Obstetrics & Gynecology
Amenorrhea
- Absence of menstruation. Pathological amenorrhea is the failure to menstruate for at least 6 months
- It can be divided into:
• 1ry amenorrhea ⟶ lack of menstruation before the age of 16 years or 14 in the absence of secondary
characteristic (the average age for menarche is 12-14 years old)
• 2ry amenorrhea⟶ cessation of menstrual cycles following established cycles
Etiology
• Hypothalamic amenorrhea Female athlete tirade:
- most common 1. 2ry amenorrhea
2. Osteoporosis
- usually due to low BMI or excessive exercise
3. Anorexia nervosa
- FSH, LH and prolactin are all low
• PCOS
• Hyperprolactinemia
• Premature ovarian failure (POI): raised FSH
• Anatomical problems • Asherman’s $ → adhesions of the endometrium
- usually results in 1ry amenorrhea often associated with dilatations and curettage
- vaginal examination to rule out imperforate hymen is of the intrauterine cavity
important • It results in infertility and they often experience
- pelvic US: to determine pelvic anatomy (Mullerian menstrual irregularities
agenesis)
- anatomical problems can also cause 2ry amenorrhea (Asherman’s syndrome)
• Thyroid problems (both hyper & hypo)
• Pregnancy
Short stature Turner Syndrome
Hirsutism, acne (androgen excess) PCOS, Hyperprolactinemia
Menopausal symptoms in women before 40s Premature ovarian failure
Eating disorder Anorexia nervosa
Galactorrhea hyperprolactinemia
Dysmenorrhea
1ry Dysmenorrhea 2ry Dysmenorrhea
Common etiologies:
- Endometriosis
no obvious organic cause
- Adenomyosis
- PID
Management: Management:
• NSAIDs such as Mefenamic acid (1st line) • Treat the underlying cause
• COCP (2nd line if the only symptom is pain)
• Mirena IUS
- Dysmenorrhea > Mefenamic acid (NSAIDs)
- Menorrhagia > Tranexamic acid (antifibrolytic → inhibits fibrinolysis)
Hematometra
- Accumulation of blood within the uterus, commonly caused by imperforate hymen or transverse vaginal septum
- 1ry amenorrhea and cyclical pain
Imperforate hymen → bluish bulging membrane visible at the introitus
Transverse vaginal septum → possible abdominal mass
PLABverse - 1
, Obstetrics & Gynecology
Endometriosis
➢ Presence of endometrial-like tissue outside the uterine cavity. It's estrogen dependent, and therefore mostly
affects women during their reproductive years. If the ectopic endometrial tissue is within the myometrium
itself, it's called adenomyosis. Up to 10-12% of women have a degree of endometriosis
Features:
4 DYS- + CYClical pain
- Chronic pelvic pain (cyclic or constant)
• DYSmenorrhea
- Dysmenorrhea – pain often starts days before bleeding
• DYSpareunia
- Deep dyspareunia (indicates possible involvement of uterosacral ligaments)
• DYSuria
- Subfertility
• DYSchezia
Investigations:
• Laparoscopy is the gold-standard investigation
• TVUS (to diagnose & to exclude of an ovarian endometrioma) - Drug therapy does not seem to have a significant
Management: impact on fertility rates. However, laparoscopic
- NSAIDs (Mefenamic acid) excision and ablation of endometriotic ovarian
- COCP cysts may improve fertility
- Levonorgestrel IUS - It's acceptable to use COCP to treat pain without
Surgery: laparoscopic diagnosis as long as fertility isn't the
• Laparoscopic excision and ablation of endometrioid lesions issue
reduce associated pain
PID
➢ Infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the
surrounding peritoneum. Most commonly caused by ascending infection from the endocervix
Causative organisms
• Chlamydia → most common cause
