OBGYN Review File (Final) - KSUMSC

OBGYNReviewFile(Final)

References

• Doctors’slidesandnotes• Kaplannotes• 435teamwork• mededvideo

Doneby• AlluluAlsulayhim• EbtisamAlmutairi• HaifaAlwael• JawaherAbanumy• LailaMathkour• NadaAldakheel• RawanAlQahtani

Anatomyoffemalepelvic

FemaleExternalGenitalia(vulva)Bartholinglands• liesoneachsideofthevagina,intheposteriorlowerthird1/3oftheintroitus.• Secretemucus–alkaline• Bartholincyst:whentheorificeoftheBartholinductbecomesobstructed.Management

:isconservativeunlesspressuresymptomsoccurduetosize.• Bartholinabscess:itmayoccurduetoinfection(mostlycausedbyE.coliandanaerobic

Bacteroidesspecies,andseldomduetogonococcus).Management:OutpatienttreatmentisI&DwithplacementofaWordcatheterunderlocalanesthesia

InternalreproductiveOrgansVagina• Invaginaonlyknowtheepitheliumandacidity.• Thecoveringepitheliumofvaginaisnon-keratinizedsquamousepithelium,it'stough

whichleadtotheacidity• Thevaginaisacidic.IthaslowPH=4.5,soit'sverydifficulttogetbacterialinfections.Supportsofcervixanduterus• Cardinalligaments:ifthisligamentisaffectedthenitwillleadtouterineprolapse• Pubocervicalligaments• UterosacralligamentsEpisiotomyIndications:• fetalweightgreaterthan4kg• operativedelivery• shoulderdystocia• CrowningoffetalheadFetalCirculation• Theumbilicalvein,carryingoxygenatedbloodfromtheplacentatothefetalbodythroughthe

ductusvenosus,whichdirectlyenterstheinferiorvenacava• IVC→cristadividens→rightatrium→foramenovale→leftatrium→leftventricle→

ascendingaorta→brain,heartandupperlimbs• SVC+IVC→rightventricle→ductusarteriosus→descendingaorta→visceraandlowerlimbs• Ductusarteriosus:shuntsmildlyoxygenatedbloodfrompulmonaryarterytodescendingaorta• Ductusvenosus:shuntshighlyoxygenatedbloodfromumbilicalveintotheIVC,sothisstructure

carriesoxygentofetalorgans)

EmbryologyoftheFemaleGenitalOrgan• Gonads:Thegonadsdevelopfromthemesotheliumonthegenitalridge• Uterus&FallopianTubes:FusionofthetwoPMNducts(mullerianducts)• Vagina:Theupper2/3ofthevaginaformedbymulleriantubercle.Thelower1/3formedby

urogenitalsinus

CongenitalMalformationsoftheFemaleGenitalTract• 45XOembryotheovariesdevelopbutundergoatresia→streakovaries• MullerianAgenesis:Failureofmullerianductdevelopment→absenceoftheuppervagina,

cervixanduterus.ovariesarepresentbecauseovariesdon’tdevelopfromMullerianducts)IntersexualityCongenitalAdrenalHyperplasia(CAH):Deficienciesofvariousenzymesrequiredforcortisol&aldosteronebiosynthesis(21-hydroxylase).femalemaypresentatbirthwithambiguousgenitalia.Youwillfind17-α-hydroxyprogesterone↑.Tx:Cortisol.

Physiologyofmenstrualcycle

MenstrualcycleoccurswiththematurationoftheHypothalamicpituitaryovarianaxis.Thehormonesproducedincludegonadotropin-releasinghormone(GnRH)fromthehypothalamus,whichstimulatesfollicle-stimulatinghormone(FSH)andluteinizinghormone(LH)fromtheanteriorpituitary,whichstimulatesestrogenandprogesteronefromtheovarianfollicle.

• Ovary:functional&morphologicchangesresultinginfollicularmaturation,ovulationandcorpusluteumformation.

• Endometrium:functionalandmorphologicchanges,eithertoprepareitforconceptionorsheddingofthemenstrualendometrium.

• FSH:stimulatesthegrowthofgranulosacellsandinducesthearomataseenzymethatconvertsandrogenstoestrogens.

• LH:stimulatestheproductionofandrogensbythethecacells,whichthengetconvertedtoestrogensinthegranulosacellsbythearomataseenzyme.TheLHsurge,stimulatessynthesisofprostaglandinstoenhancefollicleruptureandovulation.LHincreasesinthepre-ovulatoryperiod.

Phasesofmenstrualcycle

Menstrualphase Duetostrongvasoconstrictionandproteolyticactivity,functionalstratumofendometrialtissuediesandisdischargedduringmenstrualbleeding

Follicularphase Duetotheriseoffolliclestimulatinghormone(FSH)duringthefirstdaysofthecycle,severalovarianfolliclesarestimulated

Ovulation Mostimportantevent:LHsurgesurge=suddenincrease.LHincreasesinthepreovulatorystage

Lutealphase HighlevelsofEstrogenandProgesteronesuppressproductionofFSHandLHthatthecorpusluteumneedstomaintainitself.

Physiologicalchangesinpregnancyhematologicalchanges:

• pregnancyishypercoagulablestate,soMoreriskforDVTsandPEs.• MinimalnormalHblevelforpregnantwomenis10g/dl.• physiologicalsystolicmurmurdevelopwhichdisappearsafterdelivery(Ejectionsystolic

murmur),whilearrhythmiasarepathological!• Peripheralresistancedecreases.Renalchanges:Dilationoftheureters,kidneypelvis&calyces.Endocrinechanges:• Prolactinlevel ↑untilthe30thweekofpregnancythenmore slowly toterm.

so,sometimesthepregnantladymaytellyouthatherbreastissecretingmilkandthatiscompletelynormal.

• enlargementofthyroidglandcausedbylowplasmaiodinelevels.• Thereisincreaseinweightofapproximately12.5kgatterm.

Gestationaldiabetesmellitus

• Gestationaldiabetesiscarbohydrateintolerancethatoccursinpregnancyafterthe24thweek

• PrevioushistoryofGDMisariskfactorforearlyscreeninginpatientswithmildcarbohydrateresistance.

• 2-h75gOGTTisthestandardofcaretestandwhat’scurrentlyusednowdaysforgestationaldiabetes.

• Afastingplasmaglucose>7.0mmol/L(126mg/dl)isdiagnosticofovertdiabetes.• ManagementbeforeconceptionindiabeticwomenincludecontrollingHbA1clevels• Iftheglycosylatedhemoglobiniselevated,orderafetalechocardiogramat22–24weeks

toassessforcongenitalheartdisease.EffectsofDMonpregnancy:Maternaleffects:• Thecesareansectionrateindiabeticpregnanciesapproaches50%becauseoffetal

macrosomia.• Injurytothebirthcanalsecondarytomacrosomia.Fetaleffects:• Hypoglycemiawhenbabyisexposedtohismom’shighbloodglucoselevels,he

produceslotsofinsulinsoassoonasthebaby’scirculationisdetachedfromhismotherhe’sexposedtohighinsulinanditcauseshypoglycemia.

• Hypocalcemiacausedbyfailuretoincreaseparathyroidhormonesynthesisafterbirth.• MostcommonfetalanomalieswithovertDMareNeuralTubeDefectsandcongenital

heartdisease.• Fetalsurveillanceformacrosomia

Anemiainpregnancy

• Serumirondecreases• TotalBindingIronCapacity(TBIC)increases• Instrictvegetarians,VitaminB12isalsodeficient.• ToconfirmIronDeficiencyAnemiayouneedtohave:decreasedIronandincreased

ferritin&transferrinlevels.• Anemiamanagement:Ifshe’slessthan30weekswegiveirontablets,butifmorethan

30weekswegiveironparenteraltherapyduringpregnancyPreconception,antepartum,intrapartumandpostpartumcare

Preconceptioncare• Womenshouldtakeadailymultivitamincontainingfolicacid(0.4mgperday)• womenwhohavehadaninfantwithaneuraltubedefect“highriskwomen”should

takevitaminsplus4mgoffolicaciddailybeforeconception.Highriskwomen:previousHxofNeuraltubedefectsorifsheisonanti-epilepticsorobese

• Rubella:ifthemotherIgG-vethensheshouldhavethevaccineandavoidpregnancyfor3months

Antepartumcare• Toxoplasmosis:ifthemotherIgG-vethensheshouldavoidpets,cookhermeatswell.

