O&G Notes
Gynaecological History
 Name, Age, Occupation
 PC
o Details, time-scale, previous Rx
 HPC
o Focus on main complaint
o Pattern of menstrual bleeding – cycle length, regularity, bleeding time, IMB, amount inc.
o Menarche & menopause
o PV Discharge
o Pelvic / abdominal pain
o Continence if applicable
o Sexual problems & contraception
o Prolapse (bowel Sx)
 Past Gynaecological History
o Dates, smears, surgery &c.
 Past Obstetric History
o Children, age, problems, abortions
 Past medical History (unlikely to be much in PACES)
 Drug History and allergies
 Social History
o Smoker? Drinker?
 Family History
o Breast/ovarian ca, Heart disease
Gynaecological Examination
General: appearance, anaemia, LN, BP, pulse
Breast/axillae: inspect and palpate
Abdomen: inspect, palpate (suprapubic), percuss, ascultate
Vaginal: inspect Vulva, digital exam (bimanual). Cuscos’s speculum, Sims (if prolapse)
Obstetric History
 General enquiry about progress of pregnancy. Ice breaker.
 Patient age,
 Pregnancy No?
 EDD
o Date from 1st day of LMP. Median duration is 40 weeks from LMP assuming 28 day cycle &
ovulation on day 14.
o Date of LMP + 9 months + 7 days.
o Term = 37 - 42/40!




Enquire about scans – dating ~12/40 and Abnormality ~20/40
Past Obstetric History
o Children, age, gestation, complications, mode of delivery, abortions (recurrent?), BP
o Gravida – total No of pregnancies
o Parity – No of live births + stillbirths + terminations
Past Gynaecological History
o Dates, smears, surgery &c.
Social History


o Very important: marriage & consent, social class and maternal mortality, domestic violence,
child protection, smoking, EtOH, drugs, occupation, support.
PMH
o Important esp DM, HT, Epliepsy, Renal disease, Venous thromboembolism (VTE).
FH
Obstetric examination
 BP & urine dip
 Abdominal Examination – comfort of the mother.
o Inspection: scars, foetal mvt, striae gravidarum, linea nigra
o Palpation: Symphisis-fundal height (SFH) in cm.
 Stage of pregnancy? What next?
 Macrosomia, multiples, polyhydramnios
 IUGR, oligohydramnios
 Foetal poles
 Lie – after 34/40. Longitudinal, transverse, oblique.
 Presentation – after 34/40.
 Engagement – 5ths palpable.
o Ausculatation – Pinard stechoscope or dopper sonicaid
Cervical screening
Cervical screening is not a test for cancer. It is a method of preventing cancer by detecting and treating
early abnormalities
25 – 49 screened 3 yearly
50 – 64 screened 5 yearly
65+ screened only if recent abnormalities or no tests since aged 50
Liquid based Cytology (LBC)
A sample of cells is taken from the cervix for analysis.
Antenatal screening
Basic Screening
 Rhesus incompatibility
 Rubella susceptibility
 Haemoglobinopathies
 Diabetes
 Foetal Abnormality
o Down’s Syndrome
o Open neural tube defect
o Other structural defects
Additional Screening
 Amniocentesis (>35yrs/ In addition to
serum screening)
 Genetic screening (FHx)
 TaySachs (Ashkenazy Jews etc)



Infections
o Hepatitis B & C
o HIV
o VDRL
o Bacterial
Pre-eclampsia
Foetal Growth




