Perinatal Womens - neonatology, gynaecology, obstetrics notes

8/11/2019 Perinatal Womens - neonatology, gynaecology, obstetrics notes

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Perinatal womens RNSH

Table of Contents

Useful abbreviations and tidbits (but not necessarily examinable)

Perineal tears

Bicornuate uterus

Molar pregnancy/Gestational trophoblastic disease

D&C Dilatation and Curettage

Wharton's Jelly

SUA Single Umbilical Artery ("two vessel cord")

PROM/SROM Premature/Prelabour/Spontaneous Rupture of Membranes

NBAC/VBAC Next/Vaginal birth after Caesarean

ECV External Cephalic Version

Bartholin's cyst/abscess

Random notes

Neonatology

Neonatal Resuscitation (in exams for sure)

Neonatal Jaundice

HPV vaccine/cervical cancer

Pap smear

Pelvic Masses

Relevant Pelvic Anatomy

Benign ovarian cysts

Fibroids

Risk of malignancy index 1x2x3

Holistic women's health

Abortion

Premenstrual syndrome

Vaginismus

Vaginal Examination

Menopause

Primary ovarian insufficiency (POI)

Normal Labour

4 stages of Labour

Mechanism of labour

Progress of Labour

Pain relief in Labour

Placenta

Malpresentations

Monitoring in labour

Normal pregnancy

Maternal changes in pregnancy

Twin pregnancies

Preterm birth/labour

Antenatal corticosteroids

Tocolysis/ tocolytics to suppress labour

Oral Antibiotics

IV Magnesium sulfate MgSO4

TPL sample questions

Pelvic Pain


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Acute onset pain: reflects fresh tissue damage, resolves as tissue heals

Chronic pain: >6 months, intermittent, constant pain

Red flags

Endometriosis

Pelvic inflammatory disease

Normal menstrual cycle:

Hypoglycemia in neonates (very common in the newborn)

Maternal factors leading to neonatal BSL

Neonatal factors that make baby at risk of hypoglycemia

Management of hypoglycaemic neonate

Perinatal indigenous health

Perinatal chromosomal abnormalities

1st trimester screening

2nd trimester screening

Pregnancy timeline

Anti D antibodies/haemolytic disease of the foetus

Premature and low birth weight infants

Prevent preterm delivery

Prepare for preterm delivery

Acute preterm neonatal problems

Medium/long term preterm neonatal problems

Viability

Cerebral palsy

Gynae-oncology

Uro-Gynaecological issues

Pelvic Organ Prolapse POP

Postnatal mood disorders - perinatal anxiety and depression

Respiratory Distress in newborn infants

1. Transient Tachypnoea of the newborn TTN

2. Hyaline membrane disease HMD

3. Pneumonia/sepsis - should ALWAYS be a ddx

4. Pneumothorax

5. Meconium aspiration

6. Structural abnormalities

7. Diaphragmatic hernia

8. Other

Vomiting in the neonate

Pathologic vomiting

Newborn Examination

Perinatal infections

Rubella

Varicella zoster virus

CMV

Parvovirus

Herpes Simplex Virus

HIV

Hep C

Toxoplasmosis

Syphilis

Listeria

Multiple pregnancies


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High risk Obstetrics

Estimated date of delivery

Post partum haemorrhage

Primary PPH

Secondary PPH

Prevention of PPH

Management of PPH

Preeclampsia

Diabetes in pregnancy

Multiple pregnancies

Small for gestational age

Intrauterine Growth Restriction

Symmetric (30%) vs Asymmetric (70%)

Gynaecological cancers

Infertility

IVF cycle

Complications of IVF:

Bleeding in early pregnancy

Miscarriage

Miscarriage types

Ectopic pregnancy

Mgmt of ectopics

Gestational Trophoblastic Disease

Persistent GTN and choriocarcinoma

Breastfeeding

Medications

Methyldopa/aldomet


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Useful abbreviations and tidbits (but not necessarily examinable)

Perineal tears

1st degree - limited to vaginal mucosa and skin of the introitus

2nd degree - extends to the fascia and muscles of perineal body

3rd degree - trauma involves anal sphincter 4th degree - extends to the rectal lumen, through the rectal mucosa

Bicornuate uterus

Heart shaped uterus, two horns separated by a septum

associated with infertility - the most common symptomatic presentation is with early pregnancy loss

and cervical incompetence

preterm delivery in 15-25%

malpresentation in 40-50%, breech presentation in partial bicornuate, transverse in others.

risk of deformities in the foetus

Molar pregnancy/Gestational trophoblastic disease

Abnormal trophoblastic proliferation of foetal tissue

Non-neoplastic or neoplastic

Non-neoplastic: Exaggerated placental site, placental site nodule, complete/partial

hydatidiform mole

Neoplastic: invasive mole, choriocarcinoma, placental site trophoblastic tumour, epithelioid

trophoblastic tumours. Also referred to as gestational trophoblast in neoplasia

Clinical manifestations include:

Vaginal bleeding

Enlarged uterus

Pelvic pressure or pain

Theca lutein cysts

Anaemia

Hyperemesis gravidarum

Hyperthyroidism

Preeclampsia before 20/40

Vaginal passage of hydropic vessels

D&C Dilatation and Curettage

Indications

Diagnostic

Endometrial carcinoma

Endometrial hyperplasia

Therapeutic

Treatment of incomplete, missed, septic, induced abortions

Initial treatment of molar pregnancies (gestational trophoblastic disease)

Temporary management of excessive/prolonged vaginal bleeding unresponsive to

hormonal therapy

Suction curette as management, for postpartum haemorrhage with retained products

of conception
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Wharton's Jelly

Clear, gelatinous substance that surrounds the umbilical vessels within the cord

SUA Single Umbilical Artery ("two vessel cord")

Can occur in 0.5-6% of pregnancies

Some placental abnormalities may be increased with SUA including:

Velamentous insertion

Abnormally short cord

Placenta praevia

True knot in cord

Circumvallate placenta

Placental infarcts

Documented associated foetal abnormalities include:

Cardiac

Genitourinary

Renal

Gastrointestinal

Some degree of IUGR

PROM/SROM Premature/Prelabour/Spontaneous Rupture of Membranes

Used interchangeably

NBAC/VBAC Next/Vaginal birth after Caesarean

NBACs carry risk of:

Rupture during labour (1:200)

Rupture during labour requiring subsequent hysterectomy (1:1000)

Stillbirth

Encouraged, but issue is not really encouraging NBACs, but to decrease overall first Caesareans

(WHO recommended 15% Caesarean as first delivery, NSW average 30%)

ECV External Cephalic Version

External manipulation/rotation of breech-position foetus to cephalic presentation

Performed at non-labour or near-term, with reduced risk of non-cephalic and Caesarean births (ref.

UpToDate External cephalic version)

Factors associated with reduced success of ECV include:

Nulliparity

Anterior placenta

Lateral/corneal placenta

Decreased amniotic fluid volume

Low birth weight

Descent of breech into pelvis

Maternal obesity

Posteriorly located fetal spine

Firm maternal abdominal muscles


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Frank breech presentation

Ruptured membranes

Tense uterus

Non-palpable foetal head

Bartholin's cyst/abscess

Bartholin's glands are bilateral structures on the labia that provide external lubrication to the vagina

Can become abscesses/cysts if inadequate drainage occurs i.e. blockage triggered by infections,

small gland opening etc. Occurs in 2-3% of women

Bartholins cysts usually occur unilaterally, measuring between 2-3cm, most are asymptomatic, and

are usually sterile. Larger cysts can very uncomfortable/painful

If asymptomatic, no management is required unless the patient is >40 years and screening for

carcinoma. Management includes surgical drainage via incision and marsupialization (maintaining a

patent surgical opening by applying stitches), or by insertion of Word Catheter (small draining

catheter approx. 5cm long, left in place for a few weeks to enable thorough drainage)

Random notes

At the 12 week USS you can detect: anencephaly, abdominal wall defects, bladder outflow

obstruction, cystic hydroma

Can detect oligohydramnios at 18-24wk USS

fetal position can be palpated at >36wks

extended breech - head is in the midline

methyldopa first line in pregnancy for hypertension

pregnancy delays gastric emptying - adds to nausea and vomiting

HELLP - complication of preeclampsia (haemolysis, elevated liver enzymes, low platelets)

ergometrine is contraindicated in women with hypertension, asthma or active cardiovascular disease reasons for induction of labour: APH, IUGR, hypertension, postmaturity, diabetes

Failure to progress - need to look up when they call it!!!!!!

salbutamol inhibits uterine smooth muscle contractility

shoulder dystocia classic presentation - head delivers slowly, neck does not appear, chin retracting

against perineum

bacterial vaginosis - gardenella vaginosis, mycoplasma hominis, mobiluncus, clue cells, clue cells

and cream coloured discharge, fishlike odour on the addition of potassium hydroxide, vaginal fluid ph

>4.5. does not present with irregular bleeding.

molluscum contagiosum - pearl white lesions, cryotherapy is the treatment of choice

gonorrhoea - gram negative diplococcus

candida - grey curd like discharge, high vaginal swab

crabs - vaginal itching, brown specks on underwear (lice droppings)

syphilis - primary (single painless ulcer, chancre), secondary (multiple wart like lesions, condylomata

lata, usually occurs within 2 years of infection)

Pearl index is defined as the number of women who will become pregnant if 100 women use that

form of contraception for one year.

Mirena common contraindications - pregnancy, liver failure, mechanical heart valve,

ovarian/endometrial cancer.

Copper IUD common contraindications - pregnancy, irregular bleeding, anaemia,wilsons disease,

ectopics, copper allergy.

