Transcript MCCQE Review: Gynecology

MCCQE Review:
Gynecology
Dr. Jessica Dy
Division of Reproductive Medicine
Department of Obstetrics and
Gynecology
Overview
Objectives of MCCQE in Gynecology
Selected Topics: Part 1
Sexual Development
Menstrual Abnormalities
(amenorrhea, PCO, abnormal bleeding patterns)
Contraception
Intermission
Overview
Selected Topics: Part 2
Pelvic Pain
Pelvic Mass
Infertility
Pelvic Relaxation/Prolapse
Intermission
Overview
Selected Topics: Part 3
PAP Smears
Gynecologic Infections(Graphic)
Ectopic Pregnancies
Domestic Violence
End – Good Luck on your examination
MCCQE Objectives:
Gynecology:
Breast Disorders
Infertility/Impotence/Sexual Dysfunction
Menstrual Cycle Abnormal/Amenorrhea/Pre-menstrual Syndrome
Menopause
PAP Smear/Screening/Prevention
Pelvic Mass
Pelvic Pain
Contraception/Pregnancy Prevention/Termination
Prolapse/Pelvic Relaxation
Vaginal Bleeding,Excessive/Irregular/Painful/Dysmenorrhea
Vaginal Discharge/Urinary Symptoms, Vulvar Lesions, STDs
Violence, Family
(Child,Elderly,Adult,Spouse,Rape,Violence Against Women)
Italic = covered under other specialities
MCCQE Objectives:
Full Clinical Presentation List:
Sexual Maturation(normal,abnormal)
Part 1
Female Sexual Development
“Baby Has Gone Mad!”
Breast Development (Thelarche) 10.5 yo
Hair Development (Pubarche) 11.0 yo
Growth (peak height velocity) 11.4 yo
Menstruation (Menarche) 12.8yo
Note growth spurt superimposed on pubertal process
-begins prior to thelarche
Female Sexual Development
In General:
-low levels of FSH and LH are found in infants and prepubertal
girls
- prior to onset of pubertal changes, levels of FSH and LH rise
(initially at night-LH)
- estradiol levels rise and breast development occurs, eventually
sufficient estrogen is available to initiates endometrial growth
and menses
-andrenache(pubarche) biologically unrelated event, but
temporally related to other pubertal changes
Female Sexual Development:
Precocious Puberty
(development of secondary sexual characteristics before 8yo)
Types:
1) GnRH Dependent(True Precocious Puberty)
-early activation of hypothalamic-pituitary-ovarian axis
2) GnRH Independent(Precocious Pseudopuberty)
- sexual maturation not related to GnRH secretion
(eg.extra pituitary secretion of gonadotropins, or
sex steroid secretion)
Female Sexual Development:
Precocious Puberty
Causes:
1) GnRH Dependent
Idiopathic
CNS problem
74%
7% (tumors, encephalitis, menigitis,
hydrocephalus, skull injury/deformity)
2) GnRH Independent
Ovarian(cyst or tumor)
11%
McCune-Albright syndrome 5% (autonamous early production of E2
by ovaries, cycstic bone lesions-#’s, café au lait)
Adrenal
2%
Ectopic FSH/LH
0.5%
Hypothyroidism
?
Female Sexual Development:
Precocious Puberty
Investigations:
initial:- bone age, height and wieght
- estradiol levels(precocious breast development)
- androgens- DHEAS, Testosterone(precocious andrenarche)
- FSH,LH,TSH levels
secondary: - imaging of pituitary/sella
- ultrasound ovaries, uterus, image adrenals
- bone scan(McCune-Albright)
Female Sexual Development:
Precocious Puberty: Findings
Cause
1) GnRH Dependent
FSH/LH
Estradoil
DHAS
Gonadal Size
Idiopathic
CNS problem
Increased
Increased
Increased
Increased
Normal
Normal
Increased
Increased
Decreased
Decreased
Decreased
Increased
Increased
Increased
Increased
Increased
Normal
Normal
Increased
Normal
Uni. Increased
Increased
Small
Increased
2) GnRH Independent
Ovarian(cyst or tumor)
McCune-Albright syndrome
Adrenal
Ectopic FSH/LH
Bone age is advanced compared to chronological age in all causes,
except hypothyroidism.(unknown reason)
Female Sexual Development:
Precocious Puberty
Treatment:
Aimed at underlying process
Tumor-resect,radiation,chemo
Idiopathic- GnRH agonist therapy
McCune-Albright- MPA
- Testolactone-aromatase inhibitor
Delayed Puberty- discussed as primary amenorrhea
Suggested sites for more information
http://www.utdol.com and search precocious puberty
http://www.utdol.com/application/topic.asp?r=/application/topic.asp&file=r_endo_m/9737&type=A&selectedTitle=1~25&app=utdol
Amenorrhea
Definition:
Primary Amenorrhea
- no period by age 14 in absence of growth or
development of secondary sex characteristics
- or no period by age 16 regardless of presence
of normal growth and development with the
appearance of secondary sex characteristics
Amenorrhea
Definition:
Secondary Amenorrhea
- in a woman who has been menstruating, the
absence of periods for a length of time
equivalent to a total of at least 3 of the previous
cycle intervals, or 6 months of amenorrhea
Amenorrhea
Etiology:
Pregnancy
Thyroid disease
Prolactin disease
PCO and its variants
Hypothalamic disease
Ovarian failure(resistance)
Endometrial failure
Developmental, genetic disorders
Amenorrhea -Hypothalamic
Stress induced
anorexia nervosa – loss of pulsatile GnRH secretion
- 15% below body weight starts to return
-exercise induced
-critical body fat threshold
-centrally acting agents
(melatonin, opiods, and CRH increase)
Amenorrhea -Hypothalamic
Overall:
When available energy is excessively diverted or
insufficient, reproduction is suspended in order to
support essential metabolism for survival.
Diagnosis of exclusion
Amenorrhea -Pituitary
Pituitary Adenomas:
non-functioning – most common (30-40% of all pituitary)
prolactinoma
growth hormone secreting - acromegaly
ACTH secreting - Cushing’s Disease
Amenorrhea -Pituitary
Adenomas Overall:
Elevated levels of prolactin cause decrease secretion of
GnRH from hypothalamus, therefore decreased FSH/LH
and amenorrhea (hypothalamic amenorrhea)
Any mass lesion may cause stalk compression (-relieves
prolactin from Dopamine suppression therefore can
cause hyperprolactinemia)
Amenorrhea
Rare Pituitary Lesions
Sarcoidosis
Tuberculosis
Teratomas
Crayniophyphyrangieoma
Lymphocytic hypophysitis
Sheehan’s Syndrome
Post partum hemorrhage with ischemic necrosis of
anterior pituitary (portal system)
-failure of lactation
Amenorrhea -Ovary
Anovulatory – PCO – condition where ovaries contain
multiple early stage follicles which do not mature
secrete androgens in excess of E2
-related problems with insulin receptor function and
lipids, hyperandrogenism and unopposed estrogen
Ovarian failure – premature exhaustion of follicles < 40 years
-radiation, chemotherapy, genetic, iatrogenic,
idiopathic
Amenorrhea -Ovarian Abnormal
Development
Dysgenetic Gonads (Abnormal chromosome complement)
- Turner’s Syndrome
+/- mosiacisms – 45X
- XY Swyer’s syndrome
testes develop abnormality or failed to develop
no testosterone effect but AMH
testis streaks-fibrous bands
- Testicular ferminization
also a Mullarian abnormality
defect is one of a spectrum of androgen insensitivities
Amenorrhea -Ovarian Abnormal
Development
Dygenesis of Gonad XX
-accelerated germ cell loss with premature
degeneration of ovaries
Amenorrhea -Genital Tract
Blockage (mullarian abnormalities)
- transverse septum
- imperforate hymen
- non-communicating cavities
Endometrial Failure – Asherman’s syndrome
- secondary to vigorous D&C – usually postpartum
- ++ adhesions/synechia in uterine cavity
To Test: give both E2 then P4 and withdrawal
if period then outflow tract not obstructed &/- failure
Amenorrhea
BHCG
TSH
Prolactin
hypothyroid
pregnancy
hyperprolactinemia
Within Normal Limits
Progesterone Challenge
-Provera 10mg x 10d
Bleeding
No Bleeding
Anovulation
Estrogen & Progesterone
Bleeding
No Bleeding
End Organ Problem
-obstruction
-failure
FSH and LH
High
Ovarian Failure
Normal or Low
CT Scan of Sella
-Sellar lesion
-hypothalamic amenorrhea
Approach to Amenorrhea
If Prolactin elevated- investigate for hyperprolactinemia
If pregnant stop investigating
Approach to Amenorrhea 2
Approach to Amenorrhea 3
Approach to Amenorrhea 4
Approach to Amenorrhea 5
Approach to Amenorrhea 6
Approach to Amenorrhea 7
Including:
Dysgenetic Gonad
Gonadal Dysgenesis
-therefore do Karyotype
Approach to Amenorrhea 8
Abnormal
Hypothamic,or pituitary
lesion
Normal
PCOS
PCOS – Polycystic Ovarian Syndrome
described in 1935 by two gynecologists- Stein and
Leventhal
large polycystic ovaries with amenorrhea
Triad of:
amenorrhea
obesity
hirsutism
