Gynae/OBS - CP

Abnormal Genital Tract Bleeding

Abnormal genital
tract bleeding

Peri/post-
Pre-menarchial Reproductive age
menopausal

Pregnant Non-pregnant

Early Late Ovulatory Anovulatory

Miscarriage Intermenstrual Age related

Molar pregnancy Menorrhagic Endocrine

Ectopic Others

Vaginal bleeding is considered abnormal when it occurs at an unexpected time before menarche or after
menopause or when it varies from the normal amount or pattern, to abnormal pattern. Abnormal pattern of
vaginal bleeding is bleeding lasting more than 7 days, flow more than 80 ml, usually in clots and interval less
than 21 and 35 days, or intermenstrual bleeding. It is usually associated with iron deficiency anemia. The
abnormal vaginal bleeding may be pre-menarchial, during reproductive age and post- menopausal.
Abnormal uterine bleeding according to the pattern:
a. Intermenstrual bleeding: occurs between regular menstrual periods
b. Menorrhagia: cyclical, prolonged (>7 days) and or excessive (>80ml).
c. Metrorrhagia: Prolonged or excessive uterine bleeding occurring at irregular and more frequent than
normal intervals.
d. Polymenorrhea: Uterine bleeding occurring at intervals of less than 21 days.
e. Oligomenorrhea: Uterine bleeding occurring at intervals of more than 35 days.
f. Postmenopausal bleeding: Recurrence of bleeding in a menopausal woman at least 6 months to 1 year
after cessation of cycles

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Pre-Menarchial bleeding
Clinical cues:
Ask for
- Age of the patient
- Pattern of bleeding
- History of trauma or sexual abuse
- History of vaginal discharge
- History of easy bruising, gum or nose bleeding

Look for
- Vital signs/Anemia
- Sexual development (secondary sexual characteristics)
- Any abdominal mass
- Any evidence of trauma or sexual assault
- Abnormal vaginal discharge
- Petechiae/echymosis

Investigations
- CBC and clotting profile if clinically indicated
- USG may be helpful to see the uterus and ovaries
- Hormonal assays (if considering precocious puberty or hormone producing tumour)

Comment
- Internal examination should not be done in girls who are not sexually active

Diagnoses to consider in Pre-menarchial bleeding:

Precocious puberty
Trauma
Sexual abuse
Foreign body
Infection
Coagulopathy
Hormone producing ovarian tumor.

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Abnormal genital tract bleeding Reproductive years

Reproductive age,
abnormal genital bleeding

Pregnant Non-pregnant
The first question to address in any woman in the reproductive age group who has abnormal genital bleeding, is
whether or not she is pregnant.
Ask for:
Date of last menstrual period

Be specific about the date of the last normal menstrual bleed common for women to become
pregnant, have a little spotting at around the date of the next scheduled period, and then bleed heavily
from a miscarriage a few weeks later.

General timing of menstrual cycle prior to this episode

Sexual activity (even if unmarried)

Use of contraception (type, and whether forgotten to take at correct time)

Use of drugs which might interfere with effective oral contraceptive pill (e.g. antibiotics,
anticonvulsants)

Symptoms of early pregnancy e.g.Breast tenderness or nausea

Investigations:
Do a urine pregnancy test.

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Bleeding in the pregnant woman

Reproductive age,
abnormal genital bleeding

Non-Pregnant Pregnant

Late (covered in
complicated preg Early pregnancy
CP)

Miscarriage Molar pregnancy Ectopic

Complete Partial

Incomplete Complete

Threatened Choriocarcinoma

Missed abortion

Septic abortion

Clinical clues
Ask for
Ask the same questions as above. In addition ask:

Amount of bleeding
Presence of clots or products of conception
Presence of abdominal pain and nature of pain severe pain localized to right or left iliac fossa suggests
possible ectopic pregnancy
History of fever or bloody discharge mixed with pus s/o septic abortion
History of attempted induced abortion s/o septic abortion
History of hyper-emesis s/o molar pregnancy

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Features suggestive of circulatory compromise from excessive bleeding e.g. fainting attacks, dizziness on
standing, palpitations, shortness of breath.
Use of IUCD or past history of ectopic pregnancy (increased risk of ectopic)
Maternal age - >35yrs increased risk of molar pregnancy, there is increased risk of miscarriage with
increased maternal age.
Past medical history of Gestational Trophoblastic disease (GTD or molar pregnancy)
History of recurrent miscarriage (s/o underlying medical condition predisposing to miscarriage e.g.
Factor V Leiden deficiency, SLE, hypothyroidism) significant increase of further miscarriage after 3
consecutive miscarriages.
Smoking and alcohol use (increased risk of miscarriage with heavy use of either)
Drug history use of NSAID in the first trimester may increase risk of miscarriage

Look for

Evidence of circulatory compromise pulse, BP, capillary refill time

Fever s/o sepsis
Anaemia
On abdominal palpation
o look for tenderness if guarding and rigidity s/o ruptured ectopic
o Uterine mass if uterus larger than predicted from dates, s/o molar pregnancy
PV examination
o Presence of clots or products of conception in vagina or in os
o Is the os open? if open s/o incomplete miscarriage, if closed s/o either complete or threatened
miscarriage
o Presence of tender mass in fornices s/o ectopic
o Boggy tender uterus s/o sepsis
Investigations:
CBC, Cross-match
Urine pregnancy test if not already done
Ultrasound for site of pregnancy (intrauterine or ectopic), foetal viability to distinguish missed
abortion or threatened (look for cardiac activity absent in missed abortion), typical appearance of
molar pregnancy (snow storm)
If molar pregnancy is suspected after ultrasound examination then further investigations are indicated
looking for metastatic disease e.g. CXR,
Quantitative serum hCG concentration is useful in evaluation of molar pregnancy and ectopic pregnancy
(see details in comments). hCG is always elevated in women with Gestational trophoblastic disease
(GTD) and is usually higher than that observed with intrauterine or ectopic pregnancies of the same
gestational age.
Histological examination of tissue this should be done for all miscarriages as a proportion of them
may be partial molar pregnancies. It also distinguishes between complete and partial moles.

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Comments
Miscarriage
Miscarriage refers to a pregnancy that ends spontaneously before the fetus has reached a viable gestational age.
Spontaneous miscarriage is the commonest complication of pregnancy. Many miscarriages occur without the
patient ever knowing that she is pregnant. The commonest reason for miscarriage is chromosomal abnormality
(50%).
Threatened abortion, is common and is defined as bleeding through a closed cervical os in the first half of
pregnancy. The bleeding is often painless, but may be accompanied by minimal/mild suprapubic pain. On
examination, the uterine size is appropriate for gestational age and the cervix is long and closed. Fetal cardiac
activity is detectable by ultrasound if the gestation is sufficiently advanced. The exact etiology of bleeding often
cannot be determined and is frequently attributed to marginal separation of the placenta.
The term "threatened" abortion is used to describe these cases because pregnancy loss does not always follow
vaginal bleeding in early pregnancy, even after repeated episodes or large amounts of bleeding. In fact, 90 to 96
percent of pregnancies with both fetal cardiac activity and vaginal bleeding at 7 to 11 weeks of gestation will
result in an ongoing pregnancy, with the higher success rate occurring at the later gestational ages.No change in
pregnancy management is indicated because of the low predictive value for adverse outcome and the lack of
effective interventions.
Inevitable or incomplete abortion the key feature is that the cervical os is open. Gestational tissue can often
be felt or visualized through the internal cervical os.
In complete abortion the uterus is small and well contracted with a closed cervix, scant vaginal bleeding, and
only mild cramping.
A missed abortion refers to in-utero death of the embryo or fetus prior to the 20th week of gestation, with
retention of the pregnancy for a prolonged period of time. Women may notice that symptoms associated with
early pregnancy (eg, nausea, breast tenderness) have abated and they don't "feel pregnant" anymore; vaginal
bleeding may occur. The cervix is usually closed.

Ectopic pregnancy
Ectopic pregnancy is easily missed, so a high index of suspicion is needed in any pregnant woman presenting
with low abdominal pain. They may have only light PV bleeding or none at all. A transvaginal ultrasound (TVS)
is essential to make sure the pregnancy is intrauterine. If acomplex adnexal mass is seen with a positive
pregnancy test, or a yolk sac is seen outside the uterus then the diagnosis of ectopic is clear cut. If no yolk sac or
embryo is seen, this may be because the pregnancy is too early to be visible in utero, or it may be an ectopic
pregnancy. At this stage it is helpful to do a quantitative serum hCG concentration.
The discriminatory zone is based upon the correlation between visibility of the gestational sac and the hCG
concentration, and is of major diagnostic importance. It is defined as the serum hCG level above which a
gestational sac should be visualized by ultrasound examination if an intrauterine pregnancy is present. In most
institutions, this serum hCG level is 1500 or 2000 IU/L with TVS.
Where the hCGis above the discriminatory zone, it should be possible to see an intrauterine pregnancy by TVS.
If there is no visualized intrauterine pregnancy and no complex adnexal mass the next step is to repeat the TVS
examination and hCG concentration two days later. If an intrauterine pregnancy is still not observed on TVS,
then the pregnancy is abnormal.
An ectopic pregnancy can be diagnosed if the serum hCG concentration is increasing or plateaued.
Treatment can be started.

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A falling hCG concentration is most consistent with a failed pregnancy (eg, arrested pregnancy, blighted
ovum, tubal abortion, spontaneously resolving ectopic pregnancy). Weekly hCG concentrations should
be monitored until the result is negative for pregnancy.
Where the hCGis below the discriminatory zone, TVS is not sensitive for determining the location of the
pregnancy. A serum hCG concentration less than 1500 IU/L should be followed by repetition of hCG in three
days to follow the rate of rise. HCG concentrations usually double every 1.4 to two days until six to seven weeks
of gestation in viable intrauterine pregnancies (and in some ectopic gestations)
A normally rising hCG concentration should be evaluated with TVS when the hCG reaches the
discriminatory zone. At that time, an intrauterine pregnancy or an ectopic pregnancy can be diagnosed.
If the hCG concentration does not double over 72 hours then the pregnancy is abnormal (an ectopic
gestation or intrauterine pregnancy that is destined to abort). The clinician can be reasonably certain
that a normal intrauterine pregnancy is not present.

Molar pregnancy / Gestational trophoblastic disease (GTD)

The pathogenesis of GTD is unique because the maternal tumor arises from gestational rather than maternal
tissue. 90% of all GTD are complete or partial hydatidiform moles. These are noninvasive, localized tumors that
develop as a result of an aberrant fertilization event that leads to a proliferative process. The next most
common type of GTD is malignant, choriocarcinoma.
GTD is much commoner in Asian populations (1 per 12 to 500 pregnancies) than in North American or European
countries.
Complete hydatidiform mole result of fertilization of an empty ovum by two sperms or a single sperm that
duplicates, resulting in a 46 XX or 46 XY karyotype. The complete mole lacks a foetus and there is usually
excessive uterine size for the expected "gestational age"
Partial hydatidiform mole result of fertilization of a haploid ovum by two sperm or duplication of one sperm,
resulting in a triploid karyotype (69 XXY, 69 XXX, 69 XYY). Partial moles are the only type of GTD that are
associated with the presence of a fetus, and fetal cardiac activity may be detected.
Choriocarcinoma arises from cytotrophoblast occurs in approximately 1 in 16,000 normal gestations, 1 in
15,000 abortions, and 1 in 40 complete molar pregnancies. About 50 percent of cases of choriocarcinoma arise
from complete hydatidiform mole, an additional 25 percent arise after normal pregnancies, and 25 percent
follow spontaneous abortion or ectopic pregnancy. Choriocarcinoma is the most aggressive GTN, and is
characterized by early vascular invasion and widespread metastases. Respiratory symptoms (eg, cough, chest
pain, hemoptysis) or signs of gastrointestinal, urologic, and intracerebral bleeding are indicative of metastatic
disease. Hepatic involvement from advanced disease may cause epigastric or right upper quadrant pain.

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Abnormal
bleeding in
reproductive
age

Pregnant Non-pregnant

Early
Late pregnancy
pregnancy

Antepartum Post-partum

Antepartum haemorrhage usually refers to uterine bleeding after 20 weeks of gestation that is unrelated to
labor and delivery. Antepartum hemorrhage complicates 4 to 5 percent of pregnancies.

Clinical clues
Ask for:
Amount of bleeding (although this may be misleading since bleeding can be concealed in the uterine
cavity)
Signs of haemodynamic instability (fainting attacks, dizziness on standing, palpitations or shortness of
breath)
Presence of abdominal pain (if present s/o placental or uterine rupture, if absent s/o placenta previa)
Presence of uterine contractions it is common to have a bloody show as part of early labour
Foetal movements
History of trauma s/o placental abruption or uterine rupture
Maternal hypertension, preterm premature rupture of membranes, smoking history all risk factors for
placental abruption.

Look for:
Haemodynamic compromise BP, pulse, capillary refill time, pallor
Abdominal tenderness
Fundal height and correlate to dates
Presentation of foetus if transverse lie, or foetal head not engaged, more s/o placenta previa
Foetal heart rate
DO NOT DO a digital examination of the cervix in a woman presenting with bleeding in the second half
of pregnancy until placenta previa has been excluded.Digital examination of a placenta previa can cause
immediate, severe hemorrhage.

Investigations

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Ultrasound is the most important investigation to come to a diagnosis

CBC and crossmatch

Comments
In women with uterine bleeding who are Rh D negative they should be given anti-D immune globulin.
Diagnoses to consider:
Placenta previa (20 percent)
Abruptio placenta (30 percent)
Uterine rupture (rare)
Vasa previa (rare)
Cervical cancer
Cervical polyps
Fibroids
Vaginitis

In the remaining cases, the exact etiology of the antepartum bleeding cannot be determined and is frequently
attributed to marginal separation of the placenta.

Post partum haemorrhage

Postpartum hemorrhage can be defined as excessive bleeding that makes the patient symptomatic and/or
results in signs of hypovolemia.

Ask for:
Lightheadedness, palpitations, diaphoresis, confusion

Look for:
Hypotension, tachycardia, oliguria, decreased oxygen saturation

Comments
The most common causes of postpartum hemorrhage are atony, trauma, and acquired or congenital coagulation
defects.
Management depends on the cause and whetherthe patient has had a vaginal birth or cesarean delivery.
Women with a prior PPH have as much as a 10 percent risk of recurrence in a subsequent pregnancy.

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Abnormal bleeding in the non-pregnant woman

Approximately 90% of abnormal genital bleeding in the reproductive age group results from anovulation, and
10% of cases occur with ovulatory cycles. The commonest cause is dysfunctional uterine bleeding but this is a
diagnosis of exclusion and other causes should be considered first.

Anovulatory bleeding

Reproductive age,
abnormal genital
bleeding

Pregnant Non-pregnant

Ovulatory Anovulatory

Age related Others (wt

Endocrine /
(perimenarchial and loss/stress/systemic
Metabolic
perimenopausal) disease/drugs)

For any abnormal genital tract bleeding during reproductive age, rule out pregnancy related bleeding (perform
pregnancy test).
Anovulatory cycles occur in the absence of cyclical hormonal changes that determine the menstrual cycle and
the amount of bleeding correlates directly with the duration of unopposed estrogen stimulation.
During peri-menarchal and perimenopause, there are more frequent anovulatory cycles.
Prolonged exposure to unopposed estrogen stimulation increases the risk of endometrial hyperplasia and
endometrial carcinoma.
Loss of normal ovulatory function occurs because of the
a. Immature hypothalamic - pituitary axis: Post pubertal
b. Dysfunction of hypothalamic - pituitary axis: e.g. hyperprolactinoma, stress and rapid weight loss.
c. Abnormality of normal feedback signals: There is no rise and fall of estrogen consequently no negative
feedback on FSH secretion. The most common causes of persistent estrogen action are pregnancy,
ovarian and adrenal tumors, hepatic disease or thyroid abnormalities, Progesterone contraception and
extragonadal production of estrogen(obesity).
d. Lack of mid cycle LH surge: This is due to failure of ovary to produce critical estradiol levels or increase in
androgen levels e.g. Polycystic ovaries and obesity.

