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O&G Phase 3a Revision Session: Obstetrics & Gynaecology Society

Join the Whistle-stop Tour of Obstetrics and Gynaecology with the Peer Teaching Society. Learn about stages of labour, gestational diabetes, pre-eclampsia, gynaecological conditions, and more. Don't miss out on this informative session!

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O&G Phase 3a Revision Session: Obstetrics & Gynaecology Society

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  1. 2019/2020

  2. Whistle-stop tour of O&G! Phase 3a Revision Session By Obstetrics & Gynaecology Society 05/09/2019 The Peer Teaching Society is not liable for false or misleading information…

  3. Contents • Obstetrics • Stages of labour • Gestational diabetes • Rhesus • Pre-eclampsia & Eclampsia • APH and PPH • Gynae • Incontinence • Fibroids • Prolapse • Endometriosis • PCOS • PID • Acute • Ovarian torsion • Rupture Ectopic The Peer Teaching Society is not liable for false or misleading information…

  4. Obstetrics The Peer Teaching Society is not liable for false or misleading information…

  5. Stages of Labour • Normal Labour – 37 to 42 weeks gestation • Roles of hormones • Prostaglandin - ↓ cervical resistance (cervical ripening) + ↑ release of Oxytocin from Post. Pituitary • Oxytocin – Stimulate Uterine Contraction • Diagnosis of Labour • Painful regular progressive uterine contractions • Cervical Dilatation + Effacement - Commonly with Show (pink/white mucus plug) &/or Rupture of membranes The Peer Teaching Society is not liable for false or misleading information…

  6. Stages of Labour The Peer Teaching Society is not liable for false or misleading information…

  7. 1st Stage • Latent Phase • Nulliparous ♀ usually up to 18h • Multiparous ♀ ~12h • Active Phase • Nulliparous ♀: 0.5 – 1 cm/h • Multiparous ♀: 1 – 2cm/h • Suspect Failure to progress/ Abnormal labour if • Protracted <2cm dilatation in 4 hours OR • Protracted/ Arrested Descent/ Slowing of progress in Multips The Peer Teaching Society is not liable for false or misleading information…

  8. Abnormal 1st stage and causes • (a) Inefficient uterine contractions • Commonest in Nulliparous ♀ (problem with “Power”) • Mx: Amniotomy & Syntocinon to augment labour • (b) Cephalopelvic disproportion CPD • Commonest in Multiparous ♀ • Problem with “passenger” i.e. malposition/malpresentation or “passage” i.e. inadequate pelvis • May lead to secondary arrest(previously good contractions). Signs = Caput & Moulding • Mx: usually C-section The Peer Teaching Society is not liable for false or misleading information…

  9. 2nd Stage • Prolonged 2nd stage: • Nulliparous ♀: Not delivered aft 2h of active pushing • Multiparous ♀: Not delivered aft 1h of active pushing • Mx: • Assisted Vaginal Delivery • C-section The Peer Teaching Society is not liable for false or misleading information…

  10. 3rd Stage • Physiological Management • No Syntometrine/Syntocinon given • Cord allowed to stop pulsating before clamping & cutting • Placenta delivered by maternal effort alone (↑ risk of haemorrhage) • Change to active if haemorrhage/placenta not delivered by 1h • Active Management (↓ rate of PPH) • IM Syntometrine/ Syntocinon • Deferred Clamping & Cutting of cord • Controlled cord traction (push down suprapubically; prevent uterine inversion) The Peer Teaching Society is not liable for false or misleading information…

  11. Diabetes in Pregnancy & GDM Definition of GDM: • Carbohydrate intolerance which is diagnosed in pregnancy. • May or may not resolve after pregnancy Patho: (Pregnancy is “Diabetogenic”) • ↓ gluc. tolerance due to change in carb. metabolism & antagonistic effects of hPL, Progesterone & cortisol Risk factors: • Maternal Obesity BMI >30 • Previous macrosomicbaby • Previous GDM; 1st-degree relative w DM The Peer Teaching Society is not liable for false or misleading information…

