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Khaled khalilia

Gynecology & Obstetrics
Khaled khalilia
IMLE

2016

Khaled khalilia

1

Khaled khalilia
Menstrual disorders
Amenorrhea
 Absence of menes for X ≥ 3 Months
 Injury to arcuate nucleus


 Normal menes:
- Frequency  21-35 day
- Duration  3-7 day
- Volume  30-80 ml
 Oigomenorrhea: bleeding > 35 day
 Polymenorrhea: bleeding < 21 day
 Metrorrhagia: bleeding at irregular interval
 Hypomenorrhea: low intensity bleeding ↓
 Hypermenorrhea: high intensity bleeding ↑


Primary Amenorrhea
Def:
- No Menes at Age 14 without secondary sexual
development
...


-

ET:

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Tx:


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Idiopathic
POS
Acromegaly
Danazol, Cyclosporine, Phenytoin, Corticosteroids
Prolactin ↑
Cushing Syndrome
Ovarian Tumor
Von-Hipel-lindau
Cong
...
Pituitary Necrosis)
Asherman Syndrome (intrauterine scarring following
D&C)

-

Hirsutism
Def: excessive growth of androgen-responsive hair in
women
...


ET:

ET:
 With secondary sex development:
- Müllerian agenesis
- Androgen insensivity syndrome (Morris)
- Imperforate Hymen
- Hyperprolactinemia ↑
- Hypothyroidism ↓
- Polycystic Ovary Syndrome ( PCOS )
- Cushing Syndrome
- Anorexia Nervosa
- Congenital Adrenal Hyperplasia
- Pituitary Tumor
 without secondary sex development:
- Kallman Syndrome
- Turner Syndrome XO (Gonadal Dysgenesis)
- Diabetes Mellitus (DM)

Virilization

Premenstrual Syndrome

Secondary Amenorrhea
Def:
-

Arcuate nucleus injury
Ovarian Failure
Hyperprolactinemia ↑
polycystic ovarian syndrome

Dysmenorrhea
Primary
Menstrual pain in absence of
organic disease
...


 PID
 Uterine Myoma
 Adenomyosis
 Endometriosis
 Adhesion
 Cervical stenosis
 Uterine polyps

Antiprostaglandins (Naproxen)
NSAIDs (first line)
Combined oral contraceptive
Progestin (IM,oral,IUD)
Endometrial ablation (increase the risk of infertility,
miscarriage, preterm labor, antepartum hemorrhage, and
abnormal placental attachment
...
)

Development + Puberty






The age of onset of puberty varies and is correlated with osseous maturation
The breast bud (thelarche) is the 1st sign of puberty (10-11 yr), followed by pubic hair (pubarche) 6-12 mo later
...

precocious puberty Tx  long-acting GnRH agonist leuprolide (Lupron)
The production of sex steroids induces secondary sex characteristics, endometrial proliferation (leading to menstruation), vaginal cornification, and growth of
long bones
...

 ↓ Estrogen
 ↑ FSH
S+S:
Vagina
 Smaller
 Atrophy
 Dry
 Pale/dry epithelia
 Ligament ↓Tone
Bone
 ↓Ca
 Osteoporosis 
Fractures
Uterus
 Petechial
Hemorrhage
 ↓ Size
 Thin endometrial
mucosa
Hair
 ↑ Body hair
Breast
 ↓ Turgor
 ↓Form/Fullness


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Vasomotor symptoms
Hot flush (Red skin) + sweats
Amenorrhea
Osteoporosis
Sleep Disturbances (Insomnia)
Urinary incontinence
Dysuria
Dyspareunia
Atrophic vaginitis
↓Estrogen
↓Gonadotropin

Hormone Replacement Therapy
 Estrogen, Progesterone and Progestin
Indication:
 Relief menopausal symptoms
 Prevent + Tx of Osteoporosis
 Prevent Cardiovascular diseases (↓LDL)
 Decrease dementia
Complication:
 endometrial Cancer / breast
 DVT
 Uterine Bleeding
 Edema
Contraindication:
 Liver Disease
 Undiagnosed vaginal Bleeding
 Breast cancer
 Uterine cancer
 DVT
 Cardiovascular disease

Menopausal Syndrome

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Irritability ,palpitation
↓ libido
Insomnia
Fatigue
Headache
Depression

Dysfunctional uterine Bleeding (DUB)
 Unexplained abnormal Bleeding
...

 Β-HCG ( rule out pregnancy)
 Coagulation profile ,exclude Von Willebrand
 FSH, LH
 US (Fibroid, Polyp)
 Day 21  progesteroneconfirm ovulation
Tx:
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Khaled khalilia

Resuscitation (if unstable)
Oral contraceptive
Clomiphene Citrate ( want children)
D&C (stop bleeding)
Endometrial Ablation (x children)
Hysterectomy (x children) definitive Tx

Khaled khalilia
Menstrual disorders
Endometriosis

Bartholin Gland Cyst

 The presence of functioning endometrial tissue (glands and stroma) outside
their usual location in the uterine cavity
...