COCP side effects - HTN, thrombosis, migraine, irregular bleeding

COCP common contraindications - hx HTN, life long smoking, smokers > 35 years, pregnancy,

migraine, thrombosis, IHD, stroke, liver disease.


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mini pill POP side effects - ovarian cysts, weight gain, breast tenderness, headaches

medroxyprogesterone IM (depoprovera) contraindications - osteoporosis

fibromas are ovarian tumours associated with a pleural effusion and ascites, commonly referred to

as meig's syndrome

serous cystadenoma can be benign or malignant and make up 50% of ovarian tumours

endometriosis is associated with painful intercourse and painful periods. vaginal endometriosis is

characterised by the presence of blue nodules following speculum examination. COCP is the first

line treatment of choice.

HRT lowers one's risk of bowel cancer.

Only associated cancer with PCOS is endometrial cancer. Raised LH:FSH is a very useful test for

PCOS.

classical presentation of a cervical ectropion seen commonly during puberty, pregnancy and the use

of the oral contraceptive pill. new onset vaginal discharge, erythematous raw-looking cervix.

granulosa cell tumour - slow growing, commonly malignant, secretes oestrogen, may cause

postmenopausal bleeding or endometrial carcinoma

thecoma - similar to granulosa cell tumours but mostly benign

clear cell carcinoma - 10% of all ovarian cancers, malignant, poor prognosis

imipramine (tricyclic antidepressant) - associated with urinary retention and overflow incontinencedue to detrusor dysfunction. has anticholinergic side effects.

varicella - visual disturbance, skin scarring, limb hypoplasia, neurological abnormalities,

rubella - cataracts, deafness, learning difficulties, heart disease, hepatosplenomegaly. flu like illness,

fine macular rash over trunk. dx by serology

toxoplasmosis - mother commonly affected in third trimester, incubation up to 20 days, flu like

symptoms, glandular fever type, dx by serology, assoc hydrocephalus.

cmv -12 wk incubation, most common cause of congenital neuro abnormalities, can cause flu like

illness, assoc thrombocytopenia, primary infection confirmed by the presence of IgM

GBS - affects ~25% of women in pregnancy, preterm labour, penicillin, asymptomatic infection,

pyrexia in labour is a risk factor

parvovirus - foetal anaemia, myocarditis, incubation 18-20 days, dx by serology

listeria in pregnancy - treat with penicillin, dx by blood culture. may result in stillbirth, miscarriage,

preterm delivery. unpasteurized products.

leading cause of death in women in pregnancy is VTE

lymphogranuloma venereum- pustular like lesion, not painful, developing countries, can be on vagina,

vulva or cervix. treat with doxycycline 100mg bd 3wks.

cardiac output increases by 40% because of a fall in vascular resistance

Renal plasma flow increases by 60-80%, resulting in increase GFR

creatinine clearance goes up by 50%, resulting in decrease in serum urea and creatinine

iron increases by 3 fold due to increase blood volume in pregnancy, increased foetal needs and

blood loss during delivery

folate increases 10-20 fold due to increase foetal needs and red cell development


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Neonatology

Neonatology

Newborn baby screen

Head fontanelles and sutures

Eyes

Red reflex good

No red reflex (congenital cataract)

White pupil (retinoblastoma)

Ear tips higher than eyes

Must check hard + soft palate with finger (hard to identify cleft palate from pure observation)

Chest listen for heart murmurs (VSD, AS, AR, patent ductus arteriosus)

Check fingers (5 digits) and palm creases (one line samian feature boooo)

Abdomen for hepatosplenomegaly

Umbilical cord not oozy and disgusting

Femoral pulses (together for aortic coarctation)

Testes descended or coming down in boys

Check for 3 holes in girls

Turn over and check back for tufts of hair, patent anus

Hip displacement check by push down and abduct one at a time. Normal should not feel joints

clicking.

Ortolani tests - push down - dislocate

Barlows test - push out - displace

- hips are examined one at a time - flex infant's hips & knees to 90 deg - thigh is gently

abducted & bringing femoral head from its dislocated posterior position to opposite the

acetabulum, hence reducing femoral head into acetabulum - in positive finding, there is

a palpable & audible clunk as hip reduces

Feet normal - 5 digits, talipes

Measure HC, length, weight

Neonatal Resuscitation (in exams for sure)

Resuscitation preparation

Radiant warmer turned on and heating

Oxygen source open with good flow

Suction apparatus (100)

Laryngoscope

Resuscitation bag and mask


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1. Warm and Wipe, stimulate the baby by rubbing it

2. Suction (use finger to obscure the little hole - enables suction). UpToDate states that suction should

first begin in the mouth then the nostrils

3. Mask/PPV positive pressure ventilation (1/sec for 30 s) remember turn on air flow. Use O2 6-8L/min,

room air mix (~21% O2 roughly) - keep head in neutral position

a. Meanwhile checking HR, sats via pulse oximetry

b. If HR 60-100 keep mask with flow (air or more oxygen)

c. If HR 60 or less commence CPR

4. Cardiac compression/massage

a. O2 @ 100%

b. 3 compressions 1 breath every two seconds

c. Use thumb tips go 1/3 down

d. Reassess

Babies are obligate nose-breathers XD important for breast feeding/sucking (or something like that)


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Respiratory distress in the neonate

Signs

Nodding - when using accessory muscles

Nares flaring

Grunting - maintain airways patency (physiologically similar to pursed-lips breathing in

COPD)

?Tracheal tug

Always respiratory distress in sepsis, kidney failure, meningitis etc cuz increase in lactic acid as

baby body fight and blood pH goes down. Baby removes carbon dioxide as quickly as possible

Neonatal Jaundice

Why is there neonatal jaundice? Theory - bilirubin is an antioxidant, protective in the first few days of life

Most common form of jaundice in neonates =

Unconjugated - pathological - haemolysis - external [alloimmunity (ABO/Rh)], internal [G6PD deficiency]

Sepsis

!Persistent jaundice - ask for fractionated bilirubin to determine the exact cause of the persistent jaundice

(need to rule out biliary atresia)

G6PD - precipitated by some infections, antibiotics (sulfamethoxazole), naphthalene (mothballs)


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Kernicterus - deposition of aggregated bilirubin in the basal ganglia, causes encephalopathy

Respiratory Distress in newborn infants

Causes: infection/pneumonia, transient tachypnoea of the newborn, hyaline membrane disease (preemies),

meconium aspiration (term or postterm babies), acute pneumothorax,

1. Transient Tachypnoea of the newborn TTN

Mild preterm 34 - 36 wks, retained fetal lung fluid, more common in cesarean section delivery, absenceof Labour, tachypnoea from birth usually resolves within 48HR, xray shows alveolar infiltrate, wet lung.

2. Hyaline membrane disease HMD

preterm, lack of surfactant, no antenatal corticosteroids given, more likely in cesarean section delivery,

tachypnoea from birth, worsening symptoms over 24 to 48 hours, Xray shows generalised ground glass

opacity and air bronchograms, some alveoli closed some alveoli are overextended, baby should start

making its own surfactant by day 3 or 4

3. Pneumonia/sepsis - should ALWAYS be a ddx

predisposing factors: ruptured membranes, chorioamnionitis (maternal fever or abdominal tenderness),

GBS, gram negative organism (e. Coli). Sx: lethargy, apnea, bradycardia,temperature instability, feed

intolerance

4. Pneumothorax

Consider in baby with acute deterioration. Can shine a light to the baby to transilluminate the lungs.

5. Meconium aspiration

Baby passes Meconium in the womb, the breathes it in. Usually posts term, SGA, poor placental function

causes underlying hypoxic tendency with added stress of Labour . Associated with pulmonary hypertension,

secondary surfactant deficiency. Increased risk of pneumothorax and secondary infection. X Ray: coarse

patchy changes throughout lung fields.Therefore, we try to induce Labour at 41 weeks, since post term babies have higher morbidity, mortality,

including meconium aspiration.

6. Structural abnormalities

Choanal atresia obstructing nose (since babies are obligate nose breathers)

Cleft palate

Tracheo-oesophageal fistula

Cystic/dysplastic changes in lung

7. Diaphragmatic hernia

8. Other

metabolic acidosis, pulmonary hypertension of the newborn, congenital heart disease, anaemia (haemolysis

in rh disease, feto maternal haemorrhage) , polycythaemia, hypoplastic lungs, oligohydramnios, potter's

syndrome, perinatal asphyxia, neurological malformation or injury

key facts to work out in Hx or examination

time/mode (c section? Labor or not?)/complications in delivery, gestational age, temperature,

ruptured membranes, mother has fever or abdominal tenderness, gram negative organisms, time of

onset of respiratory distress, antenatal/family history

Head nodding, expiratory grunting/moaning, suprasternal and subcostal recession, nasal flaring,

RR>60, tachycardia (first sign), cyanosis

TABC resuscitation, O2 saturation, heart rate, apnoeas

investigations


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o CXR, bloods (FBC, blood gas, blood cultures, CRP), electrolytes when baby is 6hours old (before that

it mainly reflects mothers circulation)

Management

Resuscitation

Oxygen - intubation, CPAP, nasal prongs

Vomiting in the neonate "Possetting" - mild vomiting - most commonly associated with feeds

Most commonly, cause of vomiting due to a slow gut

Normal vomiting - yellow or white, milk or mucus only, NO blood or bile, NOT projectile, neonate

otherwise well

Pathologic vomiting

blood stained (maybe due to swallowed blood or other),

bile stained!!! (most worrying sign, suggest bowel obstruction may need surgical intervention, causes:

malrotation of midgut and volvulus twisting mesentery and blood vessels, small bowel atresia ( e.g.duodenal atresia, present antenatally with polyhydramnios 50% as baby isn't swallowing liquid, down

syndrome 30%), necrotising enterocolitis (common in pre termers, ischemic gut wall with bacteria

invasion, pneumatosis of bowel wall, gas in portal veins), meconium ileus (esp in babies with cystic

fibrosis 80%, delayed passage of meconium), anal atresia ),

projectile vomiting (pyloric stenosis),

unwell baby,

FTT, gord/sepsis/uti/inborn error of metabolism,

associated choking/aspiration, diarrhoea

key facts to work out in Hx or examination

Baby well or unwell, quantity/colour/when did it start/how long/frequency

Abdominal dissension, passed meconium yet?,stool blood/mucus, diarrhoea

Assess for vital signs, hydration status, abdominal examination (patent anus?), syndromic features

Investigations

Lateral/decubitus AND AP abdo XRAY,

BLOODS (FBC, cultures, for infection. electrolytes for fluid status)

Management

nil by mouth, NG tube, IV fluids

transfer to neonatal unit, paediatric surgical team referral

Consider or give antibiotics

Newborn Examination

Size of the baby, big or small

Posture and colour

Flexion of extremities is normal - floppy baby = neuromuscular problem.

