OBSTETRICS

1
OBSTETRICS
2

• Placenta- HCG (doubles every 48hrs untill 12 wks),

3
Antenatal care

• ve pregnancy test- Attend GP
• Referred for booking at hospital.
• Booking USS scan to date pregnancy.
• Full Hx and booking bloods.
• Identify LOW risk (Community/Green) or HIGH risk
  (Consultant/Red).

4
Booking Investigations

• FBC (Rpt 28 wks and term)
• Blood group and abs. (rpt 28wks if Rh ve)
• Rubella status
• HEP B/C, HIV. If no Hx chicken pox do Varicella.
• Dip urine
• OGTT, Haemaglobinopathy screen.

5
Each visit.

• BP
• Dip urine
• Fundal height (1 cm/week)
• Fetal heart with Doptone.
• Palpate abdomen for presentation/station.

6
Screening

• CUBS -11-13 wks
• 16 wks AFP/HCG
• Gives risk for trisomy 21/ spina bifida. Not
  definitive. (DS? , SB? ) If gt 1in 250, referred
  for counselling.
• 20 wks anomaly scan. Structural abnormalities.
• CVS (9-11 wks)/ Amniocentisis (gt15 wks).
  Karyotype. 1 risk of miscarriage.

7
Labour

• Prim- 12-24 hrs
• Multi- 6-12 hrs
• Can start with Show, SRM or regular painful
  contractions.
• Classified labour when gt3 cm dilated- effaced.

8
Stages in Labour

• Stage I- Onset of labour to full dilatation.
• Stage II- Full dilatation to delivery of baby
  (lt3hrs in prim, lt2hrs in Multi)
• Stage III- Birth of baby to delivery of placenta.
  (lt1hr)
• Can be active Syntocinon/Syntometrine.
• Physiological.

9
Partogram
10
Progress

• Monitor FH
• Contractions- 3-5 good contraction in 10 mins.
• Examine for Cx dilatation/ station/ position
  every 4hrs.

11
Presentation
12
Station
13
Position

• Related to OCCIPUT (posterior fontanelle)

Symphysis Pubis
Direct
L
R
ANTERIOR
Left
Right
TRANSVERSE
TRANSVERSE
POSTERIOR
L
R
Direct
Sacrum
14
Analgesia in labour

• Breathing/ TENS/ Bath/ Co-codamol
• Entonox (Nitrous oxide/ oxygen)
• Morphine- can cause neonatal resp depression.
• Epidural- L3/4 ( Needs IV fluids, Catheter,
  Continuous CTG)
• Can be topped up if needs LUSCS.

15
Types of delivery

• SVD
• Assisted delivery- Forceps/ Ventouse.
• LUSCS- Emergency/ Elective

16
Emergencies

• Malpresentation- Breech, face, Brow, compound-
  Needs LUSCS.
• Cord prolapse- Cord comes out with fluid. Elevate
  presenting part- Crash LUSCS.
• Shoulder dystocia- Head delivered. Shoulders
  stuck. Manoeuvres to try disimpact.

17
The puerperium

• 6 wks post natal
• Uterus shrinks- Lochia produced.
• PPH (secondary)
• DVT/PE
• Haemarrhoids/ Constipation
• Post natal depression.

18
Breast feeding.

• Oestrogen and Progesterone stimulate breast
  proliferation.
• Prolactin stimulates milk production and descent
  into alveoli.
• Oxytocin stimulates milk ejection.
• First thick yellow fluid- Colostrum.
• Maintained by suckling.

19
Breast feeding
20
Breast feeding

• Skin to skin contact/ Bonding
• Receives all required nutrients.
• Passive immunity of antibodies.
• Cant breast feed with certain medications or if
  HIV ve.

21
Complications

• Cracked nipples
• Mastitis
• Milk stasis
• Poor supply-
• Domperidone.

