Core Clinical Cases in Obstetrics and Gynaecology, 2nd edition: a problem-solving approach

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Offline Computer — Download Bookshelf software to your desktop so you can view your eBooks with or without Internet access. View Cart. Reduced fetal movements may have been noted before the induction of labour. Meconium-stained liquor during labour may be associated with fetal hypoxia Box 4.

Box 4. Aspirating the upper airway at the time of delivery to clear meconium can reduce the risk of this occurring. A4 Examination would include abdominal palpation, where the fundus as assessed by the symphysiofundal measurement may be small for dates. Her height no evidence of short stature and the fact that the vertex is engaged do not support cephalopelvic disproportion. The lack of requirement for analgesia would support inadequate uterine contractions. The frequency and duration of contractions should be recorded. Risk factors for cephalopelvic disproportion e.

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Examination would include an abdominal palpation to assess the clinical size of the baby, to assess the amount of head that is palpable in order to determine whether the head is engaged, and also to assess the frequency and strength of uterine contractions. Assessment of fetal position should be made as a malposition e. An assessment of the presence and degree of moulding overlapping skull bones and caput scalp oedema is required, and would support cephalopelvic disproportion.

An assessment of liquor colour should be made, with the presence of meconium indicating the possibility of fetal hypoxia. Maternal well-being pulse, blood pressure, temperature, urine output should be assessed and adequate analgesia provided. A6 Commence oxytocin Syntocinon and reassess in 4 h if there is still no concern about fetal condition. Oxytocin makes the contractions more regular, stronger and more frequent, resulting in effective uterine contractions that will lead to cervical dilatation and fetal head descent.

Her height short stature and the fact that her baby is clinically large macrosomic point towards cephalopelvic disproportion. Her uterine contractions are adequate as recorded on the partogram. A4 Examination would include an abdominal palpation to assess the clinical size of the baby and to assess the amount of fetal head that is palpable in order to determine whether the head is engaged. The frequency and strength of uterine contractions also need to be assessed.

At vaginal examination, assessment of the position of the vertex would be required as a malposition e. An assessment should be made of the degree of moulding overlapping skull bones and caput scalp oedema , the presence of which would support cephalopelvic disproportion. The colour of the liquor should be noted, with the presence of meconium indicating the possibility of fetal hypoxia. Assessment should also be made of maternal well-being and adequate pain relief should be provided. Caesarean section under spinal or epidural anaesthesia is required because, according to the partogram, the cervix has not dilated for 4 h, the fetal head has not descended in the maternal pelvis and labour has not progressed despite 4 h of uterine stimulation with oxytocin.

Attendance at parent-craft classes will help the woman to prepare for labour. Entonox inhalation has a rapid onset with mild analgesic effects. It is most effective in early labour. It is best to start inhaling before the onset of a contraction and to continue until the end of the contraction. It can cause light- headedness and nausea. Opiates such as pethidine and diamorphine can be given as an intramuscular injection every 4—6 h.

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Pethidine has central sedative effects rather than providing effective analgesia. It also causes nausea, so there is often a need for antiemetics. It can cause a sleep pattern in the fetus so the fetal heart rate may show some abnormality. At birth, respiratory depression can also occur in the neonate. Diamorphine given in a similar fashion has a stronger analgesic effect. Epidural analgesia with or without opiates is a very effective form of analgesia that can be either given intermittently or infused continuously via a pump.

It is useful if surgical delivery is required. This is usually two doses 6—12 h apart. The prostaglandin usually softens and effaces the cervix. Sometimes it can initiate labour, but its main role in this situation is to ripen the cervix before ARM. Clinical cases CASE 5. Urinalysis is negative. Her blood pressure had previously been recorded in the range — to 80—85 mmHg in the mid-trimester. The fetus was clinically an appropriate size for dates.

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CASE 5. Her weight is kg. Her pregnancy has been progressing well. Her haemoglobin level was noted to be 8. A year-old woman with type 1 diabetes is taking the combined oral contraceptive COC pill. She wants to come off the pill to try for a pregnancy. Q1: What pre-pregnancy counselling would you provide for this woman? A year-old woman who has epilepsy controlled by treatment is planning to get married. She is concerned about pregnancy and her epileptic medication.

She has been seizure free for 6 years on two antiepileptic drugs. She has not recently been reviewed by a neurologist. Q1: What pre-pregnancy care and counselling would you give this woman? She is a primigravida, and among such women pre-eclampsia is more common. A3 Any related symptoms e. Past history of medical disorders that might cause hypertension e. Taking blood pressure to rule out pre- existing essential hypertension.

