16 OBSTETRICS 17 GYNAECOLOGY 17.05 • Pelvic inflammatory disease
• Endometriosis • Fibroids
16.01 Antenatal care 17.01 • Male subfertility
• Pre-pregnancy counselling • Female genital mutilation
• Physiological changes in pregnancy • Amenorrhoea – primary & secondary 17.06 • Subfertility
• Antental care • Polycystic ovarian syndrome • Ovarian hyperstimulation syndrome
• Structural abnormalities • Physiological menstrual periods
17.07 • Vulval problems
16.02 Antenatal care 17.02 • Menorrhagia • Genital warts • Genital herpes
• Aneuploidy & screening • Premenstrual syndrome • Vulval carcinoma
• Invasive testing • Use of anti-D • Menopause
• Antenatal care timetable • Hormone replacement therapy 17.08 • Vaginal discharge DDx
• Urinary incontinence
16.03 Antenatal care 17.03 • Termination of pregnancy • Pelvic organ prolapse
• Minor symptoms in pregnancy • Miscarriage
• Hyperemesis gravidum • Recurrent miscarriage 17.09 • Cervical cancer + screening
• Thromboprophylaxis • VTE • Vaginal cancer • Endometrial
17.04 • Ectopic pregnancy • Endometrial cancer hyperplasia
16.04 Pre-existing problems • Gestational trophoblastic disease
• Hypertension • Anaemia 17.10 • Ovarian cancer
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• Diabetes • Hyperthyroidism • Ovarian cysts • Torsion
• Jaundice • Malaria
• Renal disease
16.05 Pre-existing problems 16.12 Labour and problems
• Psychiatric conditions – drugs • Retained placenta
• Epilepsy • Connective tissue disease • Instrumental vaginal delivery
• HIV • Rubella • Measles • Caesarean section • Stillbirth
16.06 Ante/perinatal infections 16.13 Labour and problems
• Syphilis • CMV • Parvovirus B19 • Placenta problems – vasa praevia,
• Toxoplasmosis • Listeria placenta accreta, placenta praevia
• Hepatitis B & E • Perineal tears + episiotomy
• Puerperal psychosis
16.07 Ante/perinatal infections
• Herpes simplex • Varicella zoster 16.14 Obstetric emergencies
• Chlamydia • Gonorrhoea • Sepsis in the puerperium
• Clostridium • TB • Group B Strep • Eclampsia • Placental abruption
• Opthalmia neonatorum • Cord prolapse • Shoulder dystosia
16.08 Antenatal problems 16.15 Obstetric emergencies
• Abdominal pain in pregnancy DDx • Uterine rupture
• Pre-eclampsia • HELLP syndrome • Postpartum haemorrhage
• Oligohydramnios • Polyhydramnios • Amniotic fluid embolism
• Small for gestational age • DIC & coagulation defects
16.09 Perinatal baby problems 16.16 Contraception
• Prematurity • Postmaturity • Combined pill, patch, ring
• Birth injuries • Condoms • Progesterone-only pill
• Injectable contraceptives
16.10 Labour and problems • Implantable contraceptives
• Normal labour • Induction
• Pain relief in labour • Monitoring 16.17 Contraception
• Intrauterine system • Copper IUD
16.11 Labour and problems • Emergency contraception
• Multiple pregnancies (twins/triplets) • Postpartum contraception
• Breech presentation • Contraception for specific populations
• Meconium-related problems - >40yos - Obese pts
• Reduced foetal movements - Epilepsy - Transgender/nonbinary
, Female genital mutilation Primary amenorrhoea Secondary amenorrhea Polycystic ovarian syndrome
D: removal or partial removal of external D: failure to start menstruating by D: Cessation of menstruation D: condition of ovarian dysfunction Rotterdam Dx criteria (≥2 of 3):
female genitalia or injury to other internal • 15yo in girls with normal sexual • For 3-6mo in women with previously involving hyperandrogenism, oligo- • Polycystic ovaries (≥12 follicles or
female genital organs characteristics, or normal and regular menses menorrhoea, and polycystic ovaries ovarian volume >10 cm3 on US)
• Illegal in the UK • 13yo in girls with no secondary sexual • For 6-12mo in women with previous • Oligo-ovulation or anovulation
- Engage child safeguarding characteristics oligomenorrhea R: FHx, early onset of pubic/axillary hair • Clinical and/or biochemical signs of
- Any new cases in <18yo must be and apocrine sweat gland development hyperandrogenism
reported to police A/P: Causes (=adrenarche), obesity - eg ↑LH:FSH ratio
• Traditionally practised in Africa, some • In those with normal sexual • In those with no features of androgen