Toxoplasmosis
Alcohol/Drug Misuse questioning/testing
DV/ CP issues
Mental health
GDM Screening
 Mini-GTT done at 27/0
 50g glucose (263mls Lucozade)
 Blood glucose assessment 1hr later
o >13mmol/L = GDM
o 7.9-13mmol/L = refer for GTT
Down’s Syndrome Screening
The Integrated Test
 11-13/40: “Stage 1”
o Nuchal Translucency measurement
o Blood Sample (PAPP-A)
o 2nd Stage appointment given for 3-4/40
 15-16/40: “Stage 2”
o Blood Sample (AFP, Ue3, free BhCG)
o Calculation of risk
o Measurements of the five markers are used together with the women’s age to calculate her
risk
About 1:100 fall into the screen +ve group and about 1:10 of these have an affected pregnancy
Triple Test
 14-20/40
o Take blood sample (AGE + AFP + uE3 + free BhCG)
Contraception
Type
COCP
Women
Failure
Most popular 0.2
method for
under 30’s
Benefits
Good control,
Well accepted,
Women in
control,
Reduction in
menstrual blood
loss and
dysmennorhoea
(therapeutic)
Side effects
Nausea, headache,
breakthrough
bleeding, breast
tenderness
Hirsuitism/acne,
weight gain, vaginal
dryness, facial skin
pigmentation
Irregular bleeding
and amenorrhoea in
up to 50%, Weight
gain, breast
tenderness,
headache and acne
Amenorrhoea and
breakthrough
bleeding
Contraindications
Migraines, IHD, CVA
HTN, Oestrogen
dep. Neoplasia,
Liver disease,
Smoking, Age
>35yrs, Breast
feeding, Obesity,
Type II diabetes
POP (mini-pill) Any COCP
contraindicat
ion
Good
motivation
1.0
Few CI, No
interference with
breast feeding,
broad spectrum
antibiotics
Injectables
(Depot
Progesterone)
Poor
compliant
Travel/ away
from
pharmacy
<2
IM injections can
last 8‐12 weeks,
SC implants can
last 3‐5 years,
Reduced
menstrual blood
loss
IUD (Copper
Coil)
IUD
(Hormone)
Older,
Multips
Menorrhagia
Rx, woman
with CI to the
OCP
Casual sex
1‐ 1.5
High reliability,
Easy insertion
and removal,
Changed every 5
years
Pelvic infections,
Perforation,
Menstrual
disturbances, Falls
out, Pain
Injectables are
irreversible until
effects worn off,
Normal cycle and
fertility may take 6
months after
stopping, Protection
again STDs is
minimal
Pregnancy,
Undiagnosed
irregular genial tract
bleeding, PID,
Previous ectopic
Only if used
incorrectly
High user
motivation
Finished
families
Religious?
0.02/
0.13
20‐30
Insertion before
sex, STD
protection, Non
hormonal
Permanent
Post OP
complications
STD and Pregnancy
Permanent
Condoms,
caps,
diaphragms
Sterilisation
Natural
0.2‐0.5
5.0
No treatments
Emergency Contraception
 Post coital Pill:
o 100μg of ethinyloestradiol and 500μg of levonorgestrel repeated after 12 hours
o Must be given within 72hrs of unprotected intercourse to delay ovulation and inhibit
implantation
 Emergency IUCD:
o Inserted within 5 days of unprotected intercourse to prevent implantation
o Follow up is essential after EC to exclude ongoing pregnancy and give advice regarding
future contraceptive methods.
GYNAECOLOGY
Gynae Cancers
Cervical
Ovarian
Endometrial
Vulval
Vaginal
Features
40-44 yrs and 70-74 yrs,
Abnormal bleeding
(intermenstrual and post-coital),
asymptomatic with abnormal
smear, Risk Factors include: Early
intercourse, high number of
partners, HPV, lower
socioeconomic group, smoking,
partner with protate or penile ca.
CIN – premalignant condition.
45-65 yrs, Vague Sx, Pain on
ovarian torsion or bleeding, Abdo
distension, urinary frequency, GI
Sx
Mean age 61yrs, commonly
intermenstrual or postmenopausal bleeding, Risk factors
include: Obesity, Nulliparity, late
menopause, PCOS, Oestrogen
therapy, tamoxifen Tx, DM, FHx
of breast or colon Ca.
63-65 yrs, Pruritus, Lump/ulcer,
Bleeding, Pain, Risk factors
include: Smoking,
immunosuppression, vulval
maturation disorders, Hx of VIN,
CIN or HPV
VIN – premalignant condition.
Abnormal bleeding,
Amenorrhea
 Primary
o Menstruation has never occurred
Investigation
Biopsy and
staging
Treatment
1a- Cone Biopsy
1b-2a- Radical abdo hysterectomy,
Radical trachlectomy (preserve
fertility)
2b+ radiotherapy and
chemotherapy
USS
Raised Ca 125
Laparotomy debulking, TAH & BSO
& Omentum, Chemo- if epithelial
Biopsy, EUA,
CXR
TAH & BSO, Add radiotherapy,
Palliative Chemotherapy
WLE, Groin lymphadenopathy
Biopsy, EUA,
MRI, CXR

