haemorrhage, and infection of the retained tissue. There are various methods of dealing with this at delivery, or if patients present back to the delivery suite with some pieces retained.Obstetrics and gynaecology: overview
Obstetrics and gynaecology: cancer
Obstetrics and gynaecology: emergencies
Obstetrics and gynaecology (O&G) is a surgical specialty that deals with pregnancy, childbirth, and diseases of the female reproductive tract including infertility and cancer. Most hospitals provide both O&G services, with some tertiary units acting as stand-alone trusts, with a link to a local ED. If you are placed at a peripheral hospital, you are likely to see both O&G services that are required for your training. However, those of you placed at tertiary centres may also get the opportunity to see subspecialist clinics or services (e.g. fertility, fetal medicine, and advanced laparoscopic surgery).
Antenatal care is the complex of interventions that a pregnant woman receives from organized healthcare services. This includes planning for pregnancy and continues into the early neonatal and postpartum period. The objectives are to:
• promote and maintain physical, mental, and social health of mother and baby through:
• detecting and managing complications
• preparing the mother to experience normal puerperium.
This is essential for women with pre-existing diseases such as diabetes or epilepsy, or those with a drug or alcohol abuse concern. Both pre-pregnancy and antenatal visits are used to reinforce positive health messages including:
• folic acid—400 mcg or 5 mg depending on whether they are higher risk.
Women who have diabetes are at a higher risk of miscarriages, fetal cardiac anomalies, small babies, and still births. It is important to optimize their glycaemic control and ensure they have appropriate check-ups throughout their pregnancy including ophthalmology and renal review. You will see these women in diabetic antenatal clinics where they will come for their pre-pregnancy counselling, monitoring of their ideal HbA1c before they conceive, and a plan for a future pregnancy.
A urine pregnancy test can be performed at any time from the first day of a missed period, where a woman can be pregnant around 2 weeks after conception. The test measures the beta subunit of human chorionic gonadotropin (hCG) (in urine or blood), which is produced by trophoblasts on day 6 after fertilization. The first antenatal visit (before the 12th week) includes:
The average pregnancy “gestation” is 40 weeks or 280 days from the first day of the last menstrual period (LMP). You can also use Naegele’s rule:
• Subtract 3 months from the first day of the LMP.
• Correct the year if necessary.
Observe a newly pregnant woman have her booking visit with the antenatal department around 10–12 weeks of her pregnancy. You will see this in antenatal clinic with the midwives for low-risk pregnancies, and with the doctors for high-risk pregnancies.
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During their booking, women will have a due date provided according to their dating scan (first scan). This EDD (estimated date of delivery) can be used to create a customized growth chart specific to the woman bearing in mind her height, weight, ethnicity and previous babies. Learn about why this is important especially with monitoring fetal growth (symphysio-fundal height measurements).
• First stage: from the onset of labour until full dilatation of cervix.
• Second stage: from full dilation of the cervix until delivery of the baby.
• Third stage: from the delivery of the baby until complete delivery of placenta and membranes.
Observe the care of a woman during normal delivery. Differentiate the different stages of labour, and either observe or actively participate in the delivery of the baby.
A delivery that occurs after 24 weeks and before 37 weeks of gestation. Most babies born closer to 37 weeks do very well, with minimal intervention from the neonatal unit, or without requiring intensive care or resuscitation. Babies born earlier, or those where the pregnancy has an underlying pathology (e.g. severe pre-eclampsia) with growth restriction, require liaison with an appropriate neonatal unit for a suitable level of care for the neonate. IM steroids need to be administered to the mother to improve fetal lung maturity, which in turn improves neonatal outcome.
All or part of the placenta is left behind in the uterus during delivery beyond 30 min with an active third stage and beyond 60 min with a passive third stage. This can be due to some adherence or invasion of the placenta into the myometrium. The latter tends to occur where there have been scars on the uterus, e.g. a previous caesarean section (CS) or myomectomy. A retained placenta can haemorrhage, and infection of the retained tissue. There are various methods of dealing with this at delivery, or if patients present back to the delivery suite with some pieces retained.
Twin pregnancies, although a source of much joy to the parents, have a high-risk start during pregnancy. Multiple pregnancies are known to have a higher risk of congenital anomalies, cerebral palsy, twin-to-twin transfusion syndrome, growth restriction, preterm labour, pre-eclampsia, still birth, maternal anaemia, morbidity, and mortality. There are different types of twins. During a booking scan of a twin pregnancy, the state of the amniotic sac determines whether the pregnancy is dichorionic (i.e. two placentas) or monochorionic (i.e. one placenta). Look for the ‘lambda (λ) sign’ for the dichorionic twin pregnancies.
