PerinatalwomensRNSH

TableofContents
Usefulabbreviationsandtidbits(butnotnecessarilyexaminable)
Perinealtears
Bicornuateuterus
Molarpregnancy/Gestationaltrophoblasticdisease
D&CDilatationandCurettage
Wharton'sJelly
SUASingleUmbilicalArtery("twovesselcord")
PROM/SROMPremature/Prelabour/SpontaneousRuptureofMembranes
NBAC/VBACNext/VaginalbirthafterCaesarean
ECVExternalCephalicVersion
Bartholin'scyst/abscess
Randomnotes
Neonatology
NeonatalResuscitation(inexamsforsure)
NeonatalJaundice
HPVvaccine/cervicalcancer
Papsmear
PelvicMasses
RelevantPelvicAnatomy
Benignovariancysts
Fibroids
Riskofmalignancyindex1x2x3
Holisticwomen'shealth
Abortion
Premenstrualsyndrome
Vaginismus
VaginalExamination
Menopause
Primaryovarianinsufficiency(POI)
NormalLabour
4stagesofLabour
Mechanismoflabour
ProgressofLabour
PainreliefinLabour
Placenta
Malpresentations
Monitoringinlabour
Normalpregnancy
Maternalchangesinpregnancy
Twinpregnancies
Pretermbirth/labour
Antenatalcorticosteroids
Tocolysis/tocolyticstosuppresslabour
OralAntibiotics
IVMagnesiumsulfateMgSO4
TPLsamplequestions
PelvicPain
Acuteonsetpain:reflectsfreshtissuedamage,resolvesastissueheals
Chronicpain:>6months,intermittent,constantpain
Redflags
Endometriosis
Pelvicinflammatorydisease
Normalmenstrualcycle:
Hypoglycemiainneonates(verycommoninthenewborn)
MaternalfactorsleadingtoneonatalBSL
Neonatalfactorsthatmakebabyatriskofhypoglycemia
Managementofhypoglycaemicneonate
Perinatalindigenoushealth
Perinatalchromosomalabnormalities
1sttrimesterscreening
2ndtrimesterscreening
Pregnancytimeline
AntiDantibodies/haemolyticdiseaseofthefoetus
Prematureandlowbirthweightinfants
Preventpretermdelivery
Prepareforpretermdelivery
Acutepretermneonatalproblems
Medium/longtermpretermneonatalproblems
Viability
Cerebralpalsy
Gynaeoncology
UroGynaecologicalissues
PelvicOrganProlapsePOP
Postnatalmooddisordersperinatalanxietyanddepression
RespiratoryDistressinnewborninfants
1.TransientTachypnoeaofthenewbornTTN
2.HyalinemembranediseaseHMD
3.Pneumonia/sepsisshouldALWAYSbeaddx
4.Pneumothorax
5.Meconiumaspiration
6.Structuralabnormalities
7.Diaphragmatichernia
8.Other
Vomitingintheneonate
Pathologicvomiting
NewbornExamination
Perinatalinfections
Rubella
Varicellazostervirus
CMV
Parvovirus
HerpesSimplexVirus
HIV
HepC
Toxoplasmosis
Syphilis
Listeria
Multiplepregnancies
HighriskObstetrics
Estimateddateofdelivery
Postpartumhaemorrhage
PrimaryPPH
SecondaryPPH
PreventionofPPH
ManagementofPPH
Preeclampsia
Diabetesinpregnancy
Multiplepregnancies
Smallforgestationalage
IntrauterineGrowthRestriction
Symmetric(30%)vsAsymmetric(70%)
Gynaecologicalcancers
Infertility
IVFcycle
ComplicationsofIVF:
Bleedinginearlypregnancy
Miscarriage
Miscarriagetypes
Ectopicpregnancy
Mgmtofectopics
GestationalTrophoblasticDisease
PersistentGTNandchoriocarcinoma
Breastfeeding
Medications
Methyldopa/aldomet



Usefulabbreviationsandtidbits(butnotnecessarilyexaminable)

Perinealtears
1stdegreelimitedtovaginalmucosaandskinoftheintroitus
2nddegreeextendstothefasciaandmusclesofperinealbody
3rddegreetraumainvolvesanalsphincter
4thdegreeextendstotherectallumen,throughtherectalmucosa
Bicornuateuterus
Heartshapeduterus,twohornsseparatedbyaseptum
associatedwithinfertilitythemostcommonsymptomaticpresentationiswithearlypregnancyloss
andcervicalincompetence
pretermdeliveryin1525%
malpresentationin4050%,breechpresentationinpartialbicornuate,transverseinothers.
riskofdeformitiesinthefoetus
Molarpregnancy/Gestationaltrophoblasticdisease
Abnormaltrophoblasticproliferationoffoetaltissue
Nonneoplasticorneoplastic
Nonneoplastic:Exaggeratedplacentalsite,placentalsitenodule,complete/partial
hydatidiformmole
Neoplastic:invasivemole,choriocarcinoma,placentalsitetrophoblastictumour,epithelioid
trophoblastictumours.Alsoreferredtoasgestationaltrophoblastinneoplasia
Clinicalmanifestationsinclude:
Vaginalbleeding
Enlargeduterus
Pelvicpressureorpain
Thecaluteincysts
Anaemia
Hyperemesisgravidarum
Hyperthyroidism
Preeclampsiabefore20/40
Vaginalpassageofhydropicvessels
D&CDilatationandCurettage
Indications
Diagnostic
Endometrialcarcinoma
Endometrialhyperplasia
Therapeutic
Treatmentofincomplete,missed,septic,inducedabortions
Initialtreatmentofmolarpregnancies(gestationaltrophoblasticdisease)
Temporarymanagementofexcessive/prolongedvaginalbleedingunresponsiveto
hormonaltherapy
Suctioncuretteasmanagement,forpostpartumhaemorrhagewithretainedproducts
ofconception

Wharton'sJelly
Clear,gelatinoussubstancethatsurroundstheumbilicalvesselswithinthecord

SUASingleUmbilicalArtery("twovesselcord")
Canoccurin0.56%ofpregnancies
SomeplacentalabnormalitiesmaybeincreasedwithSUAincluding:
Velamentousinsertion
Abnormallyshortcord
Placentapraevia
Trueknotincord
Circumvallateplacenta
Placentalinfarcts
Documentedassociatedfoetalabnormalitiesinclude:
Cardiac
Genitourinary
Renal
Gastrointestinal
SomedegreeofIUGR

PROM/SROMPremature/Prelabour/SpontaneousRuptureofMembranes
Usedinterchangeably

NBAC/VBACNext/VaginalbirthafterCaesarean
NBACscarryriskof:
Ruptureduringlabour(1:200)
Ruptureduringlabourrequiringsubsequenthysterectomy(1:1000)
Stillbirth
Encouraged,butissueisnotreallyencouragingNBACs,buttodecreaseoverallfirstCaesareans
(WHOrecommended15%Caesareanasfirstdelivery,NSWaverage30%)

ECVExternalCephalicVersion
Externalmanipulation/rotationofbreechpositionfoetustocephalicpresentation
Performedatnonlabourornearterm,withreducedriskofnoncephalicandCaesareanbirths(ref.
UpToDateExternalcephalicversion)
FactorsassociatedwithreducedsuccessofECVinclude:
Nulliparity
Anteriorplacenta
Lateral/cornealplacenta
Decreasedamnioticfluidvolume
Lowbirthweight
Descentofbreechintopelvis
Maternalobesity
Posteriorlylocatedfetalspine
Firmmaternalabdominalmuscles
Frankbreechpresentation
Rupturedmembranes
Tenseuterus
Nonpalpablefoetalhead

Bartholin'scyst/abscess
Bartholin'sglandsarebilateralstructuresonthelabiathatprovideexternallubricationtothevagina
Canbecomeabscesses/cystsifinadequatedrainageoccursi.e.blockagetriggeredbyinfections,
smallglandopeningetc.Occursin23%ofwomen
Bartholinscystsusuallyoccurunilaterally,measuringbetween23cm,mostareasymptomatic,and
areusuallysterile.Largercystscanveryuncomfortable/painful
Ifasymptomatic,nomanagementisrequiredunlessthepatientis>40yearsandscreeningfor
carcinoma.Managementincludessurgicaldrainageviaincisionandmarsupialization(maintaininga
patentsurgicalopeningbyapplyingstitches),orbyinsertionofWordCatheter(smalldraining
catheterapprox.5cmlong,leftinplaceforafewweekstoenablethoroughdrainage)

Randomnotes
Atthe12weekUSSyoucandetect:anencephaly,abdominalwalldefects,bladderoutflow
obstruction,cystichydroma
Candetectoligohydramniosat1824wkUSS
fetalpositioncanbepalpatedat>36wks
extendedbreechheadisinthemidline
methyldopafirstlineinpregnancyforhypertension
pregnancydelaysgastricemptyingaddstonauseaandvomiting
HELLPcomplicationofpreeclampsia(haemolysis,elevatedliverenzymes,lowplatelets)
ergometrineiscontraindicatedinwomenwithhypertension,asthmaoractivecardiovasculardisease
reasonsforinductionoflabour:APH,IUGR,hypertension,postmaturity,diabetes
Failuretoprogressneedtolookupwhentheycallit!!!!!!
salbutamolinhibitsuterinesmoothmusclecontractility
shoulderdystociaclassicpresentationheaddeliversslowly,neckdoesnotappear,chinretracting
againstperineum
bacterialvaginosisgardenellavaginosis,mycoplasmahominis,mobiluncus,cluecells,cluecells
andcreamcoloureddischarge,fishlikeodourontheadditionofpotassiumhydroxide,vaginalfluidph
>4.5.doesnotpresentwithirregularbleeding.
molluscumcontagiosumpearlwhitelesions,cryotherapyisthetreatmentofchoice
gonorrhoeagramnegativediplococcus
candidagreycurdlikedischarge,highvaginalswab
crabsvaginalitching,brownspecksonunderwear(licedroppings)
syphilisprimary(singlepainlessulcer,chancre),secondary(multiplewartlikelesions,condylomata
lata,usuallyoccurswithin2yearsofinfection)
Pearlindexisdefinedasthenumberofwomenwhowillbecomepregnantif100womenusethat
formofcontraceptionforoneyear.
Mirenacommoncontraindicationspregnancy,liverfailure,mechanicalheartvalve,
ovarian/endometrialcancer.
CopperIUDcommoncontraindicationspregnancy,irregularbleeding,anaemia,wilsonsdisease,
ectopics,copperallergy.
COCPsideeffectsHTN,thrombosis,migraine,irregularbleeding
COCPcommoncontraindicationshxHTN,lifelongsmoking,smokers>35years,pregnancy,
migraine,thrombosis,IHD,stroke,liverdisease.
minipillPOPsideeffectsovariancysts,weightgain,breasttenderness,headaches
medroxyprogesteroneIM(depoprovera)contraindicationsosteoporosis
fibromasareovariantumoursassociatedwithapleuraleffusionandascites,commonlyreferredto
asmeig'ssyndrome
serouscystadenomacanbebenignormalignantandmakeup50%ofovariantumours
endometriosisisassociatedwithpainfulintercourseandpainfulperiods.vaginalendometriosisis
characterisedbythepresenceofbluenodulesfollowingspeculumexamination.COCPisthefirst
linetreatmentofchoice.
HRTlowersone'sriskofbowelcancer.
OnlyassociatedcancerwithPCOSisendometrialcancer.RaisedLH:FSHisaveryusefultestfor
PCOS.
classicalpresentationofacervicalectropionseencommonlyduringpuberty,pregnancyandtheuse
oftheoralcontraceptivepill.newonsetvaginaldischarge,erythematousrawlookingcervix.
granulosacelltumourslowgrowing,commonlymalignant,secretesoestrogen,maycause
postmenopausalbleedingorendometrialcarcinoma
thecomasimilartogranulosacelltumoursbutmostlybenign
clearcellcarcinoma10%ofallovariancancers,malignant,poorprognosis
imipramine(tricyclicantidepressant)associatedwithurinaryretentionandoverflowincontinence
duetodetrusordysfunction.hasanticholinergicsideeffects.
varicellavisualdisturbance,skinscarring,limbhypoplasia,neurologicalabnormalities,
rubellacataracts,deafness,learningdifficulties,heartdisease,hepatosplenomegaly.flulikeillness,
finemacularrashovertrunk.dxbyserology
toxoplasmosismothercommonlyaffectedinthirdtrimester,incubationupto20days,flulike
symptoms,glandularfevertype,dxbyserology,assochydrocephalus.
cmv12wkincubation,mostcommoncauseofcongenitalneuroabnormalities,cancauseflulike
illness,assocthrombocytopenia,primaryinfectionconfirmedbythepresenceofIgM
GBSaffects~25%ofwomeninpregnancy,pretermlabour,penicillin,asymptomaticinfection,
pyrexiainlabourisariskfactor
parvovirusfoetalanaemia,myocarditis,incubation1820days,dxbyserology
listeriainpregnancytreatwithpenicillin,dxbybloodculture.mayresultinstillbirth,miscarriage,
pretermdelivery.unpasteurizedproducts.
leadingcauseofdeathinwomeninpregnancyisVTE
lymphogranulomavenereumpustularlikelesion,notpainful,developingcountries,canbeonvagina,
vulvaorcervix.treatwithdoxycycline100mgbd3wks.

cardiacoutputincreasesby40%becauseofafallinvascularresistance
Renalplasmaflowincreasesby6080%,resultinginincreaseGFR
creatinineclearancegoesupby50%,resultingindecreaseinserumureaandcreatinine
ironincreasesby3foldduetoincreasebloodvolumeinpregnancy,increasedfoetalneedsand
bloodlossduringdelivery
folateincreases1020foldduetoincreasefoetalneedsandredcelldevelopment

Neonatology
Neonatology

Newbornbabyscreen
Headfontanellesandsutures
Eyes
Redreflexgood
Noredreflex(congenitalcataract)
Whitepupil(retinoblastoma)
Eartipshigherthaneyes
Mustcheckhard+softpalatewithfinger(hardtoidentifycleftpalatefrompureobservation)
Chestlistenforheartmurmurs(VSD,AS,AR,patentductusarteriosus)
Checkfingers(5digits)andpalmcreases(onelinesamianfeatureboooo)
Abdomenforhepatosplenomegaly
Umbilicalcordnotoozyanddisgusting
Femoralpulses(togetherforaorticcoarctation)
Testesdescendedorcomingdowninboys
Checkfor3holesingirls
Turnoverandcheckbackfortuftsofhair,patentanus
Hipdisplacementcheckbypushdownandabductoneatatime.Normalshouldnotfeeljoints
clicking.
Ortolanitestspushdowndislocate
Barlowstestpushoutdisplace
hipsareexaminedoneatatimeflexinfant'ships&kneesto90degthighisgently
abducted&bringingfemoralheadfromitsdislocatedposteriorpositiontooppositethe
acetabulum,hencereducingfemoralheadintoacetabuluminpositivefinding,thereis
apalpable&audibleclunkashipreduces

Feetnormal5digits,talipes
MeasureHC,length,weight

NeonatalResuscitation(inexamsforsure)
Resuscitationpreparation
Radiantwarmerturnedonandheating
Oxygensourceopenwithgoodflow
Suctionapparatus(100)
Laryngoscope
Resuscitationbagandmask


1. WarmandWipe,stimulatethebabybyrubbingit
2. Suction(usefingertoobscurethelittleholeenablessuction).UpToDatestatesthatsuctionshould
firstbegininthemouththenthenostrils
3. Mask/PPVpositivepressureventilation(1/secfor30s)rememberturnonairflow.UseO268L/min,
roomairmix(~21%O2roughly)keepheadinneutralposition
a. MeanwhilecheckingHR,satsviapulseoximetry
b. IfHR60100keepmaskwithflow(airormoreoxygen)
c. IfHR60orlesscommenceCPR
4. Cardiaccompression/massage
a. O2@100%
b. 3compressions1breatheverytwoseconds
c. Usethumbtipsgo1/3down
d. Reassess

BabiesareobligatenosebreathersXDimportantforbreastfeeding/sucking(orsomethinglikethat)



Respiratorydistressintheneonate
Signs
Noddingwhenusingaccessorymuscles
Naresflaring
Gruntingmaintainairwayspatency(physiologicallysimilartopursedlipsbreathingin
COPD)
?Trachealtug
Alwaysrespiratorydistressinsepsis,kidneyfailure,meningitisetccuzincreaseinlacticacidas
babybodyfightandbloodpHgoesdown.Babyremovescarbondioxideasquicklyaspossible

NeonatalJaundice

Whyisthereneonataljaundice?Theorybilirubinisanantioxidant,protectiveinthefirstfewdaysoflife

Mostcommonformofjaundiceinneonates=
Unconjugatedpathologicalhaemolysisexternal[alloimmunity(ABO/Rh)],internal[G6PDdeficiency]
Sepsis

!Persistentjaundiceaskforfractionatedbilirubintodeterminetheexactcauseofthepersistentjaundice
(needtoruleoutbiliaryatresia)

G6PDprecipitatedbysomeinfections,antibiotics(sulfamethoxazole),naphthalene(mothballs)