One arm up one arm down - brachial plexus injury probably with delivery if the shoulder

Pink with transient acrocyanosis (blue feet, palms) - Pink colour is normal

Head to body size

Jaundice - slight is normal. Jaundice on day 1 is PATHOLOGICAL. Day 3 or 4 mild jaundice in face is

normal, if all throughout eyes or body, may be abnormal. >2 weeks, likely to be pathological.

Skin appearance


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Mild peeling/dryness is normal (especially common in IUGR, post term babies)

Vernix caseosa - normal. Protective greasy white material, covers infants between 35 - 38 weeks

Livedo reticularis - blood vessels visible in the skin. Due to immature vascular system. Common and

normal.

Growth restricted

Scrawny, wrinkly skin over buttocks, like an old wise man

Fine hair over the face and body. Lanugo. Mostly in preterm babies. Lost in 1st month of life.

Baby skin things /Vascular birthmarks -

o naevus flammeus (Stalk Mark), irregular bordered pink/red macule, blanched with pressure, generally

fade by 2 years, found in 50% newborns, found on nape of neck, face

o

Mongolian blue spot - esp in Asian babies, buttocks/flanks, fade overtime but not completely,

melanocytes in the dermis

o Milia - 40% of newborns, like whiteheads on nose

o Harlequin phenomenon - baby red on one side (blanches) and white on the other, transient seconds to

minutes, more likely in unwell babies with fever/infection, occurs in first few days of life.

o erythema toxicum - 70% of newborns, any part of bodies, red base with tiny yellow/ white papule,

small bump. Need to differentiate from staph infection. Maybe related to hormonal changes

o Strawberry haemangioma - can grow rapidly, bright red, raised, lobulated, regress from 9 months on

can take 7 years for it to completely disappear. Usually leave it to regress on its own. Send to

dermatologist if it

Staph infection - pus filled papules with red base. Swab to confirm. IV abx.

o Milia - vesicles, sweat glands

o Caput succedaneum - oedematous thickening of the scalp between skin and epicranial aponeurosis

o Bruising from vacuum extraction - monitored for subgaleal haemorrhage (between epicranial

aponeurosis and the periosteum), vague generalised scalp swelling/fluctuance, buggy behind ears.Manage by giving blood and replacing blood loss.

o Cephalohematoma - subperiosteal, lump on the head, often appears on 2nd day of life, often has a

hard irregular bony margin around it.

Tongue tie

Short frenulum, interference with breast feeding. Manage by clipping frenulum.

Oral Candida: white patches on tongue, gums, lips and buccal mucosa. Maybe on cheeks too. Not just on

tongue. Treat with topical antifungal. Treat mother too as she is breast feeding

Preauricular skin tag - may be associated with renal anomaly (as ears develop at the same time as kidneys)

Umbilical hernia - common in preemies, develops in first month, spontaneously regressed by 6 to 18

months.

Inguinal hernia - needs referral to paediatric surgeon and surgery within 4 weeks as it can strangulate easily.

Sacral dimple - below or over coccyx is not a problem and disappears on its own. If it is higher up or has

hair, be wary of spina bifida.

Herpes infection - vesicles that cluster, unwell neurologically, start on acyclovir immediately (even if you

suspect) as babies can get encephalitis or pneumonitis easily. Typically develops in 1st or 2nd week of life

as the virus is acquired during birth.

Polydactyl - most common is extra little finger.

Nappy dermatitis - needs barrier cream, contact dermatitis, mild steroid, check if there's a secondary fungal


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infection. Does.baby have loose stools? Need to manage that

Genital thrush - red tender satellite lesions inside skin folds and creases.

Congenital hydrocele - translucent sweeping around testes, transilluminates, spontaneous disappearance

after 1 year. May be a sign that Inguinal canal is still open, so need to check for Inguinal hernia.

Hymenal tag - regressed over first 2 months of life. Profusion of redundant mucosa.

Perinatal infections

susceptibility in pregnancy - Decreased immune surveillance, lack of physiologic surveillance

modes of transmission - birth (ascending/ vertical transmission), transplacental, trauma (iatrogenic e.g.

amniocentesis, chorionic villus sample)


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iatrogenic.

MRSE, MRSA - use vancomycin

amphotericin - fungal infections

Swab nose, throat, umbilicus, groin. Gastric aspirate, ear swab. Blood cultures. FBC, blood film, CRP.

Treat empirically based on suspicion.

Gives babies probiotics, reduces rate of necrotizing enterocolitis. Particularly to babies who aren't

breastfed.

Mothers shouldn't have any unpasteurized products (milk, juices): pasteurization occurs at 68 degrees,kills off the vitamins.

Following will be in exams !!!!!!

Risk factors of sepsis in the mother

Diabetes - glucose good growing ground for bacteria

Prolonged rupture of membranes - 18hrs

IVDU

GBS positive

Malnourished mother: iron and zinc deficiency

Mother's occupation

Prolonged labour

Tachycardia, tachypnoea (acidosis), fever

Triad of chorioamnionitis: Abdominal Tender + fever + abnormal bloods/inflammatory markers (high

WBC, CRP)

Risk of sepsis in baby

Apnoea should never happen in term babies

Floppy baby

Increased neutrophil count

Dehydrated, vomiting, tachycardia, lethargic, encephalopathic

Look up I:T ratio, if no immature band forms in babies, means.....?

Rubella

- teratogenic, 10% susceptible, transmission via aerosol/respiratory,

o Sx: generalised rash, fever, cough, conjunctivitis, arthralgia, lymphadenopathy, usually mild illness

o Vaccine is live. Women can try getting pregnant 1 month after vaccine. Direct transplacental

transmission, causes ischemia in blood vessels.

o Risk of congenital rubella, 100% in first 8 weeks. 50% in 8 to 12 weeks.

o Gregg's triad: cataract, salt and pepper retinopathy, PDA, PS, Sensorineural deafness.

o If found to be infected, terminate pregnancy as it is so teratogenic

o For women that are vaccinated but don't seroconvert, give repeat vaccinations

o

No treatment for rubella

Varicella zoster virus

o More worried about mum than the baby (Sx varicella pneumonia, vesicular rash) . Can give varicella

immunoglobulin if exposed within 96 hours. Check IgG, IgM. Treat with acyclovir.

o Foetal varicella syndrome - not very common, highest risk (1.5%) in the first 20 weeks and if mum is

infected a few days before delivery. Affects skin, limb hypoplasia.


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CMV

Blood transfusions - CMV infections

o CMV is not screened for all blood.

o

Therefore, if requesting blood for pregnant patients, need to make sure pathologist knows so they give

you CMV negative blood!!!

o CMV if the most common causes of congenital infections - 2% of live births. Transmitted through

urine, nasopharynx and blood. Maternal foetal transmission in 50%. Usually asymptomatic.

o Foetal effect - microcephaly, deafness, hydrops fetalis (effusion in 2 cavities), intracranial

calcifications etc

o Check for infection by maternal serology IgM or IgG and IgG avidity test to determine if it's an acute or

old infection (as IgM can stay positive for up to 12 months). Need to repeat in 2 weeks to look for

seroconversion. Secondary reactivation of CMV infection.

o Check in foetus by fetal scan and amniocentesis.

o No vaccine currently available.

Parvovirus

o Crosses placenta 1:400

o Slapcheek, arthralgia, maternal Serology IgM detectable in 1-3 weeks

o Leads to foetal anaemia and hydrops fetalis.

o U/S middle cerebral artery doppler - peak systolic velocity increases due to anaemia, scan every 1 to

2 weeks to monitor.

o Treat the anaemia

Herpes Simplex Virus

oAcquired during delivery.

o if there is primary infection at the time of delivery, recommend cesarean section. Note once

membranes have ruptured, there is a risk of ascending infection. Treat with acyclovir.

o

If primary infection in early pregnancy, IgG developed and can cross the placenta and protect the baby

o If secondary infection, not so clear what to do.

o Biggest concern for baby is viral encephalitis or pneumonitis

HIV

o

breastfeeding has high risk of transmission ~45%, therefore recommend bottle feeding

o Manage or lower risk by using antiretroviral therapy

o Side effect HAART in pregnancy- preterm birth,

o If there is a detectable viral load, needs c section. If not detectable and on HAART, can have vaginal

delivery

Hep C

o

perinatal transmission 5% , rarely occurs if RNA Negative

Toxoplasmosis

o

congenital infection: ventriculomegaly, intracranial calcifications

Syphilis

o VDRL screening toil, need TPHA to correct for false positives


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o congenital infection: early - rhinitis etc, later - hutchinsons teeth (notched teeth),

Listeria

o

Long 72 day incubation

o Uncommon foodborne infection

o Serology not useful, need to culture.

o

Meconium stained liquor in preterm labour

o Treat with penicillin +- gentamicin for 2 weeks or 6 weeks

investigations

Bloods (FBC, EUC, blood cultures, Serology)

Stool, urine culture

Screening: HIV, Syphilis, Hep BC, rubella, haemophilus,

TORCH screening

CXR/Doppler - exclude DVT, PE

Normal movements in pregnancy - 10 times in 2 hours

Polyhydramnios is a risk for preterm labour

>20 weeks, termination can occur if the mother's health is at risk, usually via approval from ethics

committee

Trisomy 21 -

Sx: epicanthic fold, flat nose bridge, small low set ears, shallow philtrum, simian fold, sandal toes, inverted

distal phalanx of digit 5.