Cervicitis → is purely infection of the cervix not involving
• Neisseria gonorrhea
other pelvic organs
Risk factors • It presents with discharge, tender cervix (chandelier
• Age <25 sign) and dyspareunia but NO menstrual irregularities
• Previous STIs or lower abdominal pain
• New sexual partner or multiple partners • If just Cervicitis – Chlamydia:
• - Doxy 100mg twice a day for seven days (1st line)
Uterine instrumentation - Azithromycin 1g s a single dose, followed by
• IUD 500mg once daily for 2 days
• Post-partum endometritis - If pregnant → Erythromycin
Features • If just Cervicitis – Neisseria gonorrhea:
- Ceftriaxone 1g IM as a single dose
• Lower abdominal pain
- Ciprofloxacin 500mg orally as a single dose if the
• Fever organism is susceptible to ciprofloxacin
• Deep dyspareunia (painful sexual intercourse)
• Dysuria and menstrual irregularities may occur • Pelvic abscess or tubo-ovarian abscesses are
possible complications of PID
• Vaginal or cervical discharge often purulent (NOT offensive)
• US is the diagnostic imaging method of choice
• Cervical excitation (tenderness) for acute pelvic pain in gynecology
• Abnormal vaginal bleeding (intermenstrual, postcoital) • Fitz-Hugh-Curtis $ → a complication of PID,
Complications usually presents with an acute onset of RUQ
• Infertility pain (aggravated by breathing or coughing. Pain
may refer to right shoulder)
• Chronic pelvic pain • Endocervical swab → PID
• Ectopic pregnancy • USG → complications of PID
• In males → Acute epididymitis
Management
- Outpatient: IM Ceftriaxone + oral Doxycycline + oral Metronidazole for 14 days OR Ofloxacin + Metronidazole
- Inpatient: IV Ceftriaxone + IV Doxy + oral Metro for 14 days OR IV Ofloxacin + IV Metronidazole for 14 days
PLABverse - 2
, Obstetrics & Gynecology
Chickenpox exposure in pregnancy
➢ Caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal
root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed as
fetal varicella syndrome
➢ The incubation period is 10-14 days but can be as long as 21 days
Fetal varicella syndrome (FVS)
• Risk of FVS following maternal varicella is 1% if occurred before 20 weeks, very few occur between 20-28
and none after 28 weeks
• Features include: skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning
disabilities
Other risks to the fetus
• Shingles in infancy: 1-2% risk if maternal exposure in the 2nd or 3rd trimester
• Severe neonatal varicella: if mother develops RASH between 5 days before or 2 days after birth there is a
risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases
Management of chickenpox exposure
1. Who gets checked for varicella antibodies?
- If the woman's immunity to chickenpox is unknown and if there is no previous history of chickenpox or
shingles
- Serum should be tested before administration of VZIG, 1. Pregnant exposed to chickenpox → check woman's
immunity (previous infection, varicella antibodies)
it takes 1-2 days or few hours if the serum is stored from
2. Not immunized → VZIG
an antenatal booking blood sample 3. Chickenpox rash develops (24h) → oral acyclovir
2. Who gets VZIG?
- If the pregnant woman is not immune to VZV and she has had a significant exposure, she should be offered
VZIG as soon as possible
- VZIG is effective when given up to 10 days after contact
- If the immune status is unknown, administration of VZIG can be delayed until serology results are available
- VZIG has NO significance once chickenpox has developed and should therefore NOT be used in pregnant