Babywillhavebrainclassification,ventriculomegalyandseizure• Syphilis:babywillhave:Sniffles(rhinitis),Sabershin,Saddlenose,Hutchinson'Steeth• Rubella:babywillhaveblueberrymuffin(petechiaeorpurpura),cataracts,congenital

heartdefect,hepatosplenomegalyanddeafness• Herpes:ifthemotherhasactiveherpesdeliverwithC/S.congenitalherpesare:IUGR,

pretermandblindness• Smokingincreasestheriskof:Miscarriage,placentalabruption,Growthretardation,

SuddenInfantDeathSyndrome,birthdefectandpretermdelivery.• Estimateddateofdelivery:Add7daystothefirstdayofLMP,subtract3months,add

oneyearIntrapartumcare

• Labor:progressivecervicaleffacementanddilationresultingfromregularpainfuluterinecontractions

• Falselabor“Braxton-Hickscontractions”:Painless,irregularcontractionswithoutcervicaldilatation&effacement.

• Station:isthefetalpresentingpartinrelationtoischialspine• Signsofplacentalseparation:afreshshowofblood,umbilicalcordlengthens,the

fundusoftheuterusrisesupandtheuterusbecomesfirmandglobular.Postpartumcare• ifthepatienthasperinealpainthemostimportantDDxis:1-hematoma:ifitissmall

thenleaveitandgiveanalgesia,ifitisbigandbleeding(youwillseevitalabnormalityandthesizeisbig)thendodrainage2-tightsuturethenletheruseheatlampandsitzbath

• RhoGAM:IfthemotherisRh(D)negative,andherbabyisRh(D)positive,sheshouldbeadministered300μgofRhoGAMIMwithin72hoursofdelivery.

AntenatalfetalassessmentIndicationforantepartumfetalsurveillance:• Maternal• Pregnancycomplication:(decreasedfetalmovements“mostcommonindication‘,IUGR)LatePregnancyAssessment:1-Fetalmovementcounting(kickchart):• Started~28winnormalpregnancy,~24winhighriskpregnancy.

o CARDIFFTECHNIQUE:10movementsin12hourso 2-SADOVSKYTECHNIQUE:4movements/hour

2-Contractionstresstest(CST):Atleast 2uterinecontractionsover20minutes.3)Nonstresstest(NST):• Thefirststepintheassessmentoffetalwell-beingistheNST.• Reactive:

o Atleasttwoaccelerationsfrombaselineof15bpmforatleast15secwithin20minuteso “<32weeks,≥10beats/min,lasting≥10s”

• Non-reactive:Noaccelerationfor40min>contractionstresstestorbiophysicalprofile4-Amnioticfluidindex(AFI)• Normalvalue:5-25cm• <5cm(urinarytrackanomalies,renalperfusion)• >24cm(GItrackanomalies,decreasedfetalswallowing)5)Biophysicalprofile(BPP):CombinesNSTwithUSS estimationAFV, fetalbreathing, bodymovementreflex/tone/extension-flexionmovement.6-DopplerVelocimetry:DopplerstudiesaremostlyvaluableforIUGRInterpretationofCTG:

FHRBaseline Normal Baseline110–160bpm“Severe”bradycardia<100bpmTachycardia>180bpm

Acceleration Accelerationsarealwaysreassuring.

Deceleration Early=HeadcompressionLate=uteroplacentalInsufficiencyVariable=Cordcompression

Tachycardia Chorioamnionitis,Mimeticdrugs

InvasiveFetalAssessment:AMNIOCENTESIS• Doneafter15w• Indications:Bilirubinlevel(inRH-isoimmunisation)CHORIONICVILLUSSAMPLING• Theprocedureofchoiceforfirsttrimesterprenataldiagnosisofgeneticdisorders.• Usuallydoneafter10w• Complication:limbdefects,fetallossCORDOCENTESIS:Usuallydoneafterthe1sttrimester(after13weeks)

AbnormalPresentation

Terminology• Lie:relationshipoflongitudinalaxisoffetustolongitudinalaxisofmother.Canbe:

longitudinal,transverse,oroblique.• Attitude:relationofthefetalpartstoeachother.Canbe:vertex(maximalflexion→

mostcommon),brow(partiallyextended),face(maximalextension).• Position:relationoffetalpartstomaternalbonypelvis.• Station:cmaboveorbelowischialspine.• Presentation:partofthefetusthatoccupiesthepelvis.Canbe:cephalic,breech,or

shoulder.• Landmarksofdifferentpresentations:Vertex→occipitalbone/Face→mentum"chin"

/Brow→frontalbone.

AbnormalfetalpresentationBreech(mostcommon)presentation• Types:complete,frank,footling(dangerous;riskofcordprolapse).• Causes:

o Maternal:pretermlabor(mostcommoncauseofbreech),fibroid,uterineanomalies,smallpelvis.

o Fetal:multiple,placentaprevia,oligo/polyhydramnios,shortumbilicalcord.

• Management:o Before36weeks→waitforspontaneousturningofbaby.o After36weeks→shouldbeofferedoptions:

§ Vaginalbreechdelivery(VBD):lithotomyposition→afterbuttocksprotrudesfromvulvadoepisiotomy→deliverbodythenhead.

§ Externalcephalicversion(ECV):ü doneafter38weeks,ifmumrh-vegiveanti-D,ü Contraindications:contractedpelvis,scaruterusfromprevC/Sor

myomectomy,placentaprevia.ü Complications:membranerupture,uterinerupture,abruptio

placenta,cordprolapse.§ ElectiveC/S

Facepresentation• Causes:unknownpossiblyexcessivetoneofextensormusclesoffetalneck.• Diagnosis:duringlaborbypalpatingnose+mouth+eyesinvaginalexam• Management(modeofdelivery):

o Mento-anterior→vaginaldeliveryispossibleusingforceps.o Mento-posterior→caesarean.

Browpresentation• Diagnosis:duringlaborbypalpatinganteriorfontanelle+supra-orbitalridge+noseon

vaginalexam.• Management:deliverybycaesarean(b/cpresentingdiameteris13.5cm“mento-

vertical”whichisincompatiblewithvaginaldelivery).Shoulderpresentation• Causes:transverseorobliquelie,placentaprevia,highparity,pelvictumor,uterine

anomaly.• Management:

o Intactmembrane→ECVmaybeattemptedifnootherpathology.o Rupturedmembrane→deliverybyemergencycaesarean.

ThromboembolicDisease

• DupplexDoppler,x-rayvenogram&V/Qscanarethemaindiagnostictools.• Duringpregnancy,LMWHisthepreferredanticoagulantasitismoreeffectiveandsafer

thanstandardheparin.Oralanticoagulantiscontraindicated.(Ifsheisonwarfarinswitchtoheparin)

• Oralanticoagulantsshouldnotbegivenatanystageduringpregnancybuttheyaresafe&maybemoreconvenientafterdelivery.

Bleedinginearlypregnancy(abortion)

• Femalepresentswithvaginalbleedingin1sttrimester:o Ddx:spontaneousabortion,viableintrauterinepregnancy,ectopicpregnancy.o Assessment:

§ serialβHCG(if↑50%in48hours=viable)§ transvaginalUS(todeterminesiteofpregnancy)

Cervixopen Cervixclosed

Productspassed Incompleteabortion Completeabortion

ProductsNOTpassed Inevitableabortion Missedabortion

• Spontaneousabortionislossofpregnancybefore20weeksgestation.• Causes:

o 1sttrimester:chromosomalabnormalities→↑with↑maternalage.o 2ndtrimester:maternalsystemicdisease,antiphospholipidsyndrome,abnormal

placenta,anatomicreasons,cervicalincompetence(hxofcervicalconebiopsy).o Otherriskfactors:historyofabortion,smoking,uncontrolledDM.

• Types:o Threatenedabortion:bleeding+closedcervix+viableintrauterinepregnancy

(intactsac+normalfetalheart).o Inevitableabortion:bleeding+crampinglowerabdominalpain+cervicopen.o Missedabortion:vaginalbleeding+closedcervix+USshowslongfetalsacwithno

fetalheartactivity⇒needsevacuation(D&C)• Treatment:

o Conservative/expectantmanagement:watchandwait.o Medical:vaginalmisoprostol(usedtoinducelabor)o Surgical:D&Co REMEMBERtogiveRhoGAMtoRh-vewomen.

• Complications:hemorrhage,endometritis,septicabortion.• Furtherinvestigations:ifrecurrent2ndtrimesterabortions→Hysterosalpingogram.

Multiplepregnancies

Types:• Zygosity:

o Dizygotic“fraternal”:morethan2eggsfertilized.o Monozygotic“identical”:splittingofovumafterfertilization.

