obs and gynae revision lecture
TRANSCRIPT
8/18/2019 Obs and Gynae Revision Lecture
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OBSTETRICS
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• Placenta- HCG (doubles every 48hrsunt l !" #$s%
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&ntenatal care
• 've re)nancy test- &ttend GP• Re*erred *or boo$ n) at hos tal• Boo$ n) +SS scan to date re)nancy• ,ull H and boo$ n) bloods• Ident *y .O/ r s$ (Co00un ty1Green%
or HIGH r s$ (Consultant1Red%
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Boo$ n) Invest )at ons
• ,BC (R t "8 #$s%• Blood )rou and abs2 (r t "8#$s%•
Rubella status• HEP B1C3 HI 3 Sy h2 I* no H ch c$en o
do ar cella• 5 ur ne
• OGTT3 Hae0o)lob no athy screen
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Each v s t
• BP• 5 ur ne• ,undal he )ht (! c01#ee$%• ,etal heart # th 5o tone• Pal ate abdo0en *or
resentat on1stat on
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Screen n)• C+BS -!!-!6 #$s• ,ree *etal 57&• !4-" #$s 9screen n) bloods• G ves r s$ *or tr so0y "!2 7ot
de:n t ve2 (5S ↓ 3 SB ↑ % I* ; ! n !< 3re*erred *or counsell n)
• " #$s ano0aly scan Structuralabnor0al t es1 S na B :da
• C S (=-!! #$s%1 &0n ocentes s (;!<
#$s%2 >aryoty e2 !? r s$ o*0 scarr a e2
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.abour
• Pr 0 arous- !"-"4 hrs• @ult arous- A-!" hrs• +sually de:ned as the onset o*
a n*ul3 re)ular contract ons3 0orethan one every ten 0 nutes3 # th
ro)ress ve cerv cal e ace0ent andd latat on acco0 an ed by descent o*the resent n) art2
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In t at on• Phys olo) cal *actors lar)ely
un$no#n2• Occurs #hen *actors #h ch nh b t
contract ons and 0a nta n a closedcerv d 0 n sh and are succeededby the act ons o* *actors #h ch do the
o os te2• Increase n ntracellular *ree calc u0
br n)s about contract on2
Prosta)land ns and o ytoc n ncrease
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Sta)es n .abour• Sta)e I- Onset o* labour to *ull
d latat on2 latent and act ve hase(;6c0 d lated2%
• Sta)e II- ,ull d latat on to del very o*baby ( 4hrs n r 03 6hrs n @ult %Pass ve and act ve2
• Sta)e III- B rth o* baby to del very o*lacenta2 ( !hr% Can be act ve 9
(Syntoc non1Synto0etr ne% or
Phys olo) cal2
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Pro)ress
• Con:r0 resentat on• @on tor ,H -Inter0 ttent1 Cont nuous• +ter ne 0uscle Contract ons- 6-<
)ood contract ons n ! 0 ns2• E a0 ne *or C d latat on1
e ace0ent1 stat on and os t onevery 4hrs2 E ect 0 n 0u0
ro)ress 2<-!c01hr2
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Pro)ress
• Con:r0 resentat on• @on tor ,H -Inter0 ttent1 Cont nuous• +ter ne 0uscle Contract ons- 6-<
)ood contract ons n ! 0 ns2• E a0 ne *or C d latat on1
e ace0ent1 stat on and os t onevery 4hrs2 E ect 0 n 0u0
ro)ress 2<-!c01hr2
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Parto)ra0
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,etal @on tor n)2
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Presentat on
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Stat on
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Pos t on• Related to OCCIP+T ( oster or
*ontanelle%5 rect
5 rect
R )ht .e*t
R
R .
.
POSTERIOR
&7TERIOR
TR&7S ERSE TR&7S ERSE
Sy0 hys s Pub s
Sacru0
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Pos t on• Related to OCCIP+T ( oster or
*ontanelle%
5 rect
5 rect
R )ht .e*t
R
R.
.
