Common Obstetric Procedures

1. Amniocentesis
Withdrawal of fluid from the amniotic sac to obtain fluid and cells for a variety of tests.Usually performed using ultrasonographic guidance to reduce the risk of fetal loss.

Indications: Determine the presence of genetic diseases (e.g., Down syndrome, Tay-Sachs), any fetal structural abnormalities (neural tube defects), fetal lung maturity, or intrauterine infection (i.e., chorioamnionitis)

Risks : 0.5% risk of fetal loss because of bleeding, infection, preterm labor or fetal injury.

2. Cerclage
It is the placement of a suture into and around the cervix to hold it closed. It is usually performed between 12 and 14 weeks and removed before labor begins.

Indications: Used to prevent cervical opening in an incompetent cervix and prevent preterm delivery or miscarriage.

Benefits: It is controversial whether a cerclage reduces the likelihood of a preterm delivery.

3. Cesarean delivery
It is the delivery of the fetus by making an incision through the abdomen and uterus. The incision can be made in two ways:

• (1) Classical midline longitudinal incision
• (2) Lower uterine segment section—transverse cut above the bladder; more commonly used and less bleeding

Gynecology History Taking - A Brief Discussion

The key to any consultation is taking an accurate and complete history. This is relevant in all medical disciplines and particularly in gynecology. Do not assume that the referral letter contains all the relevant information. It is important to ask what the main problem is – it may be hidden away among a list of relatively unimportant or misleading complaints.
Women may find discussing gynecological symptoms difficult and require.

The following points are very important to consider:

Privacy: The consultation should be held in a room with adequate facilities and privacy. Permission should be sought for any students who are present.

Time: The patient should be allowed to tell her own story before any attempt is made to elicit specific symptoms.

Sympathy: The doctor’s manner must be one of interest and understanding.

Gynecological history follows the standard principles of medical history taking but there are a number of other issues that are relevant to gynecology.

Here is a list given first for the standard history and then the points that are additional for gynecology history.

Standard history taking

• Age
• Presenting complaint
• Past medical history
• Medication history
• Allergies
• Social history
• Family history
• Systemic inquiry

Additional features relevant to gynecology

• Parity
• Obstetric history
• Contraception
• Smear history
• Menstrual history – this will often be part of the presenting complaint

Minor Symptoms of Pregnancy

Symptoms and signs in the first 10 weeks:
Early symptoms are

• amenorrhoea (missed periods), 
• nausea, 
• vomiting, and 
• bladder irritability. 
• Breasts engorge, nipples enlarge (darken at 12 weeks), Montgomery’s tubercles (sebaceous glands on
• nipples) become prominent. 
• Vulval vascularity increases and the cervix softens and looks bluish (4 weeks). 
• At 6–10 weeks the uterine body is more globular.
• Temperature rises (<37.8°C).

Other Symptoms Through out Pregnancy 

Headaches, palpitations, and fainting are all commoner in pregnancy. It is due to dilated peripheral circulation, increased sweating and feeling hot.
Management: Increase fluid intake: take showers. If feels faint from postural hypotension, stand slowly.

Urinary frequency is due to pressure of the fetal head on the bladder in later pregnancy. Exclude UTI.

Constipation tends to occur as gut motility decreases. Adequate oral fluids and a high-fibre diet help combat it. Avoid stimulant laxatives—they increase uterine activity in some women.
Increased venous distensibility and pelvic congestion predispose to haemorrhoids (if they prolapse, rest the mother head down, apply ice packs and replace them) and varicose veins. Resting with feet up and properly worn elastic stockings help.

Cervical Polyps

Cervical polyps are friable, fleshy, finger like growths that emanate from the cervical os or endocervical canal.

Clinical features: They are typically asymptomatic, but may bleed with minimal trauma such as intercourse or douching. Single polyps are more common, but multiple polyps can occur.

         Cervical Polyps. Several fleshy fingerlike growths are seen protruding from the cervical os.

Etiology: The etiology of polyps varies and may be related to

• infection, 
• chronic inflammation, or 
• excess estrogen.

Understanding Gestational Trophoblast Disease

Introduction
The abnormal proliferation of gestational trophoblast tissue forms a spectrum of diseases from the usually benign partial hydatidiform mole through to the highly malignant choriocarcinoma and placental site trophoblast tumours.
The biology, diagnosis and therapy of these diseases, combined with their psychological impact, makes trophoblast disease an extremely important and interesting area of gynecological and oncology care.

Classification
The World Health Organization classification divides trophoblast disease into the pre malignant partial and complete hydatidiform moles and the malignant disorders of invasive mole, choriocarcinoma and placental site tumors.