Examination would include fundoscopy to identify hypertensive retinopathy. Hypertensive disorders of pregnancy are associated with intrauterine restricted growth IUGR. A6 Pre-eclampsia is usually a progressive condition. Treatment lies in delivery. In the meantime the aim is to monitor and control blood pressure and to plan delivery as close to fetal maturity as possible. Delivery is indicated if there is concern for maternal condition e.

IUGR, fetal distress. The woman should be admitted to the antenatal ward and monitored to assess progression of the condition. Biochemical renal and liver function and haematological to look for evidence of falling platelets and developing disseminated intravascular coagulation or DIC assessment should be performed as described above. Regular at least 4-hourly blood pressure assessments should be made in order to identify worsening condition. Twice-daily urinalysis should be performed to assess increasing proteinuria. Assessment of fetal condition, including ultrasound biometry, umbilical Doppler and cardiotocography should be undertaken.

Maternal steroids should be administered in case early delivery is indicated. This controls blood pressure and reduces the risk of complications such as cerebrovascular accidents but does not alter the progression of pre-eclampsia. Labetalol and nifedipine are appropriate antihypertensive agents for this purpose. In this instance, magnesium sulphate as an anticonvulsant agent should be commenced to reduce the risk of eclampsia.

Box 5. Examination should include fundoscopy for diabetic retinopathy and abdominal palpation for evidence of a LFD fetus or polyhydramnios. However, current recommendations are that women with impaired glucose tolerance should be managed for the remainder of their pregnancy as if they had type 1 diabetes. A regimen of pre-prandial short-acting human insulin three times daily Humulin S and overnight longer-acting insulin Humulin I should be used.

Insulin requirements will increase during pregnancy and should be adjusted accordingly. The team should include an obstetrician with an interest in diabetes in pregnancy, a diabetes physician, a midwife, a diabetes nurse and a dietitian. Blood glucose levels should be checked hourly. Women who are controlled by diet do not need to monitor blood glucose levels during labour. In most women this will be normal, but they remain at risk of developing diabetes in the future 40—50 per cent of cases. They should all therefore be given general advice about weight and diet, and should have annual fasting blood glucose tests for early detection of diabetes.

This is the most common type of anaemia in pregnancy, affecting about 10 per cent of women. Her vegetarian diet would predispose to reduced iron intake. A3 An additional history would include symptoms e. Around 10 per cent of African—Caribbean individuals in the UK are heterozygous for sickle-cell disease, and thalassaemia is most prevalent in individuals from the Mediterranean region and south-east Asia. A4 Examination would include a search for evidence of pallor generally the sclera and palms and abdominal examination for hepatosplenomegaly.

Haemoglobin estimation in pregnancy should not be the only parameter to be assessed as a sign of anaemia, because it can be lowered as a result of haemodilution. If the woman is Sickledex positive, her partner should be tested and appropriate counselling given about the prenatal diagnosis. The aim should be to correct anaemia before delivery. However, as folic acid reduces the risk of neural tube defects, it should be recommended to all women. They may in extreme situations e. Treatment includes exchange transfusions, screening for infection, folic acid and avoidance of precipitating factors for crises.

Iron should be avoided. They may require transfusion. Pregnancy in homozygous individuals is uncommon. However, in these cases folic acid is required but iron should be avoided. A glycated haemoglobin concentration would give an indication of longer-term control. However, women with epilepsy, particularly those taking antiepileptic drugs, are at increased risk of giving birth to a baby with congenital anomalies e.

Suggest referral to a neurologist to consider pre-pregnancy withdrawal of antiepileptic drugs or a change to monotherapy. Clinical cases CASE 6. She had been in labour on this occasion for 12 h after a spontaneous onset. She continues to bleed heavily. CASE 6. A year-old primiparous woman had a traumatic vaginal delivery after an h labour. Labour was induced after pre- labour rupture of the membranes for over 48 h. Three days post-delivery the woman feels shivery and has had a temperature of She is a smoker, but had stopped smoking during pregnancy.

An older primigravida feels that she has very little interest in her baby 3 days after delivery. She is a solicitor by profession, and became pregnant after assisted conception. The pregnancy and delivery were uneventful. There is no past history or family history of mental illness. A primigravida has just delivered a healthy g baby. Q1: What are the advantages and disadvantages of breast-feeding? There was no fetal distress or birth asphyxia. The baby started grunting at 30 min of age. Clinical examination and radiograph suggest transient tachypnoea of the newborn TTN.

