Obstetrics and Gynaecology

Topics In This Section

Puerperal Complications

Endometritis
Mastitis
Postpartum Depression
Postpartum Haemorrhage
Postpartum Psychosis
Postpartum Urinary Retention
Sheehan's Syndrome
Uterine Inversion

Gynaecology

Adenomyosis
Amenorrhoea
Bacterial Vaginosis
Bartholinitis/Bartholin Gland Abscess
Candidiasis
Cervical Cancer
Cervical Ectropion (Eversion)
Cervical Polyp
Chancroid
Chlamydia
Missed OCP
Dysfunctional (Abnormal) Uterine Bleeding
Endometrial Carcinoma
Endometriosis
Gonorrhoea
Herpes Simplex Virus
Human Papillomavirus
Infertility
Leiomyomata (Fibroids)
Lichen Simplex Chronicus
Lichen Sclerosis
Menopause
Ovarian Torsion
Ovarian Tumours
Pelvic Inflammatory Disease
Pinworm Vulvovaginitis
Polycystic Ovarian Syndrome
Postmenopausal Bleeding (non-specific)
Stress Incontinence
Syphilis
Trichomoniasis
Vulvar Abscess
Vulvar Malignancy

Maternal Conditions In Pregnancy

Acute Fatty Liver of Pregnancy
Eclampsia
Gestational Diabetes Mellitus
Gestational Hypertension
Hyperemesis Gravidarum
Lower Urinary Tract Infection
Obstetric Cholestatis
Peripartum Cardiomyopathy
Pre-Eclampsia
Venous Thromboembolism

Obstetric Complications in Pregnancy

Abnormal Placentation
First Trimester Infection (CMV)
Ectopic Pregnancy
Gestational Trophoblastic Disease
Accelerated Fetal Growth
Miscarriage
Multiple Gestation
Oligohydramnios
Placental Abruption
Placenta Previa
Polyhydramnios
Twin-twin Transfusion Syndrome
Vasa Previa

Labour and Delivery Complications

Care in Labor
Amniotic Fluid Embolus
Breech Presentation
Chorioamniotis
Vaginal Birth after C-Section
Intrauterine Fetal Death
Premature Rupture of Membranes
Preterm Labour
Prolonged Pregnancy
Shoulder Dystocia
Umbilical Cord Prolapse
Uterine Rupture


Obstetrics: Maternal conditions in pregnancy

Acute fatty liver of pregnancy

Clinical features:

  •  Occurs during 3rd trimester
  • Nausea and vomiting, abdominal pain, jaundice. disseminated intravascular coagulation (DIC), renal failure.

 Investigation:

  • Diagnosis usually based on: Combination of symptoms + timing (3rd trimester or after delivery) + investigation results (CBE, LFT, EUC, BSL, coags)
  • Diagnostic: liver biopsy (not commonly performed) - showing microvesicular fatty infiltration of hepatocytes.

Treatment:

  • Maternal stabilization. Deliver baby (regardless of gestational age)

Note: High risk of maternal/fetal mortality

 

Eclampsia

Clinical features:

  • New onset tonic-clonic seizure in woman with pre-existing preeclampsia

Investigation:

  • Clinical diagnosis based on above features.

Treatment:

  • Initial:
    • ABCs. Roll to left lateral decubitus position. O2 via facemask. Magnesium sulfate. Aggressive antihypertensive therapy (hydralazine or labetalol).
  • Definitive:
    • Delivery (likely via C-section or induction)

 

Gestational diabetes mellitus

Clinical features:

  • Often asymptomatic.

Investigation:

  • Diagnostic: Oral Glucose Tolerance Test (OGTT).
  • If high risk (Example: personal/family history of DM/GDM): then OGTT at 14 weeks. All other women: OGTT at 24-28 weeks.

Treatment:

  • 1st line: diet modification and physical activity (+ fasting BSL monitoringand at 2 hours postprandial)
  • If: not meeting glycaemic targets in 2 weeks. Then: Insulin (+ BSL monitoring)
  • Ultrasound at 32 weeks (for macrosomia and polyhydramnios)
  • If: poor BSL control or evidence of GDM complications. Then: consider induction of labour at 38 weeks

Follow-up:

  • OGTT 6 weeks - 6 months after delivery (to confirm resolution of GDM)

 

Gestational hypertension

Clinical features:

  • Usually asymptomatic.
  • Criteria: BP ≥140 systolic or ≥90 diastolic developing after 20 week gestation
  • If: hypertensive before 20 week GA, then: defined as pre-existing hypertension.

Investigation:

  • Diagnostic: Clinical diagnosis (see above).
  • Key parts of workup:
    • Performed weekly for remainder of pregnancy:
    • Urine dipstick or spot urinary protein: creatinine ratio and 24 collection. If: proteinuria (>300mg in 24 hours), then: preeclampsia
    • CBE and LFTs. If: Haemolytic anaemia, elevated LFTs and low platelets, then: HELLP syndrome

Treatment:

  • If: preeclampsia or HELLP syndrome, then: see respective sections
  • If: otherwise, then: labetalol OR nifedepine OR methldopa OR hydralazine (PO usually.)
  • If: severe, then: consider IV administration of BP lowering medications. Induce at 37 weeks of GA

 

Hyperemesis gravidarum

Clinical features:

  • Criteria generally varies:
    • Nausea and vomiting in pregnancy severe enough to warrant admission for rehydration
    • Nausea and vomiting in pregnancy with ketones in urine and ≥5% body weight loss

Investigation:

  • Diagnostic: Clinical diagnosis (see above)
  • Urine dipstick (for ketones). EUC (for electrolyte abnormalities). Urine MCS (for UTI).
  • Ultrasound on admission (rule out gestational trophoblastic disease)

Treatment:

  • Initial: IV fluids. Consider thiamine/glucose for prolonged vomiting (to prevent Wernicke’s encephalopathy). Correct electrolyte abnormalities.
  • Best:
    • Non-pharmacological: Stay hydrated. Avoid mixing fluids and solids. Small, frequent meals. Avoid food high in daily, fat and spice. Increase sleep/rest. Ginger. Acupuncture.
    • Pharmacological:
      • 1st line: Doxylamine + B6 OR Metoclopramide
      • 2nd line: Ondansetron

 

Lower urinary tract infection

Clinical features:

  • Dysuria.
  • Urinary frequency.
  • Foul smell to urine.

Investigation:

  • Initial: Urine dipstick (Leucocytes, blood, nitrates)

Diagnostic: Quantitative Urine MC&S

  • Treatment:
    • Best:
      • 1st line: cephalexin or nitrofurantoin or Augmentin
      • If: possible, then: avoid trimethoprim (especially in 1st trimester).
      • If GBS diagnosed, then: Penicillin V
      • If: pyelonephritis, then empiric: gentamicin and ampicillin IV
    • Follow-up:
      • Monthly urine MC&S
  • Note: In pregnancy you treat asymptomatic bacteriuria.