Associated problems: hypothyroidism, early feeding problems, cardiac (PDA), mental developmentAutomatically qualify for government subsidised early intervention program

With a baby with perinatal asphyxia, need to determine if the encephalopathy is due to hypoxic event or other

thing (e.g. infection), need to work out if it was caused by intrapartum event or by something during delivery.

Cord blood bass ph


18/60


19/60

Small for gestational ageCauses for Small for gestational age risk factors

1. Uteroplacental factors- preeclampsia, chronic hypertension, diabetes, cardiovascular disease,

autoimmune disease (e.g. coeliac), smoking etc

2. Maternal factors - Small mother, ethnicity, poor maternal nutrition/anaemia, comorbidities ( asabove, that causes placental problems and difficulty delivering nutrients to the foetus), infection

(rubella, CMV, toxoplasmosis, herpes),

3. Foetal factors - Chromosomal abnormalities, genetic disorders, cardiac or organ developmental

problems

Tests you could offer for small gestational age

History - mothers ethnicity, small person, family history of genetic disorders etc

Investigations you could offer or review

Nuchal translucency scans (11-14 weeks) + blood serum to work out chromosomal

abnormality risks for trisomy 13, 18 21

Amniocentesis (15 weeks onwards)

Serial Foetal morphology/growth U/S - measures head circumference, abdominal

circumference, femur length, estimated weight, structural abnormalities, assess the amount

of amniotic fluid (extrapolates based on biggest fluid pocket in the 4 quadrants)

umbilical artery doppler placental S/D ratio - systolic / diastolic ratio gives an

indication of the vascular resistance in the placenta. Look for elevated S/D ratios,

which indicate diminished diastolic flow reflecting increased vascular resistance form

the placenta.

Serial U/S growth scans at regular intervals (e.g. every 3 weeks)

Foetal non-stress testing (NST aka CTG (cardiotocography))regularly and monitor for foetalmovements

Reactive (normal) - presence of two or more fetal heart rate accelerationswithin a

20-minute period, with or without fetal movement discernible by the woman.

Accelerations are defined as 15 bpm above baselines for at least 15 seconds if

beyond 32 weeks gestation, or 10 bpm for at least 10 seconds if at or below 32

weeks.

Nonreactive (abnormal) - presence of less than two fetal heart rate accelerations

within a 20-minute period over a 40-minute testing period

Intrauterine Growth Restriction

The most widely used definition of IUGR is a fetus whose estimated weight is below the 10th percentile for

its gestational age and whose abdominal circumference is below the 2.5th percentile. Foetus that has poor

growth.

Symmetric (30%) vs Asymmetric (70%)

Symmetric growth restriction (aka Global growth restriction) implies a fetus whose entire body is

proportionally small. More likely to have long term neurological sequelae.

Foetus has developed slowly throughout the whole pregnancy

Early intrauterineinfections, such as cytomegalovirus, rubellaor toxoplasmosis

Chromosomal abnormalities

Anemia

Maternal substance abuse (prenatal alcohol use can result in Fetal alcohol syndrome)

Asymmetric growth restriction implies a fetus who is undernourished and is directing most of its
http://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FFetal_alcohol_syndrome&sa=D&sntz=1&usg=AFQjCNG2kyhnpwHyE2fjFmlR3FD1CC2kWQhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FFetal_alcohol_syndrome&sa=D&sntz=1&usg=AFQjCNG2kyhnpwHyE2fjFmlR3FD1CC2kWQhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FSubstance_abuse&sa=D&sntz=1&usg=AFQjCNHI2GiIjY48nApcDPQgcVYgro3yWwhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FSubstance_abuse&sa=D&sntz=1&usg=AFQjCNHI2GiIjY48nApcDPQgcVYgro3yWwhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FAnemia&sa=D&sntz=1&usg=AFQjCNHraVHe0JbHgoPQfDRt9N5wmzWdnwhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FAnemia&sa=D&sntz=1&usg=AFQjCNHraVHe0JbHgoPQfDRt9N5wmzWdnwhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FChromosome&sa=D&sntz=1&usg=AFQjCNGhjU2KWzwIp3PjeRNGVyNsF_elwghttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FToxoplasmosis&sa=D&sntz=1&usg=AFQjCNEKThjW89EM5SpcKCvhe2YAMWz0-Qhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FToxoplasmosis&sa=D&sntz=1&usg=AFQjCNEKThjW89EM5SpcKCvhe2YAMWz0-Qhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FToxoplasmosis&sa=D&sntz=1&usg=AFQjCNEKThjW89EM5SpcKCvhe2YAMWz0-Qhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FRubella&sa=D&sntz=1&usg=AFQjCNFhXa4HlmUJcZuc0uNhmFCPAauS1ghttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FRubella&sa=D&sntz=1&usg=AFQjCNFhXa4HlmUJcZuc0uNhmFCPAauS1ghttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FCytomegalovirus&sa=D&sntz=1&usg=AFQjCNGffW0LML9CvPB8C_-0saTterCyjAhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FCytomegalovirus&sa=D&sntz=1&usg=AFQjCNGffW0LML9CvPB8C_-0saTterCyjAhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FUterus&sa=D&sntz=1&usg=AFQjCNHa24KEph_Txyc_EXFeB5qske2rtwhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FUterus&sa=D&sntz=1&usg=AFQjCNHa24KEph_Txyc_EXFeB5qske2rtwhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FCardiotocography%23Accelerations&sa=D&sntz=1&usg=AFQjCNGhT0uiVmgcD10QP7CyDCzUoIBH1ghttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FCardiotocography%23Accelerations&sa=D&sntz=1&usg=AFQjCNGhT0uiVmgcD10QP7CyDCzUoIBH1ghttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FNonstress_test%23cite_note-5&sa=D&sntz=1&usg=AFQjCNFbLHWNaCJByXvDpp6f8DzmIcFwdAhttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FCardiotocography%23Accelerations&sa=D&sntz=1&usg=AFQjCNGhT0uiVmgcD10QP7CyDCzUoIBH1ghttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FCardiotocography%23Accelerations&sa=D&sntz=1&usg=AFQjCNGhT0uiVmgcD10QP7CyDCzUoIBH1ghttp://www.google.com/url?q=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FCardiotocography&sa=D&sntz=1&usg=AFQjCNGTsS4CFgTiC2g2lkZuX8HDHf293A


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energy to maintaining growth of vital organs, such as the brain and heart, at the expense of the liver,

muscle and fat. This type of growth restriction is usually the result of placental insufficiency. Head

circumference is normal and comparatively larger than the rest of the body.

Usually caused by insult by extrinsic factors e.g. Chronic high blood pressure, Severe

malnutrition, Genetic mutations, EhlersDanlos syndrome

Premature and low birth weight infants

1. Prematurity, 2. Low Birth Weight most common reason for admission to NICU.

Premature 42 weeks


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2. problems with uterus/placental circulation ( multiple pregnancy, infection, abruption, poor circulation),

3. Fetal abnormality (chromosomal or structural abnormalities)

Prevent preterm delivery

Abx - treat infections or likely infections

Tocolytics

Bed rest

Prepare for preterm delivery


Decide on delivery via cesarean section (don't want baby to go through stress of vaginal delivery)

Acute preterm neonatal problems

Inadequate ventilation - CPAP (neopuff), O2 via nasal prongs, etc

Hypothermia - prone to heat loss, poor mechanism for heat production, lack brown fat. Polyethylene

plastic wrap, water/sweat keeps the baby warm and the heater can penetrate through the plastic.

Medium/long term preterm neonatal problems

Respiratory

o

Respiratory distress syndrome / hyaline membrane disease - lack of surfactant - may need to intubate

or use continuous positive airway pressure ventilation

oApnea for >20 seconds and desaturation - immature respiratory centres in brain

o Infections. Give IV penicillin (GBS) and gentamicin (e.coli) for 2 days.

o Chronic lung disease. Most resolve in 1-2 years.

Metabolic - need to closely monitor electrolytes and sugars. Do abg, euc.

o Hypoglycemia/hyperglycemia

o

Hypocalcaemia

o Hyponatremia/hypernatremia

oAcidosis

Gastro

o Poor feeding

o

Reflux

o Necrotising enterocolitis

o Lack of coordination with sucking and swallowing ( mechanism develops at 33 or 34 weeks,

therefore< 33 w/o babies need NG tube or orogastric tube)

Jaundice - phototherapy. Monitor with TCB and SBR, plot on neonatal jaundice chart and work out

therapy. !!!know how to explain jaundice to the parents - potential OSCE station!!!