Kernicterusdepositionofaggregatedbilirubininthebasalganglia,causesencephalopathy
RespiratoryDistressinnewborninfants
Causes:infection/pneumonia,transienttachypnoeaofthenewborn,hyalinemembranedisease(preemies),
meconiumaspiration(termorposttermbabies),acutepneumothorax,
1.TransientTachypnoeaofthenewbornTTN
Mildpreterm3436wks,retainedfetallungfluid,morecommonincesareansectiondelivery,absence
ofLabour,tachypnoeafrombirthusuallyresolveswithin48HR,xrayshowsalveolarinfiltrate,wetlung.
2.HyalinemembranediseaseHMD
preterm,lackofsurfactant,noantenatalcorticosteroidsgiven,morelikelyincesareansectiondelivery,
tachypnoeafrombirth,worseningsymptomsover24to48hours,Xrayshowsgeneralisedgroundglass
opacityandairbronchograms,somealveoliclosedsomealveoliareoverextended,babyshouldstart
makingitsownsurfactantbyday3or4
3.Pneumonia/sepsisshouldALWAYSbeaddx
predisposingfactors:rupturedmembranes,chorioamnionitis(maternalfeverorabdominaltenderness),
GBS,gramnegativeorganism(e.Coli).Sx:lethargy,apnea,bradycardia,temperatureinstability,feed
intolerance
4.Pneumothorax
Considerinbabywithacutedeterioration.Canshinealighttothebabytotransilluminatethelungs.
5.Meconiumaspiration
BabypassesMeconiuminthewomb,thebreathesitin.Usuallypoststerm,SGA,poorplacentalfunction
causesunderlyinghypoxictendencywithaddedstressofLabour.Associatedwithpulmonaryhypertension,
secondarysurfactantdeficiency.Increasedriskofpneumothoraxandsecondaryinfection.XRay:coarse
patchychangesthroughoutlungfields.
Therefore,wetrytoinduceLabourat41weeks,sinceposttermbabieshavehighermorbidity,mortality,
includingmeconiumaspiration.
6.Structuralabnormalities
Choanalatresiaobstructingnose(sincebabiesareobligatenosebreathers)
Cleftpalate
Tracheooesophagealfistula
Cystic/dysplasticchangesinlung
7.Diaphragmatichernia
8.Other
metabolicacidosis,pulmonaryhypertensionofthenewborn,congenitalheartdisease,anaemia(haemolysis
inrhdisease,fetomaternalhaemorrhage),polycythaemia,hypoplasticlungs,oligohydramnios,potter's
syndrome,perinatalasphyxia,neurologicalmalformationorinjury

keyfactstoworkoutinHxorexamination
time/mode(csection?Laborornot?)/complicationsindelivery,gestationalage,temperature,
rupturedmembranes,motherhasfeverorabdominaltenderness,gramnegativeorganisms,timeof
onsetofrespiratorydistress,antenatal/familyhistory
Headnodding,expiratorygrunting/moaning,suprasternalandsubcostalrecession,nasalflaring,
RR>60,tachycardia(firstsign),cyanosis
TABCresuscitation,O2saturation,heartrate,apnoeas
investigations
oCXR,bloods(FBC,bloodgas,bloodcultures,CRP),electrolyteswhenbabyis6hoursold(beforethat
itmainlyreflectsmotherscirculation)
Management
Resuscitation
Oxygenintubation,CPAP,nasalprongs

Vomitingintheneonate
"Possetting"mildvomitingmostcommonlyassociatedwithfeeds
Mostcommonly,causeofvomitingduetoaslowgut
Normalvomitingyelloworwhite,milkormucusonly,NObloodorbile,NOTprojectile,neonate
otherwisewell

Pathologicvomiting
bloodstained(maybeduetoswallowedbloodorother),
bilestained!!!(mostworryingsign,suggestbowelobstructionmayneedsurgicalintervention,causes:
malrotationofmidgutandvolvulustwistingmesenteryandbloodvessels,smallbowelatresia(e.g.
duodenalatresia,presentantenatallywithpolyhydramnios50%asbabyisn'tswallowingliquid,down
syndrome30%),necrotisingenterocolitis(commoninpretermers,ischemicgutwallwithbacteria
invasion,pneumatosisofbowelwall,gasinportalveins),meconiumileus(espinbabieswithcystic
fibrosis80%,delayedpassageofmeconium),analatresia),
projectilevomiting(pyloricstenosis),
unwellbaby,
FTT,gord/sepsis/uti/inbornerrorofmetabolism,
associatedchoking/aspiration,diarrhoea

keyfactstoworkoutinHxorexamination
Babywellorunwell,quantity/colour/whendiditstart/howlong/frequency
Abdominaldissension,passedmeconiumyet?,stoolblood/mucus,diarrhoea
Assessforvitalsigns,hydrationstatus,abdominalexamination(patentanus?),syndromicfeatures
Investigations
Lateral/decubitusANDAPabdoXRAY,
BLOODS(FBC,cultures,forinfection.electrolytesforfluidstatus)
Management
nilbymouth,NGtube,IVfluids
transfertoneonatalunit,paediatricsurgicalteamreferral
Considerorgiveantibiotics

NewbornExamination

Sizeofthebaby,bigorsmall
Postureandcolour
Flexionofextremitiesisnormalfloppybaby=neuromuscularproblem.
Onearmuponearmdownbrachialplexusinjuryprobablywithdeliveryiftheshoulder
Pinkwithtransientacrocyanosis(bluefeet,palms)Pinkcolourisnormal
Headtobodysize
Jaundiceslightisnormal.Jaundiceonday1isPATHOLOGICAL.Day3or4mildjaundiceinfaceis
normal,ifallthroughouteyesorbody,maybeabnormal.>2weeks,likelytobepathological.
Skinappearance
Mildpeeling/drynessisnormal(especiallycommoninIUGR,posttermbabies)
Vernixcaseosanormal.Protectivegreasywhitematerial,coversinfantsbetween3538weeks
Livedoreticularisbloodvesselsvisibleintheskin.Duetoimmaturevascularsystem.Commonand
normal.

Growthrestricted
Scrawny,wrinklyskinoverbuttocks,likeanoldwiseman
Finehairoverthefaceandbody.Lanugo.Mostlyinpretermbabies.Lostin1stmonthoflife.

Babyskinthings/Vascularbirthmarks
onaevusflammeus(StalkMark),irregularborderedpink/redmacule,blanchedwithpressure,generally
fadeby2years,foundin50%newborns,foundonnapeofneck,face
oMongolianbluespotespinAsianbabies,buttocks/flanks,fadeovertimebutnotcompletely,
melanocytesinthedermis
oMilia40%ofnewborns,likewhiteheadsonnose
oHarlequinphenomenonbabyredononeside(blanches)andwhiteontheother,transientsecondsto
minutes,morelikelyinunwellbabieswithfever/infection,occursinfirstfewdaysoflife.
oerythematoxicum70%ofnewborns,anypartofbodies,redbasewithtinyyellow/whitepapule,
smallbump.Needtodifferentiatefromstaphinfection.Mayberelatedtohormonalchanges
oStrawberryhaemangiomacangrowrapidly,brightred,raised,lobulated,regressfrom9monthson
cantake7yearsforittocompletelydisappear.Usuallyleaveittoregressonitsown.Sendto
dermatologistifit

Staphinfectionpusfilledpapuleswithredbase.Swabtoconfirm.IVabx.
oMiliavesicles,sweatglands
oCaputsuccedaneumoedematousthickeningofthescalpbetweenskinandepicranialaponeurosis
oBruisingfromvacuumextractionmonitoredforsubgalealhaemorrhage(betweenepicranial
aponeurosisandtheperiosteum),vaguegeneralisedscalpswelling/fluctuance,buggybehindears.
Managebygivingbloodandreplacingbloodloss.
oCephalohematomasubperiosteal,lumponthehead,oftenappearson2nddayoflife,oftenhasa
hardirregularbonymarginaroundit.
Tonguetie
Shortfrenulum,interferencewithbreastfeeding.Managebyclippingfrenulum.

OralCandida:whitepatchesontongue,gums,lipsandbuccalmucosa.Maybeoncheekstoo.Notjuston
tongue.Treatwithtopicalantifungal.Treatmothertooassheisbreastfeeding

Preauricularskintagmaybeassociatedwithrenalanomaly(asearsdevelopatthesametimeaskidneys)

Umbilicalherniacommoninpreemies,developsinfirstmonth,spontaneouslyregressedby6to18
months.
Inguinalhernianeedsreferraltopaediatricsurgeonandsurgerywithin4weeksasitcanstrangulateeasily.
Sacraldimplebeloworovercoccyxisnotaproblemanddisappearsonitsown.Ifitishigheruporhas
hair,bewaryofspinabifida.

Herpesinfectionvesiclesthatcluster,unwellneurologically,startonacyclovirimmediately(evenifyou
suspect)asbabiescangetencephalitisorpneumonitiseasily.Typicallydevelopsin1stor2ndweekoflife
asthevirusisacquiredduringbirth.

Polydactylmostcommonisextralittlefinger.
Nappydermatitisneedsbarriercream,contactdermatitis,mildsteroid,checkifthere'sasecondaryfungal
infection.Does.babyhaveloosestools?Needtomanagethat
Genitalthrushredtendersatellitelesionsinsideskinfoldsandcreases.
Congenitalhydroceletranslucentsweepingaroundtestes,transilluminates,spontaneousdisappearance
after1year.MaybeasignthatInguinalcanalisstillopen,soneedtocheckforInguinalhernia.
Hymenaltagregressedoverfirst2monthsoflife.Profusionofredundantmucosa.

Perinatalinfections
susceptibilityinpregnancyDecreasedimmunesurveillance,lackofphysiologicsurveillance
modesoftransmissionbirth(ascending/verticaltransmission),transplacental,trauma(iatrogenice.g.
amniocentesis,chorionicvillussample)
<25yrstestforchlamydiaandgonorrheaaswell
oTORCHscreening:toxoplasmosis,other(syphilis,parvovirus,hepbc,HIV),rubella,cmv,hsv

Neonatalinfection
PROMhighriskofneonatalsepsis,ascendinginfections,immaturelungs
25%ofveryLBWhaveneonatalsepsis.
TransplacentalIgGpassageoccursin3rdtrimester,prematurebabiesmissthatthereforehavevery
immatureimmunesystems

Originsofinfections
1.Intrauterine:
TORCHS(toxoplasmosis,rubella,CMV,herpessimplex2,syphilis),varicella,hepBorC,HIV
Ascendinge.coli(gentamicin),klebsiella,pseudomonas,betahaemolyticstreptococcus(penicillin),
listeriamonocytogenes
2.Intrapartum
Gonorrhea
chlamydia
GBS
HSV2
3.Nosocomial
Staph.Aureus
Staphepidermidis
GBS
salmonella
Gramnegatives
Candidaalbicans

TORCHINFECTIONINFIRSTTRIMESTER=BAD
GBSfatalin20%ofneonatesinfected.LVSin28and36weeks.Ifpositive,giveantibioticsintrapartum
tomothertoreduceincidenceoftransmissionto.baby.GBScanbepassedviabreastfeeding.
MotherwhohashadGBSoncewillbemorelikelytohaveitagainwithdifferent,moreaggressive
straininsecondpregnancy.
Delivery<37wks,ruptureofmembranes,chorioamnionitis?
Treatmentformother:erythromycin?
Respiratorydistress,hypothermia,allgoodsignsthatindicateinfection.

2typesofneonatalsepsis
Earlyonset:generallye.Coli,GBS.Usepenicillinandgentamicin.CausesAmnionitis,ascending
infection,transplacental.
Lateonset:generallystaphaureusorepidermis.Useflucloxacillinandgentamicin.Causesoften
iatrogenic.
MRSE,MRSAusevancomycin
amphotericinfungalinfections
Swabnose,throat,umbilicus,groin.Gastricaspirate,earswab.Bloodcultures.FBC,bloodfilm,CRP.
Treatempiricallybasedonsuspicion.
Givesbabiesprobiotics,reducesrateofnecrotizingenterocolitis.Particularlytobabieswhoaren't
breastfed.
Mothersshouldn'thaveanyunpasteurizedproducts(milk,juices):pasteurizationoccursat68degrees,
killsoffthevitamins.

Followingwillbeinexams!!!!!!
Riskfactorsofsepsisinthemother
Diabetesglucosegoodgrowinggroundforbacteria
Prolongedruptureofmembranes18hrs
IVDU
GBSpositive
Malnourishedmother:ironandzincdeficiency
Mother'soccupation
Prolongedlabour
Tachycardia,tachypnoea(acidosis),fever
Triadofchorioamnionitis:AbdominalTender+fever+abnormalbloods/inflammatorymarkers(high
WBC,CRP)
Riskofsepsisinbaby
Apnoeashouldneverhappenintermbabies
Floppybaby
Increasedneutrophilcount
Dehydrated,vomiting,tachycardia,lethargic,encephalopathic
LookupI:Tratio,ifnoimmaturebandformsinbabies,means.....?


Rubella
teratogenic,10%susceptible,transmissionviaaerosol/respiratory,
oSx:generalisedrash,fever,cough,conjunctivitis,arthralgia,lymphadenopathy,usuallymildillness
oVaccineislive.Womencantrygettingpregnant1monthaftervaccine.Directtransplacental
transmission,causesischemiainbloodvessels.
oRiskofcongenitalrubella,100%infirst8weeks.50%in8to12weeks.
oGregg'striad:cataract,saltandpepperretinopathy,PDA,PS,Sensorineuraldeafness.
oIffoundtobeinfected,terminatepregnancyasitissoteratogenic
oForwomenthatarevaccinatedbutdon'tseroconvert,giverepeatvaccinations
oNotreatmentforrubella

Varicellazostervirus
oMoreworriedaboutmumthanthebaby(Sxvaricellapneumonia,vesicularrash).Cangivevaricella
immunoglobulinifexposedwithin96hours.CheckIgG,IgM.Treatwithacyclovir.
oFoetalvaricellasyndromenotverycommon,highestrisk(1.5%)inthefirst20weeksandifmumis
infectedafewdaysbeforedelivery.Affectsskin,limbhypoplasia.

CMV
BloodtransfusionsCMVinfections
oCMVisnotscreenedforallblood.
oTherefore,ifrequestingbloodforpregnantpatients,needtomakesurepathologistknowssotheygive
youCMVnegativeblood!!!
oCMVifthemostcommoncausesofcongenitalinfections2%oflivebirths.Transmittedthrough
urine,nasopharynxandblood.Maternalfoetaltransmissionin50%.Usuallyasymptomatic.
oFoetaleffectmicrocephaly,deafness,hydropsfetalis(effusionin2cavities),intracranial
calcificationsetc
oCheckforinfectionbymaternalserologyIgMorIgGandIgGaviditytesttodetermineifit'sanacuteor
oldinfection(asIgMcanstaypositiveforupto12months).Needtorepeatin2weekstolookfor
seroconversion.SecondaryreactivationofCMVinfection.
oCheckinfoetusbyfetalscanandamniocentesis.
oNovaccinecurrentlyavailable.

Parvovirus
oCrossesplacenta1:400
oSlapcheek,arthralgia,maternalSerologyIgMdetectablein13weeks
oLeadstofoetalanaemiaandhydropsfetalis.
oU/Smiddlecerebralarterydopplerpeaksystolicvelocityincreasesduetoanaemia,scanevery1to
2weekstomonitor.
oTreattheanaemia

HerpesSimplexVirus
oAcquiredduringdelivery.
oifthereisprimaryinfectionatthetimeofdelivery,recommendcesareansection.Noteonce
membraneshaveruptured,thereisariskofascendinginfection.Treatwithacyclovir.
oIfprimaryinfectioninearlypregnancy,IgGdevelopedandcancrosstheplacentaandprotectthebaby
oIfsecondaryinfection,notsoclearwhattodo.
oBiggestconcernforbabyisviralencephalitisorpneumonitis

HIV
obreastfeedinghashighriskoftransmission~45%,thereforerecommendbottlefeeding
oManageorlowerriskbyusingantiretroviraltherapy
oSideeffectHAARTinpregnancypretermbirth,
oIfthereisadetectableviralload,needscsection.IfnotdetectableandonHAART,canhavevaginal
delivery

HepC
operinataltransmission5%,rarelyoccursifRNANegative

Toxoplasmosis
ocongenitalinfection:ventriculomegaly,intracranialcalcifications

Syphilis
oVDRLscreeningtoil,needTPHAtocorrectforfalsepositives
ocongenitalinfection:earlyrhinitisetc,laterhutchinsonsteeth(notchedteeth),

Listeria
oLong72dayincubation
oUncommonfoodborneinfection
oSerologynotuseful,needtoculture.
oMeconiumstainedliquorinpretermlabour
oTreatwithpenicillin+gentamicinfor2weeksor6weeks

investigations
Bloods(FBC,EUC,bloodcultures,Serology)
Stool,urineculture
Screening:HIV,Syphilis,HepBC,rubella,haemophilus,
TORCHscreening
CXR/DopplerexcludeDVT,PE

Normalmovementsinpregnancy10timesin2hours

Polyhydramniosisariskforpretermlabour

>20weeks,terminationcanoccurifthemother'shealthisatrisk,usuallyviaapprovalfromethics
committee

Trisomy21
Sx:epicanthicfold,flatnosebridge,smalllowsetears,shallowphiltrum,simianfold,sandaltoes,inverted
distalphalanxofdigit5.
Associatedproblems:hypothyroidism,earlyfeedingproblems,cardiac(PDA),mentaldevelopment
Automaticallyqualifyforgovernmentsubsidisedearlyinterventionprogram

Withababywithperinatalasphyxia,needtodetermineiftheencephalopathyisduetohypoxiceventorother
thing(e.g.infection),needtoworkoutifitwascausedbyintrapartumeventorbysomethingduringdelivery.
Cordbloodbassph<7.0,severeperinatalasphyxia,requirestherapeutichypothermia
HIE1irritable,hyperalert,headache,crying,difficulttosettlebabydoeswell
HIE2floppy,lessresponsive,moaning,periodicbreathingbaby.ORSeizuringbaby.Usuallyhave
multiorgandysfunctionbenefitsfrom.Cooling.50%well,25%neurologicalimpairment,25%die.
HIE3unresponsive,decorticate,comatosebabyuniversallydobad
Babiesdropweighttillday4,gainbacktobirthweightby1week.