 

Obstetric cholestasis

Clinical features:

  • Pruritus of hands/feet.
  • Typically no rash present.

Investigation:

  • Diagnostic: Clinical (+ bile acids)

Treatment:

  • Best:
    • If: at term. Then: Deliver
    • If: pre-term. Then: ursodeoxycholic acid

Note: Associated with increased risk of sudden foetal death

 

Peripartum cardiomyopathy

Clinical features:

  • Generally >36 weeks gestation.
  • Often <4 weeks postpartum.
  • Features of heart failure (e.g. PND, SOB, peripheral oedema)

Investigation:

  • Diagnostic: Echocardiogram

Treatment:

  • Best: If: necessary for maternal health, then: deliver early (aim for vaginal delivery).
  • Treat heart failure as for any other adult (although avoiding ACEI/other teratogens).

Note: Return to baseline cardiac function within months after delivering is common

 

Preeclampsia

Clinical features:

  • Initially asymptomatic.
  • Associated with headaches, visual disturbances (flashing lights), epigastric pain, nausea and vomiting, peripheral oedema
  • Late stage – progression to HELLP syndrome or eclampsia

Investigation:

  • Initial: protein: creatinine ratio
  • Diagnostic: 24 hour urinary protein collection (>300mg) + hypertension (pre-existing or gestational) (BP >140/90)
  • Workup: CBE, LFTs

Treatment:

  • Best:
    • If: severe preeclampsia OR close to term. Then: stabilize BP with labetalol or hydralazine (aim for diastolic 90-100 to maintain foetal perfusion). Give magnesium sulfate. Then deliver (induce or C-section)
    • If: stable mild preeclampsia and far from term. Then: admit, daily monitoring and twice weekly bloods, fortnight foetal growth scans.
    • If: Magnesium toxicity. Then: consider calcium gluconate

 

Venous thromboembolism

Clinical features:

  • Features of DVT/PE

Investigations:

  • D-dimer unlikely to be useful (increases during pregnancy)
    • If: DVT suspected. Then: Leg Doppler USS
    • If: PE suspected. Then: CTPA vs. V/Q scan controversial

Treatment:

  • LMWH. Avoid warfarin (teratogenic). Continue anticoagulation for ≥6 weeks following delivery.

 

Obstetric complications in pregnancy

Abnormal placentation:

General:

  • Accreta - abnormal adherence of placenta with no plane of separation
  • Increta - Invades into the myometrium
  • Percreta - penetrates whole thickness of myometrium up to the serosal surface

Clinical features/Diagnosis:

  • Failure to deliver the placenta

Management (Post Delivery):

  • If: densely adherent, then do not try to remove. Clip cord and observe closely
    • If: stable, then: trial methotrexate (may avoid hysterectomy)
    • If: unstable, then: consider uterine artery embolisation, hysterectomy or ligation of internal iliac arteries

 

First Trimester Infection (CMV)

Clinical features:

  • Generally asymptomatic.
  • May present with low fever, myalgias and fatigue.
  • Lymphadenopathy.

Diagnosis:

  • CMV serology.
    • If: primary infection, then: expect positive IgM and negative IgG
    • IgM positive and IgG positive can also indicate primary infection.
    • Low IgGindicates infection in last 3-4 months.

Management:

  • Foetal risk assessment: ultrasound (to look for ascites, microcephaly and IUGR) AND Amniocentesis
  • Counselling regarding risk
    • If: primary infection is confirmed, then: 50% chance of infecting foetus.
    • If: infected foetus, then: 10% of these will be symptomatic.
    • Congenital CMV in future pregnancies for up to 4 years after seroconversion.

 

Ectopic pregnancy

Clinical features:

  • RLQ/LLQ abdominal pain.
  • Spotting.
  • Amenorrhoea.

Investigations:

  • Initial: beta-hCG. Coagulation studies.
  • Diagnostic: TVUS. Or Transabdominal (less sensitive)
    • If: nothing visible intrauterine on TVUS and beta-hCG >1,500.
      • Then: likely ectopic
    • If: nothing visible intrauterine on TVUS and beta-hCG <1,500.
      • Then repeat beta-hCG in 48 hours.
    • If: beta-hCG hasn’t doubled, then: non-viable pregnancy (either intrauterine or ectopic).

Treatment:

  • If: patient is haemodynamically stable, has easy access for follow-up and gestational sac <3.5cm in size, then: can consider trial of methotrexate. Must follow-up closely to ensure effective.
  • If: otherwise, then: laparoscopic surgery

Note: Intrauterine pregnancy should be visible on TVUS as beta-hCG of 1,500 and be visible on transabdominal USS on 3,000.

 

Gestational trophoblastic disease

Clinical features

  • First trimester severe nausea/vomiting.
  • Abnormal uterine bleeding.
  • Increased SFH.
  • Positive pregnancy test

Investigation

  • Initial: Quantitative serum B-HCG (expect to be elevated >100,000)
  • Diagnostic: USS
  • Chest X-ray, LFTs
  • Evacuate uterus (D&C) for histology (diagnostic for type)

Treatment:

  • Based on histological diagnosis following D&C
    • If: Benign GTD (incomplete or complete molar pregnancy).
  • Then: may require no further treatment.
    • If: Malignant GTD (invasive mole or choriocarcinoma).
  • Then: chemotherapy (methotrexate and dactinomycin)
    • If: residual uterine disease. Then: hysterectomy
  • Repeat vaginal ultrasound 7 days after D&C
  • Post D&C B-HCG monitor weekly for 13 weeks, then monthly for 9 months
  • Avoid further pregnancy for at least 6 months

 

Intrauterine growth restriction

Clinical Features:

  • Definition: Estimated Fetal Weight (EFW) <10th percentile. Tested by abdominal exam, fundus height and ultrasound
  • Important to compare based on previous measurements to determine if growth is plateauing or possibly constitutional

Investigations:

  • Assess state of fetus: Ultrasound, amniotic fluid index and umbilical artery Doppler
    • If: Doppler = reversed/absent flow, then: admit for CTG and delivery
    • If: Doppler = increased resistance, then: repeat assessment in 2 weeks
  • Consider investigating underlying cause: serology for TORCH, CBE, chromosome/karyotype, thrombophilia screen
  • Monitor fetal growth (USS measurement every 2 weeks and amniotic fluid index)

Treatment:

  • Best:
    • Modify controllable risk factors (smoking, alcohol, nutrition, maternal illness).
    • Consider delivering early (normally by C-section as IUGR fetus withstands labour poorly).

