Gynaecological History

O&G Notes

Gynaecological History

• Name, Age, Occupation
• PC
• Details, time-scale, previous Rx
• HPC
• Focus on main complaint
• Pattern of menstrual bleeding – cycle length, regularity, bleeding time, IMB, amount inc.
• Menarche & menopause
• PV Discharge
• Pelvic / abdominal pain
• Continence if applicable
• Sexual problems & contraception
• Prolapse (bowel Sx)

• Past Gynaecological History
• Dates, smears, surgery &c.
• Past Obstetric History
• Children, age, problems, abortions
• Past medical History (unlikely to be much in PACES)
• Drug History and allergies
• Social History
• Smoker? Drinker?
• Family History
• 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
• Date from 1st day of LMP. Median duration is 40 weeks from LMP assuming 28 day cycle & ovulation on day 14.
• Date of LMP + 9 months + 7 days.
• Term = 37 - 42/40!

• Enquire about scans – dating ~12/40 and Abnormality ~20/40
• Past Obstetric History
• Children, age, gestation, complications, mode of delivery, abortions (recurrent?), BP
• Gravida – total No of pregnancies
• Parity – No of live births + stillbirths + terminations
• Past Gynaecological History
• Dates, smears, surgery &c.
• Social History
• Very important: marriage & consent, social class and maternal mortality, domestic violence, child protection, smoking, EtOH, drugs, occupation, support.

• PMH
• Important esp DM, HT, Epliepsy, Renal disease, Venous thromboembolism (VTE).
• FH

Obstetric examination

• BP & urine dip
• Abdominal Examination – comfort of the mother.
• Inspection: scars, foetal mvt, striae gravidarum, linea nigra
• 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.
• 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
• Down’s Syndrome
• Open neural tube defect
• Other structural defects
• Infections
• Hepatitis B & C
• HIV
• VDRL
• Bacterial
• Pre-eclampsia
• Foetal Growth

Additional Screening

• Amniocentesis (>35yrs/ In addition to serum screening)
• Genetic screening (FHx)
• TaySachs (Ashkenazy Jews etc)
• 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
• >13mmol/L = GDM
• 7.9-13mmol/L = refer for GTT

Down’s Syndrome Screening

The Integrated Test

• 11-13/40: “Stage 1”
• Nuchal Translucency measurement
• Blood Sample (PAPP-A)
• 2nd Stage appointment given for 3-4/40
• 15-16/40: “Stage 2”
• Blood Sample (AFP, Ue3, free BhCG)
• Calculation of risk
• 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
• Take blood sample (AGE + AFP + uE3 + free BhCG)

Contraception

Type / Women / Failure / Benefits / Side effects / Contraindications
COCP / Most popular method for
under 30’s / 0.2 / Good control, Well accepted, Women in control, Reduction in menstrual blood loss and dysmennorhoea (therapeutic) / Nausea, headache,
breakthrough
bleeding, breast
tenderness
Hirsuitism/acne, weight gain, vaginal dryness, facial skin pigmentation / Migraines, IHD, CVA HTN, Oestrogen dep. Neoplasia, Liver disease, Smoking, Age >35yrs, Breast feeding, Obesity, Type II diabetes
POP (mini-pill) / Any COCP contraindication
Good motivation / 1.0 / Few CI, No interference with breast feeding, broad spectrum antibiotics / Irregular bleeding and amenorrhoea in up to 50%, Weight gain, breast tenderness, headache and acne
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 / Amenorrhoea and breakthrough bleeding / Injectables are irreversible until effects worn off, Normal cycle and fertility may take 6 months after stopping, Protection again STDs is minimal
IUD (Copper Coil) / Older, Multips / 1‐ 1.5 / High reliability, Easy insertion and removal, Changed every 5 years / Pelvic infections, Perforation, Menstrual disturbances, Falls out, Pain / Pregnancy, Undiagnosed irregular genial tract bleeding, PID, Previous ectopic
IUD (Hormone) / Menorrhagia Rx, woman with CI to the OCP / 0.2‐0.5
Condoms, caps, diaphragms / Casual sex / 5.0 / Insertion before sex, STD protection, Non hormonal / Only if used incorrectly / High user motivation
Sterilisation / Finished families / 0.02/
0.13 / Permanent / Post OP complications / Permanent
Natural / Religious? / 20‐30 / No treatments / STD and Pregnancy

Emergency Contraception

• Post coital Pill:
• 100μg of ethinyloestradiol and 500μg of levonorgestrel repeated after 12 hours
• Must be given within 72hrs of unprotected intercourse to delay ovulation and inhibit implantation
• Emergency IUCD:
• Inserted within 5 days of unprotected intercourse to prevent implantation
• Follow up is essential after EC to exclude ongoing pregnancy and give advice regarding future contraceptive methods.