 Gunmetal, powder burns, chocolate cyst
Risk factors:
 Family History
 Single women
 Marry late
 ↓ or X children
Dx:
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Tx:

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S+S:
 Dysmenorrhea
 Dyspareunia
 Dyschezia (painful defecation)
 Pelvic pain
 Infertility
CA-125: correlate with disease degree, response to treatment, marker of
recurrence
...

(good for patient who don’t want children, Severe)
Best time to become Pregnant is immediately after conservative surgery

 secrete mucous and become obstructed  cyst or abscess
 lateral side of the Vulva ( 1 - 4 cm)
Tx:

 Drainage  catheter (done at the office)
 Recurrence  Marsupialization






Polycystic Ovarian Syndrome
Dx:
 Amenorrhea
 US: bilateral enlarged ovaries + multiple cysts
 Irregular Menes
 ↑ Androgen (Testosterone)  virilization
 Hirsutism
 ↑Estrogen (outside ovary):
 Obesity
 ↑LH secretion
 Acne
 ↓FSH secretion
 DM-Type 2
 LH:FSH ratio > 3:1
 Infertility
Tx:
 Lifestyle (↑Excercuise, ↓ BMI)
 Oral Contraceptive (prevent Endometrial Hyperplasia)
...

MRI  most accurate test
Hysterectomy  only definitive Treatment
Tx: NSAIDS

Nabothian Cyst

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

mucus-filled cyst on the surface of the cervix
Blockage of crypts in the uterine cervix
harmless and usually disappear on their own
Dx: colposcopyor biopsy (exclude cancer)
 Tx: electrocautery and cryofreezing

Khaled khalilia

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Khaled khalilia

5

Syndromes
Asherman Syndrome

Sheehan Syndrome

 Trauma to the Endometrium, after
a dilation and curettage (D&C)
performed after: miscarriage,
delivery, surgical termination of
pregnancy can lead to the
development of Intrauterine scars
resulting in adhesions
...

 Hypopituitarism ↓
 ChildbirthBlood loss  Hypovolemic
Shock  Ischemic Necrosis (Ant
...
↑HCG

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abdominal pain
bloating
Nausea/ Vomiting
Diarrhea
Tenderness (ovaries)

Cx:


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ovarian torsion
ovarian rupture
thrombophlebitis
renal insufficiency
Venous thrombosis

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Hypogonadotropic hypogonadism
X/Delayed pubertal Development
↓Poor secondary sexual characteristic
Normal Stature
Female phenotype
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̊
Amenorrhea 1̊ ̊̊̊
Anosmia
↓FSH, ↓LH
↓Testosterone
↓Sperm count
Short Stature
Infertility

Tx: Hormoe Replacement

Female: Estrogen

Male: Testpsterone

Ovarian Hyper-stimulation Synd

S+S:

Kallman Syndrome

Müllerian agenesis
 Mayer-Rokitansky-Kuster-Hauser
syndrome
...

 primary Amenorrhea 15%
normal development of breasts, sexual
hair, ovaries, tubes, and external genitalia
...

2
...


Ammenorhea
Eating Disorders
Osteopenia/Osteoporosis

 Menstrual Bleeding following
Administration of Estrogen and
Progesterone
...
gonorrhea

Dx:
 Clue cells
 Fish odor

Dx:

Dx:
Tx:
 Mitronidazole (2gr single dose)

Tx:

Tx:
Antifungal:
 Econazole
 Miconazole
 Fluconazole (oral)

Extra:
 ↑increased risk for preterm
labor

Syphilis
Et: Treponema pallidum
S+S:
1
...

2
...
Optic atrophy, tabes dorsalis,
aortic aneurysm, Gumma
Dx:
 Aspiration: Ulcer/Node
 Darkfield microscopy (most
sensitive, specific)

 + VDRL
 FTA-ABS (specific anti treponemal
antibody test)  Confirmation

Tx:
 Penicillin G (IM)
 Treat Partner
Extra:
 gumma: soft, non-cancerous growth

Herpes Simplex

Gonorrhea

Et:
 90% HSV-2(Genital)
 10% HSV-1 (Oral)

ET: N
...



