CERVICAL CANCER SCREENING
1.
2.
3.
HPV testing (primary screening for 30-49 years
old, performed 5 yearly) QS. Why 5-yearly?
Conventional Pap smear → Fixative spray (95%
ethyl alcohol), Ayre’s spatula (fish tail for endo
(long)/ectocervix (short)and blunted end for
lateral fornix)
LBC → ThinPrep, SurePath using cervical brush
(180o rotate)
PRESENCE OF LESION DURING PAP SMEAR
PROCEED WITH COLPOSCOPY
COUNSELLING AFTER PAP SMEAR
https://www.healthline.com/health/womens-health/bl
eeding-after-pap-smear#concerning-symptoms
MANAGEMENT FOR PRECANCEROUS CHANGES OF
CERVIX
1. Loop electrosurgical excision procedure (LEEP)
2. Cone biopsy procedure
3. Cryosurgery / laser surgery
4. Hysterectomy
QS. Screening not done < 25 years old because no
evidence of increased risk of cancer at that age with
HPV vaccination is likely to reduce the risk of cervical
cancer further in young women.
QS. Screening not done > age of 65 if adequate previous
routine screening is done unless the patient does not
meet adequate prior screening criteria or at special risk.
However, the incidence rate for cervical cancer at this
age and above still remains high.
CONVENTIONAL PAP SMEAR
SCREENING POLICY
1. 21-29 years old, 50-65 years old advised for Pap
smear screening
2. Sexually active 30-49 years old should be
screened
3. Screening interval 2 year consecutively
(increase the sensitivity up to 80%) → 3 yearly.
INDICATIONS FOR CONVENTIONAL PAP SMEAR
To detect precancerous conditions of the cervix
~ Untreated precancerous conditions of the cervix may
become cervical cancer after 10 years or more. This
precancerous condition occurs at the transformation
zone whereby columnar (glandular) cells constantly
change to squamous cells which are susceptible to HPV
effect.
ADVISE PRIOR PAP SMEAR PROCEDURE
1. No douching or vaginal medication, sexual
intercouse within 24h
2. Delay pap smear until menses stop
3. Can be done during pregnancy
INTERPRETATION OF PAP SMEAR
1. NILM
2. Squamous cell lesions (SIL)
● LSIL → CIN 1 (mild dysplasia)
● HSIL → CIN 2 (moderate to severe
dysplasia), CIN 3 (severe dysplasia and
carcinoma in situ)
3. Glandular cell lesions
● Atypical glandular cells
● Adenocarcinoma in situ (AIS) preinvasive cancer
LBC PAP SMEAR
INDICATIONS FOR LBC
1. To detect dysplastic/ abnormal cervical cancer
2. To detect high risk HPV virus
ADVANTAGES OF LBC TO CONVENTIONAL PAP SMEAR
1. Lower contamination by blood cells, pus and
mucus
2. More uniformity of cell population, monolayer
3. To reduce the rate of inadequate cytology from
9% to 1.6%
4. High sensitivity with lower artefacts in cellular
morphology
5. Able to detect oncogenic HPV virus
DISADVANTAGES OF LBC TO CONVENTIONAL PAP
SMEAR
1. Expensive
2.
Higher false positive rate
PREMATURE PRELABOUR RUPTURE OF
MEMBRANE (PPROM)
PROM - ROM prior to labour at 37 weeks and above
PPROM - ROM prior to labour AND before 37 weeks
*Infection → tachycardia, febrile, chorioamnionitis
(oligohydramnios/ uterine tenderness).