This occurs in monochorionic pregnancies, where the fetuses share a placenta. As a result of this shared blood flow, anastomoses that develop can result in 
blood supply to one of the twins, with conversely reduced blood supply in the other. The syndrome starts off with an imbalance in liquor in the amniotic sacs, resulting eventually in fetal mortality if untreated. Laser ablation: stopping the blood flow through these anastomoses is necessary to avoid unequal distribution of blood between the fetuses.
~20% of pregnancies miscarry. There are different types of miscarriage:
• Threatened: admitted with pain and/or bleeding, cervical os closed.
• Inevitable: admitted with pain and/or bleeding, cervical os open.
• Incomplete: admitted with pain and/or bleeding, cervical os open, passed some products of conception.
• Complete: admitted with pain and/or bleeding that are resolving, cervical os closed, passed all products of conception.
• Missed: asymptomatic or pain and/or bleeding, cervical os closed, scan shows no fetal HR.
• With sepsis: admitted with pain and/or bleeding, signs of infection.
• Recurrent: more than three recurrent consecutive miscarriages.
Options must involve psychological evaluation with access to formal counselling if required, and information on support groups.
• Conservative: watch and wait with follow-up appointment.
• Medical: mifepristone for cervical priming followed by misoprostol for uterine contractions.
• Surgical: evacuation of retained products of conception (ERPC/ERPOC/EVAC).
A woman with early pregnancy (up to 12 weeks) bleeding and/or pain: if she has a little bleeding with no pain, she may be followed up in the early pregnancy assessment unit with a scan. If she has heavy bleeding, she will be admitted and if haemodynamically unstable, may require an ERPC in theatre. If she presents only with RIF or LIF pain and/or minimal bleeding, an ectopic pregnancy will need to be ruled out with an US scan. Learn to take a history and perform an examination of a woman who comes into hospital in early pregnancy (up to 12 weeks) with bleeding and/or pain. Consider how to differentiate between miscarriage and ectopic pregnancies.
These are a group of disorders including complete and partial molar pregnancies, invasive mole, choriocarcinoma, and the very rare placental site trophoblastic tumour.
Are diploid and only contain genetic material from one sperm. This usually arises due to a duplication of a single sperm following fertilization of an ‘empty’ ovum. There is no evidence of any fetal tissue. Some complete moles (20–25%) can arise after dispermic fertilization of an ‘empty’ ovum.
Usually have two sets of paternal haploid genes and one set of maternal haploid genes, making it triploid. This occurs after dispermic fertilization of an ovum. In this, there is usually evidence of a fetus or fetal RBCs.
Some women may remain asymptomatic, and others commonly present with irregular vaginal bleeding, hyperemesis, excessive uterine enlargement, and an early failed pregnancy on US scan.
US is easier with a complete molar pregnancy which can have a ‘snowstorm appearance’. However, a final diagnosis is only made on histological examination of the products of conception.
Involves removal of the products of conception by suction curettage or evacuation, ± chemotherapy depending on their level of hCG which needs to be monitored.
All women, regardless of age, are offered screening for Down's syndrome. The risk of Down’s syndrome rises with maternal age. The aim of this screening programme is to identify those at higher risk of having a baby with Down’s syndrome and offer diagnostic testing using either chorionic villus sampling or amniocentesis. Women found to be carrying a baby with Down's syndrome will be offered expert counselling and support; they may be offered a termination of pregnancy or they may choose to continue with the affected pregnancy with support. The challenge of a prenatal screening programme is to identify women in whom a risk of Down's syndrome is sufficiently high to justify such an invasive test and to minimize the risk of miscarrying a healthy baby.
This procedure takes between 11 and 13 weeks of gestation and involves transabdominal or transcervical sampling of the placental/chorionic tissue. There is a 1–2% risk of miscarriage and it offers a diagnostic answer of chromosomal anomalies with the fetus.
This procedure takes place after 15 weeks of gestation. A spinal needle is inserted through the maternal abdominal and uterine walls into the pocket of amniotic fluid within the amniotic sac. 10–20 mL of fluid is aspirated. There is a 0.5–1% risk of miscarriage.
Endometrial cancer is the most common gynaecological malignancy in developed countries.
Include oestrogen exposure (early menarche, late menopause, nulliparity, unopposed oestrogen use in HRT), tamoxifen use, increasing age, PCOS, HNPCC, obesity combined with diabetes, and hypertension.
Women usually present with postmenopausal bleeding, where vaginal bleeding occurs after 12 months of amenorrhoea.
Include performing a transabdominal/transvaginal US scan where an endometrial thickness <4 mm is considered low risk. Other tests include an endometrial biopsy (Pipelle®/curettage) as well as hysteroscopy. The majority of endometrial cancer is histologically adenocarcinoma, and rarely sarcoma. CT scans stage the disease.
The mainstay of management is surgical ± radiotherapy, and possibly chemotherapy.
