Gynecology

Clinical history

1. CC+HOPI:
PV bleeding
Vaginal discharge
Abdominal pain
Mass in abdomen

2. Systemic Review
3. Menstrual history
4. PMH/PSH
5. Drug history
6. Past Obs history
7. Past Gynae history
8. Family history
9. Social History

Physical examination

General: BMI, signs of anaemia

Systemic examination: Breast (if suspect malignancy), CVS, RS (need to assess for presurgical
assessment), Thyroid (hyperthyroidism)
Local Examination (Abdominal examination)
Vaginal examination
- Speculum examination
- Bimanual examination
Rectal examination (only if indicated)

Investigations

- Urine pregnancy test

- Blood test
i. Haemoglobin/ Gxm
ii. Hormonal assays (if indicated) usually thyroid function tests
iii. Serum beta-HCG
iv. Cervical cytology screening (if indicated)
v. Endometrial biopsy (TRO endo Ca/hyperplasia)
vi. Microbiological identification: vaginal pH assessment, culture & sensitivity
vii. Urine microscopy +/- culture
- Imaging
i. Ultrasound (transabdominal/transvaginal)
- Diagnostic hysteroscopy
- Diagnostic laparoscopy
- Colposcopy
 Early pregnancy bleedings (miscarriage, ectopic pregnancy, molar pregnancy, other
causes)

1. Miscarriage= a pregnancy that ends spontaneously before 22 weeks of gestation

Clinical presentation= PV bleeding, abdominal pain

Etiological factors
- Chromosomal abnormalities
i. Autosomal trisomy
ii. Monosomy X
iii. Triploidy
- Medical/endocrine disorders
 Endocrine factors
i. Hypothyroidism
ii. Diabetes mellitus
iii. Polycystic ovarian syndrome (PCOS)
 Maternal medical illness
i. Diabetes mellitus
ii. Hypertension
iii. Thrombophilia
 Immunological disorders
i. Anti-phospholipid syndrome
- Uterine abnormalities
i. Cervical incompetence
ii. Bicornuate/septate uterus
iii. Uterine fibroid
iv. Uterine synechiae
v. Placenta abruption
- Infections (any acute infection with high fever)
i. Herpes simplex
ii. Human papilloma virus (HPV)
iii. Chlamydia
iv. Malaria
- Drugs/chemicals (cytotoxic, cocaine, industrial chemical agents)

 Anatomical abnormalities and maternal medical illness are etiological factors during
2nd trimesters while the rest are 1st trimester.

Risk factors that increase chances of miscarriage

 - Advanced maternal age
- Previous history of miscarriage
- Smoking
- Alcohol
- Trauma (RTA,fall,abdominal massage, amniocentesis, chronic villous sampling)
- Caffeine
- High grade fever
Type of Ultrasound scan findings Clinical presentation Management
miscarriage
Threatened Intrauterine pregnancy Vaginal bleeding and abdominal Supportive
miscarriage (with FH) pain
Speculum: cervical os closed
Inevitable Intrauterine pregnancy Vaginal bleeding and abdominal Expectant, medical
miscarriage (no FH) pain or surgical
Speculum: cervical os open
incomplete Retained products of Vaginal bleeding and abdominal Remove pregnancy
miscarriage conception pain tissue at time of
Speculum: cervical os open, speculum if
products of conception located possible
in cervical os Expectant, medical
or surgical
Complete Empty uterus (need Pain and bleeding have resolved Supportive
miscarriage serum hCG to exclude Speculum: cervical os closed
ectopic pregnancy if no
previous USS identifying
intrauterine pregnancy)
Missed Intrauterine pregnancy Asymptomatic Expectant, medical
miscarriage (no FH) Often diagnosed at booking USS or surgical
Septic - Fever, Heavy vaginal bleeding, -
miscarriage Foul-smelling vaginal discharge
Investigations
 Urine pregnancy test
- To confirm pregnancy
- To distinguish a complete miscarriage from a threatened miscarriage or ectopic
pregnancy
 Speculum examination
- Source of bleeding (cervical Os)
- Intensity of bleeding (active, heavy, clots)
- Any presence or passage of tissue
 Full blood count
- Elevated white cell count indicates infection seen in septic miscarriage
 - Hemoglobin level and group & save, cross matching to assess the need of transfusion
if bleeding is significant
- Check if mother is rhesus negative or positive, if rhesus negative and non-sensitized,
anti-D immunoglobulin should be given if:
i. Ectopic pregnancy
ii. All miscarriage over 12 weeks (including threatened)
iii. All miscarriage requiring surgical evacuation
iv. Heavy bleeding or has pain in threatened miscarriage below 12 weeks