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 FTA-abs are diagnostic even in the
presence of SLE

 penicillin allergy: Desensitization with
phenoxymethyl penicillin

ET:
 6, 11  condyloma
 16, 18, and 31  cervical neoplasia
S+S:
 Asymptomatic
 Wart like lesion
 Hyperkeratotic
 Edema
 Macular lesion
Dx:

Cytology

Colposcopy (Biopsy)
Tx:

Acyclovir
Active infection during labor 
C-Section

Pelvic inflammatory Disease

rd

Human Papilloma Virus (HPV)

C
...
Gonorrhea
E-coli
Staphlococcus
Streptococcus
Actinomyces israelii

S+S:

Khaled khalilia

Sexually transmitted Diseases

6

Khaled khalilia
Gynecology Disorders
Gestational Trophoblastic Disease
1
...
Invasive mole (chorio-adenoma destruens )
3
...
Chorio-carcinoma

Leiomyoma (Fibroids)
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Fibromyoma, Fibroid, Leiomyoma, Myoma
Uterine myoma  most common benign Tumor of Female Genital Tract
...
(↑ during reproductive years x> 35)
Have rich vascular supply
Anemia  most common complication
Types:
Summucous:
Intramural: within uterine wall  prolonged bleeding + Dysmenorrhea
Sunserous: bladder symptoms, constipation, back pain

S+S:

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Asymptomatic
Uterine Bleeding
Dysmenorrhea
Pelvis pain
Pelvis Pressure
Urinary frequency + urgency
Urinary retention
Constipation
Infertility
Compression of ureter, Bladder, Rectum
...

 Treat anemia if present
...

 Medical:
 NSAIDS
 OCC /Depo-provera
 GnRH-analouges: (Leuprolide, Danazol)
 Short term (6 months)
 Before myomectomy,Hysterectomy  reduce fibroid size
 Reduce bleeding
 Progesterone
 Mifepristone
 Surgery:
 Myomectomy (preserve fertility)
 Hysterectomy

Khaled khalilia

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Khaled khalilia
Conditions during pregnancy
Placenta Previa

Placental Abruption

Def:

Def: Separation of Placenta from it’s site of implantation before the delivery of the Fetus
...

 Obstacle in front of the Fetal presenting part
...


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rd

PAINFULL vaginal Bleeding (3 Trimester)
Uterine: contracted, Tender, Hard
Pain
Shock/ Anemia
Coagulopathy (Consumptive)
Hb↓, WBC↑
Fetal Distress

Complication:
 Fetal death
 Premature
 Intrauterine Hypoxia
 DIC
 Anemia
 Sheehan Syndrome
 Life threatening (Emergency)
Tx:

Tx:

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 GA < 37 + minimal Bleeding:
 Hospital Admission
 Corticosteroid (Lung maturity)
 Limited physical activity
 GA ≥ 37, Profuse Bleeding, L/S ratio > 2:1  C-Section

C-Section:
 Patient in Labor
 Mature Fetus + Bleeding
 Immature Fetus + severe Bleeding ↑↑
 Total placenta pravia + Dead Fetus
 Fetal Distress

S+S:
Preeclampsia
Drugs
PROM
Choriamnionitis
Trauma
Uterine myoma

Vaginal Delivery:
 X < 28 wk (Little surviving chance)
 Dead Fetus (minimal Bleeding, cervix
= soft + effaced)

Premature + Bleeding (few)  Observe
Associated conditions:
 placenta accreta → abnormally firm adherence to the uterine wall
 placenta increta → placental villi invade the myometrium
 placenta percreta → placental villi penetrate through the myometrium

Khaled khalilia

Stabilize mother: O2, IV Fluid, RBC
Fibrinoge 4 gr
Furosemide (pulmonary congestion)
Fresh Frozen Plasma
Cryoprecipitate
Delivery:
C-section: Fetal Distress, Maternal Distress, Labor fail to progress, Bleeding↑↑)
...
40 – 41 GA
o Healthy, uncomplicated pregnancy:

Tx:

o
o

Gestational age (LMP)
US (CRL)
Quickening

Tx:
 Wait for spontaneous Labor/ripening
 Induction of Labor  PG-Gel for cervical ripening
...






Tocolytics (Suppression of Labor):  Indomethacin
Doesn’t inhibit preterm labor completely (X<48 hrs
...
)
Preterm, live, immature fetus, intact membrane, cervical dilation <4cm

2
...
Cervical Cerclage (placement of cervical sutures at the level of internal Os and
removed in the 3rd Trimester)  Cervical Incompetence




X No induction of Labor
Fetal monitoring

o Maternal Risk / Fetal distress:
 Cervical ripening (PG) + induction of Labor
2
...
At 42 GA
o Induce Labor (even if everything is normal)

Khaled khalilia

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Khaled khalilia
Conditions during pregnancy
PROM (Premature rupture of membrane)
Def:

Et:
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Spontaneous Abortion

Spontaneous rupture of the membrane at any time of GA before the onset of Labor
...
Trachomatis
STD
↓Nutrition
Twin pregnancy
Placenta previa
Hydramnios
Abnormal presentation

ET:
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S+S:
 Sudden gush of Fluid / continuous leake
 Color / consistency of fluid
 ↑ increased prominence of fetal palpation

mechanical causes: (incompetent cervix, uterine malposition, Asherman Syndrome)
infections: ( CMV, Toxoplasmosis, malaria)
genetic causes: ( Aneuploid, Euploid , Antiphospholipid syndrome)
endocrine causes: ( Combined deficiency of E and P )
immunological causes: (Antiphospholipid antibody IgG, IgM)
maternal systemic conditions: (Endocrine, Blood incompatibility, Toxin)
 Aneuploidy: (abnormal no
...

