cal (@ nor%

Endometrial ablation• <? sat s:ed• @ust have b o sy r or to carry n) out• ,a0 ly should be co0 lete• .&SH alternat ve

Myomectomy (fbroids)

Sur) cal (@a or%



Sur) cal (@a or%• Hysterecto0y '1- BSO• Should not be cons dered unless tr ed

alternat ve treat0ent or has verylar)e :bro ds

Endo0etr os s



Endo0etr os sEcto c endo0etr al t ssue+sual s tes• Pouch o* 5ou)las• +terosacral l )a0ents•

Ovar an *ossae• Bladder• / th n uter ne 0uscle (adeno0yos s%

ery rare lun)s3 bra n3 0uscle

+sually resent # th a n1 n*ert ll tyGraded I-I

Treat0ent 9 COCP3 ro)esterones3 GnRH3 sur) cal



UrinaryIncontinance and

rola se

Prola se• 5 # # d d l 0 t # $ ) *



• 5o#n#ard d s lace0ent- #ea$en n) o*su ort ( elv c Door%

5e:n t ons



5e:n t ons

• +terova) nal- uterus and c• Cystocele- Bladder• Rectocele- .ar)e bo#el• Enterocele- s0all bo#el

+terova) nal



+terova) nal

• Grade I

+terova) nal



+terova) nal

• Grade II

+terova) nal



+terova) nal

• Grade III- co0 lete evers on

Grade III



Grade III

Procedent a



Procedent a• +lcerat on



Rec

Sy 0to0s



Sy 0to0s

• USo0eth n) co0 n) do#n• 5 sco0*ort• +r nary s• Recurrent +TI s• Const at on1 5 culty e0 ty n) bo#el

Treat0ent



Treat0ent

• @ ld- Oestro)en crea0 - Pelv c Door e erc ses

• @od1Severe- Conservat ve (Pessary% vsSur) cal ( elv c Door re a r1 a) nalhysterecto0y1@esh%

Pessar es



Pessar es

+r nary ncont nence



r nary ncont nence

+r)e• Overact ve bladder• Inab l ty to delay *ollo# n) sensat on to

vo de2)2 >ey n the door• 5etrusor nstab l ty3 neuro)en c bladder3

n*ect onStress• .oss o* ur ne #hen ntra-abdo0 nal

ressure ncreased•

/ea$ elv c Door or s h ncter

Treat0ents 9 +r)e



)

• . *estyle chan)es (#e )ht3 ca e ne3 Du d%• ,reFuency volu0e chart• Out at ent cont nence ro)ra00e• &nt -chol ner) c 0ed cat ons• Boto (rare%

Treat0ents- Stress



• Phys o (P,E3 Electr cal st 0ulat on o*0uscles%

• +rethral bul$ n)• Sub-urethral sl n) (T T-O%• Col osus ens on

• = ? ha y a*ter sur)ery• Prola se sur)ery can 0a$e ur nary

sy0 to0s #orse and *or urodyna0 cs :rst



Gynaecolo) cal

cancers

Endo0etr al cancer



• @ost co00on )ynae cancer• &denocarc no0a 0ost co00on 8 -8<?• @ean a)e A yrs• R s$s- 7ull arous obes ty E" only HRT

late 0eno ause(Oestro)en %

Sy0 to0s and 5 a)nos s



y )• P@B• Heavy rre)ular bleed n)• 7one

• T +SS (&ssess endo0etr al th c$ness%• !"00 re0eno ause 400

ost0eno ause• P elle b o sy• Hysterosco y3 5KC

Sta) n)



) )

Stage I Confined to uterusStage Ia No myometrial invasion

Stage Ib Myometrial invasion <50%

Stage Ic Myometrial invasion >50%

Stage II Involvement of cervix

Stage III Pelvic s readStage I! "ladder#rectum#distant $lung

Treat0ent



• Hysterecto0y• Pelv c clearance

o0entecto0y1a end cecto0y• Che0othera y1 Hor0one thera y

(advanced%• < yr surv val Stage I &5%

Stage II 5'%

Stage III (0%

Stage I! )0%

Ovar an cancer



• @ost deadly• Pea$ a)e A8-8<yrs old• = ? s orad c3 ! ? )enet c• E thel al tu0ours 8<?• Increased r s$ 7ull arous3 h )her soc al

class3 ovulat on nduct on•

5ecreased r s$- COC use




y )

• &bdo d stens on10ass• &bdo a n• /e )ht loss1loss o* a et te

• Ca!"< ;6< ost 0eno ausal• &sc t c ta• I0a) n)- T +SS3 CT3 @RI3 CJR• .a aroto0y

Ovar an tu0our



Sta) n)



) )

Stage I *+5% Confined to ovariesStage Ia ,ne ovary

Stage Ib "ot- ovaries

Stage Ic .ve ascitic cytology

Stage II *)0% Confined to elvis

Stage III */5% Confined to eritoneal cavityStage I! *+0% istant s read

Treat0ent



•

Pelv c clearance 'che0othera y

• Rad othera y• < yr surv val

Stage I 1&%

Stage II 5)%

Stage III +0%

Stage I! 5%

Cerv cal cancer



• Pea$ a)e 4<-<< (can occur as youn) as " %• R s$s 9 5e*ault n) s0ears @ult le artners HP !A'!8 (8 -= ?% COC use S0o$ n)

Cerv cal screen n)



• C s0ear- 7ICE )u del nes• Every 6 yrs *ro0 a)e " -A<yrs• . Fu d based cytolo)y• Re) stered # th SCCRS• &bnor0al results re*erred to Col osco y