• Chorionicity:chorionic(#ofplacenta)vsamniotic(#ofsac)

o Dichorionic-diamniotic→divisionoccurs0-3days.o Monochorionic-diamniotic→divisionoccurs4-8days.o Monochorionic-monoamniotic→divisionoccurs6-12days.o Conjoined/Siamesetwins→divisionafter12days.

Complications• Maternal:anemia,hyperemesisgravidarum,preeclampsia,GDM,hydramnios,C/S,

uterineatony&postpartumhemorrhage.• Fetal:congenitalabnormalities,IUGR,placentalabruption,cordentanglement(mono-

mono),malpresentation,prematurity,placentaprevia,cordprolapse.• TTTS(twin-to-twintransfusionsyndrome)inmonochorionic→imbalanceofbloodflow

b/wAVcommunicationsleadingto:o Onebaby“donor”=underperfused(hypovolemia,hypotension,oligohydramnios,

anemia,growthrestriction)o Otherbaby“recipient”=overperfused(hypervolemia,hypertension,

polyhydramnios,cardiomegaly,thrombosis,edema,ascites).

Management• EarlyUSisdiagnostic(showsnumberoffetuses).• TodeterminechorionicitydoearlyUS(lambdasign→di-ditwins).• Monitoringisimportant!Bothmother(BP,GDM)andbabies.• Management:

o Adequatenutritionformother=iron+folate+calcium.o ThemodeofdeliverydependsonGA,chorionicity,presentation,etc..o Mo-moarealwaysdeliveredpreterm(32-34W)duetoriskofcordentanglementby

C/S+betamethasone.o Di-mo(at34-37+6W)anddi-di(canreachupto38weeks)canbedeliveredeither:

§ Vaginallyifcephalic-cephalic(mostcommonpresentation)orcephalic-breech.§ C/Sifbreech-breechorbreech-cephalic.§ Notethatthefirstfetustobedelivereddeterminesthemodeofdelivery.

PreEclampsia/Eclampsia/GestationalHTN• Preeclampsia:Onsetofhighbloodpressure(>140/90)after20weeksgestationwith

proteinuria(+1dipstickor300mg/dl)orendorgandysfunctionorwithoutproteinuriawithpresenceof1ormoreofseverpreeclampsia

• Eclampsia:presenceofnew-onsetgrandmalseizuresinawomanwithpreeclampsia• chronichypertension:knownhypertensionbeforepregnancyordevelopmentofhypertension

before20weeks’gestation.• superimposedpreeclampsia:thosewomenwithchronichypertensionwhodevelopnewonset

proteinuria.• gestationalhypertension:hypertensionwithoutproteinuriaorothersignsoforgandysfunction

firstappearsafter20weeks’gestationorwithin48to72hoursofdeliveryandresolvesby12weekspostpartum.

• Severpreeclamisa:thrombocytopenia,DIC,elevatedtransaminasesorothersignsofhepaticinjury,CNSsymptoms,anelevatedserumcreatininelevel,pulmonaryedema

Management

• PreeclampsiaGestationalage37ormore→delivery• severepreeclampsiaoreclampsiawhosediseasepresentsatorbeyond34weeks’gestation→

delivery• Severepreeclampsiapresentingatlessthan34weeks’gestation

o seizureprophylaxis:magnesiumsulfateIV,IMo controlofhypertension(Arterialbloodpressure≥160mmHgsystolicor≥110mmHg

diastolicmustbetreatedimmediately)§ Hydralazine:thebest§ LabetalolHydrochloride:Avoidifevidenceofasthmaoracuteheartfailure.§ Nifedipine.

• Eclampsia:Treatmentforseizureismagnesiumsulfate&deliveryofbaby.• Chronichypertension

o Methyldopaisthesafestantihypertensivemedicationinpregnancy.o calciumchannelblockers.o labetalol

Posttermpregnancy

• Definition:pregnancyreachingorextendingbeyond42weeksofestimatedgestationalage.

• Mostcommoncause:incorrectestimationofgestationalage.• Complications:

o Maternal:vaginaltrauma,caesareansection(andsubsequentcomplications:infection,bleeding,thromboembolicevents,visceralinjury),postpartumhemorrhage.

o Fetal:§ Macrosomia:>4.5kg→↑riskofC/S,shoulderdystocia.§ Postmaturitysyndrome:duetoinfarctionofplacenta→decreasefetal

subcutaneousfat+drywrinklyskin+longfingernails.§ Meconiumaspirationsyndrome:leadingtochemicalpneumonitis,mechanical

obstruction.§ Oligohydramnios:babyprioritizesbloodtobrain&thusdecreaseurine

production.§ Intrauterinefetaldemise(UFD)increasesafter41weeks.

• Intervention:o Firstwemustaccuratelymeasuregestationalage.o Membranesweeping→releaseprostaglandinsthatincreasechanceof

spontaneouslabor.o Fetalsurveillanceshouldbeginat41weeks“expectantmanagement”o Inductionoflaborshouldoccurbetween41&42weeks.

InductionOfLabor(IOL)

• Risks:Abnormalfetalheartratepatterns,Deliveryofpreterminfantduetoincorrectestimation

ofGA,Meconiumfetalaspiration• Indications:Post-termpregnancy,IUGR,Non-reassuringfetalsurveillance,Maternalmedical

conditions(DM,renaldisease,HPT,gestationalHPT),Fetaldeath.• Contraindications:Previousmyomectomy,Fetaltransverselie,Placentaprevia,VasapreviaMethodsofIOL• Ifthecervixisstillunfavorable:cervicalripeningwithprostaglandinE1orE2• Consideramniotomy+oxytocinonlyifthecervixispartiallydilatedandcompletelyeffaced,and

thefetalheadiswellapplied

IUFDManagement

Watchfulexpectancy

• About80%ofpatientsexperiencethespontaneousonsetoflaborwithin2to3weeksoffetaldemise.

• Rarecomplicationsincludeintrauterineinfectionandmaternalcoagulopathy

Inductionoflabor(IOL)

• Indications:emotional,thoseinriskofchorioamnionitis,IUFD>5weeksFromweek12-28• VaginalsuppositoriesofprostaglandinE2(dinoprostone)

o contraindicatedinpatientswithprioruterineincisions,patientswithhistoryofasthmaoractivepulmonarydisease

• Misoprostol

• After28weeks• ifthecervixisfavorable:Misoprostolfollowedbyoxytocin

OperativeDeliveries• Instrumentsusedinoperativevaginaldelivery:ForcepsandVacuum(ventouseextractor)• Thevacuumextractoriscontraindicatedinpretermdelivery

Indicationsofoperativedelivery• Maternalo Prolongedorarrested2ndstagelaborepicallyinMaternalcardiacdiseaseo Poormaternalefforto Patientswithretinaldetachmentorpostopforsimilarocularconditions.

• Fetalo Fetaldistresso Prematurity(useForcepsonly)o Certainmalpositionse.g.occipitoposterior

PrerequisiteforforcepsandventouseCervixhastobefullydilated+Membranesruptured+Headhastobeengaged(0station)+Headpositionknown+Vertex(cephalic)presentation.ComplicationsofInstrumentalDelivery

Genitaltractlacerations(Cervix,vagina),maternalHemorrhage,FacialPalsytothefetus

PuerperalsepsisCommonpostpartuminfections

Riskfactors Causes Clinicalfinding Management

Urinarytractinfection

Foleycatheterorvaginalprocedure

Normalbowelflora

• Highfever• Costovertebral

flanktenderness• Positiveurinalysis

Nitrofurantoin&cephalosporins

Woundinfection Emergencycesareansectionafterprolongedruptureofmembraneandprolongedlabor

StreptococcusStaphylococcus

Persistentspikingfeverdespiteantibiotics.

Cephalosporin

Mastitisorbreastabscess

Breastfeedingwomen S.aureus • Feverofvariabledegree

• localized,unilateralbreasttenderness.

7-10daysofDicloxacillin

Endometritis • Cesareansection• ProlongedROM• Prolonginternal

fetalmonitoring

polymicrobialinfections

gentamicin&clindamycin

RhesusIsoimmunizationRequirements1. Mothermustbeantigennegative2. Babymustbeantigenpositive.(Sofatheris+).3. AdequatefetalRBCsmustcrossoverintothematernalcirculation4. AntibodiesassociatedwithHemolyticdiseaseofthenewborn(Erythroblastosisfetalis)5. Asignificanttiterofmaternalantibodiesmustbepresenttocrossoverthefetus(>1:8)DetectingFetomaternal/TransplacentalHemorrhageKleihauer-Betketest:ThiscanassesswhethermorethanonevialofRhoGAMneedstobegivenwhenlargevolumesoffetal–maternalbleedmayoccur(e.g.,abruptioplacentae).