Women present with postmenopausal bleeding and are investigated in rapid access gynaecology clinics to rule out endometrial cancer. They will have a pelvic US with endometrial Pipelle® biopsy and may proceed to have a hysteroscopy.
This is an investigation where a camera is inserted through the vagina and cervix into the uterus to examine the endometrial cavity and look for abnormalities including polyps, fibroids, or abnormalities in the endometrial lining. Advances in this area mean this can be done as an outpatient procedure with some local anaesthetic, or can be offered traditionally under GA.
Ovarian cancer is the fourth most common malignancy in women. Unfortunately, due to non-specific symptoms, a majority present with advanced disease with poor survival. This usually occurs in postmenopausal women with a 1:80 lifetime risk.
Include unopposed oestrogen production (nulliparity, early menarche, late menopause), familial (BRCA1, BRCA2, HNPCC), and iatrogenic (in vitro fertilization (IVF), clomifene).
Include pregnancy, breastfeeding, and the use of the combined oral contraceptive pill.
Ovarian cancer can be of epithelial, germ cell, or metastatic origin. Epithelial cell tumours include cystadenocarcinomas, which comprise 90% of cancer: serous cell (cancer antigen (CA)-125), mucinous (CA19-9), endometrial (CA125), and clear cell carcinoma. Germ cell tumours occur in 10% of women who are younger, e.g. dysgerminomas (LDH) and yolk sac tumours (alpha fetoprotein). Metastatic tumours can be of endometrial, breast, stomach, or colorectal origin.
Women usually present with abdominal pain and swelling, anorexia, and bladder and bowel symptoms due to pressure effects.
Include US scan, CT, and bloods, following which staging is performed surgically. Multidisciplinary assistance is sought to decide between debulking surgery versus chemotherapy.
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• A RMI helps differentiate benign from malignant ovarian masses.
• RMI >200 increases risk of malignancy.
• RMI = CA125 × menopausal status × US features.
• US (1 point for each): multilocular cysts, solid area, metastases, ascites, bilateral lesions (U = 1 if 1 point, U = 3 if 2–5 points).
• Menopausal status: M = 1 if premenopausal, M = 3 if postmenopausal.
Cervical cancer is the third commonest gynaecological malignancy, with a peak incidence at 45–50 years of age.
99.7% is due to HPV, and other causes include smoking, HIV, and the combined oral contraceptive pill.
80% squamous cell carcinoma, and 20% adenocarcinoma.
Postcoital/intermenstrual or postmenopausal bleeding. Women can have persistent vaginal discharge, and only in late stages present with pain or thrombosis.
The cervix usually has an exophytic lesion and looks friable.
Include colposcopy, biopsy ± MRI or CT scans.
The case is usually discussed at an MDT meeting with surgery and chemoradiotherapy depending on the staging (see Table 23.1 for action plans).
Women present with intermenstrual and/or postcoital bleeding and are examined to find cervical abnormalities (i.e. ulceration or a nodular cervix on palpation). Their smear history is taken and investigations include colposcopy ± hysteroscopy.
Women aged >25 years are routinely invited every 3 years to attend for a cervical smear. About 1 in 20 women will have an abnormal smear that requires further testing or treatment. The screening programme runs as follows:
• 25 years: first invitation to cervical screening in England and Northern Ireland (age 20 in Scotland and Wales).
• 25–49 years: cervical screening tests are every 3 years.
• 50–64 years: cervical screening tests are every 5 years.
• 65 years: routine cervical screening ceases.
Women >65 years of age should be screened if:
• they have not had a cervical screening test since the age of 50
• a recent cervical screening test has been abnormal.
Table 23.1 Smear test action plans
| Result | Means | Action |
| Normal (90%) | Normal | Routine recall |
| Inadequate (2%) | Not enough cervical cells picked up | 3 consecutive—colposcopy |
| Borderline changes squamous cells (3–4%) | Cells are not quite normal | 3 consecutive—colposcopy |
| Borderline changes endocervical cells (3–4%) | Cells are not quite normal | Colposcopy |
| Mild dyskaryosis (2%) | Mild changes in the cells | Colposcopy |
| Moderate/severe dyskaryosis (0.6–0.7%) | Moderate/severe changes in the cells | Colposcopy |
| Invasive/glandular neoplasia (<0.1%) | New growth of cells suggesting cancer | Urgent colposcopy within 2 weeks |
(See Fig 23.1 for cervical intraepithelial neoplasia.) This is where the woman is placed in the lithotomy position and her cervix is examined using a speculum and microscope. Cervical biopsy or treatments such as excision can be performed under local anaesthetic.
Fig 23.1 Cervical intraepithelial neoplasia. Reproduced with permission from Graham H Barker, www.colposcopy.org.uk.
Is the inability to conceive after 1–2 years of regular unprotected intercourse in the absence of pathology. The cumulative pregnancy rate after 1 year is 85%, and after 2 years is 92%. Infertility affects 15% of couples and can be divided into primary (70%) and secondary (30%).