PCOS -Clinically
-biochemistry – LH/FSH ratio >2-3 and elevated androgens
(increased testosterone, DHEAS, 17-OH progesterone)
-U/S - multiple follicles peripherally arranged
(string of pearls appearance)
- not specific 8-25% of normally cycling women will
have this appearance
-~14% of women on the pill will have this appearance
-recently appreciated to be a spectrum of
disease severity/presentations
What is PCOS
-a syndrome resulting from chronic anovulation
-can be associated with high insulin levels in many
patients
-diagnosis is made clinically +/- biochemical support
-evidence of oligo/anovulation
-evidence of androgen excess
-+/- evidence of insulin resistance
Why is this Important?
1.
2.
3.
4.
5.
6.
Infertility
Menstrual bleeding problems – amenorrhea – DUB
Hirsutism, acne and alopecia
Increased risk of endometrial cancer
Increased risk of CAD
Increased risk of type II diabetes if insulin resistant
Insulin Story
Defect in insulin receptor
- altered phosphorylation at serine (increased) and
tyrosine (decreased) residues on insulin receptor
- this reduces signal transmission and causes a post
receptor problem and glucose transport decreases
- this phosphorylation of serine may increase the
activity of enzymes that make androgens in both
the ovaries and adrenals
Insulin Story: Net Result
– increased insulin levels secondary to decreased
tissue uptake of glucose
- increased androgen production from both adrenals
and ovaries (LH and insulin act synergistically to
increase androgen production by theca cells in
ovary).
Treatment
Treatment depends on patient’s immediate concerns and risk
factors
-weight loss through diet and exercise
-treatment with progesterone to prevent endometrial
hyperplasia – cancer
-Metformin to decrease insulin levels
? reduce risk of progression to type II diabetes
? improve lipid profiles
·
? induce ovulation
sensitize to ovulation induction
Treatment
Ovulation induction
Clomiphene
SERMS (letrozole/tamoxifen)
FSH ovulation induction
Ovarian drilling
Abnormal Uterine Bleeding
(Unrelated to Pregnancy)
Menorrhagia: cyclic menstrual bleeding occurring at regular intervals
excessive amount and/or duration
(>80 ml menstrual fluid/>7 days)
Metrorrhagia: uterine bleeding occurring at irregular intervals
Menometrorrhagia: uterine bleeding irregular frequency and
excessive in amount
Abnormal Bleeding
Causes of “Organic” Abnormal Uterine Bleeding:
uterine -polyps,
-fibroids
-trauma
-infections-PID, endometritis,
-IUD
-exogenous hormones
-endometrial cancer, hyperplasia
-cervical cancer, infection
other -vulvovaginitis
-vaginal,vulvar,ovarian cancer
-coagulation disorders
-thyroid disease
Abnormal Bleeding
Dysfunctional Uterine Bleeding(DUB): Uterine bleeding without any
evidence of organic disease(ie no polyps, malignancy, pregnancy, etc.)
90% related to anovulation
10% can be ovulatory
Anovulatory DUB
-no ovulation, therefore no progesterone secretion
-endometrium exposed to prolonged and unopposed estrogen
resulting in estrogen breakthrough bleeding
(fragile, un-uniform growth of endometrium-areas of shedding
and re-growth)
Abnormal Bleeding
Ovulatory DUB(uncommon)
- ? Luteal phase progesterone unable to maintain
endometrium
Abnormal Bleeding
Investigations:
-Bhcg
-CBC
-R/O organic diseases -hx & px
-endometrial biopsy
-+/- ultrasound
Treatment dependent on Cause
Abnormal Bleeding
DUB Treatment:
Mild: OCP 1 tab tid then continuous x 4-6 months
OR
cyclic provera 5-10 mg po od x10d monthly
Severe: stabilize patient as required
premarin IV 25 mg q4-6h
+/- add OCP or provera
OR
D&C if severely ill or unresponsive to medical Tx
Abnormal Bleeding
DUB Longterm Treatment:
OCP
cyclic provera 5-10 mg po od x10d monthly
progestin only pill
progesterone IUD
NSAIDS-menorrhagia
anti-fibrinolytic agents- menorrhagia
surgical - endometrial ablation, hysterectomy
Contraception
27 yo nulligravid medical student was “celebrating” with her
male partner (Chiropractic student) after she had successfully passed
the MCCQE part 1. Her LMP was 14 days ago and she has regular
28 day cycles with the molimina. Immediately after intercourse she
noticed his condom was no longer on his penis and exclaimed
“Oh my, your condom must have fallen off and must still be
in my vagina !”. He then replied “Condom, what condom?”.
What would be the appropriate medical management(s) to
offer this couple? (You may chose up to three answers)
Contraception
A) Urgent pregnancy test (serum)
B) Menstrual Extraction in office
C) Suggest expectant management with possible therapeutic
abortion if required
D) 2 ovral tablets po q12h x 2 doses
E) MTX 50 mg/m2 IM x1
F) Insertion of copper containing IUD
G) 0.75 mg Levonorgestrel po q12h x 2doses
H) Suggest partner to perform ‘spinal manipulation’ to delay
endometrial growth and prevent implantation
Contraception
Yuzpe Method ‘Morning After Pill’
within 72 hours of intercourse
2 ovral tablets q12 x 2 doses
(often combined with Gravol 50mg)
6% chance of pregnancy per single act of intercourse
Yuzpe method decreases to 2%
Contraception
Levonorgestrel
within 72 hours of intercourse
0.75mg levonorgestrel q12 x 2 doses
(less nausea)
slightly improved efficacy to Yuzpe ~1%
Contraception
Copper IUD Insertion
within 5 days of intercourse
0.1% failure rate
Ideally used in patients with no contraindications to IUD
pregnancy
undiagnosed vaginal bleeding
pelvic infection
suspected gynecologic malignancy
copper allergy/Wilson’s disease
(previous ectopics, mullerian abnormalities, valvular HD)
Contraception
OCP
Contraindications:
pregnancy
undiagnosed vaginal bleeding
active liver disease (hepatoma)
previous or active thromboembolic disease
estrogen sensitive cancer
age >35 smoker
uncontrolled hypertension
Contraception
Method
Typical use
(%preg/y)
Perfect use
(%preg/y)
Chance
Withdrawal
Condom
Condom + spermicide
Female condom
Diaphragm
IUD-Copper
85
85%
19
4
12
3
5 (Toronto notes)
21
5
18
6
0.8-2.0 *
0.6-1.5
* different from Toronto Notes(3-5%)
Contraception
Method
Typical use
(%preg/y)
Perfect use
(%preg/y)
OCP
Depo Provera
Norplant
~3
0.3
0.05
0.1
0.3
0.05
Female Sterilization
Male Sterilization
0.05
0.15
0.05
0.1
Clinical Gynecologic Endocrinology and Infertility 6th ed. Pg.880
Part 2
Pelvic Pain
26 yo G0P0 woman presents to the office with 8 years of constant
pelvic pain. She has had 3 previous diagnostic laparoscopies
(2 months, 2 years, and 6 years ago). All demonstrated a normal
pelvis. She has recently be seen by specialists in General Surgery,
GI, Urology, Orthopedics, and Gynecology. All investigations have
been normal and no cause for the pain has been found.
Chronic Pelvic Pain:
Non-Gynecologic Causes,
Childhood Sexual/Physical Abuse
Pelvic Pain
What other avenues of history or investigation are indicated?
(you may chose up to 2)
A) history of drug dependency or abuse
B) repeat pelvic ultrasound
C) history of previous sexual abuse/assualt
D) CBC, lytes, BUN, Cr
E) exploratory laparotomy
Pelvic Pain
Approach:
1) History - chronic vs acute
2) Physical Exam
Pain History:
 C Severity
 O Onset
 L Location
 D Duration
 E Exacerbating/relieving factors
 R Radiation
Pelvic Pain
DDx (enormous)
Gynecologic:
Pregnancy:
infectious-PID
ectopic
endometriosis
spontaneous abortion
adenomyosis
incarcerated uterus
fibroids
degenerating fibroids
ovarian cysts, rupture, torsion
ovarian cyst - rupture
dysmenorrhea
hemorrhage
adhesions
ovarian torsion
prolapse
cancer
Pelvic Pain
DDx continued
Non-Gynecologic:
-urinary tract(infection, stones, retention, interstitial cystitis)
-bowel(IBS, obstruction, IBD, diverticulitis,
constipation, appendicitis, mesenteric adenitis, infarction,
hernia)
-musculoskeletal(nerve entrapment, referred pain,
abdominal wall, joint, tumors, MS)
-psychological trauma(~20% of chronic pelvic pain patients
have a history of sexual abuse/assault)
Pelvic Pain
Investigations:
(Dependent on symptoms and findings at presentation)
Gynecology related
- BHCG, cultures, U/S
- laparoscopy
Bowel related
- stool cultures
- endoscopy
- U/S,CT,MRI
Urologic
- urine cultures, urinanalysis
- IVP, U/S, CT
Musculoskeletal
- X-rays, CT, MRI
Endometriosis
Definition:

Endometrial tissue growing
outside of the uterus.
Pain History, Endometriosis:
 Is
pain worse with menses ?
 Do prostaglandin inhibitors help ?
 Is there pain with deep intercourse ?
 Is there pain with defecation when on
menses ?
 Do you need to miss work or confine
yourself to bed when in pain ?
Most Common Endometriosis
Sites
Endometriosis: Signs & Symptoms
 Symptoms:






Dysmenorrhea
Deep
Dyspareunia
Pelvic Pain
Infertility
Pain with BM or
voiding especially
with menses.
asymptomatic
 Signs:


pelvic tenderness
& nodularity.
Retroverted
and/or fixed
uterus
Endometriosis
 Diagnosis
can only be made by visualizing
disease by laparoscopy or laparotomy.
Endometriosis
 Typically
associated with painful menses
and/or deep dyspareunia.
 Stage of disease does not correlate with
the severity of pain symptoms.
 Suspect bowel involvement if painful BM
(dyskesia) with menses.
 The diagnosis can only be made by
laparoscopy of laparotomy.
Endometriosis: Pain Relief

Medical Therapy
Oral Contraceptives
Provera (MPA)
Danazol
GnRH-A
Surgical Therapy:
% of Patients
30 – 100%
55 – 100%
80 – 100%
80 – 100%
60 – 100%
Endometriosis: Recurrent Pain
after therapy

Medical Therapy

Surgical Therapy

30 – 40 % within 12
months of treatment.