POSTERIOR
&7TERIOR
TR&7S ERSE TR&7S ERSE
Sy0 hys s Pub s
Sacru0
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&nal)es a n labour• Breath n)1 TE7S1 Bath1 Co-coda0ol• Entono (7 trous o de1 o y)en%•
@or h ne- can cause CTG chan)es1neonatal res de ress on2• Re0 *entanyl PC&2•
E dural- .614 ( 7eeds I Du ds3Catheter3 Cont nuous CTG%• Can be to ed u * needs .+SCS2
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Proble0s2
• Prolon)ed latent hase• &rrest o* d latat on• &rrest o* descent o* resent n) art2• ,etal co0 ro0 se2
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Ty es o* del very
• S 5• &ss sted del very• a) nal breech del very2• .+SCS (lo#er uter ne se)0ent
caesarean sect on%
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S 5
• En)a)e0ent• 5escent• Internal rotat on• Cro#n n)1E tens on• Rest tut on• 5el very o* ant then ost shoulder2
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Th rd sta)e
• 5el very o* lacenta2• Controlled cord tract on2• Guard uters2• Syntoc non1 Synto0etr ne2• R s$ o* PPH
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E0er)enc es
• @al resentat on- Breech3 *ace3 Bro#3co0 ound- .+SCS2
• Cord rola se- Cord co0es out # thDu d2 Elevate resent n) art- Crash.+SCS
•
Shoulder dystoc a- Head del vered2Shoulders stuc$2 @anoeuvres to tryd s 0 act2
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The uer er u0• A #$s ost natal• +terus shr n$s- .och a roduced•
PPH (secondary%• 5 T1PE• Hae0arrho ds1 Const at on•
Postnatal de ress on
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Breast *eed n)
• Oestrogen and Progesteronest 0ulate breast rol *erat on
• Prolactin st 0ulates 0 l$ roduct onand descent nto alveol
• Oxytocin st 0ulates 0 l$ e ect on• , rst th c$ yello# Du d- Colostru0• @a nta ned by suc$l n)
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Breast *eed n)
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Breast *eed n)
• S$ n to s$ n contact1 Bond n)• Rece ves all reFu red nutr ents• Pass ve 00un ty o* ant bod es
• Can t breast *eed # th certa n0ed cat ons or * HI 've
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Co0 l cat ons
• Crac$ed n les• @ast t s• @ l$ stas s• Poor su ly-• 5o0 er done
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PRE TER@ .&BO+R
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5e:n t on
• Onset o* labour be*ore 6 #ee$s
• Presence o* uter ne contract ons o*su c ent *reFuency and ntens ty tocause d lat on o* the cerv r or toter0 )estat on
• Cause lar)ely un$no#n- no cause*ound n < ? cases
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R s$ ,actors• Social factors- lo# soc al class- youn) 0other- lo# 0aternal #e )ht
- s0o$ n)
• Over distension of uterus- 0ult le re)nancy
- olyhydra0n os
• Fetal anomaly
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R s$ ,actor• Uterine anomaly- con)en tal- cerv cal nco0 etence
• Infection-0aternal yre al llness-chor o-a0n on t s (caused by re0ature ru ture o*
0e0branes%
• Trauma- n ury-sur)ery dur n) re)nancy
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5ru) treat0ent -Tocolys s• 5esc s on to treat de ends on
)estat on and stero ds• Treat0ent does not have any bene:t
on er -natal 0ortal ty• aluable *or delay n) del very unt ltrans*er to un t # th su tableneonatal care can be rov ded
• &llo#s t 0e *or cort costero ds to be) ven to accelerate *etal lun)0atur ty2
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5ru) treat0ent
• DHP Calcium channel blockers(n *ed ne%
• Inh b t uter ne 0uscle contract on• 7o roven bene:t over
beta0 0et cs3 other than *e#er s de
e ects• 5ose o* " 0) ) ven *ollo#ed by ! -
" 0) ) ven 6-4t 0es da ly
de end n) on uter ne act v ty
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Tocolys s
• Oxytocin rece tor anta!onist(atos ban "
• Bloc$s act on o* o ytoc n on uterus#h ch st 0ulates contract ons
• G ven I 3 0a 0u0 durat on 48hours• . censed *or nh b t on o* re0ature
labour bet#een "4 and 66 #ee$s)estat on