Q1: Explain to the mother what is wrong with her baby and how it will be managed. Examination would include measurement of pulse and blood pressure for evidence of shock. An assessment of blood loss and continuing loss is required. Abdominal examination would include palpation of the uterine fundus to look for a poorly contracted uterus.

Any vaginal or perineal trauma should be sutured. Ensure that an adequate request has been made for cross-matched blood at least 8 units and check clotting. Continue to compress the uterus bimanually if it is not contracted. Continue the intravenous infusion of Syntocinon. Consider giving rectal, intramuscular or intramyometrial prostaglandin. Catheterize the patient to monitor urine output and insert a central venous pressure line. If the bleeding persists, examine under an anaesthetic to check that the uterine cavity is empty of retained products of conception, and to identify and suture any trauma to the cervix, vagina or perineum.

If bleeding still persists, consider a laparotomy with ligation of the internal iliac arteries or hysterectomy. Delivery associated with perineal lacerations has a high probability of developing infection as a result of perineal cross- infection. A prolonged labour with ruptured membranes and repeated vaginal examinations during induction of labour can result in endometritis.

Smoking is also a risk factor for chest infection. Symptoms of shivers and a temperature indicate an infection. A3 For endometritis, the lochia may be offensive. A history of frequency and dysuria may indicate a UTI, which is a common cause of postpartum pyrexia. If the patient is also catheterized during labour, this can lead to a UTI. An enquiry should be made to ensure that the placenta was complete at the third stage of labour, to exclude infection of a retained placenta.

This history may not be diagnostic.

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A4 Pulse, blood pressure, peripheral perfusion and signs of cyanosis should be sought. Vulval examination of the perineal wound would also be mandatory. A vaginal examination should be performed to determine whether the cervical os is open. It may indicate retained products and an enlarged tender uterus. If the patient had a caesarean section, a wound haematoma infection or abscess would need to be excluded. Keep the wound clean and dry to allow rapid healing. If an abscess is present, any sutures should be cut to allow the abscess to drain. Incise and drain if there is an obvious abscess.

Half the deaths are postnatal, usually occurring after discharge from hospital. Early mobility and hydration are important preventive measures for all postnatal women. Management of DVT and pulmonary embolism should be arranged in collaboration with the physicians so that the appropriate anticoagulant regimen is administered. Risk markers should be tested 6 weeks postpartum i.

In most cases with the given history there is no psychiatric problem, because minor psychological symptoms are common after birth. However, this case needs further investigation in order to exclude major psychosis or depression, particularly if the symptoms occur later, around 4—6 weeks after birth. The history should explore psychological symptoms such as variation in mood, poor sleep, weeping, lethargy, irritability, hallucinations, delusions, etc. Operative mode of delivery, multiple pregnancy and complications during pregnancy all increase the likelihood of major mental illness.

Early diagnosis is important, because it can interfere with mother—baby bonding. The mother should be separated from the baby because there is a risk of neglect and harm. Neuroleptics may be used. Disadvantages include the following:. Despite these minor disadvantages, all mothers should be encouraged to breast-feed their babies. This should be done in a systematic manner so that the patient understands the nature of the consultation. Introduction 1 mark 2. Explanation 5 marks Give 0 mark if not attempted, 0. Clinical cases CASE 7. A year-old nulliparous woman presents to the gynaecology outpatient clinic with heavy, regular periods.

Her menstrual cycle is 28 days. Up to 40 sanitary towels are required for each period. Her recent smear was negative and she is not using any contraception. CASE 7. A year-old schoolteacher with two children complains of a 9-month history of heavy irregular periods. Her menstrual cycle is erratic and can vary between 3 and 6 weeks, with periods lasting 5—7 days. Before the onset of menstrual problems her cycles were regular every 4 weeks. Her recent cervical smear is negative, and she has no intermenstrual bleeding.

The patient has been sterilized. A year-old woman presents with a 4-month history of bleeding after intercourse. She is uncertain about when her last smear was taken. She has four children and currently uses the combined oral contraceptive pill for contraception. A year-old woman presents with an month history of increasingly heavy periods. She has a regular cycle with 7 days of bleeding every 28—30 days. Clinical examination and investigations are unremarkable. A diagnosis of dysfunctional uterine bleeding DUB is reached. Q1: If she opted for surgical management, what factors would you consider important when counselling her?