13% within 3 years
and 19 % within 5
years of surgery.
Conclusion: For Further Information
For Further Information
www.pelvicpain.org
www.endometriosisassn.org
Courtesy Dr. Paul Claman
Pelvic Mass
Approach:
1) History- symptoms of bowel/bladder function
- wt loss/gain
- abdo girth changes
- fatigue
- fevers/chills
- vaginal discharge
- pregnancy symptoms(amenorrhea,
molimina)
- pain
Pelvic Mass
DDx: Gynecologic
a) uterine pregnancy
fibroid(s)-leiomyomata, leiomyosarcoma
adenomyoisis
endometrial carcinoma
hematometria
b) adnexal ovarian cyst(corp luteum, follicular, theca lutein,
endometrioma, benign, malignant)
ectopic pregnancy, luteoma of pregnancy
tubo-ovarian abscess, pyosalpinx, pelvic abscess
hydrosalpinx, fallopian tube cancer
c) other
pelvic kidney
GI masses, abscesses, lymph nodes
Pelvic Mass
2) Physical Exam - complete general survey(including nodes)
- abdominal exam
- pelvic-speculum
-bimanual
-pelvi-rectal
3) Investigations - U/S (abdominal and endovaginal)
- +/- CT or MRI
- pre-op investigations
- +/- pregnancy test
Pelvic Mass
Treatment/management dependent of nature of mass
Suggested site for more information
http://www.utdol.com and search adnexal mass
http://www.utdol.com/application/topic.asp?file=genwomen/2368&type=A&selectedTitle=1~15
Infertility
Infertility:
one year of ‘frequent’ unprotected intercourse
without conception
(Speroff 6th ed)
10-15% of couples in the reproductive age group
Infertility -Epidemiology
Time Required for Conception in Couples
Who Will Attain Pregnancy
Duration of Exposure
% Pregnant
3 months
57%
6 months
72%
12 months
85%
24 months
93%
Guttmacher 1956
Preliminary Diagnosis
Fertility Requirements
1) Oocyte: regular ovulation, good quality oocytes
2) Normal Female Genital Tract: patent tubes,
‘relatively’ normal uterus, cervix and vagina
3) Sperm: sufficient quantity and quality
4) Implantation: appropriate endometrial/embryo interaction
e.g. ‘luteal phase deficiency’, ‘septa’,‘polyps’
5) Immunological Factors: appropriate immunological environment
e.g. ‘endometriosis’, ‘antisperm antibodies’
‘Antiphospholipid Syndrome’, ‘Blocking
antibodies’
Preliminary Diagnosis
15%


Ovarian Problems (15%)
35%
Tubal/Pelvic Pathology (35%)

Sperm Problems (35%)

Unexplained (10 to 15%)
15%
35%
*Pt counseling 40-40-20
Preliminary Diagnosis: Ovary
Anovulation
Dx
- History of regular menses with molimina
- mid luteal progesterone (progesterone > 20)
- urinary LH surge kits
- BBT’s
(serial ultrasound, endometrial biopsy,
symptothermal)
Preliminary Diagnosis: Ovary
Decreased Ovarian Reserve
Poor Oocyte Quality through;
premature follicular exhaustion
or
advancing female age
Day 3 FSH levels (normal upper limit <10)
Preliminary Diagnosis: Ovary
Hyperprolactinemia:
-suppresses GnRH pulsatile secretion (hypogonadotropic)
-inhibits progesterone secretion by granulosa cells
”luteal phase defect”
Hypothyroidism:
-elevation of TRH leads to release of prolactin
-possible interaction with autoimmune disease
and increased risk of miscarriage
Hyperthroidism:
-75% of women with hyperthyroidism have normal menses
-more of concern re: pregnancy-Graves’
Preliminary Diagnosis: Ovary
Overall Primary Investigations:
- Day 3 FSH
- Day ‘21’ progesterone
- TSH
- Prolactin
- rubella IgG
Preliminary Diagnosis: Tubal
Tubal Obstruction
approximately 40% of female infertility
causes; a) infection (GC, Chlamydia, TB)
PID first episode 12% risk of tubal infertiity
second
23%
“
third
54%
“
b) appendicitis
c) endometriosis
d) septic abortion
e) tubal/pelvic surgery
Preliminary Diagnosis: Tubal
Overall Primary Investigations:
Dependent on Radiological services available:
- HSG
or
- Hysterosonogram with contrast
or
- Laparoscopy
Preliminary Diagnosis: Tubal
Dx -Hysterosalpingogram
Preliminary Diagnosis: Tubal
Dx -Hysterosonogram with Ultrasonic Contrast (echovist)
Preliminary Diagnosis: Tubal
Dx -Laparoscopy
Preliminary Diagnosis: Sperm
Dx - Semenanalysis
WHO Criteria:
volume
concentration
motility
morphology
> 2.0 ml
> 20 million sperm/ml
> 50%
> 30% normal forms
*> 14% strict Kruger
Total motile count >40 million sperm
=volume x concentration x motility
Preliminary Diagnosis: Sperm
Semen Variability
Preliminary Diagnosis: Sperm
- variability within individuals requires
at least 2 separate semenanalysis
separated by several weeks
- spermatogenesis requires 69 to 72 days
- illness during that time could lead to lower
than usual parameters for that individual
Note if oligospermia present
check- FSH,LH,TSH,Prolactin, Testosterone, +/- Karyotype
Preliminary Diagnosis: Sperm
Classification:
A) Pre testicular
Hypothalamic, pituitary (low LH,FSH,T)
B) Testicular
Testicular failure(sometimes high FHS, low T)
Genetic
Acquired Insult
C) Post testicular(normal FSH,LH,T)
obstruction
coital disorders
Preliminary Diagnosis: Sperm
Overall Primary Investigations:
-semenanalysis x 2
Treatment Options
Approach treatment based on Fertility Requirements
1) Oocytes
2) Normal Female Genital Tract
3) Sperm
use these three categories to organize treatment options
for each particular couple
Treatment Options
Oocyte Problems:
1) Annovulation
2) Poor Ovarian Reserve
Tx-hypothyroidism
-hyperprolactinemia
aggressive stimulation IUI/IVF
donor oocytes
donor embryos
adoption
PCO
- wt loss
-clomiphene
-metformin
-letrozole/tamoxifen
-FSH ovulation induction
-laparoscopic ovarian drilling
Treatment Options: Tubal
In General
-surgery best suited to mild distal disease
-IVF best option for; proximal tubal obstruction
bilateral hydrosalpinges
severe distal disease
Treatment Options: Tubal
Surgical Repair
-mild distal tubal disease in isolation can result in up to
80% pregnancy rates
-with moderate to severe disease pregnancy rates fall to 30
to 15% respectively
(Schlaff et al. 1990)
Treatment Options: Tubal
In Vitro Fertilization
Initially used as a treatment for tubal obstruction
where tubal surgery is not possible
Currently, indications for IVF have expanded to
include most forms of infertility
Treatment of choice for severe tubal disease, and
severe sperm defects ( ICSI +/- TESA, etc.)
Treatment Options: Sperm
Options dependent on degree sperm defect(s):
1) Intrauterine insemination of washed sperm
- Ideal to inseminate >10 x 106 motile sperm
2) Donor sperm
- safe, easy to use, much less expensive
- non-genetic male parentage
Treatment Options: Sperm
3) Intracytoplasmic Sperm Injection (ICSI)
- require very few moving sperm
- can combine with testicular sperm retrieval
- requires IVF (female risks & discomfort)
Treatment Options: Sperm
4) Varicocelle repair
5) Hormonal replacement (hypothalamic, pituitary)
6) Surgical repair of obstruction
Conclusions
1.
Preliminary Diagnosis of Infertility based on
investigations of requirements of fertility
a) Oocytes
b) Tubes
c) Sperm
2.
If possible treatment is directed at specific
requirements of fertility.
Pelvic Relaxation/Prolapse
Cystocele - downward displacement of bladder
Uterine Prolapse - descent of the uterus and cervix down
the vaginal canal toward the vaginal introitus
Rectocele - protrusion of the rectum into the posterior
vagina lumen
Enterocele - herniation of small bowel into the
vaginal lumen
Vaginal Vault Prolapse - descent of the vaginal apex down
the vaginal canal towards the introitus
Cystocele / Rectocele/
Enterocele