  12. GDM - Complications • Effects of Pregnancy on Diabetes • ↑ risk of DKA/Hypoglycaemia • ↑ risk of progression of Retinopathy/Nephropathy (can cause HTN/Pre-eclampsia) Effects of Diabetes on Pregnancy [SMASH] • Shoulder Dystocia (Erb’s Palsy) • Macrosomnia (classically AC >> HC on USS) • Amniotic Fluid Excess (Polyhydramnios)  • Still birth • HTN, Hypoglycaemia (neonate due to fetal hyperinsulinaemia) The Peer Teaching Society is not liable for false or misleading information…

  13. GDM - Diagnosis • Diagnosis - OGTT (2hr, 75g oral glucose) • Done at booking.  • If normal done again at 24-28weeks • OGTT: >7.8mmol/L • Fasting: >5.6mmol/L The Peer Teaching Society is not liable for false or misleading information…

  14. GDM - Management • Preconceptual counselling (Pre-existing diabetes) • Achieving optimal control • Assessing severity of disease/ screening for complications • HTN, Retinopathy, Nephropathy • Alter drug therapy: Insulin; Metformin; Glibenclamide • STOP: (1) ACEis, (2) Statins, (3) All other hypoglycaemics • Folic acid (↑ risk of neural tube defects) The Peer Teaching Society is not liable for false or misleading information…

  15. GDM - Management • Antenatal Care (MDT approach) • GDM offer Tx in this order • (1) Diet/exercise -> (2) Metformin -> (3) Insulin -> (4) Glibenclamide (last resort/decline insulin or metform) • Target blood glucose: • Fetal monitoring:  • Serial USS 2-4 wkly (?polyhydramnios/macrosomnia/IUGR) • Fetal Echo @20-24 wks (?CHD) The Peer Teaching Society is not liable for false or misleading information…

  16. GDM - Management • Labour • Delivery no later than 40+6 weeks • Offer IOL at 37 - 38+6 weeks • By 39 weeks (elective by IOL) • Vaginal Delivery preferred + Continuous Electronic Fetal monitoring • Consider Elective CS if EFW >4.0kg • Intrapartum: BG level maintained with insulin sliding scale + IV dextrose The Peer Teaching Society is not liable for false or misleading information…

  17. GDM - Management • Puerperium • Breastfeeding strongly advised • Monitor Fetal BG (risk of hypoglycaemia) • Postpartum (GDM) • Stop insulin & arrange OGTT at 6 wks postpartum The Peer Teaching Society is not liable for false or misleading information…

  18. Rhesus disease/ Isoimmunisation • Definition: Maternal antibody response mounted against fetal red cells • Pathophysiology: only in Rh-ve ♀ with Rh +ve ♂ • Sensitization in 1st pregnancy • Foetal blood crosses into maternal circulation • Maternal immune response to Rh D+ve antigens on foetal RBCs (initially IgM cannot cross placenta, hence current pregnancy not at risk) • Re-exposure in subsequent pregnancy • Memory b cells produces rapid immune response (IgG) which crosses into foetal circulation -> haemolytic anaemia (foetal hydrops if severe) The Peer Teaching Society is not liable for false or misleading information…

  19. Rhesus disease/ Isoimmunisation • Management • All ♀ are checked Rhesus at booking visit, 28 and 34 weeks • Assessing fetal anaemia • MCA Doppler (↑ flow velocity) • Foetal Blood Sampling • Prevention = anti-D Immunoglobulin • Kleihauer Test (esp large feto-maternal haemorrhage) as standard Anti-D dose may not be enough The Peer Teaching Society is not liable for false or misleading information…

  20. Hypertensive Disorders of Pregnancy • Definition: • Chronic Hypertension - HTN before pregnancy. (Also includes BP ≥ 140/90 in ♀ before 20 wks gestation) • Pregnancy-Induced Hypertension • Gestational non-proteinuric HTN • New persistent BP ≥ 140/90 after 20wks gestation w/o evidence of pre-eclampsia • Pre-eclampsia - (i) HTN + (ii) Proteinuria specific to pregnancy & puerperium The Peer Teaching Society is not liable for false or misleading information…

  21. Pre-eclampsia - Risk Factors • Risk Factors (NOPE 2 FAT) • Nulliparity • Obesity • Previous Hx • Extremes of Age • 2 = twins • Family Hx • Autoimmune (Antiphospholipids) • Twins • Pathophysiology • Failure of trophoblastic endovascular remodeling • Spiral arteries remain high-resistance (coil & not dilated) • Causes Placenta ischaemia The Peer Teaching Society is not liable for false or misleading information…