A year-old woman is having considerable problems with menorrhagia DUB , which has been unresponsive to medical treatment. She has been offered a hysterectomy by her gynaecologist, who has given her some time to consider this option. Q1: Can you reassure her? What factors would you consider important when counselling her? Dysfunctional uterine bleeding Menorrhagia not associated with organic disease of the genital tract. It accounts for two-thirds of all menorrhagia cases. Premenstrual syndrome Recurrent premenstrual symptoms somatic, psychological or behavioural producing social, family and occupational disturbance, usually relieved by menstruation.

Anovular DUB would lengthen the cycle and is more common in perimenopausal women see Case 7. Intermenstrual bleeding could be associated with anovular DUB, endometrial or cervical polyp, or rarely carcinoma but unlikely at this age. Large clots and the large number of sanitary towels required indicate the severity of the problem. Painful periods dysmenorrhoea could indicate endometriosis or adenomyosis. A3 Seek indications of the quality of life e.

Enquire about drug history and family history of bleeding disorders. Pallor on general examination may indicate anaemia caused by blood loss. It may be undertaken in younger women with menorrhagia who are not responding to medical treatment. Treat anaemia with iron supplements. Treat primary DUB as described below. This in itself can improve quality of life. It will reduce menstrual blood loss by about 50 per cent.

It can be used in conjunction with tranexamic acid. There are several different types available e. Submucous fibroid. Intramural fibroid. In anovular DUB high unopposed high oestrogen levels can cause a prolonged cycle in which the endometrium may even undergo hyperplasia metropathia haemorrhagica — endometrial glands are dilated and crowded.

The duration of symptoms is an indication that this condition is unlikely to resolve spontaneously without treatment. Obesity, hypertension and diabetes are risk factors for hyperplasia and endometrial cancer and hyperplasia see Case 4. A4 General examination to exclude pallor. Gonadotrophin levels should be measured during or just after menses. Endometrial thickness indicates endometrial pathology. It is recommended that all women over 40 years of age with irregular vaginal bleeding should have an endometrial biopsy.

The pill is associated with cervical ectropion. The pill together with pregnancy and puberty as risk factors are commonly remembered as the three Ps. A vaginal discharge may be associated with cervicitis. A careful inspection of the vulva and speculum examination of the vagina and particularly the cervix is mandatory. See Case 5. This can be done as an out- patient procedure without anaesthesia. In addition, consideration would need to be given to whether the ovaries should be removed in order to reduce the risk of ovarian cancer. If so, oestrogen-alone hormone replacement treatment would be necessary to protect against cardiovascular disease and osteoporosisshould be offered.

Ovaries may be conserved to continue functioning until the natural menopause. In addition, pregnancy should be avoided and sterilization may be considered at the same time as ablation. It is generally accepted that sexual function remains unchanged and may even improve. Clinical cases CASE 8. I have not had any for 7 months. A year-old woman attends a gynaecology clinic concerned that she has not had a menstrual period for 7 months.

Her periods have been gradually becoming more infrequent. She has a normal healthy appetite and diet. She claims not to have been sexually active for the past 12 months. Her home pregnancy test is negative.

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CASE 8. A year-old woman has been experiencing pelvic pain, irritability, bloatedness and breast pain for 3—4 days before her periods. These symptoms have occurred cyclically over a period of 4—6 months, and they disappear after the onset of menses. Her periods are regular and painful but not heavy. She has two children and uses condoms for contraception.

There is no history of psychiatric illness. She has a family history of heart disease and breast cancer. A year-old woman has menopausal symptoms. As a result of this and the fact that she has a family history of osteoporosis, she wishes to start hormone replacement therapy HRT. However, compliance is a problem in women who start HRT. Q2: What would be an appropriate screening programme for this patient if she were happy to start HRT?

A year-old has been told that she should stop taking her combined HRT because this is associated with an increased risk of breast cancer. Menopause Lack of menstruation for more than 12 months, associated with cessation of ovarian function and reproductive capacity. Virilism Androgenic changes more extensive than hirsutism, including amenorrhoea, breast atrophy, clitoromegaly and temporal balding.

A2 Pregnancy, the most common cause of secondary amenorrhoea, is unlikely in this case because the patient is not sexually active and a urinary pregnancy test is negative. Moreover, as she has a normal diet, she does not have anorexia nervosa-related amenorrhoea.

A3 An additional history should be obtained about menopausal symptoms i. PCOS would normally be associated with infertility and oligomenorrhoea. Headaches and visual disturbances may suggest pressure on the optic chiasma from a prolactinoma in the anterior pituitary. A drug history e. The condition of the skin and hair may indicate thyroid abnormalities. Hirsutism and acne are associated with PCOS. Evidence of striae and stigmata of virilization may be an indication of severe PCOS or a hormone-producing tumour. A breast examination should be performed to ensure normality of secondary sexual characteristics and to check for galactorrhoea a sign of prolactinoma.