Renal immaturity

Patent ductus arteriosus - causes pulmonary oedema, left to right shunt. Confirm with echo. Give

ibuprofen to encourage it to close.

Anaemia of prematurity at 5 or 6 weeks - iatrogenic causes, ineffective erythropoiesis, poor iron stores,

bone marrow is less sensitive to hypoxia. May need blood transfusion up to 24 or 25 weeks. May need

iron supplementation.

Infection - immature immune system - misses maternal transfer of immunity from 33 weeks onwards

and misses out on colostrum

Neurological

o Intraventricular haemorrhage - do coronal ultrasound. Bleeds from choroid plexus, can extend, risk

obstructing CSF flow, may lead to decrease blood flow to brain, brain matter dies, causing cysts to

form. Grade 1 (terminal matrix haemorrhage) to 4 (bad). Give IV vitamin K to help with clotting

factors to prevent intraventricular haemorrhage.

o Retinopathy of prematurity (Vision) - abnormal growth of blood vessels near retina


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(neovascularization). Causing fibrosis, retinal detachment. Stage 1 to 5 (total retinal detachment).

o Hearing - abnormally developed cochlear and auditory nerve. Gentamicin given may have long term

affect on their hearing too.

Viability

26 weeks onward have good outcomes (>85% survival). Grey zone 23 to 25 weeks (medical advice is to

avoid resuscitation as mortality rate is 50%, severe disability is 25%). 25 weeks is difficult.

Less than 23 weeks, 0% survival.

23 to 25 week morbidities. 100% respiratory support, a good portion will have chronic lung disease.

>90% of premmies attend normal school programs

Cerebral palsy

2.5kg 1.5/1000

Hard to diagnose early. May only dx 8 to 12 months. Need to monitor tone of baby and general motor

development

Early indicators may be IVH or periventricular leukomalacia (PVL)


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Gynaecology

HPV vaccine/cervical cancer

High risk types - 16 and 18 ( cause 70 to 80%)

Low risk - 6 and 11 (cause low risk pap smear changes and genital warts)

Gardasil - 6, 11, 16 and 18 also cross protection. Long lasting protection. At least 10 years.

50% of women HPV positive within 3 months with only one partner.

HPV lies within the keratinocytes, therefore any skin to skin contact with genitalia increases risk of infection.

CIN 2 or 3, 35% regress in 6 months, do repeat colposcopy and pap smear in 6 months.

Vulval or vaginal lesions are less likely to regress.

Prevents from genital warts. Incubation is short?

Laryngeal papilloma, affects respiratory function - in vertical transmission from mum to baby during birth,

associated with type 6 and 11

HPV vaccine - 0, 2 and 6 months.

Pap smear Transformation zone ~ area which was squamous pre-pubertally and has undergone metaplastic

change to become glandular columnar epithelium (higher than the transition zone)

Transition zone ~ point of the squamous columnar junction

Pap smear the transformation zone

Cytology ~ leukocytes (neutrophil), pap cells stain keratin orange and other things green. Squamous

cells have big cytoplasm compared with nucleus. Glandular cells ~ mucin producing cells,

honeycomb looking. Note all epithelial cells have keratin, squamous have high molecular weight and

glandular cells have low molecular weight. Endometrial glands ~ clumping.

Need to fix slide at 20cm distance. Too close, you'll freeze it, too far and it wont fix, degrades and

affects interpretation. Dont want to do a pap smear and end up with technically unsatisfactorysample

Even thin spread of the material.

Need to correctly label them with pencil (name, DOB).

Undirected pap smears ~ screening tool, done by scientists usually

Directed pap smears ~ seen by pathologist and scientist, when you suspect or know there is

abnormality

Australian Modified bethesda grading used to determine and guide treatment. More useful than CIN1

or 2 or 3 grading. Need to know Australian Modified Bethesda Grading, which is reported in the

pathology report, guides treatment instead of CIN grading

Can find bacteria in pap smear: actinomyces, trichomonas, gardnerella

Day 7 to 15 is the best time to do a pap smear

HPV + CIN1 = Low risk, do repeat smear in 6 to 12 months

HPV + CIN2 or 3 = High risk, unlikely to regress on its own, need to do colposcopy and biopsy to

confirm

HPV DNA testing to replace pap smears as a screening tool for cervical cancer

Liquid based cytology thin prep - added benefit of HPV DNA testing

High Risk Strains - 16, 18, 31, 35 (no vaccine currently available against these strains)


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Table 1 The Australian Modified Bethesda System 2004, comparison with previous terminology

New Australian NHMRC

terminology

AMBS 2004

Australian NHMRC endorsed

terminology 1994

Incorporates

Squamous abnormalities

Possible low-grade squamous

intraepithelial lesion

Low-grade epithelial abnormality

Nonspecific minor squamous

cell changes. Changes that

suggest but fall short of

HPV/CIN 1

Low-grade squamous



HPV effect, CIN 1

Possible high-grade squamous

lesion

Inconclusive, possible

high-grade squamous

abnormality

Changes that suggest, but fall

short of, CIN 2, CIN 3, or SCC

High-grade squamous


High-grade epithelial

abnormality

CIN 2, CIN 3

Squamous cell carcinoma


abnormality

Squamous cell carcinoma.

Glandular abnormalities

Atypical endocervical cells of

undetermined significance


Nonspecific minor cell

changes in endocervical cells.

Atypical glandular cells of

undetermined significance


Nonspecific minor cell

changes in glandular cells

Possible high-grade glandular

lesion

Inconclusive, possible

high-grade glandularabnormality

Changes that suggest, but fall

short of, AIS oradenocarcinoma

Adenocarcinoma


abnormality

Adenocarcinoma


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Pelvic Masses

Relevant Pelvic Anatomy

Round ligaments - support the uterus in pregnancy. Lots of shooting pelvic pain is caused by the

ligaments being stretched and taut.

Uterosacral ligaments + Cardinal ligaments* - *main support for uterus to the scrum.

Broad ligament - double layer of perineum, wrapping around vessels

Ovarian arteries and veins - passes over external iliac artery

Ovaries look white in real life.

Ureters - need to identify and save during gynecological surgery. Movement described as

vermiculation.

Internal iliac arteries > uterine artery runs over the ureter "water under the bridge"

Vaginal arteries and anastomosis.

Bladder - emptied with catheter. Looks flat and transparent.

Obliterated umbilical artery

Pouch of Douglas

3 million oocytes (foetus) > 300,000 (baby) > 300 periods in a lifetime. Lots of wasted ovaries.

DDx

Extra ovarian - Ectopic, fibroids, abscess, irritable bowel syndrome, inflammatory bowel disease

Ovarian - 1. Endometriomas (chocolate cysts), 2. Serous cystadenoma, 3. Teratoma, 4. Hemorrhagic

cysts, 5. Mucinous cystadenoma, others. Neoplasm

--> Classify as benign or malignant, functional or pathological, Extraovarian or Ovarian

Functional vs pathological

Serous, mucinous, endometriosis,

Benign vs Malignant

Determines the nature of surgery

Benign ovarian cysts

Histology epithelial cells, germ cells, sex cord/stromal cells

Functional - corpus luteum 'yellow body'

Polycystic ovaries - 20 per cent of women have, though only a proportion have PCOS.

U/S and irregular bleeding and higher levels of testosterone

Types of cells - Epithelial, Serous, Mucinous, Endometriomal, Stromal (sex cord) , Transitional cell

Teratoma aka dermoid (germ cell) - most common solid type benign mass in the ovary. Classically have

skin, hair, sebum (gives it a yellow appearance) . Can undergo torsion. Can be bilateral. Rarely undergoes

malignant change.

MGMT

For functional cysts - observe and do repeat u/s. Can suppress with the pill if recurrent.

Surgically, laparoscopic. If malignant do laparotomy.

Sx: pain due to acute stretching of rupture or bleed of the cysts or tumors or torsion. Mass effect. If slow


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growing then there usually is no or little pain.

Torsion of ovary - traditional thought that 6 hours where it can be saved (like torsion of the testes) . (Thought

now is it is viable over at least 24 hours maybe even 72 hours based on animal studies).

Ovarian ligament stretches with an ovarian mass and causes torsion.

Fibroids

Most common pelvic tumour in women 30 - 70%

Monoclonal

Hormonally stimulated, most shrink after menopause.

Malignant change is very rare.

Location - intramural, subserosal (mass effect, pressure/pain symptoms, trouble with intercourse, push on

ureter, bladder urinary urgency, incomplete voiding), push on bowel constipation, can tort), submucosal

(heavy bleeding, spotting between periods, infertility), cervical (trouble with delivery), etc

Mgmt - Medical nsaids, tranexamic acid, mirena, copper IUD, OCP

Surgical, endometrial ablation, uterine artery embolisation, myomectomy (laparotomy, laparoscopy,

hysteroscopy), hysterectomy

Risk of malignancy index 1x2x3

1) Premenopausal 1 pt, Postmenopausal 3 pt.

2) Nature of cysts simple 1 pt , some complexity 2 pt, complex 3 pt.

3) Serum CA125 level.


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Holistic women's health

Abortion

Levonorgestrel - most efficacious within 12 hours

Misoprostol with mifepristone (RU486) - anti progesterone, results in expulsion of products of conception

within a few hours (up to 9 weeks gestation), works by delaying ovulation

Methotrexate - anti folate properties

IUD - insert within 5 days of intercourse, makes the uterus unsuitable for implantation

Surgical - dilation and curettage

Premenstrual syndrome

Anytime following ovulation to the first few days of bleeding. Important to have at least one week free after

bleeding.

OCP and mood - may help with PMS in terms of levelling out the highs and lows. But is the same if you take

the 4 days off?