 Transabdominal-FH @ 7 weeks/TVUSS- FH @ 6 weeks

- To look for intrauterine gestational sac /Any retained products of conception
(depends on type of miscarriage)
- Presence of fetal heart activity
- Assess viability of pregnancy
- Assess endometrium thickness (indicates complete miscarriage if endometrial
thickness is less than 15 mm)
- Any adnexal mass
- Free fluid
 Serial serum BhCG – to check if there’s any abnormal rise or decreasing values may
suggest a failing intrauterine pregnancy or an ectopic pregnancy. 85% of normal
intrauterine pregnancies has a rise of 66% in samples taken 48 hours apart. Serum
BhCG value of >150 IU/l at day 14 following embryo transfer is a/w a high chance of
successful pregnancy

If this is a recurrent miscarriage, additional investigation that should be done is

antiphospholipid antibodies, imaging of uterus, cytogenetic analysis

Differential diagnosis
 Ectopic pregnancy
 Local causes- vaginal tear from coitus, cervical ectropion, carcinoma of the cervix

Management
- Expectant management
i. Spontaneous miscarriage
ii. Avoid surgical intervention but may be required if there is heavy bleeding
- Medical management
i. Involves misoprostol (PGE analogue) or mifeprestione (progesterone
antagonist) SE: pain, vomiting, diarrhea
ii. Pain relief and antiemetics are prescribed
- Surgical management
i. Indication: persistent extensive bleeding/hemodynamic instability/ patient’s
choice
ii. Manual vacuum aspiration (local/general anesthetic)
iii. Suction curette insertion (vaginal/sublingual misoprostol dilate cervix) (but
we use Cervagem to dilate and soften the cervix)
 iv. Evacuation of retained product of conception (ERPOC)- standard procedure
may cause complication such as cervical trauma, subsequent cervical
incompetence, uterine perforation, uterine adhesions or post op pelvic
infection.

Type of Management
miscarriage
Threatened Observation (expectant), pelvic rest, folic acid supplement and
luteal support
Inevitable Expectant, medical or surgical
• Principle of Management:
q Measures general condition of patient
q Accelerate process of expulsion
q Maintain strict asepsis
• General measures:
q Shock: Treat with IV fluid therapy and blood transfusion
q Excessive bleeding: Administer Ergometrine or Syntometrine
• Active treatment:
q Await spontaneous expulsion
q Augmentation with oxytocin

Incomplete Removal during speculum, expectant, medical or surgical

• Assess hemodynamic status and stabilize by giving IV fluid
and blood transfusion
• Administer 0.5mg IM Ergometrine (control bleeding and
contract uterus)
• Under anesthesia, suction dilatation and curettage is done
(removal of conception product)  send to histopathology
examination

Complete Supportive
• Product of conception is sent to verify intrauterine
pregnancy
• Observe patient for any further bleeding or signs of infection
Missed Expectant, medical or surgical
• Uterus (<12 wks gestation):
q Vaginal evacuation done without delay
q Cervical os need to dilated first and followed by suction
evacuation under gen. anesthesia
• Uterus (>12 wks gestation):
q Induction can be done by oxytocin or prostaglandin
• Medication: Misoprostol, Mifepristone
q SE: Pain, vomiting and diarrhea
q Surgical evacuation is considered only after 7 days if patient
fails to respond.