 The termination of pregnancy before 20 weeks gestation based upon the date of the
first day of the LMP
...
\
 Chromosomal abnormality = 70 %

Dx:
 Ultrasound: differentiate between types
Tx:

Type
Sterile speculum exam
Nitrazine Paper  Amniotic Fluid turn paper BLUE
fern test (air-dry a drop of the fluid on a slide ► examine for arborization)
cervical aspect (degree of effacement and dilatation)
check for cord prolapse
Culture
determination = L/S ratio

Complete

Incomplete

Tx:
 depends on Fetal GA and the presence of Chorioamnionitis
...


Threatened

Septic

 GA < 26 maternal Risk

diagnosis of amnionitis:
 Physical examination → signs of infection (fever, tachycardia)
...

 US examination → fetal size
...

 Dead Fetus
 Dilation of Cervix
 Intact product of
Conception
 Cervix= closed + Soft
 Intact product of
Conception
 Intrauterine Bleeding

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Watch + wait
Misoprostol
D&C +/- oxytocin
Watch + wait
Misoprostol
D&C +/- oxytocin


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


Watch + wait
Misoprostol
D&C +/- oxytocin
Watch + wait
Rest

 D&C
 AB 
Metronidazole
Levofloxacin

10

Khaled khalilia
Conditions during pregnancy
Polyhydramnios

Macrosomia

Def:
 source  amniotic epithelium
...

 anencephaly and spina bifida  increased transudation of fluid from the exposed
meninges into the amniotic cavity
...

 Maternal conditions associated with hydramnios are heart disease, preeclampsia,
severe anemia, Toxoplasma or CLMV infections, Syphilis

th

Def: infant weight > 90 percentile for a particular GA or X > 4000 gr
Et/ Risk factors:



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

 ACUTE: severe Symptoms, Rapid accumulation, Obstetrical Emergency
 Chronic: not severe Symptoms, slow accumulation

Et:

S+S:
 Dyspnea
 Palpitation
 Abdominal Enlargement
 Edema
 Pain
 Varicose vein
 Uterus: large, ↑Tone
 Fetal parts: cant be felt
 FHR: difficult to hear
Cant define presentation

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

Idiopathic
DM Type 1
Multiple Gestation
Rh+ Isoimmunization
Anemia
Preeclampsia
Infection
CNS Anomaly: Spina
befidia,Anencephalus,
Hydrocephalus
 TTTTS
 Esophageal atresia
 Duodenal atresia

Complication:
 Placental rupture
 Postpartum hemorrhage
 PROM
 Erythroblastosis
 Fetal malformation
 Umbilical Cord Prolapse

Dx:
Ultrasound
Tx:





Bed rest
NSAIDs
Amniocenthesis
Amniotomy

Oligohydramnios
Def: ↓ decrease Amniotic Fluid
ET:

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

Idiopathic
Preeclampsia
ACE-I
PG-inhibitors
Congenital Urinary Tract anomalies (Renal agenesis, obstruction)
Hypoxemia
IUGR
Ruptured membrane
chromosomal anomalies

S+S:
Complication:





smaller symphysiofundal height
fetal malpresentation (Breech)
prominence of fetal parts
↓amniotic fluid
...

 tubal hypoplasia
 tortuosity
 congenital diverticula
 accessory ostia
 partial stenosis
 Inflammatory: PID ( 50%), septic abortion, puerperal sepsis, medical termination →
intraluminal / peritubal adhesions
 Surgical: tubal reconstructive surgery, recanalisation of tubes
 Tumor: broad ligament myoma, ovarian tumor
 Miscellaneous causes: IUD, endometriosis, ART, hormonal perturbations → tubal
dysfunctions

Risk Factors:
 Previous ectopic pregnancy
 IUD
 Infertility
 Smoking
 Uterine Leiomyoma
 Abnormal uterine anatomy
 Adhesion
 Abdominal surgery
 Fallopian tube surgery
 Clomiphene Citrate (induction of
ovulation)
 Salpingitis (Luimen narrowing)
 Septic abortion

Sites of ectopic pregnancy:

o
o
o
o

o
o




Tube: ( ↑ recurrence rate)
isthmic (25%)
ampullary (55%)
fimbrial (17%)
interstitial (2%)
Uterine
Corneal
Cervical
Intraligamentous
Ovarien
Abdominal
o Primary
o Secondary
 heterotopic

Def: descent of the cord to a level adjacent to or below the presenting part, causing cord
compression between presenting part and pelvis
...
Lie below the
presenting part
 NO ruptured membranes
o Funic presentation = cord presentation = procubitus → one or more loops of
umbilical cord between the fetal presenting part and the cervix,
...