 

Accelerated Fetal Growth

Clinical features:

  • Increased SFH (> 90th percentile).
  • Important to compare with previous measurements.
  • Macrosomia = (>4000g or 90th centile)

Investigation:

  • USS (for biparietal diameter, head and abdominal circumference).
  • Follow-up with serial measurements.
  • Oral Glucose Tolerance Test

Treatment:

  • Best:
    • Consider induction of labour:
  • At term, If: estimated fetal weight >5,000g
  • At 37 weeks, If: diabetic

Note: No evidence that C-section improves outcomes

 

Miscarriage

Clinical features:

  • Loss of pregnancy at <20 weeks
  • Cramping abdominal pain.
  • Uterine bleeding (+/- loss of products of conception).
  • Cervical os may be open or closed.

Types:

  • Threatened (closed os, no POC expelled)
  • Inevitable (open os, no POC expelled)
  • Incomplete (open os, some POC expelled)
  • Complete (closed os, POC expelled, USS shows empty uterus)
  • Missed (closed os, no POC expelled, USS shows retained tissue and no cardiac activity at CRL >8mm) (if: at >20 wks. Then: called intrauterine fetal demise)
  • Septic (endometritis and US shows absent fetal cardiac activity).

Investigation and treatment:

  • If: missed miscarriage, then: TVUS (expect to see no heartbeat with CRL >8mm OR gestation sack >25mm without fetus visible). If: result unclear, then: conduct TVUS again in 1 week. Treatment options may include:
    • (a) Expectant management (wait for products of conception to pass)
    • (b) Pharmacological (mifepristone then misoprostol). Available up to 9 weeks gestation
    • (c) Surgical. If: <13 weeks, then: vacuum is an option. If: >13 weeks, then: D&C.
  • If: heavy bleeding or pain or prolonged symptoms. Then: D&C
    • If: septic miscarriage. Then: swab for microscopy and culture. Then: antibiotics. Then: 12 hours later D&C
    • If: complete miscarriage. Then: clinical diagnosis.

Note: intrauterine pregnancy should be visible on TVUS when beta hCG > 1500

 

Multiple gestation

Clinical features

  • Increased SFH.
  • Hyperemesis.

Investigation:

  • Diagnostic: Ultrasound

Treatment:

  • Best:
    • Increased antenatal fetal surveillance (every 2-3 weeks in 3rd trimester gestation to assess for IUGR)
    • If: Twin A is in vertex position. Then: may attempt vaginal delivery
    • If: Otherwise. Then: C-section

 

Oligohydramnios

Clinical features

  • Decreased SFH.

Investigation:

  • Diagnostic: Amniotic fluid index (AFI) <5cm on US
  • Workup: Admit to hospital for investigation and fetal monitoring. Rule out inaccurate GA and rupture of membranes. Look for underlying causes (incl. Doppler of umbilical cord and uterine artery).

Treatment:

  • Initial: Admit to hospital and ensure adequate maternal hydration.
  • Best: Treat underlying cause or consider delivery.

 

Placental abruption

Clinical features

  • Abdominal pain.
  • Vaginal bleeding – not always present
  • Hard “Wood-like” uterus on palpation
  • May have decreased fetal movements and haemodynamic instability.
  • May follow trauma (e.g. Motor vehicle accident).

Investigation:

  • Diagnostic: Clinical Diagnosis
  • CTG (to assess for fetal distress)
  • Workup: Transabdominal/Transvaginal US (primarily to rule out placenta praevia - not sensitive test for placental abruption)

Treatment:

  • Initial: Maternal IV fluids +/- O2 and vitals monitoring. Indwelling catheter, Group and hold packed RBCs, platelets and fresh frozen plasma (due to risk of developing DIC)
    • Best:
      • If: fetal/maternal distress. Then: C-section
      • If: term and no fetal/maternal distress, then: stabilise and deliver (vaginal or C-section)
      • If: very preterm and no fetal/maternal distress, then: can consider monitoring

Note: If risk of Postpartum Haemorrhage. Consider anti-D.

 

Placenta previa

Clinical features:

  • Painless vaginal bleeding occurring >20 weeks gestation.

Investigation:

  • Initial/Diagnostic: Transabdominal or Transvaginal US
  • If: bleeding, then: determine if patient requires anti-D (incl. Blood group, antibodies and Kleihauer-Betke test)

Treatment:

  • Initial: maternal IV fluids +/- O2 and monitoring of maternal and fetal vitals.
    • Best
      • If: no bleeding, then: can be managed as outpatient. Follow-up: USS every 2 weeks
      • If: active bleeding, then: admit (any bleeding requires at least 24 hour admission), ABCs, CTG, Apts test (to check for vasa previa), deliver if >34 weeks.
      • If: placenta previa and stable, then: C-section at 37 weeks

Note: Do not perform a vaginal exam until placenta previa has been ruled out by US. Majority of low-lying placentas identified at 20 weeks will not be low at term. Consider anti-D.

 

Polyhydramnios

Clinical features:

  • Increased SFH (Symphysial Fundal Height)

Investigation:

  • Diagnostic: Amniotic fluid index (AFI) >25cm
  • Work up to determine underlying cause: USS (in particular morphology). Screen for maternal illness/infection

Treatment:

  • Best:
    • If: Mild/moderate severity. Then: No treatment required.
    • If: severe. Then: admit and consider therapeutic amniocentesis
    • Treat underlying cause

 

Twin-twin transfusion syndrome

Clinical features

  • Usually detected on USS.

Investigation:

  • Initial: Ultrasound showing disparity in fetal size in monochorionic twins
  • Diagnostic: US Doppler flow analysis
  • Recommended surveillance: Ultrasound every 2 weeks from 16 weeks

Treatment:

  • Best:
  • Consider: intrauterine blood transfusion to donor twin, laser ablation or Laparoscopic occlusion of placental vessel.

 

Vasa previa

Clinical features:

  • Painless vaginal bleeding.
  • Classically following artificial rupture of membranes.

Investigation:

  • Initial: Apt test (turns pink if foetal bleeding), Wright stain (shows nucleated RBCs if foetal bleeding). Foetal distress on CTG
  • Diagnostic: umbilical artery Doppler (waveforms at same rate as fetal heart rate).

Treatment:

  • Best:
    • If: antenatal diagnosis (All women with history of low lying placenta should have Doppler USS to assess placental site). Then: plan for elective C-section
    • If: suspected diagnosis with fetal compromise. Then: Emergency C-section followed by neonatal resuscitation.