CRITERIA TO DIAGNOSE PPROM
1. Pooling in posterior fornix (on speculum)
2. Nitrazine test positive - increased pH of
amniotic fluid, low specificity
3. Microscope - ferning of fluid (high salt in
amniotic fluid evaporates)
4. + UFEME TRO UTI
MANAGEMENT (including stated above)
● Abx oral erythromycin 250mg QID - 10 days
○ HVS → antibiotic treatment
● Maternal WB → vital signs, TWC and CRP
● Foetal WB → CTG (if tachycardia, may sign of
intrauterine infection)
● Ultrasound → AF volume
● Delivery
○ Consider it if at 34W, informed ↑ risk
of chorioamnionitis, ↓ risk of neonatal
respi problems
○ Placental swab C&S and HPE should
be sent
RISK FACTORS OF PRETERM LABOUR/ PPROM
Non-modifiable, major
● Infection (vaginal/intra-amniotic)
● Previous preterm delivery
● Twin pregnancies
● Uterine abnormalities
Cervical anomalies (incompetence; damage
from repeated D&C, cervical fibroids)
● Recurrent APH, illness (sepsis), invasive
procedure
Non-modifiable, minor
● Teenager with second pregnancies
● Primid or grand multipara
● Education (not beyond secondary)
Modifiable
● Smoking, drug abuse (cocaine esp)
● BMI < 20
● Inter-pregnancy interval <1 year
●
CHORIOAMNIONITIS
3TF ~ temperature, tachycardia (maternal/foetal),
tenderness (uterus), foul discharge
RISK FACTORS
● PPROM, prolonged ROM/ prolonged labour
● Multiple vaginal examination during labour,
internal monitoring
● Vaginal infection, bacterial vaginosis
INVESTIGATIONS
● FBC (TWC)
● HVS C&S
● Amniotic fluid analysis
○ C&S, Glucose concentration, AF
esterase
MANAGEMENT
● Pad charting
● Abx - 3 doses of IV abx and oral antibiotics for
10 days
○ IV cefuroxime → IV Metronidazole →
oral cefuroxime
● Delivery (SVD/ operative)
COMPLICATIONS OF CHORIOAMNIONITIS
● Increased perinatal mortality and RDS,
●
●
neonatal sepsis, IVH (preterm)
Maternal bacteremia/ sepsis
Uteroplacental bleeding
ANTEPARTUM HAEMORRHAGE
Per vaginal bleeding occurring after 22 weeks
(miscarriage and 22 weeks and before)
DIFFERENTIAL
● PP, PA, VP
● Uterine rupture
● Cervical lesion (cervicitis, polyp, ectropion,
cancer)
● Bowel/bladder bleed
● Coagulopathy
PLACENTA PRAEVIA
Low lying of placenta after 28 weeks (between 22 and
28 weeks are called low lying)
Minor → type 1, type 2 anterior
Major → type 2 posterior, 3, 4
DIFFERENTIAL DIAGNOSIS PER VAGINAL BLEEDING
PP, PA, VP, bladder/bowel injury, scar dehiscence,
coagulopathy, cervical lesion
COMPLAINT
● Painless per vaginal bleeding → TVS >TAS
● Uterus SNT
● Presenting part higher up/displaced
● Hypovolemic shock/anaemia → FBC, Hb
Don’t do VE until PP has been ruled out
RISK FACTORS FOR PLACENTA PRAEVIA
● Previous scar (CS, abdominal surgery, D&C,
myomectomy, abortion)
● Previous PP
● AMA, multipara
● Uterine tumour/ anomalie
PREECLAMPSIA & HYPERTENSION IN
PREGNANCY
1. Assess patient with high risk & moderate risk
2. Aspirin 75 - 100 mg from 12 weeks
3. Routine BP measuring
MANAGEMENT OF PREECLAMPSIA
1. Assess preeclampsia, concerns include
a. BP 160mmHg and above
b. Biochemical & haematological
investigations CAP
i.
Creatinine 90umol/L or
1mg/100mL and above
ii.
ALT 70 IU/L or twice upper
limit of N range and above
iii.
Platelet < 150,000/uL
c. Signs of impending eclampsia
d. Signs of impending pulmonary
oedema
e. Other signs of severe preeclampsia
f. Suspected fetal compromise
g. Others
2. Antihypertensive (labetalol > nifedipine >
methyldopa)
a. Admission 140/90 above
b. Anti hypertensive & targeted BP
135/85 or less
c. Dipstick proteinuria testing if clinically
indicated
d. Blood tests FBC, LFT, RP
e. Foetal assessment FHR
3. Delivery before 37 weeks if
a. Uncontrolled BP after 3 or more
antihypertensives
b. SPO2 < 90%
c. HELLP syndrome
d. Neurological features - severe
intractable headache, repeated visual
scotoma, eclampsia
e. Placental abruption
f. Umbilical artery Doppler - reversed
diastolic flow
4. Delivery < 34w - IV MgSO4 corticosteroid
5. Delivery at 34-36w - IV MgSO4
6. Delivery at 37w - as usual
MANAGEMENT OF CHRONIC HYPERTENSION
**Stop current ACEi, ARBS, thiazide drugs (risk of
congenital abnormalities)
1. Conservative - weight mx, exercise, healthy
diet, lower salt in diet
2.