 If compression is complete and prolonged  it induces asphyxia, metabolic acidosis
and death
...
after delivery
 Late  24 hr
...


S+S:
 ↑ uterus Size
 Edema
 Varicose vein
 HR: 2x different fetal HR

Et:

1
...


2
...
Trauma: Laceration, Episiotomy, Hematoma
4
...
In uterine atony this does not occur

Twin-to-twin transfusion syndrome (TTTTS)
 Arterial blood from donor twin passes through placenta into vein of recipient twin
 Vascular Anastomosis (only in Monochorionic):
 Perfused: (Take)
o ↑ Hypervolemia, ↑BP
o Heart Failure, Edema
o Polyhydramnios
o Hepatosplenomegaly
o ↑Bilirubin (Kernicterus)
 Hypo perfused: (give)
o Hypoxemia
o Oligohydramnios
o IUGR
o Hypovolemia, ↓BP
o Anemia
Tx:
 Amniocenthesis
 Intrauterine Blood Transfusion
 Laparoscopy: occlusion of placenta vessels

2 Eggs
2 Sperm







Identical Twins
Same Gender
Same Blood Type
Different Fingerprint
30 %
TTTS
Hydrations
Malformation
2 Amnion, 2 chorion
2 Amnion, 1 chorion
1 Amnion, 1 chorion

Fraternal Twins
Different/same Sex
2 Amnion, 2 Chorion
No vascular Anastomosis
Normal Amniotic Fluid
70%

Tx:
 Vaginal Delivery  if Twin A present as Vertex
 C-Section
o if first Twin not in Vertex
o Hypotonic uterine dysfunction
o Fetal distress
o Cord prolapse
o Prematurity
o Placenta previa
 Twin A (vaginal delivery)  Twin B (C-Section)

Khaled khalilia

13

Khaled khalilia
Conditions during pregnancy
Gestational Diabetes

Rh+ Incompatibility

Risk Factors:

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


Def:
 occurs when the mother is Rh negative and the baby is Rh positive
 not a problem in the first pregnancy  mother has not developed Antibodies to
the foreign Rh+
...

 When the Mother gets pregnant for the second time her antibodies attack the
second Rh+ Baby  Hemolysis (Hemolytic Disease)
...
GA
 Random non-fasting 50 gr Glucose load  serum measurement of Glucose (1 hr
...

o X<140 mg/dl  Normal
o X>140 mg/dl  do OGTT (Oral Glucose Tolerance Test):
 diagnosis of gestational diabetes is made if X ≥ 2 of the four values meet or exceed the
following:
o Fasting serum glucose concentration >95 mg/dL (5
...
6 mmol/L)
o 3-hour serum glucose concentration >140 mg/dL (7
...
)
Never tell the pregnant women to lose weight: /
Glycemic Target:
o FPG < 95 mg/dl
o 1h PG < 140
o 2h PG < 120

Dx:
 Antibody Screen  done to see if mother Rh- or Rh+
 Antibody titer  done to see how many antibodies to Rh+ blood the mother has
...

 indirect Coombs test screen blood from antenatal women for IgG antibodies
that may pass through the placenta and cause hemolytic disease of the newborn
...

 Bilirubin
Prophylaxis:
 Exogenous Rh IgG (Rhogam)  to all Rh- and antibody screen negative women in
the following scenarios:
 Routinely at 28 wk GA (protection)
 Within 72h of the birth of Rh+ fetus
 + kleinhauer-Betke test
 Invasive Procedures
 Ectopic pregnancy
Complication:
 Fetal RBC Hemolysis
 Fetal Anemia
 Edema
 Ascites
 Fetal Hydrops
 Erythroblastosis fetalis
Tx:
 Intrauterine blood transfusion
 At Delivery, if the Baby is Rh+  give the mother anti-D Rh immunoglobulin again
...