Causes of infertility and treatments:
• Anovulatory (hypothalamic–pituitary–ovarian axis):
• Ovarian dysfunction (PCOS) weight loss, clomiphene, ovarian drilling.
• Hypergonadotropic hypogonadism (premature ovarian failure) ovum donation.
• Hypogonadotropic hypogonadism (stress, weight loss, hyperprolactinaemia) weight gain.
• Tubal (pelvic inflammatory disease, endometriosis) surgery, IVF.
• Uterine (fibroids/Asherman’s syndrome) myomectomy, adhesiolysis.
• Neoplastic (chemo/radiotherapy)
• Endocrine: hyperprolactinaemia
• Drugs and environment: smoking, alcohol.
For the female include day 2 follicle-stimulating hormone/luteinizing hormone; oestradiol; mid-luteal progesterone; hysterosalpingography/laparoscopy and dye; and US scan pelvis. For the male, the most important test is the semen analysis.
Includes correcting lifestyle factors e.g. stop smoking; reduce alcohol intake; diet and exercise.
Women with PCOS present with oligomenorrhoea, biochemical features (raised luteinizing hormone to follicle-stimulating hormone ratio), and physical features (hirsutism).
Includes stimulating regular ovulation, metformin, or operating for ovarian drilling to stimulate normal ovulation.
Women with pelvic inflammatory disease present with chronic pelvic pain and inability to conceive due to hydrosalpinx (swollen fallopian tubes filled with fluid) or pyosalpinx (filled with pus). Damage to the cilia in the fallopian tubes as well as adhesions result in inability to conceive.
Options include Filshie clip sterilization and IVF. By mechanically blocking the tubes, it protects implanted embryos from adverse effects of fluid collected in the fallopian tubes.
There are two main causes of incontinence:
Involuntary urine loss associated with stress due to intra-abdominal pressure (while coughing, exercising, etc.), but in the absence of bladder muscle (detrusor) contractions.
Include raised BMI, multiparous, high birth weight or medical conditions predisposing to chronic cough (COPD/asthma).
Involuntary loss of urine associated with frequency and urgency with or without urge incontinence. The diagnosis is based on symptoms alone, and assumes there is no underlying organic pathology.
• Frequency: voiding more than eight times a day or more than 2-hourly
• Nocturia: interruption of sleep due to more than one micturition every night. Voiding twice at night over the age of 70 years and three times over the age of 80 years is within normal limits
• Urgency: feeling of a sudden, compelling desire to pass urine, which is difficult to defer
Include urological (UTI/bladder masses); gynaecological (cystocele/pelvic masses e.g. fibroids/previous pelvic surgery); genital (urethral caruncle/atrophy); medical (upper motor neuron lesion/impaired renal function/congestive heart failure/diabetes); or general (excessive fluid intake/anxiety/habit/pregnancy). Rare causes include fistulae, congenital abnormality, and urethral diverticula.
Is usually surgical.
This is a procedure to assess the function of the bladder in response to filling, intra-abdominal (coughing), and emptying. The volume of urine and the rate at which the bladder empties are measured. A catheter is inserted into the bladder to measure internal pressure. This is to determine whether the woman has stress incontinence, an overactive bladder, or mixed incontinence.
Is descent of the pelvic genital organs towards or through the vaginal introitus. There are different types and degrees of prolapse:
• First degree: descent of the cervix and uterus but not up to introitus.
• Second degree: descent of the cervix up to the introitus.
• Third degree: descent of the cervix and whole uterus through introitus.
• Procidentia: whole of the uterus out of the introitus.
Include childbirth, increasing age, connective tissue disorder (collagen defects), chronic cough, chronic constipation, intra-abdominal masses or ascites, obesity, or pelvic surgery.
• (Cystourethrocoele is the commonest.)
Women usually present with a dragging sensation of ‘something coming down’ and a lump/fullness in the vagina, which is worse at the end of the day and relieved with lying down. They may also present with difficulties in passing urine or stools, and/or dyspareunia.
Is either conservative or surgical. These include physiotherapy (pelvic floor exercises) ± electrical stimulation, intravaginal ring or shelf pessary, or surgery.
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• Anterior/posterior vaginal wall repair.
• Laparoscopic sacrohysteropexy.
• Sacrocolpopexy: abdominal or laparoscopic suturing of vault to the body of the sacrum directly or via graft (e.g. Prolene® mesh).
• Sacrospinous fixation: vaginal fixing of vault to the sacrospinous ligament. Complications: damage to sciatic nerve and pudendal vessels; buttock pain; recurrent anterior compartment prolapse.
The following are all O&G emergencies, which you will either have a chance to observe, participate in, or at least read about and discuss at tutorials. The mother’s life always takes priority.