External beam radiotherapy and
intravaginal radiotherapy
Secondary
o No menstruation for > 6 months
Primary
Hypothalamous Kallmann’s syndrome, tumour, trauma,
stress, low BMI
Pituitary
Hyperprolactinaemia
Gonads
PCOS, Streak Gonads, Ovarian tumour,
hermaphroditism
Uterus
Pregnancy, congenital absence
Cervix
Vagina
Endocrine
Drugs
Secondary
Kallmann’s syndrome, tumour, trauma,
stress, low BMI
Hyperprolactinaemia, Sheehan’s syndrome
PCOS, Streak Gonads, Ovarian tumour,
ovarian failure/removal
Pregnancy, hysterectomy, Ashermann’s
syndrome
Post-surgical stenosis
Congenital absence, imperforate hymen
DM, Thyroid disease, adrenal disease,
androgen insensitivity
Phenothiazines, chemotherapy,
radiotherapy
Investigations
 Chromosomal analysis
 Hormone profile
o βhCG
o FSH/LH
DM, Thyroid disease, adrenal disease,
Phenothiazines, chemotherapy,
radiotherapy

o Prolcatin
o TSH
o T3/T4
USS
Menorrhagia
 > 80ml of menstrual blood loss per period
 Often associated with dysmenorrhoea
Systemic Disorders
Local causes
Thyroid disease, clotting disorders
Fibroids, Endometrial Polyps, endometrial ca,
endometriosis, PID, dysfunctional uterine
bleeding
IUCD, oral anti-coagulants
Iatrogenic causes
Investigations
 USS


Hysteroscopy
Management
 Medical
o Prostaglandin inhibitors
(mefenamic acid)
o Anti-fibrinolytics and haemostatics
(tranexamic acid)
o Progestogens

Blood tests
o IUCD’s
o COCP
Surgical
o Endometrial ablation
o Hysterectomy
Dysmenorrhoea
 Primary
o Dysmenorrhoea from menarche
 Secondary
o Dysmenorrhoea in women with previously painless periods caused by patholog
 Often described as cramping pain, radiates to back/upper thighs
Cervical
Uterine
PID
Fibroids, endometrial polyps, Ashermann’s
syndrome, infection, adenomyosis, stenosis
Pelvic
Endometriosis
Investigations
 Microbial swabs for infection
 Pelvic USS


Hysteroscopy
Laparoscopy
Postmenopausal bleeding
 Bleeding more than 12 months after the menopause
Ovary
Uterus
Ovarian ca, oestrogen secreting tumour
Submucosal fibrid, atrophic changes, polyps,
hyperplasia, carcinoma
Atrophic changes, malignancy
Atrophic changes
Urethral caruncle, heamaturia
Vulvitis, dystrophy, malignancy
Cervix
Vagina
Urethra
Vulva
Investigations
 Pelvic USS


Hysteroscopy
Endometrial biopsy
Fibroids
 Benign tumours of the myometrium
Risk Factors
 Age
 Nulligravidity
 Obesity
Features
 Asymptomatic
 Menstrual abnormalities (increased
bleeding)
 Abdominopelvic mass
 Pain
 Subfertility
 Pressure Sx
o Urinary frequency





Afro-carribean ethnicity
Smoking, COCP and pregnancy are
protective
o Nocturia
o Urgency
o Rectal pressure
Pregnancy complications
Firm irregular uterus
Fibroid moves with uterus on bimanual
examination
Investigations
 USS
 Hysteroscopy


MRI
Laparotomy
Management
 GnRH
o Decrease size prior to surgery


Hysterectomy
Myomectomy
Endometriosis
 Presence of functional endometrium outside of uterine cavity
 Endometriosis of the myometrium is adenomyosis
Features
 Secondary dysmenorrhoea
 Deep dyspareunia


Pelvic pain
Infertility

Tender retroverted, retroflexed fixed
uterus

Pain on moving cervix anteriorly

Surgical
o Conservative excisision and
adhesion dissection
o Radical hysterectomy + bilateral
salpingo-oophrectomy
Investigations
 Laparoscopy
Management
 Medical
o COCP
o Progestogens
o GnRH analogues
o Gestrinone
o Danazol
Pelvic Inflammatory Disease
Clinical syndrome associated with ascending spread of microorganisms from vagina/cervix to
endometrium, fallopian tubes and contiguous structures
 Most common causes are :
o Chlamydia trachomatis
o Nisseria Gonorrhoeae
Risk factors
 < 25 yrs of age
 Single
 Multiple sexual partners
 Young at first intercourse
 High frequency of sex




Hx f STD’s
Hx of PID
Recent instrumentation of uterus
IUCD
Features
 Pelvic/lower abdo pain
 Deep dyspareunia
 Dysmenorrhoea
 Abnormal/increased vaginal d/c
 Fever