Cystocele


Rectocele


Descent of anterior
vaginal wall and
overlying bladder base
herniation of bulging of
posterior vaginal wall
and underlying rectum
into vaginal lumen
Enterocele

herniation of
peritoneum (+/intraperitoneal
contents) in areas of
pelvic floor
Pelvic Relaxation/Prolapse
Predisposing Factors:
-aging
-vaginal childbirth
-menopause(decreased estrogen)
-changes in pelvic anatomy(surgery)
-obesity
-chronic cough
-chronic constipation
Pelvic Relaxation/Prolapse
Symptoms:
-Pelvic pressure, heaviness
-dragging sensation
-low back ache
-possibly relief with lying down
-voiding difficulty, incomplete emptying, UTIs
-constipation(pt’s may report having to reduce the
rectocele to have a bowel movement)
Pelvic Relaxation/Prolapse
Treatment
- Conservative
-Pessary, Kegels, wieght loss, stool softeners, HRT
smoking cessation
(wide range of pessaries exist for most forms
of prolapse -not useful for rectocele)
- Surgical
Anterior Repair (Cystocele)
Posterior Repair (Rectocele)
Vault suspension(Vault Prolapse following hyst)
Enterocele Repair abdominal approach(Enterocele)
Vaginal Hysterectomy(Uterine Prolapse)
Part 3
PAP Smear Management
Screening Test
- sampling of transformation zone
- detection of early pre-malignant squamous lesions
- yearly examination once sexually active
-multiple classification systems
Bethesda System widely practiced
PAP Smear Management
1996 Ontario Cervical Screening Guidelines
Women of all ages who are, or ever have been,
sexually active should be screened.
After three normal "Pap" tests (reported as
satisfactory for evaluation) at one-year intervals,
screening should be continued every two years.
If there have been four normal "Pap" tests in
the previous ten years, screening may be
discontinued after the age of seventy.
Note: These recommendations do not apply to those
women who have had previous abnormal "Pap"
tests.
http://www.cancercare.on.ca/prevention_cervicalScreening.htm
PAP Smear Management
Possible Results(Squamous)
Within Normal Limits
Atypical Squamous Cells of Undetermined Significance (ASCUS)
may favour reactive or premalignant/malignant process
Low Grade Squamous Intraepithelial Lesion (LSIL)
High Grade Squamous Intraepithelial Lesion (HSIL)
Squamous Cell Carcinoma
PAP Smear Management
PAP Smear Management
PAP Smear Management
Possible Results(Adeno)
Within Normal Limits
Atypical Glandular Cells of Undetermined Significance (AGUS)
may favour reactive or premalignant/malignant process
Adenocarcinoma(endocervical, endometrial, extra-uterine, NOS)
PAP Smear Management
Management
-AGUS referral for
colposcopy & ECC, endometrial bx
may need cone bx
-Adenocarcinoma
endometrial bx, search for primary
PAP Smear Management
Ontario Modified Bethesda System 1997
Ontario Modified Bethesda System 2001
Interpretation/Result
Within Normal Limits
Negative for Intraepithelial Lesion or Malignancy
Benign cellular changes:
Endometrial cells, cytologically benign in a post-menopausal woman
Endometrial cells in woman >40 years of age
Atypical squamous cells of undetermined significance (ASCUS)
Atypical Squamous Cells
Favour reactive
Undetermined Significance (ASC-US)
Favour SIL
Cannot exclude HSIL (ASC-H)
Low Grade Squamous Intraepithelial Lesion (LSIL)
Low Grade Squamous Intraepithelial Lesion (LSIL)
High Grade Squamous Intraepithelial Lesion (HSIL)
High Grade Squamous Intraepithelial Lesion (HSIL)
Squamous Cell Carcinoma
Squamous Cell Carcinoma
PAP Smear Management
Ontario Modified Bethesda System 1997
Ontario Modified Bethesda System 2001
Atypical glandular cells of undermined significance (AGUS)
Atypical Endocervical cells
Favour reactive endocervical
Favour neoplastic endocervical
Favour endometrial
Not otherwise specified
Not otherwise specified
Favour neoplastic
Atypical Endometrial cells
Not otherwise specified
Favour neoplastic
Atypical Glandularl cells
Not otherwise specified
Favour neoplastic
Atypical glandular cells, consistent with adenocarcinoma in situ
Malignant cells present consistent with adenocarcinoma
Endocervical Adenocarcinoma in situ
Adenocarcinoma
Endocervical
Enometrial
Extra-uterine
Not otherwise specified
PAP Smear Management
Statement of Adequacy
Recommendation
Within normal limits:
Satisfactory for evaluation
Continue with normal screening
interval (see Screening Interval
Guidelines)
Within normal limits:
Satisfactory for evaluation
but limited by: state reason
If previous Pap tests have been
normal, and satisfactory for
evaluation, continue normal
screening interval. If there is no
previous Pap test or no test
satisfactory for evaluation, the
test should be repeated earlier
than one year.
Unsatisfactory for evaluation
Repeat in three months
PAP Smear Management
Diagnostic Category
Recommendation
Benign cellular changes:
Inflammation
Culture and treatment, if
appropriate
Continue with normal screening
interval
Benign cellular changes:
Non-Specific
If previous tests have been
normal and satisfactory for
evaluation, continue with
normal screening interval.
PAP Smear Management
Diagnostic Category
Atypical squamous cells of
undetermined significance
(ASCUS)
Low-grade intraepithelial
lesion (LSIL)
* See ASCUS subclassification
Recommendation
The minimum recommendation is to repeat at
six-month intervals for up to two years. If a
second diagnosis of ASCUS or LSIL occurs in
a two-year period, colposcopy could be
considered. If there is no evidence of
cytological progression on repeat Pap tests, it is
acceptable to follow the patient for up to two