An abdominopelvic mass would indicate a possible pregnancy or hormone-producing ovarian tumour. Thick endometrium is associated with polycystic ovaries, but thin endometrium is associated with premature menopause. If pregnancy is desired, then commence ovulation induction see Case 6. Box 8. Premenstrual syndrome is common around the age of 35 years. This complex problem of unknown aetiology occurs during the week before menstruation, and is classically resolved by menstruation.

Adenomyosis is associated with painful periods that are usually heavy. Any susceptibility to accidents, criminal acts and suicide indicates severe disability, which occurs in 3 per cent of cases. Sympathetic handling, support, reassurance about the absence of pathology and understanding particularly by family members are very important. Symptomatic relief is both diagnostic and therapeutic.

Total abdominal hysterectomy and bilateral salpingo- oophorectomy would represent a permanent solution. The average age of menopause in the UK is 51 years.


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This patient has been suffering from menopausal symptoms for 3 years, indicating that the climacteric and menopause are occurring at the appropriate age. Other symptoms of the menopause include depression, loss of libido, hair loss, dry skin and painful intercourse as a result of a dry vagina dyspareunia. It would be important to exclude any evidence of vaginal bleeding, which would warrant further investigations see Case General examination, including blood pressure measurement, is necessary to exclude hypertension. Examination of the breasts is mandatory, but it is likely that, if the patient is registered with a general practice, she will have been called for breast screening through the national screening programme initiated at 51 years of age.

Pelvic examination would be necessary only if a recent cervical smear had not been taken. A6 This patient should be given combined oestrogen and progestogen preparations, because she has an intact uterus. There are several different preparations of HRT available oral, patches, implants and gel. They can induce monthly withdrawal bleeding, 3-monthly withdrawal bleeding or no withdrawal bleeding. The continuous combined preparations would be highly suitable for this patient because she has been amenorrhoeic for at least a year. This would improve her long-term compliance with HRT.

Current evidence does not support the use of HRT when there is a history of heart disease and breast cancer, although HRT would not be contraindicated if the patient was adequately counselled see below. Counselling should be reinforced with written literature. Table 8. However, women should be fully informed of the added risk of breast cancer and be involved in the decision-making process.

A2 For this patient, the insertion of the levonorgestrel intrauterine coil releasing the progestogen component of HRT with systemic E2 preparation may reduce her breast cancer risk because systemic progestogens are implicated in the increase in breast cancer risk. Clinical cases CASE 9. A year-old parous woman complains of involuntary urinary loss on exercise, sneezing or coughing. CASE 9. She has a frequency of 10—12 times during the day.

At night she gets up three or four times to void. There is also involuntary urinary loss, particularly when she cannot reach the toilet immediately. She has suffered from this problem for the last 20 years, but it has gradually been worsening since her periods stopped 10 years ago. She is not on hormone replacement therapy HRT. Recently the urinary loss has increased so much that it has become a major hygienic problem. Her social activities have become severely restricted because of the worsening of the condition.

She has been treated for urinary tract infections on several occasions in the past. There is no history of diabetes or hypertension. She has had four vaginal deliveries, one of which was assisted by forceps. There were no macrosomic babies. She does not have urinary or bowel incontinence. A year-old woman presents with a history of incontinence of urine and urinary frequency. She describes a sudden urge to pass urine followed by incontinence, but she can also leak when lifting and coughing.

You have excluded a urinary tract infection and pelvic examination is unremarkable. You decide to perform urodynamic investigations. Q1: In counselling this patient, what points would you wish to make about the reasons for performing the investigation? Q2: What does the investigation involve? A year-old woman is referred with a procidentia that is reducible. There are no pelvic masses or urinary or faecal problems. Incontinence Involuntary urine loss that is objectively demonstrable and that is a social or hygienic problem.

Genuine stress incontinence synonymous with sphincter incompetence Involuntary urine loss associated with stress resulting from increased intra-abdominal pressure e. Detrusor instability Involuntary urine loss associated with loss of inhibition of detrusor contractions during stress. Frequency Normal frequency is usually every 4 h and it decreases by 1 h per decade. Voiding more often than six times a day or more frequently than every 2 h is usually regarded as abnormal. Nocturia Interruption of sleep as a result of micturition more than once every night. Voiding twice at night over the age of 70 years and three times over the age of 80 years is considered to be within normal limits.