Septic • Admit for further management

 • Take FBC, blood for culture and sensitivity (C&S), swab from
endocervix for C&S, serum electrolytes
• I.V hydration
• Broad spectrum IV antibiotics (gram positive, gram negative
and anaerobe coverage)
• Iv ampicillin + im gentamicin + iv metronidazole / im
ceftriaxone + oral or iv doxycycline + iv metronidazole / iv
clindamycin + iv gentamicin
# antibiotics should be continued for at least 2 days after patient is
fever-free (usual duration is 7-10 days)
• Dilatation and Curettage (D&C) after adequate tissue level of
antibiotics in a hemodynamically stable patient
#arrange for surgical evacuation after 12-24 hrs of commencing iv
antibiotics if there is presence of POC.
Recurrent • Aspirin, low dose heparin
• Surgical (uterine septum, uterine incompetence)
• Medical (progesterone, corticosteroid, metformin)
• Psychological support
• Serial USS

Complications of miscarriage

Immediate:
- Major: anemia, hemorrhage, thromboembolism, operative trauma and infection
- Minor: lower abdominal pain, bleeding and pelvic infection
Late:
- Infertility

2. Ectopic pregnancy = implantation of a pregnancy outside the uterine cavity

Sites of ectopic pregnancy Causes/Risk factors of ectopic pregnancy

Common  Fallopian tube damage d/t pelvic infection

- Ampulla - Chlamydia/ gonorrhea
- Isthmus  Previous ectopic pregnancy
- Fimbriae  Previous tubal surgery
- Interstitium  Functional alterations in the fallopian tube
Rare d/t smoking & increased maternal age
- Ovary  Previous abdominal surgery
- Cervix (appendicectomy, caesarean section)
- Abdominal cavity  In-vitro fertilization
- Caesarean section scar  Use of IUCD
 Endometriosis
 Conception on oral contraceptive
Clinical presentation
 - Amenorrhea
- Lower abdominal pain (localized or generalized)
- PV bleeding
Others: shoulder tip pain (referred pain d/t irritation of the diaphragm from the free
blood in the peritoneal cavity), dizziness and syncope/pre-syncopal attacks (d/t
anemia and hypotension), passage of tissue (decidual cast), pregnancy symptoms
# ruptured ectopic pregnancy: signs of an acute abdomen, hypovolemic shock, positive UPT.
However, important to be aware that it is common women to experience bleeding or
abdominal pain with a viable intrauterine pregnancy.

Physical examination
- Pallor, lower abdominal tenderness, guarding or rebound tenderness, PV bleeding,
adnexal mass and/or tenderness
- May present in shock with hypotension and abdominal distension
Spielberg’s criteria (ovarian pregnancy)
Investigation
- Urine pregnancy test: positive
i. intact ipsilateral tube clearly separates
- Speculum examination
from ovary
i. Cervical excitation positive
ii. gestation occupying normal position
- Pelvic Ultrasound scan
of ovary
i. To assess intrauterine pregnancy/extrauterine
iii. gestational sac connected to uterus
ii. Viability of the pregnancy
by utero-ovarian ligament
iii. Any adnexal mass
iv. ovarian tissue must be located in sac
iv. Any free fluid
wall
v. Any retained POC
vi. Assess endometrial thickness <15 mm (in complete miscarriage)
vii. Check if any mass at POD (pouch of Douglas)
## if ectopic pregnancy usually empty uterus, with adnexal mass at possible implantation
location.
- Serum BhCG level: suboptimal rise, plateau or fall between 48 hrs
- FBC (if Ddx is infection) (Hb, GXM)
- Laparoscopy

Differential diagnosis

i. Miscarriage: threatened, inevitable, incomplete

ii. PID: eg. Salpingitis
iii. Ovarian cyst: twisted or ruptured
iv. Hemorrhagic corpus luteum cyst
v. UTI in pregnancy: cystitis, pyelonephritis
vi. Appendicitis (may be perforated)

Management

General
- Resuscitation (two iv access, large bore if hemodynamically unstable)
- Group and cross match blood
 - Check blood group and rhesus. Give anti-D immunoglobulin if rhesus negative at a
dose of 250 iu (50 microgrammes)