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Khaled khalilia
Tumors
Ovarian Tumor






Most common in Young patient (20s)  Germ Cell origin (Teratoma,dysgerminoma↑)

Dx:






Endometrial Cancer
 Adenocarcinoma: x > 80% (most common)
 ↑Estrogen, X progesterone  Endometrium HyperplasiaAdenocarcinoma
 most endometrial cancers are diagnosed as Stage I

Benign: cystic, smooth, unilateral, mobile
Malignant: Solid, nodular, Bilateral, Fixed
Protective Factors: OCP, Pregnancy, Breastfeeding
Serous: most common ovarian cancer 50 % (Postmenopausal)

CA-125
US
Labaroscopy (Biopsy)
Pelvic ultrasound findings of: ovarian papillary
vegetations, ovarian > 10 cm, ascites, ovarian
torsion, or solid ovarian lesions  Do
exploratory laparotomy
...


S+S:
 Asymptomatic
 Abd
...


Risk Factors:
 ↑Age > 40
 Nulliparity
 Family History (BRCA-1)

Stage:






↑Age (60-70)
Uterine Bleeding (postmenopausal)
...

 Want children:
 surgery + preserve ( uterus, opposite Tube + Ovary ) if they are free of Tumor
 Remove remaining reproductive Organs after Childbearing
...

Chemotherapy: Cisplastin + Cyclophosphamide

Stage 1: Limited to Uterine Fundus
1A
X No myometrial invasion
1B
Myometrial invasion X≤ 50 %
1C
Myometrial invasion X > 50 %
Stage 2: Extend to Cervix  Stromal invasion
Stage 3: Local/Regional spread
3A
Invade serosa / Adnexa
3B
Vaginal metastasis
3C
Pelvis metastasis / para-aortic LN metastasis
Stage 4: invade Bladder/Bowel mucosa + Distant metastasis
4A Invade Bladder/Rectum (confirmed by Biopsy)
4B Distant metastasis

Tx:
Stage I:

 Total Hyterectomy
 + Bilateral Salpingo-oophorectomy
 + peritoneal cyto
...

 Extended-field radiation for extra pelvic cancer (depending on the site and extent)
Stage 4: systemic chemotherapy
Recurrence: high-dose progestins (Depo-Provera)

Endometrial Hyperplasia
It is considered weakly premalignant because it progresses to
endometrial carcinoma in approximately 1% of women
...

 Intestine  first affected by spread and encroachment of ovarian cancer
...

Radiotherapy
Chemotherapy (Cisplastin,Doxorubicin)

 85% squamous cell carcinoma
 15% adenocarcinoma arising from endocervical glands

S+S:






Asymptomatic
postcoital bleeding
malodorous discharge
pelvic pain
ulceration

Risk Factors:
 ↑ Age (x>40)
 HPV (16
...

Bad prognosis
Types:
most common after age 40
 Leiomyosarcoma
rapidly enlarging uterus  Pain
 Endometrial stroma
Vaginal Bleeding: most common symptom
vaginal discharge
...

 Most common in postmenopausal women (can occur at any age)
 associated with a higher risk of cancer  Vulvar carcinoma
S+S:

Pruritus

Dyspareunia

Burning

Tx: Topical steroid (clobetasol)

Squamous cell Hyperplasia






Surface thickened and hyperkeratotic
Postmenopausal women ↑
Pruritus (most common symptom)
Dx: Biopsy
Tx: corticosteroid

1)

squamous cell carcinoma:
 most common type 90%

S+S:

 Pruritus
 Bloody vaginal discharge
 Postmenopausal bleeding
 Ulcerated lesion
 cauliflowerlike lesion
Dx: Biopsy (always)
Risk factors:
 HPV 16 positivity
 smoking
 immunosuppression

Squamous cell carcinoma staging
0
I
II
III
IV
IVa

Carcinoma in situ
Limited to vaginal wall x<2cm
Limited to vulva/perineum X>2cm
Spread to lower
urethra/anus/Unilateral LN
Invade into
Bladder/rectum/bilateral LN
Distant metastasis

Staging: done during surgery
Tx:
 Unilateral lesion without LN involvement  modified radical vulvectomy
 Bilateral  radical vulvectomy
 Involved LN must undergo Lymphadenectomy
lymphatic drainage : superficial inguinal lymph nodes  deep femoral nodes
external iliac lymph nodes
...

 Longitudinal
 Transverse
 Oblique

 First Stage: (4-12hr)
o Latent phase:
 Uterine contraction  infrequent and irregular
 Slow cervical dilation and effacement (3-4 cm)
o Active phase:
 Rapid cervical dilation to full dilation  1
...
5)
 Painful, regular contraction 2-3 min, lasting 1 min
 Second Stage: (20-50 min)
o Full Dilation  Delivery
o Fetal Head descent
o Steps:
 Engagement
 Descent
 Flexion
 Internal rotation
 Extension
 External rotation
 Delivery of Anterior shoulder
 Delivery of Posterior shoulder
 Third Stage: (5-30 min)
o Immediately after Delivery
o Separation and expulsion of the placenta (Blood, uterus rise, uterus  Firm
and globular, umbilical cord protrude)
o May last up to 30 min
o Give oxytocin (reduce risk of PPH)

Attitude: Posture of the
Fetus
...