Tachycardia
Abdo tenderness
Cervical excitation
Adnexal swelling & tenderness
Investigations
 WCC, CRP, ESR
 Blood cultures
 STD screen



MSU
Pregnancy test
TV USS

Laparoscopy
Management
 Antibiotic Therapy

Contact tracing

Surgery (rare)
Complications
 Pelvic abscess
 Septicaemia
 Septic shock



Infertility
Ectopic pregnancy
Chronic pelvic pain



Dyspareunia
Menstrual disturbance
Psychological effects
Urogynaecology
Stress
Incontinence
Urge
Incontinence
Prolapse
Causes
Neurological injury,
urethral injury,
pelvic trauma
Features
Involuntary loss of
urine during physical
activity
Risk Factors:
Childbirth, Chronic
coughing, age,
Obesity, Smoking
Inflammatory
disorders, bladder
stones, neuro
disorders, bladder
cancer
Strong, sudden need
to urinate followed
by urine leakage,
abdo discomfort,
frequent urination
Congenital
connective tissues
disorders, prolonged
or difficult labour,
postmenopausal
atrophy, chronically
raised intra-abdo
pressure,
hysterectomy,
colposuspension
Investigations
Rule out UTI,
Urodynamic
testing,
Cystoscopy,
Urogram
Local discomfort,
Examination
feeling of descent,
?d/c, ? backache, GU
sx, GI sx,
Treatment
Lifestyle changes,
pelvic floor exercises,
TVT,
Colposuspension,
sling procedure
Lifestyle changes,
bladder training,
Anticholinergic
agents, Electrical
stimulation reflex
inhibition of
detrusor, Cystoplasty
augmentation
Pelvic floor exercises,
HRT, vaginal
pessaries, surgical
repair
Menopause
 Retrospective dx made after >12mths of ammenorhea
 45 – 55 yrs

Climacteric endocrine changes:
o Hypothalamic-pituitary hyperactivity (↑FSH/LH)
o ↓ progesterone
o Unopposed oestrogen secretion
Features
 Vasomotor symptoms
o Hot flushes
o Night sweats
 End-organ atrophy
o Vaginal dryness
o Increased susceptibility to
infection
o Prolapse
o Urinary sx
Investigations
 Hormone profile
o Oestrogen
o FSH/LH





Psychological Symptoms
o Depression
o ↓ libido
o Irritability
o Poor memory
Long-term effects
o Osteoporosis
o Cardiovascular disease
Cervical smear
Mammogram
Pelvic USS

Endometrial sampling
Management
 Lifestyle changes
 Tx of co-morbid conditions
 Psychological support

Bone mineral density scan


HRT
Oseteoporosis prophylaxis
OBSTETRICS
Ante Partum Haemorrhage
Risk factors
Placenta Praevia
Age, Higher parity,
(Placenta is wholly Multiple
or partially
pregnancy,
attached to lower
Previous C/S,
uterine segment)
Succenturiate
placental lobe,
Smoking
Placental
Pre-eclampsia,
Abruption
Abdominal trauma,
(placental
smoking, cocaine
attachment is
use, lower
disrupted by
socioeconomic
haemorrhage)
group, external
cephalic version
Features
Third trimester
unprovoked PV
bleeding, Soft nontender uterus,
Cephalic
presentation is not
engaged
Bleeding and
constant abdo
pain, Uterus is hard
and tender,
Complications
PPH, Placenta
Accreta,
Managment
USS scan at 20
weeks – follow up
in third trimester if
low placenta,
Cross-match blood,
Immediate C/S
Renal failure,
disseminated
intravascular
coagulaton, PPH,
HB, Cross-match
blood, clotting
screen, Urinalysis,
Depending on
severity delivery of
fetus as life saving
procedure for
mother
Kelihauer test on
PV blood, Fetus
must be delivered
urgently to avoid
exsanguination,
Vasa Praevia
(velamentous
insertion of cord
and vessels lie over
internal os)
Post –Partum Haemorrhage
Risk factors
 Multiple Pregnancy
 Grand Multip
 Polyhydramnios
 Fibroid uterus


Uterine Atony
o Failure of contraction of uterus
after delivery
Genital Tract Trauma
o From trauma to:
 Preineum
 Vagina
 Cervix
Prevention
 Treatment of anaemia in pregnancy
 Clotting screen



Prolonged labour
Previous PPH
APH






 Uterus
Retained products
Coagulation disorders
Uterine Inversion
Uterine Rupture
Endometritis
Persistent Molar pregnancy