 

Obstetrics: Labour and delivery complications

Care in Labor (including obstructed labor)

Clinical features:

  • Regular painful uterine contractions with cervical changes.
  • May have fluid loss with rupture of membranes

Investigation

  • Initial: vaginal examination (every 4 hours), vitals every hour (external Doppler)
  • Consider CTG (if oxytocin or epidural)

Management:

  • If: failure to progress, then:
    • Assess possible causes:
  • Power (CTG to assess for adequate contractions)
  • Passenger (review predicted size and current presentation)
  • Passage (indicated by increased molding of fetal skull and prominent ischial spines)
    • Then: Augmentation: (1) ARM with oxytocin infusion, perform vaginal exam after 4 hrs. (2) Consider epidural in absence of posterior position fetal head
  • If: above fails, then: consider delivery via C-section

 

Amniotic fluid embolus

Clinical features

  • Variable presentations.
  • Classically: Hypoxia, haemodynamic instability and DIC.
  • Acute pulmonary oedema → SOB and Cough.
  • Fetal distress.

Investigation:

  • Diagnostic: Clinical diagnosis

Treatment:

  • Best: Supportive measures (High flow O2, ventilation support, fluid resuscitation, inotropic support +/- intubation), coagulopathy correction and ICU admission
    • If: maternal cardiac arrest unresponsive to resuscitation, then: perform perimortem C-section

Note: Essentially is an anaphylactic reaction to amniotic fluid, which has got into maternal circulation. High mortality rate.

 

Breech presentation

Clinical:

  • Abdominal palpation: lie vertical, presentation breech

Investigation:

  • Diagnostic: Ultrasound to confirm type breech presentation.
  • Types include: Frank, complete, footling

Treatment:

  • Best:
    • If: GA <37wks. Then: Monitor for spontaneous revert to vertex. Approximately 3/4 spontaneously reverts by week 38.
    • At term: Offer External Cephalic Version (ECV) with salbutamol tocolysis (if no complications) OR C-section.
  • For ECV, there must be facilities available for emergency C-section (risk of placental abruption).
  • Both trial of labour and C-section are possible options. Provide information and get informed consent.

 

Chorioamnionitis

Clinical features:

  • Foul smelling vaginal discharge, uterine tenderness, and fever.
  • Predisposing: Premature Preterm Rupture of Membrane

Investigation:

  • Initial: low and high vaginal swab for culture, CBE
  • Diagnostic: amniotic fluid shows raised leukocytes or bacteria

Treatment:

  • Best:
    • 1st line: IV ampicillin, gentamicin and metronidazole.
    • Need to expedite delivery

 

Vaginal birth after C-section (VBAC):

Management

  • Notable risk of uterine rupture
    • If: previous C-section was LSCS,
    • Then: can offer repeat LSCS OR spontaneous onset of labor
  • Prostaglandin induction and oxytocin augmentation increases risk of rupture

 

Intrauterine fetal death

Clinical Features:

  • Absence of fetal movement

Investigation:

  • Diagnostic: US showing absent fetal heart rate and movement

Treatment:

  • Best: Induction of labour (and monitor for maternal coagulopathy). Follow-up with psychological care and determine cause and plan for future pregnancies

 

Premature rupture of membranes

Clinical features:

  • Rupture of membranes >4 hours before onset of labour.

Investigation:

  • Initial: Sterile speculum examination. Amnistick (nitrazine stick - turns blue) or ferning (both indicate membranes have ruptured)

Diagnostic (if doubt): US guided instillation of indigo carmine dye to check for leakage (not commonly performed)

  • Follow-up: WCC + CRP and CTG every 2-3 days until delivery

 

Treatment (with/without labor):

  • Best:
    • All: Benzylpenicillin IV. If: allergic, then: clindamycin.
    • If: fetal distress or chorioamnionitis. Then: deliver urgently regardless of GA (see chorioamnionitis management summary)
    • If: GA ≥37 wks. Then: induce. If: preterm, then: discuss risks vs. benefits of early delivery
  • Note: Also known as ‘Pre-labour’ rupture of membranes (i.e. ‘premature’ in this instance refers to rupture prior to onset of labour, rather than a given number of weeks of gestation). If premature rupture of membranes and <37 weeks gestation, then called preterm premature rupture of membranes (PPROM).

 

Preterm labour

Clinical features:

  • Onset of labour at GA <37 week.
  • Onset defined by regular uterine contractions and concurrent cervical change

Investigation:

  • Diagnostic: Clinical diagnosis (see above)
  • Fetal fibronectin to determine if likely to deliver in next 7 days (high negative predictive value)

Treatment:

  • Best:
    • If GBS positive: then benzylpenicillin
    • If: any contraindications to tocolysis (e.g. preeclampsia/eclampsia, chorioamnionitis, IUGR). Then: Proceed with delivery
    • If: Not contraindicated. Then: Tocolysis (nifedipine is first line) for <48 hours to allow for administration of betamethasone and transfer to centre with appropriate facilities. Then delivery.
    • If: <35 weeks. Then: steroids (betamethasone)
    • If: <30 weeks. Then: Magnesium sulphate

 

Prolonged pregnancy

Clinical features:

  • GA >41 weeks

Investigation:

  • Diagnostic: Clinical diagnosis.

Treatment:

  • Best:
    • If: GA 40-41 weeks. Then: expectant management
    • If: GA >41 weeks. Then: Offer induction of labour or C-section
    • If: GA >41 weeks and patient chooses expectant management. Then: serial fetal surveillance. If: decreased amniotic fluid index detected. Then: induce labour.

 

Shoulder dystocia

Clinical Feature:

  • “Turtle Sign” – appearance and retraction of fetal head during labour

Investigation:

  • Diagnostic: Clinical diagnosis

Treatment:

  • Best:
    • Immediate: call for urgent help (obstetric emergency)
    • 1st line: Series of repositioning manoeuvres
  • McRobert’s maneuver
  • Suprapubic pressure
  • Wood’s corkscrew
  • Episiotomy
  • Hands and knees

2nd line: Other options such as Zavanelli maneuver, symphiostomy

 

Umbilical cord prolapse

Clinical Features:

  • Sudden decrease in fetal heart rate
  • Occasional palpation of cord on vaginal examination

Investigation:

  • Diagnostic: Clinical diagnosis (cord visible or palpable)
  • CTG showing Severe variable decelerations

Treatment:

  • Best:
    • If: fetus alive. Then: O2 to mother. Alleviate pressure of presenting part on cord by manually pressing on it (maintain this position until C-section). Apply warm saline soaks to cord. Emergency C-section.
    • If: Fetus not viable. Then: allow labour.