Premenstrual Dysphoric disorder - important to screen for underlying depression or other mental health

disorder. Also screen for postpartum depression.

Associated Sx - headache, bloating, abdominal discomfort, irritability, change in bowel habits, back pain

Normal menstrual cycle length 23 to 31 days

Mgmt - lifestyle modification (exercise, food, sleep, family dynamics), OCP, hysterectomy, antidepressants

(SSRIs in very small doses, works even when you take it for 2 weeks out of the 4 after ovulation, anti-anxiety

effects)

Vaginismus

Do you lubricate or get wet? Do you enjoy sexual intercourse? Foreplay? Positions? Do you come to

orgasm? Pain during sex? Ejaculation, when, where, withdrawal?

Do you use tampons?

Explore other factors : relationship between husband and wife? Religious, cultural factors? Sexual assault?

Pelvic floor exercises always help

Check for other anxiety factors in her life.

Vaginal Examination

Make sure you ask for permission for everything.

Menopause

Perimenopause

12 months of continuous amenorrhea

45-55 years

Check Beta-inhibin/AMH levels


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Biochemical markers and investigations of menopause - FSH, LH, AMH, antral follicle count (US)

Classical symptoms

Hot flushes (~65% in western countries, 25% significant hot flushes)

80% > 1 year duration

9% beyond 70 years old

Common cause for presentation

Night sweats

Insomnia

Mood & Memory changes

Aches and pains ('catalogue of doom')

Definition: permanent cessation of menstruation resulting from loss of ovarian follicular activity. Recognised

to have occurred after 12 consecutive months of amenorrhoea.

Mean aged 45 to 55 years.

4 stages: 1. Prereproductive, 2. Reproductive, 3. Menopausal transition, 4. Postmenopause

FSH, AMH, b inhibin, antral follicle count (via u/s) vary throughout these stages

Most common Sx:

Hot flushes (65% in western countries, 80% often last for more than 1 year, 80% free of symptoms in 5

years, 25% have severe hot flushes, 9% continue to have hot flushes >70 years)

Night sweats, insomnia, mood and memory changes, aches and pains

Long term factors: cardiovascular and osteoporosis

Mgmt:

- Lifestyle changes: weight loss, exercise, diet (- phytoestrogens (E from plants), most commonly from soy

and legumes. Mediterranean diet, Japanese diet also higher in flavonoids.)

- HRT: most effective treatment for moderate to severe symptoms. Most appropriate to use/initiate if you

had menopause within 10 years. Initiate treatment when symptoms are troublesome. If woman has had a

hysterectomy, then she only needs oestrogen. If not, then they need oestrogen and progestogen (blanket

term for progesterone and synthetic progesterone). No major harm if used for less than 5 years. Second line

treatment for osteoporosis.

Link to increased risk of breast cancer probably due to progestogen but really only if HRT is used for morethan 5 years. Oestrogen alone is pretty safe.

Good evidence to show HRT helps protect/preserve cardiovascular health. Oral OCP and HRT increase

thromboembolism and ischaemic stroke risk, but not significantly until they are >60 years (dermal patches

do not increase risk). Combined HRT does not increase risk of endometrial cancer (unopposed E increases

risk of endometrial cancer). Dosing is continuous oestrogen and progesterone for those that had not

menstruated for 1 year.

Sequential therapy is used for those who are not yet menopausal, where they are given

continuous oestrogen and 10 - 12 days of progestogen so they get a withdrawal bleed.

Continuous therapy - continual oestrogen and progestogen without break

- Remifemin - natural black cohosh. Herbal product that can be trialled in women who are contraindicated


29/60

for oestrogen HRT preparations. (e.g. those who had breast cancer before)

- gabapentin 900mg (high dose) a day for those with severe flushes ( safer to use for patients who have

early menopause as a result of chemotherapy in breast cancer)

- antidepressants (venlafaxine, paroxetine, escitalopram, citalopram ), reduces hot flushes by 67%

- HRT with SERM e.g. tamoxifen, bazedoxifene (oestrogen and selective oestrogen receptor modulator):

acts entirely via oestrogen, alleviates vasomotor symptoms, protects endometrium (note this is entirelydose related), reverse bone density, does not stimulate breast tissue. VTE risk is no greater than using E

alone.

- Vagifem - pessary in vagina. Helps restore elasticity and the normal bacterial flora so that it is better

lubricated and less incidence of UTIs.

- no evidence for Troche - which are lozenges made up with various levels of testosterone, oestrogen,

progesterone, DHEA by compounding chemist. Dont work. No evidence to support. Most of the lozenge

gets loss in the buccal mucosa and oesophagus anyway. Don't work most absorbed in GIT, don't make it to

systemic system.

s/e: mastalgia, breast enlargement, somnolence, insomnia, reduced libido

For interest - difference between HRT and OCP. OCP has higher doses of oestrogen and progestogen

which are given daily, after which there is a placebo to allow for bleeding. OCP use synthetic oestrogen.

HRT uses natural oestrogen at lower doses.

Menopause clinic

Q to cover in Menopause hx:

What is your reason for attending the clinic?

Menopausal (or oestrogen deficiency) symptoms to cover: hot flushes, light headed feelings,

headaches, irritability, depression, unloved feelings, poor memory, sleeplessness, unusual

tiredness, backache, joint pains, muscle pains, new facial hair, unusually dry skin, loss of

libido/sexual desire, dry vagina, pain/discomfort during intercourse?

Have you had a hysterectomy?

When was your LMP? last pap smear? last mammogram?

Have you ever taken HRT? if so, when did you start or stop? Why did you stop? If you are still taking

it now, are you taking oestrogen ? progestogen? both?

Have you tried any other alternate therapies to control menopausal symptoms?

How has your health been in general? Past medical history?

Family our past history of : osteoporosis, heart disease, stroke, cancer of the

breast/ovary/uterus/cervix/others?

Vagifem - pessaries (or tablets) inserted into vagina for 2 weeks continuously, after which you insert 1 tablet

Vaginal cream - messy but provides lubrication

o both help increase elasticity of the vaginal wall, help with maintaining the bacterial flora to decrease

likelihood of getting UTIs.

Troche - not evidence based, 'bioidenticals' lozenges made up by compounding chemists of Testosterone,estrogen, progesterone, DHEA specifically tailored to the patients hormonal levels.


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Primary ovarian insufficiency (POI)

Menopausal levels of FSH and LH, symptoms (irregular menses) in women under 40 or in adolescent girls.

Due to decreased number of follicles or accelerated rate of follicular loss. Most idiopathic causes unknown,

iatrogenic most common (chemotherapy, radiotherapy). Immunological (hypothyroidism, hashimotos,

Addison disease) and other genetic (e.g. fragile x), infections (e.g. TB), metabolic causes (e.g. myasthenia

gravis)

Think of it as an endocrine deficiency syndrome (early loss of oestrogen, progestogen etc)

Long term causes are similar to menopause but exaggerated. Also infertility.

Treatment is similar to that for menopausal women, but doses of oestrogen may be higher, and will need to

be given until they are at least 45years old.

Breast cancer

Increased breast density is the single highest indicator after genetics or family history that increase risk of

getting breast cancer. 1 in 8 get breast cancer.

Pelvic Pain

Acute onset pain: reflects fresh tissue damage, resolves as tissue heals

Gynaecological

pregnancy complications: ectopic, miscarriage

Ovarian cysts complications: rupture, torsion, haemorrhage PID

Endometriosis

Surgical : appendix, calculi

Chronic pain: >6 months, intermittent, constant pain

Gynaecological

Chronic PID

endometriosis

Adenomyosis

Fibroids

Surgical: chronic appendicitis renal calculi, IBS/IBD, diverticulitis

Other: musculoskeletal, neuropathic pain, interstitial cystitis

Red flags

bleeding per rectum

new bowel sx >50 yo

new pain after menopause

pelvic mass

suicidal ideation


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excessive weight loss

irregular vaginal bleeding >40yo

postcoital bleeding

Endometriosis

Endometriosis - CYCLICAL PERIOD PAIN, CYCLICAL dysmenorrhoea , dyspareunia, pelvic pain,

dyschezia, back pain

1 in 10 women

Sx: pain (with period, during ovulation, passing urine, intercourse, lower back pain), abnormal bleeding,

cyclical nature, infertility (30% of infertile women have endometriosis), cyclical bowel pain

(dyschezia)/symptoms

Causes: Potentially caused by retrograde menstruation and coelomic metaplasia in susceptible patients.

(Genetic factors, poorer immune systems (many women who suffer from endometriosis complain of

chronic fatigue, have sle, thyroid related disease, allergies), Environmental dioxins, weight, delayed

childbearing and fewer children (more menstrual cycles)

Stage 1 (minimal) to 4 (lots of adhesions, severe disease) - determined based on laparoscopic findings

Complications of laparoscopy:

3 types of risk. 1. General anaesthetic (incubation, reaction), 2. General surgical risk (bleeding, infection,

wound site) 3. Specific surgical risk (bowel, bladder, ureter complications)

Endometriotic cyst: chocolate cysts, endometrial cells in cysts, haemosiderin.

Mechanism of infertility in endometriosis: unfriendly immunological environment for the ova and sperm.

Suboptimal environment for endometrial implantation. Damage to ovary, ovulation process, tubal damage.

Medications for endometriosis

Analgesics to manage the pain.

OCP helps to manage the disease. Since progestogen is given continuously, the endometrium cannot

develop as much therefore it's thinner and therefore there is less bleeding.

Danazol (testosterone based) not popular. Look like a man.