Pre-malignant pathology and presentation

1. Partial mole: Partial moles are triploid with two sets of paternal and one set of maternal chromosomes.
Macroscopically Partial moles often resembles the normal products of conception with an embryo initially present which usually dies by week 8–9.
The histology shows less swelling of the chorionic villi than in complete moleand there are usually only focal changes. As a result the diagnosis of Partial mole can often be missed after a miscarriage or termination.
The clinical presentation of Partial mole is most frequently via irregular bleeding or by detection on routine ultrasound.
The obstetric management is by suction evacuation and these patients should all be followed up by serial hCG measurement.
It is fortunate that Partial moles rarely moves onto malignant disease

Thromboprophylaxis In Pregnancy

Pregnancy is a hypercoagulable state so it is always important to consider the need for thromboprophylaxis before pregnancy, at booking, if admitted to hospital, throughout the antenatal
period, at start of labour and once delivered.

Risk factors For Thrombosis
• Age >35 years old
• Early pregnancy BMI >30
• Smoker
• Parity ≥3
• Multiple pregnancy
• Assisted reproduction
• Gross varicose veins
• Paraplegia
• Sickle cell disease/SLE
• Nephrotic syndrome
• Some cardiac causes
• Past thromboembolism
• Thrombophilia
• Myeloproliferative diseases.
• Inflammatory bowel disease.
• Hyperemesis/dehydration
• Pre-eclampsia
• Immobility for ≥3 days e.g symphysis pubis dysfunction
• Ovarian hyperstimulation
• Major infection (e.g pyelonephritis, wound infection) so hospital admission
• Labor lasting >24h
• Mid-cavity forceps
• Elective caesarean
• Blood loss >1L/transfusion history
• Surgery in puerperium e.g evacuation of retained products of conception
• Postpartum sterilization
• Long travel time (≥4h)

Vaginitis - Types And Management

Introduction:

Vaginitis is an inflammation of the vagina that can result in discharge, itching and pain. The cause is usually a change in the normal balance of vaginal bacteria or an infection. Reduced estrogen levels after menopause and some skin disorders can also cause vaginitis.

The most common types of vaginitis are described below: 
Candidal vaginitis is characterized by a thick, clumping, white discharge and vulvar discomfort. Intense vulvar erythema, pruritus, and /or burning are often present.

Predisposing factors may include
oral contraceptive,
antibiotic, or corticosteroid use;
pregnancy; and
diabetes.

Characteristics: White, thick, clumping discharge, vaginal pH <4.5, microscopic findings include: Hyphae andspores in KOH

Diagnosis: A microscopic slide prepare with 10% potassium hydroxide yielding characteristic branched chain hyphae and spores establishes the diagnosis.
Sexually transmitted diseases are not usually associated with isolated Candidal vaginitis.

Ectopic Pregnancy - Clinical Presentation & Management

Definition: An ectopic pregnancy occurs when a fertilized egg implants somewhere other than the main cavity of the uterus, most commonly in the Fallopian tubes.

Background:
First descriptions of ectopic pregnancy in England dates back to 1731 when Gifford described implantation of a pregnancy outside the uterine cavity.
Charles Meigs provided particularly vivid descriptions of severe cases of ectopic pregnancy in the mid-nineteenth century, when ectopic pregnancy was considered to be a rare, but universally
fatal condition.
With the improvements in surgical techniques at the turn of the twentieth century ectopic pregnancy became curable . However, it was still considered a very serious problem with high mortality rates. This perception has changed only recently with the increased ability to establish the diagnosis of ectopic pregnancy non-invasively in women with minimal clinical symptoms.
Although there has been a massive increase in the incidence of ectopic pregnancy in recent years, the
mortality of the disease has been static . Therefore the main challenge in modern clinical practice is to identify and treat as early as possible cases of ectopic pregnancy with the potential to cause serious morbidity and death, and at the same time to minimize interventions in those destined to be resolved without causing any harm.

Risk Factors For Ectopic pregnancy: 
A number of factors have been identified, which increase individual risk of ectopic implantation.

An association between increased maternal age and ectopic pregnancy has been well documented in the past. The incidence of ectopic pregnancy is three times higher in women aged 35–44 in comparison to those in the age group 15–24.

A past history of sexually transmitted disease also increases the risk of ectopic pregnancy.

A list of the risk factors associated with increased chances of ectopic pregnancy is given below:

• History of previous ectopic pregnancy
• (IUCD) or sterlization failure
• Pelvic inflammatory disease
• Chlamydia infection
• Early age of intercourse and multiple partners
• History of infertility
• Previous pelvic surgery
• Increased maternal age
• Cigarette smoking
• Strenuous physical exercise
• In utero DES exposure