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Ask for
- Age, parity
- Menstrual history
- Post-coital bleeding (Bleeding after intercourse suggest cervical pathology, either malignant or benign or
due to inflammation or a polyp)
- Contraception (Depoprovera and progesterone only pill are common causes of irregular vaginal
bleeding)
- Medical history for endocrine problem (heat and cold intolerance, sweating tremor are the suggestive
for thyroid disease).
- Drug history: Medications such as phenothiazines, metoclopramide or domperidone affect prolactin
secretion
- History of weight loss or known systemic disease (TB, Malignancy)
- Recent stressful life events
- Fever, lower abdominal pain and unhealthy PV discharge are the suggestive of infective process.

Look for:
- General condition and vital signs
- Body mass index as a measure of obesity
- Pallor
- Hirsuitism and acne (may point to polycystic ovarian disease)
- Any abdominal mass
- Cervix (PS exam)- ectropian, polyp
- Uterine size and adnexia (Bimanual exam)

Investigation
To rule out systemic disease e.g. chronic infection, malignancy
Thyroid function
Hormonal assays (e.g. prolactin, FSH, LH, oestrogen, progesterone)
USG of abdomen and pelvis (for PCOD and tumours)

Comments
Dysfunctional uterine bleeding is irregular, abnormal uterine bleeding that is not caused by a tumor, infection,
or pregnancy

Diagnoses to consider
- Contraceptive use hormonal one
- Thyroid problem
- Polycystic Ovarian Disease (PCOD)
- Stress rapid weight loss and systemic illness
- Obesity
- Ovarian or adrenal tumor
- Prolactinoma
Dysfunctional uterine bleeding is the diagnosis which is made after the all the other possible diagnosis
has been ruled out

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 Gynae/OBS - CP

Abnormal Genital Tract Bleeding: Ovulatory

Ovulatory
Genital Tract
Bleeding

Intermenstrual Menorrhagic

Coagulopathy
Platelet IUD Neoplasm
Infection Neoplasm disorder/Liver Endometritis Benign/Maligmant
disease/Leuke
mia
Benign Malignant Endometial Ca Fibroid
Cervival Vagina/Cervix/ Cervical Ca Adenomyosis
polyp/Ectropian Uterus

This is less common cause of abnormal uterine bleeding and is commonly associated with declining ovarian
function.
a.Midcycle spotting: occurs due to decrease in estrogen at midcycle, just before ovulation
b.Frequent menstrual bleeding: due to shortened follicular phase
c.Luteal phase deficiency: is associated with premenstrual spotting and occurs due to decreased
progesterone levels.
d. Prolonged corpus luteum activity: due to persistent corpus luteum
Ask for:
- Age, parity
- Menstrual history including days, number of pad/ home made pads soaked
- Contraception
- History of post coital bleeding s/o cervical malignancy, erosion or polyp
- Medical history for endocrine problem, bleeding disorder
- Drug history including exogenous hormones, anticoagulants, aspirin, anticonvulsants, and antibiotics.
Alternative and complementary medicine modalities, such as herbs and supplements.
- Fever and lower abdominal pain

Look for:
- Vital signs
- Pallor
- Abdominal mass
- Cervix (PS exam): looking for polyps,erosion
- Uterine size, adnexia (Bimanual exam): Size of the uterus in terms of pregnancy size, consistency, feeling
of mass like fibroid etc and mobility of the uterus. Adnexia- any mass and its consistency, mobility and
size.

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Investigations
- Pregnancy test (in reproductive age group)
- CBC (for anaemia or infection)
- Thyroid function
- Prolactin, oestrogen,hydroxyprogesterone
- Coagulation profile
- Androgen profile (Testosterone, dehydroepiandrosterone)
- Ultrasound
- Cervical smear
- Endometrial biopsy
- Hysteroscopy

Diagnoses to consider
- Fibroid uterus
- Adenomyosis
- Cervical polyp
- Ectropian (presence of columnar epithelium outside of cervical opening)
- Cervical/Endometrial malignancy
- Intrauterine contraceptive device (IUD)
- Infection
- Bleeding disorder

Abnormal Genital Bleeding: Postmenopausal

Abnormal genital tract bleeding

( post menopausal)

Benign condition Malignant condition

Atrophic endometrium, Vaginal/cervical/endometrial/Fallopian tube
Uterine prolapse ,Polyps and infection malignancies

Clinical Clues:
Ask for:
- Age of the patient
- Date of menopause
- Detail history of bleeding
- Presence of post-coital bleeding s/o cervical malignancy
- Concurrent medical disease
- Medicine e.g. Hormone replacement therapy

Look for:
- General condition
- Vital signs and pallor
- Any abdominal mass
- Atropy or abnormal growths in vulva/vagina/cervix
- Mass or tenderness in uterus/adnexa
- Digital rectal examination (if relevant)
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 Gynae/OBS - CP

Investigations
- Complete blood count and ESR
- Coagulation profile (Platelet/PT/aPTT)
- Cervical (Pap) smear
- Ultrasound
- Endometrial biopsy
- Hysteroscopy

Comments:
- Those who are unmarried, internal examination is avoided
- In peri or post menopausal age group possible malignancies should be ruled out first
(cervical/Endometrial/ovarian)

Management topics for abnormal genital bleeding

1. Discuss the Physiology, S/S of pregnancy, Ectopic pregnancy, H Mole
2. Management of incomplete and complete miscarriage (medical and surgical) + monitoring
3. Management of ectopic pregnancy
4. Pathophysiology of normal menstruation + Management of DUB
5. Pathophysiology of functional ovarian cysts + recognition and management of ovulatory pain
6. Management of post partumhaemorrhage primary and secondary (including manual removal of
placenta)

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 Gynae/OBS - CP

Amenorrhoea
Amenorrhoea

Physiological Pathological

lactation/
Primary Secondary
pregnancy

Structural
Menopause Ovarian disorder
abnormality

Hypothalamic-
Pituitary Hypothalamic
Gonadal failure pituitary axis
dysfunction dysfunction
dysfunction

Functional Thyroid disease

Genetic Drugs

Uterine disorder

Amenorrhoea means absence of menstruation. This is not a diagnosis but only a symptom. Physiologic
amenorrhea is the absence of menstrual bleeding during pregnancy, lactation and after menopause. It is not a
disease and does not need to be evaluated.

Menopause is a normal, natural event representing the end of menstruation technically defined as the final
period, it is not an abrupt event, but a gradual process. It is usually confirmed when a woman has missed her
periods for 12 consecutive months (in the absence of other obvious causes). Menopause is associated with
reduced functioning of the ovaries due to loss of ovarian sensitivity to gonadotropin stimulation, resulting in
lower levels of estrogen and other hormones. Menopause occurs, on average, at age 51. It is termed
physiological if it occurs after the age of 40yrs.

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Amenorrhoea

Physiologic
Pathologic
Lactation/Pregnancy

Primary

Secondary

Based on medical history and physical examination findings, the patients with amenorrhoea are divided into two
groups:
1. Patients without previous menstrual function i.e. Primary amenorrhoea
2. Patients with previous menstrual function i.e. Secondary amenorrhoea

Pathologic amenorrhea is suspected in the following clinical situations:

Primary amenorrhoea
a. At 14 years of age, in the absence of menstruation and secondary sexual characteristics like
development of breast and appearance of axillary and pubic hair.
b. At 16 years of age, regardless of whether there are secondary sexual characteristics

Secondary amenorrhoea
At any age when menstrual bleeding have ceased in a woman who previously had normal menstrual
function.

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Primary Amenorrhoea

Amenorrhoea

Primary Secondary
No menstruation Had menstruation
before before

Structural
abnormality

Pituitary Hypothalamic
Gonadal failure
dysfunction dysfunction

Functional Congenital

Primary Amenorrhoea means no menstruation before

Ask for:
- Age of the patient
- Eating habit ( anorexia nervosa or severe weight loss lead to secondary pituitary dysfunction leading to
amenorrhea)
- Any stress (affects hypothalamic pituitary index)
- Use of any medicine e.g. contraceptive pill
- Cyclical lower abdominal pain (suggests menstruation occurring but disorder of outflow tract)
- Swelling in lower abdomen

Look for:
- Height/weight/Nutritional status
- Presence or absence of secondary sexual characteristics like breast development and appearance of
axillary and pubic hair.
- webbed neck, shield chest and cubitus valgus (Turner syndrome)
- External genitalia for any abnormality like bulging of hymen (imperforated hymen)
- Digital rectal examination for any mass in pelvis (e.g. haematocolpos)
- Functional vaginal depth

Investigation:
- Ultrasound of abdomen and pelvis
- Hormone analysis e.g. gonadotrophins
- Diagnostic laparoscopy
- Karyotyping (e.g. Turners syndrome XO)
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Comments:
- Menstrual function depends on visible external evidence of the menstrual discharge.
- Absence of menstruation may be related to:
a. Structural abnormality of the outflow tract
b. disorders of the ovary
c. disorders of the anterior pituitary
d. disorders of the central nervous (hypothalamic) factor.

Disorders of the outflow tract

The outflow tract that connects the internal genital source of flow should be connected with the outside. The
outflow tract requires patency and continuity of the vaginal orifice, the vaginal canal and the endocervix with
the uterine cavity.
Imperforated hymen is one example of outflow obstruction, where the patient menstruates but blood is
collected within uterus and vagina. Ultrasound examination may reveal hematometra and hematocolpus.
Congenitally mal developed uterus with no functional endometrium. Mayer-Kuster-Rockitansky-Hauser
syndrome consists of hypoplasia of the internal vagina, absence of the uterus and fallopian tubes, but rarely
uterus may be normal, but lacking a conduit to the introuitus, or may have bicornuate rudimentary cords. Note
that ovarian function is normal in these patients, as well as growth and development of the secondary sexual
characteristics.
Androgen insensitivity (testicular feminization) is the likely diagnosis when a blind vaginal canal is encountered
and the uterus is absent. The individual has testes and an XY karyotype, and is phenotypically female with
absent pubic or axillary hair. Frequently these patients have inguinal hernias because the testes are partially
descended. Growth and development are normal, with greater overall height than average. The breasts may be
large, but nipples are small, areole are pale and glandular tissue is not abundant.
Intravenous pyelography (IVP) should be performed in all patients with any degree of mulleriandysgenesis
because of high risk or associated renal abnormalities.

Disorders of the ovary

Ovarian dysfunction: ovaries do not secrete the hormones which regulate the changes in endometrium and
producing menstruation. Gonadal dysgenesis is the example. This may be associated with normal karyotype, 45
X0 (Turner syndrome), 47 XXX, mosaicism, XY gonadal dysgenesis and deletion in X short and long arms.High
levels of FSH (greater than 40 mIU/ml,): indicate gonadal failure.

Disorders of the anterior pituitary and hypothalamus

Failure of pituitary and hypothalamus is diagnosed by hormone analysis. Low levels of FSH (less than 5 mIU/ml,)
indicate pituitary failure or inactivity (think of hypothalamic dysfunction)
Laparoscopy may be needed to determine the extent of the mulleriandygenesis or to ascertain the nature of the
dysgenetic gonads.
In some girls with no obvious cause, there is a delay of menstruation which is called constitutional delay.

Possible diagnoses to consider in primary amenorrhea with normal secondary sexual characteristics
- Imperforate hymen
- Transverse vaginal septum
- Absent vagina and a non-functioning uterus (Meyer-Rokitansky-Kuster-Hauser syndrome)
- XY female (androgen insensitivity)
- Constitutional delay
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Patient with previous menstrual function (Secondary Amenorrhoea)

Secondary
amenorrhoea

Pregnancy and
lactation

Hypothalamic-pituitary Uterus disorder e.g.

Ovarian disorder Thyroid disease Drugs
axis disorder Ashermans

Polycystic ovarian Functional

Contraceptives
disease hypothalamic disorder

Premature ovarian
Pituitary disease Others
failure

Adenoma
Iatrogenic e.g. surgery
(hyperprolactinaemia)

Other

Patients with secondary amenorrhoea are usually in reproductive age group, so pregnancy is to be ruled out
first. Once the pregnancy is ruled out
Ask for
- Age of the patient
- Mothers age when she had menopause
- Whether the patient is lactating lactationalamenorrhoea (physiological)
- Contraception especially Depoprovera, which causes amenorrhoea in some ladies. Oral contraceptive
may also cause amenorrhoea
- Other drugs e.g. danazol, metoclopramide, antipsychotics (cause amenorrhoea due to
hyperprolactinaemia)
- Has she suffered from any recent stress, change in weight, diet or exercise habits? (functional
hypothalamic disorder)
- Acne, hirsuitism, deepening of voice Polycystic Ovarian Syndrome (PCOS)
- Symptoms of oestrogen deficiency (hot flashes, vaginal dryness, poor sleep, reduced libido) early
menopause due to premature ovarian failure
- History of severe post-partum hemorrhage- Sheehans syndrome (Damage to pituitary)
- History of curettage or endometritis in post partum period get scarring of endometrial lining
(Ashermans syndrome)
- Ask for any milky discharge from breast- Galactorrhoea (suggests hyper prolactinaemia drug related or
due to pituitary adenoma)
- Headaches, visual field defects, fatigue, polyuria or polydypsia (Hypothalamic pituitary disease)
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- History of heat or cold intolerance, Weight gain or weight loss Thyroid disorder
- History of poorly controlled diabetes
- Radiation exposure or chemotherapy premature ovarian failure
- History of oophorectomy or hysterectomy (surgical menopause)
- History of autoimmune disease

Look for
- General condition: thin, average built and obese. Calculate BMI
- Thyroid enlargement and features of thyroid disorder: weight loss or gain, tachycardia, excessive
sweating.
- Milky discharge from breast
- Excessive hair growth on unusual sites.
- BP, BMI and CVS examination (after menopause women are at increased risk of Cardiovascular disease)
- Breast tenderness and any lumps (menopausal women may want to start oestrogen therapy)
- PV examination for atrophic vaginal tissue

Investigations
- Pregnancy test
- Thyroid function test
- Prolactin (pituitary tumours)
- Follicular stimulating hormone and luteinizing hormone (While it is possible to check for raised FSH to
confirm menopause, in actual fact this is rarely necessary and the diagnosis is made based on age and
clinical symptoms. FSH may also be normal even when a woman is clearly menopausal)
- Measurement of plasma testosterone and dehydroepiandrosterone sulfate (testosterone
andDehydroepiandrosteronesulphate (DHEAS) may be elevated in disease of the ovary and adrenal
gland).
- Measure morning and afternoon levels of cortisol to test for Cushing disease.
- Blood glucose for diabetes as a cause of amenorrhea.
Consider bone densitometry

Other test:
- Ultrasound examination
- Hysteroscopy if suspected Ashermans syndrome (uterine synechia)
- Progesterone challenge test (see Appendix 1)

Comments:
The initial step in the workup of the amenorrhoic patient is to exclude pregnancy.

One of the commonest causes of secondary amenorrhoea is functional hypothalamic disorder. This is by
definition not pathological, but it can have consequences of bone loss if prolongued. Common risk factors for
function hypothalamic disorder are:
Weight loss, exercise and eating disorders
Nutritional deficiency is also important especially in women with low body fat who have a low fat intake.
Emotional distress and other stress (e.g. burns, myocardial infarction)

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Progesterone challenge test

If an amenorrhoic patient has negative pregnancy test, a measurement of TSH, a prolactin level and
progesterone challenge test should be performed.
Progesterone challenge test: The purpose of the progesterone challenge test is to assess the level of
endogeneous estrogen and the competence of the outflow tract.
If the withdrawal test is positive (patient bleeds 2-7 days after the conclusion of the progesterone),
prolactin and TSH levels are normal, a diagnosis of anovulation can be reliably established. Using this
test, the presence of a functional outflow tract and a uterus lined with a reactive endometrium
sufficiently prepared by endogeneous estrogen is confirmed. Furthermore, it confirms the presence
of estrogen, and functional hypothalamic - pituitary ovarian axis.
In patients with positive withdrawal test, another diagnostic step includes assessment of the level of
gonadotropins. It should be performed 2 weeks after following the progestational challenge test.