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POST P&RT+@
H&E@ORRH&GE
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PPH
• ;< 0ls blood loss P• Pr 0ary or secondary
• Secondary- endo0etr t s1RPOC
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Pr 0ary PPH
• E0er)ency• &BC
• &- tal$ to t• B- *ac al O"• C- I &ccess (" lar)e venDons% ,BC3 Coa)3 J-0atch I Du ds
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Causes
• T- Tone• T- T ssue•
T- Trau0a• T- Thro0b n
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Tone
• &ton c uterus = ?• Catheter se• B 0anual co0 ress on• I@ syntoc non ! u• I@ er)o0etr ne < 0c)• I Syntoc non n*us on 4 u• I@ Hae0abate (PG," α % "< 0c)
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B 0anual co0 ress on
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T ssue
• Chec$ lacenta• @anual re0oval
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Trau0a
• Gen tal tract trau0a• Re a r
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Thro0b n
• Chase Coa) result• Contact hae0atolo)y• /atch *or s )ns o* 5IC
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&7TE P&RT+@
H&E@ORRH&GE
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&PH
• Bleed n) *ro0 the )en tal tract a*ter"4 #$s )estat on
•
"-<? o* re)nanc es• I0 ortant cause o* 0aternal and
*etal 0orb d ty and 0ortal ty
• 5on t *or)et &nt 5 n Rh-ve #o0en
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Causes
• Placenta raev a• Placental abru t on• Sho#• .ocal causes
• asa raev a
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Placenta raev a
• Placenta develo s n lo#er uter nese)0ent2 2<? o* all re)nanc es
•
R s$ *actors- ncreased a)e -0ult arous - rev .+SCS
- S0o$ n) - rev h story - 0ult le re)nancy
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Class :cat on
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Presentat on
• " #$ +SS (= ? # ll 0 )rate%• Pa nless va) nal bleed n)-
un rovo$ed• Post co tal bleed n)• @al resentat on
• @ass ve hae0orrha)e 0ay *ollo##arn n) bleed
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5 a)nos s
• E1 S eculu0 should not be carr edout * PP sus ected
•
+SS (T scan best%• @RI scann n) can hel detect accreta
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@ana)e0ent (@a or%• I* sy0 to0at c- ad0 t• .ar)e cannula3 GKS• 5el very at 6 -68#$s by .+SCS
(earl er * nd cated%• Best to have blood3 cell salva)e and
ntervent onal rad olo)y ready
• I* hae0orrha)e- &BC3 stab l se0other then e0er)ency .+SCS
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Placental &bru t on
• Bleed n) *ollo# n) se arat on o*nor0ally s ted lacenta2 2<-!2<? o*
all re)nanc es• R s$ *actors- Increased a)e - @ult arous
- S0o$ n) - Recreat onal dru) use - &bdo0 nal trau0a
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Class :cat on
Revealed1Concealed
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Presentat on
• P bleed n)- &0ount 0ay notcorrelate # th s )n :cance o*
hae0orrha)e• &bdo0 nal a n1 tens on• Shoc$1 colla se•
,etal d stress
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5 a)nos s
• +sually cl n cal• +SS (only
* 0other and baby
stable%
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@ana)e0ent
• &BC• Resusc tat on• 5el very * reFu red• Increased r s$ o* PPH• /atch *or s )ns o* 5IC
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@ISC&RRI&GE
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@ scarr a)e
• !< ? o* all con:r0ed re)nanc es• Threatened• Inev table• Co0 lete1Inco0 lete• @ ssed• Recurrent• @olar
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Threatened 0 scarr a)e
• P bleed n) '1- abdo a n• @ ld• Os closed• +SS con:r0s v able re)nancy• @ay lead on to 0 scarr a)e
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Inev table 0 scarr a)e
• Heavy P bleed n) and a n• O en cerv• Products n canal
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Co0 lete1 Inco0 lete
• Co0 lete- roducts assed anduterus e0 ty