 Expectant management
- For patients who are hemodynamically stable and symptomatic
- Patient requires serial hCG measurements until levels are undetectable

 Medical management
q Methotrexate
q Indications: minimal symptoms, adnexal mass <40mm in diameter, current
serum hCG <3000 IU/L
q MOA: folic acid antagonist inhibits DNA synthesis particularly affecting
trophoblastic cells
q SE: stomatitis, conjucativitis, GI upset, photosensitive skin reaction, non-
specific abdominal pain
q CI: chronic liver, renal or hematological disorder, active infection,
immunodeficiency, breastfeeding
q Other advices: avoid sexual intercourse during treatment, avoid conceiving
for 3 months after treatment, avoid alcohol and prolonged exposure to
sunlight during treatment
q After treatment, serum hCG level is routinely measured on day 4,7 and 11
then weekly thereafter until undetectable

 Surgical management
- Laparoscopy: preferred approach
- Laparotomy: only done when there’s no endoscopic facilities or when the patient is
severely compromised (large hemoperitoneum, clinically unstable, dense pelvic
adhesions)

Types of procedure Salpingectomy Salpingostomy

-Removal of fallopian tube & EP -small opening is made over site
within of EP & EP is extracted via
-recommended if affected tube opening
is severely damaged & -recommended only if the
contralateral tube is healthy contralateral tube is absent or
visibly damaged & a/w higher
rate of subsequent ectopic
pregnancy
Advantages No close monitoring Can preserve fertility if
contralateral tube abnormal
Disadvantages If contralateral tube abnormal, High risk if bleeding
patients may have difficulty - May need to proceed with
getting pregnant, require IVF salpingectomy
Require frequent serum BhCG
follow up
 3. Molar pregnancy

Gestational trophoblastic disease (GTD)= hydatidiform mole, chorioadenoma

destruens (invasive mole), choriocarcinoma and placental-site trophoblastic tumor/
spectrum of conditions that includes complete and partial hydatidiform mole,
invasive mole and choriocarcinoma (Ten teachers)

Gestational trophoblastic neoplasia (GTN)= subset of GTD with high serum BhCG in
the absence of normal pregnancy and need chemotherapy. This can arise following
molar or normal pregnancy

Classification of molar pregnancy (hydatidiform mole= a neoplasm of the trophoblast

which involves both epithelial layers, cytotrophoblast and syncytiotrophoblast )

Types Complete hydatidiform mole Partial hydatidiform mole

Ultrasound Characteristic feature Often misdiagnosed or missed at
presentation
Serum High Lower levels
BhCG
Uterus Larger than dates Often small uterus
Pathology All villi are hydropic and no fetal May have normal villi and fetal
circulation. Absence of fetus, cord or circulation. Fetus (usually
amnion abnormal), cord and/or amnion
may be present. May have fetal
heart activity
Cytogenetic
studies

46, XX (90%) mostly paternal origin Triploid paternal and maternal

46,XY (10%) origin
Persistent 15-20% risk Low (0.5%)
GTN risk

Other types Invasive mole Choriocarcinoma

of GTD
Definition - A condition in which the molar - Highly malignant tumor
tissue invades through decidua arising from chorionic
and into myometrium and its epithelium
associated blood vessels - Rare condition and non-
 gestational variant can
arise directly in ovary
- Only about 2% of moles
give rise to
choriocarcinoma but the
risk is 1000 times greater
than the risk after normal
delivery
Partial/ - Results from a complete, rather - Occurs most commonly
complete than a partial mole after a complete molar
mole pregnancy but can also
occur after any pregnancy
Complication - Perforation of uterus may - Commonest site for these
occur, resulting in invasion of tumors to metastasize is
the parametrium lung

Clinical presentation of molar pregnancy

- Early pregnancy bleeding: degree of bleeding is variable but significant

- Excessive nausea and vomiting in early pregnancy (hyperemesis gravidarum) :
related to high levels of serum BhCG
- Symptoms of hyperthyroidism such as weight loss, tremors, heat intolerance,
diarrhea, palpitations: BhCG is a thyrotropic molecule and when in excess, they bind
to TSH receptor
- Larger than expected uterine size for gestation

