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