  22. Pre-eclampsia - Presentation • Presentation: • Most Asymptomatic, symptoms usually occur with severe disease • Headache, Visual disturbances • Epigastric/ RUQ pain; N+V • Rapid oedema (esp. face) • O/E • Hypertension • Proteinuria • Facial Oedema • Epigastric/RUQ pain • Brisk hyperreflexia &/or Ankle Clonus The Peer Teaching Society is not liable for false or misleading information…

  23. Pre-eclampsia - Complications • Severe complications • Eclampsia • HELLP • Cerebral haemorrhage/ Stroke • Renal failure • Placenta Abruption • Foetal complications • IUGR (Placental insufficiency) • Preterm • Oligohydramnios (hypoperfusion of placenta) • IUFD The Peer Teaching Society is not liable for false or misleading information…

  24. Pre-eclampsia - Diagnosis (1) New persistent ↑↑ in BP ≥ 140/90 after 20 wks gestation + Proteinuria ≥ 300mg in 24hr collection / +2 on dipstick • Severity Classification The Peer Teaching Society is not liable for false or misleading information…

  25. Pre-eclampsia - Management • Only cure = delivery of placenta • Route of delivery preferably IOL + Vaginal • Low dose Aspirin (75mg) from 12 weeks till birth if pregnancy at risk • Steroids(Bethamethasone) if mod/severe @ 34 wks • Eclampsia = IV Magnesium Sulphate • Once given = deliver • Acute severe Pre-eclampsia = PO Labetalol (1st line) • Can consider Hydralazine or Nifedipine • Methyldopa if asthmatic/CHF The Peer Teaching Society is not liable for false or misleading information…

  26. Antepartum Haemorrhage (APH) Definition: Bleeding from genital tract after 24 wks gestation & prior to onset of labour • Minor = <50mL • Major = 50 – 1000mL • Massive = >1000mL &/or signs of shock The Peer Teaching Society is not liable for false or misleading information…

  27. Placenta Accreta Spectrum Risk Factors: • Previous Accreta • CS • Uterine Surgery Investigations: - USS, MRI can complement Management: • Aim to deliver 35 – 36+0 weeks • CS Hysterectomy w placenta in-situ • Uterine preserving surgery The Peer Teaching Society is not liable for false or misleading information…

  28. Placenta Praevia - Definition: Implantation of placenta, wholly or in part, in the lower segment of the uterus. • ~90% “Low-lying” placentas at 20wks resolve as pregnancy progress (lower uterine segment grows) • Risk factors • Multiparity, Smoking, Multiple Pregnancy, Advanced age, Previous PP or Previous CS The Peer Teaching Society is not liable for false or misleading information…

  29. Placenta Praevia • Classification • Marginal – Placenta in lower segment of uterus close to OS (2cm from internal OS) • Major – Placenta lies over the OS (Cervical effacement & dilatation = catastrophic bleeding) The Peer Teaching Society is not liable for false or misleading information…

  30. Placenta Praevia • Presentation • Typically Intermittent Painless Bleeds (bright red), ↑↑ frequency and severity over weeks • Uterine examination • Soft Uterus • Foetalmalpresentatione.g. Breech & Transverse lie are common • Foetal head not engaged & high • Ix: Diagnostic USS if low-lying placenta at 2nd trimester USS, repeat USS at 32 wks to exclude PP • If persistent at 32 wks -> Another TVUSS at 36 wks The Peer Teaching Society is not liable for false or misleading information…

  31. Placenta Praevia • Management • Advice to avoid sexual intercourse/ intense exercise • C/I to do vaginal examination • If placenta <20mm from IOS <16 wks = Low-lying placenta -> recommend TVS at 32 wks • Admit for ♀ w Major PP who have previously bled for monitoring till delivery • Delivery • ELCS at 37-39 wks (if placental edge <2cm from int.OS) • if severe bleed = Emergency CS. • Single course of steroids recommended between 34-35+6wks • Tocolysis if ♀ symptomatic, not given if delivery indicated The Peer Teaching Society is not liable for false or misleading information…