Another common cause of secondary amenorrhoea is PCOS

- If serum FSH level is abnormally low or normal, perform imaging of the sellaturcica to distinguish
between a pituitary and hypothalamic (CNS) failure.
- If patient has amenorrhea without galactorrhea, low levels of FSH and LH (less than 5 IU/L) and normal
imaging studies, the patient is classified as hypothalamic amenorrhea
(hypogonadotropichypogonadism). The mechanism is suppression of a pulsatile GnRH secretion.
- If patient repeatedly has elevated gonadotropin levels it is likely that patient presents with a premature
ovarian failure (Autoimmune).
Women may suffer from climacteric symptoms before actual menopause starts. The length of time over which
the climacteric occurs is widely variable; symptoms may begin during perimenopause and continue for 5-10
years after menopause.
Osteoporosis risks increase after menopause. A bone mineral density test, or bone densitometry, can quickly
measure the amount of calcium in the bones.
Prior to menopause, the risk of Coronary artery disease (CAD) for women lags behind the risk for men by
approximately 10 years. After menopause, women come to have similar risks of CAD as men of the same age.
Other pituitary disorders which can cause amenorrhoea include: craniopharyngioma, meningioma, radiation,
infarction of the pituitary, Sheehans syndrome.

Diagnoses to consider in Secondary Amenorrhea (in order of frequency) Balen et al 1993

1. Polycystic Ovarian disease (PCOS)
2. Premature ovarian failure (before age 40yrs causes include autoimmune disease, genetic or enzyme
defect, abnormal gonadotrophins)
3. Hyperprolactinaemia (pituitary adenoma, hypothyroidism, PCOS, drugs such as phenothiazines,
domperidone and metoclopramide)
4. Anorexia nervosa
5. Hypogonadotrphichypogonadism
6. Hypopituitarism
7. Exercise related amenorrhea
8. Use of depoprovera and norplant

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Management topics for Amenorrhoea

1. Review of basic science of hypothalamic pituitary ovarian axis
2. Symptoms of polycystic ovarian syndrome and association with metabolic syndrome + management of
PCOS (especially fertility issues)
3. Anatomy of Bartholins cysts and management of Bartholin abscess + management of sebaceous cyst
abscess.
4. Management of patients with premature ovarian failure (health promotion and prevention issues).
5. Overview of recommended antenatal health care in Nepal rationale behind use of folic acid, iron,
albendazole and calcium. Recommended screening tests.

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Complicated Pregnancy

Complicated
pregnancy

Maternal factors Foetal factors Large for dates Small for dates

Blood group Intrauterine growth

Hypertension Polyhydramnios
incompatibility retardation

Congenital Constitutionally
Pregnancy induced Multiple pregnancy
abnormality small

Large baby or
Pre-existing Oligohydramnios
wrong dates

Infection

Systemic disease
e.g. cardiac, renal,
vascular, liver

Diabetes

Overt

Gestational

Social or
psychological
factors

Anaemia

Pregnancy may be complicated by disease or abnormality in either the mother or the foetus. Complications in
the mother may have adverse effects on the foetus and vice versa. Some conditions must be screened for (in
the mother or the foetus) as there are few symptoms, others may present clinically, often as women being
either large for dates or small for dates.

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Maternal factors to
screen for

Social or
Hypertension Infection Systemic disease Diabetes psychological Anaemia
factors

All women should receive regular antenatal care. During this period factors which will adversely affect the
woman, the pregnancy and the foetus can be identified by careful history taking, examination and certain
investigations.
Clinical clues:
Ask for:
Age of mother higher rate of adverse outcomes in teenage mothers or elderly mothers
Last menstrual period to calculate gestational age
Previous menstrual history
Current medical problems e.g. cough, fever, dysuria, SOB, swelling of limbs (point to a current infection
or underlying systemic disease)
Previous obstetric history
o number of previous pregnancies (increased risk of problems in first pregnancy [primigravida] or
after many pregnancies [grand multiparity]),
o outcome of previous pregnancies (e.g. miscarriage, ectopic, trophoblastic disease, still birth,
fetal malformation),
o previous problems during pregnancy (e.g. hypertension, gestational diabetes, antepartum
haemorrhage, preterm labour)
o previous problems during delivery (e.g. caesarean section, forceps delivery, post-partum
haemorrhage).
Past medical and surgical history especially conditions such as diabetes, hypertension, renal disease,
autoimmune disease.
Smoking status and history of alcohol intake (effect on fetus)
Diet
Occupation
Drug history
o previous contraceptive use
o narcotic abuse (will adversely affect the fetus)
o many drugs are contraindicated in pregnancy
Vaccination history especially immunization against Hep B and rubella (in MMR vaccine).
Family history of genetic conditions e.g. sickle cell disease, family history of pre-eclampsia (increased risk
in this mother)
Psychosocial history e.g. poverty, poor family relationships, previous psychiatric illness all increase risk
of problems during the pregnancy. These women need extra support.

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Look for:
General examination for anaemia, jaundice, lymphadenopathy, oedema
Height and weight (very underweight risk of small for gestational age babies, very obese increased
risk of fetal macrosomy and pre-eclampsia)
Blood pressure at every ANC visit
Oedema at every ANC visit
Full physical exam to look for evidence of heart disease, lung disease, rheumatological disease etc. at
first booking appointment
Obstetric examination at each visit to assess foetal growth, presentation of foetus and foetal heart rate.

Investigations:
At booking ANC
Haemoglobin (anaemia is common)
Syphilis screen with VDRL (important to identify and treat early to avoid foetal infection)
HBsAg for exposure to Hepatitis B (will need to immunize the neonate soon after birth if positive)
HIV (has implications for foetal and maternal treatment)
Blood group especially rhesus status
Urinalysis for proteinuria and glucose gives a baseline for whole pregnancy

At subsequent ANC
Urinalysis for proteinuria (screen for pre-eclampsia and also possible UTI) and glucose at every visit
Urinalysis for pyuria if protein positive (risk of asymptomatic UTI)
Glucose challenge test - Screening for gestational diabetes at around 24 weeks gestation (see later in CP)
Repeat haemoglobin to check for anaemia once or twice
In rhesus negative women need to check for antibodies later in pregnancy
USG should be done at least once in the pregnancy best time is at 20wks when a full screen for foetal
abnormalities can be done. USG may also be done in first trimester to rule out ectopic.

Comments:
Anaemia is an important cause of morbidity and mortality in both the mother and the foetus. It is routinely
screened for and in Nepal all women are given iron supplementation as part of their ANC care. In addition, in
Nepal all women are given albendazole at around 20 wks gestation to treat hookworm, which is a major cause of
anaemia.
In different parts of the world other screening may be done e.g. for Toxoplasmosis, Rubella antibodies,
screening for Downs syndrome.
There is little good evidence for the frequency of ANC visits that should be recommended.

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Hypertension in
pregnancy

Pregnancy induced Pre-existing

hypertension (PIH) hypertension

PIH without Chronic hypertension

proteinuria (without proteinuria)

Pregnancy induced
Chronic renal disease
proteinuria (no
(with proteinuria)
hypertension)

Pre-eclampsia (preg Chronic hypertension

induced proteinuria with superimposed
and HTN) Pre-eclampsia

Definition of hypertension:
One measurement of diastolic BP of 110mmHg or more OR
Two consecutive measurements of diastolic BP of >90mgHg 4hrs or more apart

Definition of proteinuria:
One 24hr urine collection with total protein excretion of 300mg or more OR
Two random clean-catch urine specimens with 2+ (1g albumin/l) or more on reagent strip

Pregnancy induced hypertension (PIH) is defined as hypertension and/or proteinuria developing after 20wks of
pregnancy, during labour or in the puerperium in a previously normotensive non-proteinuric woman.
Pre-existing hypertension is defined as hypertension and/or proteinuria in pregnancy in a woman diagnosed
either before pregnancy, before 20 wks of pregnancy or persisting after pregnancy.
Sometimes there are no records of previous hypertension because the woman has not presented to medical
care until after 20 wks of gestation. In this situation it is not possible to classify into the above categories and it
is important to exclude underlying renal disease.
Clinical clues:
Ask for:
BP measurements prior to pregnancy or in early pregnancy (before 20wks gest)
Previous records of proteinuria
Known history of hypertension, renal disease
History of conditions that predispose to hypertension and renal disease (e.g. SLE, diabetes)

Look for:
Blood pressure
Proteinuria on dipstick
Oedema

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Pregnancy induced
hypertension

Pregnancy induced Pre-eclampsia

PIH without
proteinuria (without (proteinuria +
proteinuria
hypertension) hypertension)

Mild Severe

Clinical clues
Ask for:
LMP to calculate gestational age
Symptoms suggesting increasing severity of pre-eclampsia
o Generalized oedema (not just dependent in legs)
o Headaches
o Visual disturbance
o Epigastric pain
o Increasing shortness of breath
Previous history of pre-eclampsia (increased risk in subequent pregnancies)
Family history of pre-eclampsia (PE) in mother or sisters (increased risk PE)

Look for:
Oedema of hands and face
Pulse, blood pressure
Reflexes - get increased briskness in pre-eclampsia
Fundal height (to assess gestational age)
Foetal heart rate (for foetal well being)

Investigations:
Routine:
Dipstick of urine for proteinuria (2+ criteria for significant proteinuria)
24hr urine collection for protein
Serum urate - elevation characteristic of pre-eclampsia (PE). May precede proteinuria by 1-2 weeks.
Levels correlate with disease severity
Platelet count - thrombocytopaenia in PE
Transaminase - elevated in PE
USG
o for fetal abdominal circumference to detect small for gestational age (SGA) - increased risk in PE
o for amniotic fluid volume
o for umbilical artery Doppler or fetal heart rate monitoring

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Subsequent investigations
Fibrinogen, prothrombin time, partial thromboplastin time, D dimer if thrombocytopenia
Blood film, lactate dehydrogenase or haptoglobin if thrombocytopaenia and raised transaminase or
fall in Hb.
Biophysical profile of fetus if abnormal initial tests and oligohydramnios.
Comments:
PIH occurs in around 16-24% of first pregnancies and 12-15% of subsequent pregnancies. Most cases occur after
34 wks gestation. Pre-eclampsia complicates 3-5% of first pregnancies and 1% subsequent pregnancies.
Eclampsia (seizure) is a complication of hypertensive disorders of pregnancy. No single feature is consistentlyy
present. 20% of women with eclampsia are normotensive and 30% have no premonitory proteinuria.
Pre-eclampsia is an important cause of maternal mortality and morbidity (abruption placenta, acute renal
failure, pulmonary oedema, pleural effusions and death). It also contributes to perinatal mortality, mainly due
to the necessity of preterm delivery, or still birth.
Serial USG measurements of fetal abdominal circumference and liquor volume are helpful to predict fetal
growth retardation.

Criteria for severe Pre-eclampsia:

BP of >160mmHg systolic or >110mmHg diastolic on at least two occasions, at least 6hrs apart with the
patient at rest
Proteinuria >5g per 24hr
Oliguria (<400ml in 24hr)
Cerebral or visual disturbance
Epigastric pain
Pulmonary oedema or cyanosis
Impaired liver funciton
Thrombocytopaenia

Complications of severe PE include eclampsia (convulsions), HELLP syndrome (Haemolysis, Elevated Liver
enzymes, Low Platelet count), DIC (disseminated intravascular coagulopathy), pulmonary oedema and acute
renal failure.

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Pre-existing
hypertension

Chronic renal disease Chronic hypertension

Chronic hypertension
with superimposed
(without proteinuria) (with proteinuria) pre-eclampsia

Clinical clues
Ask for:
Gestational age if less than 20wks pre-existing hypertension
Known previous history of hypertension (documented if possible)
Previous drug history
Maternal age
History of diabetes, renal disease, cardiomyopathy, connective tissue disease or antiphospolipid
syndrome, coarctation of the aorta, rheumatic heart disease, liver disease
Outcome of previous pregnancies (increased risk if previous perinatal loss)

Look for:
Anaemia (chronic renal disease)
Blood pressure
Fundal height for gestational age
Full physical examination looking for secondary causes of hypertension (see CP on hypertension)

Investigations:
Urea and Creatinine
Electrolytes
CBC for anaemia, thrombocytopaenia
Urinalysis for proteinuria, microscopy of urine for casts (intrinsic renal disease)
Special investigations if suspect pre-eclampsia (as described above)

Comments:
Pre-existing hypertension increases the risk of a woman developing pre-eclampsia

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Infection

Genito-urinary
Other e.g.
infection e.g.
Urine infection Congenital infections pneumonia, TB,
Bacterial vaginosis,
Hepatitis E
Herpes

Asymptomatic TORCH*

Symptomatic HIV and Hepatitis B

UTI Syphilis

Pyelonephritis

*TORCH Toxoplasmosis, Rubella, Cytomegalovirus, Herpes

Infection in the mother may impact the foetus either directly through vertical transmission via the placenta (e.g.
congenital infections leading to fetal malformation), at time of delivery (e.g. Herpes simplex) or indirectly (e.g.
urine infection in mother increases risk of preterm labour and growth retardation). Untreated bacterial
vaginosis may also lead to preterm labour.

Clinical clues
Ask for:
Maternal fever
Dysuria, urinary frequency, loin pain (although many UTIs in women are asymptomatic and should be
screened for)
Jaundice (Hepatitis E is an important cause of morbidity and mortality in pregnant women in Nepal)
Rash (rubella, cytomegalovirus, herpes)
Symptoms suggestive of systemic infection e.g. cough, haemoptysis, diarrhoea
Symptoms suggestive of genito urinary infection e.g. increased, offensive smelling vaginal discharge
(bacterial vaginosis although may be asymptomatic), painful genital ulcers (herpes risk to fetus after
vaginal delivery)
Risk factors for HIV and Hepatitis B (use of IV drugs, blood transfusion history, multiple sexual partners,
husband migrant worker)
Contact with patients suffering from rubella or chicken pox
Drug history women may have taken medication for their illness which can adversely affect the foetus.

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Look for:
Fever, anaemia, jaundice, lymph nodes
Skin rashes
Physical examination as directed by history (e.g. respiratory exam if c/o cough and haemoptysis)

Investigations
(as directed by history and examination or as part of routine screening for important asymptomatic disease):
Urinalysis should be considered at every ANC as asymptomatic bacteriuria is common and may cause
foetal growth retardation
CBC (for leucocytosis)
Liver function tests (for infectious hepatitis [e.g. Hepatitis E], in HELLP syndrome)
Hepatitis E serology
HBsAg screening for hep B
HIV screening
VDRL screening for syphilis (do TPHA if VDRL is positive)
TORCH screening not done routinely. To be done if previous pregnancy outcomes poor (e.g.
preterm/IUGR/Still birth)
High vaginal swab screening for bacterial vaginosis (not routinely done)

Comments
Conditions such as Hep B, HIV and Syphilis are routinely screened for because early detection will influence
maternal and neonatal care.
The risk to the foetus of infection will depend on the gestational age at which they are exposed. The highest risk
period is generally in the first trimester. In herpes virus infection the highest risk is during vaginal delivery with
consequent serious illness in the foetus.

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Systemic disease
in mother

Endocrine disease
Autoimmune or
Heart disease Renal disease e.g. thyroid, Epilepsy
rheumatological
diabetes

Any systemic disease in the mother may have an adverse effect on the pregnancy. Some medical conditions are
exacerbated in pregnancy (others improve) and the medication used for some conditions needs to be changed
in order to avoid teratogenicity.