women who have developed a chickenpox rash
3. Who gets oral acyclovir?
- Oral acyclovir should be prescribed for pregnant women with chickenpox if they present within 24 hours of
the onset of the rash and if they are ≤ 20 weeks gestation
Chronic hypertension
- Hypertension that is present at the booking visit or before 20 weeks or if the woman is already on
antihypertensive medications
Gestational hypertension
- New hypertension presenting after 20 weeks without significant proteinuria
- Once developed → Refer for a same day assessment in the maternal unit
- If blood test come back at an acceptable level and she’s asymptomatic → she’s advised to measure blood
pressure four times daily and to come back if the BP >150/100 → Oral labetalol would be given
NHS guidelines for IV magnesium sulphate administration
- Women in a critical care setting who have severe hypertension or severe pre-eclampsia who have or
previously had an eclamptic fit
- Women with severe preeclampsia who are in a critical care setting if birth is planned within 24h
PLABverse - 3
Amenorrhea
- Absence of menstruation. Pathological amenorrhea is the failure to menstruate for at least 6 months
- It can be divided into:
• 1ry amenorrhea ⟶ lack of menstruation before the age of 16 years or 14 in the absence of secondary
characteristic (the average age for menarche is 12-14 years old)
• 2ry amenorrhea⟶ cessation of menstrual cycles following established cycles
Etiology
• Hypothalamic amenorrhea Female athlete tirade:
- most common 1. 2ry amenorrhea
2. Osteoporosis
- usually due to low BMI or excessive exercise
3. Anorexia nervosa
- FSH, LH and prolactin are all low
• PCOS
• Hyperprolactinemia
• Premature ovarian failure (POI): raised FSH
• Anatomical problems • Asherman’s $ → adhesions of the endometrium
- usually results in 1ry amenorrhea often associated with dilatations and curettage
- vaginal examination to rule out imperforate hymen is of the intrauterine cavity
important • It results in infertility and they often experience
- pelvic US: to determine pelvic anatomy (Mullerian menstrual irregularities
agenesis)
- anatomical problems can also cause 2ry amenorrhea (Asherman’s syndrome)
• Thyroid problems (both hyper & hypo)
• Pregnancy
Short stature Turner Syndrome
Hirsutism, acne (androgen excess) PCOS, Hyperprolactinemia
Menopausal symptoms in women before 40s Premature ovarian failure
Eating disorder Anorexia nervosa
Galactorrhea hyperprolactinemia
Dysmenorrhea
1ry Dysmenorrhea 2ry Dysmenorrhea
Common etiologies:
- Endometriosis
no obvious organic cause
- Adenomyosis
- PID
Management: Management:
• NSAIDs such as Mefenamic acid (1st line) • Treat the underlying cause
• COCP (2nd line if the only symptom is pain)
• Mirena IUS
- Dysmenorrhea > Mefenamic acid (NSAIDs)
- Menorrhagia > Tranexamic acid (antifibrolytic → inhibits fibrinolysis)
Hematometra
- Accumulation of blood within the uterus, commonly caused by imperforate hymen or transverse vaginal septum
- 1ry amenorrhea and cyclical pain
Imperforate hymen → bluish bulging membrane visible at the introitus
Transverse vaginal septum → possible abdominal mass
PLABverse - 1
, Obstetrics & Gynecology
Endometriosis
➢ Presence of endometrial-like tissue outside the uterine cavity. It's estrogen dependent, and therefore mostly
affects women during their reproductive years. If the ectopic endometrial tissue is within the myometrium
itself, it's called adenomyosis. Up to 10-12% of women have a degree of endometriosis
Features:
4 DYS- + CYClical pain
- Chronic pelvic pain (cyclic or constant)
• DYSmenorrhea
- Dysmenorrhea – pain often starts days before bleeding
• DYSpareunia
- Deep dyspareunia (indicates possible involvement of uterosacral ligaments)
• DYSuria
- Subfertility
• DYSchezia
Investigations:
• Laparoscopy is the gold-standard investigation
• TVUS (to diagnose & to exclude of an ovarian endometrioma) - Drug therapy does not seem to have a significant
Management: impact on fertility rates. However, laparoscopic
- NSAIDs (Mefenamic acid) excision and ablation of endometriotic ovarian
- COCP cysts may improve fertility
- Levonorgestrel IUS - It's acceptable to use COCP to treat pain without
Surgery: laparoscopic diagnosis as long as fertility isn't the
• Laparoscopic excision and ablation of endometrioid lesions issue
reduce associated pain
PID
➢ Infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the
surrounding peritoneum. Most commonly caused by ascending infection from the endocervix
Causative organisms
• Chlamydia → most common cause