  32. Placenta Abruption • Definition: Premature separation of a normally-sited placenta from the uterine side wall • Revealed Abruption vs Concealed Abruption (no visible bleeding) • Risk Factors / Aetiology • Previous abruption, Pre-eclampsia, IUGR, Abnormal placentation, Rapid uterine decompression (ruptured membranes w Polyhydramnios) The Peer Teaching Society is not liable for false or misleading information…

  33. Placenta Abruption • Presentation • Classically Abdominal Pain +/- Bleeding • **Painful bleeding** typically sudden onset, severe & constant • Contraction -> Blood + Clot = irritant (promotes contraction) • O/E = tender, contracting WOODY-HARD UTERUS • Maternal shock (may be out of proportion to PV bleed) • Foetal Distress – Abnormal CTG The Peer Teaching Society is not liable for false or misleading information…

  34. Placental Abruption • Diagnosis usually made on Clinical grounds • Ix to assess severity and form plan • Foetal CTG • USS • Maternal well-being = FBC, Clotting, X-match, U&E • Management • Immediate Delivery • usually Emergency CS + Resus simultaneously The Peer Teaching Society is not liable for false or misleading information…

  35. Vasa Praevia • Foetal vessels runs in membrane below presenting foetal part • Sx [TRIAD] • (1) ROM (SROM/ARM) • (2) APH • (3) Foetal Distress • Presentation usually (a) ROM -> then (b) PV bleed {painless} -> Rapid Foetal Distress {Bradycardia} The Peer Teaching Society is not liable for false or misleading information…

  36. Postpartum Haemorrhage (PPH) Definitions: • Minor PPH = 500-1000mL • Major PPH = >1000mL • Primary PPH = Loss of >500mL of blood from genital tract within 24h of the birth of baby • Secondary PPH = Abnormal/ Excessive bleeding from genital tract between 24h – 6wks postpartum - Usually due to infection (Endometritis) or Retained Placental Products The Peer Teaching Society is not liable for false or misleading information…

  37. Primary PPH Aetiology – 4Ts • TONE: Uterine Atony • Lack of contractions after delivery -> Uterine vessels not clamp down • RFs: prolonged labour (tires out), nulliparity, gran multiparity, overdistended uterus (polyhydramnios, multipregnancy, macrosomnia), prev PPH) • TRAUMA: Perineal/ Vaginal Lacerations • e.g. Perineal Tear/ Episiotomy • Rarely Uterine Rupture or Cervical Tear • TISSUE: Retained Placenta • Partial separation -> uterus can’t contract properly • THROMBIN: Coagulopathy • e.g. Haemophila A/B, anticoaugulant therapy, DIC The Peer Teaching Society is not liable for false or misleading information…

  38. PPH - features • Symptoms • Prolonged & worsening vaginal bleeding after delivery • PV Bleeding/Clots • Abdominal/Pelvic Pain • Signs • Pyrexia, Tachycardia, Tachypnoea, Hypotension • ↓ Level of Conscious • Pale Skin • Complications - Shock, DIC The Peer Teaching Society is not liable for false or misleading information…

  39. PPH - Management • Minor PPH w/o clinical signs of shock - IV Fluids, X-match blood, Regular clinical monitoring & obs (BP, Pulse, SpO2, FBC, Clotting) • Major PPH • Resuscitate – ABC. • Tx and stop cause of bleeding • Lacerations = Suture • Retained Placenta = Manual Evacuation • Uterine Atony • Bimanual uterine compression • Ergometrine IV/IM • Oxytocin infusion (if still bleeding Misoprostol, Carboprost) • Surgical = Uterine Tamponade w Rusch Balloon, B-Lynch suture, UAE, Hysterectomy The Peer Teaching Society is not liable for false or misleading information…

  40. Gynae The Peer Teaching Society is not liable for false or misleading information…

  41. Incontinence • Types of incontinence • Stress incontinence • Urge incontinence • Mixed Urinary Incontinence • Neurogenic Bladder (cortical, spastic (UMN), flaccid (LMN)) The Peer Teaching Society is not liable for false or misleading information…