22
POST PARTUM HAEMORRHAGE
23
PPH

• gt500mls blood loss PV.
• Primary or secondary.
• Secondary- endometritis/RPOC

24
Primary PPH

• Emergency
• ABC
• A- talk to pt
• B- facial O2
• C- IV Access (2 large venflons)
• FBC, Coag, X-match
• IV fluids

25
Causes

• T- Tone
• T- Tissue
• T- Trauma
• T- Thrombin

26
Tone

• Atonic uterus 90
• Catheterise
• Bimanual compression
• IM syntocinon 10iu
• IM ergometrine 500mcg
• IV Syntocinon infusion 40iu
• IM Haemabate (PGF2? ) 250mcg

27
Bimanual compression
28
Tissue

• Check placenta.
• Manual removal.

29
Trauma

• Genital tract trauma.
• Repair.

30
Thrombin

• Chase Coag result.
• Contact haematology.
• Watch for signs of DIC.

31
ANTE PARTUM HAEMORRHAGE
32
APH

• Bleeding from the genital tract after 24 wks
  gest.
• 2-5 of pregnancies.
• Important cause of maternal and fetal morbidity
  and mortality.
• Dont forget Anti D in Rh-ve women

33
Causes

• Placenta praevia
• Placental abruption
• Show
• Local causes
• Vasa praevia

34
Placenta praevia

• Placenta develops in lower uterine segment. 0.5
  of all pregnancies.
• Risk factors- increased age
• -multiparous
• - prev LUSCS
• - Smoking
• - prev history
• - mulitple pregnancy

35
Classification
36
Presentation

• 20 wk USS (97 will migrate)
• Painless vaginal bleeding- unprovoked
• Post coital bleeding.
• Malpresentation
• Massive haemorrhage may follow warning bleed.

37
Diagnosis

• VE/ Speculum should not be carried out if PP
  suspected.
• USS (TV scan best)
• MRI scanning can
• detect accreta.

38
Management (Major)

• If asymptomatic- admit from 35-36wks.
• Large cannula, GS.
• Delivery at 37-38wks by LUSCS.
• Best to have blood and interventional radiology
  ready.
• If haemorrhage- ABC, stabilise mother then
  emergency LUSCS.

39
Placental Abruption

• Bleeding following separation of normally sited
  placenta. 0.5-1.5 of all pregnancies.
• Risk factors- Increased age
• - Multiparous
• - Smoking
• - Recreational drug use
• - Abdominal trauma.

40
Classification
Revealed/ Concealed
41
Presentation

• PV bleeding- Ammount may not correlate with
  significance of haemorrhage.
• Abdo pain/ tension.
• Shock/ collapse.
• Fetal distress.

42
Diagnosis

• Usually clinical
• USS (only
• if mother
• and baby
• stable)

43
Management

• ABC
• Resuscitation
• Delivery if required.
• Increased risk of PPH
• Watch for signs of DIC.

44

• MISCARRIAGE

45
Miscarriage

• 15 of all confirmed pregnancies.
• Threatened
• Inevitable
• Complete/Incomplete
• Missed
• Recurrent
• Molar

46
Threatened miscarriage

• PV bleeding /- abdo pain
• Mild
• Os closed
• USS confirms viable pregnancy.
• May lead on to miscarriage.

47
Inevitable miscarriage

• Heavy PV bleeding and pain
• Open cervix
• Products in canal.

48
Complete/ Incomplete

• Complete- products passed and uterus empty
• Incomplete- Not all products passed but no FH on
  USS and PV bleeding.

49
Missed miscarriage

• Pregnancy Loss with no sx.
• Can be picked up at booking scan.
• Pregnancy sx usually gone away

50
Management

• Expectant- Await body to pass pregnancy
• Surgical- Evac
• Medical- Mifepristone and Misoprostil

51
Recurrent miscarriage

• 3 or more miscarriages
• 1 of all women
• Chromosomal abnormality
• Congenital uterine abnormalities
• Cervical incompetence
• Infection
• PCOS
• Thrombophilia

52
Molar pregnancy

• High HCG, Large uterus.
• PV Bleeding.
• PARTIAL MOLE
• Where part of placenta overgrows (proliferates).
  May be developing fetus present, but is
  genetically abnormal and cannot survive outside
  the womb. Two sperm enter egg and instead of
  forming twins forms an abnormal foetus. Triploid.