3.
4.
5.
6.
Continue current antihypertensives drugs if
safe
Target BP after medication 135/85
Labetalol > nifedipine > methyldopa
Offer aspirin 75 - 100mg OD from 12 weeks
Delivery offered after 37 weeks if BP
COMPLICATION OF MOTHER WITH OBESE
Pre-pregnancy
● Risk of miscarriage and recurrent
● DM, heart problem, DVT
Antenatal
● GDM
● Difficulty to assess foetus (palpation and scan)
- wrong dates
Intrapartum
● Anaesthetic complication (aspiration, failed
regional anaesthesia)
● Poor progress, difficult to perform CS due to
thick subcutaneous tissue
● Risk of delivery complication
Postpartum
● Risk of PPH
INDUCTION OF LABOUR (IOL)
Artificial initiation of labour prior to spontaneous
labour
INDICATION FOR IOL
● Maternal - request, medical disorders (GDM,
DM, HPT, autoimmune)
● Foetal - postdate, IUGR, SGA
BISHOP SCORE
To predict the likelihood of IOL by determining labour
progress based on cervical score. Cut of score →
unfavourable for IOL (6 and below)
6 and below → pharmacological method (PGE2
prostin 3mg BD)
● Above 6 → mechanical method (Foley/
laminaria, S&S, ARM+Pitocin)
COMPLICATION OF PROSTAGLANDIN
● Hyperstimulation of uterus → foetal distress,
PPH, uterine rupture
●
WHAT ARE THE CAUSES OF FGR?
● Intrinsic foetal growth potential →
chromosomal abnormalities, trisomy, foetal
infections
● Maternal → malnutrition, cyanotic HD, smoking
and drug abuse
STATION
Station is the relationship of the foetal presenting part
to the ischial spine (0)
POLYHYDRAMNIOS & OLIGOHYDRAMNIOS
1.
BREECH PRESENTATION
TRIAL OF SCAR (TOS)/ VBAC
Defined as 1 previous scar at the lower segment of the
uterus. Before offering TOS, must asked for
● Indication - risk of CPD, foetal distress,
abnormal lie
● Contraindications - prev J incision, upper
segment tear, maternal postpartum
complications (PPH, endometritis)
*PGE2 in VBAC (IOL) is reduced from 3mg BD → 1.5mg
BD to reduce risk of uterine rupture
CAUSES OF BREECH
● Prematurity
● Placenta praevia type 4
● Uterine anomaly, fibroid
● Congenital foetal anomalies → NT scan (10-14
weeks), detailed scan (18-20 weeks)
MODE OF DELIVERY
1. ECV (offer 36 - 37 weeks)
2. Assisted breech delivery
3. ELLSCS if SVD is contraindicated
ABDOMINAL EXAMINATION
FOETAL GROWTH RESTRICTION (FGR)
Defined as failure of foetus to achieve its genetic growth
potential
● Constitutionally small (healthy, both parents
small size)
● Foetal - chromosomal abnormalities (trisomy),
congenital anomalies, foetal infections
● Placental insufficiency
SGA/ IUGR
● SGA - foetal weight below 10th centile for its
gestational age
● IUGR - pathological process restricting foetal
growth rate
https://elearning.rcog.org.uk/easi-resource/maternal-a
nd-fetal-assessment/examination/abdominal-examinat
ion
HEAD PALPABLE
● Head palpable only in cephalic presentation.
● The amount of descent and engagement of the
head is assessed by feeling how many fifths of
the head are palpable above the brim of the
pelvis
● Head engaged when it is 2/5th palpable with
the widest diameter of the head had descents
into the pelvis
● Forcep delivery - acceptable if 1/5th palpable
● Vacuum delivery - acceptable of if 0/5th
palpable
2.