Cervicitis → is purely infection of the cervix not involving
• Neisseria gonorrhea
other pelvic organs
Risk factors • It presents with discharge, tender cervix (chandelier
• Age <25 sign) and dyspareunia but NO menstrual irregularities
• Previous STIs or lower abdominal pain
• New sexual partner or multiple partners • If just Cervicitis – Chlamydia:
• - Doxy 100mg twice a day for seven days (1st line)
Uterine instrumentation - Azithromycin 1g s a single dose, followed by
• IUD 500mg once daily for 2 days
• Post-partum endometritis - If pregnant → Erythromycin
Features • If just Cervicitis – Neisseria gonorrhea:
- Ceftriaxone 1g IM as a single dose
• Lower abdominal pain
- Ciprofloxacin 500mg orally as a single dose if the
• Fever organism is susceptible to ciprofloxacin
• Deep dyspareunia (painful sexual intercourse)
• Dysuria and menstrual irregularities may occur • Pelvic abscess or tubo-ovarian abscesses are
possible complications of PID
• Vaginal or cervical discharge often purulent (NOT offensive)
• US is the diagnostic imaging method of choice
• Cervical excitation (tenderness) for acute pelvic pain in gynecology
• Abnormal vaginal bleeding (intermenstrual, postcoital) • Fitz-Hugh-Curtis $ → a complication of PID,
Complications usually presents with an acute onset of RUQ
• Infertility pain (aggravated by breathing or coughing. Pain
may refer to right shoulder)
• Chronic pelvic pain • Endocervical swab → PID
• Ectopic pregnancy • USG → complications of PID
• In males → Acute epididymitis
Management
- Outpatient: IM Ceftriaxone + oral Doxycycline + oral Metronidazole for 14 days OR Ofloxacin + Metronidazole
- Inpatient: IV Ceftriaxone + IV Doxy + oral Metro for 14 days OR IV Ofloxacin + IV Metronidazole for 14 days
PLABverse - 2
, Obstetrics & Gynecology
Chickenpox exposure in pregnancy
➢ Caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal
root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed as
fetal varicella syndrome
➢ The incubation period is 10-14 days but can be as long as 21 days
Fetal varicella syndrome (FVS)
• Risk of FVS following maternal varicella is 1% if occurred before 20 weeks, very few occur between 20-28
and none after 28 weeks
• Features include: skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning
disabilities
Other risks to the fetus
• Shingles in infancy: 1-2% risk if maternal exposure in the 2nd or 3rd trimester
• Severe neonatal varicella: if mother develops RASH between 5 days before or 2 days after birth there is a
risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases
Management of chickenpox exposure
1. Who gets checked for varicella antibodies?
- If the woman's immunity to chickenpox is unknown and if there is no previous history of chickenpox or
shingles
- Serum should be tested before administration of VZIG, 1. Pregnant exposed to chickenpox → check woman's
immunity (previous infection, varicella antibodies)
it takes 1-2 days or few hours if the serum is stored from
2. Not immunized → VZIG
an antenatal booking blood sample 3. Chickenpox rash develops (24h) → oral acyclovir
2. Who gets VZIG?
- If the pregnant woman is not immune to VZV and she has had a significant exposure, she should be offered
VZIG as soon as possible
- VZIG is effective when given up to 10 days after contact
- If the immune status is unknown, administration of VZIG can be delayed until serology results are available
- VZIG has NO significance once chickenpox has developed and should therefore NOT be used in pregnant
women who have developed a chickenpox rash
3. Who gets oral acyclovir?
- Oral acyclovir should be prescribed for pregnant women with chickenpox if they present within 24 hours of
the onset of the rash and if they are ≤ 20 weeks gestation
Chronic hypertension
- Hypertension that is present at the booking visit or before 20 weeks or if the woman is already on
antihypertensive medications
Gestational hypertension
- New hypertension presenting after 20 weeks without significant proteinuria
- Once developed → Refer for a same day assessment in the maternal unit
- If blood test come back at an acceptable level and she’s asymptomatic → she’s advised to measure blood
pressure four times daily and to come back if the BP >150/100 → Oral labetalol would be given
NHS guidelines for IV magnesium sulphate administration
- Women in a critical care setting who have severe hypertension or severe pre-eclampsia who have or
previously had an eclamptic fit
- Women with severe preeclampsia who are in a critical care setting if birth is planned within 24h
PLABverse - 3