Uterovaginal prolapse Descent of the pelvic genital organs towards or through the vaginal introitus:. A2 A history of involuntary urinary loss resulting from a rise in intra-abdominal pressure e. Sphincter incompetence will often be associated with multiparity, prolonged labour, and symptoms of uterovaginal prolapse and faecal incontinence.

In neurological disorders such as multiple sclerosis, incontinence will usually be a secondary symptom. Physical examination should be performed with a comfortably full bladder, when incontinence should be demonstrated by asking the patient to cough. Pelvic examination is usually normal in women with incontinence.

Incontinence is sometimes associated with pelvic masses e. Occasionally, incontinence is associated with neurological disease. In sphincter incompetence urodynamics are normal, i. This is commonly achieved by elevation of the bladder neck using colposuspension. A history of urgency, frequency and nocturia with or without associated UTIs is highly suggestive of detrusor instability.

Postmenopausal atrophic changes of the bladder will also be a contributory factor in this case. Fluid intake habits, particularly in relation to tea, coffee and alcohol, are important with regard to the symptomatology. Haematuria may indicate a bladder stone or tumour. Involuntary urinary loss as a result of a rise in intra-abdominal pressure e. Incontinence may be associated with symptoms of uterovaginal prolapse and faecal incontinence. A4 Physical examination should be performed with a comfortably full bladder, when incontinence may be demonstrated by asking the patient to cough.

There may be uterovaginal descent on straining. Pelvic examination may reveal a pelvic mass — which may be the cause of urinary symptoms resulting from pressure effects. Occasionally incontinence is associated with neurological disease. Examination of S2, S3 and S4 dermatomes is essential. In detrusor instability, urodynamics might show:. Urodynamic investigations are not essential as a matter of routine. They should, however, be undertaken in patients who are not responding to supportive and medical therapeutic measures. Fluid intake habits may have to be altered in order to manage the symptoms e.

Detrusor instability can be treated conservatively using techniques for bladder training to re-establish central bladder control. Urinary tract infections should be treated with appropriate antibiotics. Anticholinergic drugs may produce detrusor relaxation side effects include dry mouth, blurred vision and constipation.

These are end-stage procedures with a high morbidity rate and long- term problems. Prolapse premenopause is uncommon. It is said that women who have a physically demanding job are at high risk of prolapse. The sensation of prolapse is typically worse at the end of the day. Uterovesical Peritoneum pouch. Cystocele Urethra Combined urethra and bladder Small prolapse is Cervix bowel loops in urethrocystocele Pouch of Douglas Second degree First degree uterine uterine Urethrocele prolapse prolapse Enterocele. It is important to ascertain a history of urinary incontinence see Cases 9.

In general, stress incontinence is not associated with cystocele. The use of HRT may reduce the risk of prolapse. Postnatal exercises are considered to be a preventive measure for future prolapse. Smoking history and cough associated with smoking or respiratory illnesses may exacerbate the symptoms of prolapse. Chronic cough is a poor prognostic factor for the success of prolapse surgery. It is also important to establish whether the patient is sexually active. Exclude an abdominal mass and examine the external genitalia to assess signs of atrophy. Ask the patient to cough in order to detect any stress incontinence although elicitation of this at the time of examination is not conclusive evidence of her incontinence.

A bimanual examination should be performed to exclude a pelvic mass. A5 The diagnosis is primarily made on the basis of the clinical examination. Pessaries are more likely to be helpful in women with a prominent suprapubic arch and strong perineal body for support; otherwise the pessary is easily expelled. Pessaries are generally replaced every 4—6 months. The latter should be the preferred option if there is urodynamically established concurrent genuine stress incontinence. This operation should be performed only if a vaginal hysterectomy is not possible.

Anterior repair and posterior repair are performed if appropriate. The vaginal vault should be suspended. In all of these surgical interventions, the rate of recurrence is high if preventive measures e. HRT, reduction in body weight and stopping smoking in the case of chronic cough are not implemented. In any repair operation, the vagina and introitus should not be obliterated, which would prevent dyspareunia or inhibit intercourse. The procidentia is unlikely to cause any serious harm, but it is considered to be a progressive condition.

Alternatively, combined HRT can be prescribed.

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This has a higher likelihood of success, but is incompatible with sexual function. They can cause bleeding as a result of pressure on atrophic vaginal skin. If excoriation or ulceration occurs, the pessaries should be left out and topical oestrogen cream prescribed daily for 2—4 weeks. Clinical cases CASE A year-old single woman is found to have an abnormal smear on routine screening. She has had regular smears since the age of 25 years, and previous smears have been normal.