• Inco0 lete- 7ot all roducts assedbut no ,H on +SS and P bleed n)
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@ ssed 0 scarr a)e
• Pre)nancy .oss # th no s• Can be c$ed u at boo$ n) scan• Pre)nancy s usually )one a#ay
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@ana)e0ent
• E ectant- &#a t body to assre)nancy
•
Sur) cal- Evac• @ & 9 0anual vacuu0 as rat on• @ed cal- @ *e r stone and @ so rostol
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Recurrent 0 scarr a)e• 6 or 0ore 0 scarr a)es• !? o* all #o0en•
Chro0oso0al abnor0al ty• Con)en tal uter ne abnor0al t es• Cerv cal nco0 etence• In*ect on• PCOS• Thro0bo h ll a
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@olar re)nancy• H )h HCG3 .ar)e uterus• P Bleed n)
P#$TI#% 'O%(• /here art o* lacenta over)ro#s
( rol *erates% @ay be develo n) *etus
resent3 but s )enet cally abnor0al andcannot surv ve outs de the #o0b2 T#os er0 enter e)) and nstead o* *or0 n)t# ns *or0s an abnor0al *oetus2 Tr lo d2
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@olar re)nancy
• CO'P%(T( 'O%(• /hole lacenta s abnor0al and
)ro#s ra dly2 7o develo n) *etus2One s er0 enters the e)) but onlyhal* o* one set o* chro0oso0es are
resent2 &neu lo d2
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5 a)nosed on +SS
Sno# stor0a earance
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@ana)e0ent
• Sur) cal evac• Products sent to lab *or con*or0at on• Re) ster # th @olar re)nancy un t
(5undee%- They # ll *ollo# u• Trac$ HCG to • 7o ne# re)nancy *or ! yr but need
to avo d co0b ned hor0onalcontrace t on
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Can ro)ress to22222P($SIST()T *(ST#TIO)#%
T$OPHO+%#STIC DIS(#S(• Part o* the 0ole re0a ns n any art o* the
body des te n t al treat0ent -can )ro#Fu c$ly
CHO$IOC#$CI)O'#• Rare but curable *or0 o* cancer- lacenta
beco0es 0al )nant• Can s read throu)hout the body3 usually
to lun)s3 l ver and bra n2 Treat0ent sche0othera y
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@+.TIP.EPREG7&7CL
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@ult le re)nancy
• Inc dence o* t# ns M!1!• Tr lets M!14• Pred s os n) *actors 9Increased a)e -,a0 ly1 ersonal
H
- ,ert l tytreat0ent
-Race
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Ter0s
• @ono15 Ny)ot c- 7o2 o* e0bryos• Chor on c ty- 7o2 o* lacentas• &0n on c ty- 7o2 o* a0n ot c sacs
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5 Ny)ot c t# ns
• 7on dent cal• " e0bryos 0 lant• &l#ays " lacentas and " sacs
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@onoNy)ot c t# ns
• Ident cal• ! e0bryo s l ts• S l t 6 days- 5C5& 4- days- @C5& 8-!" days- @C@&- rare
!6-!< days - con o ned t# ns
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5 a)nos s• Boo$ n) scan• Be*ore * hy ere0es s1 *ert l ty R
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&ntenatal co0 l cat ons
,ET&.• Increased re-ter0 del very and
seFualae• Increased r s$ o* ano0al es• Increased r s$ I+GR1I+5
• In @C t# ns- T# n to T# n Trans*us onsyndro0e (TTTTS%
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&ntenatal co0 l cat ons
@&TER7&.• Severe hy ere0es s• Increase r s$ 0 scarr a)e• Increase r s$ o* anae0 a3 Pre-
ecla0 s a3 Pelv c a n3 &PH3
Placental raev a3 Gestat onald abetes and PPH2• Cord acc dents
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&ntenatal care
• H )h R s$• @ore v s ts• &no0aly scan at !8-" #$s2 (cant
really do C+BS1&,P%• Iron tablets• Ser al Gro#th scans• 5el very M68#$s
5 l
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5el very• a) nal vs .+SCS• I* t# n I s Breech or s )n :cantly
s0aller- .+SCS• I* t# n I s ce hal c- could try a) nal
del very• Cont nuous 0on tor n) (,SE on t# n
I%• I access• 5 culty s # th t# n II- Should be A
0 ns a*ter I at 0ost•
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T# n to T# n Trans*us on
• @onochor on c t# ns• Placental arter ovascular
anasta0os s• +neven d str but on• 5onor t# n 9anae0 c3 I+GR3