years, at which point all patients with persistent
abnormalities should be referred for
colposcopy.
It is noted that there will be clinical situations
(e.g., poor compliance, previous abnormal Pap
test) in which immediate colposcopy and
biopsy are the recommended forms of
investigation
PAP Smear Management
Diagnostic Category
Recommendation
High-grade intraepithelial
lesion (HSIL)
Colposcopy
Squamous cell carcinoma
Colposcopy
Endometrial cells,
cytologically benign in a
postmenopausal woman
These findings should be
interpreted in light of the clinical
scenario.
PAP Smear Management
Diagnostic Category
Atypical glandular cells of
undetermined significance
(AGUS): Favor endometrial
origin
AGUS: Favor reactive
endocervical cells
Recommendation
Suggest endometrial sampling
Repeat test in six months
PAP Smear Management
Diagnostic Category
AGUS: Favor neoplastic
endocervical cells
AGUS: Not otherwise
specified
Recommendation
Colposcopy.
It is recognized that follow-up of
Pap tests diagnosed as AGUS
may include sampling of the
endocervical canal, in addition to
colposcopy
PAP Smear Management
Diagnostic Category
Atypical glandular cells
consistent with
adenocarcinoma in situ
Recommendation
Colposcopy.
With cytological evidence of
adenocarcinoma in situ, a
diagnostic cone biopsy should be
performed (i.e. knife excision,
not loop electrodiathermy
excision procedure - LEEP).
PAP Smear Management
Diagnostic Category
Recommendation
Malignant cells present
consistent with
adenocarcinoma
Suggest further investigation
Malignant cells present NOS
Suggest further investigation
NOTE:
These are minimum guidelines only. There may be clinical situations which require earlier follow-up
referral for colposcopy. Any repeat Pap test should not be performed earlier than three months.
The Pap test should not be used in the assessment of a visible cervical lesion. These patients require
biopsy for accurate diagnosis.
Revised Ontario Cervical Screening Guidelines consistent with Bethesda 2001 will be released in
2005. The Ontario Cervical Screening Program will release additional information at that time.
http://www.cancercare.on.ca/prevention_3550.htm
Case
19 year old G0 woman presents to the ER with lower abdo/pelvic
pain for 2 days. She had developed a fever today and a vaginal
discharge. She has recently become sexually active, and is not
using contraception. A pregnancy test is negative.
Case
What is the most likely diagnosis?
A) early appendicitis
B) chlamydial cervicitis
C) disseminated herpes
D) PID
E) trichomonas vaginitis
Gynecologic Infections
Acute Pelvic Inflammatory Disease (PID)
- clinical diagnosis implying patient has upper genital
tract infection and inflammation
-ascending infection to endometrium, tubes, peritonium
-most often an STD-chlamydia, gonorrhea
-rarely endogenous vaginal bacteria, TB
Gynecologic Infections
Presentation
- spectrum of severity
- fever
- pain, and tenderness
- RUQ pain (Fitz-Hugh-Curtis)
- vaginal discharge or bleeding
- nausea, vomiting,
- dysuria- rare
Gynecologic Infections
Diagnosis:
pelvic pain
cervical motion tenderness
adnexal tenderness
with fever
or- high WBC
- cervical discharge
- positive cultures for chlamydia, gonorrhea
- high risk partner
- pelvic abscess clinically, or U/S Dx
Patients suspected of having PID should have U/S to r/o abscess
Partner should be evaluated and treated for STD’s
Gynecologic Infections
Reasons to Admit for PID
-abscess
-moderately, severely ill
-unable to tolerate oral meds
-immunocompromised
-pregnant
-atypical infection
-previous instrumentation
-failed outpatient management
-unreliable for follow up or compliance
-uncertain diagnosis
Gynecologic Infections
Treatment:
Outpatient -
ceftriaxone 250mg IM x1
and
doxycycline 100mg BID x 14 days
OR
Ofloxacin 400mg PO QID x 14 days
and
Clindamycin 450mg PO QID x 14 days
(metronidazole 500mg PO BID x 14 days)
Gynecologic Infections
Inpatient:
Cefoxitin 2g or Cefotetan 2g IV q6h (at least 48 h)
and
Doxycycline 100mg BID x 14 days
OR
Clindamycin 900mg IV q8h (at least 48 h)
and
Gentamicin 2mg/kg + 1.5mg/kg q8h (at least 48 h)
If no improvement within 48 h may need to drain abscess
-precutaneously, laparoscopically, laparotomy
Pelvic Inflammatory Disease
Parenteral Regimen A
Cefotetan 2 g IV q 12 hours
or
Cefoxitin 2 g IV q 6 hours
PLUS
Doxycycline 100 mg orally/IV
q 12 hrs
Pelvic Inflammatory Disease
Parenteral Regimen B
Clindamycin 900 mg IV q 8 hours
PLUS
Gentamicin loading dose IV/IM (2 mg/kg) followed
by maintenance dose (1.5 mg/kg) q 8 hours.
Single daily dosing may be substituted.
Pelvic Inflammatory Disease
Alternative Parenteral Regimens
Ofloxacin 400 mg IV q 12 hours
or
Levofloxacin 500 mg IV once daily
WITH OR WITHOUT
Metronidazole 500 mg IV q 8 hours
or
Ampicillin/Sulbactam 3 g IV q 6 hrs
PLUS
Doxycycline 100 mg orally/IV q 12 hrs
Pelvic Inflammatory Disease
Oral Regimen A
Ofloxacin 400 mg twice daily for 14 days
or
Levofloxacin 500 mg once daily for 14 days
WITH OR WITHOUT
Metronidazole 500 mg twice daily for 14
days
Pelvic Inflammatory Disease
Oral Regimen B
Ceftriaxone 250 mg IM in a single dose
or
Cefoxitin 2 g IM in a single dose and
Probenecid 1 g administered concurrently
PLUS
Doxycycline 100 mg twice daily for 14 days
WITH or WITHOUT
Metronidazole 500 mg twice daily for 14 days
Pelvic Inflammatory Disease
Management of Sex Partners

Male sex partners of women with PID should
be examined and treated for sexual contact 60
days preceding pt’s onset of symptoms