NeonatalSepsis
Commonoccursin25%ofVLBW.Alsoverycommoncauseofpremature+/pretermbirth
Immatureimmunity(doesnotdevelopuntilthe3rdtrimester)
Increasedsusceptibilitytootherwiseinconsequentialorganisation
TransplacentalinfectionsTORCHS:toxoplasmosis,rubella,cytomegalovirus,herpessimplex
2,syphilis
Varicella,HepB,HepC,HIV
Hypoglycemiainneonates(verycommoninthenewborn)
BSLdiffusedfrommaternalcirculation,hencetheyarecloselyrelated.Oncethecordisclamped,thebaby
needstorelyonitownglucoseregulation.
UsuallythereisatransientfallinBSLduringthefirst2hoursafterbirth.Stabilisedby4to8hours.Hence
theaimistogetthebabybreastfeedingwithinthefirst30minutes.

MaternalfactorsleadingtoneonatalBSL
Timingoflastfeedpriortodelivery
Maternaldiabetesandinsulintherapy
DurationofLabour
IVglucoseadministrationorlackoftomum

Neonatalfactorsthatmakebabyatriskofhypoglycemia
SCREENallthesehighriskinfantsbelow(notscreenedforfulltermhealthybabies).Usestripand
glucometerbutbewarythatlowfiguresaren'taccurate,confirmwithbloods.

Lackofglycogenstores:lowbirthweight/small<2.5kgbabies,prematurebabies,SGA/IUGR(substrate
deficiencysecondarytoimmaturityofenzymepathwayspluslackoffat/sugarstores)(normalweightbaby
doesnotexcludeIUGR,needtophysicallyexaminebabytoseeifthey'rewrinklyandthin)
Increasedlevelsofcirculatinginsulin:babiesofdiabeticmother,severelygrowthrestrictedbaby,bigbabies
>4.5kg
Excessuseofglycogenstores:infectedbabies,hypothermiaandhyperthermiababies,respiratorydistress
syndrome,illbaby
Inadequateprovisionofsubstrate:vomitingbabies,babythatisn'tfedorisn'tfeedingwell.
Termbabiesnormally2.4to4.4kg.
Largeforgestationalage(LGA)>4.5kgorbabiesofdiabeticmothers
Foetalhyperglycaemiaprematurematurationoffetalpancreaticislets/hypertrophyofbetacells
Neonatalhypoglycaemiahypoglycemiaafterinterruptionoftheintrauterineglucosesupplyfrommother
withbabythathashighinsulinlevels.

NormalBSL>2.6mmol/Lforbabies.Consequenceofprolongedhypoglycaemia,neurologicsequelae
(irritability,jitteriness,tremors,poorfeeding,lethargy,apnea/cyanosis,hypotonia,convulsions/seizures,later
coma,neurodevelopmentaldelay)
Managementofhypoglycaemicneonate
Feedassoonasafterbirthbreastmilkandcomplementaryfeedifthere'snotenoughmilk.Feed
continuouslyevery3to4hours.
ObjectiveistoraiseBSL>2.6
Anybabywithsignificantsymptomsofhypoglycemia,admittoNICU.
IVfluids10%dextroseat60ml/kg/day.IncreaseconcentrationofdextroseincrementallyuntilBSL
past2.6mmol/L(notpass15%otherwisetooirritatingtovein).GiveIMglucagonifnotabletogetIV
accessorifglucosealonedoesnotwork.Canalsoconsiderhydrocortisoneafterwards.
Persistenthypoglycemiainsulin>10mU/Lwhenbloodglucoseis<2.6mmol/Lisdiagnosticof
hyperinsulinism.Diazoxide1015mg/kg/dayusedonlyintreatmentinhyperinsulinism(s/efluid
retention,hirsutism,poorfeeding).

*Wheneveryoudoinsulin,cortisol,growthhormone,mustalsodoBSLatthesametime,otherwise
theresultisuninterpretable!*

Pathologicalcausesofhyperinsulinism
Hyperinsulinism:IDDM(transienthypoglycemia),persistenthyperinsulinismhypogcofinfancy(beta
hypoplasia)
Inbornerrorsofmetabolism:??

Smallforgestationalage
CausesforSmallforgestationalageriskfactors

1. Uteroplacentalfactorspreeclampsia,chronichypertension,diabetes,cardiovasculardisease,
autoimmunedisease(e.g.coeliac),smokingetc
2. MaternalfactorsSmallmother,ethnicity,poormaternalnutrition/anaemia,comorbidities(as
above,thatcausesplacentalproblemsanddifficultydeliveringnutrientstothefoetus),infection
(rubella,CMV,toxoplasmosis,herpes),
3. FoetalfactorsChromosomalabnormalities,geneticdisorders,cardiacororgandevelopmental
problems

Testsyoucouldofferforsmallgestationalage
Historymothersethnicity,smallperson,familyhistoryofgeneticdisordersetc
Investigationsyoucouldofferorreview
Nuchaltranslucencyscans(1114weeks)+bloodserumtoworkoutchromosomal
abnormalityrisksfortrisomy13,1821
Amniocentesis(15weeksonwards)
SerialFoetalmorphology/growthU/Smeasuresheadcircumference,abdominal
circumference,femurlength,estimatedweight,structuralabnormalities,assesstheamount
ofamnioticfluid(extrapolatesbasedonbiggestfluidpocketinthe4quadrants)
umbilicalarterydopplerplacentalS/Dratiosystolic/diastolicratiogivesan
indicationofthevascularresistanceintheplacenta.LookforelevatedS/Dratios,
whichindicatediminisheddiastolicflowreflectingincreasedvascularresistanceform
theplacenta.
SerialU/Sgrowthscansatregularintervals(e.g.every3weeks)
Foetalnonstresstesting(NSTakaCTG(cardiotocography))regularlyandmonitorforfoetal
movements
Reactive(normal)presenceoftwoormorefetalheartrateaccelerationswithina
20minuteperiod,withorwithoutfetalmovementdiscerniblebythewoman.
Accelerationsaredefinedas15bpmabovebaselinesforatleast15secondsif
beyond32weeksgestation,or10bpmforatleast10secondsifatorbelow32
weeks.

Nonreactive(abnormal)presenceoflessthantwofetalheartrateaccelerations
withina20minuteperiodovera40minutetestingperiod
IntrauterineGrowthRestriction
ThemostwidelyuseddefinitionofIUGRisafetuswhoseestimatedweightisbelowthe10thpercentilefor
itsgestationalageandwhoseabdominalcircumferenceisbelowthe2.5thpercentile.Foetusthathaspoor
growth.
Symmetric(30%)vsAsymmetric(70%)
Symmetricgrowthrestriction(akaGlobalgrowthrestriction)impliesafetuswhoseentirebodyis
proportionallysmall.Morelikelytohavelongtermneurologicalsequelae.
Foetushasdevelopedslowlythroughoutthewholepregnancy
Earlyintrauterineinfections,suchascytomegalovirus,rubellaortoxoplasmosis
Chromosomalabnormalities
Anemia
Maternalsubstanceabuse(prenatalalcoholusecanresultinFetalalcoholsyndrome)
Asymmetricgrowthrestrictionimpliesafetuswhoisundernourishedandisdirectingmostofits
energytomaintaininggrowthofvitalorgans,suchasthebrainandheart,attheexpenseoftheliver,
muscleandfat.Thistypeofgrowthrestrictionisusuallytheresultofplacentalinsufficiency.Head
circumferenceisnormalandcomparativelylargerthantherestofthebody.
Usuallycausedbyinsultbyextrinsicfactorse.g.Chronichighbloodpressure,Severe
malnutrition,Geneticmutations,EhlersDanlossyndrome


Prematureandlowbirthweightinfants
1.Prematurity,2.LowBirthWeightmostcommonreasonforadmissiontoNICU.

Premature<37weeks,postterm>42weeks
<2.5kgLBW,<1.5kgVLBW,<1kgELBW
LGA>90thpercentile,SGA<10thpercentile

Keyriskfactors:
1.maternalfactors(social,medicaldisease),
2.problemswithuterus/placentalcirculation(multiplepregnancy,infection,abruption,poorcirculation),
3.Fetalabnormality(chromosomalorstructuralabnormalities)
Preventpretermdelivery
Abxtreatinfectionsorlikelyinfections
Tocolytics
Bedrest
Prepareforpretermdelivery
Antenatalcorticosteroids
Decideondeliveryviacesareansection(don'twantbabytogothroughstressofvaginaldelivery)
Acutepretermneonatalproblems
InadequateventilationCPAP(neopuff),O2vianasalprongs,etc
Hypothermiapronetoheatloss,poormechanismforheatproduction,lackbrownfat.Polyethylene
plasticwrap,water/sweatkeepsthebabywarmandtheheatercanpenetratethroughtheplastic.

Medium/longtermpretermneonatalproblems
Respiratory
oRespiratorydistresssyndrome/hyalinemembranediseaselackofsurfactantmayneedtointubate
orusecontinuouspositiveairwaypressureventilation
oApneafor>20secondsanddesaturationimmaturerespiratorycentresinbrain
oInfections.GiveIVpenicillin(GBS)andgentamicin(e.coli)for2days.
oChroniclungdisease.Mostresolvein12years.
Metabolicneedtocloselymonitorelectrolytesandsugars.Doabg,euc.
oHypoglycemia/hyperglycemia
oHypocalcaemia
oHyponatremia/hypernatremia
oAcidosis
Gastro
oPoorfeeding
oReflux
oNecrotisingenterocolitis
oLackofcoordinationwithsuckingandswallowing(mechanismdevelopsat33or34weeks,
therefore<33w/obabiesneedNGtubeororogastrictube)
Jaundicephototherapy.MonitorwithTCBandSBR,plotonneonataljaundicechartandworkout
therapy.!!!knowhowtoexplainjaundicetotheparentspotentialOSCEstation!!!
Renalimmaturity
Patentductusarteriosuscausespulmonaryoedema,lefttorightshunt.Confirmwithecho.Give
ibuprofentoencourageittoclose.
Anaemiaofprematurityat5or6weeksiatrogeniccauses,ineffectiveerythropoiesis,poorironstores,
bonemarrowislesssensitivetohypoxia.Mayneedbloodtransfusionupto24or25weeks.Mayneed
ironsupplementation.
Infectionimmatureimmunesystemmissesmaternaltransferofimmunityfrom33weeksonwards
andmissesoutoncolostrum
Neurological
oIntraventricularhaemorrhagedocoronalultrasound.Bleedsfromchoroidplexus,canextend,risk
obstructingCSFflow,mayleadtodecreasebloodflowtobrain,brainmatterdies,causingcyststo
form.Grade1(terminalmatrixhaemorrhage)to4(bad).GiveIVvitaminKtohelpwithclotting
factorstopreventintraventricularhaemorrhage.
oRetinopathyofprematurity(Vision)abnormalgrowthofbloodvesselsnearretina
(neovascularization).Causingfibrosis,retinaldetachment.Stage1to5(totalretinaldetachment).
oHearingabnormallydevelopedcochlearandauditorynerve.Gentamicingivenmayhavelongterm
affectontheirhearingtoo.


Viability
26weeksonwardhavegoodoutcomes(>85%survival).Greyzone23to25weeks(medicaladviceisto
avoidresuscitationasmortalityrateis50%,severedisabilityis25%).25weeksisdifficult.
Lessthan23weeks,0%survival.
23to25weekmorbidities.100%respiratorysupport,agoodportionwillhavechroniclungdisease.
>90%ofpremmiesattendnormalschoolprograms
Cerebralpalsy
<1.5kg50/1000,1.52.5kg8/1000,>2.5kg1.5/1000
Hardtodiagnoseearly.Mayonlydx8to12months.Needtomonitortoneofbabyandgeneralmotor
development
EarlyindicatorsmaybeIVHorperiventricularleukomalacia(PVL)




Gynaecology
HPVvaccine/cervicalcancer
Highrisktypes16and18(cause70to80%)
Lowrisk6and11(causelowriskpapsmearchangesandgenitalwarts)
Gardasil6,11,16and18alsocrossprotection.Longlastingprotection.Atleast10years.
50%ofwomenHPVpositivewithin3monthswithonlyonepartner.
HPVlieswithinthekeratinocytes,thereforeanyskintoskincontactwithgenitaliaincreasesriskofinfection.
CIN2or3,35%regressin6months,dorepeatcolposcopyandpapsmearin6months.
Vulvalorvaginallesionsarelesslikelytoregress.
Preventsfromgenitalwarts.Incubationisshort?
Laryngealpapilloma,affectsrespiratoryfunctioninverticaltransmissionfrommumtobabyduringbirth,
associatedwithtype6and11
HPVvaccine0,2and6months.

Papsmear
Transformationzone~areawhichwassquamousprepubertallyandhasundergonemetaplastic
changetobecomeglandularcolumnarepithelium(higherthanthetransitionzone)
Transitionzone~pointofthesquamouscolumnarjunction
Papsmearthetransformationzone
Cytology~leukocytes(neutrophil),papcellsstainkeratinorangeandotherthingsgreen.Squamous
cellshavebigcytoplasmcomparedwithnucleus.Glandularcells~mucinproducingcells,
honeycomblooking.Noteallepithelialcellshavekeratin,squamoushavehighmolecularweightand
glandularcellshavelowmolecularweight.Endometrialglands~clumping.
Needtofixslideat20cmdistance.Tooclose,you'llfreezeit,toofaranditwontfix,degradesand
affectsinterpretation.Dontwanttodoapapsmearandendupwithtechnicallyunsatisfactory
sample
Eventhinspreadofthematerial.
Needtocorrectlylabelthemwithpencil(name,DOB).
Undirectedpapsmears~screeningtool,donebyscientistsusually
Directedpapsmears~seenbypathologistandscientist,whenyoususpectorknowthereis
abnormality
AustralianModifiedbethesdagradingusedtodetermineandguidetreatment.MoreusefulthanCIN1
or2or3grading.NeedtoknowAustralianModifiedBethesdaGrading,whichisreportedinthe
pathologyreport,guidestreatmentinsteadofCINgrading
Canfindbacteriainpapsmear:actinomyces,trichomonas,gardnerella
Day7to15isthebesttimetodoapapsmear
HPV+CIN1=Lowrisk,dorepeatsmearin6to12months
HPV+CIN2or3=Highrisk,unlikelytoregressonitsown,needtodocolposcopyandbiopsyto
confirm
HPVDNAtestingtoreplacepapsmearsasascreeningtoolforcervicalcancer
LiquidbasedcytologythinprepaddedbenefitofHPVDNAtesting
HighRiskStrains16,18,31,35(novaccinecurrentlyavailableagainstthesestrains)









Table1 TheAustralianModifiedBethesdaSystem2004,comparisonwithpreviousterminology
NewAustralianNHMRC
terminology
AMBS2004
AustralianNHMRCendorsed
terminology1994
Incorporates
Squamousabnormalities
Possiblelowgradesquamous
intraepitheliallesion
Lowgradeepithelialabnormality Nonspecificminorsquamous
cellchanges.Changesthat
suggestbutfallshortof
HPV/CIN1
Lowgradesquamous
intraepitheliallesion
Lowgradeepithelialabnormality HPVeffect,CIN1
Possiblehighgradesquamous
lesion
Inconclusive,possible
highgradesquamous
abnormality
Changesthatsuggest,butfall
shortof,CIN2,CIN3,orSCC
Highgradesquamous
intraepitheliallesion
Highgradeepithelial
abnormality
CIN2,CIN3
Squamouscellcarcinoma Highgradeepithelial
abnormality
Squamouscellcarcinoma.
Glandularabnormalities
Atypicalendocervicalcellsof
undeterminedsignificance
Lowgradeepithelialabnormality Nonspecificminorcell
changesinendocervicalcells.
Atypicalglandularcellsof
undeterminedsignificance
Lowgradeepithelialabnormality Nonspecificminorcell
changesinglandularcells
Possiblehighgradeglandular
lesion
Inconclusive,possible
highgradeglandular
abnormality
Changesthatsuggest,butfall
shortof,AISor
adenocarcinoma
Adenocarcinoma Highgradeepithelial
abnormality
Adenocarcinoma