53
Molar pregnancy

• COMPLETE MOLE
• Whole placenta is abnormal and grows rapidly. No
  developing fetus. One sperm enters the egg but
  only half of one set of chromosomes are present.
  Aneuploid.

54
Diagnosed on USS
Snow storm appearance
55
Management

• Surgical evac
• Products sent to lab for conformation.
• Register with Molar pregnancy unit (Dundee)- They
  will follow up.
• Track HCG to 0.
• No new pregnancy for 1 yr but need to avoid
  combined hormonal contraception.

56
Can progress to.....

• PERSISTENT GESTATIONAL  
• TROPHOBLASTIC DISEASE
• Part of the mole remains in any part of the body
  despite initial treatment -can grow quickly.
• CHORIOCARCINOMA
• Rare but curable form of cancer- placenta becomes
  malignant. Can arise from a molar pregnancy. Can
  spread throughout the body, usually to lungs,
  liver and brain. Treatment is chemotherapy.

57

• MULTIPLE PREGNANCY

58
Multiple pregnancy

• Incidence of twins 1/100
• Triplets 1/4000
• Predisposing factors Increased age
• -Family/personal
  Hx
• - Fertility
  treatment
• -Race

59
Terms

• Mono/Dizygotic- No. of embryos
• Chorionicity- No. of placentas
• Amnionicity- No. of amniotic sacs

60
Dizygotic twins

• Non identical
• 2 embryos implant.
• Always 2 placentas and 2 sacs.

61
Monozygotic twins

• Identical
• 1 embryo splits.
• Split lt3 days- DCDA
• 4-7 days- MCDA
• 8-12 days- MCMA- rare
• 13-15 days - conjoined twins

62
(No Transcript)
63
Diagnosis

• Booking scan
• Before if hyperemesis.

64
Antenatal complications

• FETAL
• Increased pre-term delivery and sequalae.
• Increased risk of anomalies
• Increased risk IUGR/IUD
• In MC twins- Twin to Twin Transfusion syndrome
  (TTTTS)

65
Antenatal complications

• MATERNAL
• Severe hyperemesis
• Increase risk miscarriage
• Increase risk of anaemia, Pre-eclampsia, Pelvic
  pain, APH, Placental praevia, Gestational
  diabetes and PPH.
• Cord accidents.

66
Antenatal care

• High Risk
• More visits.
• Anomaly scan at 18-20 wks. (cant really do
  CUBS/AFP)
• Iron tablets
• Serial Growth scans
• Delivery 38wks

67
Delivery

• Vaginal vs LUSCS.
• If twin I is Breech or smaller- LUSCS
• If twin I is ceph and bigger- could try Vaginal
  delivery.
• Continuous monitoring (FSE on twin I)
• IV access.
• Difficulty is with twin II- Should be 60 mins
  after I at most.
• Worst case vaginal twin I, LUSCS Twin II

68
Twin to Twin Transfusion

• Monochorionic twins
• Placental arteriovascular anastamosis.
• Uneven distribution.
• Donor twin anaemic, IUGR, oligohydramnios
• Recipient twin- Polycythemic, Polyhydramnios,
  Ascites and pleural effusions.

69
TTTS
70
Treatment

• Risky
• Laser ablation of anastomosis vessels
• Early delivery.

71
Small for dates fetus
72
Small for Dates

• Constitutionally small baby
• Intra uterine growth restriction (IUGR)
• Usually picked up by measuring fundal height.
• Confirmed on USS (Growth scan)

73
Fetal growth chart.
74
Constitutionally small

• Small mother.
• Symmetrically small.
• Less that 10th centile but growing appropriately.
• Normal liquor volume
• Normal umbilical artery dopplers

75
IUGR

• Asymmetrical growth.
• Low liquor volumes.
• Not growing along centiles.
• Sometimes fetal distress.