Ask for:
Previous history of medical problems e.g. known diabetes, Systemic Lupus Erythematosis, Epilepsy,
heart disease, Rheumatoid arthritis
Control of these conditions e.g. frequency of seizures, need for medication
Symptoms suggestive of systemic disease e.g. palpitations, chest pain, increasing shortness of breath,
joint pain and swelling, skin rashes
History of frequent miscarriages (associated with antiphospholipid syndrome and SLE)
Previous history of problems during pregnancy
Drug history including allergies

Look for:
Anaemia, cyanosis, jaundice, LN, clubbing
Pulse and blood pressure
Skin rashes, joint swelling
Heart sounds for murmur
Physical exam as directed by the history.
Obstetric examination to determine foetal growth and well being

Investigations (directed by history and examination)

CBC, ESR
Urea and creatinine
Blood glucose, HbAIC for diabetes
Electrolytes
Liver function
Thyroid function
Urinalysis for protein (especially in renal disease)
ECG
Echocardiography
USG for foetal abnormality
Drug levels e.g. antiepileptics
ANA and Rheumatoid factor for SLE and RA

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Comments:
Women with known chronic systemic disease require a team approach between obstetricians and the
relevant specialist
Rheumatic heart disease remains an important cause of cardiac disease in women of child bearing age in
Nepal. It is essential to examine the heart for murmurs at the booking in appointment. A systolic
ejection murmur is heard in almost all pregnant women at the left sternal edge. It varies with posture
and as long as there is no other abnormality it can be explained by the increased stroke output
(hyperdynamic circulation) in normal pregnancy.
Most women with pre-existing cardiac abnormality (mainly regurgitant lesions) do well if they are
asymptomatic or only mildly symptomatic before pregnancy. Important exceptions are women with
pulmonary hypertension, mitral or aortic stenosis.
Poor diabetic control predisposes to congenital abnormalities particularly of the CNS, cardiac and renal
systems. As organogenesis occurs very early in pregnancy it is important that diabetic women wishing to
become pregnant have excellent control prior to conception.
Some drugs used in control of systemic disease are contraindicated in pregnancy. Important ones to
remember are ACE inhibitors (used in renal disease), methotrexate (used in rheumatological conditions),
avoid sodium valproate if possible (used in epilepsy)
The dose of some drugs should be modified in pregnancy as pharmacokinetics change e.g. thyroid
disease need to carefully monitor control, antiepileptic drugs often need to increase dose to maintain
seizure control. In hypothyroidism during pregnancy the dose of thyroxine is increased by 33% to 50%.
Pregnancy can alter the activity of many autoimmune diseases. E.g. 80% of patients with Rheumatoid
arthritis go into remission during pregnancy and around the same number will flare again during the
early post partum period. Around 1/3 of women with SLE will suffer a flare during pregnancy.
In epilepsy the risk to the foetus of uncontrolled seizures in the mother is greater than the risk from the
antiepileptic drugs but there is a slight increase in the risk of malformations. To minimize the risk use
monotherapy, avoid valproate if possible, give folic acid supplements.

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Diabetes

Overt Gestational
Diabetes diagnosed during pregnancy is classified as overt or gestational. Some women in the overt group will
have pre-existing diabetes, but some may be diagnosed for the first time in pregnancy.
Overt diabetes women who meet any of the following criteria at their initial prenatal visit:
Fasting plasma glucose 126 mg/dL *7.0 mmol/L+, or
HbA1C 6.5 percent using a standardized assay, or
Random plasma glucose 200 mg/dL *11.1 mmol/+ that is subsequently confirmed by elevated fasting
plasma glucose or A1C, as noted above
Gestational diabetes A diagnosis of gestational diabetes can be made in women who meet either of the
following criteria
Fasting plasma glucose 92 mg/dL, but <126 mg/dL at any gestational age
At 24 to 28 weeks of gestation: 75 gram two hour oral glucose tolerance test (GTT) with at least one
abnormal result: fasting plasma glucose 92 mg/dL but <126 mg/dL or one hour 180 mg/dL or two hour
153 mg/dL
(American Diabetes Association criteria 2011)

Ask for:
Factors associated with increased risk of diabetes
o A family history of diabetes, especially in first degree relatives
o Age greater than 25 years
o Previous delivery of a baby greater than 4kg
o Personal history of abnormal glucose tolerance
o Previous unexplained perinatal loss or birth of a malformed child
o Glycosuria at the first prenatal visit
o Known case of Polycystic ovary syndrome
o Current use of glucocorticoids
o Essential hypertension or pregnancy-related hypertension
Known diabetes
Drug history

Look for:
Hypertension
Obesity - body mass index over 30 (increased risk DM)

Investigations:
Glucose challenge test followed by Glucose tolerance test if needed
HbAIc
Creatinine
Lipid profile

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 Gynae/OBS - CP

Comments:
Two step approach to screening and diagnosis
1. 50 gram oral glucose challenge test for screening. The 50 gram oral glucose load is given without regard to the
time elapsed since the last meal and plasma glucose is measured one hour later. A value 130 mg/dL is
considered abnormal
2. Women with an abnormal value are then given a 100 gram three hour oral GTT for definitive diagnosis
(American college of Obstetrics and Gynaecology guidelines 2001)
Women from South Asia have an increased risk of diabetes and thus are routinely screened for gestational
diabetes between 24 to 28 weeks gestation using a glucose challenge test.

A 50g GCT value at 1hr of >140mg/dL is 80% sensitive for gestational diabetes, while a 1hr value of > 130mg/dL
is 90% sensitive for gestational diabetes

Adverse outcomes related to diabetes in pregnancy increase with the glucose levels and include:
Preeclampsia
Hydramnios
Fetal macrosomia
Fetal organomegaly (hepatomegaly, cardiomegaly)
Birth trauma
Operative delivery
Perinatal mortality
Neonatal respiratory problems and metabolic complications (hypoglycemia, hyperbilirubinemia,
hypocalcemia)

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Complicated
pregnancy

Maternal factors Foetal factors Large for dates Small for dates

Intrauterine
Blood group Multiple
growth
incompatibility pregnancy
retardation

Constitutionally
ABO Polyhydramnios
small

Big baby or
Rhesus Oligohydramnios
wrong dates

Congenital
abnormality

Foetal factors to screen for:

Ask for:
LMP for gestational age
Maternal blood group (if known)
If Rhesus negative - Outcome of previous pregnancies and history of receiving Anti-D prophylaxis or
treatment
If Rhesus negative any interventions in pregnancy e.g. amniocentesis which could lead to sensitization
Previous history of miscarriage
Previous history of blood transfusion
Birth of children with congenital abnormality in the past
Family history of congenital abnormality
Drug history e.g. anticonvulsants increase risk of neural tube defects
History of maternal infection which may cause congenital abnormality (see TORCH)
Results of USG scans
o Polyhydramnios (see later)
o Oligohydramnios (see later)
o Evidence of congenital abnormality

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 Gynae/OBS - CP

Look for:
Fundal height to assess foetal growth (greater than expected for gestational age in multiple pregnancy
and polyhydramnios, lower than expected if congenital abnormality and foetal growth retardation)
Foetal parts
Foetal heart sound

Investigations:

CBC in mother (for infection or idiopathic thrombocytopaenic purpura)

Maternal blood group if mother is Rhesus negative, check husbands blood group. If he is Rhesus
positive there is risk the fetus may also be Rhesus positive and risk of incompatibility
In Rh ve women check for maternal Rh antibodies (positive indirect Coombs test)
If Coombs test positive get maternal antibody tire
Fetal cord blood at birth look for anaemia, raised bilirubin, Coombs test, babys blood group if baby
is Rhesus negative no treatment needed, if Rhesus positive needs prophylactic anti-D
USG to assess foetal health, number of babies and liquor volume
Urinalysis

Comments
Rh- isoimmunisation may develop as a result of transfusion of Rh positive blood to a Rh negative
woman, or when there is a significant fetomaternal leak from a Rh-positive fetus to a Rh- negative
mother (eg during abortion, ectopic pregnancy, following normal delivery, Caesarian section, trauma to
abdomen etc)
In Rhesus isoimmunisation there is destruction of fetal RBC causing anaemia, raised bilirubin (due to
haemolysis) and if very severe anaemia heart failure, generalized oedema, ascites and pericardial
effusion (hydrops fetalis)
ABO incompatibility may also lead to iso-immunization but is usually less severe.

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Large for dates

Multiple Big baby or

Polyhydramnios
pregnancy wrong dates

Ask for:
LMP to calculate gestational age
Results of early ultrasound to check LMP is accurate
If woman feels excessively large and heavy
Previous history of multiple pregnancy or family history
History of treatment for infertility (more likely to have multiple pregnancy if given ovulation stimulation)
Excessive nausea and vomiting in early pregnancy (evidence of multiple pregnancy)

Look for:
Fundal height
Foetal parts
o palpation of at least three distinct separate poles (e.g. two heads and a breech) s/o of multiple
pregnancy
o if difficult to find or ballottable s/o polyhydramnios
Foetal heart sound may be heard in two separate areas (only diagnostic if there is a difference of 10
beats/minute in the heart rates), may be hard to find in polyhydramnios

Investigations:
USG is the most useful investigation to assess number of foetuss, foetal health, and liquor volume

Comments:
Polyhydramnios may be defined as > 2000ml of liquor because it becomes clinically obvious at this point.
Many cases of polyhydramnios are idiopathic. Other important causes are:
o Maternal diabetes
o Fetal malformation e.g. anencephaly, spina bifida, hydrocephaly, oesophageal atresia
o Multiple pregnancy
o Hydrops fetalis in Rh-incompatibility

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Small for
dates

Intrauterine
Constitutionally
growth retardation Oligohydramnios
small
(IUGR)

Foetal factors Placental factors Maternal factors

IUGR is the term used to for a fetus that has not reached its growth potential because of genetic or
environmental factors. This must be distinguished from a constitutionally small, but otherwise healthy fetus.

Ask for:
LMP for gestational age
Maternal health any chronic illness may limit oxygen or nutrient supply to the fetus.
Maternal anaemia important cause of IUGR
Maternal age (extremes of age associated with IUGR)
Spacing between pregnancies (increased risk of IUGR if short spacing)
History of IUGR or stillbirth in previous pregnancies
History of pre-eclampsia (leads to uteroplacental insufficiency)
Intake of alcohol or illicit drugs
Smoking history
Place of residence (? At high altitude)
Socio-economic status

Look for:
Sequential symphysis- fundal height measurements (to monitor growth and alert to the need for further
assessment).
Physical examination of mother to find evidence of chronic systemic disease especially BP, CVS system

Investigations:
USG
Haemoglobin
Creatinine
Screening for TORCH
Karyotyping
Urinalysis for proteinuria and pyuria

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Comments:
To truly assess foetal growth it is necessary to monitor the trend in abdominal size with respect to head
size over a period of time. Intrauterine nutritional deprivation preferentially slows down the normal
increase in fetal abdominal size. A constitutionally small foetal will have a normal growth rate.
IUGR may be caused by fetal, placental, or maternal factors or a mixture of all three.
o Fetal factors (often poor prognosis):
Genetic disease
Congenital malformations e.g. renal agenesis
Fetal infection e.g. TORCH
Multiple pregnancies (individual foetuses at increased risk of IUGR although fundal
height not small for dates)
o Placental factors (better prognosis):
Ischaemic placental disease e.g. in pre-eclampsia, abruption
o Maternal factors
disease associated with reduced uteroplacental perfusion e.g. hypertension, renal
disease, SLE, antiphospholipid syndrome
nutritional deficiency
chronic hypoxemia e.g. pulmonary disease, severe anaemia, living at high altitude
Smoking
Alcohol intake or use of illicit drugs
Toxins e.g. warfarin, anticonvulsants, antineoplastic agents

Maternal genes influence birth weight more than paternal genes, but both have an effect. Maternal
height, pre-pregnancy weight, parity and ethnicity all have an important contribution towards ultimate
fetal weight.
Oligohydramnios refers to reduced liquor volume (amniotic fluid index <5) and may be:
o Maternal
Conditions associated with uteroplacental insufficiency (eg, preeclampsia, chronic
hypertension, collagen vascular disease, nephropathy)
Medications (eg, angiotensin converting enzyme inhibitors)
o Placental
Abruption, Twin to twin transfusion, Placental thrombosis or infarction
o Fetal
Chromosomal abnormalities, Congenital abnormalities e.g. renal agenesis), Growth
restriction, Foetal death, Postterm pregnancy, Ruptured fetal membranes
o Idiopathic

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 Gynae/OBS - CP

There are 2 major categories of IUGR: symmetrical and asymmetrical.

Asymmetrical IUGR is more common. In asymmetrical IUGR, there is restriction of weight followed by length.
The head continues to grow at normal or near-normal rates (head sparing). This is a protective mechanism that
may have evolved to promote brain development. This type of IUGR is most commonly caused
by extrinsic factors that affect the fetus at later gestational ages.
Symmetrical IUGR is less common and is more worrisome. This type of IUGR usually begins early in gestation.
Since most neurons are developed by the 18th week of gestation, the fetus with symmetrical IUGR is more likely
to have permanent neurological sequela.

Management topics complicated pregnancy:

1. Definition of hyperemesis and how to manage it

2. Rhesus prophylaxis and treatment
3. Pre-eclampsia recognition, pathophysiology and management
4. Gestational diabetes how to screen for it, management
5. HIV in pregnancy prevention of maternal-foetal infection, advice for breastfeeding
6. Effect of tobacco on foetus, evidence on effectiveness of strategies to stop smoking
7. Management of UTI and pyeloneprhitis in preg
8. Pathophysiology of Anaemia in preg (dilutional and actual) + its management

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 Gynae/OBS - CP

Contraception

Patient requests
contraception

Permanent Temporary

Male Female
Male Female
sterilization sterilization

Definition:
The permanent method is undertaken with the primary objective of preventing further pregnancy permanently.
When this method is used fertility does not return. It is a surgical method: tubectomy in a woman and
vasectomy in a man. Sterilization is suited to those couples who have completed their family and do not want to
bear the inconvenience or cost of the other methods, or the other methods are contraindicated.
Before deciding on the appropriate form of contraception for a patient, some basic information must be
gathered.

Clinical clues:
Ask about
Age
Obstetric history
menstrual history
Medical history (hypertension, diabetes, coagulation disorder, allergies)
Previous operative history
Any ongoing medications
What does the patient already know about contraceptive methods?
What method does he/she prefer?

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 Gynae/OBS - CP

Permanent

Male sterilization Female sterilization

(vasectomy) (tubectomy)
Male sterilization (vasectomy)
Vasectomy consists of cutting the vas deferens and disrupting the passage of sperms.
Ask for
age
medical history (allergies, hypertension, diabetes, coagulopathy)
surgical history (particularly any history of problems with anaesthetics or other problems after surgery)
completion of family
Look for
general examination: pallor, icterus
elevated BP
systemic examination
local examination ---- hydrocele, hernia, skin lesion, varicosities
any sign of Sexually transmitted diseases (STDs ) e.g. penile ulcers or urethral discharge.
Investigations
(These are not always necessary, especially if the procedure is being done under local anaesthetic)
Hb, TC, DC, Platelets
RBS
HIV, HbsAg, VDRL

Comments:
Vasectomy consists of cutting the vas deferens and disrupting the passage of sperms. It is done through a small
incision in the scrotum under local anesthesia. The sterility is not immediate. The sperms are stored in the
reproductive tract for up to 3 months. The couple should therefore abstain from intercourse during this period
or use other methods of contraception.
Vasectomy continues to be simpler, safer, less expensive and more effective than female sterilization.