parts of India and Indonesia; not limited characteristics excess A/P: unknown, ?inheritance, ?insulin Mx: *wt loss*
to any particular cultural or religious - Physiological causes - Physiological causes (eg pregnancy, resistance, overlap with metabolic • Hirsutism and acne
group - Genito-urinary malformations, eg lactation, menopause) syndrome - COCP (third gen); balance with risk of
imperforate hymen - Hypothalamic dysfunction, eg due to VTE
WHO classification - Endocrine disorders chronic illness or stress, excessive S/smx: - If no response, trial of topical
• Type I: partial/total removal of clitoris ◊ Hyper/hypothyroidism exercise • Obesity (PCOS does not cause obesity, eflornithine, or other drugs under
and/or prepuce ◊ Hyperprolactinaemia - Hyper/hypothyroidism but many women with PCOS are specialist supervision
◊ Cushing's syndrome - Primary ovarian insufficiency, eg due
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• II: partial/total removal of clitoris and obese) • Infertility
labia minora ± excision of labia majora • In those with no secondary sexual to chemo, radiotherapy • Subfertility and infertility - medications: clomifene (induces
• III: narrowing of vaginal orifice with characteristics, amenorrhea is due to - Sheehan syndrome (postpartum • Menstrual disturbances ovulation), metformin, or combination
creation of covering seal by cutting and primary ovarian insufficiency hypopituitarism due to necrosis of - Oligomenorrhea and amenorrhea - ovarian drilling for those who don't
appositioning the labia minora and/or - Chromosomal irregularities, eg pituitary gland) • Features of hyperandrogenism respond to clomifene
majora ± excision of clitoris Turner's syndrome - Asherman syndrome (intrauterine - Hirsutism - Acne - use of COCP to control bleeding and
(=infibulation) - Hypothalamic-pituitary dysfunction, eg adhesions) • Acanthosis nigricans (due to insulin ↓risk of endometrial cancer
• IV: any other harmful procedures to the stress, wt loss • In those with features of androgen resistance)
female genitalia for non-medical excess (eg hirsutism, acne, virilisation)
purposes, eg pricking, piercing Ix: • Exclude pregnancy (bHCG) - PCOS Ix:
• FBC, U&Es, coeliac screen, thyroid - Cushing's syndrome • Pelvic US looking for ovarian cysts
function test - Late-onset congenital adrenal • Baseline bloods: FSH, LH, TSH,
Complications hyperplasia
• Gonadotrophins prolactin, testosterone, sex hormone-
- ↓LH/FSH ≈ hypothalamic cause
• Acutely: death, blood loss, sepsis, pain, - Androgen-secreting tumours of the binding globulin (SHBG)
- ↑LH/FSH ≈ ovarian problem or
urinary retention, infxns (HIV, hepatitis, ovary or adrenal gland - Prolactin and testosterone may be
tetanus)
gonadal dysgenesis (eg Turner's) normal or mildly elevated
• Long-term: inability to have sexual
• Prolactin • Oestradiol Ix: as per primary amenorrhea - SHBG is normal to low in PCOS
• Androgen – may be ↑ in PCOS
intercourse (= apareunia), superficial
• Check for impaired glucose tolerance
dyspareunia, anorgasmia, sexual
dysfunction, chronic pain, scarring, slow Mx: exclude pregnancy, lactation, and
urination, UTIs, etc Mx: • Treat underlying cause menopause (in ≥40yo) LH
• Maternal consequences: PPH, ↑risk of • If pt has primary ovarian insuff due to • Treat underlying cause Progesterone
C-sec, episiotomy, fistula, difficulty in gonadal dysgenesis, they may benefit
examining and catheterising, etc from HRT Oestrogen
FSH
Mx: Day Hormonal change Ovarian cycle Uterine cycle
• Defibulation (reconstructive surgery of
infibulated scar) – may be done 0-4 Menses Follicular phase Luteal phase
antenatally
4-14 LH/FSH stimulate follicular Follicular phase Proliferative phase; laying
- If not done antenatally, deliver in unit
maturation. Estradiol Maturation of dominant down new endometrial Menses
with emergency obstetric care Ovulation
- Offer epidural if vag exam poorly secreted by maturing follicle into Graafian follicle layer (estrogen driven)
follicle. (mainly FSH driven)
tolerated / episiotomy anticipated
• Screen for hep C 14 GnRH surge → LH just * Ovulation *
• Repair post-delivery should control before ovulation
bleeding. Re-infibulation is illegal.