She has two children aged 2 and 7 years. She is separated from her partner, who fathered both children. She is currently using the oral contraceptive pill; she is not in a stable relationship. CASE A year-old woman presents with gradual enlargement of the abdomen, changes in bowel habit and weight loss. The general practitioner had felt a lower abdominal mass and referred the patient urgently to the gynaecology clinic. A year-old woman has been amenorrhoeic for the past 18 months, and recently started to have some vaginal bleeding. Her last cervical smear, taken 2 years ago, was normal. Do I have cancer?

Having had a routine cervical smear 2 weeks earlier, a year-old woman returns to see you her GP about the result. Q1: Counsel this patient about her smear result. Will I get cancer? A year-old woman presents with genital warts. She is worried that the virus that causes warts also causes cervical cancer. She has never had a cervical smear.

From the given history, one can elicit only some of the risk factors for cervical intraepithelial neoplasia e. However, it is not possible to be certain of the diagnosis without further investigation. A3 The history of additional risk factors associated with cervical intraepithelial neoplasia and cancer should be obtained, e. Gynaecological symptoms such as intermenstrual bleeding and postcoital bleeding may be indicative of a local lesion.

Inspection of the vulva and vagina may reveal discharge or infection. Inspection of the cervix may show a cervical ectropion, a polyp or a tumour. In most cases, however, cervical inspection with the naked eye will be normal. In the case of cervical cancer, examination will also determine staging, but this is usually performed under anaesthesia together with cystoscopy.

If a sexually transmitted disease is diagnosed, the male partner will also need to be examined. Squamous metaplasia of columnar epithelium Squamo- columnar junction SCJ. Cervical ectropian representing Columnar epithelium undergoes pouting of columnar epitheluim squamous metaplasia under which is subject to acidic the influence of acidic vaginal vaginal environment. This 'weak' epithelium is now This is called the 'Transformation subject to 'trauma' from risk Zone' from where CIN and factors e.

Cervical ectropian commonly occurs in the three P's: Puberty, Pill and Pregnancy. At colposcopy, directed biopsies should be taken to establish a histological diagnosis. Repeat smear at 6 months — if abnormality is persistent refer for colposcopy Mild dyskaryosis Repeat smear at 6 months — if abnormality is persistent refer for colposcopy.

A2 Gradual abdominal distension and changes in bowel habits in a postmenopausal patient with a pelvic mass are highly suspicious of an ovarian tumour. A3 Nulliparity, early menarche, late menopause, higher social class and history of breast cancer are associated with ovarian neoplasm. Use of the oral contraceptive pill has a protective effect. Postmenopausal bleeding can be a symptom of ovarian cancer, but it may also be the result of endometrial or fallopian tube cancer.

A urinary and bowel history should be obtained.


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  • The diagnosis cannot be established without further investigation. A4 A general examination should be performed, looking for lymphadenopathy and lower limb oedema. Ascites should be demonstrated on abdominal examination. Bimanual examination will detect pelvic mass, its relationship to the uterus and its mobility. A5 Investigations should be performed to exclude ovarian tumour. If a mass is detected, its nature whether cystic or solid and origin may be determined by the scan. Postcoital bleeding could also suggest a cervical polyp or cancer. Hypertension, diabetes and obesity are risk factors for endometrial hyperplasia and cancer.

    Information about cervical smear reports must be obtained, bearing in mind that a negative smear history does not exclude the possibility of cervical cancer in women with symptoms of postmenopausal bleeding. In this case there might also be a history of painful dry vagina during intercourse, which would suggest atrophic vaginitis. A4 A general examination should be performed to exclude pallor and lymphadenopathy. Speculum examination will demonstrate local causes such as atrophic vaginitis and cervical polyps or carcinoma.

    Bimanual examination should be performed to assess uterine size, mobility and adnexal pathology. The primary aim of investigations is to exclude gynaecological cancer. If this is so after thorough investigations, then the patient can be reassured. Alternatively, the HRT dose may be altered to provide a preparation with a higher oestrogen content.

    The nature of the investigation and treatment would be as follows:. Not all of these types are associated with cervical cancer. These changes are easily cured before they become cancerous. A cervical smear should be taken every 3 years. A year-old single woman has vulval and vaginal itching and discharge. Her recent cervical smear was normal. She has recently started a new relationship and is currently using the oral contraceptive pill. There are no urinary symptoms. A year-old woman presents with fever, lower abdominal and pelvic pain, and a foul-smelling vaginal discharge.