TechniquestoEvaluateFetalRhStatus• MCAdoppler(mostvaluabletodetectfetalanemia)• Amnioticfluidspectrophotometry(besttoestimatefetalbilirubinconcentration)• Percutaneousumbilicalbloodsampling(PUBS)→wecanmeasurefetalHb,Hct,bloodgases,pH,

andbilirubinlevels.ManagementPlan/Approach• Fetalriskispresent(haveallrequirements)butnosevereanemia:1stpregnancygiveRho-GAM,

not1stpregnancyjustwaitandwatch• Atypicalantibodytiter(1:8):managementisconservative.RepeatthetiterMonthly(2to4

weeks)aslongasitremains<1:8.• Severeanemia(PUBSshowsfetalhematocrittobe≤25%orMCAflowiselevated):Intrauterine

transfusion(freshORh-)• Timingofdelivery:• Deliveryisperformedifgestationalageis>34week.• Ifdeliveryisexpectedtooccurbefore34weeks’gestationbetamethasoneshouldbegivenat

least48hoursbeforedeliver• Rho-GAM• AspreventioninpregnantwomanwhenthereissignificantriskoffetalRBCspassingintoher

circulation• Uncomplicatedpregnancy(ifsheisRh-andtiteris<1:8):300μgofRhoGAMprophylactically.• Within72hof(deliveryofanRh(D)-positiveinfant,chorionicvillussampling(CVS),orD&C)→

300mcgofRhoGAM• AllpregnantwomenwhoareRhD-veandAntiD-veandexperience→(spontaneousorinduced

abortion,ectopicpregnancy,significantvaginalbleeding,abdominaltrauma,orexternalcephalicversion)shouldreceive50to100μgbefore12weekofgestationand300μgafter12week.

• “partial”molarpregnancy.

PROM• Prematureruptureofthemembranes(PROM):Prematureruptureofmembranesbeforethe

onsetoflabor• pretermPROM(PPROM):Pretermprematureruptureofmembranesoccurringbefore37weeks

estimatedgestationalageDiagnosis• onphysicalexam:Asterilespeculumexamination(poolingtest)+Anultrasoundshouldbe

performedtoassessfetalpositionaswellastoassesstheamountofamnioticfluid• confirmation:Nitrazinepaperwhichwillturnblue+Ferning• Chorioamnionitisisdiagnosedclinicallywithallthefollowingcriterianeeded:Maternalfeverand

uterinetenderness,purulentfluidfromcervicalosandmaternalleukocytosisandmaternaltachycardia.

Management• Ifthepatientisterm>37weeks:Ifthepatientdoesnotgointospontaneouslaboron

herownthenlaborinductionshouldbeperformedwithoxytocin.• from34to36weeksandsixdays:Aninductionoflaborhasstartedforthesepatients

onceruptureofmembranesisconfirmed.Ifthefetusisbreachthenacesareansectionwillhavetobeperformed.SomanagementexactlysameastermPROM.

• between24weeksand33and6days:inpatient+Corticosteroids+Tocolytics+Antibiotics.Deliverywillbeinducedbetween32and34weeks

• PROMoccurslessthan(<23wofGA):Eitherinducelaborormanagepatientwithbedrestathome.

• Chorioamnionitis:delivery

Pretermlabor• Deliverybetween24-37wksofEGAthatincludeuterinecontractions+cervicaldilation(atleast

2cm)orchangeinserialexamination(indilationoreffacement).• Evaluations:Vaginalexamination→cervicallength,dilation,station,presentation.Swap/Culture

forpresenceofGroupBstrep.• Diagnosis:TrueUterinecontractions→4/20min.(Poorindicatorofpretermlabor).Cervical

changes→80%effacementor2cmdilation.(Goodindicator)Management• Hydrationandbedrest• Antibiotic• Ifapatientdoesn’trespondtohydrationandbedrest,giveTocolytictherapy.• Betamethasoneif<34w.• DeliveryinPretermlaborisusuallyvaginally(normallyorusingoutletforceps),exceptforverylow-birthfetuses(↓1500g)wherecesareandeliveryisbetter,asin28wks.breechpresentation.

• HxofpretermlabororHxofshortcervix:Progesterone• Ifpatientis24-34weeksEGA:Corticosteroids:Mostimportanttoreducetheratesfor

Respiratorydistresssyndrome,Intracranialhemorrhage,Necrotizingenterocolitis,anddeath.

Bleedinginearlypregnancy(Ectopic)

• Definition:implantationofembryooutsidetheuterinecavity(mostcommonlyfallopiantube,specificallydistalampulla).

• Riskfactors:PID(x3),historyofectopic,historyoftubalsurgery,historyofchlamydiainfection,smoking,idiopathic,IUCD.

• Presentation:amenorrhea+unilaterallowerabdominalpain+vaginalbleeding.• Investigation:serialβHCG(noorpoorincreaseinlevels)+vaginalUS(absenceof

intrauterinepregnancy).• Management:

o Medical→methotrexate.§ Absolute#:hemodynamicinstability,liver/kidneydisease,lungdisease,breast

feeding,notcomplyingw/followupβHCGtesting.§ Relative#:fetalcardiacactivity,largeectopic>3.5cm,highβHCG>5000mIU.

o Surgical:§ laparoscopy(better)orlaparotomy(reservedforruptured)

§ salpingostomy(onlyremovingectopicpregnancy/mayrecur)orsalpingectomy(removalofentiretube/betterifothertubeisnormal).

3rdtrimesterbleeding• Placentalabruption(painfulvaginalbleeding)“mostcommon”

o Riskfactors:trauma,cocaine,HTN,multiplegestations,prevhxofabruption.o Diagnosebyclinicalexamination.

• Placentaprevia(painlessvaginalbleeding)o DiagnosebyUS(digitalcervicalexamis#).o Riskfactors:prev.C/S.historyofmyomectomy,multiparous,advancedage,

smoking,multiplegestations.o Management:modeofdeliveryisC/S.o Complications:bleedingorextensionofplacentaltissue(accreta,increta,

percreta)mayrequirecaesareanhysterectomy.o Vasaprevia(fetalbloodloss→canleadtoantepartumhemorrhage+fetal

death)• Note:Kleihauer-betketestcandetermineifbabyormotherisbleedingbydetecting

fetalerythrocytesinmaternalblood.

IntrauterineGrowthRestriction(IUGR)IUGR:estimatedfetalweight(EFW)<5−10%ileforgestationalage.Orbirthweight<2,500gramTypes:1-SymmetricIUGR:• Headandabdomenbothsmall• Etiology:Fetal(decreasedgrowthpotential)• causes:aneuploidy(T21,T18,T13);infection(TORCH/alsocouldbemalaria.),structural

anomalies• Workup:detailedsonogram,karyotype,andscreenforfetalinfections2-AsymmetricIUGR:• Headnormal,abdomensmall• Etiology:Maternal+Placental• Placental:primaryplacentaldisease),infarction,abruption,TTTS,velamentouscordinsertion.• Maternal:hypertension,smallvesseldisease(SLE,ChronicDM1),malnutrition,tobacco,alcohol,

streetdrugs,antiphospholipidsyndrome,Infections,Teratogenexposure.• Workup:Monitoringiswithserialsonograms,non-stresstest,AFI,biophysicalprofile,and

umbilicalarteryDopplersDiagnosis:

• Screeningtoollow-riskwomenistheassessmentofuterinesizebyfundalheightmeasurement.• Ultrasonographyisthegoldstandardtoassessfetalweight• Doppler(umbilical,uterinearteryS/Dratio,MCA).• Absent/reversedend-diastolicflowpredictsworseprenataloutcomesanditsusuallyan

indicatorfordelivery.Antepartumcare:• Fetalmonitoring->normal.DOUltrasonography->• normalgrowth=noclinicalintervention.• abnormalstronglysuggestsIUGR->deliveryisindicatedatgestationalagesof34weeks.• assessPulmonarymaturitybyamniocentesis,butIfsevereoligohydramnios->deliveryshould

bestronglyconsideredwithoutassessmentoflungmaturity.• .ambiguous(equivocalforIUGR->bedrest(w/kickcounting),fetalsurveillance,andserialU/S

measurementsat3-weeklyintervals.Afterbirth:• Examine:toruleoutcongenitalanomalies,chronicinfections.• Monitor:(hypoglycemia,hypothermia,Respiratorydistresssyndrome)Macrosomia:• >90−95%ileforgestationalage.Or(EFW)4000-4500grams• management:Electivecesarean(ifEFW>4,500gindiabeticmotheror>5,000ginnondiabetic

mother).