76
Causes

• Placental insufficiency
• Fetal anomalies
• Drugs
• Infection

77
Placental insufficiency

• Most Common
• Abnormalities in placental development.
• Diabetes
• Pre-eclampsia
• Thrombophilia
• Connective tissue diseases
• Placental infarction/abruption

78
Drugs

• Smoking (2-fold risk)
• Alcohol
• Recreational drugs
• Beta-Blockers

79
Management

• Increased monitoring
• Growth scans, liquor volumes and umbilical artery
  dopplers every 2 weeks.
• Early delivery

80
(No Transcript)
81
Pre- eclampsia

• Increased BP and proteinuria /- oedema.
• gt 30 mmHg systolic or gt15mmHg diastolic above
  booking BP or
• Diastolic gt90mmHg.
• Only 20 of patients with increased BP in
  pregnancy have pre-eclampisa. (80 are PIH-
  pregnancy induced hypertension.

82
Severe

• Defined severe if
• 3 protein or more in urinalysis.
• BP gt170/110
• Visual disturbances/headache/ papilloedema
• RUQ/Epigastric pain/tenderness.
• Clonus
• Oliguria/ Renal failure.
• HELLP syndrome (Haemolysis, Elevated Liver
  enzymes, Low Platelets)
• All above suggest eclampsia could be imminent.

83
Aetiology

• Largely unknown.
• Immunological disturbance? decreased invasion of
  maternal spiral arteries into placenta? decreased
  placental function.
• Endothelial cell damage? Fibrin fragments which
  break away and deposit in-
• kidney? Renal failure, proteinuria.
• CNS? convulsions.

84
Risk factors

• Primigravida.
• lt20yrs age and gt35yrs age.
• Family/ Personal history of Pre-eclamsia.
• Multiple pregnancy
• Obesity
• Non smokers.
• Pre-existing hypertension or renal disease.

85
Risks to mother

• Renal/Hepatic failure
• HELLP
• Stroke
• Disseminated intravascular coagulopathy. (DIC)
• Pulmonary oedema
• Convulsions
• Death.

86
Risks to baby

• IUGR (growth restriction)
• Placental abruption
• Prematurity
• Hypoxic damage
• Death.

87
Investigations

• History
• Exam (inc ando exam, reflexes, fundoscopy)
• Dip urine, regular BPs.
• Bloods (Large cannula, FBC, LFTs Urate, UEs,
  Coag and Grp and save)
• If severe- Urinary catheter- monitor output..
• Invasive monitoring- central
  line, ECG.
• CTG for fetal wellbeing.

88
Treament

• Treatment does not cure pre-eclampsia, its aim
  is to prevent eclampsia.
• Only cure is to DELIVER BABY.
• Mild- Antihypertensives (Labetalol 200mg 3xday or
  Methyldopa orally)
• If lt35wks gestation- steroids. 12mg betamethasone
  IM.
• Severe- IV Labetalol/hydralazine.
• - IV Magnesiuam sulphate 4g bolus
  and 1g/hr
• Monitor BP, Urine output, Reflexes, Resp rate and
  Mag levels if ? Toxicity.

89
Cont..

• CTG- for fetal wellbeing.
• Decide when safe to deliver baby. (can be
  C-section or Induction of labour)
• There is an increased risk of PPH. (Post partum
  haemorrhage)
• Continue management for 24hrs post delivery.
• If has eclamptic seizure- treat with MgSO4.

90
Future pregnancies.

• Prophylaxis in future pregnancies -Low dose
  aspirin. (75mg)
• Careful BP monitoring.
• Growth scans.

91
Diabetes in pregnancy
92
Diabetes

• Pre existing Diabetes
• Gestational Diabetes.
• Pregnancy is state of Insulin resistance.
• Placenta produces anti insulin hormones (hPL,
  cortisol and gulcagon)

93
Gestational Diabetes

• Onset with pregnancy
• Assess clinical risk and consider OGTT at 28 wks.
• Refer to Diabetic Obstetric clinic.
• Milder risks than IDDM
• Can progress to Type II DM postnatally.
• Diet controlled vs Insulin

94
How pregnancy effects Diabetes?

• Insulin requirements rise.
• Decrease in Renal function (proteinuria)
• Increased episodes of hypoglycaemia.
• Steroid use!