PelvicMasses
RelevantPelvicAnatomy
Roundligamentssupporttheuterusinpregnancy.Lotsofshootingpelvicpainiscausedbythe
ligamentsbeingstretchedandtaut.
Uterosacralligaments+Cardinalligaments**mainsupportforuterustothescrum.
Broadligamentdoublelayerofperineum,wrappingaroundvessels
Ovarianarteriesandveinspassesoverexternaliliacartery
Ovarieslookwhiteinreallife.
Uretersneedtoidentifyandsaveduringgynecologicalsurgery.Movementdescribedas
vermiculation.
Internaliliacarteries>uterinearteryrunsovertheureter"waterunderthebridge"
Vaginalarteriesandanastomosis.
Bladderemptiedwithcatheter.Looksflatandtransparent.
Obliteratedumbilicalartery
PouchofDouglas
3millionoocytes(foetus)>300,000(baby)>300periodsinalifetime.Lotsofwastedovaries.
DDx
ExtraovarianEctopic,fibroids,abscess,irritablebowelsyndrome,inflammatoryboweldisease
Ovarian1.Endometriomas(chocolatecysts),2.Serouscystadenoma,3.Teratoma,4.Hemorrhagic
cysts,5.Mucinouscystadenoma,others.Neoplasm
>Classifyasbenignormalignant,functionalorpathological,ExtraovarianorOvarian
Functionalvspathological
Serous,mucinous,endometriosis,
BenignvsMalignant
Determinesthenatureofsurgery
Benignovariancysts
Histologyepithelialcells,germcells,sexcord/stromalcells
Functionalcorpusluteum'yellowbody'
Polycysticovaries20percentofwomenhave,thoughonlyaproportionhavePCOS.
U/Sandirregularbleedingandhigherlevelsoftestosterone
TypesofcellsEpithelial,Serous,Mucinous,Endometriomal,Stromal(sexcord),Transitionalcell
Teratomaakadermoid(germcell)mostcommonsolidtypebenignmassintheovary.Classicallyhave
skin,hair,sebum(givesitayellowappearance).Canundergotorsion.Canbebilateral.Rarelyundergoes
malignantchange.
MGMT
Forfunctionalcystsobserveanddorepeatu/s.Cansuppresswiththepillifrecurrent.
Surgically,laparoscopic.Ifmalignantdolaparotomy.
Sx:painduetoacutestretchingofruptureorbleedofthecystsortumorsortorsion.Masseffect.Ifslow
growingthenthereusuallyisnoorlittlepain.
Torsionofovarytraditionalthoughtthat6hourswhereitcanbesaved(liketorsionofthetestes).(Thought
nowisitisviableoveratleast24hoursmaybeeven72hoursbasedonanimalstudies).
Ovarianligamentstretcheswithanovarianmassandcausestorsion.
Fibroids
Mostcommonpelvictumourinwomen3070%
Monoclonal
Hormonallystimulated,mostshrinkaftermenopause.
Malignantchangeisveryrare.
Locationintramural,subserosal(masseffect,pressure/painsymptoms,troublewithintercourse,pushon
ureter,bladderurinaryurgency,incompletevoiding),pushonbowelconstipation,cantort),submucosal
(heavybleeding,spottingbetweenperiods,infertility),cervical(troublewithdelivery),etc
MgmtMedicalnsaids,tranexamicacid,mirena,copperIUD,OCP
Surgical,endometrialablation,uterinearteryembolisation,myomectomy(laparotomy,laparoscopy,
hysteroscopy),hysterectomy
Riskofmalignancyindex1x2x3
1)Premenopausal1pt,Postmenopausal3pt.
2)Natureofcystssimple1pt,somecomplexity2pt,complex3pt.
3)SerumCA125level.



Holisticwomen'shealth
Abortion
Levonorgestrelmostefficaciouswithin12hours
Misoprostolwithmifepristone(RU486)antiprogesterone,resultsinexpulsionofproductsofconception
withinafewhours(upto9weeksgestation),worksbydelayingovulation
Methotrexateantifolateproperties
IUDinsertwithin5daysofintercourse,makestheuterusunsuitableforimplantation
Surgicaldilationandcurettage
Premenstrualsyndrome
Anytimefollowingovulationtothefirstfewdaysofbleeding.Importanttohaveatleastoneweekfreeafter
bleeding.
OCPandmoodmayhelpwithPMSintermsoflevellingoutthehighsandlows.Butisthesameifyoutake
the4daysoff?
PremenstrualDysphoricdisorderimportanttoscreenforunderlyingdepressionorothermentalhealth
disorder.Alsoscreenforpostpartumdepression.
AssociatedSxheadache,bloating,abdominaldiscomfort,irritability,changeinbowelhabits,backpain
Normalmenstrualcyclelength23to31days
Mgmtlifestylemodification(exercise,food,sleep,familydynamics),OCP,hysterectomy,antidepressants
(SSRIsinverysmalldoses,worksevenwhenyoutakeitfor2weeksoutofthe4afterovulation,antianxiety
effects)
Vaginismus
Doyoulubricateorgetwet?Doyouenjoysexualintercourse?Foreplay?Positions?Doyoucometo
orgasm?Painduringsex?Ejaculation,when,where,withdrawal?
Doyouusetampons?
Exploreotherfactors:relationshipbetweenhusbandandwife?Religious,culturalfactors?Sexualassault?
Pelvicfloorexercisesalwayshelp
Checkforotheranxietyfactorsinherlife.
VaginalExamination
Makesureyouaskforpermissionforeverything.
Menopause
Perimenopause
12monthsofcontinuousamenorrhea
4555years
CheckBetainhibin/AMHlevels
BiochemicalmarkersandinvestigationsofmenopauseFSH,LH,AMH,antralfolliclecount(US)
Classicalsymptoms
Hotflushes(~65%inwesterncountries,25%significanthotflushes)
80%>1yearduration
9%beyond70yearsold
Commoncauseforpresentation
Nightsweats
Insomnia
Mood&Memorychanges
Achesandpains('catalogueofdoom')

Definition:permanentcessationofmenstruationresultingfromlossofovarianfollicularactivity.Recognised
tohaveoccurredafter12consecutivemonthsofamenorrhoea.
Meanaged45to55years.
4stages:1.Prereproductive,2.Reproductive,3.Menopausaltransition,4.Postmenopause
FSH,AMH,binhibin,antralfolliclecount(viau/s)varythroughoutthesestages
MostcommonSx:
Hotflushes(65%inwesterncountries,80%oftenlastformorethan1year,80%freeofsymptomsin5
years,25%haveseverehotflushes,9%continuetohavehotflushes>70years)
Nightsweats,insomnia,moodandmemorychanges,achesandpains
Longtermfactors:cardiovascularandosteoporosis
Mgmt:
Lifestylechanges:weightloss,exercise,diet(phytoestrogens(Efromplants),mostcommonlyfromsoy
andlegumes.Mediterraneandiet,Japanesedietalsohigherinflavonoids.)
HRT:mosteffectivetreatmentformoderatetoseveresymptoms.Mostappropriatetouse/initiateifyou
hadmenopausewithin10years.Initiatetreatmentwhensymptomsaretroublesome.Ifwomanhashada
hysterectomy,thensheonlyneedsoestrogen.Ifnot,thentheyneedoestrogenandprogestogen(blanket
termforprogesteroneandsyntheticprogesterone).Nomajorharmifusedforlessthan5years.Secondline
treatmentforosteoporosis.
LinktoincreasedriskofbreastcancerprobablyduetoprogestogenbutreallyonlyifHRTisusedformore
than5years.Oestrogenaloneisprettysafe.
GoodevidencetoshowHRThelpsprotect/preservecardiovascularhealth.OralOCPandHRTincrease
thromboembolismandischaemicstrokerisk,butnotsignificantlyuntiltheyare>60years(dermalpatches
donotincreaserisk).CombinedHRTdoesnotincreaseriskofendometrialcancer(unopposedEincreases
riskofendometrialcancer).Dosingiscontinuousoestrogenandprogesteroneforthosethathadnot
menstruatedfor1year.
Sequentialtherapyisusedforthosewhoarenotyetmenopausal,wheretheyaregiven
continuousoestrogenand1012daysofprogestogensotheygetawithdrawalbleed.
Continuoustherapycontinualoestrogenandprogestogenwithoutbreak
Remifeminnaturalblackcohosh.Herbalproductthatcanbetrialledinwomenwhoarecontraindicated
foroestrogenHRTpreparations.(e.g.thosewhohadbreastcancerbefore)
gabapentin900mg(highdose)adayforthosewithsevereflushes(safertouseforpatientswhohave
earlymenopauseasaresultofchemotherapyinbreastcancer)
antidepressants(venlafaxine,paroxetine,escitalopram,citalopram),reduceshotflushesby67%
HRTwithSERMe.g.tamoxifen,bazedoxifene(oestrogenandselectiveoestrogenreceptormodulator):
actsentirelyviaoestrogen,alleviatesvasomotorsymptoms,protectsendometrium(notethisisentirely
doserelated),reversebonedensity,doesnotstimulatebreasttissue.VTEriskisnogreaterthanusingE
alone.
Vagifempessaryinvagina.Helpsrestoreelasticityandthenormalbacterialflorasothatitisbetter
lubricatedandlessincidenceofUTIs.
noevidenceforTrochewhicharelozengesmadeupwithvariouslevelsoftestosterone,oestrogen,
progesterone,DHEAbycompoundingchemist.Dontwork.Noevidencetosupport.Mostofthelozenge
getslossinthebuccalmucosaandoesophagusanyway.Don'tworkmostabsorbedinGIT,don'tmakeitto
systemicsystem.
s/e:mastalgia,breastenlargement,somnolence,insomnia,reducedlibido
ForinterestdifferencebetweenHRTandOCP.OCPhashigherdosesofoestrogenandprogestogen
whicharegivendaily,afterwhichthereisaplacebotoallowforbleeding.OCPusesyntheticoestrogen.
HRTusesnaturaloestrogenatlowerdoses.
Menopauseclinic
QtocoverinMenopausehx:
Whatisyourreasonforattendingtheclinic?
Menopausal(oroestrogendeficiency)symptomstocover:hotflushes,lightheadedfeelings,
headaches,irritability,depression,unlovedfeelings,poormemory,sleeplessness,unusual
tiredness,backache,jointpains,musclepains,newfacialhair,unusuallydryskin,lossof
libido/sexualdesire,dryvagina,pain/discomfortduringintercourse?
Haveyouhadahysterectomy?
WhenwasyourLMP?lastpapsmear?lastmammogram?
HaveyouevertakenHRT?ifso,whendidyoustartorstop?Whydidyoustop?Ifyouarestilltaking
itnow,areyoutakingoestrogen?progestogen?both?
Haveyoutriedanyotheralternatetherapiestocontrolmenopausalsymptoms?
Howhasyourhealthbeeningeneral?Pastmedicalhistory?
Familyourpasthistoryof:osteoporosis,heartdisease,stroke,cancerofthe
breast/ovary/uterus/cervix/others?
Vagifempessaries(ortablets)insertedintovaginafor2weekscontinuously,afterwhichyouinsert1tablet
Vaginalcreammessybutprovideslubrication
obothhelpincreaseelasticityofthevaginalwall,helpwithmaintainingthebacterialfloratodecrease
likelihoodofgettingUTIs.
Trochenotevidencebased,'bioidenticals'lozengesmadeupbycompoundingchemistsofTestosterone,
estrogen,progesterone,DHEAspecificallytailoredtothepatientshormonallevels.
Primaryovarianinsufficiency(POI)
MenopausallevelsofFSHandLH,symptoms(irregularmenses)inwomenunder40orinadolescentgirls.
Duetodecreasednumberoffolliclesoracceleratedrateoffollicularloss.Mostidiopathiccausesunknown,
iatrogenicmostcommon(chemotherapy,radiotherapy).Immunological(hypothyroidism,hashimotos,
Addisondisease)andothergenetic(e.g.fragilex),infections(e.g.TB),metaboliccauses(e.g.myasthenia
gravis)
Thinkofitasanendocrinedeficiencysyndrome(earlylossofoestrogen,progestogenetc)
Longtermcausesaresimilartomenopausebutexaggerated.Alsoinfertility.
Treatmentissimilartothatformenopausalwomen,butdosesofoestrogenmaybehigher,andwillneedto
begivenuntiltheyareatleast45yearsold.
Breastcancer
Increasedbreastdensityisthesinglehighestindicatoraftergeneticsorfamilyhistorythatincreaseriskof
gettingbreastcancer.1in8getbreastcancer.

PelvicPain
Acuteonsetpain:reflectsfreshtissuedamage,resolvesastissueheals
Gynaecological
pregnancycomplications:ectopic,miscarriage
Ovariancystscomplications:rupture,torsion,haemorrhage
PID
Endometriosis
Surgical:appendix,calculi
Chronicpain:>6months,intermittent,constantpain
Gynaecological
ChronicPID
endometriosis
Adenomyosis
Fibroids
Surgical:chronicappendicitisrenalcalculi,IBS/IBD,diverticulitis
Other:musculoskeletal,neuropathicpain,interstitialcystitis
Redflags
bleedingperrectum
newbowelsx>50yo
newpainaftermenopause
pelvicmass
suicidalideation
excessiveweightloss
irregularvaginalbleeding>40yo
postcoitalbleeding
Endometriosis
EndometriosisCYCLICALPERIODPAIN,CYCLICALdysmenorrhoea,dyspareunia,pelvicpain,
dyschezia,backpain
1in10women

Sx:pain(withperiod,duringovulation,passingurine,intercourse,lowerbackpain),abnormalbleeding,
cyclicalnature,infertility(30%ofinfertilewomenhaveendometriosis),cyclicalbowelpain
(dyschezia)/symptoms

Causes:Potentiallycausedbyretrogrademenstruationandcoelomicmetaplasiainsusceptiblepatients.
(Geneticfactors,poorerimmunesystems(manywomenwhosufferfromendometriosiscomplainof
chronicfatigue,havesle,thyroidrelateddisease,allergies),Environmentaldioxins,weight,delayed
childbearingandfewerchildren(moremenstrualcycles)

Stage1(minimal)to4(lotsofadhesions,severedisease)determinedbasedonlaparoscopicfindings

Complicationsoflaparoscopy:
3typesofrisk.1.Generalanaesthetic(incubation,reaction),2.Generalsurgicalrisk(bleeding,infection,
woundsite)3.Specificsurgicalrisk(bowel,bladder,uretercomplications)

Endometrioticcyst:chocolatecysts,endometrialcellsincysts,haemosiderin.

Mechanismofinfertilityinendometriosis:unfriendlyimmunologicalenvironmentfortheovaandsperm.
Suboptimalenvironmentforendometrialimplantation.Damagetoovary,ovulationprocess,tubaldamage.

Medicationsforendometriosis
Analgesicstomanagethepain.
OCPhelpstomanagethedisease.Sinceprogestogenisgivencontinuously,theendometriumcannot
developasmuchthereforeit'sthinnerandthereforethereislessbleeding.
Danazol(testosteronebased)notpopular.Looklikeaman.
Progestogens2ndline
Menopauseinducingmedications3rdline(veryeffective)includesGnRHagonist(zoladex)

Pelvicinflammatorydisease
Causes:1.Chlamydia,2.Gonorrhea,3.Mycoplasma,oranaerobes(infectionfromretainedproductsof
conception)
LowthresholdfortreatmentofPIDduetomanyimplications(earliertreatment,thelesserthedamage):
infertility(tubaldamage),ectopicpregnancy,chronicpelvicpain,recurrentepisodesofPID.Needtoadvise
usingcondoms,screeningsexualcontacts.
Mostcommoncauseofdeathinwomenfromgynaecologicalcausesisrupturedectopicpregnancy.

Structureandfunctionofthefemalereproductivesystem
Forovariestoundergotorsion,theyareusuallyabnormalovariesalready.

Normalmenstrualcycle:
1.Follicular(ovarian)/proliferative(endometrium)
2.OvulationLHspikeleadstolysisoffollicularcellwall.ciliainthetubalepitheliumbringtheeggthroughto
uterus.Thereforenormaltubalepitheliumisveryimportant.
3.Luteal(ovarian)/Secretoryphase(endometrium)rapidvascularisationtocorpusluteum(rubyred),
mittelschmerzpain,rapidbleedintocorpusluteum.Granulosacellsstarttoproduceprogesteronefor14
days.CorpusluteumwillthendieunlessthereisHCGproducedbytrophoblastofimplantedzygote.

Menstruation:averagebloodloss25to60ml.Progesteronewithdrawal,vasoconstriction,shedding,
fibrinolysis,homeostasis,reepithelialization.Heavybleedingyougetclots,notenoughenzymestobreak
downbloodtostopclotting.Lightbleeding,noclots.Canstopbleedingwithoestrogen.