PostpartumHemorrhage

• vaginaldeliverybloodloss≥500mLorcesareansectionbloodloss≥1,000mLClassifications:• Primary:99%happensonlyinthefirst24hofdelivery.Secondary:After24h.

Signs Management

Uterineatony Enlargedfloppy,softuteruslikeadough

Uterinemassage,Oxytocin,ergot,Carboprost.OrSurgeryiftheabovedidn'twork>B-lynchsuture,uterinearteryligationofInternaliliac,embolization.

Lacerations Usingvaginaldeliveryinstrumentswiththepresenceofacontracteduterus.

Suturing&repair

Retainedplacenta Missingplacentalcotyledons Uterine curettage. Ormanualremoval

DIC bleedingfromIV/venipuncturesites

Correctionofcoagulopathy

Uterineinversion Beefy-appearing,andfailuretopalpatetheuterusabdominally

elevatingthevaginalfornicesandliftingtheuterusbackandoxytocin.

Preventionofuterineatonybyactivemanagementofthirdstageoflabor:fundalmassage,gentlecordtraction,IV/IMoxytocin.

PubertyDisorderCentralprecociouspuberty(CPP)• CPPisphysiologicallynormalpubertaldevelopmentthatoccuratanearlyage.• Causes:Idiopathic,CNStumors,CNSdysfunction• Investigations:IncreasedLH:LH/FSHratio>1→PubertalgonadotropinresponseCPP.GnRH

stimulationtest:highLH>FSH• Tx:ThetreatmentofchoiceisAGnRHAnaloguePeripheralprecociouspuberty/PseudoPP(PPP).• GnRHindependentDuetoinappropriatesexhormonesecretionorexposuretoexogenoussex

steroids.• Causes:Abnormalsecretionofgonadotropins,Functioningovariantumorsorcyst,Congenital

adrenalhyperplasia• Investigations:DecreasesLH:LH/FSHratio<1→Prepubertalgonadotropinsecretion(PPP).

GnRHstimulationtest:FSH>LH• Tx:Treatthecause.

AmenorrheaPrimaryamenorrhea• ifBreastspresent,uteruspresentmostcommolyitisimperforatehymen• ifBreastspresent,uterusabsent.DifferentialdiagnosisisMüllerianagenesisorcomplete

androgeninsensitivity• ifbreastisabcentanduterusispresent:oneofDDxisTurner’ssyndrome(45x0)→gonadal

dysgenesisSecondaryamenorrhea• Asherman’ssyndrome:SecondaryamenorrheafollowingdestructionoftheendometriumBy

overzealouscurettage• Prematuremenopause:Ovarianfailure• Hyperprolactinemia:duetopituitaryadenomaseenonMRI.Tx:Bromocriptine• Sheehan’ssyndrome:Necrosisofant.pituitaryduetoseverepostpartumhemorrhage,Bcof

panpituitarismtheprolactinmaynotsecreted→unabletobreastfeedInvestigationofsecondaryamenorrhea

• PregnancyTest.Thefirststepinmanagementofsecondaryamenorrheaistoobtainaqualitativeβ-hCGtesttoruleoutpregnancy.

• ProgesteroneChallengeTest(PCT):+vemeansanovulation(e.g.PCOS)• Estrogen–ProgesteroneChallengeTest(EPCT)

o ElevatedFSHsuggestsovarianfailure(e.g.prematuremenopause)o LowFSHsuggestshypothalamic–pituitaryinsufficiency(e.g.pituitarytumors)o –veEPCTmeansabnormalflow(e.g.Ashermansyndrome)

PelvicInflammatoryDiseases(PID)• Ascendingmicroorganismsfromvagina&endocervixtoendometrium,tubes,contiguous

structures.N.Gonorrhoeae N.Gonorrhoeae

Gram–vediplococcus Intracellularorganism Producemildformofsalpingitis.

Rapidgrowth SlowgrowthRapidandintenseinflammatory

response Insidiousonset

• Signs&symptoms:Abdominalpain,AbnormalDischarge,Fever• Management:ceftriaxone+doxycycline±metronidazoleandtreatthepartner(Reinfectioncan

occurifmalepartnerisuntreated)

PolycysticOvarianSyndrome(PCOS)• Characterizedbyovulatorydysfunctionandhyperandrogenism.• asetofsymptomsduetoelevatedAndrogensinwomen.Biochemicalchanges:1. Raisedandrogenproduction.”testosterone”2. Peripheralinsulinresistanceandhyperinsulinemia3. Proposedmechanismforanovulationandelevatedandrogenlevelisduetoincreaselevelof

luteinizinghormone.Signsandsymptoms:• Menstrualdysfunction• Anovulation• Signsofhyperandrogenism(Hirsutism,acne,hairfall).• infertility.• ObesityInvestigation:LH,FSHlevels&ultrasounds&Endometrialbiopsy(malignancy)criteriaofdiagnosing:• Afterexcludingotherdiseases,wehavetofind2criteriafromthe3whichis: • anovulatorycycle(changeinmenstrualpattern).

• Hyperandrogenism(hirsutism,acne,Acanthosisnigricans,hairloss)orbiochemical• USshowspolycystic.Management:1. Lifestylemodificationisthefirstlineoftreatment2. Medicalmanagement:

o Menstrualirregularity:First-linemedicaltherapyisoralcontraceptiveo Anovulation:Clomiphenecitrateorletrozoleo Hypoglycemicagent:Metformino Topicalhairremoval:eflornithineo Topicalacneagent:benzoylperoxide,tretinointopicalcream

3. Surgicalmanagement:aimtorestoreovulation• Laparoscopically:(ectrocutare/Laserdrilling./Multiplebiopsy)

ContraceptionLongactingreversiblecontraceptionProgesteroneIUDSideeffect:lightermenstrualcycleoramenorrhea.CopperIUD:Sideeffectsincludeheavierandcrampierperiods.Implants:Sideeffectsincludeirregularbleedingspottingforthedurationofinsertion.• TheonlycontraindicationstoallIUDusearepelvicinfection,canceroftheuterus,ordistortion

orinappropriatesizeoftheuterinecavity.SterilizationMaleSterilization:• whetherrightorleftvasdeferensisligatedtopreventspermfromenteringtherestofthe

seminalfluid.• Semenanalysisiscollected4-3monthswith20ejaculatesFemaleSterilization• TubeLigationorHysteroscopytubeocclusion• Consoffemalesterilization:Ectopicpregnancy• Prosoffemalesterilization:Decreaselifetimeriskofovariancancer,Protectionfrompelvic

inflammatorydiseases.Estrogen-progesteronecontraceptives• Minipills(progesterone-onlypills)onlyworkefficientlywithregularandfrequentbreastfeeding.• increasestheriskofDVT• Contraindications:

o Migrainewithaurao Historyofbloodclotso Personalhistoryofbreastcancero Personalhistoryofliverdiseaseo Forwomenover35thelistalsoinclude:Smoking,HTNormigraine.

DepoProverainjectionsSideeffectsincludeAmenorrheaandanaverageof10poundsweightgain.Barriersfemaleandmalecondomsareprotectedagainstsexualtransmittedinfections.

EmergencyContraception• twopills0.75mgoflevonorgestrelwithin72hoursoftheintercourse.• ulipristalacetate30mganditcanbeusedupto120hoursaftertheintercourse.

Endometriosis

• Definition:Benignconditioninwhichendometrialglandsandstromaarepresent

outsidetheuterinecavityandwalls.• Occurrence:womenwithchronicpelvicpainhaveendometriosis.• Sitesofoccurrence:ovaries,Pelvicperitoneum→Posteriorcul-de-sac,Roundligament,

fallopiantube.• Symptoms:Dysmenorrhea+Dyspareunia+Dyschezia• Signs:

o fixednon-Mobileuterus.Secondarytoadhesions.o ovarianendometriosis(chocolatecyst)tenderbutnotpalpable.o uterosacralnodularity(classicsign).

• Diagnosis:2outof4o endometrialstromao endometrialglando endometrialepitheliumo hemosiderin-ladenmacrophages.

Management:• Medicaltherapy:EtherPregnancyIfWantedOrPseudopregnancyPseudomenopause.• Surgicaltherapy:Largeendometriomas(>3cm)areusuallyamenableonlytosurgical

resection.• Followup:itisNotmalignantbutassociatedwithhigherriskofovariancarcinomaby

mechanismwhichisnotclear.