    Her last menstrual period was 1 week ago. She has recently changed her sexual partner. There are no urinary or bowel symptoms. A year-old nulliparous professional woman presents with severe and incapacitating menstrual pain that requires bed- rest and interferes with her employment. The menstrual pain has been present for 1 year, but it has gradually been increasing in severity over the last few months.

    The couple have been using condoms for contraception. Should I be concerned? A patient with chronic pelvic pain is going to be admitted to hospital for diagnostic laparoscopy under general anaesthetic. Her clinical pelvic examination and pelvic ultrasound scan USS are normal. Q1: What information will you need to provide when counselling her about the investigation?

    What happens next? The above patient underwent an uneventful diagnostic laparoscopy. Round Round ligament ligament.

    Stochastic equations through the eye of the physicist basic concepts, exact results and asymptotic

    Fallopian Fallopian tube tube. Q1: What information will you need to provide when counselling her before discharge from hospital? Sexually transmitted infection STI Genital tract infection caused by sexually transmitted infective organisms e. Chronic pelvic pain Constant or intermittent, cyclic or acyclic pain located in the pelvis, which may or may not be related to menstruation, is associated with adverse effects on quality of life and has lasted for more than 6 months. No pelvic pathology is found in 50—60 per cent of cases with chronic pelvic pain. It is common at menarche.

    Dyspareunia Pain associated with sexual intercourse. A2 Associated itching, a new sexual partner, use of the oral contraceptive pill and broad-spectrum antibiotics could all be associated with candida infection although most infections involve a mixture of organisms. Urinary symptoms, absent in this case, could be associated with chlamydial infection, gonorrhoea or herpes. Typically, a thin green discharge is associated with bacterial vaginosis, a thick white discharge is caused by Candida sp. The relationship between discharge and menstruation should be established.

    Candida infection is usually premenstrual and gonococcal infection is postmenstrual. Intense itching that is worse at night is a feature of candidiasis, but could be associated with trichomonas infection. Pain, dyspareunia and burning are features of trichomonas and gonococcal infections.

    Poor personal hygiene, and the use of talcum powder, deodorants, douches and tight synthetic undergarments, may lead to itching. A family history of diabetes and symptoms of polyuria and polydipsia may indicate diabetes mellitus, which is associated with candida infections. Inspection of the vulva may reveal erythema or congestion, which is much more marked with candida than with trichomonas infection.

    The erythema may extend perianally. Gonococcal infection may be associated with painful vulval swelling and urethral discharge. Multiple small vesicles with ulcers are associated with herpes. Speculum examination may demonstrate discharge with associated erythema. A search should be made for any foreign bodies e.

    A sample of the discharge should be taken for microscopy, culture and sensitivity. Trichomonas infection is associated with reddish—purple spots in the vagina and cervix strawberry cervix. Cervical ectropion may be a cause of discharge without infection. A bimanual examination should be performed to assess pelvic tenderness, which may suggest PID. The male partner should also be examined. No organisms are usually seen in physiological discharge. Separate swabs should be taken for Chlamydia sp. Investigations of the male partner should also be carried out.

    Otherwise treat as candida infection. Pyrexia, pelvic pain and foul-smelling vaginal discharge are very probably the result of PID. A recent change of sexual partner is a risk factor for PID. Swinging pyrexia is typically associated with a pelvic abscess. A sexual history should be obtained, enquiring about the number of sexual partners, any recent casual sexual encounters, history of STIs and previous history of PID.

    The oral contraceptive pill reduces the risk of PID, but does not necessarily prevent it. Copper intrauterine contraceptive devices are associated with PID, and are also associated with recent gynaecological surgery and delivery or miscarriage. A4 General examination should include measurement of temperature, blood pressure and pulse to assess shock.

    Inspection of the vulva, vagina and cervix may demonstrate discharge with associated erythema. A sample of the discharge should be taken for microbiology. Separate swabs for gonococci and Chlamydia sp. Digital examination of the cervix may show excitation. Bimanual examination should be performed to assess pelvic tenderness, which may suggest PID. It may also reveal a mass, which could be a pelvic abscess. An indwelling catheter should be used to monitor urine output.

    Otherwise, treat PID with antibiotics directed at the suspected organism or according to culture and sensitivity reports. The combination of painful intercourse dyspareunia and painful periods is typical of endometriosis, a condition that is more prevalent in nulliparous women of high social class. Pelvic pain caused by endometriosis typically starts several days before the period and remains severe in intensity for several days after it. However, primary dysmenorrhoea usually eases within 1—2 days of the onset of menses.


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