Causes of polyhydramnios
● Congenital anomalies
(esophageal-duodenal atresia,
anencephaly (reduced swallowing,
↓ADH)
● Hydrops fetalis
● Diabetic mother
Causes of oligohydramnios
● Renal → Foetal renal agenesis,
polycystic kidney, urethral
obstruction/ VUR
● Foetal IUGR
● Postdate pregnancy
● PROM
Primary
dysmenorrhea
Occur due to prostaglandin, commonly within 2 years of menarche
● Spasmodic suprapubic pain/ lower abdomen
● During menstruation
● Associated w/ NVD, fatigue, headache, pallor, cold sweats
Secondary
dysmenorrhea
Occur in the presence of disorders eg PAL, PID, common in the 20-30s
● Dull, aching chronic pelvic pain/ lower front & back pain
● Persist even after menstruation
● No systemic discomfort
● VE: lesion palpable or do laparoscopy
Secondary
dysmenorrhea
(causes)
Ovarian
dysmenorrhea
Right ovarian vein
syndrome
(ovarian dysmenorrhea)
Mittelschmerz
syndrome
●
●
●
●
●
●
Polyp of endometrium
Adenomyosis
Leiomyoma (fibroid)
Endometriosis
Chronic pelvic infection
IUCD in utero
●
●
●
2-3 days prior to menses
Continuous and dull pain ~ either one/both lower quadrants
Right ovarian vein crosses the ureter at the right angle → varicose, dilated ovarian veins
inducing chronic ureteral obstruction → risk for infection & pyelonephritis → pain
●
●
●
Chronic pelvic pain
Chronic pelvic pain
(gynaecology causes)
Chronic pelvic pain
(non-gynae causes)
Chronic pelvic pain
(management)
c/o
○ Persistent unilateral pain <12h ~hypogastrium/ one side iliac fossa
○ Assoc w NV and constipation
○ May assoc w sligh PV bleed/excessive mucoid vaginal discharge
Occur during mid menstrual period
MX: analgesic, assurance, OCP if wish to have anovulation
Lower abdominal pelvic pain for ≥6 months, not exclusively cyclical/ intercourse related and
not relieved by analgesic
1.
2.
3.
FT & ovaries → torsion ovarian cyst, PID, malignancy, remnant of ovaries
post-surgery
Uterus → adenomyosis, fibroid, endometriosis, uterovaginal prolapse, malignancy
VV → vulva pain syndrome, varicocele (pelvic venous congestion)
1.
2.
3.
4.
GUT → UTI includ bladder infection (cystitis), calculi, urinary retention
GIT → IBS, IBD, malignancy, abdominal adhesions
Ortho → PID, OA, spondylolisthesis
Psychology → abuse (physical/ emo)
Issue pain
● NSAID +/- PCM/COX2i
● PO gabapentin/ amitriptyline ~neuropathic pain
● Transcutaneous electrical nerve stimulation
Dyspareunia
(investigation)
●
●
●
●
●
Superficial (Introitus/ vagina) and deep (pelvis)
US/ CT pelvic/ MRI → pelvic masses, rectovaginal septum endometriosis, rectal/anal
lesions
Dx laparoscopic → adhesion, PID, endometriosis, pelvic mass
Sigmoidoscopy → GIT pathology (IBD, diverticular)
Microbiological study → infection
Pelvic Inflammatory Disease
Pelvic inflammatory
disease
Mnemonic I FACE PID
● I → infertility
● F → Fitz-Hugh Curtis syndrome (perihepatitis)
○ RUQ pain, “violin string” perihepatic
adhesion on laparoscopy
● A → abscess tubo-ovarian
● C → chronic pelvic pain
● E → ectopic pregnancy
● P → peritonitis
● I → intestinal obstruction
● D → disseminated infection eg sepsis, arteritis, arthritis, endocarditis, meningitis
Pelvic inflammatory
disease
Inflammation of the upper genital tract (above cervix) including endometrium, fallopian
tubes, ovaries, pelvic peritoneum +/- adjacent structures.