95
How Diabetes effects pregnancy?

• Increased risk of congenital abnormalities.
• Increases risk IUD/Neonatal death.
• Increased risk Pre-eclampsia
• Polyhydramnios
• Macrosomia/IUGR
• Prematurity
• Postnatal hypogycaemia and Jaundice.

96
Antenatal care

• Pre-conception counselling
• Multi-disciplinary approach.
• Strict Diabetic control.
• Detailed Anomaly scan.
• ANC every 2 weeks with growth scans.
• Induction at 38 wks.

97
Labour

• Continuous GTG
• Sliding scale in certain cases- Half as soon as
  placental delivered.
• 6 wk follow up- GTT.

98

• BREAK

99
GYNAECOLOGY

• Normal Menstruation

100
Normal Menstruation

• Cycle 22-35 days
• Duration of bleeding lt7 days
• Blood loss lt80mls
• Menstrual Phase- endometrium shed. Discharged
  through Cx by uterine contractions.

101
Normal cycle
102
Proliferative (Follicular) phase

• Day 5-13
• Ovarian follicular growth
• Increasing oestrogen
• Growth and vascularisation of endometrium.
• Ovulation occurs day 14.
• Ovulation occurs 14 days prior to next period in
  a cycle that is not 28 days.

103
Secretory (luteal) phase

• Day 15-28
• Progesterone increases. Produced by corpus
  luteum.
• Maintains endometrial thickness, preparing for
  implantation.
• Ends with demise of corpus luteum

104
Menstrual phase

• Day 1-5
• Decline of oestrogen and progesterone.
• Breakdown of endometrium- sheds.

105
Menorrhagia
106
Menorrhagia

• Defined as gt 80mls blood loss /month.
• Heavy mentrual blood loss affecting QOL or
  causing anaemia.
• 10 of all women.
• Most common gynae referral.

107
Assessment

• History- particularly menstrual. (Cycle, length,
  how many pads?, flooding)
• Examination- Abdo/ PV.
• -Speculum- smear/swabs

108
Investigations

• Pelvic USS
• FBC, clotting, TFTs
• In older women (gt40yrs)
• Pipelle biopsy
• Hysteroscopy, DC.

109
Causes

• Dysfunctional Uterine bleeding (more common at
  extremes of reproductive age)
• Diagnosis of exclusion.
• Fibroids
• Endometial ca

110
Fibroids

• Benign tumours of myometrium
• 20 incidence in women gt40yrs old.

111
Management

• MEDICAL- Non-hormonal
• - Hormonal
• SURGICAL- Minor
• - Major

112
Medical

• Non- hormonal
• Mefenamic acid (NSAID)
• Tranexamic acid (antifibrinolytic)
• Both taken during period only.

113
Medical

• Hormonal
• Progestogens- Norethisterone
• - Provera
• - POP (Cerazette)
• Mirena coil
• COC, Depoprovera, GNRH analogues.

114
Surgical (Minor)

• MEA- Microwave endometrial ablation.
• 75 satisfied.
• Must have biopsy prior
• to carrying out.
• Family should be complete
• Myomectomy (fibroids)

115
Surgical (Major)

• Hysterectomy /- BSO.
• Should not be considered unless tried alternative
  treatment or has very large fibroids.

116
Urinary incontinance and prolapse
117
Prolapse

• Downward displacement- weakening of support
  (pelvic floor)

118
Definitions

• Uterovaginal- uterus and cx
• Cystocele- Bladder
• Rectocele- Large bowel
• Enterocele- small bowel

119
Uterovaginal

• Grade I

120
Uterovaginal

• Grade II

121
Uterovaginal

• Grade III- complete eversion.

122
Grade III
123
Procedentia

• Ulceration

124
Rec
125
Sypmtoms

• Something coming down
• Discomfort
• Urinary sx
• Recurrent UTIs
• Constipation/ Difficulty emptying bowel.

126
Treatment

• Mild- Oestrogen cream
• - Pelvic floor exercises.
• Mod/Severe- Conservative (Pessary) vs Surgical
  (pelvic floor repair/ Vaginal hysterectomy/Mesh)

127
Pessaries
128
Urinary incontinence

• Urge
• Stress

129
Urge

• Overactive bladder.
• Inability to delay voiding after sensation.
• Infection, stones, CNS disorders.
• Usually no cause.