Occur in ~11:1000 pregnancies.
There is an incidence in women who have had previous ectopics, undergone IVF, tubal surgery, or diagnosed with pelvic inflammatory disease. It is a preventable cause of maternal mortality (0.2:1000 ectopic pregnancies).
Women present with a history of amenorrhoea, bleeding, and uni/bilateral pelvic pain. They can also present with diarrhoea, shoulder tip pain relating to the side of the ectopic, as well as symptoms of shock.
Include blood hCG and US scans.
The cornerstone of diagnosis is laparoscopy, where simultaneous management involving removing the ectopic (salpingotomy) or removal of the tube and ectopic (salpingectomy) can be performed. Methotrexate can be used for smaller ectopics with a lower hCG level and follow-up monitoring.
For bleeding in pregnancy include placental abruption (most common pathology), placenta praevia (second commonest pathology), and others including vasa praevia, cervical polyp, erosion, carcinoma, and uterine rupture.
Painful bleeding where there are tetanic contractions of uterus.
Demonstrates fetal distress and is pathological, denoting a lack of blood (and oxygen) supply to the fetus. US scanning is of no relevance as this is a purely clinical diagnosis.
Abruption are by a previous abruption (×10), maternal diseases (hypertension/thrombophilia), abnormal placentation (praevia), smoking, cocaine and amphetamines, or abdominal trauma.
The placenta covers or is within 2 cm of the internal cervical os. It occurs in 0.5–1% of pregnancies.
Are by previous CS (×6), multiparity (×2.6), previous dilation and curettage, and smoking.
This usually presents with painless bleeding and is diagnosed by clinical acumen and/or US.
Can include placental abruption, intrauterine growth restriction, fetal malpresentation, or postpartum haemorrhage.
It is a multisystem disease of pregnancy with pregnancy-induced hypertension (>140/90 mmHg) and proteinuria (0.3 g/24 hours) after 20 weeks of gestation. Pre-eclampsia is the second highest cause of maternal death (source: CEMACH). This occurs in 2–3% of all pregnancies, of which 2% develop eclampsia.
Women who suffer with essential hypertension have a 15% risk of developing pre-eclampsia. Organs affected can include the heart, kidneys (ATN), liver (subcapsular haemorrhage), blood (DIC), lungs (pulmonary oedema), and brain (CVA).
There is a spectrum of hypertensive disorders of pregnancy ranging from pregnancy-induced hypertension pre-eclamptic toxaemia HELLP eclampsia, with a gradual in fetal/maternal morbidity and mortality. Eclampsia is the occurrence of a tonic–clonic seizure with incidences of 38% antenatal, 18% intrapartum, and 44% postnatal.
Although the pathophysiology is not confirmed, it is understood to be related to poor trophoblastic invasion into the maternal myometrial spiral arterioles. This results in uteroplacental underperfusion and placental hypoxia the release of antiangiogenic factors causing endothelial damage.
Include headache (frontal), blurred vision/flashing lights, nausea, vomiting, epigastric pain, and peripheral oedema.
Include pedal/hands/facial oedema, RUQ tenderness, hyper-reflexia, clonus, and tonic–clonic seizures.
Include urine for proteinuria >0.3 g/24 hours urine protein (protein:creatinine ratio). Blood tests to check for FBC (thrombocytopenia), LFT (elevated transaminases), U&E, clotting (DIC), and elevated uric acid. USS is performed to identify in utero fetal growth restriction, liquor volume, and umbilical artery Doppler.
Is multidisciplinary and can require HDU admission. The main aim is to control BP and control or prevent seizures.
Drugs that can be used to control hypertension include labetalol, nifedipine, hydralazine, and methyldopa. MgSO4 is used for seizure prevention. Fluid management is important to avoid overload. Fetal monitoring, and planning the time and mode of delivery are essential.
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MgSO4 is recommended by the MAGPIE trial that demonstrated 58% risk reduction in seizure occurrence. It needs to be continued 24 hours from the last fit or from the time of delivery, whichever is most recent. Clinical monitoring is essential, i.e. respiratory rate, urine output, reflexes, ECG, SaO2. Mg2+ level monitoring can be conducted if signs of toxicity. Fluid management is important to avoid pulmonary oedema, which is a major cause of mortality. Fluid intake should be restricted to 85 mL/hour with monitoring on an input–output chart, with the assistance of CVP monitoring if necessary.
This is a rare complication occurring in 0.05–0.5% of pregnancies. It is a result of excessive traction on the placenta to deliver it during the third stage. The woman suffers vasovagal shock and resulting massive bleeding.
Involves manual repositioning of the uterus.
This is a rare emergency occurring in 2:100,000 pregnancies. However, there is a very high mortality rate of 80%.
An anaphylactic reaction to fetal antigens or due to severe sepsis. It occurs at delivery and results in pulmonary hypertension, left ventricular dysfunction or failure, coagulopathy, and a massive postpartum haemorrhage.