ol )ohydra0n os• Rec ent t# n- Polycythae0 c3
Polyhydra0n os3 &sc tes and leural
e us ons
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TTTS
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Treat0ent
• R s$y• .aser ablat on o* anasto0os s
vessels• Early del very
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S0all *or dates*etus
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S0all *or 5ates
• Const tut onally s0all baby• ,etal )ro#th restr ct on (,GR%•
+sually c$ed u by 0easur n)*undal he )ht
• Con:r0ed on +SS (Gro#th scan%
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,etal )ro#th chart
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Const tut onally s0all
• S0all 0other• Sy00etr cally s0all2•
.ess that ! th cent le but )ro# n)a ro r ately
• 7or0al l Fuor volu0e• 7or0al u0b l cal artery do lers
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I+GR
• &sy00etr cal )ro#th• .o# l Fuor volu0es1 &bnor0al
5o lers• 7ot )ro# n) alon) cent les• So0et 0es *etal d stress
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Causes
• Placental nsu c ency• ,etal ano0al es•
5ru)s• In*ect on
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Placental nsu c ency
• @ost Co00on• &bnor0al t es n lacental
develo 0ent• 5 abetes• Pre-ecla0 s a•
Thro0bo h l a• Connect ve t ssue d seases• Placental n*arct on1abru t on
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5ru)s
• S0o$ n) ("-*old r s$%• &lcohol•
Recreat onal dru)s• Beta-Bloc$ers
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@ana)e0ent
• Increased 0on tor n)• Gro#th scans3 l Fuor volu0es and
u0b l cal artery do lers every "#ee$s• Early del very
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Pre- ecla0 s a
• Increased BP and rote nur a '1- oede0a• ; 6 00H) systol c or ;!<00H)
d astol c above boo$ n) BP or• Systol c ;!< 00H)• Only " ? o* at ents # th ncreased BP n
re)nancy have re-ecla0 sa (8 ? are
PIH- re)nancy nduced hy ertens on
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Severe
5e:ned severe *• 6' rote n or 0ore n ur nalys s• BP ;! 1!!•
sual d sturbances1headache1 a lloede0a• R+Q1E )astr c a n1tenderness• Clonus• Ol )ur a1 Renal *a lure•
HE..P syndro0e ( H ae0olys s3 ( levated % verenNy0es3 %o# P latelets%• &ll above su))est ecla0 s a could be 00 nent2
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&et olo)y
• .ar)ely un$no#n• I00unolo) cal d sturbance decreased
nvas on o* 0aternal s ral arter es ntolacenta decreased lacental *unct on
• Endothel al cell da0a)e , br n *ra)0ents#h ch brea$ a#ay and de os t n-
•
$ dney Renal *a lure3 rote nur a• C7S convuls ons
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R s$ *actors
• Pr 0 )rav da• " yrs a)e and ;6<yrs a)e2•
,a0 ly1 Personal h story o* Pre-ecla0s a• @ult le re)nancy• Obes ty• 7on s0o$ers• Pre-e st n) hy ertens on or renal
d sease
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R s$s to 0other
• Renal1He at c *a lure• HE..P•
Stro$e• 5 sse0 nated ntravascularcoa)ulo athy (5IC%
• Pul0onary oede0a• Convuls ons• 5eath
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R s$s to baby
• I+GR ()ro#th restr ct on%• Placental abru t on•
Pre0atur ty• Hy o c da0a)e• 5eath
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Invest )at ons
• H story• E a0 ( nc ando e a03 reDe es3
*undosco y%• 5 ur ne3 re)ular BP s• Bloods (.ar)e cannula3 ,BC3 .,T s +rate3
+KE s3 Coa) and Gr and save%• I* severe- +r nary catheter- 0on tor
out ut22 Invas ve 0on tor n)- central l ne3
ECG2
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Trea0ent
• Treat0ent does not cure re-ecla0 s a3 t s a 0 sto revent ecla0 s a
• Only cure s to 5E.I ER B&BL•
'ild, &nt hy ertens ves (.abetalol " 0) 6 dayor @ethyldo a orally%• I* 6<#$s )estat on- stero ds2 !"0)
beta0ethasone I@2• Severe - I .abetalol1hydralaN ne - I @a)nes u0 sul hate 4) bolus and
!)1hr• @on tor BP3 +r ne out ut3 ReDe es3 Res rate and
@a) levels * To c ty