14-28 Progesterone secreted by Luteal phase: post- Secretory: endometrium
corpus luteum. LH/FSH ovulation corpus luteum receptive to implantation
levels decrease (LH/FSH helps formation of (progesterone supported)
corpus luteum)
Gynaecology 17.01 FGM, Amenorrhoea, PCOS
• Endometriosis • Fibroids
16.01 Antenatal care 17.01 • Male subfertility
• Pre-pregnancy counselling • Female genital mutilation
• Physiological changes in pregnancy • Amenorrhoea – primary & secondary 17.06 • Subfertility
• Antental care • Polycystic ovarian syndrome • Ovarian hyperstimulation syndrome
• Structural abnormalities • Physiological menstrual periods
17.07 • Vulval problems
16.02 Antenatal care 17.02 • Menorrhagia • Genital warts • Genital herpes
• Aneuploidy & screening • Premenstrual syndrome • Vulval carcinoma
• Invasive testing • Use of anti-D • Menopause
• Antenatal care timetable • Hormone replacement therapy 17.08 • Vaginal discharge DDx
• Urinary incontinence
16.03 Antenatal care 17.03 • Termination of pregnancy • Pelvic organ prolapse
• Minor symptoms in pregnancy • Miscarriage
• Hyperemesis gravidum • Recurrent miscarriage 17.09 • Cervical cancer + screening
• Thromboprophylaxis • VTE • Vaginal cancer • Endometrial
17.04 • Ectopic pregnancy • Endometrial cancer hyperplasia
16.04 Pre-existing problems • Gestational trophoblastic disease
• Hypertension • Anaemia 17.10 • Ovarian cancer
© quackquackmed.com
• Diabetes • Hyperthyroidism • Ovarian cysts • Torsion
• Jaundice • Malaria
• Renal disease
16.05 Pre-existing problems 16.12 Labour and problems
• Psychiatric conditions – drugs • Retained placenta
• Epilepsy • Connective tissue disease • Instrumental vaginal delivery
• HIV • Rubella • Measles • Caesarean section • Stillbirth
16.06 Ante/perinatal infections 16.13 Labour and problems
• Syphilis • CMV • Parvovirus B19 • Placenta problems – vasa praevia,
• Toxoplasmosis • Listeria placenta accreta, placenta praevia
• Hepatitis B & E • Perineal tears + episiotomy
• Puerperal psychosis
16.07 Ante/perinatal infections
• Herpes simplex • Varicella zoster 16.14 Obstetric emergencies
• Chlamydia • Gonorrhoea • Sepsis in the puerperium
• Clostridium • TB • Group B Strep • Eclampsia • Placental abruption
• Opthalmia neonatorum • Cord prolapse • Shoulder dystosia
16.08 Antenatal problems 16.15 Obstetric emergencies
• Abdominal pain in pregnancy DDx • Uterine rupture
• Pre-eclampsia • HELLP syndrome • Postpartum haemorrhage
• Oligohydramnios • Polyhydramnios • Amniotic fluid embolism
• Small for gestational age • DIC & coagulation defects
16.09 Perinatal baby problems 16.16 Contraception
• Prematurity • Postmaturity • Combined pill, patch, ring
• Birth injuries • Condoms • Progesterone-only pill
• Injectable contraceptives
16.10 Labour and problems • Implantable contraceptives
• Normal labour • Induction
• Pain relief in labour • Monitoring 16.17 Contraception
• Intrauterine system • Copper IUD
16.11 Labour and problems • Emergency contraception
• Multiple pregnancies (twins/triplets) • Postpartum contraception
• Breech presentation • Contraception for specific populations
• Meconium-related problems - >40yos - Obese pts
• Reduced foetal movements - Epilepsy - Transgender/nonbinary
, Female genital mutilation Primary amenorrhoea Secondary amenorrhea Polycystic ovarian syndrome
D: removal or partial removal of external D: failure to start menstruating by D: Cessation of menstruation D: condition of ovarian dysfunction Rotterdam Dx criteria (≥2 of 3):
female genitalia or injury to other internal • 15yo in girls with normal sexual • For 3-6mo in women with previously involving hyperandrogenism, oligo- • Polycystic ovaries (≥12 follicles or
female genital organs characteristics, or normal and regular menses menorrhoea, and polycystic ovaries ovarian volume >10 cm3 on US)
• Illegal in the UK • 13yo in girls with no secondary sexual • For 6-12mo in women with previous • Oligo-ovulation or anovulation
- Engage child safeguarding characteristics oligomenorrhea R: FHx, early onset of pubic/axillary hair • Clinical and/or biochemical signs of
- Any new cases in <18yo must be and apocrine sweat gland development hyperandrogenism
reported to police A/P: Causes (=adrenarche), obesity - eg ↑LH:FSH ratio
• Traditionally practised in Africa, some • In those with normal sexual • In those with no features of androgen