It can present with rigors, perspiration, restlessness, coughing, cyanosis, hypotension, tachycardia, arrhythmia, convulsions, or with a cardiac arrest and DIC.
Is clinical and CXR, ABG, and ECG can be performed.
Is purely supportive with an aggressive treatment of coagulopathy with fresh frozen plasma.
Include multiparity, placental abruption, abdominal trauma, external cephalic version, fetal death, and amniocentesis.
This is a rare complication occurring in 0.2–0.6% of pregnancies.
Include long umbilical cord, breech/transverse, small fetus, multiparity, twins, and artificial rupture of membranes.
By inspection of the vulva ± vaginal examination.
Involves elevating the presenting part of the fetus to relieve pressure off the umbilical cord. If the fetal head is low and cervix is fully dilated, an instrumental delivery can be performed. If not, a CS is advised.
After the delivery of the fetal head, the anterior shoulder of the fetus is ‘stuck’ behind the mother’s symphysis pubis. The midwife or doctor will diagnose this once there is difficulty in delivering the body of the baby with gentle traction. The incidence is <1%, but has implications for fetal and maternal morbidity and mortality. Mothers can suffer from postpartum haemorrhage, third- and fourth-degree tears, and psychological sequelae. Brachial plexus injury is the most important complication that can affect babies, where they end up with Erb’s or Klumpke’s palsy.
Include macrosomia, previous dystocia, obesity, multiparity, and diabetes mellitus.
Is currently the leading cause of direct maternal deaths; with group A streptococcal infection one of the main culprits. Other organisms include Streptococcus groups B and D, pneumococcus, and Escherichia coli. Severe sepsis with acute organ dysfunction has a mortality rate of 20–40%, which to 60% if septic shock develops.
• Sepsis: infection + systemic manifestations of infection.
• Severe sepsis: sepsis + organ dysfunction or tissue hypoperfusion.
• Septic shock: persistence of hypoperfusion (i.e. refractory) despite adequate fluid replacement therapy.
For maternal sepsis have been identified as obesity, impaired glucose tolerance/diabetes, impaired immunity/immunosuppressant medication, anaemia, vaginal discharge, history of pelvic infection, history of group B Streptococcus infection, amniocentesis and other invasive procedures, cervical cerclage, prolonged spontaneous rupture of membranes, group A Streptococcus infection in close contacts/family members, and women from minority ethnic groups.
Include fever or rigors, D&V, rash, abdominal/pelvic pain and tenderness, offensive vaginal discharge, productive cough, or irritative urinary symptoms.
Include pyrexia, hypothermia, tachycardia, tachypnoea, hypoxia, hypotension, oliguria, impaired consciousness, and failure to respond to treatment. An Early Warning Score should be utilized to highlight patients that require urgent review, or those that require transfer to ITU.
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• Obtain blood cultures/swabs prior to antibiotics.
• Broad-spectrum antibiotic within the first hour.
• Hypotension/lactate >4 mmol/L:
• 20 mL/kg crystalloid/colloid.
• Hypotension despite fluid resuscitation (septic shock)/lactate >4 mmol/L:
In ~3–4% of pregnancies at term, the bottom of the fetus is the presenting part towards the pelvis. Antenatal diagnosis through clinical examination or US should have a further US scan. If no contraindicating factors, an external cephalic version should be arranged around 37 weeks’ gestation, where an attempt is made to ‘turn’ the baby into a cephalic position with pressure placed on the abdomen.
If a woman presents in the early stages of labour with a previously undiagnosed breech presentation, she should be informed that a planned CS carries a reduced perinatal mortality and early neonatal morbidity for the baby at term compared with planned vaginal birth. There is no evidence that the long-term health of babies with a breech presentation delivered at term is influenced by how the baby is born. A breech delivery is more complicated due to the delivery of the after-coming head once the body is delivered. A CS should be considered if there is a delay in the first or second stage of labour, or there is suspected fetal distress. A fetal blood sample from the buttocks of the baby should be avoided. Breech extraction should be performed by a skilled practitioner.
p. 378This is the third commonest cause of direct maternal death. The risk of VTE/PE is sixfold in pregnancy.
This occurs because of Virchow’s triad where there is a change in the composition of blood ( clotting factors), venous stasis (uterine pressure), and damage to endothelium (operative delivery). Other risk factors are similar to any VTE scoring, i.e. obesity, thrombophilia.
Presents with calf pain ± oedema with signs of tenderness and increasing swelling.
Include USS leg Doppler ± venogram.
Presents with pleuritic chest pain, haemoptysis, dyspnoea, tachypnoea, pyrexia ± collapse.
Include ABG, CXR, leg venous Doppler, V/Q scans ± CT pulmonary angiogram.