Lowergenitaltractinfections

Vulvarvaginitis

Bacterialvaginosis(mostcommon)• Polymicrobialinfection→imbalanceofnormalaerobic&anaerobicorganisms.• Riskfactors:postmenopausalwomen.• Symptoms:thinwhitedischarge,fishyodor.• Diagnosis:wetmount(cluecellsw/stippledborder),pH>4.5,whifftest.• Treatment:metronidazole1stline(oralorvaginal),orclindamycin(vaginal).Vulvovaginalcandidiasis• Organism:candidaalbicans→mostcommon.• Riskfactors:DM,obesity,pregnancy,antibiotics,C/S,OCP,tightclothes.• Symptoms:thickwhitecheesydischarge,itching,dyspareunia.

• Diagnosis:wetmount(pseudohyphae,yeast),pH<4.5,+veyeastculture.• Treatment:fluconazole(antifungalsingledose),orvaginalmiconazole.Trichomoniasis• Organism:trichomonasvaginalis→facilitatestransmissionofHIV• Riskfactors:swimmingpools,hottubs,STDs.Associatedw/PID,endometritis.• Symptoms:yellowprofusefrothydischarge,malodorous,strawberrycervix.• Diagnosis:wetmount(flagellatedmotileorg.),pH>4.5,testforotherSTDs.• Management:metronidazole(1stline)+treatpartner.

DysmenorrheaPrimarydysmenorrhea

• Thesymptomstypicallybeginseveralhourspriortotheonsetofmenstruationandcontinuefor1to3days.

• SymptomsappeartobecausedbyexcessproductionofendometrialprostaglandinF2αresultingfromthespiralarteriolarconstrictionandnecrosisthatfollowprogesteronewithdrawalasthecorpusluteuminvolutes

• Treatment:NSAIDsarefirst-line.OralcontraceptivessecondlineSecondarydysmenorrheaCauses4. Endometriosis 5. Adhesions 6. PelvicInflammatoryInfection7. Adenomyosis 8. Leiomyomata 9. Polyps10. Cervicalstenosis 11. Tumors(benignor

malignant)orcysts

ManagementTreattheunderlyingcause

Menopause• Menopauseisdefinedas12monthsofamenorrhea,associatedwithelevationof(FSH,LH)• AtthetimeofmenopauseFSHconcentrations>30mIU/mlSignandSymptoms• Amenorrhea:Themostcommonsymptomissecondaryamenorrhea• Hotflushes:predictableprofusesweatingandsensationofheat• Increasedriskofosteoporosis

o WegiveCa2++vitaminD,encouragethemtodoweight–bearingexercise,stopsmokingandalcohol.WecouldgiveHRTorbisphosphonates(alendronate,risedronate)orSERM(raloxifene)

Management

SystemicHormonetherapy(HRT):Itisthemosteffectivetreatmentforhotflushes.Ifshehasauteruswegiveestrogen+progesterone(toprotectherfromendometrialcancer).Ifshehasnouteruswegiveestrogenonly.

PelvicFloorDisorders• Cystocele:Herniationorbulgingoftheanteriorvaginalwallandoverlyingbladderbaseintothe

vaginallumen.Triad:1-Postmenopausalwoman2-Anteriorvaginalwallprotrusion3-Urinaryincontinence

• Rectocele:Herniationorbulgingoftheposteriorvaginalwallandunderlyingrectumintothevaginallumen.Triad:1-Postmenopausalwoman2-Posteriorvaginalwallprotrusion3-Digitallyassistedremovalofstool

• Enterocele:HerniationofthepouchofDouglascontainingsmallbowelintothevaginallumen• Symptoms:Vaginalpressureorheaviness,Vaginalorperinealpainordiscomfort• Riskfactors:Onevaginaldeliveryormore,Pelvicsurgery,increasedintra-abdominalpressurePelvicOrganProlapseQuantificationexamination• Stage0:Noprolapse,thecervixorvaginalcuffisatthetopofthevagina.• StageI:Theleadingpartoftheprolapseismorethan1cmabovethehymen• StageII:Theleadingpartoftheprolapseislessthanorequalto1cmaboveorbelow

thehymen• StageIII:Theleadingedgeismorethan1cmbeyondthehymen,butlessthanor

equaltothetotalvaginallength• StageIV(Procidentia):CompleteeversionManagementKegelexercises+PessariesIncontinence

Stress

incontinence

Hypertonic(urge)

incontinence

Hypotonic(neurogenic)incontinence

Irritablebladder Fistula

Cause

MuliparityIncreaseabdominalpressure

Detrusormuscleoveractivity

AbsentDetrusormusclecontractionduetoneurologicalcause(MS,DM,trauma)

Inflammationcomingfromstone,UTIorcancer

Previousradiationorsurgeryonthepelvic.IBD(crohn)

Presentation

Urinelosswithincreasedintra-abdominalpressure

UrgencyNocturnalLeakofurine

Lossofurineintermittentlyinsmallamountsandpelvicfullness.

Frequency,urgency,dysuria

Contiousleakwithnormalfunction

Diagnosis

YoumayfindcystoceleQ-tiptest+veUrineanalysis–ve

PhysicalexaminationnormalUrineanalysis–ve

Physicalexamination:distendedbladder

Physicalexaminationisnormal

Youwillseethefistulaonphysicalexamination

Cystometry-ve

Cystometry:involuntarydetrusorcontractions

Urineanalysis–veCytometry:markedlyincreasedresidualvolume

Urineanalysis:WBCs,RBCsCytometry:normal

Treatment

KeagelPessariesSurgery(Tension-FreeVaginalTapeormmK)

Anticholinergicmedications:oxybutyninandtolterodine

Intermittentself-catheterization.Cholinergicmedications+α-adrenergicblocker

Treattheunderlysingcause

Surgery(fistuloectomy)

Infertility

FibroidTypesoffibroids• Intramuralisthemostcommontype&usuallyasymptomatic.• Subserosal,canbedescribedasnon-tenderfirmmass.Itssymptomsdependontheir

location(pressuresymptoms).

Infirtility

Testthemale(erection,flagellated,count)

Maleproblem

1- erectiledysfunction:council+PDE5Inhibitors2- countingandmotility:doartificialinseminationA- IUI(intrauterineinsemination)B- IVF(invirtofertilization)

Femaleproblem

Roleoutovulationproblem

Anovulation

Prolactinomaorthyroidproblem

PCOS

Normal

Check for↓ovarianreserve

Normal ↓ovarianreserve

AnatomyviaHSG

Normal Anatomyproblem

Diagnosticlaproscopy

Unexplaned Endometriosis

+ve -ve

+ve -ve

↑prolactinorTSH SignsofPCOS

Antimullerial hormoneFollicular countDay3FSH/estrdiol

+ve-ve

-ve +ve

-ve +ve

Treatmedically Giveclomiphene

NotreatmentL

Surgicalrepairorartificialinsemination

Doscop laserablation

Doartificialinsemination

Howtocheckforovulation?Basaltemperature

UrineLHDay22progesterone

• Submucosal,distorttheuterinecavity.Mostcommonpresentasmenorrhagiaormetrorrhagia.

• Othertypes,pedunculated&parasitic.Degenerationsoffibroids:• Reddegeneration,inpregnantwomen.extreme,acutepain,andnarcotics.Shouldbe

managedbyanalgesiainpregnant.Myomectomydoneafterpregnancy.• Calcificdegeneration,it'spotentialtobecomesarcoma.• Othersdegenerationslike,Hyaline,fatty,cystic,necrosis.DxofFibroidsHx&PE,US(abdominal&transvaginalUStoexcludeendometrialhyperplasia),CT&MRI.Hysteroscopy(forsubmucosalfibroids).Biopsy.Management.• Observationmostly.• Medicationsifsherefusedsurgery.Deprovera,GnRHanalogous,Danazol• Surgery,Myomectomy.Ifpatientwishestomaintainfertility.Hysterectomy,Ifpatient

hascompletedherchildbearing;definitivetherapyisanabdominalorvaginalhysterectomy.

• Embolizationifshewantstopreservetheuterus.

Abnormaluterinebleeding• menstrualflowoutsideofnormalregularity,frequency,volumeorduration.common

andcanrangefromcompleteabsenceofbleeding(amenorrhea)tolife-threateninghemorrhage.

EtiologyPALMCOEINacronymforAUBdifferentials.structural(PALM,mostcommoninperiandpost-menopausalwomen):• Polyp.• Adenomyosis.identifyinganenlarged,symmetric,tenderuterus.• Leiomyoma.• Malignancy.functional(COEIN,mostcommoninreproductivewomen):• Coagulopathy:mostcommoninadolescentwomenwhopresentswithheavybleeding.• OvulatoryDysfunction:PCOS(mostcommoncauseofovulatorydysfunction),STD.• Endometrialprocess:usuallyaffectedbyestrogen.• Iatrogenic.• Notyetclassified.EvaluationofAUB• Hx&PE.• Iftheperiodisirregular:ovulatorydysfunction.• Ifthereisbleedingbetweentheperiods:structuralcause• Heavyperiods:coagulopathy• Labs:Thyroid,CBC,Anemia,coagulopathy.

