Abdominal Pain In Pregnancy

Abdominal pain or periods like cramps are one of the very common symptoms of pregnancy. Most of the time it is normal and nothing to worry about but sometimes there may be some serious underlying reason for the pain. 

Normal Pregnancy Pains

- Once you get pregnant your uterus starts to grow and this may cause mild to moderate pain in your lower abdomen and lower back. The pain feels like a pressure or like some stretching or pulling. Some woman may describe it as similar to usual periods like cramps. 

Later in pregnancy when baby grows and puts on weight , you may feel uncomfortable and abdominal organs do get pushed away giving a sense of pressure and pain. 

How to Get Relief   

If abdominal pain is mild and not a sign of labor or any other serious underlying condition it usually gets relieved by:

- Changing your posture

- Lying down and getting some rest.

- Drinking plenty of fluids. 

- Taking a warm bath.

- Eating some light snacks.

- Gentle stretching of back and leg muscles. 

Serious Causes 

Management Of Asthma In Pregnancy

Introduction
Asthma is the most common respiratory disorder affecting 3% of women of childbearing age. Pregnancy has a variable effect on asthma but for the vast majority of women there is no impact whatsoever.

The most common reason due to which asthma symptoms appear is that patients reduce their treatment because of a belief that the medication may be harmful. All commonly used medications
to control asthma are safe in pregnancy. All patients must be reassured that any flairs of their asthma must not be ignored and that treatment with medication such as steroids is safe both for themselves and for their fetus.

With regard to the effect of asthma on fetal outcome, there is no evidence that there is any significant impact on fetal growth or outcome.

Any patient whose asthma seems to be deteriorating, particularly in the third trimester, should be seen by an obstetric physician for review. It is obviously desirable that control of their asthma should be at its optimum prior to the onset of labor.

Management Of Asthma In Pregnancy
The best way to manage asthma is to avoid having an attack in the first place. 

Patient should be counselled to avoid exposure to her asthma triggers. This would help in improving the symptoms and decreasing the need of medications. 

The treatment and medicines are almost the same for pregnant woman as well as non pregnant asthma patients.

Management of Acute Asthma

• Pregnant women with asthma should be considered to be high-risk patients, and their management requires a close monitoring by the physician as well as an obstetrician.
• Evaluation in the emergency department and treatment of the pregnant asthmatic patient is almost the same as in the nonpregnant state, with some modifications.

Gynecological Examination - A Brief Discussion

General Principles
The majority of women have varying degrees of anxiety about vaginal examination.
Examination is usually more informative in a relaxed patient and a number of simple measures can be used to make the patient feel at ease.

Women should be given an appropriate area to change in privacy. A sheet should be provided to allow the woman to cover herself. A chaperone should be present for any intimate examination. This should apply for both male and female practitioners. The chaperone provides two purposes, firstly as a source of support and distraction for the patient but also to provide evidence that no improper behavior has taken place.
Formal consent should be given for any intimate examination by a student including under anesthesia.

An explanation of the purpose of the examination should be given to the woman and permission sought to perform the examination. Simple terms should be used to explain the likely sensations experienced. The examination should be thorough but gentle. The patient should feel confident that you will stop the examination if she wishes.

Abdominal Examination:
This must never be omitted, whatever be the patient’s complaint.

• Many gynecological tumors form large swellings, which could be palpated on abdominal examination. 
• Also an abdominal examination may reveal an undisclosed pregnancy
• Always examine the upper abdomen. 
• Be certain that the bladder is empty.
• Ask the patient to tell you if you are hurting her.

All the classical techniques of inspection, palpation, percussion and auscultation are advised, but the most important is gentle palpation with the flat of the hand to detect solid or semi-solid tumors.
The examiner must bear in mind the various intra-abdominal structures which may give rise to swellings.

Sickle-cell Disease in Pregnancy

Sickle-cell disease (SCD) is caused by a group of hemoglobin disorders (single gene recessive) which predispose to ‘sickling’ of red cells in low oxygen conditions causing vaso-occlusion in small vessels, and cells prone to increased haemolytic breakdown.
Sickle cell disease is most prevalent in those of African descent but it is also prevalent in the Caribbean, Middle East, Mediterranean, parts of India, South and Central America.

Disease complications include 

• painful crises, 
• stroke,
• pulmonary hypertension,
• renal dysfunction, 
• leg ulcers, 
• retinal disease, 
• avascular necrosis (eg of hip).

Pregnancy complications include

• maternal painful crises,
• prematurity 
• fetal growth restriction. 
• increased chances of maternal infection, 
• thromboembolic events and 
• pre-eclampsia.

Preconception Care 

• Women with SCD should be under annual clinic review to monitor disease. Arrange hematology specialist for a preconception review. 