 

Uterine rupture

Clinical features:

  • Sudden loss of fetal station during labour.
  • Abdominal pain different from contractions.
  • Fetal distress.
  • Vaginal bleeding.
  • Fetal bradycardia (70% of cases), atypical pattern of pain
  • Predisposing: previous C-section, prolonged labour, oxytocin during labour, multiple gestations.

Investigation:

  • Diagnosis made on clinical grounds

Treatment:

  • Best: Resuscitation, urgent laparotomy/C-section.
    • 1st line: Repair of uterus
    • 2nd line: hysterectomy

 

Obstetrics: Puerperal complications

Endometritis

Clinical features

  • Occurs typically following delivery
  • Foul smelling vaginal discharge.
  • Abdominal pain.
  • Fever.

Investigation:

  • Swab for culture. Blood cultures, CBE, urine MCS.
  • Diagnostic: endometrial biopsy (rarely performed).

Treatment:

  • Best: Oral or IV antibiotics (Clindamycin and gentamicin)

 

Mastitis

See Surgery → Breast endocrine surgery

 

Postpartum depression

Clinical features

  • Depressed mood >2 weeks post birth of baby.
  • OR Presence of severe depressive symptoms (e.g. complete lack of interest in baby, suicidal or homicidal/infanticidal ideation)

Investigation:

  • Clinical diagnosis
  • CBE, TFT (to exclude organic causes)

Treatment:

  • Risk +/- detention +/- mandatory reporting
  • Best: Treat as standard depression. SSRIs, SNRIs and TCAs are okay while breastfeeding.

 

Postpartum haemorrhage

Clinical features

  • >500mL blood loss during/after vaginal delivery or >1,000mL for C-section

Investigation:

  • Clinical diagnosis
  • Workup to determine underlying cause: physical examination. CBE, coagulation profiles. Ultrasound can confirm diagnosis of retained placental tissue.

Treatment:

  • Initial: Resuscitation with ABCs, 2 large bore IVs and crystalloids.
  • Best: Treat underlying cause
    • If: retained placental tissue. Then: Uterine massage. Oxytocin. Controlled cord traction. Then manual removal of placental tissue in theatre. If: required, then: D&C. May require embolisation or hysterectomy.
    • If: Uterine atony. Then: Uterine massage. Then oxytocin. Then ergometrine.
    • If: trauma. Then: surgical repair.
    • If: Coagulopathy. Then: correct coagulopathy.

 

Postpartum psychosis

Clinical features:

  • Psychosis usually developing <2 weeks following delivery.
  • Predisposing: Bipolar in particular, and any other mental illness.

Investigation:

  • Clinical diagnosis
  • Always enquire about suicidal/infanticidal ideation
  • Consider urine drug screen

Treatment:

  • Risk +/- detention +/- mandatory reporting
  • Best: options include antipsychotics, anticonvulsants and ECT.

Note: Some antipsychotics are relatively contraindicated during breastfeeding.

 

Postpartum urinary retention

Clinical features:

  • Urinary retention.

Investigation:

  • Clinical diagnosis

Treatment:

  • Best:
    • If: unable to void 6-8 hours post delivery. Then: in/out catheter
    • If: If still unable to void a further 6 hours later. Then: place catheter.
    • Remove catheter after 24 hours.
    • After removal of catheter, determine if patient can void. If: not, then: discharge home with either indwelling catheter or intermittent self-catheterisation

Note: majority will resolve spontaneously with time

 

Sheehan’s syndrome

Clinical features:

  • Occurs following severe Post Partum Haemorrhage
  • Evidence of hypopituitarism, such as: inability to breastfeed, lack of return of normal periods, hypothyroidism (fatigue, weight gain, cold intolerance.)

Investigation:

  • Diagnostic: Provocative hormone testing of hormones that are clinically deficient (e.g. short synacthen test) and brain MRI.

Treatment:

  • Best: Replace deficient hormones

Note: Patients may recover TSH and FSH/LH after replacement of cortisol.

 

Uterine inversion

Clinical features

  • Visible inversion of uterus (e.g. to introitus).
  • Hypotension.
  • Postpartum haemorrhage.

Investigation:

  • Clinical diagnosis

Treatment:

  • Best:
    • ABCs: IV crystalloids. (Call for help)
    • Tocolytic drug (indomethacin) to relax uterus.
    • Attempt manual replacement of uterus and removal of placenta.
    • IV oxytocin
    • May require laparotomy.

Note: Causes shock through vasovagal response + blood loss

 

Gynaecology

Adenomyosis

Clinical features:

  • Sharp, knife-like dysmenorrhoea.
  • Enlarged tender boggy globular uterus.

Investigation:

  • Initial: Clinical diagnosis. US may help.
  • “Predictably identified” on MRI
  • Diagnostic: Biopsy/examination of tissue after hysterectomy

Treatment:

  • Best:
    • Symptomatic: NSAIDs
    • Definitive: Hysterectomy

 

Amenorrhoea

Clinical features/Diagnosis:

  • Absence of period by age 16.
  • Absence of period by age 14 with absence of normal growth/secondary characteristics.
  • Absence of period for 3 cycles or 6 months

Diagnosis:

  • Based on clinical features

Management:

  • Initial screening: beta-hCG, TSH, Prolactin
  • If normal: then evaluate ovarian function as follows:
    • (a) FSH (if: elevated, then: primary ovarian insufficiency. If: FSH low, then suspect hypogonadal hypogonadism),
    • (b) Oestradiol. If: low (with low FSH), then: indicates hypogonadal hypogonadism (e.g. weight loss or exercise related)
    • (c) Progestogen challenge (PCT),
  • If PCT Positive (withdrawal bleed), this indicates endometrium working + outflow tract intact. Then: cause is anovulation
  • If PCT Negative (no withdrawal bleed). Then: Hysteroscope or hysterosalpingogram (likely scarring of endometrium)

 

Bacterial vaginosis

Clinical features:

  • Thin/white vaginal discharge
  • Fishy smell.
  • Commonly caused by Gardnerella vaginalis

Investigation:

  • Diagnostic: Saline wet mount (expecting to see >20% clue cells - epithelial cells with multiple bacteria adhering to their surfaces). Positive KOH whiff test. Vaginal pH >4.5

Treatment:

  • Best:
    • If: patient is not pregnant and asymptomatic. Then: No treatment.
    • If: pregnant OR symptomatic. Then: Metronidazole.

 

Bartholinitis/Bartholin gland abscess

Clinical features:

  • Pain, erythema and swelling in location of bartholin’s glands.