• EMBinhighriskwomen,likeDM,Obesity.• US.

ONCOLOGYREVISION(DonebyRawanALQahtani)

1. Cervical neoplasms:

• Howtoscreenforcervicalcancerandwhen?1. ByPapsmear:westartscreenthepatientattheageof>21yearsold,every3years.Until65yearsoldwhichis

theupperlimitbecausetheincidenceisnotsignificant.2. HPVtest:Itistheotherwayforscreening.westartscreenthepatientattheageof>30yearsold,every5years.

Why>30,Because80-90%ofthemwillbepositiveforHPVinfectioninpatients20-30yearsoldandtheywillclearitspontaneouslybytheirimmunesystems.Only10-20%theywillhavepersistentinfectionwhichwillprogressandchangetheirDNAandleadtotumorgrowth.ForthosewhohavepersistentHPVpositivewehavetodocolposcopytovisualizethecervix,ifwecannotseeanythingwewilltakerandombiopsytodetectanypremalignantlesion.

• HowHPVcausecarcinogenictransformation?Afterenteringourbody,ittargetsthecervicalcellsandstarttochangeDNAespeciallytwotumorsuppressorgenewhicharep53andretinoblastoma.SoViralproteincalledE6suppressesp53,whileE7suppressretinoblastomagene. Thesetwogeneswereimportantascheckpointwhichpreventandcorrectanyabnormalchangeincells.Soinhibitionoftumorsuppressorgenewillleadtocarcinogenesischanges.Thisprocesstakesfrom10-15yearstoyearstoprogressintocancerandneedlesstimeinimmunocompromisedpatients.

• HPVVaccine:o 99.9%ofcervicalcancerisHPVpositive,sothisistheonlycancerwhichweknowthecauseofitanditis

preventablebyHPVVaccine.o TherearedifferentoncogenestrainsofHPV,suchas16&18&31&33&45&52&58whichcause95%of

cervicalcancer.While6&11arebenignstrainwhichcausewarts.o Nowthelatestvaccine(Gardasil)covers9strainwhichare(16,18,31,33,45,52,58).o Someofstudiesshows93%decreasedtheincidenceofcervicalcancerwiththosewhohadhighgradelesion.

Whichmeanyouprevent93%ofpeoplewithhighgradelesiontoprogresstocancer.o Patientswhoare+veoralreadyshowdysplasiacanstillreceiveHPVvaccine,asitcanprotectthemfromother

strainsofHPV.o Insomecountrytheyvaccinatedbothfemaleandmale.

• Whataretheexpectedresultsfrompapsmear?o Normal(Iwillrepeatitevery3year)o Cancer:(Squamouscellcarcinoma(70%)orAdenocarcinoma(20%)whichismoreaggressiveandcomefromthe

canal)o precancerousabnormality(DYSPLESIA),

§ Highgrade(HSL).§ Lowgrade(ASCUS&LSL){ASCUS=Atypicalsquamouscellofundeterminedsignificant,thisisthemost

commonabnormalityinpapsmear,andtheonlyindicationforHPVtestwithbestadvantageandcosteffectivewaytoscreenthepeoplewithASCUSbyusingHPVtestsoanypatientwithASCUSitisworthtoscreenthemwithHPV}.ü Ifitwaspositive,wegotocolposcopy.ü Ifitwasnegative,wegotonormalscreeningevery3years.

• What wewilldonextincaseofabnormalfindinginpapsmear?

WewillgoforcolposcopytovisualizethecervixIfshowsalesionyoucantakeintralesionalbiopsy.Ifnot,takearandombiopsy.

o IftheywerenegativeorlowgradesuchasCIN1,reassurethepatientandfollowherafter6months.o IftheywereCIN2orCIN3,wehavetodosomethingadditionaleitherconebiopsyorLEEP.Lookingformargins,if

theyare-vesothepatientistreatedwhichmeanIalreadyhavetakenthelesionsononeedforfurthertherapy,ifthemarginswerepositivewehavetodoanotherconebiopsyandcouncilherabouthysterectomyifshecompletedherfamily.

o Ifthebiopsyshowscancer,whichisdefinedasinvasionofbasementmembrane.Inprecancerouslesionordysplasia,itmayinvolvethewholethickness,butitneverneverinvadesthebasementmembrane.Onceitstartsinvadethebasementmembraneitisnowinvasivecervicalcancer.

• Whatisthemostcommonhistopathologicalcervicalcancer?Squamouscellcarcinoma(70%)orAdenocarcinoma(25%)lymphoma,sarcomaandmetastasis(5%).

• StagingofCervicalcancer:o Inanycancer,weneedtostagesowecandeterminethemanagement.o Cervicalcancerisclinicallystagingwhichmeanbysimpletoolssuchas(CT,MRI,physicalexamination,histories,

colposcopy,proctoscopyandcystoscopy)wecanstageit.Unlikeothergyncancerwhichsurgicallystagingwhichmeanweneedtodosurgerytostageit.Evenifthesurgeryrevealpositivefindingsuchaslymphnodeorinvasiveofrectumwewillnotchangeourclinicalstagingorupgradeit.Butforsurethemanagementwillbechangeaccordingtothefinding.

o Themostcommongynecologicalcancerindevelopingcountryiscervical,becausethelowsocioeconomicstatus.o ThemostcommongynecologicalcancerindevelopedcountryisEndometrial,becausetheirlifestyleandobesity.o ThemostcommongynecologicalcancerinSaudiArabiacountryisOvarian

- Done by Luluh Alzeghayer,435 <3

Forexample,aladywasdiagnosedwithinvasivesquamouscellcarcinomaofcervix.shewascomplainingoflowerlimbswellingduetolymphedemaorsciaticpainandfootdrop,orwithinvestigationshehadhydronephrosis,wecandiagnoseherclinicallyasstage3B.Somepatientmaydieduetorenalfailurenotfromcervicalcanceritself

o Anotherexample,aladywasdiagnosedwithinvasivesquamouscellcarcinomaofcervix. HerPelvicexamination

revealedthickeningoftherightparametriumbutnotouttothelateralSidewall.wecandiagnoseherclinicallyasstage2B.

o Anotherexample,aladywasdiagnosedwithinvasivesquamouscellcarcinomaofcervix.shewascomplainingofpassingstoolthroughvaginalopening.wecandiagnoseherclinicallyasstage4A.

o Incaseof1A1isdependofageandparity,ifsheisayoungladywhoisplanningtohavekids,wegotoconebiopsywithnegativemargins,ifsheiselderlywomenwhocompletedherfamilywegotosimplehysterectomy.

o Thesamefromstage1A2-2A2,wewillgoforradicalhysterectomyifsheiselderlywomen,andinyoungwomenwithlowparitywegofortrachelectomywhichisasurgicalprocedureusedtotreateligiblewomenwithearlystagecervicalcancerbyremovingonlythecervix,uppervaginaandparametrium.

o 4Bitisapalliativecarewhichcouldbecomfortcarewithanalgesicandantiemeticor

o couldbechemotherbyorsurgerytodecreasetheaccelerateofdiseaseandexpandthelifealittlebit.Forexample,wecandopalliativehysterectomyforthosewhocomplainofvaginalbleedingbutthatwillnotcurethepatient.

o Itisgoodforthepatientifshepresentswithearlystagesowecureher,becauseunlikeothergynecologicalcanceruninsecondstagewecannotdoasurgeryandwegoforchemoradiation.IncervicalcancertheMainpresentingcomplaintispostcoitalbleeding

o Theindicationforchemoradiationincervicalcancer(positivemargins,positivelymphnode,positiveparametria.Iftheyarenegativepatientdoesnotneedradiationandthefollowupaftersurgeryitisenough.

o Thefollowup,thefirsttwoyearsevery3months,thenextthreeyearsevery6months.

2. Ovarian neoplasms:

o Done by Luluh Alzeghayer,435 <3

• Epitheliumovariantumor:

o Debulking(cytoreduction)=TAH-BSO+LNremoval+omentectomy+anyvisibledisease.o TheypresentwithNonspecificsymptoms:abdominaldistension,ascites,intestinalobstruction,paraneoplastic

syndromee.g.weightloss.o themostcommonstageatthepresentationinpatientwithovariantumor?Stage3:peritonealmetastasis.o Whatarethemarkersforovariantumor?