*or cold coa)ulo athy1..ETV•

U ade Goody e ect Increase "!? u ta$e

Cerv cal s0ear



Pre-cancerous chan)es



•

Trans*or0at onNone

• 5ys$aryos s• Cerv cal

ntrae thel alneo las a (CI7%

• @ay ers st *or

years• Can revert to

nor0al• 6 ? CI7 6 # ll

CIN ) 2bnormal cells inlo3er )#(e it-elium only4

CIN + 2bnormal cells inlo3er only4

CIN ( Carcinoma in*situ46ull t-ic7ness ofe it-elium

Cerv cal cancer



• Post co tal bleed n)• &bnor0al d schar)e1 bleed n)• /e )ht loss• Pa n

• E+&3 cystosco y3 roctosco y• Cone b o sy• ..ETV

Sta) n)



Stage Ia Micro <(mm in de t-

Stage Ib Confined to Cx

Stage II 8xtends to u er vagina

Stage III 8xtends to elvic side 3all or lo3er

vaginaStage I! istant s read* bladder#rectum#beyond4

Treat0ent



•

Hysterecto0y-Rad cal

• Rad othera y• Che0othera y• <yr surv val

Stage I '0%

Stage II 1)%

Stage III (+%

Stage I! )5%

acc nat on



• Gardas l• Protects a)a nst HP !A K !83 A K !!• ==? e ect ve• G rls a)e !"-!6 yrs old• / ll st ll need s0ears as rare C

cancers and current o ulat on notrotected2

ulval cancer



• .east co00on• Pea$ a)e A<- yrs old• SFua0ous carc no0a ="?• R s$s- HS HP (!A1!8% S0o$ n)

I00unosu res on• I7




• Pru tus vulva• ulval a n1 d schar)e• .u0 or ulcer

• 5 a)nosed by vulval b o sy

ulval cancer



Sta) n)



Stage I <+cm lesion confined to vulva

Stage II >+cm lesion confined to vulva

Stage III 9ocal s read or node involvement

Stage I! 2dvanced local s read or bilateralnode involement4 $inguinal: femoral:

elvic4

Treat0ent



•

Sta)es I-III 9Rad calvulvecto0y• Rad othera y1

Che0othera y• Sta)e I - Pall at ve

only• < yr surv val

Stage I ;&%

Stage II '5%

Stage III &/%

Strage I! (0%

Poly cyst c ovar an



Poly cyst c ovar ansyndro0ePCOS

PCOS



• ary n) de)rees• +n$no#n aet olo)y•

Cl n cal s )ns- Ol )o0enorrhoea - Obes ty - H rsut s0

Endocr ne 0easure0ents



• Increased .H1 .o# ,SH---; ncreased.H ,SH rat o

• Increased testosterone• 5ecreased SHBG• Insul n res stance and 0 a red )lucose

tolerance2 (!!?%•

@oderate hy er rolact nae0 a-occas onally

+SS assess0ent



• Increased ovar an volu0e• ! -!< 0 crocysts ! 00 n d a0eter• UStr n) o* earls

PCOS



PCOS



5 a)nos s can be 0ade * has " o* 6• Cl n cal *eatures• Endocr ne :nd n)s• +SS :nd n)s

Treat0ent



• /e )ht loss• @et*or0 n• .aser R *or h rsu t s0• COC3 @ rena3 5e o rovera• ,ert l ty R # th clo0 d



Ecto c

re)nancy

Ecto c re)nancy



I0 lantat on outs de uterus!2"? o* re)nanc esInc dence r s n)• Tubal -= ?• Cerv• Ovary• Per toneu0• &bdo0 nal

R s$ *actors



• STI1PI5• I+51@ rena• Prev ous Ecto c• Ster l sat on1 Tubal Sur)ery• &ss sted re roduct on

Presentat on



• &0enorrhoea3 've re)nancy test• Ty cally at A-8 #$s )estat on• 7o sy0 to0s• Pa n (.I,1RI,1Shoulder t % -= ?• P s ott n)- ?• ,a nt3 colla se3 hae0odyna0 c

co0 ro0 se -!<?

5 a)nos s



• Cl n cal ( er ton s03 adne al 0ass3unstable%

• Seru0 HCG trac$ n)• T +SS (no I+ re)nancy3 adne al 0ass3

*ree Du d%• .a arosco y

T +SS



@ana)e0ent



• I &ccess3 ,BC3 GKS1 J-0atch• Resusc tat on * reFu red• &nt 5 * Rh-ve• Sur) cal vs @ed cal vs Conservat ve

Sur) cal



• .a arosco cSal n)ecto0y

• &ny s )ns o*ru ture

• .a aroto0y• Chec$ other tube

s not da0a)ed

@ed cal• @ethotre ate < 0)10"



@ethotre ate- < 0)10"• @ust :t cr ter a and be

co0 l ant to *ollo# u• Chec$ +KE s and .,T s• HCG trac$ n)- 0ay n t ally r se• <-! ? reFu re sur)ery•

7o re)nancy *or 6 0onths• &vo d alcohol1 sunl )ht



,ollo# u 1 ,uturere)nanc esA # $ * ll #



)• A #ee$ *ollo# u a t• 5e br e* • Good contrace t on• S n)le ecto c- A - ? # ll have I+

re)nancy• SubseFuent re)nanc es ! -!<? # ll be

ecto c•

obs and gynae revision lecture

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