Investigation:

  • Diagnostic: Clinical diagnosis

Treatment:

  • Best:
    • If: Asymptomatic cyst present. Then: No treatment +/- warm soaks + sitz baths.
    • If: Symptomatic with cellulitis. Then: Cephalexin
    • If: Symptomatic with abscess. Then: Incision and drainage with marsupialisation

 

Candidiasis

Clinical features:

  • Thick, white, cottage cheese like vaginal discharge.
  • Pruritus.

Investigation:

  • Diagnostic: Saline KOH wet mount (reveals hyphae and spores). Vaginal pH <4.5

Treatment:

  • Best: Fluconazole 1 tablet 150mg stat
  • Treat only symptomatic patients

 

Cervical cancer

Clinical features:

  • Can be asymptomatic
  • Or may have vaginal bleeding (e.g. postcoital or intermenstrual), dyspareunia.
  • Can metastasise and present with systemic symptoms of cancer such as weight loss, fatigue and bone pain.

Investigation:

  • Screening: Pap smear
    • New guidelines pending
  • Diagnostic (If: symptomatic or clinically abnormal cervix. Then: this is initial test): Colposcopy and biopsy

Treatment:

  • Best:
    • If: Symptomatic/clinically abnormal cervix. Then: Colposcopy with large loop excision of the transformational zone
    • If: adenocarcinoma suspected. Then: Cold knife cone biopsy may be used also.
    • If: Stage I (limited to cervix) and:
    • If: fertility desired. Then: Cervicectomy and lymphadenectomy
    • If: fertility not desired. Then: Radical hysterectomy, lymphadenectomy and postoperative chemoradiotherapy.
    • If: Stage II, III or IV: Chemoradiotherapy (including cisplatin).

 

Cervical ectropion (cervical eversion)

Clinical features:

  • May be asymptomatic
  • Vaginal discharge. Vaginal bleeding (e.g. postcoital or intermenstrual)
  • Area of erythema around external os

Investigation:

  • Diagnostic: Colposcopy and biopsy showing simple columnar epithelium extending past external os

Treatment:

  • Best:
    • If: Asymptomatic. Then: no treatment
    • If: Symptomatic and bothersome. Then: Ablation

 

Cervical polyp (endocervical polyps)

Clinical features:

  • May be asymptomatic.
  • Vaginal bleeding (e.g. intermenstrual or postcoital)
  • Polyp visible on speculum examination (bleeds easily if touched).

Investigation:

  • Diagnostic: Clinical diagnosis.
  • May be confirmed by histology.

Treatment:

  • Best: Removal. If: thin stalk, then: may be able to be removed with forceps. Otherwise may require cauterization or surgery.

 

Chancroid

Clinical features:

  • Genital ulcer. Classically single, deep ulcer. Grey/yellow exudate on base of ulcer. Painful. May have lymphadenopathy

Investigation:

  • Diagnostic: MC&S of ulcer exudate (organisms form parallel strands)

Treatment:

  • Best: Azithromycin

 

Chlamydia

Clinical features

  • Often asymptomatic
  • May have dysuria, discharge and fever.

Investigation:

  • Diagnostic: Morning urine NAAT, cervical swabs
  • Caused by chlamydia trachomatis

Treatment:

  • Best: Azithromycin OR doxycycline

 

Missed OCP

Management:

  • If: <24 hours since scheduled OCP dose (i.e. <48 hours since last pill). Then: take the missed pill now. Take the next pill at normal time. No need for extra precautions.
  • If: >24 hours since scheduled OCP dose (ie >48 hours since last pill) and:
  • If: took pill for previous 7 days. Then: take today’s pill and continue pack (if end of active pills in next 7 days, then skip the inactive pills and start new pack). Encourage patient to exercise extra precautions for 7 days.
  • If: didn’t take pill for previous 7 days. Then:
  • If: sex in previous 7 days without other contraception. Then: consider emergency contraception.
  • If: no UPSI in previous 7 days. Then: extra precautions for next 7 days
  • All: counsel patient on STI prevention and pap smears

 

Dysfunctional (abnormal) Uterine Bleeding

Clinical features:

  • Definition: abnormal quantity (e.g. heavy periods ≥80 mL), duration (e.g. long periods, >7 days) or timing (e.g. irregular periods)

Investigation:

  • Rule out other causes
    • Urine and serum beta-hCG.
    • CBE and iron studies.
    • TSH. Pap smear. STI screen. Coagulation studies.
    • TVUS
    • If: >45. Then: endometrial biopsy
  • Treatment
    • If: no underlying cause found. Then:
      • Explanation and reassurance.
      • NSAIDs (start 48 hours before period) and antifibrinolytics such as tranexamic acid.
      • COCP/levonorgestrel IUS.
      • Surgical intervention (endometrial ablation or hysterectomy)

 

Endometrial carcinoma

Clinical features:

  • Postmenopausal bleeding or abnormal uterine bleeding.
  • Fatigue and weight loss.
  • Symptoms of metastases.

Investigation:

  • Initial: TVUS
  • Diagnostic: Endometrial biopsy OR hysteroscopy and D/C (see postmenopausal bleeding summary)

Treatment:

  • Best:
  • If: Biopsy positive for malignancy. Then: Hysterectomy/bilateral salpingo-oophorectomy +/- chemotherapy or radiotherapy

 

Endometriosis

Clinical features:

  • Dysmenorrhoea.
  • Infertility.
  • Dyspareunia.
  • Abnormal uterine bleeding.
  • Posterior fornix tenderness or adnexal tenderness.

Investigation:

  • Initial: TVUS to exclude other causes (e.g. fibroids)
  • Diagnostic: Laparoscopy with direct visualisation and biopsy of lesions. Biopsy reveals endometrial mucosa outside of the uterine cavity.

Treatment:

  • Best:
    • Initial: 3 months NSAIDS.
    • OCP
    • Conservative laparoscopy using electrocauterisation
    • GnRH agonists - induce pseudomenopause
    • Bilateral salpingo-oophorectomy +/- hysterectomy
  • Note: Poor correlation between severity of disease and severity of symptoms. Surgery is aimed at treating fertility

 

Gonorrhoea

Clinical features:

  • Purulent vaginal discharge.
  • Associated with dysuria and lower abdominal pain.
  • May be asymptomatic
  • May also cause rectal/pharyngeal infection.

Investigation:

  • Diagnostic: Discharge MC&S.
  • Organism – Neisseria gonorrhoeae

Treatment:

  • Best: Ceftriaxone (for gonorrhoea) + azithromycin (to cover chlamydia)

 

Herpes simplex virus

Clinical features:

  • Pain/burning/tingling may precede lesion appearance.
  • Painful multiple vesicles/ulcers. Fever.
  • Multiple small vesicles on erythematous base.
  • Lymphadenopathy.