Hypothalamus:unmyelinatednervefibres(synthesizesGnRH),myelinatedfibres(regulatestheGnRH)
PulsatileGnRHsecretionamountofGnRHdependsontheabsoluteamountproducedandtheamountof
receptorsavailable.

AnteriorpituitarymakesFSH,LH
FSHstimulatesfollicularmaturationandaromatisationofandrogenstooestrogen
LHStimulatesthecacellstoproduceandrogen,ovummaturationandresumptionofmeioticdivision(LH
surgeduetochangedpositivefeedbackbyE),ovulationandlutenisationofgranulosacells,formationof
corpusluteum.
InhibitinhibitFSH
ActivinstimulateFSH
Gynaecologicalcancers
Endometrialcancer
Mostcommongynaecologicalcancer,roughly1in80
Mostlyapostmenopausalcancer,veryuncommoninyoungpeopleexceptinwomenwith
PCOS(unopposedoestrogen)
Checkstagingofendometrialcancers
Riskfactorsinclude
Age
Highsocioeconomicgroup
Nulliparity
Infertility
Earlymenarche
Latenaturalmenopause
Obesity(naturallycompoundswithincreasedoestrogen)
PCOS
Diabetes,hypertension
Tamoxifen
Unopposedexogenousoestrogens
Symptomsinclude:
Abnormalvaginaldischarge
Postmenopausalbleeding,irregularbleedinganddischarge
Painordifficultywithmicturition
Painnotusual,ifbleedingisheavythenpainisassociatedwithanexpulsiveuterine
contraction
Gynaeoncology
Endometrialcancermostcommongynecologicalcancer.1in8women.RF:Cancerof
premenopausalwomen.unopposed(endogenous/exogenous)oestrogenstimulation.Nulliparity.
Infertility.Earlymenarche,latemenopause.Obesity!!!(Fatconvertsandrogenstooestrogen).PCO(not
ovulating,justoestrogennoprogestogen).Tamoxifenuse(SERM,weakoestrogenintheendometrium).
Hypertension.
oHNPCClynchsyndrome.Microsatelliteinstability.50%riskofendometrialcancer.
oSx:postmenopausalbleeding!!!!!,abnormalvaginaldischarge,irregularbleeding/discharge,painor
difficultywithmicturition(advancedcancers).
oDx:dilatationandcurettagemaintest.5%will.haveapositivepaptest.Outpatientendometrial
sampling(looksforhypoplasticendometrium.notdonemuchinaustralia)
oMx.:totalhysterectomyandbilateralsalpingooophorectomy.Pelvic+paraaorticnodedissection.
Removetheuterusattimeofsurgery.Oftenavoidnodesifthecancerissuperficialduetoriskof
lymphoedema.Forhigherriskdisease,mayuseradiotherapyandchemotherapyasadjuvantbutnot
standard.Hormonaltherapyusedinyoungwomenbygivinghighdoseprogestogen(provera,
mirena,combinedwithcurettage),mayactuallyhelpcellsregresssothatthefemalecanhave
babies,aftertheyhavehadenoughkids,dohysterectomy.
oOncecancerhasspreadoutsideuterus,incurable,poorsurvival.

Cervicalcancer:
IncidenceinAustraliaisapprox.1in218
Incidenceisdecreasingindevelopedcountries
1stor2ndmostcommoncauseofcancerdeathinwomenworldwide
Knownriskfactors:
Earlycoitarche
Multiplesexualpartners
Lowersocioeconomicgroup
Smoking
HPVexposure(oncogenicsubtypes)
Sx:Asymptomatic,Postcoitalbleeding,Intermenstrualbleeding,Abnormaldischarge,Pain,Urinaryorbowel
symptoms

Ovariancancer:leadingcauseofdeathfromGynaecologicalcancerinAustralia.90%derivedfrom
coelomicepithelium(cellsfromfallopiantube).PeakageRF:endometriosis,BRCA1(Cangetitvery
young),BRCA2,HNPCC,lowparity,earlymenarche,latemenopause,incessantovulation.
oix:transvaginalultrasound
oProphylacticsurgeryforwomenwithhighrisk.Prophylacticsalpingooophorectomy.
oInpostmenopausalwomenwhoaregettinghysterectomyforwhateverreason,dosalpingectomy.try
toleaveovariesastheyprotectwomenfromheartdisease.
oOvariancancersspreadcoelomically,toomentum.Ifspreadtoperitoneumorabdominalorgans,you
wouldsurgicallydebunkasmuchaspossibleandthenusechemotherapy.Maydoneoadjuvant
chemotherapytoreducethesizeandreduceascites,reducesmorbidityfromsurgery.Good
responseratetochemotherapybutpoorcurerates.Carboplatinandtaxol.
oTumourmarkersCA125.
oGermcelltumoursofteninyoungwomen:yolksactumour,immatureTeratoma,dye?.Canbecured
withchemotherapy.
oCystadenomas,transitionalcell,mucinous,endometrial,clearcell,peritonealcancer
oStromaltumours:granulosacell,sertoliladencelltumourstreatwithsurgery.
oEpithelialcancers:benign,borderlinetumours(stratifiedepithelium,highmitoticcount,atypicalcells)
,cancer(invadesanddestroynormaltissue)

Vulvalcancer:

Gestationaltrophoblasticdisease(molarpregnancies):mole=amorphousmass.Rarebutisfully
curabletumoursfromtheproductsofconception.1in600.Morecommoninsoutheastasian.
Advancedmaternalageforincompletemoles.Historyofspontaneousabortions.
oHydatidiformmole(grapelike).PartialmolesderivedfromTripoliconceptus(1haploidmaternal,diploid
ispaternal.69XYY),mayhavefoetusunlikeCompletemoles(diploidallpaternalchromosome46XX
mostly,46XYastherewasanemptyeggandspermfertilization,nofoetus).Needtoknowpartialvs
completemole!!!!U/Sdiagnosis,lookslikeasnowstorm,tinyvesicles.
Mx:suctioncurettage.FollowbHCGuntilitgoestozeroasquicklyaspossiblee.g.8weeks.If
bhCGtakeslongtodecrease,thenneedtofollowupfor12monthstoensurethereisno
recurrence.TellpatienttoavoidgettingpregnantatthistimeotherconfusingbhCG.IfbHCGis
persistentlyhigh,thengivechemotherapymethotrexate.
Complications.Thecaluteincysts,respiratorydistresssyndrome.Etc
oGestationalchoriocarcinomarapidlymetastaticdisease,hyperemesisgravidarumasyouhavevery
highhCG,lotsofbleeding.
oPlacentalsitetumour.
oEpithelioidtrophoblastictumour.Canbeinvasive.
oPhantomserumhCG.RarefalsepositivehCGduetoantibodyagainstantigenintest.LookforhCGin
theurineasantibodiesdon'tgointourine.

UroGynaecologicalissues
Incontinence:33%ofwomenpast25yearswillhaveincontinenceinsometimeintheirlife.

3types
Stressincontinence:weakbladderneck,involuntaryleakage
stressurinaryincontinence
Urodynamicstressincontinence

Urgeincontinence:involuntaryleakageprecededbyurgency

Mixedincontinence

Overactivebladderin1520%ofwomen,idiopathiccauses
oSensoryurgency
oDetrusoroveractivity:involuntaryleakagewhenDetrusor>urethralpressure
ourgency*(cardinalsymptom),frequency(>8voidsaday),nocturia,urgeincontinence.Intravesical
spasmisfeltasurgency.

Riskfactorforstressincontinence
Childbirth/pregnancy,>4kg,3rddegreestear,forceps,lengthy2ndstage
Obesity

Management:vaginaloestriol.Vagifem?
Hx:type,whenitstarred,triggers,pads?,urinaryincontinence,obstetrichistoryetchowoftentotheygoto
thetoilet,howmuchdoesitimpacttheirlife,UTI.
specificexamination:stressprovocationtest,transperinealu/s.

Normalvalues:mean24HRvolume1430ml,meanfrequency6/24,averagevolvoided250ml.

Womenwithstressincontinence,bladdershrinksbecausetheyemptyittoooftenanditdoesn'thold
volume.Viciouscycle.
Healthybladdershouldemptyto0.Anythinggreaterthan30to40mmhgisaproblem.

StressincontinenceMgmt:
olifestylechangesandbladderretraining(lesscaffeine,bettertoilethabits,increasewaterhabit)Pelvic
floormuscletraining,midurethralslings,pessaries

Urgeincontinencemgmt
Meds:antimuscarinics(reducebladderspasm),anticholinergics(ditropan,vesicare)s/e:drymouth,
dryeyes,constipationcontraindicatedinptwithglaucoma,ulcerativecolitis.
Botox,injectingintobladderviacystoscopy.Usually30sites.Lasts9months.OverParalysebladder
andneedtoselfcatheterise(10%).Veryexpensive.
Sacralnervestimulator,implantedinbaseofspinetoS3.Usedforfaecalandurinaryincontinence.

PelvicOrganProlapsePOP
e.g.Bladdercystocele,Rectusrectocele,Vagina/vaginavault,Cervix
Cervicalprolapse
Causes:obesity,pregnancy/childbirth,age
Sx:asymptomatic,dyspareunia,feelabulge,somethingcomingdown,urinarysymptoms,paininN
Gradeit:mildmoderate,severe
Mgmt:watchandwait,ringpessaries,definitivetreatmentsurgerytotalvaginalhysterectomy,
sacrocolpopexy(attachvaginatosacrum?)
Importantquestions:Areyousexuallyactive?Ifno,doyouhaveambitiontobesexuallyactive?Importantto
knowbecauseitwilldeterminehowtightyouclosethevagina.


Obstetrics
Perinatalindigenoushealth
Shortanswer/SBAtestonblackboard,Summaryofwomen'shealthtoread
AboriginalMedicalServiceaboriginalcommunitycontrolled,morethanGPservices,culturalsafety.3key
groups:community,medical,administrative
Indigenousmaternaldeath21.5per100,000
Youngerbirthage.Cervicalcancer10.3per100,000(5xnonindigenous)
Mostofthefiguresbelowis2xormoretheratefornonindigenouspopulations
Fetaldeathrate12per1000births
Neonataldeathrate6per1000births
preterm14%,lbw13%,shorterlengthofstay3days
Remoteindigcommunities1in4womenhaveSTI>poorhealth,infertility,ectopics
Familyviolenceexperiencedby24%ofATSIaged>15years
LeadingcausesofdeathinATSI1.Cardiovascular,2.Malignancy,3.Diabetes,4.Respiratorydiseaseand
smoking.

Estimateddateofdelivery
Naegele'sruletoworkoutestimateddateofdeliveryusingdateofLMP=dayplus7,monthminus3(plusa
year).
Wherehercyclevariesfrom28days,addorsubtractthedifferencefromtheEDDworkedoutusing
Naegelesrule.
Forthistobeaccurate,needtoconfirmwiththepatient:
Cycleregularity
Lengthofcycle
AccuratedateofLMP
Recentcontraceptivepillusage
Perinatalchromosomalabnormalities
Incidenceofaneuploidy:>50%miscarriages,5%stillbirth,0.5%livebirths
Maternalageisthesimplestscreeningtool.
Trisomy13,18,21mostcommonaneuploidyandassociatedwithincreasingmaternalage.Allhavelow
PAPPAlevels.
Downsyndrome:RiskofTrisomy21at35years1/350,1%at40years.1.2per1000birthsinAustralia.NT
plusbloodsscreening:falsepositiverate5%,misses1in10cases.

Screeningtests:NT(11to14wks),bloods(pappa,bhcg,afpetc),NIPT(10weeksonwards,worksfor
twinstoo)
ORoptiontodonothing

Diagnostictests:CVS(11to14wks),amniocentesis(15weeksonwards),
Pregnancyisdividedintothreetrimesters:
Firsttrimesterconceptionto12weeks
Secondtrimester12to24weeks
Thirdtrimester24to40weeks.
1sttrimesterscreening
Nuchaltranslucencyscreeningat11to14weeks:fluidbehindthebackoftheneckmeasuredinmm.
Thicker>3mmindownsyndromebabies.
Bloods:biochemicalmarkersincreasedfreebHCGandlowPAPPA(madebyplacenta)inTrisomy21.
(InTrisomy13/18,bHCGisdecreased,inTurnerssyndrome,bHCGisnormal).
Chorionicvillussampling(CVS)biopsyfromtheplacenta.Canbedone11to14weeks(earlier).Risk:
trickiertodo(needtolocatetheplacenta),>1%increasedriskofmiscarriage.Fullkaryotyperesultstake
2.5weeks.PCR/FISHtestforthecommonsyndromeswithin24hours(99.9%accurate).
Amniocentesisskincellsfromfoetusinthe20mlamnioticfluid.Canbedonefrom15weeksonwards.
Easiertodo.Risk:1%increasedriskofmiscarriage.ResultstakesameamountoftimeforCVS.
NIPT(noninvasiveprenataltestingcellfreefoetalDNAinmaternalplasma),microarrays(besttest)
Newscreeningmethodstodetectchromosomalabnormalities.Privatised,costlystill.CopyNumber
VariantsanygainorlossinDNA.
12weekscancheckifit'smultiplepregnancies,screenforsyndromes,datethepregnancy.
Screenuterinearteryforpreeclampsia,pretermdelivery,
2ndtrimesterscreening
Fetalmorphologyultrasounddoneat20weeks.Looksforstructuralabnormalities,assessesfetal
growth,localisedplacenta,multiplepregnancies,assessformarkersofaneuploidy.
Fetalbloodsamplefineneedlethroughabdominalwallanduterusintoplacentalcord.Candofrom18
weeks.Donewhenbabyisanaemic,duetotop3reasons:transfusioninrhesusdiseaseormumhas
parvovirus(babygetsslapcheek)orfetalmaternalhaemorrhage.Othersincludethalassemia.
Otherwisenotdoneduetohighriskofmarriage.

Pregnancytimeline
Conception
Themomentofconceptioniswhenthewomansovum(egg)isfertilisedbythemanssperm.Thegender
andinheritedcharacteristicsaredecidedinthatinstant.

Week1
Thisfirstweekisactuallyyourmenstrualperiod.Becauseyourexpectedbirthdate(EDDorEDB)is
calculatedfromthefirstdayofyourlastperiod,thisweekcountsaspartofyour40weekpregnancy,even
thoughyourbabyhasntbeenconceivedyet.

Week2
Fertilisationofyoureggbythespermwilltakeplaceneartheendofthisweek.

Week3
Thirtyhoursafterconception,thecellsplitsintotwo.Threedayslater,thecell(zygote)hasdividedinto16
cells.Aftertwomoredays,thezygotehasmigratedfromthefallopiantubetotheuterus(womb).Seven
daysafterconception,thezygoteburrowsitselfintotheplumputerinelining(endometrium).Thezygoteis
nowknownasablastocyst.

Week4
Thedevelopingbabyistinierthanagrainofrice.Therapidlydividingcellsareintheprocessofformingthe
variousbodysystems,includingthedigestivesystem.

Week5
Theevolvingneuraltubewilleventuallybecomethecentralnervoussystem(brainandspinalcord).

Week6
Thebabyisnowknownasanembryo.Itisaround3mminlength.Bythisstage,itissecretingspecial
hormonesthatpreventthemotherfromhavingamenstrualperiod.

Week7
Theheartisbeating.Theembryohasdevelopeditsplacentaandamnioticsac.Theplacentaisburrowing
intotheuterinewalltoaccessoxygenandnutrientsfromthemothersbloodstream.

Week8
Theembryoisnowaround1.3cminlength.Therapidlygrowingspinalcordlookslikeatail.Theheadis
disproportionatelylarge.

Week9
Theeyes,mouthandtongueareforming.Thetinymusclesallowtheembryotostartmovingabout.Blood
cellsarebeingmadebytheembryosliver.

Week10
Theembryoisnowknownasafetusandisabout2.5cminlength.Allofthebodilyorgansareformed.The
handsandfeet,whichpreviouslylookedlikenubsorpaddles,arenowevolvingfingersandtoes.Thebrainis
activeandhasbrainwaves.

Week11
Teetharebuddinginsidethegums.Thetinyheartisdevelopingfurther.

Week12
Thefingersandtoesarerecognisable,butstillstucktogetherwithwebsofskin.Thefirsttrimester
combinedscreeningtest(maternalbloodtest+ultrasoundofbaby)canbedonearoundthistime.
Thistestchecksfortrisomy18(Edwardsyndrome)andtrisomy21(Downsyndrome).

Week13
Thefetuscanswimaboutquitevigorously.Itisnowmorethan7cminlength.

Week14
Theeyelidsarefusedoverthefullydevelopedeyes.Thebabycannowmutelycry,sinceithasvocalcords.
Itmayevenstartsuckingitsthumb.Thefingersandtoesaregrowingnails.

Week16
Thefetusisaround14cminlength.Eyelashesandeyebrowshaveappeared,andthetonguehas
tastebuds.Thesecondtrimestermaternalserumscreeningwillbeofferedatthistimeifthefirst
trimestertestwasnotdone(seeweek12).