Cephalic presentation





Vertex
Sinciput
Brow
Face

Breech Presentation
 Complete
 Frank
 Footling

Shoulder
presentation

Position: relationship
of presenting part to
maternal pelvic

most common: OA (Left)

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Khaled khalilia
Fetal Monitoring
Fetal Distress
 Baseline FHR
o normal range is 110-160 bpm
o parameter of fetal well-being vs
...

 Reactive NST:
o Detection of 2 Fetal movements
o Acceleration of FHR > 15 bpm ( lasting 15-20 Seconds) over 20 min
...


Biophysical Profile
Def: Us assesment of the Fetus +/- NST

Consist of:
 Fetal HR
 Fetal Tone
 Fetal Breathing
 Fetal Movements
 Amniotic Fluid level

Indication:
 Abnormal NST
 Post-term pregnancy
 ↓ fetal movements
 Fetal Distress

BPP:
 8 – 10  Normal
 4 – 8  Inconclusive
 X < 4  Abnormal

Acceleration: (Not dangerous)
 ↑HR > 15 ( for x > 15 Sec )
 At least 2 accelerations every 15 min
...
Hydramnios

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Khaled khalilia

Physiological Change during Pregnancy
↑ Increased

↓ Decreased

Screening

General
Β-hCG

 ↑ HR
 ↑Cardiac output 40%
 ↑ Plasma Volume 40%
 ↑ Blood volume
 ↑ TBG
 ↑ Total urinary output
 ↑GFR









 ↓ BP
 ↓ Htk
 ↓ Creatinine
 ↓ Ca²
 ↓TLC, RV










Heart L
...

Spider Angioma 
Striae gravidarum  connective tissue change
↑ Areola pigmentation 
Chadwick sign  Blue Discoloration of Vagina & Cervix
...

+ in Serum  9 d post-conception
+ in Urine  28 d after first day of LMP
...

Best initial Test when suspecting pregnancy

Screening Tests:
 Β-hCG
 US (8-12wk)  CRL
 Triple Screen: Maternal Serum α-Fetoprotein, β-hCG, Estriol
...
↑
MSAFP: dating error, Neural tube defect, abdominal wall defect
...
patient with Rh isoimmunization
...

 Nägele Rule: Estimation of the day of Delivery by: Last menstrual period – 3 months +7
Days
...
Of pregnancies of any Gestation (include: current pregnancy,
abortion, Ectopic pregnancy, moles)
...

Parity: (TPAL):
o T: Nr
...
Of premature infants
o A: Nr
...
Of living children

Quickening: ( feeling fetal movements)
Primapara:
Multipara:

Khaled khalilia

Gynecoid

Anthropoid

Android

Platepelloid

21

Khaled khalilia

Contraindicated Drugs:

ACE-Inhibitors

Tetracycline

Retinoids

Misoprostol
↑↑ adverse Effects:

Phenytoin

Valproate

Lithium

Carbamazepine

Warfarin

Erythromycin

Chloramphenicol
Vaccine:

Contrindicated: (MMR) Rubella, Mumps, measles + oral typhoid

Safe: Tetanus, Diphteria, Influenxa, Hepatitis B, Pertusis

Termination of Pregnancy:
 Medical:
o X < 9 wk  methotrexat + Misoprostol
o X > 12 wk  Prostaglandins or Misoprostol
 Surgical:
o X < 12 dilation + vacum aspiration +/- curettage
o X > 12 dilation and evacuation

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Khaled khalilia

Khaled khalilia

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Khaled khalilia

Khaled khalilia

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Khaled khalilia
Contraception
Hormones

Barrier methods

 Combined Oral
Contraceptive
 Progestin-only-pill
 Mirena IUD
 Transdermal
 Nuva Ring
 Depo-Provera

Surgical

Natural

 Diaphragm condom
 Spermicides

 Male Sterilization
 Female Sterilization

Postcoital

 Coitus Interruptus
 Period
 Breast feeding (Lactation)







Estrogen
Estrogen/progestin
Cooper IUD (after)
Danazol
Mifepristone (Emergency)

Combined Oral Contraception
Absolute contraindication
 M
...
a:
 inhibit LH,FSH  ovulatory Supression
 Decidualization of Endometrium
 Thickening of cervical mucous ↓ sperm
penetration
...

 Drug interaction: Rifampin, Phenobarbital,
Phenytoin
...

 examination of the ejaculate for sperm-free
on two successive occasions  Effective
 ↓ failure (pregnancy) rate
 Female Sterilization:
 uterine Tube ligation
 can be performed immediately postpartum
...
o
...

 Cooper Device (Must be removed every 6 years)
...