130
Treatments

• Lifestyle changes.
• Frequency volume chart.
• Out patient continence programme.
• Anti-cholinergic medications.
• Botox (rare)

131
Stress

• Loss of urine when increase on intra-abdominal
  pressure.
• Weak pelvic floor/urethral sphincter.
• Confirm on Urodynamic studies.

132
Treatments

• Physio (PFE, Electrical stimmulation of muscles)
• Urethral bulking
• Sub-urethral sling (TVT-O)
• Colposuspension.
• 90 happy after surgery

133
Gynaecological cancers
134
Endometrial cancer

• Most common gynae cancer
• Adenocarcinoma most common. 80-85
• Mean age 60yrs
• Risks- Nulluparous,
• obesity
• E2 only HRT
• late menopause.

135
Symptoms and Diagnosis

• PMB
• Heavy irregular bleeding
• None
• TV USS (Assess endometrial thickness)
• Pipelle biopsy
• Hysteroscopy, DC.

136
Stageing
Stage I Confined to uterus
Stage Ia No myometrial invasion
Stage Ib Myometrial invasion lt50
Stage Ic Myometrial invasion gt50
Stage II Involvement of cervix
Stage III Pelvic spread
Stage IV Bladder/rectum/distant (lung)
137
Treatment

• Pelvic clearance. (inc omentectomy/appendicectomy)
  
• If advanced- Chemotherapy/ Hormone therapy
• 5 yr survival

Stage I 75
Stage II 58
Stage III 30
Stage IV 10
138
Ovarian cancer

• Most deadly.
• Peak age 68-85yrs old.
• 90 sporadic, 10 genetic
• Epithelial tumours -85
• Increased risk- Nulliparous, highr social class.
  Ovulation induction Rx.
• Decreased risk- COC use

139
Symptoms and Diagnosis

• Abdo distension/mass
• Abdo pain
• Weight loss/ loss of appetite.
• Ca125 gt35 post menopausal.
• Imaging- TV USS, CT, MRI, CXR
• Laparotomy

140
Ovarian tumour
141
Stageing
Stage I -25 Confined to ovaries
Stage Ia One ovary
Stage Ib Both ovaries
Stage Ic ve ascitic cytology
Stage II -10 Confined to pelvis
Stage III -45 Confined to peritoneal cavity
Stage IV -20 Distant spread
142
Treatment

• Pelvic clearance chemotherapy
• Radiotherapy
• 5 yr survival

Stage I 67
Stage II 51
Stage III 20
Stage IV 5
143
Cervical caner

• Peak age 45-55 (can occur as young as 20)
• Risks Defaulting smears
• Multiple partners
• HPV 1618 (80-90)
• COC use
• Smoking

144
Cervical screening

• Cx smear- NICE guidelines
• Every 3 yrs from age 20-65 yrs
• Liquid based cytology
• Registerd with SCCRS
• Abnormal results referred to Colposcopy for cold
  coagulopathy/LLETZ
• Jade Goody effect. Increase 21 uptake.

145
Cervical smear
146
Pre-cancerous changes

• Transformation zone
• Dyskaryosis (mild-severe)
• Cervical intraepithelial neoplasia (CIN)
• May persist for years.
• Can revert to normal.
• 30 CIN 3 will progress to cancer.

CIN 1 Abnormal cells in lower 1/3 epithelium only.
CIN 2 Abnormal cells in lower ½ only.
CIN 3 Carcinoma in-situ. Full thickness of epithelium
147
Cervical cancer
148
Symptoms and Diagnosis

• Post coital bleeding
• Abnormal discharge/ bleeding
• Weight loss.
• Pain
• EUA, cystoscopy, proctoscopy.
• Cone biopsy
• LLETZ

149
Stageing
Stage Ia Micro lt3mm in depth
Stage Ib Confined to Cx
Stage II Extends to upper vagina
Stage III Extends to pelvic side wall or lower vagina
Stage IV Distant spread- bladder/rectum/beyond.
150
Treatment