Week1820
Anultrasoundwillbeoffered.Thisfetalmorphologyscanistocheckforstructuralabnormalities,
positionofplacentaandmultiplepregnancies.Interestingly,hiccoughsinthefetuscanoftenbe
observed.

Week20
Thefetusisaround21cminlength.Theearsarefullyfunctioningandcanhearmuffledsoundsfromthe
outsideworld.Thefingertipshaveprints.Thegenitalscannowbedistinguishedwithanultrasound
scan.

Week24
Thefetusisaround33cminlength.Thefusedeyelidsnowseparateintoupperandlowerlids,enablingthe
babytoopenandshutitseyes.Theskiniscoveredinfinehair(lanugo)andprotectedbyalayerofwaxy
secretion(vernix).Thebabymakesbreathingmovementswithitslungs.

Week28
Yourbabynowweighsabout1kg(1,000g)or2lb2oz(twopounds,twoounces)andmeasuresabout25
cm(10inches)fromcrowntorump.Thecrowntotoelengthisaround37cm.Thegrowingbodyhas
caughtupwiththelargeheadandthebabynowseemsmoreinproportion.

Week32
Thebabyspendsmostofitstimeasleep.Itsmovementsarestrongandcoordinated.Ithasprobably
assumedtheheaddownpositionbynow,inpreparationforbirth.

Week36
Thebabyisaround46cminlength.Ithasprobablynestleditsheadintoitsmotherspelvis,readyforbirth.If
itisbornnow,itschancesforsurvivalareexcellent.Developmentofthelungsisrapidoverthenextfew
weeks.

Week40
Thebabyisaround51cminlengthandreadytobeborn.Itisunknownexactlywhatcausestheonsetof
labour.Itismostlikelyacombinationofphysical,hormonalandemotionalfactorsbetweenthemotherand
baby.

Pretermbirth/labour
infantbornbefore37weeksofgestationispreterm.
3741weeksand6daysisfullterm.
42weeksandoverispostterm.
Miscarriage:>20weeksandor>400gotherwiseitisaregisteredbirth
Pretermbirthriskfactors:multiplepregnancy(biggestriskfactor),spontaneouspretermlabour,preterm
ruptureofmembrane,cervicalincompetence,iatrogenic,preeclampsia,antepartumhaemorrhage.
Antenatalcorticosteroids
Crossestheplacenta,enterfoetalcirculation.Singlecourseconsideredinallpretermdeliveriesfrom26
(24?)weeksonwards,pretermruptureofmembranesandhypertension.Needtodecidehowlikelythe
motherisgoingtodeliverwithinthenext48hours,asyoucannotgiverepeatdoses.

Benefitisshownupto34+6weeks.

Reducesrespiratorydistresssyndrome
Reducesintraventricularhaemorrhage
Reducesnecrotisingenterocolitis
Reducesmortality
Reducessystemicinfectionsinfirst48hoursoflife
ReducesrateofNICUadmission
BetamethasoneIM11.4mg(highdose)orDexamethasone12mgIM:2dosesgiven24hoursapart.Don't
givenrepeatedsteroiddoses.
Evidenceforcorticosteroidsisforupto34weeksand6days.
Tocolysis/tocolyticstosuppresslabour
Buystimetoallowcorticosteroidstoworkandtotransfertotertiarycentre.
Calciumchannelblockers(nifedipine=adalat)nobenefitinwomenhavePPROM.
Shouldn'tbegiventowomenwhohavethreatenedpretermlabour(TPL)unlessyouneedtodelaydelivery.
Someplacesdon'tusetocolyticagents,evidenceforusingitisverypoor
OralAntibiotics
Usedforpretermprematureruptureofmembrane(PPROM).Notusedifthemembranesareintact.
Oralabxerythromycin(bacteriostaticdrug)tomotherfor10days.
ShortTermoutcomesbetter.Longtermoutcomesnodifferent.
IVMagnesiumsulfateMgSO4
Usedinwomenwithpretermbirthupto33weeks6days(before34weeksgestation).(Australian
Guidelinesisupto30weeksforpracticality).Moreprematurethebaby,themorelikelythey'dbenefit.
Given4to24hoursbeforebirthandgivecontinuously.
Usedinpreeclampsiatopreventeclampticfits.
Someevidencetosuggestitdecreaseriskofcerebralpalsyandimprovesmortalityinpretermbabies.
Somesortofneuroprotectiveeffect.S/etomother:hypotension,tachycardiathereforeneeds1to1
midwiferycare.
Cerebralpalsy1in500.Obstetricrfsincludepretermbirth<34wksand<1500g.
TPLsamplequestions
1.PPROM+G1P0+28+5+ruralhospital=steroids+abx
2.PPROM+28+5+ruralhospital+TPL=steroids+abx+MgSO4+transfertotertiaryhospital+maybe
tocolytics
3.Intactmembranes+28+5+ruralhospital+TPL=steroid+transfer+tocolytics,maybeMgSO4(But
wouldwaittillshe'sinLabour).NOABX.
4.PPROM+G1P0+35+2+ruralhospital=NOSTEROIDSorMgSO4,GIVEabx.
Questionsyoushouldaskspecificallyinathreatenedpretermlabour:
Vaginaldischarge
Foetalmovement
Abdominalpelvicpain
>Neverdoadigitalexaminationinathreatenedpretermlabourasitmaybringonthelabour.<
Amnicatorpaperwhereyoudropdischargeon,turnsblackifit'samnioticfluidorblack
Prolongedruptureofmembranes:>18hoursoflabour,babygreaterriskofinfection,mostlikelytreat
withantibioticsprophylactically

!!!PossibleOSCEstation,counsellingmotheraboutthreatenedpretermlabour,needtotransferandinterim
managementandoutcomefordelivery,likelycomplicationsinpretermdelivery,potentiallongtermoutcome
(survivalrates),whathappensifbabysurvives(NICU,management),drugsthatyoutendtogive.!!!

Normalpregnancy
Oocytelivesfor12to24hours.Spermatozoasurvivesfor3day(journeytomeetovatakes2days).Fertile
periodis5daysbeforeovulationtothedateofovulation.
LHdetectionkits,temperatureandmucuschangescanbeusedtodetectwhenawomanisovulating.
Preeclampsiachangesthespiralarteriesinthemyometriumtodilateandbecomethickerduringthefirst
fewdaysafterconceptionbeforeimplantation.
Highestpregnancyratesoccurincouplesthathaveintercourseeveryonetotwodays.
Conceptionoccursonday14ofthemenstrual,implantationoccurs6dayslater.
Immunesystemofmotherisphysiologicallysuppressedsothatherbodydoesn'trejectthebaby.
Signsandsymptomsofpregnancy
Breastarefullerandtendernessandnauseaareusuallythefirstfewsignsofpregnancy.Mostpeopleare
symptomaticbyabout8weeks.Onsetofsymptomsareabrupt.Amenorrhoea.Instantlyfeeltiredand
fatigued.Frequencyofmicturition.Constipationoccursearlyon.
Uterusbecomesapelvicorganuntil12cmthenbecomesanabdominalorgan.
Physiologicalfungalheight,fromuterinefundustopubicsymphysisincmshouldcorrelatetonumberof
weekspregnant.
Ghowmanytimeshaveyoubeenpregnant
Pbabydeliveredafter20weeks
Terminations,miscarriages
G?P?
Prematuredefinition:"notinLabour"
AntenatalSerology:HCV,HBV,HIV,Syphilis,chickenpox,rubella,FBC,EUC
Datingultrasound:Dobetween8and10weeks.Workoutwhenthebaby'saredue.Canworkoutwhen
babyisoverdue.Inducelabouraftertheyareoverdueover10daysastheplacentalosesitsefficacysinceit
isatemporaryorgan(>42weeks+riskofstillbirthincreasesexponentially).Usepregnancywheel
measuredfromlastmenstrualperiod.Ultrasoundsarelessaccuratewithincreasinggestation.
Corpusluteumpain,regressedandbleedsat10weeks.Mothermaypresentwithunilateralpain.Don'twant
toremovethecorpusluteumbefore10weeksasthepregnancymayfail.
HCGproducedbythetrophoblast.Doublesevery2daysinpregnancy.(Ifectopicornonviablepregnancy
thentheHCGwon'tdouble,thereforeworthwhiletakingtrend).bHCGdetectableinbloodasearlyasday6,
urineday14
By12weeksthebabyhasallorgans(fullydeveloped),afterthis,thebabyjustgrows.
Placentaldevelopment:maternalandfoetalblooddoesnotmixnormally.Duringbirthitdoesmix.Blood
groupisimportanttoknow.85%arepositive,15%arenegative.Ifthemotherisnegativeandthebabyis
positive,thematernalsystemwillinitiateanimmuneresponsethoughisn'tveryproficientinthefirstbaby.In
secondbaby,theimmuneresponseisstrongenoughtokillthefoetus,henceweuseantiD.
GiveantiDwithin72hoursoftheeventofthebloodmixingtothemother,ittagsthemountingimmune
responseanddestroysitsothatthemother'simmunesystemremainsnaive.Itworksfor6to8weeks.
Umbilicalcordneedstoinsertintothemiddleoftheplacenta.Ifitistotheside,thenitiscalleda
velamentouscord,anditissafertodeliverviacesareansection.Astheseplacentaareatriskofrupturing
membranes.
Maternalchangesinpregnancy
Cervicalchangesinpregnancy:softens,cyanosed,moremucous,reversionofcolumnarepithelium.
VaginaandPerineuminpregnancy:increasedvaginaldischarge,loosedwallandskin
Striaegravidarum,linesnigra(Brownlinedownthemiddle),spidernaevi,
Weightgain10to15kg.Baby3kg,placenta750g,therestisfluids.
Bloodvolumeincrease40to50%.Decreasedplatelets,increasedESR.Increasedbloodviscosity.
Lose<500mlduringdelivery.If>500ml,classifiedaspostpartumhaemorrhage.
Heartburn,stomachandintestinesdisplacedupward.Nauseaandvomiting.Bleedinggumsandnoses,
randomly.Hemorrhoidsandconstipation.
Antenatalvisits
1stvisit1216weeks
4weeklyvisitstill28weeks
2weeklyvisitstilldelivery?
Nuchaltranslucency1114weeks(optional)
Foetalmorphologyscan1820weeks.Checkfoetalanatomyandpositionofplacentainrelationtothe
baby.
FBC,Groupandhold,Antibodies28and36weeks
GTT50gat28weeks
Lowvaginalswab(groupbstrep)
LieLongitudinallie(upanddown)vstransverselie(sideways)
Stationhowfarheadissittingdowninthepelvis.Normalfoetalheartrate110160.
Dryimportanttorubthefundustoensureallthebloodandplacentamaterialhascomeoutsothatthe
uterus(myometrium)cancontractandeffectivelystopbleedingitself.
HighriskObstetrics
Hypertensioninpregnancy
1.Labetalolorotherbetablockers,don'tuseatenololasitsassociatedwithgrowthrestriction
2.Hydralazine
3.Methyldopa
GofindHypitattrial

T1DM
Particularlyatriskofplacentalgrowthinsufficiency,hencedeliverat38weeks.Canhavefoetal
macrosomiaorIUGRbabies.Havehigherincidenceofcardiacabnormalitiesandhypertensionandallother
complicationsofpregnancy.

T2DM
Diabeticdrugsandpregnancy
GESTATIONALDIABETES
nottooworriedabout,dietcontrolledusually.

Thyroiddisease
Hashimoto'sdisease
Grave'sdiseaseTSHRantibodiescancrossplacentaandcausethyrotoxicosisinthebaby.

Thrombophilias
FactorVleiden,antithrombindeficiency,antiphospholipidsyndrome,proteinc&Sdeficienciesetc
Aspregnancyisalreadyanprothromboticstate,thesewomenneedtobemonitoredvigilantlyduringthe
pregnancyandparticularlypostpartum(especiallythefirst6weeks).Oftenwouldputthesewomenon
clexaneduringthepregnancy,stoppingtemporarilyduringtheperiodofdelivery,andthenstartingagainafter
birth.
Preeclampsia
Preeclampsia
increasedriskin
Firstpregnancy
Teenagers,reducedsexualencounterswithpartner

Womenwhohavesecondpregnancywithdifferentpartnerarestillatincreasedriskdespitethefactthatitis
asecondbirth,duetoexposuretonewpaternalantigens.
Exposuretopaternalantigens,mothercreatesimmuneresponseleadingtopreeclampsia?
Smokingreducesriskofpreeclampsia,butifyougetpreeclampsiawhileyou'resmoking,thenyougetit
worse.
Outcomeformother(eclampsiacauseofmaternaldeath)andfoetusisparticularlybadinpreeclampsia.

Inpreeclampsia,thespiralarterieskeeptheirmuscularwall,smalllumen,stillundermaternalcontrol.The
placentaproducesmolecules/proteins(sFlt1,sEng)asitbecomesischaemicduetothenarrowspiral
arteries,theseproteinsblocktheVEGFreceptorsanddonotallowthearteriestoremodeltolooklikeveins.
Innormalpregnancy,thespiralarteriesgetremodeledintoveinlikevesselsandtheneurovascularinfluence
fromthemotherisremoved.

Hypertensioninvestigations
urinedipstickforproteinuria
FBC(evidenceofhaemolysis),EUC(creatinine),urate(earlymarkerofrenaldysfunction),LFTs(ALT,
AST)
ultrasound(fetalgrowth,biophysicalprofile)
AssessmentinhospitalofBP>140/90
Mgmt
Assessneedfordeliverymaternal(GA>37weeks,inabilitytocontrolHT,eclampsia)
Controlseverehypertension(riskofstroke)
Assessneedtostartmeds:allbetablockersapartfromatenolol,hydralazine,methyldopa
NOACEiorARGs.
Eclampsia
Fittingasaresultofpreeclampsiaduetocerebraloedemaandendorgandamage
Tonicclonicseizures
IVdiazepam,magnesiumsulphate
Prophylaxisforwomenatriskofpreeclampsia
LowdoseAspirinworksbutmildeffect,relativeriskreduction10%,NNT200,thereforenotreallyworth
givingaspirintoallwomen.BUTForhighriskwomen,youwouldconsidergivingaspirin.Startaspirinin
firsttrimesterat8to10weeks.
Calciumsupplementationmuchhigherrelativeriskreduction(>50%)thanaspirin.Givetothosewith
lowdietarycalciumintake.Potentiallyallshouldtakecalcium.
VitaminsCandEantioxidanteffect?Sincemarkersofoxidantstressincreasedinpreeclampsia.No
evidenceforvitaminsupplementationatthispointintime,thereispotentialevidenceofharm.

Longtermriskofpreeclampticwomen,increaseriskofhypertension,stroke,IND,VTE,mortality.Counsel
womenaboutlifestyleriskfactors.
Treatingpreeclampticwomen,goalistopreventsevereHTeclampsia.Doesnotcure.Onlydeliveryofthe
placentacuresthepreeclampsia.
Riskofeclampticfitin1weekpostpartum.Afterthat,itsveryrarepastoneweek.

Methyldopa/aldomet
Methyldopa(LMethyl3,4dihydroxyphenylalanineAldomet,Aldoril,Dopamet,Dopegyt,etc.)isan
alphaadrenergicagonist(selectivefor2adrenergicreceptors)psychoactivedrugusedasasympatholytic
orantihypertensive.Itsuseisnowmostlydeprecatedfollowingtheintroductionofalternativesaferclasses
ofagents.However,itcontinuestohavearoleinotherwisedifficulttotreathypertensionandgestational
hypertension(previouslyknownaspregnancyinducedhypertension(PIH)).

Diabetesinpregnancy
Discusscomplicationswithregardstomumandfoetus

Mumantenatal,duringpregnancy,delivery,postpartumandlongterm
Polyhydramniossugarpullswater
Instrumentaldeliverycaesarean
Prolongedlabour
Inantenatalsteroidsused,needtogivemotherextrainsulin.FoetusatmoreriskofARDS.