A Brief Discussion on Different Types of Abortion/Miscarriage.

Spontaneous Miscarriage is associated with

• vaginal bleeding an abdominal discomfort. 
• Severe pain, 
• heavy bleeding, 
• passage of clots or tissue, and 
• hypotension may also be present. 

Threatened Abortion: Mild cramping an vaginal bleeding that are not accompanied by passage of tissue or cervical dilation constitutes a threatened abortion.

Inevitable Abortion: Uterine cramping with progressive cervical dilation indicates an inevitable abortion.

Incomplete Abortion: An incomplete abortion is diagnosed when some products of conception (POC) have passed, while other retained intrauterine tissue leads to ongoing symptoms.

Septic Abortion: Fever, leukocytosis, pelvic tenderness, and malodorous cervical discharge suggest a septic abortion.

Completed Abortion: is characterized by the passage of confirmed POC, followed by resolution of bleeding and closure of the cervical os. Large blood clots or intrauterine decidual casts may be mistaken for POC and their presence cannot be use to rule out ectopic pregnancy.

Management: 

• Immediately obtain large-bore intravenous access an institute aggressive fluid resuscitation for any patient with severe pain, heavy bleeding, or hypovolemia. Also request cross-matched blood an urgent gynecologic consultation. 

Invasive Prenatal Diagnosis

Introduction
Once a woman has been given a high risk of aneuploidy based on a Down screening, a structural anomaly detected on scan or because of her previous history an obstetrician would normally counsel the women on the options of invasive karyotyping.
This counselling should be based on the risk of aneuploidy, the voluntary nature of the test, the option of no testing, the technique of the proposed test, the procedure-related loss rate and other common complications associated with the test, the timing of the result and the possible management options depending on the result of the test. This decision to balance the potential risk of the loss of an unaffected fetus against that of having an affected child is a very difficult and traumatic one and it is
important that the parents are not rushed into a premature decision.

1. Amniocentesis
Amniocentesis should be performed after 15 weeks when the uterus is an abdominal organ and the proportion of fluid needed to be removed (15–10 ml) is relatively small compared to the overall liquor volume at this gestation (150–250 ml).

Procedure: The procedure is performed under aseptic conditions under continuous ultrasound guidance. Best practice is for the operator to introduce a gauge 22–20 needle percutaneously while he or she is continuously scanning using the free hand. The needle is preferably introduced into a cord free pool of liquor avoiding the placenta. Once in place the inner stylet of the needle is withdrawn and an initial 2 ml of amniotic fluid is withdrawn by an assistant and discarded to avoid maternal contamination. Then a further 15–20 ml is removed using a 10–20 ml syringe.
A few operators use a needle guide attached to the transducer, but this has the disadvantage of being less flexible if the needle needs to be realigned.

There is clearly a learning curve with any invasive procedure. Studies have demonstrated the significance of operator experience in terms of both failed attempts and miscarriage. Amniocentesis is therefore not a routine procedure and it is recommended by the Royal College of Obstetricians
and Gynaecologists (RGOG) that it is only performed by adequately trained individuals with at least 50–100 supervised procedures and 50 procedures per annum to maintain their skills. In general only two needle insertions should be attempted and if these fail then the woman should be referred to a tertiary level fetal medicine unit for repeat attempts.
The miscarriage rate for amniocentesis is generally quoted as 1:100 (1%) .

Common Gynecologic Procedures

1. Bimanual pelvic examination
Two fingers are placed in the vagina and the flat of the opposite hand is placed on the lower abdominal wall. Gentle palpation and manipulation should delineate the position, shape, mobility, tenderness, and size of the uterus and adnexal structures.

Indications: It is a part of routine pelvic exam and part of investigation for gynecologic pathology. Tenderness may be elicited on direct palpation or on movement/ stretching of pelvic structures (i.e. acute salpingitis or pelvic inflammatory disease [PID])

Drawbacks: Difficult to elicit any information on obese patients or uncooperative patients.

2. Cervical conization
It is a surgical procedure that involves excising a cone-shaped sample of tissue that includes the entire cervical transformation zone and a portion of the endocervical canal. The sample is then examined for any signs of malignancy.
Conization can be performed using a knife (cold knife cone), laser excision, and electrocautery (large loop excision of the transformation loop electrosurgical excision procedure.

Indications: It is used for either diagnostic or therapeutic reasons. The test is done when results of a cervical biopsy indicate precancerous cells in the area or cervical cancer. It may also be done if the cervical biopsy has not revealed the cause of an abnormal Pap smear.

Complications: An early complication is excessive bleeding. Infrequent complications include cervical stenosis or incompetence.

Important Definitions Used In Gynecological Practice.