Advantages:
operative procedure is simple and can be performed with minimal training
can be done as an out patient procedure
permanence
high effectiveness
cost effectiveness
safety
quick recovery
removal of contraceptive burden from the woman
lack of significant long term side effect

Potential complications:
hematoma and infection do occur sometime
spontaneous recanalization may occur years after vasectomy
spermatocele formation is not uncommon
additional contraceptive protection is needed for about 2-3 months following operations
failure rate is about 0.1% in the first year
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Female sterilization
Occlusion of the fallopian tube in some form is the underlying principle to achieve female sterilization
Ask for
age
menstrual history
obstetric history
medical history (e.g. diabetes, hypertension, coagulopathy)
surgical history
any ongoing medications

Look for
general examination: pallor, icterus
elevated BP, pulse rate
obesity
systemic examination
local examination ---- per abdomen
per speculum, pap smear
per vaginal to r/o any uterine or ovarian masses
any local lesion
any sign of STDs

Investigations
(Not always needed)
Hb, TC, DC, Platelets
RBS
HIV, HbsAG, VDRL
Urine RE/ME
Pap smear

Comments:
It is the most popular method of terminal contraception especially in developing countries. It is ideal for those
persons who are certain they wish no further children and need a reliable contraceptive method. It can be
performed without increasing the health risks during the immediate postpartum or post abortion period.
Interval sterilization is done when the woman is not pregnant or anytime after six weeks of delivery. It can be
combined with caesarean section.

Methods of sterilization:
Laparotomy / Mini-laparotmy
Laparoscopy
Tubal ligation/tubectomy

Advantages:
easy and safe (although compared to male sterilization it is a little more difficult).
can be performed on an outpatient basis using local anesthesia
permanence
high effectiveness
cost effectiveness
nothing to buy or remember
lack of long term side effects
no need for partner compliance
privacy of choice

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 Gynae/OBS - CP

Complications:
infection
injury to bowel and bladder
bleeding
failure rate varies from 0.1-0.3%. Pregnancy occurs either because of faulty technique or due to
spontaneous recanalization

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Temporary

Male Female

Barrier
Barrier
(condom)

Natural (coitus
Hormonal
interruptus)

Oral

Injectable

IUD

Natural
Definition:
Temporary methods are commonly used to postpone or space births.
Ask for
age if > 40yrs, shouldn't use COC (combined oral contraceptive pill)
menstrual history if periods irregular or heavy, will get extra benefit from COC
obstetric history
past medical history looking especially for conditions which may be contraindications to combined
OCP (contains oestrogen and increases risk of thrombosis), e.g.
o Hypertension
o Ischaemic heart disease, diabetic complications, liver disease, TIA
o Migraine with aura or severe migraine (increased risk of stroke)
o History of DVT or other thrombosis
o History of trophoblastic disease (molar pregnancy)
o History of Breast cancer increased risk of recurrences
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 Gynae/OBS - CP

surgical history
any ongoing medications especially enzyme inducers such as rifampicin which may make hormonal
contraception less effective (need higher doses of depoprovera or COC if on rifampicin)
Is the lady currently breast feeding? - avoid COC as will stop lactation
Smoking history this also increases risk for thromboembolic disease.
duration of spacing
Ask about patient preference (will encourage compliance)
latex allergy (for condoms)
Patient/partner co-operation (important for condoms)

Look for
general examination: pallor, icterus
elevated BP, pulse rate hormonal methods not advised if raised BP
obesity don't use COC if BMI > 30 due to risk of thromboembolism
systemic examination
Breast examination looking for masses
local examination ---- per abdomen
per speculum, pap smear
per vaginal to r/o any uterine or ovarian masses
any local lesion
any sign of STDs (avoid intrauterine devices. May benefit from condom for protection from infections
and homonal method to give added contraceptive effectiveness

Comments:
1. Barrier method
These methods (male condom, vaginal spermicides,vaginal barrier, diaphragm, cervical cap) prevent sperm
deposition in the vagina or prevent sperm penetration through the cervical canal. The objective is achieved by
mechanical devices or by chemical means which produce sperm immobilization or by combined means.
Barrier methods provide protection against sexually transmitted infections and hence prevention of infertility.
Condoms are easily accessible and low cost but require partner cooperation, education. They have minimal side
effects like sensitivity,irritation vaginitis and vaginosis.
Failure rate around 3%.

2. Hormonal methods
There are four main types of hormonal methods:
Combined oral contraceptive pills - estrogen and progesterone
Progesterone only pills
Injectable progesterone - depoprovera
Progesterone implants - norplant or implanon.

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The probable mechanisms of contraception are inhibition of ovulation, producing static endometrial hypoplasia,
alteration of the character of the cervical mucus and probably interferes with the motility and secretion of the
tubes.
Hormonal contraception is one of the most effective methods available today. Failure rate 0.5%.
Advantages very effective , prevents anemia, regularizes the menstrual cycle, depot injection can be
used during lactation
Disadvantages
o Women on depo injection or on implant has a chance of irregular bleeding and amenorrhoea.

3. Intrauterine devices (IUD)

It is not a new method of contraception. However there has been a significant improvement in its design and
content. The device may be non medicated as Lippes loop or medicated by incorporating a metal as in cu T or
multiload 250 or a chemical as in progestasert.
Mode of action might be biochemical and histological changes in the endometrium, there may be increased
tubal motility and there may be impaired sperm ascent.
Failure rate 1.5 3%
It is inexpensive, simple to insert and it gives prolonged contraceptive protection. The systemic side effects are
minimal and reversibility is prompt after removal. It has some disadvantages like it requires motivation and it
has increased incidence of ectopic pregnancy. There are some contraindication for the insertion of IUDs:
presence of pelvic inflammation, Dysfunctional Uterine Bleeding, uterine prolapse,, uterine abnormality, severe
dysmenorrhoea, suspicious cervix and nullipara.
Complications: cramp like pain, syncopal attack, partial or complete perforation, abnormal vaginal beeding,PID,
spontaneous expulsion.
4. Natural method
This includes safe period or rhythm method and coitus interruptus.
Rhythm method:
The method is based on identification of the fertile period of a cycle and to abstain from sexual intercourse
during that period. This method has no side effects and it does not cost anything. Failure rate is as high as 20%.
It is very difficult to calculate the safe period if the cycle is irregular, there is compulsory abstinence and needs a
lot of motivation.
Coitus interruptus:
It is the oldest and most probably widely accepted method used by man. It requires sufficient self control by the
man so that withdrawal of penis precedes ejaculation. This method does not require any appliances and does
not cost anything. Failure rate is high around 20%.

Management topics for Contraception

1. Mechanism of action of oral contraceptive pill and instructions for patient on how to start it
2. Complications of OCP evidence in the literature, and important contraindications to OCP + important
interactions with other medications + advice that should be given to patients
3. Mechanism of action of progesterone contraception (Depoprovera + minipill + norplant) + instructions
for patient on common side effects
4. Mechanism of action of IUCD + method of insertion + advice given to patient
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Labour

Labour

Normal Abnormal

Prelabour Abnormal Obstructed Premature Prolapsed Multifetal

Post term
period presentation labour labour cord pregnancy

Occipito Shoulder Prelabour rupture

Labour
posterior dystocia of membranes

Abnormal Membranes
Latent Brow
presentation intact
Cephalopelvi
c
Active Face
disproportio
n
Maternal
First stage Transverse
factors

Soft tissue
Second stage Breech
problem

Bony pelvis
Third stage Compound
problem

Labour is considered normal when a mature foetus, presenting head first is delivered by natural effort, without
any undue prolongation of labour or complications to mother or baby.
Ask for:
Last menstrual period in order to calculate gestational age. Normal term delivery is between 37 to 42
weeks gestation. Before 37 completed weeks is premature labour.
Duration of labour pain (if prolonged s/o obstructed labour)
Whether there has been loss of clear fluid vaginally suggesting rupture of membranes (if before 37
weeks then premature rupture of membranes)
Results of last ultrasound scan (for abnormal presentation)
Bleeding or discharge
Foetal movements

Look for:
Maternal well being - pulse, BP, temperature, oedema, pallor
Foetal presentation
Abdominal palpation to assess whether the foetal head is descending (if not, s/o obstructed labour)
Foetal well being - foetal heart rate, presence of meconium stained liquor
Vaginal examination per speculum and digital
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Normal labour

Prelabour period
(with false Labour
labour pain)
Clinical clues:
Ask for:
Last menstrual period in order to calculate gestational age. Normal term delivery is between 37 to 42
weeks gestation.
Primigravida or multigravida (process of labour is usually much faster in the multigravida woman)
Presence of painful uterine contractions and their timing
o Irregular intervals suggests false labour pain in prelabour period
o Pains occurring at regular intervals and increasing in frequency and duration s/o first stage of
labour
Hardening of uterus (true labour)
Vaginal discharge
o Increased vaginal secretions common in prelabour period
o Blood stained mucus discharge show, suggesting onset of true labour with beginning of
effacement and dilatation
Sense of baby settling into lower uterine segment (with relief for mother as fundal height goes down)
Release of amniotic fluid from membranes (can occur at any time in first stage of labour or during
second stage)

Look for:
Pulse, blood pressure
Fundal height
Foetal position (e.g. cephalic presentation)
Foetal heart rate (for foetal well being)
Hardening of the uterus during contractions
Timing of contractions
PV examination to assess:
o effacement of cervix (length of cervical canal),
o dilatation of cervix (when fully dilated the first stage of labour is ended and the second stage
begun)
o station of the foetal head in relation to ischial spine,

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Comments:
Effacement of the cervix is the process of thinning out of cervix with gradual shortening of the cervix. In the
primigravida effacement happens before dilatation of the cervix. In the multigravida they occur
simulataneously.
Dilatation of the cervix is measured in terms of fingerbreadth but recorded in cm. One fingerbreadth is 1.5cm.
Two fingers equal 3cm dilatation. Where there is a cervical lip it can be 7 to 9 cm and when cervical lip is not
felt, it is full dilatation.
Prostaglandin (PGE2) is essential for cervical softening and ripening leading to effacement

Normal labour

Prelabour period
(with false labour Labour
pain)

Latent Active

First stage Second stage Third stage

Labour is divided into latent and active phase according to the degree of cervical dilatation.
Up to 3cm latent phase
3-10cm active phase
Cervical dilatation and descent of the fetus are the best parameters to decide the progress of labour, rather than
uterine contractions.
First stage: starts form the onset of true labour pains to full cervical dilatation. Average duration of first stage
of labour is 12 hours in primgravida and 6 hours in the multigravida.
Second stage: starts from full cervical dilatation to delivery of the baby. Average duration 2hrs in primigravida
and 30mins in multigravida.
Third stage: starts from delivery of the baby to expulsion of the placenta and membranes.

Ask for:
When did the painful regular contractions begin?
What is their frequency?
Have the fetal membranes ruptured (loss of clear liquor)?
Bleeding or presence of show
Foetal movements

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Look for:
Mothers vital signs: BP, pulse (repeat hourly), temperature (repeat 3hrly)
Foetal heart rate
Number of fifths of the head palpable per abdomen
Cervical dilatation on PV examination
Station of the foetal head on PV examination
Presence of bulging foetal membranes
Nature of liquor (clear healthy, meconium stained foetal distress)
Investigation:
Urine for ketones, sugar, protein and blood
Tocography (for foetal heart rate and co-ordination with contractions) if suspect foetal distress
Comments:
The progress of labour should be monitored using a partogram. This is a graph plotting cervical dilatation
against time since onset of labour. The most difficult part is deciding when labour has in fact started. This is
important because so much depends on defining starting points.
A progressive change in the cervix over a few hours will confirm established labour, so a vaginal examination at
the time of admission to the labour ward is important to establish a baseline.
In addition, the partogram should record foetal heart rate, nature of liquor, any drugs given to the mother and
any interventions done

Second stage of labour

.
This is the time period between full cervical dilatation and the delivery of the foetus.
Ask for:
Frequency of contractions
Look for:
Abdominal palpation to assess descent of foetal head
Vaginal descent of head in relation to ischial spine (PV)
Rotation of head assessed by position of sagittal suture and occiput in relation to quadrants of pelvis
Presence of foetal head at perineum

Third stage of labour

This is the time period between delivery of the foetus and delivery of the placenta and foetal membranes
Ask for:
Time of delivery of the foetus
Amount of bleeding since the delivery (up to 300mls normal)
Has she been given syntocinon or oxytocin on delivery of the foetal anterior shoulder (this reduces risk
of post partum haemorrhage)?
Look for:
Maternal pulse and blood pressure
Maternal blood loss
Is the uterus contracted and firm?
After delivery of the placenta check that it is complete (nothing left inside the uterus that may bleed
later).
Vaginal lacerations or local lesions
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Abnormal labour

Abnormal
Obstructed Premature Prolapsed cord Multifetal Post term
presentation

Premature
Occipitoposterior Shoulder dystocia rupture of
membranes

Abnormal
Face presentation Membranes intact
presentation

Brow Cephalopelvic
presentation disproportion

Transverse lie Maternal factors

Breech
Soft tissue
presentation

Compound
Bony pelvis
presentation

Ask for:
Last menstrual period in order to calculate gestational age. Normal term delivery is between 37 to 42
weeks gestation. Before 37 weeks is premature labour. After 42 weeks is post term
Duration of labour pain (if prolonged s/o obstructed labour)
Whether there has been loss of clear fluid vaginally suggesting rupture of membranes (if before 37
weeks then premature rupture of membranes)
Results of last ultrasound scan (for abnormal presentation)

Look for:

Maternal well being - pulse, BP, temperature, pallor, oedema, signs of dehydration
Foetal presentation (through abdominal and PV examination)
Abdominal palpation to assess whether the foetal head is descending (if not, s/o obstructed labour)
Foetal well being - foetal heart rate, presence of meconium stained liquor

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Abnormal presentation
Occipito Face Brow Transverse Breech
Compound
posterior presentation presentation lie presentation

Normally when the head engages the occiput is lateral and then rotates anteriorly during labour. At the same
time the head will normally become flexed so that the narrowest diameter of the foetal skull passes through the
pelvis.
Ask for:
Results of previous ultrasound
o for foetal lie (especially for transverse or breech)
o for multiple pregnancy (risk factor for abnormal presentations)
o for polyhdramnios and placenta praevia (associated with transverse lie)
LMP - assess gestational age. Prematurity associated with abnormal presentations.

Look for:
Fundal height - if lower than expected for gestational age s/o transverse lie
Abdominal palpation to assess presentation and foetal descent
o Limbs are felt anteriorly in occipito posterior (OP) presentation
o Hard round head is felt in flanks (transverse lie) or epigastric region (breech)
PV examination
o feel for number of sutures reaching each fontanelle (to differentiate between anterior and
posterior fontanelle)
o assess degree of deflexion of foetal head (if can feel both sinciput and occiput at the same level
above the symphysis pubis there is deflexion)
o feel for features of the face (face presentation)
o presence of frontal suture, anterior fontanelle, orbital ridge (brow presentation)
o feel for the anus in a straight line between the ischial tuberosities (breech presentation)

Comments:
All abnormal positions may be characterized by a prolonged first and second stage in labour.
Most malpresentations such as occipitoposterior, face and brow are only diagnosed during labour. They may
occasionally be diagnosed on USG antenatally.
Prematurity and multiple pregnancies are important risk factors for face and brow presentations.
In face presentations the foetal descent is always less advanced than vaginal examination woud suggest, as the
biparietal diameter is usually approx 7cm behind the advancing face.

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Patients in transverse lie should not be allowed to go into labour as they are at high risk of cord prolapse or
prolapse of an arm. They need to have a caesarian section. Patients who go into labour will usually develop
uterine rupture.