For both DVT and PE includes LMWH and warfarin.
Women need to be risk assessed at booking during pregnancy for appropriate prophylaxis in the antenatal and postnatal period.
A hysterectomy is surgery to remove the womb, tubes, and ovaries. This can be performed via different routes, e.g. abdominal incision, vaginal, or laparoscopic. The hysterectomy can be total (removal of womb, tubes, ovaries, and cervix) or subtotal (womb, tubes, and ovaries). Women who have a subtotal hysterectomy require ongoing cervical smears. In younger women requiring a hysterectomy, the ovaries can be conserved to avoid early menopausal symptoms. Although laparoscopic hysterectomy requires greater skill, it results in reduced hospital stay, 
infection rates, and mobility.
The Bartholin glands are pea-sized mucous secreting glands occurring at 4 and 8 o'clock on the labia minora. When the gland duct is blocked, fluid collects within the gland resulting in a cyst. If the contents of the cyst get infected, an abscess forms which may respond to oral ± IV antibiotics, or require surgery: incision and draining; or marsupialization to avoid recurrence.
This is a procedure to remove any products of pregnancy that may still be in situ within the uterus, either as a missed miscarriage requiring surgical management, or an incomplete miscarriage requiring removal of remaining tissue products. Otherwise, it may bleeding or sepsis. This procedure also takes place during the postnatal period if there are symptoms/signs of retained placental tissue. Cervical priming with prostaglandin preoperatively is followed by cervical dilatation, and the use of suction catheter to extract pregnancy/placental tissue.
This procedure is done now most commonly as a day case, where women can go home the same evening, unless they have underlying medical problems. A small, vertical incision is made within the umbilicus (intra-umbilical) to allow the Veress needle to be inserted. Two clicks should be audible: one for piercing the rectus sheath, and one for piercing the parietal peritoneum. CO2 gas insufflation is used to distend the abdomen. A trocar and port are inserted carefully into the intra-umbilical port. Once within the abdominal cavity, the trocar is removed and the port allows for a laparoscope to be inserted. Multiple small incisions in the suprapubic and iliac fossa can be created for initial diagnosis, followed by treatments such as tubal sterilization, oophorectomy, excision, or ablation of endometriosis. Once the procedure is completed, the peripheral ports are removed under direct vision to ensure no ongoing bleeding, followed by expulsion of the gas and removal of the main intra-umbilical port. The incisions can be closed using sutures, wound closure strips, or special glue.
Is commonly performed to evaluate the uterine cavity. This can be performed without anaesthetic, or with regional or general anaesthetic. Other procedures can be conducted at the same time (e.g. removal of polyp, excision of fibroid, endometrial ablation). Saline solution is used to distend the uterine cavity and the hysteroscope is usually inserted with hydrostatic pressure.
One-stop hysteroscopy clinics are being set up, where patients are having a vaginoscopy and hysteroscopy without anaesthetic, and having other procedures such as polypectomy, resection of fibroids, or insertion of Mirena® intrauterine device.
Relieves the symptoms/signs of prolapse. This could be related to the anterior vaginal wall where the urethra ± bladder can be affected, or posteriorly where the rectum can be affected. An incision is made in the vaginal wall and the excess vaginal tissue is dissected. Caution is exerted to avoid excising too much tissue and narrowing the vagina. Underlying defective fascia is repaired with sutures ± placement of a mesh. Anterior/posterior vaginal walls are sutured, and a vaginal pack inserted with urinary catheter in situ.
Is a procedure that helps women suffering from stress incontinence. The bladder is catheterized to allow urine to empty, and also to provide a guide for urethral positioning later on. The anterior vaginal wall in opened in a vertical incision and the underlying tissue is dissected. Two small cuts are made in the suprapubic region. The TVT is passed from the anterior vagina to the suprapubic area using metal trocars on either side of the urethra, using a metal guide within the urethra to deflect it away from each side as the mesh is inserted. A cystoscope is inserted to ensure no bladder perforation before adjusting the sling (mesh) to stabilize the urethra.
This is a procedure where the cervix is examined closely using magnification. The indications are abnormal smears requiring further investigation. It is performed after a vaginal speculum is inserted to visualize the cervix, where a colposcope is used with a light and magnifying lens to visualize cervical abnormalities. The use of acetic acid on the cervix stains abnormal areas white. Cervical biopsies ± large loop excision of the transformation zone (LLETZ) can also be performed at the same time.
This is a procedure that can be performed laparoscopically or via an abdominal incision (vertical/transverse) to remove subserosal or intramural fibroids, or also hysteroscopically to remove submucosal fibroids. If performed laparoscopically, morcellators are used to shred the fibroid tissue so it can be removed via the small incisions.