Sex partners should be treated empirically
with regimens effective against CT and GC
Gynecologic Infections
Complications of PID
- chronic pain, chronic PID
- infertility
- increased risk for ectopic pregnancy
- pelvic adhesions
- bacteremia with disseminated infections
Gynecologic Infections
Chlamydial Cervicitis:
- intracelluar parasite
- STD reportable disease
Presentation
- asymptomatic
- endocervical discharge
- pelvic pain discomfort to PID
- dysuria, with no bacturia
- post coital spotting
(ALWAYS R/O CERCIAL CANCER)
Gynecologic Infections
Treatment
Doxycylcine 100mg PO BID x 7 days
OR
Azthiromycin 1g PO x1
if pregnant Erythromycin, Amoxicillin
Screen and treat partners
Chlamydia trachomatis
Azithromycin 1 gm single dose
or
Doxycycline 100 mg bid x 7d
Chlamydia trachomatis
Alternative regimens
Erythromycin base 500 mg qid for 7 days
or
Erythromycin ethylsuccinate 800 mg qid for 7
days
or
Ofloxacin 300 mg twice daily for 7 days
or
Levofloxacin 500 mg for 7 days
Chlamydia trachomatis
Treatment in Pregnancy
Recommended regimens
Erythromycin base 500 mg qid for 7 days
or
Amoxicillin 500 mg three times daily for 7 days
Alternative regimens
Erythromycin base 250 mg qid for 14 days
or
Erythromycin ethylsuccinate 800 mg qid for 14
days
or
Erythromycin ethylsuccinate 400 mg qid for 14
days
or
Azithromycin 1 gm in a single dose
Gynecologic Infections
Gonorrhea Cervicitis:
- gram negative intracellular diplococci
- STD reportable disease
Presentation
-same as chlamydia
Treatment
ceftriaxone 125mg IM x1 OR cefixime 400mg PO x 1
OR ciprofloxacin 500mg PO x 1
AND
Treatment for Chlamydia
Gynecologic Infections
Gonorrhea-male
Neisseria gonorrhoeae
Cervix, Urethra, Rectum
Cefixime 400 mg
or
Ceftriaxone 125 IM
or
Ciprofloxacin 500 mg
or
Ofloxacin 400 mg/Levofloxacin 250 mg
PLUS Chlamydial therapy if infection not ruled out
Neisseria gonorrhoeae
Cervix, Urethra, Rectum
Alternative regimens
Spectinomycin 2 grams IM in a single dose
or
Single dose cephalosporin (cefotaxime 500 mg)
or
Single dose quinolone (gatifloxacin 400 mg,
lomefloxacin 400 mg, norfloxacin 800 mg)
PLUS Chlamydial therapy if infection not ruled
out
Gynecologic Infections
Gonorrhea - intracellular Gram negative diplococci
Gynecologic Infections
Vulvovaginitis
Organism
Candida(Yeast)
Discharge
White thick
Symptoms
Wet Mount
-itching
KOH
-satellite lesions -hyphae
-edematous
-red
Ph
<5
Bacterial Vaginosis
(anaerobes,
Gardnerella etc.)
grey, thin,
diffuse
fishy odour
-worse after
intercourse
-no irritation/
inflammation
5-5.5
clue cells
KOH
+whiff
test
Gynecologic Infections
Candida Vulvitis
Gynecologic Infections
Candida-KOH prep Hyphea
Gynecologic Infections
Clue cell- epithelial cell with bacteria clustered peripherally
Gynecologic Infections
Vulvovaginitis
Organism
Trichomonasis
(Trichomonas
Vaginalis)
Physiologic
( high E2 states)
Discharge
Symptoms
yellow/green -strawberry
spots
clear/white
Wet Mount
Ph
-fagellated 5-6.5
protozoa
- no irritation/ -normal
<4.5
inflammation epithelial cells
Gynecologic Infections
Trichomonas- strawberry spots
Gynecologic Infections
Trichomonas- fixed and stained
Gynecologic Infections
Treatment
Candida(Yeast)
-clotrimazole, miconazole, terconazole
-Diflucan 150 mg PO x 1(resistant cases)
-lactobacillus acidophilus
Bacterial Vaginosis
Metronidazole 500mg PO BID x 7 days
(or 2g PO x1)
OR Clindamycin 300mg PO BID x 7 days
OR topical above creams QHS x 7 days
Trichomonas
Metronidazole 500mg PO bid x 7days
or 2g PO x 1
Gynecologic Infections
Vulvar Lesions
Condylomata Acuminata
- human papilloma virus (HPV)
- strongly associated with cervical/vulvar
intraepithelia neoplasia and cancer
- acetowhite lesions, wartlike progections
Treatment
- podofilox
- imiquimod
- liquid N
- TCA
- laser, electro, excision
- intralesional interferon
Gynecologic Infections
Condylomata Acuminata
Gynecologic Infections
Condylomata Acuminata
Gynecologic Infections
Condylomata Acuminata
Gynecologic Infections
Condylomata Acuminata-male
Gynecologic Infections
Condylomata Acuminata-perianal
Papillomavirus
Patient-applied
Podofilox 0.5% solution or gel
or
Imiquimod 5% cream
Provider-administered
Cryotherapy
or
Podophyllin resin 10-25%
or
Trichloroacetic or
Bichloroacetic acid 80-90%
or
Surgical removal
Papillomavirus
Vaginal warts
Cryotherapy or TCA/BCA 80-90%
Urethral meatal warts
Cryotherapy or podophyllin 1025%
Anal warts
Cryotherapy or TCA/BCA 80-90%
Papillomavirus
Treatment in Pregnancy

Imiquimod, podophyllin, podofilox should not
be used in pregnancy

Many specialists advocate wart removal due
to possible proliferation and friability