● STI → C trachomatis, N gonorrhoeae
● Endogenous flora → E coli, G vaginalis, Staph, Strep, Enterococcus, Bacteroides, H
influenzae (recurrent cause of PID and commonly assoc w instrumentation)
● IUCD → actinomyces israelii (GP, non-acid fast anaerobe)
● Others → TB, GNB, CMV, ureaplasma urelyticum
(complications)
(aetiological organisms)
Pelvic inflammatory
disease
●
MUST lower abdominal pain
PLUS ONE tenderness of cervical motion/ uterine/ adnexal
PLUS ≥ ONE
○ Oral temperature > 38
○ Mucopurelent discharge (cervical/ vaginal)
○ WCC abundant/PMN cells ~vaginal wet mount smear + salt solution of slide
○ ESR/CRP raise
○ +ve culture → N gonorrhoeae, C trachomatis, E coli or vaginal flora
DIAGNOSTIC
○ Transvaginal sonography/ pelvic MRI/ CT
○ Thickened, fluid-filled tubes
○ +/- free pelvic fluid, or
○ +/- tuboovarian complex, or
○ Doppler studies ~ suggestive of pelvic infection (eg tubal
hyperemia)
○ Endometrial biopsy ~HPE of endometritis
○ Laparoscopic consistent with PID
Pelvic inflammatory
disease
1.
2.
3.
4.
5.
Supportive acute symptoms - analgesia, antipyrexia
Broad spectrum abx (IV ceftriaxone and flagyl to cover anaerobes)
Surgical → drainage, adhesiolysis, irrigation, unilateral adnexectomy
Diagnostic laparoscopy if fever and pain do not resolve
Screening for STD and contact tracing
Pelvic inflammatory
disease
●
●
●
Early age at 1st intercourse, sexually active (esp new/multiple partners)
Low socioeconomic group
Infections
○ h/o PID
○ Exposure to STI
○ Abdominal/ pelvic → ruptured appendicitis, diverticulitis
○ Puerperal sepsis
(criteria)
(management)
(risk factors)
●
●
●
Pelvic inflammatory
disease
(investigations)
●
Iatrogenic
○ Gynaecological procedure → HSG, hysteroscopy, endometrial biopsy, D&C
○ IUCD insertion
●
●
●
●
Bhcg ~TRO ectopic pregnancy
FBC and blood culture (if sus septicemia)
ESR/CRP raise
Urinalysis ~ TRO UTI
Speculum examination
● High Vaginal swab for gram stain, any pus cell ~ gonococcus; for C&S of causative
organism
● Cervical C&S ~ N gonorrhoea, C trachomatis (w rapid test)
● Endometrial biopsy ~ endometritis
Ultrasound of pelvis
● Adnexal mass ~ suggestive tubo-ovarian mass
● Hydrosalpinx ~ dilated fallopian tube
● Free fluid in cul-de-sac
○ Pelvic inflammatory disease
○ Endometriosis
○ Ovarian torsion
○ Uterine fibroid
○ Ectopic pregnancy
Diagnostic laparoscopy (gold standard)
● Inflammation of tubes - oedematous & erythematous
● Purulent exudates from fimbrial ends
● Pelvic abscess
● Peritubal adhesion
● Evidence of salpingo-oophoritis
Differentials
Lower abdominal
pain, adnexal
tenderness, fever,
acute abdominal s/s
(NVD)
1.
2.
3.
4.
5.
Ectopic pregnancy ~ UPT test +ve, US (empty uterus, mass in FT)
Acute appendicitis ~ NV, abdominal US (aperistaltic structure)
Ovarian cyst complications ~ sudden, acute pain, pelvic US
a. Rupture ovarian cyst: prior trauma, mild chr lower abdo discomfort w incr
intensity, peritonitis sign, unremarkable adnexal mass (dt collapsed cyst)
b. Ovarian cyst torsion: sudden, acute, unilateral, LQA pain, severe, colicky, +/NV, tender adnexal mass, localised peritoneal irritation
c. Hemorrhagic ovarian cyst: localised abdo pain, NV, pelvic mass, +/hypovolemic shock
Endometriosis ~ cyclical history, transvaginal US (endometrioma/ US ligament invol.)
, laparoscopy (peritoneal implants), biopsy (endometrial glands & stroma outside
uterine cavity)
UTI - urinary symptoms such as dysuria, urinary frequency