• Whataretheriskfactorsforovariantumor?o Nulliparity,becausewitheveryovulationthereistraumaandinjurytoepithelialline.o Anythinginterferewithovulationisprotectivesuchasmultiparity,pregnancy,hysterectomyandOCP.o Familialhistorywhichassociatedwithovariantumors:

§ BRCA1&2.RiskofbreastCAinbothis60-80%.RiskofovarianCAinBRCA1=40%,BRCA2:20%§ Lynchsyndrome(cancerofcolon60-80%,ovaries5-10%,endometrium40%,bladder,ureter,biliary,brain)

• Thesurvivalrateinovariancancerdependsonoutcomeofdebulking.• Afterthedebulkingwefollowupthepatientintheclinicwithtumormarkers.• Theomentumisacommonsiteforrecurrence.• Itiscontraindicatedtotakethebiopsyfromtheovarybecauseyouwillspreadthetumorandupstagethedisease.• Themanagementforbothtypes(seriousandmucinous)isthesame,exceptthatinmucinoustypewedo

appendicectomytoremovetheappendixasapartofsurgery,becausemostofmucinouscancerarearisefromGIoriginuntilprovenotherwise.

• WehavetodoCTscanforchest,abdominalandpelvicforallpatient.

NON-Epitheliumovariantumor• Whatisthemostcommongermcelltumor?itusedtobedysgerminomabutnowitisimmatureteratoma.• theyaretotaloppositeinprognosis,dysgerminomaiscurablewithgoodprognosewhileimmatureteratomaisonof

theworsttumorwhichaffectyoungwhichcausedeathandverybadprognose.• schillerduvalbodiesisspecialhistopathologicalfindinginyolksactumor. • Whatisthemostcommonsexcordtumor?Granulosecelltumor,itstumormarkerisinhibin.• Call-ExnerbodiesisspecialhistopathologicalfindinginGranulosecelltumor.• Whatisspecialaboutgranulosacelltumor?

1. 1-ItisEstrogensecretingtumor,sothepatientwillpresenteitherwithvaginalbleedingorbreasttendernesswhicharesignofexcessiveestrogen,besidehighinhibinlevel.

2. 2-Alsowehavetodoendometriumbiopsybecauseshehasariskfordevelopingendometriumcancer.3. 3-inaddition,thefollowupwillbeforlife,becausetheriskofrecurrenceishighevenafter35years.

• IfthepatientpresentwithhirsutismwewillthinkaboutSertoliLeydigcelltumorwhichistestosteronesecreting,anditisatypeofsexcordtumor.

Metastaticovariancancer:

Krukenbergtumors:whichmeanmetastatictumorscomefromsomewhereelsetotheovary.themostcommonismetastaticfromthestomach.Inallcasesarestage4,andthemanagementdependontheorigin.

Borderlinetumors(non-invasivebutcanmetastasized):• Itliesbetweenbenignandmalignantandfeaturefromboth.Soitdoesnotinvadelikebenignlesionbutatthesame

timeitmetastasizeslikemalignant.• Goodprognosis(80-90%).Butmayrecuraslow-grademalignanttumor.• Theydon’trespondtochemonorradiation,thegoldstandardissurgicalresection.

3. Endometrium neoplasms:

Done by Luluh Alzeghayer,435 <3

• 90%ofpatientspresentearly(stage1)duetoAUB(abnormaluterinebleeding).• MostcommoncauseofAUBinpostmenopausalwomenisgenitalatrophy.• PerformendometrialbiopsyforanypatientwithAUBwhoseage>40especiallypostmenopausal.• ThosewithstrongriskfactorssuchasobesityandPCOSorfamilyhistoryeveniftheyareyoungerthan40wewill

endometrialbiopsy.• Anyyoungwomenwhodiagnosedwithcoloncancershouldbescreenedforothergynecologicalcancer.

Theresultsofbiopsy• ItcouldbeNormal,Cancerorprecancerousabnormality(Hyperplasia)• Riskofprogressionofhyperplasia(premalignant)tomalignancy:• Simplehyperplasiawithoutatypia:1%withatypia(x10):10%• Complexhyperplasiawithoutatypia:3%withatypia(x10):30%• WehavetodoCTCAP(chest,abdominal,pelvic),ifthebiopsyshowscancer.

Done by Luluh Alzeghayer,435 <3

• Brachytherapyisaformofradiotherapytothetoppartofvaginawhichisthemostcommonsiteforrecurrence.• Stage2isunique,itinvolvesthecervix,andwemayfindalesionduringexamination.Wemanageitlikecervicalcancer

bytwoways,eitherbyradicalhysterectomywithremovalofparametrium.Orexternalbeamradiationfollowedbysimplehysterectomy.

• intheendometriumeitherchemoorradiationnotbothtogether,unlikecervicalcancerwhichstartwithchemotosensitizethetissuethenradiation.

Patientwithbenignchangeswanttopreservefertility:• Benignchangescanbetreatedbyprophylactichysterectomyorhighdoseprogesterone.• Highdoseprogesteronefortreatingapatientwithlowgradeendometroidendometrialcancer(80%

responsetotreatment)• Conditions:lowparityandwishtopreservefertility,grade1endometroidendometrialcancer,no

myometrialinvasion,LN<1cmonMRI(MRIisusedinsteadofsurgicalbiopsy).• Followupin3months,ifbiopsyis-ve,refertoIVF.ifstill+ve,doublethedoseofprogesteroneandrepeat

thebiopsyin3months.Ifsheisstill+ve,repeatMRI,ifstillshowingnolymphadenopathyandnomyometrialinvasion,continuemedicaltreatmentfor3moremonths.Afterthese9monthsfromdiagnosis),ifstill+ve,medicaltherapyfailed,andpatienthastoundergocompletesurgicalstaging.

4. GTD & GTN neoplasms:

Gestationaltrophoblasticdisease(GTD):DonebyLuluhAlzeghayer,435<3

• MostcommonPresentation:Largeuterus,vaginalbleeding,hyperemesisgravidarum,thyrotoxicosis(becausebHCGhasthesamealphasubunitofTSH).

• Diagnosis:Quantitativeb-HCG:extremelyhighbHCGlevels.• CanbeseeninUS:

o snowstormappearance(COMPLETEMOLE)

o hydropicvilli,thecaluteinovariancysts(noneedtotreatthem,theyregressafterresolutionofGTD)o partoffetusorgestationalsaccanbeseen(INCOMPLETEMOLE),itissimilartomissedabortionwhere

theycanfindpartoffetusafterabortion.• HowthePatientshouldbefollowed?andwhy?

weeklywithb-HCGuntil3consecutive-veresultsthenmonthlyfor6months.BecausetherecurrenceandthereisarisktochangeintoGTN.

• Whichtype,weneedtogiveAnti-DifthemotherisO-?Incompletemolar,becausethereisfetus.• Duringthefollowup,wegivethemOCPtoavoidconfusionregardingthesourceofhighb-HCG

GestationaltrophoblasticNeoplasia(GTN):• itistheonlyneoplasiawetreatitwithoutanybiopsyorhistopathogytodiagnose.• Wedonottakeabiopsybecausethediagnoseisclearwithcontext• HowcanIknow,itischangingtoGTN?

o b-HCGisnotdroppingasexpected,plateauingorrebounding,oro Ifstill+veafter6monthsfromthetimeofevacuation,oro Ifhistopathologyaftertheevacuationofmolarpregnancycame+veforchoriocarcinomaorInvasivemole.

• Whatarethetypes?1. Invasivemole(intheuterusbutstarttoinvade)2. Choriocarcinoma(itcanbemetastasizedtobrain,liver,andmostcommonlylung)3. Bothrespondstochemo95%withanexcellentprognosis.4. Placentalsitetrophoblastictumours(PSTTs):Highb-HCG+highHPLinpost-partumwomen=Placental

sitetrophoblasticuntilprovenotherwise. • Aftermiscarriageornormalpregnancy orterm(notaftermolar).• b-HCGishigh(usuallyinfewthousands),butnotashighasmolar• Humanplacentallactogen(HPL)iselevated.• US:highlyvascularlesion.• Biopsy(D&C),sometimes-ve(difficultdiagnosis)• Locallyinvasive,doesn’tmetastasize.Resistanttochemoandradiotherapy.• Rx.:hysterectomyorwedgeresectiontopreservefertilityiflowornoparity. • b-HCG,CXR,CTBRAIN,ABDOMEN,USSPELVISAREUSEDTODEFINETHESCOREANDTHESTAGE.• Youdon’thavetoknowthedetailofscore,justknowthecutpointis7,itisdivededintotwogroupslowrisk

andhighrisk.• ThegoodthingaboutGTNischemoandradiosensetive,butnevergiveradiobecauseyouwilldestroyboth

ovaryandendometrium.

Done by Luluh Alzeghayer,435 <3