Premature labour

Prelabour
Membranes
rupture of
intact
membranes
Preterm labour is defined as labour occuring between 24 weeks and 36 weeks + 6 days gestation

Ask for:
LMP to calculate gestational age
Presence of painful, regular uterine contractions, suggesting onset of labour
Whether there has been vaginal loss of liquor (prelabour rupture of membranes PROM)
Colour of liquor (meconium stained shows foetal distress)
Abdominal tenderness - s/o ascending infection
Previous history of preterm labour (increases risk of future preterm labour)
Maternal ill health (heart disease and systemic infection)

Look for:
Maternal fever (risk of sepsis with PROM)
Maternal tachycardia or offensive vaginal discharge (s/o ascending infection)
Fundal height to assess gestational age
Per speculum examination of vagina and cervix (avoid digital examination if there is any suggestion of
ruptured membranes as this will increase the risk of ascending infection)
Presence of liqour PV
Foetal well being using cardiotocography

Investigations
High vaginal swab for gram stain microscopy and culture at time of speculum examination
Urine microscopy and culture
CBC and CRP for infection
USG every 2 weeks to assess foetal growth if there is PROM but the patient is very premature and there
is no active labour.

Comments:
Risk factors for premature labour include: young and older age women, BMI < 19, short stature, low social class,
single mothers, smokers, anaemia, high haemoglobin, polyhydramnios, maternal ill health, placental abruption.
Braxton Hicks contractions occur commonly from 24wks gestation onwards and may mimic preterm labour.

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 Gynae/OBS - CP

Prelabour rupture of membranes - management is determined by gestational age, balancing the risk to the
mother and foetus of delayed delivery (infection e.g. pneumonitis, endometritis and septicaemia) and the risk to
the foetal of premature delivery (respiratory distress)
Infection is sometimes the cause rather than the effect of rupture of membranes.

Obstructed labour

Shoulder Abnormal Cephalopelvic Maternal

dystocia presentation disproportion factors

Soft tissue Abnormalities

mass in pelvis of Bony pelvis

All abnormal presentations may lead to obstructed labour (see earlier part of this CP)
Ask for:
LMP for gestational age
Duration of labour pain - if prolonged s/o obstructed labour
Predicted foetal weight from ultrasound (dystocia associated with increased foetal weight)
Maternal weight (maternal obesity associated with dystocia, very small thin women may have
cephalopelvic disproportion)
Maternal diabetes (increased risk of dystocia)
History of fall, rickets, polio or bone TB

Look for:
Maternal size (malnourished or obese)
Uterine size (large baby and small pelvis s/o cephalopelvic disproportion)
Pelvic examination to assess pelvic size (for cephalopelvic disproportion), soft tissue masses in vaginal
tract or abnormalities of the bony pelvis.

Investigations
USG antenatally to assess size of foetus and to rule out any pelvic mass or genital tract tumours.

Comments:
In shoulder dystocia either both shoulders remain above the pelvic brim after delivery of the vertex or
the posterior shoulder enters the pelvic cavity whilst the anterior should remains hooked behind the
symphysis pubis.

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 Gynae/OBS - CP

Shoulder dystocia is a significant cause of morbidity and mortality. Following delivery of the head the
umbilical cord pH falls and delay in completing delivery may result in asphyxia and permanent
neurological damage.
Erb's palsy is a common brachial plexus injury associated with shoulder dystocia and will normally
resolve by 6 months. Fractures may also occur.

Prolapsed cord
Comments:
Known risk factors for prolapsed cord include low birth weight, premature birth, breech presentation and being
a second born twin. However the majority of babies with prolapsed cord are infact term with normal birth
weight and cephalic presentation.

Multifetal pregnancy
Comments:
When there is more than one foetus, abnormal presentation is common especially in the second foetus. Other
complications are also more common.

Post term
Comments:
This is defined as delivery after 42 weeks gestation
Problems associated with post-term delivery include:
1. Fetal risks
a. Perinatal mortality (ie, stillbirths plus early neonatal deaths) at 42 weeks of gestation is twice
that at term. Asphyxia, meconium aspiration, and intrauterine infection all contribute to the
excess perinatal deaths
b. Higher incidence of macrosomia (4500 g). Complications of macrosomia include prolonged
labor, cephalopelvic disproportion, and shoulder dystocia, all of which increase the risk of birth
injury.
c. Approximately 20 percent of postterm fetuses have features of chronic intrauterine
malnutrition. These pregnancies are at increased risk of umbilical cord compression due to
oligohydramnios, nonreassuring fetal antepartum or intrapartum assessment tests, meconium
aspiration, short-term neonatal complications (eg, hypoglycemia, seizures, respiratory
insufficiency), and long-term neurologic sequelae.
2. Maternal risks increased frequency of labor abnormalities, third and fourth degree perineal
lacerations, and caesarean delivery

References:
Essentials of obstetrics Sabaratnam Arulkumaran
Dewhursts textbook of Obstetrics and Gynaecology 6th edition

Suggested reading:
Williams Textbook of Obstetrics
Shaw (for Gynaecology)

Management topics for Labour

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 Gynae/OBS - CP

1. Pathophysiology of normal labour +Diameters of the foetal skull and the way it moves through the pelvis
(abnormal and normal)
2. Management of preterm labour (including management of contractions and preparation for preterm
delivery)
3. Complications of premature rupture of membranes and management
4. Anatomy of the vagina and layers involved during episiotomy repair + management of cervical tear
5. Vacuum delivery its indications and how it works + common complications and their management

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 Gynae/OBS - CP

Vaginal Discharge

Vaginal
discharge

Non-
Physiological
physiological

Cervical
ectropion or Vaginal Infectious Non-infectious
polyps

Dermatological
Vulvovaginitis
disease

Prepubertal
Trauma
children

Adults Neoplasia

Cervicitis Systemic disease

Oestrogen
deficiency

Vaginal discharge is one of the most common gynaecological complaints. In healthy women the vagina contains
a small quantity of watery secretion which contains mucous, desquamated epithelial cells, Doderlein's bacilli and
lactic acid.

History and findings on physical examination are relatively nonspecific and insufficient for accurate diagnosis
and treatment of vaginitis. Nevertheless, certain features often suggest a particular diagnosis, which should be
confirmed by microscopic examination of vaginal secretions.

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Vaginal
discharge

Non-
Physiological
physiological

Cervical
ectropion or Vaginal
polyps
In reproductive aged women, normal vaginal discharge is white or transparent, thick, and mostly odorless. This
physiological discharge may become heavier at puberty, during pregnancy, with use of estrogen-progestin
contraceptives, premenstrually or at midmenstrual cycle close to the time of ovulation. It can be slightly smelly
at times and there may be some itch even with physiological discharge.
Certain cervical conditions can lead to increased physiological conditions.
Ask about
Age
Marital status (and also sexual activity dont assume unmarried women are not sexually active. Need
to ask this in private and sensitively)
Occupation and Husband's occupation (including whether husband is working abroad)
Usage of contraception
Menstrual cycle and last menstrual period
Variation of discharge and other symptoms with menstrual
Nature and colour of the discharge (physiological usually white but this is a non-specific finding)
Duration
Odour (physiological discharge usually has no odour)
Associated with blood non-physiological
Associated with itching if severe then non-physiological
Dyspareunia suggests non-physiological
Anal itching especially in children (associated pinworm)
h/o repeated UTI
h/o ring pessary insertion
h/o DM, family history
Drug history some drugs e.g. antibiotics increase the risk of candidal infections.

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Look for
general condition, temperature, vital signs
local examination of vulva and vagina
o excoriation of skin
o sign and symptoms of atrophic vaginitis (thin, pale pink skin)
o leucoplakia (white patches of skin)
o ulcers
o local swelling
P/S examination
o colour of discharge, blood stained,
o odour
o walls of vagina (mucoid discharge from walls of vagina physiological transudate)
o condition of cervix
if excessive mucoid discharge at external os - cervical source
chronic cervicitis (red friable cervix)
ectropion (red but not friable)
Presence of cervical polyps leads to increased discharge
P/V examination
o size and shape of the uterus
o position
o mobility
o tenderness
Investigations
pH of vaginal secretions
Bacteriological examination of vaginal smear

Comments:
Before labelling a woman as having physiological discharge it is important to do a physical examination and the
above simple investigations.
Mucous discharge from endocervical glands increases in cervical ectropion and cervical polyps (see later under
cervicitis). Vaginal discharge may also arise from the vagina itself through transudation through the vaginal
walls.
The pH of the normal vaginal secretions is 4.0 to 4.5. Almost all the lactic acid of the healthy vagina comes from
the fermentation of glycogen contained in the keratinized cells of the vaginal mucosa, by lactobacilli
(Doderleins). The low pH prevents the growth of other pathological bacteria. This occurs under the control of
oestrogen. In premenarchal and postmenopausal women there are less lactobacilli and the normal pH of vaginal
secretions is higher at 4.7 (so pH measurement less useful as a diagnostic tool in these women).
Measurement of vaginal pH is the single most important finding to distinguish between physiological and non-
physiological discharge. A dry cotton swab should be applied to the vaginal sidewall then the swab rolled onto
pH paper. Read the pH at around two to five minutes at room temperature.
A pH above 4.5 in a premenopausal woman suggests infections such as bacterial vaginosis or trichomoniasis (pH
5 to 6), and helps to exclude candida vulvovaginitis (pH 4 to 4.5).
Vaginal pH may be altered (usually to a higher pH) by contamination with lubricating gels, semen, douches, and
intravaginal medications.
Microscopic examination of physiological discharge reveals a predominance of squamous cells and only
occasional polymorphonuclear leukocytes (PMNs). In infective causes of discharge there are increased numbers
of PMNs.
Local congestive states of the pelvic organs such as pregnancy, acquired retroversion, chronic PID and chronic
constipation may all lead to increased vaginal secretion (physiological).
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Vaginal
discharge

Non-
Physiological
physiological

Non-
Infectious
infectious

Certain features suggest infectious as opposed to non-infectious causes of discharge.

Ask for:
Age (more non-infectious causes in older women)
Marital status and sexual activity (women who are not sexually active cannot be suffering from a
sexually transmitted disease)
Abdominal pain suggests an infective cause with associated pelvic inflammatory disease
Drug history. Antibiotics and high-estrogen contraceptives may predispose to candida vulvovaginitis;
pruritus unresponsive to antifungal agents suggests vulvar dermatitis.
Hygienic practices (Potential irritants and allergens in her environment and habits unhealthy for the
vulvar skin). Mechanical, chemical, or allergic irritation may cause vulvar symptoms mistakenly
attributed to an infectious source.
Is the menopausal patient receiving hormonal therapy (HT)? Taking systemic HT (oral, skin) does not
guarantee adequate vaginal estrogen levels.

Look for:
As above in previous section. Look especially for:
Atrophy of vaginal skin s/o non-infectious cause
Dermatological disease of the vulva leukoplakia
Mucopurulent discharge coming from the endocervix infectious cause

Investigations:
Vaginal pH
Bacteriological examination of discharge

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Vaginal
discharge

Non-
Physiological
physiological

Non-
Infectious
infectious

Vulvovaginitis Cervicitis

Vulvovaginitis is the inflammation of the vulvar or vaginal region and may be due to infection or non-infectious
causes. Cervicitis is the acute or chronic inflammation of the cervix, usually due to infection. To distinguish
between the two, a per speculum examination is needed.
Look for:
Colour of discharge, blood stained, odour
Inflammation, redness and swelling of vagina
Tenderness
Condition of cervix
Cervicitis (red friable cervix with mucopurulent discharge)
Ectropion (red but not friable)
If excessive mucoid discharge at external os may be physiological in women with
ectropion
Presence of cervical polyps leads to increased discharge
P/V examination
o size and shape of the uterus, position, mobility, tenderness
Comments:
Tenderness on cervical excitation (movement of the cervix), suggests ascending infection from the cervix and
pelvic inflammatory disease.
Cervical inflammation is suggestive of cervicitis, rather than vaginitis. Cervical erythema and erosion due to
cervicitis should be distinguished from ectropion, which represents the normal physiologic presence of
endocervical glandular tissue on the exocervix. This columnar epithelium is a darker pink than the normal
squamous epithelium. It appears as a reddened area around the external os with a well defined outer margin.
Ectropion is not friable and is more common in women taking estrogen-progestin contraceptives. The volume of
physiologic discharge may be higher in women with ectropion.

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Vulvovaginitis

In pre-pubertal
In adults
children

Bacterial
Candidiasis Trichomonas
vaginosis

The three commonest vaginal infections in adults are Candida, Trichomonas and Bacterial vaginosis. Of these
only Trichomonas is a sexually transmitted disease.

Ask for:
Age
Marital status (and also sexual activity dont assume unmarried women are not sexually active. Need
to ask this in private and sensitively)
Occupation and Husband's occupation (including whether husband is working abroad)
Usage of contraception
Menstrual cycle and last menstrual period
Variation of discharge and other symptoms with menstrual cycle
o Candida premenstrually
o Trichomonas during or just after menstruation
Nature and colour of the discharge
o Thick, white, curd-like s/o candidiasis
o Greenish-yellow and purulent s/o trichomonas
o Thin grayish s/o bacterial vaginosis
Duration
Odour (fishy smell classic for bacterial vaginosis)
Associated with blood non-physiological
Associated with itching if severe then s/o candida
Dyspareunia superficial common with severe candidal infection, deep dyspareunia s/o PID
h/o repeated UTI
h/o DM, family history
Drug history some drugs e.g. antibiotics increase the risk of candidal infections.

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Look for:
Degree of vulvovaginal inflammation - vulva usually appears normal in bacterial vaginosis. Erythema,
edema, or fissure formation suggest candidiasis, trichomoniasis, or dermatitis.
Nature and colour of discharge (as above)
Cervical inflammation
Abdominal or cervical motion tenderness s/o PID

Investigations:
Vaginal pH
Bacteriological examination of discharge (for PMNs)
Saline wet mount slide (for trichomonas)
KOH wet preparation (for candida)
Amine test (for bacterial vaginosis)
If suspect an STD should also screen for other STDs that dont present with vaginal discharge e.g.
Hepatitis B (HBsAg), syphilis (VDRL) and HIV.
Comments:
Physical examination findings alone are not sufficient to make a diagnosis but the following table gives the
likelihood of common vaginal infections based on symptoms and signs.
Likelihood of common vaginal infections

Infection Sign/symptom Likelihood ratio*

Candidiasis Pruritus absent 0.18 to 0.79

Pruritus as chief complaint 3.3

Inflammatory signs present 1.4 to 8.4

Curdlike discharge with pruritus 150

Yeast not seen on KOH wet prep 0.51 to 0.66

Bacterial vaginosis No complaint of odor 0.07

Complaint of malodorous discharge 1.6 to 3.2

Trichomoniasis Inflammatory signs present 6.4

Trichomonads on saline wet mount 51 to 310

Trichomonads absent on saline wet mount 0.34 to 0.51

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KOH: Potassium hydroxide.

* Confidence intervals are wide, but significant.
Adapted from Anderson, MR, Klink, K, Cohrssen, A. JAMA 2004; 291:1368
The degree to which these symptoms are present depends upon the extent of inflammation. Candida
vulvovaginitis, often presents with scant discharge but marked inflammatory symptoms (pruritus and soreness),
while many cases of bacterial vaginosis are asymptomatic or present with only malodorous vaginal discharge
and no inflammatory complaints. Common sexually transmitted diseases ( STD) include trichomonas vaginalis,
cervicitis related to Neisseria gonorrhoeae or Chlamydia trachomatis.
Examination of the vaginal discharge provides better diagnostic information than the patient's signs and
symptoms. The goal of the examination is to look for candidal buds or hyphae, motile trichomonads, epithelial
cells studded with adherent coccobacilli (clue cells of bacterial vaginosis) and polymorphonuclear cells (PMNs).
Excess PMNs without evidence of yeast, trichomonads, or clue cells suggests cervicitis
In the saline wet mount slide, examination should be performed within 20mins of obtaining the sample to
reduce the possibility of loss of motility of the trichomonads.
Amine test Smelling ("whiffing") the slide immediately after applying KOH is useful for detecting the fishy
(amine) odor of bacterial vaginosis.
Initial office evaluation (history and physical examination, vaginal pH, wet mount microscopy, whiff test)
correctly diagnoses 60 percent of Candida vaginitis, 70 percent of Trichomonas vaginitis, and 90 percent of
bacterial vaginosis.