Anticipation of possible PPH
Active mx of third stage of labour
o Oxytocic drugs
o Controlled cord traction for
placental delivery
Management
 IV access
 Hb, platelets, clotting and cross-match
o Clamping and cutting umbilical
cord


MDT
Surgical Mx
Hypertension in Pregnancy
Pre-existing HTN
Women with known HTN before pregnancy and those diagnosed with HTN in 1 st trimester
 Risk factors
o Age
 DM
o FHx
 Renal disease
o Medical disorders
o Ethnic group
Pregnancy induced HTN
 Non-proteinuric HTN diagnosed in second half of pregnancy
 Typically resolves within 6 weeks of delivery
Complications of HTN
 Increased risk of cerebral haemorrhage
 Increased susceptibility to IUGR
Management of HTN
 Pre-pregnancy counselling
 Identify cause
 Warned about pre-eclampsia
 Uterine artery dopplers

Increased risk of developing pre-eclampsia

Drug treatment to decrease risk of
cerebral haemorrhage
Regular BP & urinalysis
Regular fetal growth scans


Pre-eclampsia
Multisystem disorder of the endothelium causing
 Peripheral haemorrhagic necrosis
o ↑AST/ALT
 ↑Cerbral vascular resistance
 Leaky glomerular capillaries

Risk factors
 Primip
 35 + yrs
 HTN



Diagnosis
 BP ≥ 160/110 + proteinuria ≥ 2+
 BP ≥ 140/90 + proteinuria ≥2+ and at least one of
o Oliguria
o Visual disturbance, headaches,
RUQ pain
Management
o Proteinuria
High resistance vessels
o Oligohydramnios
o IUGR
Multiple pregnancy
Previous pre-eclampsia
FHx
o Platelts < 100, ALT > 50
o Creatinine > 100
o 3+ beats of clonus


Deliver baby if at term (IoL)
Continuous CTG in labour
Complications
 Eclampsia
 Renal Failure
 Hepatic Rupture
 HELLP

Fluid restriction if severe




Cerebral Haemorrhage
DIC
Pulmonary Oedema
Increased perinatal mortality



Liver rupture
Retinal detachment
Maternal death


BP controlled with IV hydralazine or
labetolol
Observe for 24 hrs



IVF
Endometriosis
Mini-pill

Medical
o Methotrexate (IM or Local)


Acceleration of DM complications
Increased risk of DKA
Eclampsia
Fitting/seizure secondary to pre-eclampsia
Complications
 Abruption
 Pulmonary oedema
 Cerebral haemorrhage
Management
 Basic resus
 IV magnesium sulphate
 IV diazepam
Ectopic Pregnancy
 Pregnancy implanted outside of uterine cavity
 Presents with Abdo pain and bleeding
Risk factors
 PID
 Tubal Surgery
 Peritonitis or pelvic surgery
 IUCD
Management
 Surgical
o Salpingectomy
o Salpinotomy
Diabetes in pregnancy
Pre-existing Diabetes
 Need increased insulin doses
 Increased risk of hypos
Complications
 Miscarrage – poor control
 Fetal congenital abnormality – if poor control at conception
 Proteinuric hypertension – increased risk if pre-existent HTN or nephropathy
 Macrosomia – increased insulin (anabolic)
 Soulder dystocia – due to macrosomia
 Polyhydramnios, IUD, still birth – fetal polyuria
 UTI or candida – glycosuria
Management
 MDT
 Dietary advice
 Folic acid preconception
 HbA1c monitoring




Increased insulin dose
Regular fundoscopy
Anomaly screening
Growth scans
Gestational Diabetes
 Increased insulin resistance due to anti-insulin hormaones (glucagons, cortisol, human placenta
lactogen)
 Usually in second or early third trimester
Risk Factors
 Hx of GDM
 Previous macrosmic baby


FHx of DM
Ethnicity
Diagnosis
 At screening
 Maternal signs and symptoms

Retrospective HbA1c testing
Management
 Dietary advice


BM monitoring
Regular scans
Obstetric Cholestasis
Features
 Late second early third trimester
 Severe pruritis of soles and palms
 No rash



Pale fatty stools
Dark urine
Decreased appetite
Investigations
 ↑ AST/ALT
 ↑ bilirubin

USS for gallstones etc


Deliver fetus if mature
Counselling


Fetal distress in labour
Fetal or neonatal intracranial
haemorrhage
Management
 Cholestyramine or antihistamine (reduce
itching)
 Early vitamin K (prevent haemorrhage)
 Featl monitoring
Complications
 PPH
 IUD
 Preterm labour