GYNAECOLOGY

Gynae Cancers

Features / Investigation / Treatment
Cervical / 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. / Biopsy and staging / 1a- Cone Biopsy
1b-2a- Radical abdo hysterectomy, Radical trachlectomy (preserve fertility)
2b+ radiotherapy and chemotherapy
Ovarian / 45-65 yrs, Vague Sx, Pain on ovarian torsion or bleeding, Abdo distension, urinary frequency, GI Sx / USS
Raised Ca 125 / Laparotomy debulking, TAH & BSO & Omentum, Chemo- if epithelial
Endometrial / Mean age 61yrs, commonly intermenstrual or post-menopausal bleeding, Risk factors include: Obesity, Nulliparity, late menopause, PCOS, Oestrogen therapy, tamoxifen Tx, DM, FHx of breast or colon Ca. / Biopsy, EUA, CXR / TAH & BSO, Add radiotherapy, Palliative Chemotherapy
Vulval / 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. / WLE, Groin lymphadenopathy
Vaginal / Abnormal bleeding, / Biopsy, EUA, MRI, CXR / External beam radiotherapy and intravaginal radiotherapy

Amenorrhea

• Primary
• Menstruation has never occurred
• Secondary
• No menstruation for > 6 months

Primary / Secondary
Hypothalamous / Kallmann’s syndrome, tumour, trauma, stress, low BMI / Kallmann’s syndrome, tumour, trauma, stress, low BMI
Pituitary / Hyperprolactinaemia / Hyperprolactinaemia, Sheehan’s syndrome
Gonads / PCOS, Streak Gonads, Ovarian tumour, hermaphroditism / PCOS, Streak Gonads, Ovarian tumour, ovarian failure/removal
Uterus / Pregnancy, congenital absence / Pregnancy, hysterectomy, Ashermann’s syndrome
Cervix / Post-surgical stenosis
Vagina / Congenital absence, imperforate hymen
Endocrine / DM, Thyroid disease, adrenal disease, androgen insensitivity / DM, Thyroid disease, adrenal disease,
Drugs / Phenothiazines, chemotherapy, radiotherapy / Phenothiazines, chemotherapy, radiotherapy

Investigations

• Chromosomal analysis
• Hormone profile
• βhCG
• FSH/LH
• Prolcatin
• TSH
• T3/T4
• USS

Menorrhagia

• > 80ml of menstrual blood loss per period
• Often associated with dysmenorrhoea

Systemic Disorders / Thyroid disease, clotting disorders
Local causes / Fibroids, Endometrial Polyps, endometrial ca, endometriosis, PID, dysfunctional uterine bleeding
Iatrogenic causes / IUCD, oral anti-coagulants

Investigations

• USS
• Hysteroscopy
• Blood tests

Management

• Medical
• Prostaglandin inhibitors (mefenamic acid)
• Anti-fibrinolytics and haemostatics (tranexamic acid)
• Progestogens
• IUCD’s
• COCP
• Surgical
• Endometrial ablation
• Hysterectomy

Dysmenorrhoea

• Primary
• Dysmenorrhoea from menarche

• Secondary

• Dysmenorrhoea in women with previously painless periods caused by patholog

• Often described as cramping pain, radiates to back/upper thighs

Cervical / PID
Uterine / 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 / Ovarian ca, oestrogen secreting tumour
Uterus / Submucosal fibrid, atrophic changes, polyps, hyperplasia, carcinoma
Cervix / Atrophic changes, malignancy
Vagina / Atrophic changes
Urethra / Urethral caruncle, heamaturia
Vulva / Vulvitis, dystrophy, malignancy

Investigations

• Pelvic USS
• Hysteroscopy
• Endometrial biopsy

Fibroids

• Benign tumours of the myometrium

Risk Factors

• Age
• Nulligravidity
• Obesity
• Afro-carribean ethnicity
• Smoking, COCP and pregnancy are protective

Features

• Asymptomatic
• Menstrual abnormalities (increased bleeding)
• Abdominopelvic mass
• Pain
• Subfertility
• Pressure Sx
• Urinary frequency
• Nocturia
• Urgency
• Rectal pressure
• Pregnancy complications
• Firm irregular uterus
• Fibroid moves with uterus on bimanual examination

Investigations

• USS
• Hysteroscopy
• MRI
• Laparotomy

Management

• GnRH
• 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

Investigations

• 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
• 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

Causes / Features / Investigations / Treatment
Stress Incontinence / Neurological injury, urethral injury, pelvic trauma
Risk Factors: Childbirth, Chronic coughing, age, Obesity, Smoking / Involuntary loss of urine during physical activity / Rule out UTI, Urodynamic testing, Cystoscopy, Urogram / Lifestyle changes, pelvic floor exercises, TVT, 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 non-tender 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 Atony
• 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 cross-match
• 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+ beats 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
• Liver rupture
• Retinal detachment
• Maternal death

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, 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

Management

• Cholestyramine or antihistamine (reduce itching)
• Early vitamin K (prevent haemorrhage)
• Featl monitoring
• Deliver fetus if mature
• Counselling

Complications

• PPH
• IUD
• Preterm labour
• Fetal distress in labour
• Fetal or neonatal intracranial haemorrhage