Vaginal
discharge

Non-
Physiological
physiological

Non-
Infectious
infectious

Vulvovaginitis Cervicitis

In
Prepubertal
children

Adults

Vulvovaginitis is a common problem in children. It usually occurs due to the presence of opportunistic bacteria
in the lower vagina inducing an inflammatory response. Pre-pubertal children are in a hypo-oestrogenic state
leading to thin sensitive vulval skin and no lactobacilli (with a resulting high pH of 7) making it an ideal culture
medium for bacteria. The anus is very close to the vaginal entrance so there is constant exposure to faecal
bacterial contamination.

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Ask about:
Age of child younger children may have put a foreign body up their vagina
Nature of discharge
Time since onset
Previous history of discharge
Skin conditions e.g. eczema
Associated itch
Anal itch

Look for:
Inspect vulva and vagina with a good light
General hygiene
Evidence of a foreign body
Excoriation of skin

Investigations:
Rarely useful. If suspect sexual abuse take a small sample of fluid for microscopy.
If suspect pin-worm put a piece of sticky tape over the anus early in the morning before the child gets out of
bed will reveal pin worm eggs on microscopy.

Comments:
The commonest cause of vulvovaginitis in children is non-specific bacterial infection. Candidiasis is rare
and usually associated with diabetes or immunodeficiency.
Vulval skin disease e.g. eczema is common in children.
Recurrent episodes of vaginal discharge should raise the suspicion of sexual abuse. Only those bacterial
infections related to venereal disease e.g. gonorrhoea are diagnostic of sexual abuse.
Girls who still wet the bed are more prone to infection as the moist environment allows secondary
irritation by bacteria
The key management of vulvovaginitis in children is good perineal care (wipe from front to back
especially after defaecation, daily washing of the vulva with simple unscented soap but not excessive
cleaning, keep the vulval area dry)

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Infection

Vulvovaginitis Cervicitis

Acute Chronic

Ask for:
Fever, abdominal pain, purulent vaginal discharge (s/o acute cervicitis which may progress to PID)
History of abortion or childbirth (especially septic abortion, puerperal sepsis)
High risk behaviour for STD (new or multiple sexual partners, or a husband working overseas)
Instrumentation during delivery (risk for chronic cervicitis)
Known history of gonococcal infection (risk for chronic cervicitis)

Look for:
Colour of discharge, blood stained, odour
Inflammation, redness and swelling of vagina
Tenderness
Condition of cervix
Red, swollen with oedema and mucopurulent discharge from endocervical canal acute
cervicitis
Erosion (soft and bleeds easily) + feels fibrosed, bulky with nabothian follicles (chronic
cervicitis)
Ectropion (red but not friable)
Presence of cervical polyps leads to increased discharge
Presence of nabothian follicles
P/V examination
o size and shape of the uterus, position, mobility, tenderness cervical excitation suggests acute
cervicitis and PID.

Investigations:
Vaginal pH
Bacteriological examination of discharge
HIV test, HBsAg, VDRL
Pap smear to exclude carcinoma in situ and cancer of the cervix

Diagnoses to consider:
Neisseria gonorrhoea
Chlamydia trachomatis

Comments:
Chronic cervicitis is usually caused by infection during abortion or childbirth. Trauma to the cervix e.g. during
delivery may also lead to a chronic cervicitis. It is a form of focal sepsis.
Nabothian follicles are produced by squamous epithelium occluding the mouths of the columnar epithelium of
an erosion (during healing) The blocked glands become distended with secretions and form small cysts which
can be seen with the naked eye.
Acute cervicitis is often due to serious infections such as Gonorrhoea or Chlamydia.
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Non-physiological
causes of discharge

Infectious Non-infectious

Systemic Oestrogen
Dermatological Trauma Neoplasia
disease deficiency

If diagnostic evaluation excludes infection, then other causes of vaginitis, need to be considered
Ask about
Age (malignancy more common in older age group, oestrogen deficiency in postmenopausal women)
Occupation and Husband's occupation
Marrried or unmarried
Loss of appetite or loss of weight (neoplasia, systemic disease)
Drug history including HRT (oral or vaginal), contraception. Pruritus unresponsive to antifungal agents
suggests vulvar dermatitis.
Hygienic practices (Potential irritants and allergens)
Use of tampons during menstruation (retained tampon source of trauma as well as infection)
Menstrual cycle and last menstrual period
Abnormal vaginal bleeding e.g. post-coital or mixed with discharge (s/o neoplasia)
Nature and colour of the discharge, duration, odour
Associated with itching s/o dermatological disease
Anal itching (pinworm)
h/o repeated UTI
h/o ring pessary insertion (trauma)
h/o DM, family history
Use of any chemicals, lubricating gels,douching (increases the vaginal pH)
Insertion of foreign body (trauma)
h/o urticaria, rashes especially eczema or allergic dermatitis

Look for
General condition (pallor, jaundice, lymph nodes), weight, temperature, vital signs
Local examination
o excoriation of skin
o sign and symptoms of atrophic vaginitis (raw inflamed areas in the vagina that bleed easily when
swabbed. Vagina is tender and inflamed and mucosa is excorited)
o leucoplakia
o ulcers
o local swelling of vulva and vagina
o vulvo-vaginal growth
P/S examination
o colour of discharge, blood stained,
o odour
o IUCD thread

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o ring pessary
o any growth-friable, bleeds on touch
o any ulcer
P/V examination
o size and shape of the uterus, position, mobility, tenderness
o consistency of cervix hard and indurated s/o neoplasia
o fullness of fornices
o involvement of parametrium and rectal mucosa

Investigations (as indicated by history and examination)

Haemoglobin, WBC, DC
Urine RE/ME/Culture
RBS/UREA
LFT
CXR
Bacteriological examination of vaginal smear
Pap Smear
cervical biopsy
vulval biopsy
endometrial biopsy
USG
CT/MRI
Colposcopy -biopsy
CA125

Comments

Early cervical cancer is frequently asymptomatic, underscoring the importance of screening. The most
common symptoms at presentation are irregular or heavy vaginal bleeding and post-coital bleeding.
Some women present with a vaginal discharge that may be watery, mucoid, or purulent and
malodorous. This is nonspecific finding and may be mistaken for vaginitis or cervicitis.
A pelvic examination should be performed in any woman with symptoms suggestive of cervical cancer.
Visualization of the cervix upon speculum examination may reveal a normal appearance or a visible
cervical lesion; large tumors may appear to replace the cervix entirely. Any lesion that is raised, friable,
or has the appearance of condyloma should be biopsied. The diagnosis of cervical cancer is made based
upon histologic evaluation of a cervical biopsy.
Screening for cervical cancer is normally via cytological examination of the cervix (pap smear). Recently
it has become possible to combine this with testing for human papillomavirus (HPV) which is central to
the development of cervical neoplasia. It can be detected in 99.7 percent of cervical cancers. Subtypes
HPV 16 and 18 are found in over 70 percent of all cervical cancers.
Risk factors for cervical cancer are mostly associated with an increased risk of acquiring or having a
compromised immune response to HPV infection; these include: early onset of sexual activity, multiple
sexual partners, a high-risk sexual partner, history of sexually transmitted infections, history of vulvar or
vaginal squamous intraepithelial neoplasia or cancer, immunosuppression. Oral contraceptive use
appears to be associated with an increased risk of cervical cancer. Cigarette smoking appears to be
associated with an increased risk of squamous cell cancer, but not adenocarcinoma.
Dermatological disease is a common non-infectious cause of vaginal discharge. This may be due to local
irritation with hygiene products or may be primary dermatological conditions such as allergic dermatitis.
Oestrogen deficiency in postmenopausal women leads to atrophic vaginitis. Urinary symptoms of

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frequency and dysuria are common. Taking systemic hormone replacement therapy (oral, skin) does not
guarantee adequate vaginal estrogen levels.
Rarely, Behcets disease, collagen vascular disease and Crohns disease may present with vaginal
discharge.

Management topics for Vaginal discharge

1. Complications of syphilis in maternal infection + management + screening tools for syphilis
2. Management approach to vaginal discharge syndrome + Management of candida, trichomonas and
bacterial vaginosis
3. Organisms commonly involved in PID + Complications + management
4. Causes of vulvovaginitis and its management + Management of cervicitis (acute and chronic)
5. Screening for cervical cancer, CIN classification and management of different levels of CIN + recent
advances in prevention of cervical cancer
6. Management of atrophic vaginitis

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Pelvic Mass
A pelvic mass is an enlargement or swelling in the lower abdomen or pelvic region. Some people may be able to
feel a pelvic mass, however, most are discovered during routine physical examinations. In women,
pelvic mass can indicate an abnormal growth on or within a female reproductive organ. The growth can be as
simple as a benign cyst or as serious as a malignant tumor. The mass can develop at any age from childhood to
postmenopausal period.

Pelvic mass

Non-
Gynaecologica
gynaecologica
l origin
l

GI tract
Uterus Ovary Fallopian tube Bladder
(lumps CP)

Ectopic Urinary
Tumour Tumour
pregnancy retention CP

Benign Tumour
Benign Infection
e.g.Fibroid (lumps CP)

Malignant Malignant

Polycystic
Infection ovarian
disease

Pregnancy Functional

Normal Hyperstimulat
ion

Hydatidiform
mole

Hematometra

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Pelvic mass

Non-
Gynaecological
gynaecological

Uterus Ovary Fallopian tube GI tract Bladder

Not all pelvic masses are of gynaecological origin.

Clinical clues
Ask for:
Age of patient malignancy commoner in older age group, pregnancy should always be suspected in
women of child bearing age
Time since onset of mass
General malaise, weight loss s/o malignancy or TB
Menstrual cycle abnormalities may suggest a gynaecological cause (usually uterine)
Last menstrual period if delayed suggests pregnancy in women of child bearing age
Contraceptive history
Abdominal pain
Fever suggests infection
Urine output if abnormal suggests bladder problem
Haematuria, dysuria s/o bladder problem
Altered bowel habit, blood in stool s/o GI pathology

Look for:
General appearance toxic (infection), cachexia (malignancy), agitated (? Urinary retention), pallor,
dehydration
Vital signs (Pulse, blood pressure, temperature) e.g. in infection get fever and tachycardia, in sepsis get
tachycardia and low BP.
Size of pelvic mass (how far does it extend?)
Consistency of pelvic mass (solid or cystic, smooth or craggy)
Tenderness
Presence of fetal parts
Position (arising in midline or from right or left fornix)
PV examination may help to better identify which organ the mass is arising from.

Investigations
Ultrasound most helpful investigation to distinguish origin of pelvic mass

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Pelvic mass

Non-
Gynaecological
gynaecological

Fallopian tube
Uterus Ovary or tubo-
ovarian

Tumour

Benign
e.g.Fibroid

Malignant

Body of uterus

Cervical

Infection

Pregnancy

Normal

Hydatid mole

Hematometra

Pelvic mass of uterine origin

Clinical clues:
Ask for:
Age of the patient (older patient malignancy, perimenopausal fibroid more likely, younger patient
consider pregnancy)
Menstrual cycle LMP, Regularity, dysmenorrhoea, nature of bleeding, amount of bleeding
Post menopausal bleeding (bleeding after 1 year of no menstruation in older women) must exclude
endometrial carcinoma
Menarche a teenager with no first period may have imperforate hymen and haematocolpos leading to
pelvic mass
Sign and symptoms of pregnancy-- nausea, vomiting, increased frequency of micturition
Abdominal pain, fullness of abdomen
H/o P/V discharge, foul smelling (s/o infection, pyometra)
Fever with chills (s/o infection)
Loss of appetite, Loss of weight (s/o malignancy)
H/O post coital bleeding (s/o cervical malignancy)
Family history of pelvic mass (for malignancies)
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Look for
General examination-- pallor, dehydration, vital signs,
Toxic look
Cachexia (malignancy)
Inguinal lymph node palpation (malignancy)
Signs of pregnancy (linea nigra, stretch marks, darkened areolae)
Fullness of pelvis
Abdominal tenderness
Presence of fetal parts
Foetal heart sound
P/V (digital vaginal exam) --- size of the uterus, consistency of uterus and cervix, fullness of the fornix,
tenderness
P/S (speculum exam) Discharge foul smelling
Cervical appearance Erosion, bluish discolouration and deposits
Spotting ,bleeding,
Presence of vesicles (for herpes infection)
P/R fullness with presence of nodules (metastasis), boggy swelling in Pouch of Douglas/ rectovesical
pouch (Bloomers shelf)
Chest Presence of ronchi crepts, B/L air entry (lung metastases in choriocarcinoma)

Investigations
Pregnancy test
Complete blood count
Serum B HCG for hydatid mole and choriocarcinoma
Chest x-ray
Ultrasonogram
Pap Smear,
Visual Inspection using Acetate (VIA) this is an alternative to pap smear when cytological services are
not available and is very useful in low resource settings. It is best combined with immediate cryotherapy
for suspicious lesions.
CT Scan
MRI

Diagnoses to consider:
Pregnancy
Hydatid Mole
Choriocarcinoma
Adenomyosis
Leiomyoma
Leiomyomasarcoma
Hematometra
Pyometra
Endometrial carcinoma
Cervical cancer

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Ovarian Mass

Ovarian mass

Other e.g.
Polycystic ovarian
Tumour Functional cysts hyperstimulation,
disease (PCO)
endometrioma

Benign Malignant

Ask For
Menstrual cycle and menstrual flow Regularity, may be amenorrhoea or oligomenorrhoea in Polycystic
ovarian syndrome (PCO)
Dysmenorrhoea (s/o endometrioma)
Last menstrual period
Abdominal pain (ovarian cysts may become painful when there is rupture, haemorrhage or torsion)
Nature of pain (colicky radiating to upper medial thigh s/o torsion of ovary, sudden and very severe
suggests haemorrhage or rupture of ovarian cyst)
Abnormal distribution of hair growth, acne and excessive hair growth (s/o PCO)
Loss of appetite and weight loss (s/o malignancy)
Gastrointestinal symptoms
o Bloating, distension, discomfort in ovarian malignancy.
o Rectal bleeding, altered bowel habit (Some GI malignancies metastasize to the ovary)
Family History or personal history of ovarian, breast or GI cancer (familial tumours)
Drug history (especially fertility treatment with gonadotrophins which can lead to massive enlargement
of the ovaries)
Look For
Toxic look
General Examinations puffiness of face, distribution of body fat (central obesity associated with PCO
Disease), anemia, cachexia
Hirsutism, Acne (PCO)
Signs of precocious puberty (early breast formation and secondary sexual characteristics) suggests
malignant ovarian tumour.
Breast examination (breast malignancy may metastasize to the ovaries)
o Presence of nodule or mass
o Tenderness
o Discharge from nipple
P/A Examination
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o Fullness of the abdomen

o wrinkling and dryness of the skin
o engorgement of the veins
o Shape and size of the mass, consistency
o motility, tenderness, regularity
o Fluid thrill shifting dullness
Lymph node palpation --- inguinal
P/V Examination
o size of the uterus or mass
o shape, consistency, motility, tenderness
o B/L fornices should be examined looking for induration and tenderness s/o involvement of
parametrium
P/R Examination - involvement of rectum

Investigations
CBC (for anaemia)
Blood CA125 tumour marker raised in ovarian cancer of epithelial origin
Alpha fetoprotein (AFP) - tumour marker
Beta human chorionic gonadotropin (b HCG) tumour marker for Hydatid mole, and choriocarcinoma.
Mammogram - If breast is involved
Endoscopy R/O Krukenberg's tumour (ovarian metastasis from gastric malignancy)
Colonoscopy if suspect primary GI malignancy with ovarian metastasis
Diagnostic Laparotomy
USG of abdomen and pelvis
CT Scan
MRI