HPV types 6 and 11 can cause respiratory
papillomatosis in infants and children

Preventative value of cesarean section is
unknown; may be indicated for pelvic outlet
obstruction
Gynecologic Infections
Vulvar Lesions
Molluscum Contagiosum
- molluscipoxvirus
- mildy contagious
- nodule with umbilicated centre
Treatment
- curette
- TCA, silver nitrate, carbonic acid
Gynecologic Infections
Molluscum Contagiosum
Gynecologic Infections
Molluscum Contagiosum
Gynecologic Infections
Molluscum Contagiosum
Gynecologic Infections
Genital Ulcers
Description
Diagnosis
Herpes
(HSVII, I(10%))
-prodromal
viral culture
-small vessicle progresses
to shallow, painful, inflamed
Syphilis
(Treponema
pallidum)
-smooth, raised border
painless, smooth base
Chancroid
(Hemophilus
ducreyi)
-irregular border, deepculture Gram stain
undermined edges, painful -GNB in rows
+/- buboe(tender lymphadenopath
dark field micro
-spirochetes
-VDRL etc.
Gynecologic Infections
Genital Herpes
Gynecologic Infections
Genital Herpes
Gynecologic Infections
Genital Herpes
Genital Herpes
First Clinical Episode
Acyclovir 400 mg tid
or
Famciclovir 250 mg tid
or
Valacyclovir 1000 mg bid
Duration of Therapy 7-10 days
Genital Herpes
Episodic Therapy
Acyclovir 400 mg three times daily x 5 days
or
Acyclovir 800 mg twice daily x 5 days
or
Famciclovir 125 mg twice daily x 5 days
or
Valacyclovir 500 mg twice daily x 3-5 days
or
Valacyclovir 1 gm orally daily x 5 days
Genital Herpes
Daily Suppression
Acyclovir 400 mg bid
or
Famciclovir 250 mg bid
or
Valacyclovir 500-1000 mg daily
Gynecologic Infections
Syphilis-male
Gynecologic Infections
Syphilis-female
Gynecologic Infections
Syphilis- Treponema pallidum
Gynecologic Infections
Darkfield Microscopy - Treponema pallidum
Syphilis
Primary, Secondary, Early Latent
Recommended regimen
Benzathine Penicillin G, 2.4 million units IM
Penicillin Allergy*
Doxycycline 100 mg twice daily x 14 days
or
Ceftriaxone 1 gm IM/IV daily x 8-10 days (limited
studies)
or
Azithromycin 2 gm single oral dose (preliminary
data)
*Use in HIV-infection has not been studied
Gynecologic Infections
Chancroid-male
Gynecologic Infections
Chancroid-male with regional adenopathy
Gynecologic Infections
Chancroid-male with regional adenopathy node ruptured
Gynecologic Infections
Hemophilus ducreyi(Chancroid GNB in row-school of fish)
Chancroid
Azithromycin 1 gm orally
or
Ceftriaxone 250 mg IM in a single dose
or
Ciprofloxacin 500 mg twice daily x 3 days
or
Erythromycin base 500 mg tid x 7 days
Gynecologic Infections
Genital Ulcers
Treatment
Herpes
(HSVII, I(10%))
10 acyclovir 400mg PO TID x 7-10d
20 acyclovir 400mg PO TID x 5d
Syphilis
(Treponema
pallidum)
benzathine penicillin G 2.4 million units IM
-treat partners
-reportable illness
Chancroid
(Hemophilus
ducreyi)
-erythromycin 500mg QID x 7 days
OR ceftriaxone 250mg IM x 1
OR azithromycin 1g PO x1
-treat partners
Case
31 yo woman complains of sudden onset of LLQ pain. The
pain is constant and worse with movements. She is late for her
menses by 3 weeks and has been actively trying to get pregnant.
Past medical history is positive for PID requiring hospitalization
for IV antibiotics for 4 days. Her vitals are stable, and afebrile.
She is having mild vaginal bleeding(<1pad) that started today.
Case
What investigations would be appropriate?
(chose up to 3)
A) CBC
B) pelvic ultrasound (endovaginal and transabdominal)
C) flat plate(x-ray) of abdomen
D) Bhcg- quantitative if positive
E) sigmoidoscopy with possible colonscopy
F) IVP with delayed films
Ectopic Pregnancy
1-2% of all pregnancies
~14% if previous ectopic pregnancy
~ 1/30,000 pregnancies will be heterotopic(1 IUP + 1 ectopic)
Ectopic Pregnancy
Types:
Tubal -Ampullary
-Isthmic
-Fimbrial
-Cornual
80%
12%
5%
2%
Abdominal
Ovarian
Cervical
1.4%
0.2%
0.2%
Ectopic Pregnancy
Risk Factors:
Tubal surgery
Previous ectopic
Previous salpingitis
Assisted Reproduction
Age < 25
previous pelvic infection
Infertility
Cigarettes
Vaginal douching
Relative Risk
20
10
4
4
3
3
2.5
2.5
2.5
Ectopic Pregnancy
Risk Factors:
-IUD use does not increase risk of ectopic over
women using no contraception
-however, if pregnant with IUD 3-4% will be ectopic
-uterine anomalies
-?progestins?
Ectopic Pregnancy
Diagnosis:
-amenorrhea
-pain
-spotting (vaginal bleeding not from direct blood loss from
tubal bleeding- hormonal event from estrogen
breakthrough bleeding)
-hypovolemic shock
Ectopic Pregnancy
Investigations:
-Hx & Px
-Bhcg Quantitative, CBC, G&S,
-pelvic ultrasound
Endovaginal
Bhcg> 1200-1500 gestational sac of a
normal pregnancy should be visible in uterus
-serial Bhcg’s
normal doubling time of Bhcg is about 2 days
inadequate doubling is concerning for ectopic or
abnormal intrauterine
-laparoscopy
-culdocentesis(of non clotted blood)-more historical note only
Ectopic Pregnancy
Treatment
Surgical(laparotomy,laparoscopy)
-salpingectomy, salpingostomy
Medical
- methotrexate 50mg/m2 IM x 1
serial Bhcg weekly f/u
- 10-15% failure rate
Ectopic Pregnancy
Ectopic Pregnancy
Ectopic Pregnancy
Salpingostomy with electrocaughtery
Ectopic Pregnancy
Ectopic Pregnancy
Electrocaughtery for hemostatsis
Ectopic Pregnancy
In this case salpingectomy needed for hemostasis
Ectopic Pregnancy
Criteria Methotrexate Tx:
-stable patient
- < 3.5 - 4 cm of ectopic pregnancy
-Bhcg<5000 iu (Dr. Claman of U of O)
-no fetal cardiac activity
-compliant to follow up
-no renal/hepatic/hematologic impairment
Violence Against women
- ~ 1 in 2 women (aged 16 onwards) will experience
some form of physical or sexual violence
-prevalence of domestic violence in Canadian women
is 29%
- acts of violence against women are ‘significantly under reported’
- estimated that only 3% of violent acts against women are identified
by primary physicians
Violence Against women
- abuse is often increased during pregnancy
- first episode of abuse may occur in pregnancy
(14% of abused women)
- estimated that only 3% of abused pregnant women reported
the abuse
Violence Against women
Role of Physician:
1) be aware
2) be approachable
3) identify problems
4) provide support and medical care
Violence Against women
When to suspect physical abuse:
- multiple visits to office with vague complaints
- shyness, fear, crying, accompanied by male partner
who is reluctant to leave
- substance abuse, depression, attempts a self harm
- injuries inconsistent with explanation of mechanism
Violence Against women
Support and Medical Care:
- not physicians role to contact authorities
- Inappropriate interventions can cause situation to
escalate at home, endangering woman or children more
- clear documentation
- provide information on community supports,
and resources and information on an exit plan
- support woman’s decisions
(refer for additional support if needed)
Violence Against women
Exit Plan:
1- Prepare a change of clothing for herself and children
with medications, keys (house and car) and keep with a
friend or neighbour.
2- cash, cheque book, and savings account book with
clothing
3- Important papers, birth certificates, SIN card, drivers
licence, automobile title, mortgage papers should be taken
if possible
4- Have a plan detailing exactly where to go regardless of
time of day(family, friend, shelter etc.)
Violence Against women
Regardless of status of plan patient should leave immediately
if she feels
there is a danger to the life, health, or safety of herself or
her child(ren)
Good Luck