Complication:
 Bleeding, cervical shock, perforation
 Infection (in case of PID: remove + AB)
 Ectopic pregnancy
 Expulsion
Risk of PIS doesn’t increase beyond first
month











Cigarette smoking
Controlled HTN
Obesity
DM
Family history of Arterial disease
Hyperprolactinemia
Depression
Chronic systemic Disease (SLE,
Sickle cell disease

progesterone-only oral contraceptives
 Taken daily without breaks
...

 Women intolerant to side effects of combined OCP
...
O
...

 held in place over the cervix by suction
...

Bacteremia risk
Dysmenorrhea
Prosthesis

Khaled khalilia








Medroxy-progesterone-acetate (150mg)
Injectable
Initiate within 5 days of beginning of normal Menes
...

 First time after 20 Wk
 Disappear 12 Wk (Postpartum)

Hellp Syndrome
 a life-threatening pregnancy complication
usually considered to be a variant of
preeclampsia
...

 Control BP (Hydralazine, Labetalol)
 Mg²SO4 : controversial +/-

S+S:
 ↑ BP (Diastolic ≥ 90)
 ↑ weight gain (rapid)
 Headache
 Epigastric pain (RUQ)
 Proteinuria
Risk Factors:
 Chronic HTN
 Renal Disease
 DM
 Polyhdraminos
 Age > 40, <18
 Previous Preeclampsia
Dx:
 Anemia/ Thrombocytopenia
 ↑ uric acid
 Roll-over Test: ↑Diastolic pressure > 20 mmHg
in supine position
...
(Grand mal, Tonic-Clonic)
...

Liver function Test (ALT, AST)
Coagulation profile

Stabilize the mother -> then deliver the Baby
...

 Vaginal:

Chronic Hypertension

28

Khaled khalilia
Gynecological Infection
Candida

Symptoms

Etiology

Fungus
 Candida Albicans

 Discharge:
Thick/white
 Pruritus
 ↑ before Menes
 ↑ during pregnancy
 Beef-RedAppearance
 Cheesy material

Trichomoniasis

Bact
...
Gonorrhea

 90% HSV-2(Genital)
 10% HSV-1 (Oral)

 Treponema pallidum

 6+11  condyloma
 16, 18, and 31 
cervical neoplasia








 Gray, thin discharge
 Fish Odor
 X no vaginal irritation














 Tingling, Burning
 Pruritus
 Ulceration + Vesicle




1
...

2
...
Optic atrophy, tabes
dorsalis, aortic
aneurysm, Gumma







 Clue cells
 Fish odor

 Cervical culture
 Nucleic acid amplification

 Gram stain
 Culture
(cervical/throat)

 Viral culture
 Cytologic smear
 HSV DNA PCR

 Aspiration: Ulcer/Node
 Darkfield microscopy

 Cytology
 Colposcopy (Biopsy)

Discharge: Yellow/Green

Strawberry spots
Pruritus
Dysuria
Frequency

 ↑↑ WBC
 Inflammatory cells
(PMN)


Investigation

Gonorrhea

 Trichomonas
Vaginalis



Treatment

Chlamydia

Asymptomatic
Muco-purulent discharg
Dysuria
Frequency
Bleeding
Symptomatic partner

test



(most sensitive, specific)

 + VDRL
 FTA-ABS (specific anti
treponemal antibody
test)  Confirmation

 Antifungal:
 Econazole
 Miconazole
 Fluconazole (oral)



 Mitronidazole
(2gr single dose)

 Sexual Transmission

 A
 Mitronidazole

 ↑increased risk for







Doxycycline or
Azithromycin (pregnant)
Amoxicillin (pregnant)
Treat Gonorrhea
Treat partner

 Associated with

Extra

preterm labor

Khaled khalilia

N
...

 Neurosyphilis: Penicillin
(IV)
 penicillin allergy:
Desensitization with
phenoxymethyl penicillin
 FTA-abs are diagnostic
even in the presence of
SLE
...
Vaginosis

Herpes Simplex

Syphilis

HPV

 Gardenerella
vaginalis

 Chlamydia Trachomatis

 N
...
Painless ulcer: vulva,
vagina, cervix
...
Maculopapular rash:
palms, soles, Limbs,
condylomata lata
6
...
gonorrhea

 Ceftriaxone(1) +
Azithromycin(1)
/Doxycycline
 Treat chlamydia
(coinfection)

 Acyclovir


 Penicillin G (IM)
 Treat Partner

 Associated with
Chlamydia

 Active infection
during labor  CSection


 gumma: soft, non-

cancerous growth 3rd
stage
...




Asymptomatic
Wart like lesion
Hyperkeratotic
Edema
Macular lesion

Khaled khalilia

Khaled khalilia

30



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