  42. Stress Incontinence  Involuntary leakage of urine on effort or EXERTION, or on sneezing or coughing ~10% of all women, 50% of all urinary incontinence is stress incontinence Due to Urethral Sphincter Weakness (detrusor pressure > closing pressure of urethra) • Pregnancy • Vaginal delivery • Forceps/instrumental delivery • Oestrogen deficiency (menopause) • Pelvic trauma/irradiation • Congenital weakness • Increased Age and Obesity The Peer Teaching Society is not liable for false or misleading information…

  43. Stress Incontinence Normal bladder • Sudden increase in intra-abdominal pressure (STRESS) • Both bladder & bladder neck compressed – both have incr. pressure • Pressure diff = unchanged Stress Incontinence • Bladder neck slipped below pelvic floor b/c of weak supports • Bladder neck not compressed = no pressure • Bladder pressure > Bladder neck pressure = incontinence The Peer Teaching Society is not liable for false or misleading information…

  44. Stress Incontinence CLINICAL FEATURES • Incontinence on COUGHING/ SNEEZING / LAUGHTER/ OTHER STRESSORS • Frequency • Urgency Ix • Urine dipstic & MSU for MC&S important to exclude UTI • FVC (frequency-volume chart) • Bladder diaries, QoL assessment • Urodynamics – not performed before starting conservative management The Peer Teaching Society is not liable for false or misleading information…

  45. Stress Incontinence MANAGEMENT • Lifestyle – avoid excessive fluid intake, weight loss in women BMI>30 • Pelvic floor muscle training (at least 3months) – FIRST LINE • Surgery – if conservative Mx has failed • Synthetic mid-urethral sling (tape) • Burch colposuspension • Drugs – Duloxetine (mod-severe SUI) • DO NOT offer first line • DO NOT offer second line, unless not suitable for surgery • SIDE EFFECTS – nausea, dyspepsia, dry mouth, dizziness, insomnia, drowsiness The Peer Teaching Society is not liable for false or misleading information…

  46. Urge Incontinence • Involuntary leakage of urine accompanied by URGENCY OAB: Urgency (with or without Urge Incontinence), with frequency or nocturia in absence of proven infection • Most frequently due to DETRUSOR OVERACTIVITY • Commonly idiopathic • Secondary to pelvic or incontinence surgery • UTI • Neurogenic (Spastic bladder) The Peer Teaching Society is not liable for false or misleading information…

  47. Urge Incontinence CLINICAL FEATURES • Urgency • Frequency • Combination with Stress Incontinence common Ix • Urine dipstic & MSU for MC&S important to exclude UTI • FVC (frequency-volume chart) • Urodynamics – not performed before starting conservative management The Peer Teaching Society is not liable for false or misleading information…

  48. Urge Incontinence MANAGEMENT • Conservative – avoid excessive fluid intake, avoid fizzy/caffeinated drinks, weight loss in women BMI>30, Pelvic floor exercises • Bladder training – at least 6 weeks • Drugs – Anticholinergics (Oxybutynin, Solifenacin, Tolterodine) – FIRST LINE • S/E: Dry mouth, constipation, nausea 4. Beta 3 agonists (mirabegron) – if anticholinergics ineffective 5. Botulinum toxin type A – if unresponsive to all of above 6. Percutaneous sacral nerve stimulation – if unresponsive to all of above Surgery is last resort. The Peer Teaching Society is not liable for false or misleading information…

  49. Prolapse Anterior wall • Cystocele (bladder) • Urethrocele (urethra) • Cystourethrocele (bladder & urethra) Posterior wall • Enterocele (small bowel) • Rectocele (rectum) Apical  Uterovaginal – uterine descent w/ inversion of vaginal apex  Vault – (post-hysterectomy) – inversion of vaginal apex The Peer Teaching Society is not liable for false or misleading information…

  50. Prolapse  Pelvic floor weakness • Vaginal delivery & process of pregnancy • Big baby delivery, prolonged second stage, instrumental delivery • Congenital • Abnormal collagen metabolism • Menopause (age) • Deterioration of collagenous connective tissue with oestrogen withdrawal • Chronic predisposing factors • Any chronic increase in intra-abdominal pressure (obesity, chronic cough, constipation, heavy lifting, pelvic mass) • Iatrogenic factors • Pelvic surgery (hysterectomy), Continence procedures (burchcolpo) The Peer Teaching Society is not liable for false or misleading information…

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