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Cont22
• CTG- *or *etal #ellbe n)• 5ec de #hen sa*e to del ver baby2 (can be
C-sect on or Induct on o* labour%• There s an ncreased r s$ o* PPH2 (Post
artu0 hae0orrha)e%• Cont nue 0ana)e0ent *or "4hrs ost
del very• I* has ecla0 t c se Nure- treat # th @)SO4
) 2
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,uture re)nanc es2
• Pro hylaxis n *uture re)nanc es-.o# dose as r n ( <0)%
•
Care*ul BP 0on tor n)• Gro#th scans
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5 abetes n
re)nancy
5 b
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5 abetes
• Pre e st n) 5 abetes• Gestat onal 5 abetes
• Pre)nancy s state o* Insul nres stance2
•
Placenta roduces ant nsul nhor0ones (hP.3 cort sol and)ulca)on%
G l 5 b
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Gestat onal 5 abetes
• Onset # th re)nancy• &ssess cl n cal r s$ and cons der
Hb&!c at boo$ n) and OGTT at "8#$s• Re*er to 5 abet c Obstetr c cl n c2•
@ lder r s$s than I55@• Can ro)ress to Ty e II 5@
ostnatally•
5 et controlled vs @et*or0 n1 Insul n
Ho# re)nancy e ects
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) y5 abetes• Insul n reFu re0ents r se• 5ecrease n Renal *unct on
( rote nur a%• Increased e sodes o* hy o)lycae0 a• /orsen n) o* Ret no athy•
Hy er)lycae0 a n Stero d use
Ho# 5 abetes e ects
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re)nancy• Increased r s$ o* con)en tal
abnor0al t es•
Increases r s$ I+517eonatal death• Increased r s$ Pre-ecla0 s a• Polyhydra0n os•
@acroso0 a1I+GR• Pre0atur ty• Postnatal hy o)ycae0 a and
aund ce2
& l
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&ntenatal care
• Pre-conce t on counsell n)• @ult -d sc l nary a roach•
Str ct 5 abet c control• 5eta led &no0aly scan• &7C every " #ee$s at 0 n 0u0 # th
)ro#th scans• Induct on at 68 #$s
b
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.abour
• Cont nuous GTG• Sl d n) scale n certa n cases- Hal* as
soon as lacental del vered• A #$ *ollo# u - GTT
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BRE&>
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GL7&ECO.OG L7or0al
@enstruat on
7 0 l @ t t
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7or0al @enstruat on
• Cycle ""-6< days• 5urat on o* bleed n) days•
Blood loss 8 0ls• @enstrual Phase- endo0etr u0 shed• 5 schar)ed throu)h C by uter ne
contract ons
7 0 l l
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7or0al cycle
Prol *erat ve (,oll cular%
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(hase
• 5ay <-!6• Ovar an *oll cular )ro#th•
Increas n) oestro)en• Gro#th and vascular sat on o*
endo0etr u0•
Ovulat on occurs day !4• Ovulat on occurs !4 days r or to
ne t er od n a cycle that s not "8
days
Secretory (luteal% hase
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Secretory (luteal% hase
• 5ay !<-"8• Pro)esterone ncreases2 Produced by
cor us luteu0• @a nta ns endo0etr al th c$ness3re ar n) *or 0 lantat on
•
Ends # th de0 se o* cor us luteu0
@enstrual hase
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@enstrual hase
• 5ay !-<• 5ecl ne o* oestro)en and
ro)esterone• Brea$do#n o* endo0etr u0- sheds
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Heavy
@enstrualBleed n)
Heavy @enstrual bleed n)
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Heavy @enstrual bleed n)
• 5e:ned as ; 8 0ls blood loss10onth
•
Heavy 0enstrual blood loss a ect n)QO. or caus n) anae0 a• ! ? o* all #o0en•
@ost co00on )ynaecolo)y re*erral
Causes
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Causes
• P&.@ COEI7Poly Coa)ulo athy
&de0o0yos s Ovulatory5ys*unct on.e o0yo0a Endo0etr al
@al )nancy Iatro)en c7ot yet class :ed
&ssess0ent
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&ssess0ent
History • @enstrual cycle len)th3 durat on• Heavy clots3 Dood n)3 ta0 ons1 ads• I@B3 PCB• &ssoc ated a n
Examination• &bdo0 nal• P• S eculu0- s0ear1s#abs
Invest )at ons
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Invest )at ons