Investigation:

  • Diagnostic: HSV DNA PCR
  • HSV 1 (oral) and HSV 2 (genital)

Treatment:

  • Best: Acyclovir

 

Human papillomavirus (causing genital warts)

Clinical features:

  • Painless genital lesions (typically raised, soft non-keratinised masses, colour varies).
  • May be pruritic, bleed or cause dyspareunia.
  • Most commonly caused by HPV types 6 and 11

Investigation:

  • Diagnostic: Clinical diagnosis usually (or biopsy)

Treatment:

  • Best:
    • Imiquod.
    • Cryotherapy or surgical removal.

Notes: High recurrence rate following clearnance.

 

Infertility

Clinical features:

  • Definition: Not conceiving after 1 year of regular unprotected sex. 80% of normal couples conceive in this time.

Investigation:

  • Male: semen analysis
  • Female:
    • Day 21 progesterone (7 days before period, to assess for ovulation)
      • If: ovulation problem. Then: endocrine workup (FSH/LH, prolactin, testosterone, DHEA-S, TFTs, AMH). Then based on results → MRI/CT pituitary
      • If: not ovulation related.
        • Then: check for tube patency and uterine cavity with hysterosaplingogram or laparoscopy

Others: check rubella immunisation status

Treatment:

  • If anovulatory cause: then ovulation induction
    • Clomiphene citrate
  • Otherwise Initial: Encourage increased frequency of intercourse (3x per week)
    • Time with ovulation - basal temp, LH surge, cervical mucus
  • If: no pregnancy after 2 years, then:
    • IVF (20% success/cycle) vs. COH-IUI (8% success/cycle)
    • Controlled ovarian hyperstimulation, intrauterine insemination (COH-IUI)
  • Notes: Ovarian hyperstimulation syndrome is rare complication of IVF. Can check for Ovarian reserve with AMH (declines) and USS antral follicle count

 

Leiomyomata (Fibroids)

Clinical features

  • Abnormal uterine bleeding (in particular menorrhagia) +/- symptoms of anaemia. Dysmenorrhoea
  • Infertility.
  • May have pelvic pressure and urinary frequency from mass
  • Enlarged irregular uterus.

Investigation:

  • Diagnostic: TVUS and biopsy (rule out endometrial cancer)

Treatment:

  • Best:
    • If: asymptomatic and fibroids <6cm in size and stable.
      • Then: Watch and wait
  • If: otherwise. Then:
    • NSAIDs
    • Tranexamic acid
    • OCP
    • GnRH agonist
  • Surgery
    • If: want to preserve fertility. Then: myomectomy.
    • If: doesn’t need to preserve fertility. Then: hysterectomy

Note: high recurrence rate (e.g. up to 60% in 5 years) after myomectomy

 

Lichen Simplex Chronicus

Clinical features:

  • Caused by recurrent itching
  • White, thickened lesion with exaggeration of skin architecture

Investigation:

  • Clinical diagnosis

Management

  • Best: Topical steroids, antihistamine to break itch-scratch cycle.

 

Lichen sclerosis

Clinical features:

  • Pruritus.
  • Dyspareunia (If mechanical narrowing of introitus is present).
  • May bleed (Due to fragility of skin).
  • Physical Exam: White plaque (may be papules at early stage). Prone to becoming hyperkeratotic or ulcerated. Associated with ‘figure-of-eight’ pattern around the vagina and anus. Late disease may result in loss of vulvar architecture.

Investigation:

  • Diagnostic: Vulvar biopsy to confirm diagnosis and evaluate for malignancy (risk of SCC)

Treatment:

  • Best:
    • 1st line: long term Topical corticosteroids
    • 2nd line: Topical calcineurin inhibitor

Notes: 10-25% develop VIN (vulval intra-epithelial neoplasia)

 

Menopause

Clinical features:

  • Absence of menses for >1 year
  • Vasomotor symptoms (hot flushes), irritability, weight gain, muscle aches/pains.

Investigation:

  • Diagnostic: Clinical diagnosis.
  • FSH levels – elevated suggests premature ovarian failure in patients <40 yo.

Treatment:

  • Best:
    • Lifestyle factors
    • Hormone replacement therapy:
  • Type:
    • If: hysterectomy. Then: oestrogen only HRT
    • If: uterus present. Then: oestrogen and progesterone HRT
  • Cyclical vs. continuous:
    • If: < 12 months from LMP, then: Cyclical HRT (because more likely to have continuing, irregular periods and cyclical enables these to be made regular)
    • If > 12 months since LMP, then: Continuous HRT (because more likely to be amenorrhoeic)
  • Patch decreases risk of DVT
    • If: only vasomotor symptoms. Then: HRT. Could also use SSRI, clonidine or gabapentin
    • If: Vaginal atrophy. Then: local oestrogen cream
    • If: osteoporosis. Then: See osteoporosis treatment
    • If: decreased libido. Then: vaginal lubrication, counselling, androgen replacement.

 

Ovarian torsion

Clinical features:

  • Sudden onset LLQ/RLQ pain.
  • Pain is sharp and constant..
  • Associated with nausea and vomiting  
  • Pain commonly starts during exercise.
  • May have had similar episode previously.

Investigation:

  • Initial: TVUS (expecting to see whirlpool sign). Ultrasound can be diagnostic, but cannot rule out if negative.
  • If: US findings nonspecific. Then: CT/MRI

Treatment:

  • Best: Surgical detorsion

 

Ovarian tumours

Clinical features:

  • May be asymptomatic until late stage.
  • Vague presentation including bowel habit change and bloating.
  • May have weight loss and fatigue
  • Palpable mass

Investigation:

  • Initial: TVUS
  • Tumour markers:
    • Epithelial (→ check CA125)
      • Serous/mucinous cystadenoma/cystadenocarcinoma
    • Stromal
      • Sertoli leydig (→ produce testosterone)
      • Granulosa-theca (→ check inhibin) (may produce excess oestrogen)
    • Germ cell
      • Dysgerminoma (→ check LDH)
      • Endodermal sinus tumour (aka yolk sac tumour) (→ check AFP)
      • Choriocarcinoma (→ check hCG)
      • Teratoma (characteristic USS)
    • Metastases
      • Upper GI cancers (→ check CA19.9)
      • Colorectal Ca (→ check CEA)
      • Krukenburg (signet ring cells on biopsy)
      • Can then calculate risk of malignancy index (RMI)
      • Staging: chest/abdo/pelvis CT (preoperative)
      • Diagnostic: histology (following removal).

Treatment:

  • Best: Varies depending on type of cancer and aetiology. Generally surgical resection (enables pathological examination) +/- chemotherapy.