Menarche – first menstrual period.

Menopause – date of final menstrual period. This can only be defined with certainty after a year has elapsed since the final menstrual period. It is also useful to ask about menopausal symptoms and hormone replacement therapy (HRT) use. The classic menopausal symptom is vasomotor flushes, but a myriad of other symptoms can also be experienced.

Perimenopause – the years of transition where irregular cycles occur. For most women, this lasts for 4 years before the final menstrual period occurs.

Menorrhagia – heavy periods. This is one of the commonest reasons that women are referred to gynecology.
You should ask for how long and how often bleeding occurs. The passage of clots and flooding through sanitary protection are signs that the menstrual flow is excessive. It can also be useful to ask about frequency of changing sanitary protection and whether ‘double’ protection is required, that is, having to wear a sanitary towel and tampon at the same time.

Abnormal Bleeding
Postcoital bleeding – bleeding occurring after intercourse.
Intermenstrual bleeding – bleeding between periods.
Postmenopausal bleeding – bleeding more than one year since LMP.

Irregular Bleeding
Primary amenorrhoea – failure to menstruate by age 16.
Secondary amenorrhoea – no menstruation for 6 months after periods are established.
Oligoamenorrhoea – infrequent, erratic periods.

Remember that anovulatory cycles occur at the extremes of menstrual life. It is therefore physiological to have erratic infrequent periods in the first few years after menarche and in the perimenopause.

Hyperemesis gravidarum - A Brief Discussion

Hyperemesis gravidarum: This is defined as persisting vomiting in pregnancy which causes weight loss (>5% of pre-pregnancy weight) and ketosis.

Incidence: It affects 1% of pregnant women.

Risk factors; Risk is increased in

• Very young, 
• primigravida, 
• working outside home, 
• preexisting diabetes, 
• hyperthyroidism, 
• psychiatric illness, 
• family history, 
• those with previous eating disorders and 
• multiple or molar pregnancy 

Clinical Presentation

• Inability to keep food or fluids down; 
• weight loss (2–5 kg)with or without nutritional deficiency, 
• dehydration, 
• hypovolaemia, 
• tachycardia, 
• postural hypotension,
• electrolyte disturbance with hypokalaemia and hyponatraemic shock,
• polyneuritis (B vitamins defeciency), 
• behaviour disorders, 
• liver and renal failure in severe cases.  
• There may be ptyalism (inability to swallow saliva) and spitting.

Workup

Bartholin gland Abscess

Introduction: Bartholin glands are locate on either side of the lower third of the vaginal introitus near the labia minora.
A cyst or abscess may result from an obstructed duct, often secondary to trauma or inflammation. Infection of the cyst is usually with mixed vaginal or fecal flora (Escherichia coli) but may also contain N gonorrhoeae and Chlamydia trachomatis.

Clinical Features: Cysts or abscesses may be asymptomatic or may lead to increasing pain, swelling,
an dyspareunia. A tender, fluctuant cystic mass with surrounding labial edema is easily appreciate on examination.

Differential diagnosis: Differentials should include

• epidermal inclusion cysts and sebaceous cysts of the labia majora, 
• hidradenitis suppurativa, 
• vulvar hematomas, 
• leiomyomas, 
• lipomas, and 
• fibromas.

Ultrasound Screening For Fetal Anomalies

Routine first trimester dating scanning has a number of benefits like
(1) it is more accurate at assessing gestational age than menstrual periods, and therefore reduces the
rates of induction of labour for post-term pregnancies
(2) detects multiple pregnancies early in pregnancy and
(3) can detect some major structural anomalies such as anencephaly.

Nuchal scan or Nuchal translucency (NT) scan: A  more detailed, although limited, anomaly scan is incorporated into a nuchal scan or nuchal translucency (NT) scan which helps in determining the basics such as

• the shape of the fetal skull, 
• presence of nose, hands and feet and 
• presence of stomach and bladder. 

Therefore, instigation of Down’s syndrome screening strategies such as the Combined or Integrated test which involve an NT scan are likely to not only increase the detection of aneuploidy but also major structural anomalies and particularly cardiac defects earlier in gestation.

Routine Second Trimester Ultrasound Screening For Fetal Anomalies 
In the UK and most of the other countries around the world. there is a policy of routine second trimester ultrasound screening for fetal anomalies .
However, detection of fetal anomalies varies considerably depending on the anomaly being screened for as well as the gestation at screening, the skill of the operator and the quality of the equipment used.

The detection of cardiac anomalies is of particular interest. Early prenatal detection of congenital heart disease (CHD) has increased due to advances in ultrasound resolution and the incorporation of at least a 4-chamber cardiac view in the routine anomaly scan.

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