Foetusmiscarriage,prematurityetc
Congentialabnormalitieshighsugarsareteratogenic,spinalcordagenesis,neuraltubedefects,
congenitalheartdisease.Thereforemotherisscannedmorefrequently
Macrosomiaparticularlyhaslargetrunkssinceinsulinisagoodgrowthfactor
Neonatalhypoglycaemiasugarcrossestheplacenta,foetususedtoproducinghighinsulin,comesout
atbirthandbecomeshypoglycemia

MGMT
Managemother'ssugarsdieticianmetforminorinsulin?Recommendsinsulinormetformin.Ideally
insulinshouldbestartedpriortoconceptionfortribediabetics.
oGoalis5and6checkthis
Regularreviewoffoetusandmother,every14weeksinfirst30weeks,every1to2tilldelivery
Hba1cevery4wks
Monitorforcomplicationsofdiabetes
mandatorybloodglucosefasting<5,after2hours<6.5
Foetalmorphologyscanning
normalpregnancyisaninsulinresistantstate


Gestationaldiabetes
1.needtoknowthescreeningforlowrisk50gscreeningtest28weeks,ifabnormalthenget75g
diagnostictest.Ifhighrisk,get75gsomewherebetween16to18weeks,thenrepeatat28weeks.
bloodtest75gtestfastingtest
>5.5initial
>7.82hour
MDTclinicendocrinologist,dietician,obstetricians
Assessmomforcomplications
2.Nothaveketoacidosis,diabeticcoma,
TimingofdeliveryinGDMgenerally40weeksinwellcontrollednotmedication,39weeksinmedicated
GDM.
Intruediabetesat37or38weeks.
Riskofcesareanneedtoknowhowtoexplaintherisktoprocedures
Generalrisks,Specificrisk
Uterinerupture
Increased

Multiplepregnancies
Monozygotictwinsidenticaltwins
Dizygotictwinsfraternaltwins(alwaysdichorionic,diamniotic.LambdasignonUS)
Notedifferencestochorionicity(outermembrane),amnionicity(innermembrane)
Outcomesaredependentonchorionicity,notzygosity
Dayofsplittingdeterminesthedevelopmentofthechorionandamnion
<72hours:DA:DC
38/7:DA:MC
MA:MC
Hydropsisessentiallycongestivecardiacfailureinababy

MZtwinssimilarratesaroundtheworld
DZtwinsvarywithgeography,etc.
increaserateoftwinsworldwide,duetoincreaseofmaternalageandincreaseUSDofART(oftennot
singleembryotransfers)
3/4ofpregnancieshavefirstbabythat'sbreechortransverse

Zygosity(eggs)alldizygotesaredichorionic.Monozygoticmaybemonoordichorionicdependingonwhen
itsplit:1st72hoursDC,DA.D48MC:DA(mostcommon?),D813:MC:MA,>d13conjoinedtwins.the
lateryousplittheworst.Needtoknowwhentwinssplit.

Chorionicity(placenta)morbidityormortalityofthefoetusdependsonthechronicity(numberofplacenta)
nottheZygosity.Thisiswhattheobstetriciancareaboutastheprognosisisonthenumberofplacentasyou
have.

DConu/slambdaortwinpeak
MConu/stsign
Animosity(amnioticsacs)

Complications
Readabouthyperemesisgravidarumhowtoidentifyandtreat!!!!!!!!!
Maternalhyperemesis,gdm,preeclampsia,fattyliver,morepainandsymptoms
Foetalprematurity,malpresentation,congenitalabnormalities,10to15%monochorionictwinto
twintransfusionTTTS(cotwindeath,remainingtwinathighriskofdeathormorbiditystroke,
cerebralpalsy)dxisbasedonu/scriteria.Polyhydramnios/oligohydramnios.Donor(big)and
recipient(small).Discordantbladder.Dopplerabnormalities,heartfailure,hydropsfetalis.
DeliverMC3637,DC3738weeks.Vaginalbirthappropriateonlyiftwinsarediamniotic,twin1
cephalic,twin2not>1kgheavierthantwinI,nofoetaldistress/compromise.Generallythoughtthat
cesareansarebetterfortwins.
UmbilicalarteryDoppler,normal,absentdiastolicflow,reversediastolicflow(foetuswilldiewithin48wks).
MCMA60%survival.Morbiditymainlyduetocordentanglement.Deliveredat32weeksviacaesarean
section.
3mostprominentrisks1.Pretermdelivery(byfarthebiggestrisk50%before37/40,22%before33/40
comparedto6.5%pretermdeliveryrateofallbirths),2.abnormalgrowth,3.gestationalhypertensive
disorders
UteroplacentalPPROm,poly/oligohydramnios,aph,placentapraevia,placentalabruption,atonicuterus,
umbilicalcordprolapse
Noevidencethatyoucandoanythingtopreventpretermbirths.
Discordantgrowth.Greaterriskofintrauterinedeathormorbidity.Evaluateabnormalgrowth.Can'tuse
fundalheights.Useultrasound.Assessgrowth,amnioticfluid,Doppler,biophysicalprofile.
Folateprophylaxis,Iron
Needtoknowsupplementationanddosages

Complications/risksfor:
Mother
Increasedriskof
Miscarriage
Antepartumhaemorrhage
Placentapositionalproblemse.g.Placentaprevia
Morningsickness
NeedforCaesareansection
Complicateddelivery:breechormalpositionedbaby
Needforbloodtransfusionduringdelivery

Baby
Prematurityproblemscanbedonetogether,thinkofitasbelow
Immaturityneedshelpwithbreathing(oxygen,CPAP),needsnutritionalsupport(IVfluids,TPN
initially)
Monitoringforcomplications1.riskofsepsis,2.IVH(headu/sforall.babies<32weeks)3.ROP
(eyecheck),4.Hearingcheck,5.Necrotisingenterocolitis,other:developmentalproblems,intellectual
development
ChanceofsurvivalMultiplepregnancies

Specificallyformonochorionictwins:
1.Growthrestriction
2.Twintotwintransfusionsyndromemonochorionic.Sharesaplacenta,connectingvesselsjoin.Onetwin
getsperfumedmoreandtheothertwinmissesout.Thereusuallyonetwinisbiggerandanotherissmaller,
onehaslotsofamnioticfluid(polyhydramnios,polycythemia),theotherhasless(oligohydramnios,
anaemic).Onetwinisknownastherecipient,andtheotheristhedonor.

Problemsofbeingfluidoverloadedordehydrated
Cardiacfailure
Persistentnewbornpulmonaryhypertensiondopamineanddobutamineusedtoincreaseforceof
contractilityofthehearttoincreasesystemicarterialpressureoverpulmonaryarterialpressure

HyperemesisGravidarum

Infertility
FSHandLH,testosterone,Fsh,Prolactin,pregnancyscreen,AMH,AFC
Papsmearuptodate
HSG,USS,laparoscopy
Semenanalysisvolume,concentration,motility,vitality,morphology,antispermantibodiesintheseminal
fluid(spermishaploid,immunesystemrecognisesitasforeign,thereforeneedtoaskabouttrauma,
previousprocedures).semenqualityfluctuates.Doeonesemenanalysis,ifnormal,don'tneedasecond.If
abnormal,doasecondone.

PCOS:2ofthe3criteriaUSS,hyperandrogenism,oligomenorrhoea/amenorrhoea

Clomid/clomipheneantioestrogen50mgfor5days,s/ethinendometrium,cervicalmucuschanges,hot
flushesetcrisk:multiplepregnancieschanceoftwins7%

IfresistanttoClomid,canaddMetformin(2ndlinetreatment)hyperinsulinism,helpsinsulinresistance
LaparoscopicovariandrillingkillsthecalcellsthatproduceLH
IVF

Letrozolearomataseinhibitor,blocksconversionoftestosteronetooestrogen5mgfor5days
Maleslookformicrodeletionsonychromosome,karyotyping,oh/fish,testosterone,prolactin,ultrasound,
testicularbiopsy
Can'tgiveexogenoustestosteronemakestheminfertile.GivehCG(lookslikeLH)andmakesthem

Artificialinseminationwithhusband'ssperm,needsatleast2millionspermforittohavechance,deposit
spermintheupperuterus.
IVFneeds50,000eggsatleast
ICSIifnotenoughsperm,orifIVFfailed.
IVFcycle
Shortcycle(antagonist)AtstartofcyclegiveFSH,somultiplefolliclesbecomedominant,giveGnrh
antagonisttostopLHsurge.Thoughstillneedtogivehcg(trigger),allowseggstomatureandcomeaway
fromwallbutnotrupture.Collecteggs36hourslater.Afterwards,needtogiveHCGorprogesteroneto
maintainthecorpusluteumotherwiseitwillinvoluteanddie.Needthecorpusluteumtomaintainthe
beginningofthepregnancy.
LongCycle(gnrhagonist)blockHPAaxisfirst.Moresideeffects,butusefulforpatientswith
endometriosis.
LHsurgematureseggandmakesitcomesawayfromthesideofthefollicle,thenmakesitrupture.

Day5gooddifferentiationoftheplacentalandfoetalcells,thisiswhenembryotransferoccurs.
Need9collected1or2transferred,1or2frozen.Forfrozeneggs,putitback5daysafterovulation.

ComplicationsofIVF:
Ovarianhyperstimulationsyndrome(OHSS)occurs3daysaftereggcollection,abdominalbloating/pain,
n/v,diarrhoea,DVTetc
Ectopicpregnancy14%ofIVFpregnancies
Multiplepregnancies8%riskinAustralia.Dizygotic.Causedbyputting2embryosin.
MiscarriagenotincreasedfromnonIVFpregnancies
PreimplantationgeneticdiagnosisPGD

Bleedinginearlypregnancy
Miscarriage
Causes
Implantationbleed
Miscarriage
Ectopic
Molar
Genitaltracttrauma/lesion
Hx:
GynaeHx:hemodynamicallystable?,abdominalpalpation(masses,tenderness,fungus,peritonism),
speculumexamination(vaginal,cervicaltrauma,cervixopen/closed,bleeding),vaginalexamination,
bimanualexamination

Ix:swabs(STI),urineMSU/HCG(positiveearlierthanserum),serumbHCG,FBC,GnH(rhesus,antibodies),
progesterone(over60inearlypregnancysuggestsgoodimplantationandviablepregnancy),U/S
(transabdominal/transvaginal)

USSpresenceoffoetalheart(6weeksonwards),presenceofgestationalsac,yolksac,adnexalmasses,
freefluid(pouchofdouglas),endometrialthickness
Rescanifcrownrumplength<7mm,gestationalsac>25mm

bHCGdoublesevery2daysuntil1012weeks.Ifincreasestoomuch,molarortwinpregnancies.Serial
measurementsimportant.

USSCanseepregnancyTV1500,TA2000,emptyuterusatthispoint,you'dbeconcernedaboutectopic
pregnancy.
Miscarriagetypes
ThreatenedPVbleedingandpain,closedcervix,75%carryontoanormalpregnancy
Inevitablecervicaldilatationandexpulsionofproductsofmiscarriage
IncompletePOCpartiallyexpelled
CompletePOCcompletelyexpelled
Missednobleeding,noFHR,POCretainedinuterus
Septicinfectionpresent

Management
Expectantwait,monitorbHCG,rescan.Aftersizeis>8weekssize,thenlesslikelyforexpectant
managementtowork.
Medicalmisoprostol(prostaglandin)tohelpdilatethecervixwhichinitiatesthemiscarriage.F/u
ultrasound.
SurgicalevacuationofRPOC(retainedproductsofconception),risksperforation,bleeding,cervical
damage,intrauterineadhesionsAsherman'ssyndrome.cervicalprimingisP0,noPVB,>10wkssize.
Recommendedforheavybleeding,molarpregnancyetc
Antid
Furthermanagementpsychologicalsupport,contraception,recurrentmiscarriage(3miscarriages
consecutively),whattoexpect,sexualintercourse,prenatalcounselling.
Ectopicpregnancy
Hx:amenorrhoea,painbeforebleeding,unilateral
RFs:previousectopic,PID,endometriosisaffectingthetubes,surgerytothetubes,progesterone
contraception,IVF,abnormalembryo,increasingmaternalage
LookforbloodinpouchofDouglas(cervicalexcitation),adnexaltenderness,adnexalmasses.
USS:freefluid,massinadnexa.Unstablepatientdonotneedimagingcangostraighttotheatresif
hemodynamicallyunstable!!!

Mgmt:
Expectantifsmallectopic,bHCG<1000,asymptomatic,nofreefluid,weeklyscans,checkbHCG
makesureitsdroppinguntilHCG<20.Compliantpatientswhocanaccesshospitaleasily.
Medicalmethotrexateifnopain,HCG<5000,<3cm,noFHR.S/eabdominalpainin75%,
stomatitis,GITupset,conjunctivitis(asmethotrexateattacksrapidlydividingtissue).
CheckbHCGonday1,4and7.15%fallofbHCGfromday4to7.Don'tgetpregnantwithin3
monthsofbHCGat0.
Surgicalsalpingectomy(bestoption),salpingostomy(notidealasdamagesmoreciliaandwilllead
torecurrentectopic).Minilaparotomy(likeasmallLSCSincision)inunstablepatient(grabtubeand
clampit,thenremove),otherwiselaparoscopic.

Pregnancyanywherenotintheuterine(endometrial)cavity
12%occurrenceintheoverallpopulation.Risingincidencedueto:
Riseinectopicduetoriseinincidenceofchlamydias.
8%ectopicinIVFpregnanciesembryocanmigrateinretrogradefashionupthetubes.
Improvedimagingtechniques

Presentingsymptoms:abdominalpain/distension,bleeding,shock,78weeksofamenorrhoea

NowoftenpickedupinimagingUSS(transvaginalbetter,highresolution,closer)beforeitbecomesacute.
Mostcommonintheampullaandfimbriaeinthefallopiantube.

Heterotopicpregnancyoneinsideoroutsideuterus(ectopic).
10%canseeafoetus.Mostofthetimeonlyseeablob,trophoblast.Oftenmaynotseeanythingatall.
Ifyoucan'tseeanything,trackHCG(shoulddoubleevery48hrs),repeatu/s.
But15%ofectopicpregnancieshavedoublinghCG.
WillnotseeanythingintheuterusifhCGis<1000.OncehCGis1500,youshouldexpecttoseeasac
usingtransvaginalscans,orhcg20002500inabdominalscanandanexperiencedsonographer.

Mgmtofectopics
medicaltherapy:givelowlevelmethotrexate50mgperm2.Antifolateproperties.Success>90%one
dose,>95%twodosesinwomenwithhCG<5000,<3cminsize,nofoetalheartvisible,compliantpatient
andcanaccesshospitalreadily.MonitorwithFBC,LFTs,EUCs,hCG(alwaysrisesonday4thenfalls).
Repeatonday4.Repeatday7andassesstoseeifseconddoseisnecessary.ifitdoesn'twork,needs
surgery.Needwaitfor3monthsafterwardstotrytogetpregnantagain.
Onday4,womentendtogetabdominalpain,swellingfromthetubes?needtoconsiderthis,doesnot
meantheyhaveruptured.

Youmayneedto
surgicaltherapy:laparoscopicsalpingostomy(incisioninanteriorborderandexpelectopic)or
salpingectomy(removetube,improvesuccessofIVF).Todecidebetweenthetwo,assesstheconditionof
theothertube.Ifothertubeisabnormal,thenyoumayneedsalpingostomytogiveherachanceofgetting
pregnantnormally.
salpingostomyneedsfollowupmonitoringofhCGtoensurehCGisfallingorzero.Ifthereispersistent
hCG,mayneedmethotrexatetofollowup.
Laparotomyrare.

withmedicalorsurgicaltherapy,bothdonotdecreaseyourriskofgettingpregnantagain.
Importanttonote:Forthosewhohave1ectopic,thereis10%chanceofrecurrenceofectopicinfollowing
pregnancy2ectopics,then3040%ofectopics.Youneedtomakesurepatientisawareandunderstands
thisfortheirnextpregnancies.

expectantmanagement:onlyifpatientwithfallinghCG,smallmassonUSS.

GestationalTrophoblasticDisease
Rarecomplicationofpregnancy1:700.Abnormaltrophoblasticproliferation.Partialorcompletemolar
pregnancy.
Weworryaboutitasthereisachanceoftransitioningtochoriocarcinomaandplacentalsitetumours.

USS:snowstormappearance.Bunchofgrapes.

Completemole:diploid.Duplicationofpaternalchromosomefertilizingemptyovum.Nofoetus.Morelikelyto
havepersistenttrophoblast,thereforemorelikelytobecomechoriocarcinoma.

Partialmole:Triploid.1Maternalchromosomeand2paternal.Abnormalfoetuspresent.

Mgmt:Surgicalmanagement,histopathologyrequired.SerialHCGuntilitisnegative.ThendorepeatbHCG
6to12monthsafterwards.Askthemnottofallpregnantasitbecomesdifficulttomonitor.

Aftereachsubsequentpregnancy,dohistopathologyonplacenta(checkitisnormaltissueandnot
malignant),monitorbHCG6weeksafterdelivery!!!
PersistentGTNandchoriocarcinoma
Canoccurafterlivebirth,thereforeneedtocheck.15%needchemotherapyaftercompletemole.0.5%
needchemoafterpartialmole.Methotrexateisfirstline.Curerates98100%.Cannotfallpregnantagain
until6monthsafterchemo.1%recurrencerate.



Malpresentations
Malpresentations
UterineSourcesofobstruction
oplacentapraevia
Grade1(minor)theplacentaismainlyintheupperpartofthewomb,butsomeextendstothelowerpart.
Grade2(marginal)theplacentareachesthecervix,butdoesn'tcoverit.
Grade3(major)theplacentapartiallycoversthecervix.
Grade4(major)theplacentacompletelycoversthecervix(mostserioustypeofplacentapraevia).
oBigfibroids(>8cm)nearthecervixorloweruterus
oCongentialmalformation
Foetalsourcesofobstruction
oMacrosomia
otransverselie,obliquelie,Compoundpresentation(foodorlegout)
oHydrocephalus
oCongenitalanomalies
Shouldersofdiabeticbabyarebiggerforagivenweightthereforemorelikelytogetshoulderdystocia.
Cervixcausesofobstruction
oCervicalstenosispreviousConebiopsy,cervixeffacesbutcan'tdilateduetofibrousscarring.
Pelviccauses
oPelvicshape/structureisandroidlike
oFractureofpelvis,particularlyifitisdisplaced.
Vagina
oVaginalatresia
oVaginalreconstruction
oConnectivetissuedisorder
oStevenJohnsonsyndromecausingstenoticvagina
oRadiotherapycausingscarring
oFemalegenitalmutilationsmallintroitus,needsanteriorepisiotomybecarefulofurethra!

