Laparoscopy Management Medical COCP Progestogens GnRH analogues Gestrinone Danazol Surgical Conservative excisision and adhesion dissection Radical hysterectomy + bilateral salpingo-oophrectomy 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 : Chlamydia trachomatis 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 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 Causes Features Investigations Treatment Stress Incontinence Neurological injury, urethral injury, pelvic trauma Involuntary loss of urine during physical activity Lifestyle changes, pelvic floor exercises, TVT,
Risk Factors: Childbirth, Chronic coughing, age, Obesity, Smoking Cystoscopy, Urogram Colposuspension, sling procedure Urge Incontinence Inflammatory disorders, bladder stones, neuro disorders, bladder cancer Strong, sudden need to urinate followed by urine leakage, abdo discomfort, frequent urination Lifestyle changes, bladder training, Anticholinergic agents, Electrical stimulation reflex inhibition of detrusor, Cystoplasty augmentation Prolapse Congenital connective tissues disorders, prolonged or difficult labour, postmenopausal atrophy, chronically raised intra-abdo pressure, hysterectomy, colposuspension Local discomfort, feeling of descent, ?d/c, ? backache, GU sx, GI sx, Examination Pelvic floor exercises, HRT, vaginal pessaries, surgical repair Menopause Retrospective dx made after >12mths of ammenorhea 45 – 55 yrs Climacteric endocrine changes: Hypothalamic-pituitary hyperactivity (↑FSH/LH) ↓ progesterone Unopposed oestrogen secretion Features Vasomotor symptoms Hot flushes Night sweats End-organ atrophy Vaginal dryness Increased susceptibility to infection Prolapse Urinary sx Psychological Symptoms Depression ↓ libido Irritability Poor memory Long-term effects Osteoporosis Cardiovascular disease Investigations Hormone profile Oestrogen FSH/LH Cervical smear Mammogram Pelvic USS Endometrial sampling Bone mineral density scan Management Lifestyle changes Tx of co-morbid conditions Psychological support HRT
Oseteoporosis prophylaxis OBSTETRICS Ante Partum Haemorrhage Risk factors Features Complications Managment Placenta Praevia (Placenta is wholly or partially attached to lower uterine segment) Age, Higher parity, Multiple pregnancy, Previous C/S, Succenturiate placental lobe, Smoking Third trimester unprovoked PV bleeding, Soft uterus, Cephalic presentation is not engaged PPH, Placenta Accreta, USS scan at 20 weeks – follow up in third trimester if low placenta, Cross-match blood, Immediate C/S Placental Abruption (placental attachment is disrupted by haemorrhage) Pre-eclampsia, Abdominal trauma, smoking, cocaine use, lower socioeconomic group, external cephalic version Bleeding and constant abdo pain, Uterus is hard and tender, 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 Vasa Praevia (velamentous insertion of cord and vessels lie over internal os) Kelihauer test on PV blood, Fetus must be delivered urgently to avoid exsanguination, Post –Partum Haemorrhage Risk factors Multiple Pregnancy Grand Multip Polyhydramnios Fibroid uterus Prolonged labour Previous PPH APH Uterine Failure of contraction of uterus after delivery Genital Tract Trauma From trauma to: Preineum Vagina Cervix Uterus Retained products Coagulation disorders Uterine Inversion Uterine Rupture Endometritis Persistent Molar pregnancy Prevention Treatment of anaemia in pregnancy Clotting screen Anticipation of possible PPH Active mx of third stage of labour Oxytocic drugs Controlled cord traction for placental delivery Clamping and cutting umbilical cord Management IV access Hb, platelets, clotting and
MDT Surgical Mx Hypertension in Pregnancy Pre-existing HTN Women with known HTN before pregnancy and those diagnosed with HTN in 1st trimester Risk factors Age FHx Medical disorders DM Renal disease 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 Increased risk of developing pre-eclampsia Management of HTN Pre-pregnancy counselling Identify cause Warned about pre-eclampsia Uterine artery dopplers 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 ↑AST/ALT ↑Cerbral vascular resistance Leaky glomerular capillaries Proteinuria High resistance vessels Oligohydramnios IUGR Risk factors Primip 35 + yrs HTN Multiple pregnancy Previous pre-eclampsia FHx Diagnosis BP ≥ 160/110 + proteinuria ≥ 2+ BP ≥ 140/90 + proteinuria ≥2+ and at least one of Oliguria Visual disturbance, headaches, RUQ pain Platelts < 100, ALT > 50 Creatinine > 100 3+ of clonus Management Deliver baby if at term (IoL) Continuous CTG in labour Fluid restriction if severe Complications Eclampsia Renal Failure Hepatic Rupture HELLP Cerebral Haemorrhage DIC
Pulmonary Oedema Increased perinatal mortality Eclampsia Fitting/seizure secondary to pre-eclampsia Complications Abruption Pulmonary oedema Cerebral haemorrhage rupture Retinal detachment Maternal Management Basic resus IV magnesium sulphate IV diazepam BP controlled with IV hydralazine or labetolol Observe for 24 hrs Ectopic Pregnancy Pregnancy implanted outside of uterine cavity Presents with Abdo pain and bleeding Risk factors PID Tubal Surgery Peritonitis or pelvic surgery IUCD IVF Endometriosis Mini-pill Management Surgical Salpingectomy Salpinotomy Medical Methotrexate (IM or Local) Diabetes in pregnancy Pre-existing Diabetes Need increased insulin doses Increased risk of hypos Acceleration of DM complications Increased risk of DKA 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, birth – fetal polyuria UTI or candida – glycosuria Management MDT Dietary advice Folic acid preconception HbA1c monitoring Increased insulin dose Regular fundoscopy Anomaly screening Growth Gestational Diabetes