Progestogens 2nd line

Menopause inducing medications 3rd line ( very effective) - includes GnRH agonist ( zoladex)

Pelvic inflammatory disease

Causes: 1. Chlamydia, 2. Gonorrhea,3. Mycoplasma, or anaerobes ( infection from retained products of

conception)

Low threshold for treatment of PID due to many implications ( earlier treatment, the lesser the damage):

infertility (tubal damage), ectopic pregnancy, chronic pelvic pain, recurrent episodes of PID. Need to advise

using condoms, screening sexual contacts.

Most common cause of death in women from gynaecological causes is ruptured ectopic pregnancy.

Structure and function of the female reproductive system

For ovaries to undergo torsion, they are usually abnormal ovaries already.


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Normal menstrual cycle:

1. Follicular (ovarian) /proliferative (endometrium)

2. Ovulation - LH spike leads to lysis of follicular cell wall. cilia in the tubal epithelium bring the egg through to

uterus. Therefore normal tubal epithelium is very important.

3. Luteal (ovarian) / Secretory phase (endometrium) - rapid vascularisation to corpus luteum ( ruby red),

mittelschmerz pain, rapid bleed into corpus luteum. Granulosa cells start to produce progesterone for 14

days. Corpus luteum will then die unless there is HCG produced by trophoblast of implanted zygote.

Menstruation: average blood loss 25 to 60 ml. Progesterone withdrawal, vasoconstriction, shedding,

fibrinolysis, homeostasis, re epithelialization. Heavy bleeding you get clots, not enough enzymes to break

down blood to stop clotting. Light bleeding, no clots. Can stop bleeding with oestrogen.

Hypothalamus: unmyelinated nerve fibres (synthesizes GnRH), myelinated fibres (regulates the GnRH)

Pulsatile GnRH secretion - amount of GnRH depends on the absolute amount produced and the amount of

receptors available.

Anterior pituitary makes FSH, LHFSH - stimulates follicular maturation and aromatisation of androgens to oestrogen

LH - Stimulates theca cells to produce androgen, ovum maturation and resumption of meiotic division ( LH

surge due to changed positive feedback by E), ovulation and lutenisation of granulosa cells, formation of

corpus luteum.

Inhibit - inhibit FSH

Activin - stimulate FSH

Gynaecological cancers

Endometrial cancer

Most common gynaecological cancer, roughly 1 in 80 Mostly a post-menopausal cancer, very uncommon in young people except in women with

PCOS (unopposed oestrogen)

Check staging of endometrial cancers

Risk factors include

Age

High socioeconomic group

Nulliparity

Infertility

Early menarche

Late natural menopause

Obesity (naturally compounds with increased oestrogen)

PCOS

Diabetes, hypertension

Tamoxifen

Unopposed exogenous oestrogens

Symptoms include:

Abnormal vaginal discharge

Postmenopausal bleeding, irregular bleeding and discharge

Pain or difficulty with micturition

Pain not usual, if bleeding is heavy then pain is associated with an expulsive uterinecontraction


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Gynae-oncology

Endometrial cancer - most common gynecological cancer. 1 in 8 women. RF: Cancer of

premenopausal women. unopposed (endogenous/exogenous) oestrogen stimulation. Nulliparity.

Infertility. Early menarche, late menopause. Obesity!!! (Fat converts androgens to oestrogen). PCO (not

ovulating, just oestrogen no progestogen). Tamoxifen use (SERM, weak oestrogen in the endometrium).

Hypertension.

o HNPCC lynch syndrome. Microsatellite instability. 50% risk of endometrial cancer.

o Sx: postmenopausal bleeding!!!!!, abnormal vaginal discharge, irregular bleeding/discharge, pain or

difficulty with micturition (advanced cancers).

o Dx: dilatation and curettage main test. 5% will.have a positive pap test. Outpatient endometrial

sampling (looks for hypoplastic endometrium. not done much in australia)

o

Mx.: total hysterectomy and bilateral salpingo oophorectomy. Pelvic +- paraaortic node dissection.

Remove the uterus at time of surgery. Often avoid nodes if the cancer is superficial due to risk of

lymphoedema. For higher risk disease, may use radiotherapy and chemotherapy as adjuvant but not

standard. Hormonal therapy used in young women by giving high dose progestogen (provera,

mirena, combined with curettage), may actually help cells regress so that the female can have

babies, after they have had enough kids, do hysterectomy.

o Once cancer has spread outside uterus, incurable, poor survival.

Cervical cancer:

Incidence in Australia is approx. 1 in 218

Incidence is decreasing in developed countries

1st or 2nd most common cause of cancer death in women worldwide

Known risk factors:

Early coitarche

Multiple sexual partners

Lower socioeconomic group

Smoking

HPV exposure (oncogenic subtypes)

Sx:Asymptomatic, Postcoital bleeding, Intermenstrual bleeding, Abnormal discharge, Pain, Urinary or bowel

symptoms

Ovarian cancer: leading cause of death from Gynaecological cancer in Australia. 90% derived from

coelomic epithelium (cells from fallopian tube). Peak age RF: endometriosis, BRCA1 (Can get it very

young), BRCA2, HNPCC,low parity, early menarche, late menopause, incessant ovulation.

o ix: transvaginal ultrasound

o Prophylactic surgery for women with high risk. Prophylactic salpingo oophorectomy.

o In postmenopausal women who are getting hysterectomy for whatever reason, do salpingectomy. try

to leave ovaries as they protect women from heart disease.

o Ovarian cancers spread coelomically, to omentum. If spread to peritoneum or abdominal organs, you

would surgically debunk as much as possible and then use chemotherapy. May do neoadjuvant

chemotherapy to reduce the size and reduce ascites, reduces morbidity from surgery. Good

response rate to chemotherapy but poor cure rates. Carboplatin and taxol.

o Tumour markers CA125.

o Germ cell tumours often in young women: yolk sac tumour, immature Teratoma, dye?. Can be cured

with chemotherapy.

o Cyst adenomas, transitional cell, mucinous, endometrial, clear cell, peritoneal cancer

o Stromal tumours: granulosa cell, sertoli laden cell tumours treat with surgery.

o Epithelial cancers: benign , borderline tumours (stratified epithelium, high mitotic count, atypical cells)

, cancer (invades and destroy normal tissue)


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Vulval cancer:

Gestational trophoblastic disease (molar pregnancies): mole = amorphous mass. Rare but is fully

curable tumours from the products of conception. 1 in 600. More common in south east asian.

Advanced maternal age for incomplete moles. History of spontaneous abortions.

o Hydatidiform mole (grapelike). Partial moles derived from Tripoli conceptus (1 haploid maternal, diploid

is paternal. 69 XYY), may have foetus unlike Complete moles (diploid all paternal chromosome 46XXmostly, 46 XY as there was an empty egg and sperm fertilization, no foetus). Need to know partial vs

complete mole!!!! U/S diagnosis, looks like a snowstorm, tiny vesicles.

Mx: suction curettage. Follow bHCG until it goes to zero as quickly as possible e.g. 8 weeks. If

bhCG takes long to decrease, then need to follow up for 12 months to ensure there is no

recurrence. Tell patient to avoid getting pregnant at this time other confusing bhCG. If bHCG is

persistently high, then give chemotherapy methotrexate.

Complications. Theca lutein cysts, respiratory distress syndrome. Etc

o Gestational choriocarcinoma - rapidly metastatic disease, hyperemesis gravidarum as you have very

high hCG, lots of bleeding.

o Placental site tumour.

o Epithelioid trophoblastic tumour. Can be invasive.

o Phantom serum hCG. Rare false positive hCG due to antibody against antigen in test. Look for hCG in

the urine as antibodies don't go into urine.

Uro-Gynaecological issuesIncontinence: 33% of women past 25 years will have incontinence in some time in their life.

3 types

Stress incontinence: weak bladder neck, involuntary leakage

stress urinary incontinence

Urodynamic stress incontinence

Urge incontinence: involuntary leakage preceded by urgency

Mixed incontinence

Overactive bladder in 15 - 20% of women, idiopathic causes

o Sensory urgency

o Detrusor overactivity: involuntary leakage when Detrusor > urethral pressure

o urgency* (cardinal symptom), frequency (>8 voids a day), nocturia, urge incontinence. Intravesical

spasm is felt as urgency.

Risk factor for stress incontinence

Childbirth/pregnancy, >4 kg, 3rd degrees tear, forceps, lengthy 2nd stage

Obesity

Management: vaginal oestriol. Vagifem?

Hx: type, when it starred, triggers, pads?, urinary incontinence, obstetric history etc how often to they go to

the toilet, how much does it impact their life, UTI.

specific examination: stress provocation test, transperineal u/s.

Normal values: mean 24HR volume 1430 ml, mean frequency 6/24, average vol voided 250ml.


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Women with stress incontinence, bladder shrinks because they empty it too often and it doesn't hold

volume. Vicious cycle.

Healthy bladder should empty to 0. Anything greater than 30 to 40 mmhg is a problem.

Stress incontinence Mgmt:

o lifestyle changes and bladder retraining (less caffeine, better toilet habits, increase water habit) Pelvic

floor muscle training, mid urethral slings, pessaries

Urge incontinence mgmt

Meds: antimuscarinics (reduce bladder spasm), anticholinergics (ditropan, vesicare) s/e: dry mouth,

dry eyes, constipation contraindicated in pt with glaucoma, ulcerative colitis.

Botox, injecting into bladder via cystoscopy. Usually 30 sites. Lasts 9 months. Over Paralyse bladder

and need to self catheterise (10%). Very expensive.

Sacral nerve stimulator, implanted in base of spine to S3. Used for faecal and urinary incontinence.