Clinical presentation of invasive mole and choriocarcinoma

- PV bleeding --> leads to anemic symptoms
- Infection
- Abdominal swelling
- Vaginal mass
- Dyspnea and hemoptysis: spread to lung
- Other symptoms of distant spread to the brain or liver

Investigations
i. Urine pregnancy test: positive
ii. Ultrasound examination of uterus: diagnosis of complete mole is almost always
made by +ve urine pregnancy test and with characteristics ultrasound findings
(multiple echoes seen within uterine cavity or so-called “snowstorm
appearance). Bilateral theca lutein cysts may be present. Diagnosis of partial
mole can be missed on scan.
iii. Serum BhCG (high in complete mole, low in partial mole)
iv. Full blood count (FBC) Hb level d/t PV bleeding, coagulation profile (PT, aPTT)
v. Serum electrolytes, creatinine and liver function tests (+/- thyroid function test)
vi. Blood group and rhesus status
vii. Chest X-ray- metastasis may be seen as either discrete, multiple or large solitary
lesions. There may be milliary pattern or pleural effusions.
viii. Imaging by MRI or CT scan is indicated only when ultrasound examination is
inconclusive or if suspect metastasis.

Management
i. GXM 2 to 4 pints of whole blood (as preparation for suction curettage)
ii. Suction evacuation followed by gentle blunt curettage should be performed as
soon as possible under anesthesia. Start Cervagem 1mg 3 hours before the
procedure and administer IV udoxan/ IM ergometrin to prevent excessive
bleeding and helps to minimize the risk of uterine perforation during the
procedure. Possible complications of the procedure are:

 Hemorrhage
 Uterine perforation
 Trophoblastic tissue embolization to the lung
 Sepsis
iii. Give anti-D immunoglobulin if rhesus negative within 72 hours of suction
curettage
iv. Repeat ultrasound examination of the uterine cavity in one week. If molar tissue,
still present, consider repeat suction curettage.
v. Follow up with serial BhCG as outpatient. Serum BhCG usually will drop to
normal within 8 to 12 weeks after evacuation of molar pregnancy. Outcome: 80%
will have spontaneous regression, 3-5% develop choriocarcinoma and 15% have
persistent mole. The need for chemothepray following a complete mole is 15-
20% and 0.5% after a partial mole.

Follow up
i. Weekly BhCG measurements should be done until it becomes
undetectable. Then two further specimens are obtained at weekly
intervals.
ii. Subsequently, the patient is tested monthly for 6 months and then at two
monthly intervals for a further 6 months to ensure that the BhCG levels
remain undetectable.
iii. If there is abnormal regression BhCG levels, look for locally invasive
disease in the uterus or metastasis to other sites.
iv. Women are advised to avoid pregnancy while on follow-up. Condom
usage are advised to avoid pregnancy for a further 6 months after the
serum BhCG levels has returned to normal value. The combined oral
contraceptive pills and HRT are safe to use if there is no other
contraindications after BhCG levels have reverted to normal. Sterilization
will be ideal if completed family.
v. Advise early ultrasound in next pregnancy because risk of recurrence is 1-
2%.

If diagnosis GTN, refer to FIGO scoring and staging. Appropriate chemotherapy +/-
surgery
• Score of 6 or less are at low risk and tend to have a good outlook regardless of how
far the cancer has spread. The tumor usually responds well to chemotherapy.
• Score of 7 or more are at high risk, and their tumors tend to respond less to
chemotherapy, even if they haven't spread much. They may require more intensive
chemotherapy.

Complication of GTD
- Thyrotoxicosis
- Persistent GTD
- Molar metastases
- Disseminated intravascular coagulation (DIC)
4. Other causes

- Local causes: cervicitis, cervical ectropion, cervical carcinoma, vaginal trauma,

vaginal infection
- Hematological disorders: sickle cell disease, thalassemia, thrombocytopenia,
leukemia