Comments:
Unfortunately early stages of ovarian cancer are asymptomatic, so many malignancies arent diagnosed until
quite late.
Functional cysts occur due to ovarian gonadotrophin stimulation and failure of follicular apoptosis. Most
functional cysts are asymptomatic, but those > 5cm in size are at risk of torsion and rapid progression.
In pelvic USG note the size, shape and volume of cyst with thickness and regularity of the wall plus the nature of
cyst contents. Functional cysts are anechoic with thin regular walls. Simple anechoic cysts may be monitored
for 1-6 months as many spontaneously resolve. Heterogenous cysts should be excised as they may be
malignant.
Ovarian neoplasms can arise from surface epithelium (80-85%), ovarian stroma (10-15%) e.g. germ-cell, sex-cord
stromal and non-specific mesenchymal tumours, or may be secondary deposits/metastases.
In adolescents there are a variety of malignant ovarian germ cell tumours:
Dysgerminoma (90% have normal menstruation)
Endodermal sinus (yolk sac) tumour
Choriocarcinoma
Embryonal cell carcinoma
Granulosa cell tumour (sex cord stromal tumour)
The tumour marker CA 125 is most useful in monitoring of response of ovarian cancer to therapy. 50% of
patients with early ovarian cancer will have a normal CA125.
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Diagnoses to consider
Functional ovarian cysts
o Follicular
o Corpus luteal cyst
o Theca luteal cyst
o Mucinous cyst
Polycystic ovarian disease (PCOD)
Endometroid cyst
Epithelial ovarian tumours (80-85%)
Serous cystadenoma
Mucinous cystadenoma
Serous cystadenocarcinoma
Adenocarcinoma

Germ cell tumour

Dysgerminoma
Immature teratoma
Mature teratoma
Gonadoblastoma

Sex cord stromal

Thecoma
Granulosa cell tumour

Fibroma
Metastasis
Krukenberg tumour
Breast

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Fallopian tube and

tubo-ovarian mass

Ectopic
Infection
pregnancy
Ask for:
LMP
Previous menstrual history
Use of intrauterine contraceptive device (increase risk for ectopic)
Abdominal pain
Fever, purulent discharge PV (s/o infection)
Spotting/bleeding
Previous history of ectopic pregnancy or surgery to uterus
Known sexually transmitted disease in the past

Look for:
Toxic look fever, tachycardia, BP
Size and extent of pelvic mass (often not palpable per abdomen, but palpable on bimanual PV
examination)
Tenderness
Pus coming from os

Investigations:
Urine pregnancy test
If positive - USG to assess if intrauterine pregnancy

Diagnoses to consider:
Ectopic pregnancy
Gonococcal infection or other STD
TB infection

Management topics:
1. Causes of ovarian cancer, prevention issues
2. Epidemiology and risk factors for uterine malignancy
3. Etiology and Types of fibroids
4. Classification of endometrial Ca and Ovarian Ca
5. Classification and management of cervical cancer

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Puerperium

Puerperium

Normal
Abnormal
(changes in:)

Uterus Bleeding

Cervix Fever

Vagina Pain

Systemic e.g.
Shortness of
blood, urinary,
breath
endocrine

Other e.g. pelvic Abnormal

floor, fascia behaviour

Puerperium is the period which begins with the termination of the third stage of labour and lasts till the genital
organs have assumed their normal condition again. The normal duration of the puerperium is from six to eight
weeks.
During the puerperium the metabolic changes of pregnancy also return to their pre-pregnancy state and
lactation is established. If the mother does not breast feed then she may quickly return to being fertile and
effective contraception is needed.
The puerperium is also a time of psychological adjustment for the mother as she copes with her anxiety about
the baby, her ability to cope with a child, feeling tired and sore, together with lots of (often conflicting) advice
from family, neighbours and medical staff.
The role of the medical team in the puerperium can be summarized as:

Monitor the physiological changes of the puerperium

Diagnose and treat any postnatal complications
Establish infant feeding
Give the mother emotional support
Advise about contraception etc

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Normal
puerperium

Other e.g.
Uterus Cervix Vagina Systemic pelvic floor,
fascia

Endometrium Myometrium

Ask for
Post partum day
period of gestation
Outcome of the fetus
mode of delivery
delivery of the placenta
secretion of breast milk
afterpains
p/v discharge, lochia - colour, odour
pain at the episiotomy site or at the incision site
fever
spinal headache if LSCS
calf muscle pain
bowel and bladder habit
signs of postpartum blues/depression, psychotic disorder

Look for
General examination
sign of fatigue, pallor
Vital signs: blood pressure, temperature, pulse rate, respiration rate
Breast examination
Abdominal examination
o height of the uterus
p/v examination
o lochia colour, odour
o episiotomy site
o hematoma

Comments:
The principle change is uterine involution. Within 10 days of delivery the uterine fundus should have
disappeared below the symphysis pubis.
The lochia is produced by the sloughing off of the decidua in the endometrial cavity. It usually clears completely
within 4 weeks of delivery. If the mother is not breast feeding then normal menstruation may resume within 6
weeks of delivery.
Other areas that are involved in the puerperium are: broad ligament, cardinal ligament, pelvic floor and fascia.
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Abnormal
puerperium

Shortness of Abnormal
Bleeding Fever Pain
breath behaviour

Secondary Post
partum Puerperal sepsis After pains Chest infection Baby blues
haemorrhage

Retained
Pulmonary Postnatal
products of Breast abscess Full bladder
embolism depression
conception

Endomyo- Wound Cardio-

Spinal headache Psychosis
metritis infection myopathy

Systemic inf Calf thigh

e.g.UTI, chest pain

Thrombo-
Adnexal torsion
embolism

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Abnormal
bleeding

Secondary post
Retained products
partum Endometritis
of conception
haemorrhage (PPH)

Coagulation
Genital tract trauma Atonic uterus
disorders

Ask for
Postpartum day
Mode of delivery (especially instrumental delivery risk of trauma)
h/o episiotomy
Place of delivery access to oxytocinon for third stage of labour
duration of labour - prolonged labour risk factor for uterine atony
amount of bleeding
o association with clots and membrane
History of collapse s/o significant blood loss
Associated with fever, foul smelling lochia, low abdominal pain s/o endometritis
Multiparity, multiple pregnancy or polyhydramnios increased risk of uterine atony
socio-economic status
h/o sexual contact
h/o fall and trauma
Known bleeding disorder
Precipitating causes for DIC (disseminated intravascular coagulation disorder) e.g. history of shock,
massive blood transfusion, placental abruption, intra-uterine death, septicaemia

Look for
general condition anxiety, toxicity
pallor
BP/Temperature/Pulse rate
Abdominal examination
o Fundal height for involution of the uterus (if delayed s/o retained products)

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o tenderness (s/o endometritis)

Petechial rashes(s/o DIC)
P/S - amount of bleeding
o scar marks
o injury
o vulval/vaginal/cervical tear
o episiotomy
o nature of lochia
o pus discharge
o old organised clots
o hanging placental tissue or membrane
o smell or odour
p/v
o os open or closed/ POC felt
o size of the uterus (subinvolution)
o consistency
o tenderness

Investigations

CBC and platelets

PT/INR
Blood Gr and Rhesus status
USG abdomen and pelvis

Comments:
Secondary post partum haemorrhage is defined as excessive bleeding from the genital tract following delivery
occurring 24 hours after the delivery.
Even a small retained fragment of placental tissue or is membranes may be sufficient to cause PPH.
Women who deliver at home will not have received oxytocic drugs in the third stage of labour and thus are
more likely to suffer from uterine atony and subsequent PPH.

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Fever

Genital tract Systemic Thrombo-

infection Breast abscess Wound infection infection e.g.
(endometritis) UTI, chest embolism

Ask for
Fever (duration, degree of fever)
malaise, fatigue
nausea and vomiting
Excessive PV bleeding, smelly lochia, abdominal tenderness (s/o endometritis)
h/o repeated UTI and catheterisation
breast pain and engorgement
loss of lactation
retraction of nipple
technique and knowledge of lactation
prolonged rupture of membranes prior to onset of labour
h/o Caesarian section or episiotomy or tear
Tenderness around any wounds
burning urine, frequency, urgency,
cough, sputum- blood stained
calf tenderness, shortness of breath (s/o thromboembolism)
pre-existing cervicitis and vaginitis, chest infection or heart disease

Look for
General condition- toxicity, pallor
Temperature, pulse, BP
Breast examination:
o breast-redness, tenderness
o retraction of nipple
o engorgement
o abscess formation
Tenderness in suprapubic region and iliac fossa
Renal angle tenderness (pyelonephritis)
Chest- decreased air entry, abnormal breath sound, crepitation (pneumonia)
Calf muscle swelling (compare both legs), redness and tenderness s/o thromboembolism
LSCS wound for redness, tenderness or pus dicharge

Investigations
CBC
Urine RE/ME , C/S
Blood C/S
Endocervical swab for C/S
Doppler USG of leg if suspect thromboembolism

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Comments
The diagnosis of postpartum endometritis is based upon clinical criteria of fever and uterine tenderness
occurring in a postpartum woman. Other signs and symptoms which support the diagnosis include foul
lochia, chills, and lower abdominal pain. The uterus may be soft and subinvoluted, which can lead to
excessive uterine bleeding
Postpartum endometritis is a common cause of postpartum febrile morbidity (defined as an oral
temperature of 38.0 degrees Celsius or more on any 2 of the first 10 days postpartum, exclusive of the
first 24 hours). The infection begins in the decidua, and then may extend into the myometrial and
parametrial tissues.
The infection is polymicrobial, usually involving a mixture of two to three aerobes and anaerobes from
the lower genital tract.
Cesarean delivery is the most important risk factor for development of postpartum endometritis.

Pain

Urinary tract
After pains related (retention, Spinal headache Calf thigh pain Adnexal torsion
pyelonephritis)

Ask for
Day of delivery
Mode of delivery LSCS, normal vaginal or complicated
h/o given a spinal anaesthetic
Location of pain, onset of pain sudden or gradual
Micturation- frequency, urgency overflow, urinary retention or incontinence
Headache, its radiation and its relation with posture
Calf muscle pain
Severity of pain on movement
Associated with fainting attack
Sciatica pain and foot drop
Look for
Toxicity, temperature, pulse, BP, respiration
pallor
Site of pain
Calf muscle tenderness, swelling, redness
Abdominal examination
o size of uterus and any tenderness
o tenderness in flanks, suprapubic, renal angle s/o UTI, retention or pyelonephritis
o Rebound tenderness in right or left iliac fossa s/o adnexal torsion
P/V size of the uterus
o tenderness
o B/L fornices fullness, tenderness
Investigations
o CBC if suspect infection
o Urinalysis
o USG of abdomen and pelvis
o Doppler USG of legs if suspect DVT

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Comments
After pains are a normal part of the post partum period. They are intermittent cramping pains felt in the lower
abdomen for the first few days, similar to menstrual cramps. They tend to get worse with successive
pregnancies.

Shortness of breath

Pulmonary
Chest infection Cardiomyopathy
embolism
Ask for
Timing of SOB if sudden onset and severe s/o pulmonary embolism, more gradual onset s/o infection
or cardiomyopathy
Fever s/o infection, but may also be thromboembolism
Associated cough + sputum s/o chest infection
Chest pain sudden onset pleuritic s/o pulmonary embolism but may also be pleurisy associated with
pneumonia
Known history of cardiac disease (cardiomyopathy)
Pain in calves s/o deep vein thrombosis
Look for
Vital signs: temperature, BP, Respiration rate, pulse rate
Toxicity, pallor, lymph nodes
Chest- wheezes, creps, abnormal breath sound (s/o pneumonia)
Heart murmur, displaced apex beat, parasternal heave, raised JVP, extra heart sounds (s/o
cardiomyopathy)
Calf muscle swelling, redness and tenderness (DVT leading to pulmonary embolism)
Investigation
CBC leucocytosis in infection, anaemia in chronic heart disease or as a cause of breathlessness
Sputum for AFB, C/S
CXR
ECG
D-Dimer (if suspect pulmonary embolism)
Troponin/ CPK -MB
Amylase
ECHO
Doppler lower limbs (for DVT)

Comments:
Heart rate and cardiac output fall in the early puerperium but there may be an early rise in stroke volume and a
rise in blood pressure (due to increased peripheral resistance). This is a time of high risk for mothers with
cardiac disease.
After delivery there is a rise in fibrinogen and many of the clotting factors, plus a sharp increase in the number
of platelets, making this a time of high risk for thromboembolic complications.
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Abnormal behaviour

Other e.g. Generalized

Postpartum blues Postpartum depression Postpartum Psychosis anxiety disorder, OCD,
Panic disorder

OCD obsessive compulsive disorder

Psychiatric disorders are common in the postpartum period and need to be screened for as they cause
significant morbidity and sometimes mortality due to suicide. A woman may have pre-existing psychiatric
disease which becomes worse in the postpartum period or she may present for the first time.
Ask for:
Persistent low mood
Reduced pleasure (including pleasure in new baby)
Tearfulness, fearfulness
Feelings of hopelessness and worthlessness
Reduced sleep, reduced appetite, reduced concentration
Suicidal thoughts
Thoughts of wanting to harm the baby (common but not usually indicating significant risk to baby)
Significant anxiety, often with panic attacks
Intense irritability and anger
Feelings of guilt
A sense of being overwhelmed or unable to care for the baby
Feelings of inadequacy, and of being a failure as a mother.
Not bonding to the baby, which further exacerbates feelings of shame and guilt and leads women to
suffer in silence
Psychotic features delusions of persecution, auditory hallucinations, extreme withdrawal and refusing
to communicate.
Factors increasing risk for depressive illness
o Personal history of depression or bipolar disorder (major risk factor)
o Depressive symptoms during pregnancy
o Family history of depression
o Premenstrual or oral contraceptive associated mood changes
o Marital conflict, lack of emotional or financial support
o Stressful life events in the previous 12 months
o Lack of perceived social support from family and friends for the pregnancy
o Living without a partner
o Unplanned pregnancy, having contemplated terminating the current pregnancy
o Previous miscarriage
o Not breastfeeding
o A lifetime history of depression in the husband or partner
o Sick leave during pregnancy related to hyperemesis, uterine irritability, or psychiatric disorder
o A congenitally malformed infant
o Pregestational or gestational diabetes
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Look for:
o General affect mood, eye contact, restlessness etc
o Mental state examination

Comments:
Postpartum blues refer to a transient condition characterized by mild, and often rapid, mood swings from
elation to sadness, irritability, anxiety, decreased concentration, insomnia, tearfulness, and crying spells. Forty
to 80 percent of postpartum women develop these mood changes, generally within two to three days of
delivery. Symptoms typically peak on the fifth postpartum day and resolve within two weeks
By comparison, a diagnosis of major and minor depression requires that depressed mood or loss of
interests/pleasure and other characteristic symptoms be present most of the day, nearly every day, for at least
two weeks.
There are no separate criteria for diagnosing post partum depression compared with ordinary depression.
Depression occurring within 12 months of delivery is generally accepted as being postpartum depression.
Women with postpartum blues are at increased risk of developing postpartum depression.
Postpartum blues typically resolve over time and with support and reassurance to the woman and her family
and insuring that she has adequate time for sleep and rest. Women with postpartum blues must also be advised
to seek evaluation promptly for postpartum depression if their symptoms do not resolve within two weeks or if
they become worse.
Paternal postpartum depression Depression also occurs in fathers after childbirth.

Management topics for Puerperium

1. Breast problems after delivery and their management
2. Causative organisms of puerperal sepsis + management of puerperal sepsis
3. Common ways in which septic abortion presents and the management of septic abortion
4. Management of uterine inversion
5. Different degrees of vaginal prolapse, prevention issues and management

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