Pelvic Organ Prolapse POPe.g. Bladder - cystocele, Rectus - rectocele, Vagina / vagina vault, Cervix

Cervical prolapse

Causes: obesity, pregnancy/childbirth, age

Sx: asymptomatic, dyspareunia, feel a bulge, something coming down, urinary symptoms, pain in N

Grade it : mild moderate, severe

Mgmt: watch and wait, ring pessaries, definitive treatment surgery - total vaginal hysterectomy,

sacrocolpopexy (attach vagina to sacrum?)

Important questions: Are you sexually active? If no, do you have ambition to be sexually active? Important to

know because it will determine how tight you close the vagina.


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Bloods: biochemical markers increased free bHCG and low PAPP-A (made by placenta) in Trisomy 21.

(In Trisomy 13/18, bHCG is decreased, in Turners syndrome, bHCG is normal).

Chorionic-villus sampling (CVS) - biopsy from the placenta. Can be done 11 to 14 weeks (earlier). Risk:

trickier to do (need to locate the placenta), >1% increased risk of miscarriage. Full karyotype results take

2.5 weeks. PCR/FISH test for the common syndromes within 24 hours (99.9% accurate).

Amniocentesis - skin cells from foetus in the 20 ml amniotic fluid. Can be done from 15 weeks onwards.

Easier to do. Risk: 1% increased risk of miscarriage. Results take same amount of time for CVS.

NIPT (non invasive prenatal testing - cell free foetal DNA in maternal plasma ), microarrays (best test) -New screening methods to detect chromosomal abnormalities. Privatised, costly still. Copy Number

Variants - any gain or loss in DNA.

12 week scan - check if it's multiple pregnancies, screen for syndromes, date the pregnancy.

Screen uterine artery for pre-eclampsia, preterm delivery,

2nd trimester screening

Fetal morphology ultrasound - done at 20 weeks. Looks for structural abnormalities, assesses fetal

growth, localised placenta, multiple pregnancies, assess for markers of aneuploidy.

Fetal blood sample - fine needle through abdominal wall and uterus into placental cord. Can do from 18

weeks. Done when baby is anaemic, due to top 3 reasons: transfusion in rhesus disease or mum hasparvovirus (baby gets slapcheek) or fetal maternal haemorrhage. Others include thalassemia.

Otherwise not done due to high risk of marriage.

Pregnancy timeline

Conception

The moment of conception is when the womans ovum (egg) is fertilised by the mans sperm. The gender

and inherited characteristics are decided in that instant.

Week 1

This first week is actually your menstrual period. Because your expected birth date (EDD or EDB) is

calculated from the first day of your last period, this week counts as part of your 40-week pregnancy, even

though your baby hasnt been conceived yet.

Week 2

Fertilisation of your egg by the sperm will take place near the end of this week.

Week 3

Thirty hours after conception, the cell splits into two. Three days later, the cell (zygote) has divided into 16

cells. After two more days, the zygote has migrated from the fallopian tube to the uterus (womb). Sevendays after conception, the zygote burrows itself into the plump uterine lining (endometrium). The zygote is

now known as a blastocyst.

Week 4

The developing baby is tinier than a grain of rice. The rapidly dividing cells are in the process of forming the

various body systems, including the digestive system.

Week 5

The evolving neural tube will eventually become the central nervous system (brain and spinal cord).

Week 6

The baby is now known as an embryo. It is around 3 mm in length. By this stage, it is secreting special

hormones that prevent the mother from having a menstrual period.


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Week 7

The heart is beating. The embryo has developed its placenta and amniotic sac. The placenta is burrowing

into the uterine wall to access oxygen and nutrients from the mothers bloodstream.

Week 8

The embryo is now around 1.3 cm in length. The rapidly growing spinal cord looks like a tail. The head is

disproportionately large.

Week 9

The eyes, mouth and tongue are forming. The tiny muscles allow the embryo to start moving about. Blood

cells are being made by the embryos liver.

Week 10

The embryo is now known as a fetus and is about 2.5 cm in length. All of the bodily organs are formed. The

hands and feet, which previously looked like nubs or paddles, are now evolving fingers and toes. The brain is

active and has brain waves.

Week 11

Teeth are budding inside the gums. The tiny heart is developing further.

Week 12

The fingers and toes are recognisable, but still stuck together with webs of skin. The first trimester

combined screening test (maternal blood test + ultrasound of baby) can be done around this time.

This test checks for trisomy 18 (Edward syndrome) and trisomy 21 (Down syndrome).

Week 13

The fetus can swim about quite vigorously. It is now more than 7 cm in length.

Week 14

The eyelids are fused over the fully developed eyes. The baby can now mutely cry, since it has vocal cords.

It may even start sucking its thumb. The fingers and toes are growing nails.

Week 16

The fetus is around 14 cm in length. Eyelashes and eyebrows have appeared, and the tongue has

tastebuds. The second trimester maternal serum screening will be offered at this time if the first

trimester test was not done (see week 12).

Week 18-20

An ultrasound will be offered. This fetal morphology scan is to check for structural abnormalities,

position of placenta and multiple pregnancies. Interestingly, hiccoughs in the fetus can often be

observed.

Week 20

The fetus is around 21 cm in length. The ears are fully functioning and can hear muffled sounds from the

outside world. The fingertips have prints. The genitals can now be distinguished with an ultrasound

scan.

Week 24

The fetus is around 33 cm in length. The fused eyelids now separate into upper and lower lids, enabling the

baby to open and shut its eyes. The skin is covered in fine hair (lanugo) and protected by a layer of waxy


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secretion (vernix). The baby makes breathing movements with its lungs.

Week 28

Your baby now weighs about 1 kg (1,000 g) or 2 lb 2oz (two pounds, two ounces) and measures about 25

cm (10 inches) from crown to rump. The crown-to-toe length is around 37 cm. The growing body has

caught up with the large head and the baby now seems more in proportion.

Week 32

The baby spends most of its time asleep. Its movements are strong and coordinated. It has probably

assumed the head down position by now, in preparation for birth.

Week 36

The baby is around 46 cm in length. It has probably nestled its head into its mothers pelvis, ready for birth. If

it is born now, its chances for survival are excellent. Development of the lungs is rapid over the next few

weeks.

Week 40

The baby is around 51 cm in length and ready to be born. It is unknown exactly what causes the onset oflabour. It is most likely a combination of physical, hormonal and emotional factors between the mother and

baby.

Preterm birth/labour

infant born before 37 weeks of gestation is preterm.

37 - 41 weeks and 6 days is full term.

42 weeks and over is postterm.

Miscarriage: >20 weeks and or >400g otherwise it is a registered birth

Preterm birth risk factors: multiple pregnancy (biggest risk factor), spontaneous preterm labour, preterm

rupture of membrane, cervical incompetence, iatrogenic, pre eclampsia, antepartum haemorrhage.


Crosses the placenta, enter foetal circulation. Single course considered in all preterm deliveries from 26

(24?) weeks onwards, preterm rupture of membranes and hypertension. Need to decide how likely the

mother is going to deliver within the next 48 hours, as you cannot give repeat doses.

Benefit is shown up to 34+6 weeks.

Reduces respiratory distress syndrome

Reduces intraventricular haemorrhage

Reduces necrotising enterocolitis

Reduces mortality

Reduces systemic infections in first 48 hours of life

Reduces rate of NICU admission

Betamethasone IM 11.4mg (high dose) or Dexamethasone 12 mg IM: 2 doses given 24 hours apart. Don't

given repeated steroid doses.


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Evidence for corticosteroids is for up to 34 weeks and 6 days.

Tocolysis/ tocolytics to suppress labour

Buys time to allow corticosteroids to work and to transfer to tertiary centre.

Calcium channel blockers (nifedipine = adalat) - no benefit in women have PPROM.

Shouldn't be given to women who have threatened preterm labour (TPL) unless you need to delay delivery.

Some places don't use tocolytic agents, evidence for using it is very poor

Oral Antibiotics

Used for preterm premature rupture of membrane (PPROM). Not used if the membranes are intact.

Oral abx erythromycin (bacteriostatic drug) to mother for 10 days.

Short Term outcomes better. Long term outcomes no different.

IV Magnesium sulfate MgSO4

Used in women with preterm birth up to 33 weeks 6 days (before 34 weeks gestation). (Australian

Guidelines is up to 30 weeks for practicality). More premature the baby, the more likely they'd benefit.

Given 4 to 24 hours before birth and give continuously.

Used in preeclampsia to prevent eclamptic fits.

Some evidence to suggest it decrease risk of cerebral palsy and improves mortality in preterm babies.

Some sort of neuroprotectiveeffect. S/e to mother: hypotension, tachycardia therefore needs 1 to 1

midwifery care.

Cerebral palsy 1 in 500. Obstetric rfs include preterm birth 18 hours of labour, baby greater risk of infection, most likely treat


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then the HCG won't double, therefore worthwhile taking trend). bHCG detectable in blood as early as day 6,

urine day 14

By 12 weeks the baby has all organs (fully developed), after this, the baby just grows.

Placental development: maternal and foetal blood does not mix normally. During birth it does mix. Blood

group is important to know. 85% are positive, 15% are negative. If the mother is negative and the baby is

positive, the maternal system will initiate an immune response though isn't very proficient in the first baby. In

second baby, the immune response is strong enough to kill the foetus, hence we use anti D.

Give anti D within 72 hours of the event of the blood mixing to the mother, it tags the mounting immune

response and destroys it so that the mother's immune system remains naive. It works for 6 to 8 weeks.

Umbilical cord needs to insert into the m

Documents

Perinatal Womens - neonatology, gynaecology, obstetrics notes