CS is one of the commonest obstetric procedures to witness in the delivery suite, and students can get involved either during emergency or elective CSs. Once the woman has appropriate analgesia, regional or general, she is catheterized aseptically to empty the bladder. An incision is made transversely in the suprapubic region where layers of subcutaneous tissue, muscle, and peritoneum are opened and the bladder is deflected downwards to protect it from injury. The lower segment of the uterus is incised transversely to allow delivery of the fetal head with concurrent pressure by the assistant on the uterine fundus to deliver the fetus. The cord is clamped and cut and the placenta is removed by controlled cord traction. Once the uterus is checked to be clean with no placental tissue remaining, it is sutured most commonly in two layers. The parietal peritoneum is opposed only and rectus sheath is sutured to prevent hernias. The skin can be sutured with either dissolvable or other sutures to be removed within 5 days.
Honours
Scrub up for a CS and identify the anatomy of the abdominal wall, i.e. layers incised in order from skin to uterine lower segment. Learn how to suture the skin with different methods: subcuticular, interrupted, and mattress sutures.
This is a procedure where a small volume of blood is obtained from the fetal scalp to determine fetal distress via analysis of pH values. It can usually be performed after cervical dilatation of 4 cm and provides an indication whether the fetus requires delivery or labour can be continued.
Honours
See Table 23.2.
Table 23.2 Fetal blood sample results: pH
| 7.25 or more | Normal result |
| 7.21–7.24 | Borderline result—repeat 30 min |
| 7.20 or less | Abnormal result—deliver |
A vacuum extractor, which is either soft or hard plastic or a metal cup, is attached to the baby's head by suction. This cup fits firmly onto the fetus. During a contraction, with the mother pushing, the operator pulls to allow delivery of the fetus. It can leave a small swelling on the fetal head called a chignon. The risks of a vacuum extractor are a resulting cephalohaematoma.
Trivia
• Category 1: immediate threat to life of the mother or fetus (decision–delivery time = 30 min)
• Category 2: no immediate threat to life of the mother or fetus (decision–delivery time = 60 min).
• Category 3: requires early delivery.
• Category 4: at a time to suit the woman and maternity services.
These are metal instruments that curve around the head of the fetus to allow for delivery when the mother pushes and the operator pulls. They can leave marks around the fetus, which take a few days to settle. These are more likely to result in maternal perineal tears and may require creating an episiotomy.
To ask the boss
• Indications for operative delivery: CS, ventouse, forceps.
• Consent process for operative delivery: CS, ventouse, forceps.
Around one in seven deliveries involves an episiotomy. NICE recommends that an episiotomy should be considered if the baby is in distress and needs to be born quickly, or if there is a clinical need, such as a delivery that needs forceps or ventouse. An episiotomy is usually made in a right mediolateral incision to avoid tearing down towards the anus.
Exams in medical schools vary, with some testing for competence during the O&G block, with others testing for competence during the OSCE.
Need to know how to take a …
• Gravidity and parity: miscarriages/terminations/stillbirths/other losses.
• Duration of symptoms: days, weeks, months, years.
• Progression of symptoms: worsening, improving, stable, fluctuating.
• Cyclical: do symptoms have any relationship to the menstrual cycle?
• Pain: SOCRATES (see pp. 148–149).
• LMP (first day of last menstrual period).
• Duration and regularity (X/28 days).
• Flow: heavy/light—number of sanitary towels/tampons useful to estimate loss.
• Dyspareunia (superficial/deep).
Menopausal symptoms: hot flushes, vaginal dryness, irregular periods, mood changes, concentration.
If postmenopausal: what age did they go through the menopause?
• Gravidity and parity: miscarriages/terminations/stillbirths/other losses.
• Antenatal/intrapartum/postnatal complications.
• Is it the same partner as previous pregnancies?
• Infection screen—syphilis, HIV.
• Other, e.g. growth/uterine artery Dopplers/liquor/umbilical artery Doppler/middle cerebral artery.
• Diagnostic tests, e.g. chorionic villus sampling/amniocentesis.
PC–HPC–pain (SOCRATES)
• Pre-eclampsia: headache, nausea and vomiting, oedema, blurred vision/flashing lights/epigastric pain.
• Diabetes: blood glucose levels.
• Urinary: dysuria, frequency, haematuria, loin tenderness, incontinence history.
• GI: appetite, nausea, vomiting, diarrhoea, constipation, PR bleeding, weight loss.
• CVS: chest pain (pleuritic), dyspnoea, palpitations.
• Respiratory: cough, sputum, wheeze.
• MSk: bone or joint pain, difficulty mobilizing.
• PMHx: diabetes, hypertension, renal disease, clotting disorders.
• Past surgical history (PSHx): especially abdominal surgery.
• Drug history (DHx): regular medications, allergies to medications or latex.
• Social history (SHx): smoking, ETOH, recreational drugs, home support, job.
• Family history (FHx): diabetes in first-degree relative, maternal pre-eclampsia.