• Hysterectomy- Radical.
• Radiotherapy
• Chemotherapy
• 5yr survival

Stage I 80
Stage II 61
Stage III 32
Stage IV 15
151
Vaccination

• Cervarix
• Protects against HPV 16 18 (not others)
• 99 effective.
• Girls age 12-13 yrs old (Current catch up to age
  18)
• Data up to 6 yrs protection
• Still need smears as rare Cx cancers
• Controversy re Promotes underage sex

152
Vulval cancer

• Least common
• Peak age 65-70 yrs old
• Squamous carcinoma 92
• Risks- HSV
• HPV (16/18)
• Smoking
• Immunosuppresion.

153
Symptoms and Diagnosis

• Pruitus vulva.
• Vulval pain/ discharge
• Lump or ulcer
• Diagnosed by vulval biopsy

154
Vulval cancer
155
Stageing
Stage I lt2cm lesion confined to vulva
Stage II gt2cm lesion confined to vulva
Stage III Local spread or node involvement
Stage IV Advanced local spread or bilateral node involement. (inguinal, femoral, pelvic.)
156
Treatment

• Stages I-III Radical vulvectomy.
• Radiotherapy/ Chemotherpay
• Stage IV- Palliative only.
• 5 yr survival

Stage I 97
Stage II 85
Stage III 74
Strage IV 30
157
Poly cystic ovarian syndromePCOS
158
PCOS

• Varying degrees.
• Unknown aetiology
• Clinical signs- Oligomenorrhoea
• - Obesity
• - Hirsutism

159
Endocrine measurements

• Increased LH/ Low FSH---gt incresased LHFSH
  ratio.
• Increased testosterone.
• Decreased SHBG.
• Insulin resistance and implaired glucose
  tolerance. (11)
• Moderate hyperprolactinaemia- occasionally.

160
USS assessment

• Increased ovarian volume.
• 10-15 microcysts lt10mm in diameter
• String of pearls

161
PCOS
162
PCOS

• Diagnosis can be made if has 2 of 3-
• Clinical features
• Endocrine findings
• USS findings.

163
Treatment

• Weight loss.
• Metformin
• Laser Rx for hirsuitism.
• COC, Mirena, Depo provera.
• Fertility Rx with clomid.

164
Ectopic pregnancy
165
Ectopic pregnancy

• Implantation outside uterus.
• 1.2 of pregnancies.
• Incidence rising
• Tubal -97
• Cervix
• Ovary
• Peritoneum
• Abdominal

166
Risk factors

• STI/PID
• IUD/Mirena
• Prev Ectopic
• Strerilisation/ Tubal Surgery
• Assisted reproduction

167
Presentation

• Amenorrhoea, ve pregnancy test.
• Typically at 6-8 wks gest.
• No symptoms.
• Pain (LIF/RIF/Shoulder tip) -90
• PV spotting- 70
• Faint, collapse, haemodynamic compromise. -15.

168
Diagnosis

• Clinical (peritonism, adnexal mass, unstable)
• Serum HCG tracking.
• TV USS (no IU pregnancy, adnexal mass, free
  fluid).
• Laparoscopy.

169
TV USS
170
Management

• IV Access, FBC, GS/ X-match.
• Resuscitation if required.
• Anti D if Rh-ve
• Surgical vs Medical vs Conservative.

171
Surgical

• Laparoscopic
• Salpingectomy.
• Any signs of
• rupture.
• Laparotomy
• Check other tube
• is not damaged

172
Medical

• Methotrexate- 50mg/m2
• Must fit criteria and be
• compliant to follow up.
• Check UEs and LFTs.
• HCG tracking- may initially
• rise.
• 5-10 require surgery.
• No pregnancy for 3 months.
• Avoid alcohol/ sunlight.

173
Conservative

• Risky.
• Must be asymptomatic and stable.
• Falling HCG.
• Track to zero.

174
Follow up/ Future pregnancies

• 6 week follow up appt
• De brief
• Good contraception
• Single ectopic- 60-70 will have IU pregnancy.
• Subsequent pregnancies 10-15 will be ectopic.
• Early Ultrasound.