parts of India and Indonesia; not limited characteristics excess A/P: unknown, ?inheritance, ?insulin Mx: *wt loss*
to any particular cultural or religious - Physiological causes - Physiological causes (eg pregnancy, resistance, overlap with metabolic • Hirsutism and acne
group - Genito-urinary malformations, eg lactation, menopause) syndrome - COCP (third gen); balance with risk of
imperforate hymen - Hypothalamic dysfunction, eg due to VTE
WHO classification - Endocrine disorders chronic illness or stress, excessive S/smx: - If no response, trial of topical
• Type I: partial/total removal of clitoris ◊ Hyper/hypothyroidism exercise • Obesity (PCOS does not cause obesity, eflornithine, or other drugs under
and/or prepuce ◊ Hyperprolactinaemia - Hyper/hypothyroidism but many women with PCOS are specialist supervision
◊ Cushing's syndrome - Primary ovarian insufficiency, eg due
© quackquackmed.com
• II: partial/total removal of clitoris and obese) • Infertility
labia minora ± excision of labia majora • In those with no secondary sexual to chemo, radiotherapy • Subfertility and infertility - medications: clomifene (induces
• III: narrowing of vaginal orifice with characteristics, amenorrhea is due to - Sheehan syndrome (postpartum • Menstrual disturbances ovulation), metformin, or combination
creation of covering seal by cutting and primary ovarian insufficiency hypopituitarism due to necrosis of - Oligomenorrhea and amenorrhea - ovarian drilling for those who don't
appositioning the labia minora and/or - Chromosomal irregularities, eg pituitary gland) • Features of hyperandrogenism respond to clomifene
majora ± excision of clitoris Turner's syndrome - Asherman syndrome (intrauterine - Hirsutism - Acne - use of COCP to control bleeding and
(=infibulation) - Hypothalamic-pituitary dysfunction, eg adhesions) • Acanthosis nigricans (due to insulin ↓risk of endometrial cancer
• IV: any other harmful procedures to the stress, wt loss • In those with features of androgen resistance)
female genitalia for non-medical excess (eg hirsutism, acne, virilisation)
purposes, eg pricking, piercing Ix: • Exclude pregnancy (bHCG) - PCOS Ix:
• FBC, U&Es, coeliac screen, thyroid - Cushing's syndrome • Pelvic US looking for ovarian cysts
function test - Late-onset congenital adrenal • Baseline bloods: FSH, LH, TSH,
Complications hyperplasia
• Gonadotrophins prolactin, testosterone, sex hormone-
- ↓LH/FSH ≈ hypothalamic cause
• Acutely: death, blood loss, sepsis, pain, - Androgen-secreting tumours of the binding globulin (SHBG)
- ↑LH/FSH ≈ ovarian problem or
urinary retention, infxns (HIV, hepatitis, ovary or adrenal gland - Prolactin and testosterone may be
tetanus)
gonadal dysgenesis (eg Turner's) normal or mildly elevated
• Long-term: inability to have sexual
• Prolactin • Oestradiol Ix: as per primary amenorrhea - SHBG is normal to low in PCOS
• Androgen – may be ↑ in PCOS
intercourse (= apareunia), superficial
• Check for impaired glucose tolerance
dyspareunia, anorgasmia, sexual
dysfunction, chronic pain, scarring, slow Mx: exclude pregnancy, lactation, and
urination, UTIs, etc Mx: • Treat underlying cause menopause (in ≥40yo) LH
• Maternal consequences: PPH, ↑risk of • If pt has primary ovarian insuff due to • Treat underlying cause Progesterone
C-sec, episiotomy, fistula, difficulty in gonadal dysgenesis, they may benefit
examining and catheterising, etc from HRT Oestrogen
FSH
Mx: Day Hormonal change Ovarian cycle Uterine cycle
• Defibulation (reconstructive surgery of
infibulated scar) – may be done 0-4 Menses Follicular phase Luteal phase
antenatally
4-14 LH/FSH stimulate follicular Follicular phase Proliferative phase; laying
- If not done antenatally, deliver in unit
maturation. Estradiol Maturation of dominant down new endometrial Menses
with emergency obstetric care Ovulation
- Offer epidural if vag exam poorly secreted by maturing follicle into Graafian follicle layer (estrogen driven)
follicle. (mainly FSH driven)
tolerated / episiotomy anticipated
• Screen for hep C 14 GnRH surge → LH just * Ovulation *
• Repair post-delivery should control before ovulation
bleeding. Re-infibulation is illegal.
14-28 Progesterone secreted by Luteal phase: post- Secretory: endometrium
corpus luteum. LH/FSH ovulation corpus luteum receptive to implantation
levels decrease (LH/FSH helps formation of (progesterone supported)
corpus luteum)
Gynaecology 17.01 FGM, Amenorrhoea, PCOS