Presentationsiswhatiscomingfirstoutoftheuterus
Cephalicpresentation
Malpresentationsanythingthatisn'tCephalic
Breechpresentation
Compoundpresentationlimbandheadout
Cordpresentationmakesureitisstillpulsingandnotcompressed
Positionofthebaby'sfacewithwomenlyingsupine
DirectoccipitalanteriorDOAnorth
DirectoccipitalposteriorDOPsouth
Rightoccipitaltransversewest
Leftoccipitaltransverseeast
LeftoccipitalAnteriorNortheast
leftoccipitalposteriorsoutheast
RightoccipitalposteriorNorthwest
rightoccipitalanteriorsouthwest
Browpositionwon'tcomeout
Faceposition
oIfinbreechthenreplaceoccipitalwithsacrume.g.directsacralanterior

Inductionoflabour
Prostaglandin
Syntocinon
Cervidil
Bishopscore
TheBishopScoreisameasureofhowsoftandripeyourcervixisbeforelabor.Itcanhelp
predictwhetherornotyourbodyisreadyforlabor,andwhetherornotaninductionislikelyto
succeedorfail.
Avaginalexamisdoneandthecareproviderevaluatesthedegreeof:
cervicaldilation(howfarthecervixhasopenedsofar)
cervicaleffacement(howthinnedoutthecervicalwallsare)
cervicalconsistency(howsoftorfirmthecervixis)
cervicalposition(whetherthecervixispointingforwardsorbackwardsrelativeto
thevaginalwalls)
foetalstation(howfardownthebabyisinthepelvis)
Generallyascoreof5orlessindicatesthewomanisunlikelytogointolaborspontaneously
atthattime,andthataninductionislikelytofail(resultinacesarean).
Ascoreof8ormoreindicatesthataninductionismorelikelytosucceed.Ascoreof9or
moreindicatesthewomanwilllikelygointolaboronherownverysoon.(minscore0,max
scoreis13)


NormalLabour
Oxytocinstimulatestheuterus
Progesteronedecreasesattheendofpregnancy
Prostaglandinsarereleasedfromtheuterusandareamajorelementoftheonsetoflabour
Braxtonhickscontractionsbecomestronger
4stagesofLabour
1.Fromtheonsetofregularuterinecontractions,accompaniedbyeffacementofthecervixanddilatationof
theos,tofulldilatationoftheosutero.Avgtime1214hours(firsttimemothercanbeupto18hours).
Shouldprogress1cmanhour.
Foramultiparousmother,effacementanddilatationoccursatthesametime,stage1oflabourisgenerally
shorter.
latent/early,active(4cmonwardsdilatationestablishedlabour),late(effacement)
Recommendedthatmothersstayathomefortheearlystages(latentstage)oflabour.Iftheygotohospital
early,thenthereishigherratesofinstrumentationandintervention.
Howtohelpcontractions,hotbathsorshowers,usehotpacks,giveabackrub(Neartheiliaccrest.Using
thumborthepalmofthehand.Supportthepregnantbellywithonehand.Suggestpartnerperform
massage,andensurethattheydoitproperly).Makesurethemotherdrinksenoughwater.Makesureshe
goestothetoileteveryhour.Talktothepartners.Needtoreassurepatientsthatlabourandthepainis
normal.
Foetalheartrateshouldbemonitored(CTG)ifinhospital.
2.Fromfulldilatation(10cm)oftheosuterotothebirthofthebaby.Avg12hours.Pushingstage.Strong
contractions23minutesapart,lasting60seconds.Womenusuallylyingrecumbentoronallfours.Women
willwanttodoapoo.Needtodoavaginalexaminationtomakesurethecervixisfullydilated.
Passivepushinginstrumentatione.g.forceps
Activepushingpushingbymother.Recommend3longpusheswitheachcontraction.Pushingdownlike
sheisdoingapoo.
3.Frombirthofthebabytoexpulsionoftheplacentaandmembranes.Averagetime515minuteswith
activemanagement.Syntocinoninjectionintothethighgiven(givewhenthebaby'santeriorshoulderisout),
tohelpexpulsionoftheplacenta(Peelsoffanddropsout).
Syntocinonhelpsreducehaemorrhageandbleeding.
4.First12hoursafterbirth.maternalobservations(fungus,lochia,bp,pulse,temperature).Perinealrepair.
Breastfeedbaby.Showerandpassurine.
Descentofthebaby'shead
Engageswhenthebabymovesfromtheabdomendowntothepelvis.oncethebabyengages,thenthere
isabout2weekstilldelivery.Ifthebabyhasnotengaged,thenitmaybeanindicationforacesarean
section.
Effacement,dilation,babyheadturningisasignoftheprogressionoflabour.Babyturnstooccipitoanterior
positionfromoccipitallateralposition(usuallyfacingtheleft).
Toestimatehowfardownthebaby'sheadisinthepelvis,youfeeltheischialspineandthetopofthebaby's
head.
Mechanismoflabour
Descentandflexionofthehead,internalrotation,crowningofthehead.
Perineumofthemotherstretchesanditburn.Skinispaperthinatthispointandepisiotomyactuallydon't
hurtthatmuch!
Extendsitsheadthenrestitutes(turnsitsheadtoitssidesotheshouldersinternallyrotatesoitisanterior
posterior),thenitexternallyrotatesandlaterallyflexes.
ProgressofLabour
PartogramRecordthecervixdilatation,howfarheadisdown,frequencyandnumberofcontractions
maternalpulseandheartrate(Pinard,Doppler,CTG),mumsvitalsigns.
Startrecordingoncelabourisestablished,4cmcervicaldilation.
PainreliefinLabour
Wavelike
Intervalinbetween
Endorphinrise
Contractionslastfor1minandareabout5minutesapart.Needtotimethecontractions.
Positionuprightandforward.
Nitrousoxide.Useintermittentlyjustbeforethecontractionbegins.S/Enauseaandvomiting.Patients
describesfeelingoozyandtipsy.
Subcutaneousmorphine(orIMpethidine).Lasts23hours.Takes20minutestowork.Crossesthe
placenta.S/Enauseaandvomiting.
Epidural.NeedsIDC.AllowedanepiduraluntiltheheadiscrowningatRNSH.Thisvariesfrompracticeto
practice.Requiresalotmoremonitoring.
Placenta
Needtomakesuretheplacentaiscomplete.Placentagivesyouaboutthehealthandenvironmentofthe
baby.
Measuretheheadcircumference,weight,injections.
Mouldingoftheheadastheboneshaveoverlappedorchangedpositionduringdeliverythroughthebirth
canal.
Monitoringinlabour
MonitoringinLabour
Monitoring2people:motherandbaby

Mother
Vitalsigns:temperature(sepsis,especiallyforwomenwithruptureofmembranes,
chorioamnionitis),pulse,bloodpressure(preeclampsia,hypertensivedisordercanoccuracutely
intrapartum,bleeding),respiratoryrate(signofinfection,pulmonaryembolism,arrhythmias)
Healthypersongoingthroughlabourshouldmaintainpulseandbloodpressure
Youngpersonloweringbloodpressurefor2ndtime,bad,goingtodie
Pain,howcontractionsaregoing?Howlong?Howregular?Howstrongtheyarecontracting
(willfeelrigid)?What'stherestingtonelike(shouldbesoftinbetween)?
Epiduralinsituneedtoknowwhatleveltheblockisusingice,iftoohigh,thencanget
numbfingers,lackofpowerinarm,difficultybreathing,numbface.Maybedueto
concentrationsbeingtoohigh.
Baby
HeartratePinardstethoscope(doesn'tpickupmaternalheartrate,onlypicksupfoetalpulse),
handheldDoppler,CTG(foetalHR,timingofcontractions(doesn'tgivestrengthofcontractions,
needtofeelforthis)givesyoutemporalrelationshipbetweencontractionandfoetaldecelerations).If
can'tfindfoetalheart,canuseultrasoundtohelplocate.Directmethod,putascalpclipintobaby's
head(Sharpclickynoise).
Environmentlookandassessliquor.Normallyshouldbeclear.Ifbabyisdistressed,babywillpoo
andloseMeconiumintotheliquor,colouringitgreen(sometimesBrown).
AcidbasebalancescalppH.Lastresortifreallyworried.Canmeasurelactate(anaerobic
metabolism,indicatesbabyisbecominghypoxic).Lactateabove4.8isbad.Willnotdoifmotherhas
aninfectionthatcouldbetransmittedtobabye.g.hepatitisb.
VaginalexaminationPositionofbaby,cervixcondition.

AntiDantibodies/haemolyticdiseaseofthefoetus
AntiDantibodies
Whenmotherisrhesusnegativeandbabyisrhesuspositive,afterfirstpregnancy,mothercandevelop
antidantibodies.Ifnotgivenantidvaccinationwithin72hoursofgivingbirthorifvaccinewasnotgivenat
28and34weeks,thenmotherwillhaveantibodieswhichmaycompromiselaterpregnancy.

Approachtotheantidantibodypositivepregnantpatient:
Bloodstocheckforantidantibodytitreleveltodetermineifpatientisatlow,moderateorhighriskof
haemolyticdiseaseofthefoetus
BloodtypingandCoombstoallpregnantwomen.15%RH
TestFather,ifRh+,retestmotherat20weeks
IfmotherCoombs+,retestat18weeks,22weeks,andevery2weeksthereafter
Checkpaternalbloodgroup,homozygousorheterozygous
Askabouthowpreviouspregnancieswent
Doultrasoundstomonitorforfoetalanaemia:
lookingspecificallyatmiddlecerebralarterypeaksystolicvelocity.MCAPSVishigherthan
averageiffoetalanaemiaduetopreferentialshuntingofbloodtobrain),plotontomaternal
gestationalageMCAPSVgraph.
Lookforsignstosuggesthydropsfetalisfluidinmorethanonecompartment.

Isoimmunehaemolyticdiseaseofthenewborn
Etiology:Rh,A,B,orminorbloodtypes(Kell,Duffy,E,C,c).
15%ofpeopleareRh
Coombs+
Maternalsensitizationduetopreviouspregnancy,transfusion,amniocentesis,abortion
ABOhemolyticdiseaseofthenewborn
15%ofpregnanciesmotherOinfantAorB
20%willdevelopsignificantjaundice
10%willneedphototherapy.
Presentation:Earlyjaundice(<24hsoflife)ManytimesCombs,butthereareantibodiesBloodsmear:
spherocytes

Postpartumhaemorrhage
Youcanthinkofitasanybloodlossthatcausesclinicalsymptomsfollowingchildbirth.

Postpartumhaemorrhageisthecommonestcauseofmaternaldeathworldwide.
88%ofdeathsfromPPHoccurredwithinthefirstfourhourspostpartum,andcancausedeathwithin2
hours.

EVERYwomanisatriskofaPPH.
PrimaryPPH
>500mLin24h=postpartumhaemorrhage
>1000mLin24h=severepostpartumhaemorrhage
<24hoursafterbirth=primarypostpartumhaemorrhage
Mostcasesoccurintheimmediatepostpartumperiod(within24hoursafterbirth).

4TsofPPH
Tone(70%)atonicuterus
Trauma(20%)lacerationtothecervixorvaginalorperineumduringdelivery
Tissue(10%)placentalremnantsthatpreventuterusfromcontractingcompletely
Thrombin(1%)coagulopathy
AnEMPTY,CONTRACTED,INTACTuteruswillnotbleedintheabsenceofCOAGULOPATHY.
SecondaryPPH
>24hours=secondarypostpartumhaemorrhage
PreventionofPPH
Activemanagementofthethirdstageoflabour
1. Injectionofoxytocic(usually10uIMsyntocinonafteranteriorshoulderisout,mainsideeffect
hypotension)
2. Controlledcordtractionandcountertraction(pressdownonpelvistopreventinvolutionof
theuterus)
3. Uterinefundalmassage
4. Examinationofthedeliveredplacentaensuringthatthewholeplacentahasbeendelivered,
checkmembranes(intactchorionandamnion),maternalsideofplacenta(continuityofplacenta,
trackbloodvesselstoensurethattheyterminatewithintheplacenta,notjustsomerandomopening
somewhere)

Monitoreverywomansvaginalbloodloss,pulse,bloodpressure,andthefirmnessofheruterinefundus
every15minutesforthefirsttwohoursafterdeliveryoftheplacenta.ThenhourlyfortwohoursThen4
hourlytill12hours.
CONSTANTVIGILANCE!!

ManagementofPPH
TriageandmanagementofthecauseofPPH4Ts
Symptomsincludedizziness,palpitations,syncope,headache,weakness,etc.
Physicalexaminationpulse,fundaltone+bloodpressure.LOOKforvaginalbloodloss(most
indicativeofPPH)butdontforgettoconsidernormalddxforsigns/Sx.

1. Fundalmassageencouragesuterinecontraction+aidsintheexpulsionofformedclotswithinthe
uterus
2. Insertionof2largebore(16gaugemaxflow215mL/min)cannulae.Administer40Uofsyntocinonin
1Lsaline/Hartmannsadministeredat250mL/hour+1Lbolusofsaline/Hartmannsstat
3. BloodsFBC,CrossmatchandCoags
4. Examinationofvaginaandtractforsignsoftraumaunderagoodlightsourcelookingforpossible
sourcesofbleeding
5. Catheterizethebladderfullbladderpreventsgoodfundalmassageandirritatestheuterusthatit
sitsadjacentto
6. Inspectplacentatodetermineifpossibleparthasbeenleftbehindinvagina
7. Monitormothersvitalsigns

Breastfeeding
Exclusivebreastfeedingfirst6monthsoflife.
Mother
Involutionofuterus
Delayedovulation
Protectionagainstbreast,ovarianosteoporosis
Oxytocinreleased

Stage1duringpregnancy,milkproductioninhibitedbyhighPandE.12weeksbeforeparturitionsignificant
increaselactose,totalprotein,Ig,sodiumandchloride.
Stage2initiallymakecolostrum,protectsbabiesgut,laxative,helpsbabypastmeconium.postpartum2
3daysstarttomakemilk.Fallinprogesteronewithhighprolactin,increasedglucoseproduction,peak
alphalactalbumin.Humanbreastmilksverysweet,changesdependsonwhatmumeats.
Stage3galactopoiesis.Establishmentandmanagementofmilk.

Prolactinmilkproducing,sucklingprovidesstimulustoincreaseprolactin.Usuallyincreases40min
afterafeed.
Oxytocininducesmilkejection.Letdownreflex.Contractionofmyoepithelialcells.Firstreleases
strongest.Keepshappeningduringafeed.Feelingofrelaxationandwellbeing.
Skintoskinfrombirth.mothersskinhasreceptorsthatadjustwarmthtokeepbabywarm.
Keepbabyonthemumforatleastanhour.Trytohaveafirstbreastfeedthen.Thisisimportantto
stimulatemilkproduction,helpsuterinecontraction,colonisationwithmothersorganism.Helpsbaby
passmeconiummorequickly.Enhancesattachmentandbonding.
IgAsecretedinmilk.Activeimmunitypassedon.
Babiessucklingreflexfromabout32weeksonwards.
Babyledfeeding/demandfeeding.Insteadofsettingtimeswhenbabyneedstofeed(likeevery3or
4hrs)

Positioningforattachment(babyledattachmentequalslesssorenipples)
Endofnippleclosetojunctionofsoftandhardpalate.
Chintobreast
Babiesnoseisfree,obligatenosebreathers
Gobbleasmuchofareolaaspossible
Tongueshouldcoverbabieslowergum
rhythmicsucking
Breastfeedingshouldn'tbepainful
Lipsarefannedout

Othertips:
Letbabyfindbreastandattachbythemselvesrootingreflex.
Australianbreastfeedingassociation
Earlychildhoodhealthcentres
Lactationconsultants
Avoidpacifiersandartificialtestsintheearlyweeks.GiveEBMwithcuporsyringe.

Postnatalmooddisordersperinatalanxietyanddepression
Affects1in5mothers,1in10fathers,50%ofnewparentsexperienceadjustmentdisorder
Usuallyfrompregnancyto12monthsafterbirth.
Characterisedbyasignificantchangeofmoodthathaslastedfor2weeksormoreisimpactingonusual
functioning.Accompaniedbyanhedonia.
Postnatalpsychosisaffects1in1000women.
Posttraumaticstressdisordersrelatedtothebirthingexperience.
ScreeningviaearlychildhoodhealthclinicvisitsusingEdinburghdepressionscaleantenatallyand
postnatally.
Ifuntreated,5070%ofwomenarestilldepressed6monthslater,25%havechronicdepression,25%have
recurrentdepression.