Note: Epithelial ovarian cancer in Australia is the leading cause of death from gynaecological malignancy

 

Pelvic inflammatory disease

Clinical features:

  • RLQ/LLQ abdominal pain.
  • Discharge and fever.
  • Recent STIs.
  • Presence of IUD.
  • RLQ/LLQ tenderness, cervical motion tenderness, adnexal tenderness.

Investigation:

  • Initial: Ultrasound, CBE. Beta-hCG (to rule out pregnancy). Endocervical swab (for NAAT and MC&S).
  • Diagnostic: Diagnostic criteria - lower abdominal/pelvic pain in sexually active female + one of uterine tenderness, adnexal tenderness, cervical motion tenderness. USS may also be diagnostic of PID.

Treatment:

  • Initial: empiric antibiotics
    • If: sexually acquired. Then: cover gonorrhoea, chlamydia and anaerobes (ceftriaxone, azithromycin and metronidazole)
    • If: Non-sexually acquired. Then: Triple antibiotics to cover gram +ve (amoxycillin) + gram -ve (gentamicin) + anaerobes (metronidazole)
  • Best: Targeted antibiotic therapy

 

Pelvic relaxation/prolapse

Clinical features:

  • Feeling of heaviness or fullness.
  • Visible protrusion on examination
  • Stress urinary incontinence

Investigation:

  • Diagnostic: Clinical diagnosis
  • POP-Q to grade severity

Treatment:

  • Best:
    • Conservative measures include: limitation of lifting and straining, high fibre diet, weight loss (in obese patients), kegel exercises and pessaries.
    • Surgical correction (type of surgery depends on type of prolapse). Most common procedure is hysterectomy with vaginal vault suspension

 

Pinworm vulvovaginitis

Clinical Features:

  • May be asymptomatic
  • Pruritus

Investigation:

  • Diagnostic: Cellophane tape test

Treatment:

  • Best: Metronidazole

 

Polycystic ovarian syndrome

Clinical Features:

  • Irregular/absence of periods
  • Hirsutism
  • Infertility
  • Weight gain
  • Acne

Investigation:

  • Diagnostic: Based on Rotterdam’s criteria - presence of two of the following:
    • (1) Oligo/anovulation
    • (2) Hyperandrogenism - clinically or biochemically (free testosterone and DHEAS)
    • (3) Polycystic ovaries on USS (10 small antral follicles in each ovary)
  • Investigate CVS risk factors: OGTT and lipid studies.

Treatment:

  • Best:
    • Lose weight. Exercise.
    • If: hirsutism, then: Hair removal methods. OCP.
    • If: infertility, then: Metformin or clomifene.

 

Postmenopausal bleeding (nonspecific)

Clinical Features:

  • Bleeding considered abnormal if:
    • Patient not on HRT and: ANY PV bleeding >12 months since last period.
    • Patient on HRT and: Breakthrough/midcycle bleeding (unless in <6 months since starting HRT) OR Unusually heavy/postcoital bleeding

Investigation:

  • Initially: Pap smear
  • Then: TVUS + endometrial biopsy (pipelle) (done in clinic, no anaesthetic)
    • If: pipelle shows cancer. Then: Treat accordingly
    • If: pipelle negative + TVUS shows stripe ≥5mm.
      • Then: Hysteroscopy + D&C
    • If: pipelle negative + TVUS <5mm. Then: follow up to see if symptoms resolve. If: symptoms don’t resolve. Then: Hysteroscopy + D&C

Treatment:

  • Depends on underlying cause

 

Stress incontinence

Clinical features:

  • Loss of continence with coughing/sneezing/exertion. No urge symptoms.

Investigation:

  • Diagnostic: Generally a clinical diagnosis. However, if: need to confirm type of urinary incontinence, then: urodynamic flow testing.

Treatment:

  • Best:
    • 1st line: Lifestyle modification (weight loss, stop smoking, resolve constipation)
    • 2nd line: Pelvic floor exercises. Topical vaginal oestrogen. If: that fails. Then: pessary
    • 3rd line: Surgical. Options include: tension-free vaginal tape. Vaginal vault suspension surgery

 

Syphilis

Clinical features:

  • STI caused by Treponema pallidum
  • Primary: painless genital ulcer
  • Secondary: maculopapular rash affecting palms and soles. May also have condylomata lata (wart-like genital lesions).
  • Tertiary: gumma formation, neurosyphilis, aortitis.

Investigation:

  • Diagnostic:
    • Dark-field microscopy.
    • Serology:
      • VDRL/RPR sensitive but nonspecific.
      • FTA-ABS specific. Always remain positive. Wait for drop in levels x4 to indicate clearance.

Treatment:

  • Best: Benzathine penicillin

Note: mandatory reporting and treat partners

 

Toxic shock syndrome

Clinical features:

  • History of prolonged use of tampon
  • Nausea/vomiting, diarrhoea, muscle weakness.
  • Hypotension, fever, macular rash that coalesces, localised erythema and swelling at site of infection, mental status changes.

Investigation:

  • Diagnostic: Clinical diagnosis (negative blood cultures)

Treatment:

  • Best: Remove source of infection (e.g. remove tampon or surgical debridement of infected sites), rapid resuscitation and empiric antibiotic therapy (anti-staph aureus antibiotics, e.g. cloxacillin). Corticosteroids.
  • If: Penicillin allergy. Then: Vancomycin.

 

Trichomoniasis

Clinical features

  • Vaginal discharge (yellow-green frothy, foul smelling).
  • Strawberry cervix.

Investigation:

  • Diagnostic: Saline wet mount showing motile flagellated organisms, many WBCs including (PMNs). pH >4.5

Treatment:

  • Best: Metronidazole

Note: Treat partner (sexually transmitted)

 

Vulvar abscess

Clinical features:

  • Fluctuant mass with erythema, tenderness and warmth.

Investigation:

  • Diagnostic: Clinical diagnosis

Treatment:

  • Best
    • If: small (<2cm). Then: warm compresses and sitz baths.
    • If: no improvement in 2-3 days. Then: antibiotics.
    • If: no improvement on antibiotics. Then: incision and drainage.
    • If: large (≥2cm). Then: incision and drainage + antibiotics

 

Vulvar malignancy

Clinical Features:

  • Skin lesion (variable appearances) that does not resolve with time
  • May have itching, pain or bleeding

Investigation:

  • Diagnostic: Colposcopy + biopsy.
  • Note to biopsy all suspicious lesions

Treatment:

  • Best:
    • If: High-grade vulvar intraephithelial neoplasia (VIN).
      • Then: options include wide local excision and laser ablation
    • If: invasive. Then: Vulvectomy and regional lymphadenectomy OR wide local excision of tumour and lymph node dissection + preoperative radio/chemotherapy