• Pelv c +SS• ,BC3 clott n)3 T,T s
In older #o0en (;4 yrs%• P elle b o sy• Hysterosco y '1- b o sy
Causes
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Causes
• 5ys*unct onal +ter ne bleed n)• , bro ds•
Poly s• Endo0etr al ca
bro ds (le o0yo0a%
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, bro ds (le o0yo0a%
• Ben )n tu0ours o* 0yo0etr u0• " ? nc dence n #o0en ;4 yrs old
@ana)e0ent
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@ana)e0ent
Medical• 7on-hor0onal•
Hor0onal
Surgical• @ nor• @a or
@ed cal
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@ed cal
Non- hormonal • @e*ena0 c ac d (7S&I5%•
Trane a0 c ac d (ant :br nolyt c% Both ta$en dur n) er od only
@ed cal
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@ed cal
Hormonal • Pro)esto)ens- 7oreth sterone
- Provera - POP (CeraNette%• @ rena co l• COC3 5e o rovera3 GnRH analo)ues• Es0ya
Rad olo) cal
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Rad olo) cal
• , bro ds• +ter ne artery e0bol sat on•
ReFu res @RI
Sur) cal (@ nor%
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Sur) cal (@ nor%
Endometrial ablation• <? sat s:ed• @ust have b o sy r or to carry n) out• ,a0 ly should be co0 lete• .&SH alternat ve
Myomectomy (fbroids)
Sur) cal (@a or%
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Sur) cal (@a or%• Hysterecto0y '1- BSO• Should not be cons dered unless tr ed
alternat ve treat0ent or has verylar)e :bro ds
Endo0etr os s
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Endo0etr os sEcto c endo0etr al t ssue+sual s tes• Pouch o* 5ou)las• +terosacral l )a0ents•
Ovar an *ossae• Bladder• / th n uter ne 0uscle (adeno0yos s%
ery rare lun)s3 bra n3 0uscle
+sually resent # th a n1 n*ert ll tyGraded I-I
Treat0ent 9 COCP3 ro)esterones3 GnRH3 sur) cal
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UrinaryIncontinance and
rola se
Prola se• 5 # # d d l 0 t # $ ) *
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• 5o#n#ard d s lace0ent- #ea$en n) o*su ort ( elv c Door%
5e:n t ons
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5e:n t ons
• +terova) nal- uterus and c• Cystocele- Bladder• Rectocele- .ar)e bo#el• Enterocele- s0all bo#el
+terova) nal
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+terova) nal
• Grade I
+terova) nal
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+terova) nal
• Grade II
+terova) nal
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+terova) nal
• Grade III- co0 lete evers on
Grade III
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Grade III
Procedent a
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Procedent a• +lcerat on
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Rec
Sy 0to0s
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Sy 0to0s
• USo0eth n) co0 n) do#n• 5 sco0*ort• +r nary s• Recurrent +TI s• Const at on1 5 culty e0 ty n) bo#el
Treat0ent
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Treat0ent
• @ ld- Oestro)en crea0 - Pelv c Door e erc ses
• @od1Severe- Conservat ve (Pessary% vsSur) cal ( elv c Door re a r1 a) nalhysterecto0y1@esh%
Pessar es
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Pessar es
+r nary ncont nence
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r nary ncont nence
+r)e• Overact ve bladder• Inab l ty to delay *ollo# n) sensat on to
vo de2)2 >ey n the door• 5etrusor nstab l ty3 neuro)en c bladder3
n*ect onStress• .oss o* ur ne #hen ntra-abdo0 nal
ressure ncreased•
/ea$ elv c Door or s h ncter
Treat0ents 9 +r)e
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)
• . *estyle chan)es (#e )ht3 ca e ne3 Du d%• ,reFuency volu0e chart• Out at ent cont nence ro)ra00e• &nt -chol ner) c 0ed cat ons• Boto (rare%
Treat0ents- Stress
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• Phys o (P,E3 Electr cal st 0ulat on o*0uscles%
• +rethral bul$ n)• Sub-urethral sl n) (T T-O%• Col osus ens on
• = ? ha y a*ter sur)ery• Prola se sur)ery can 0a$e ur nary
sy0 to0s #orse and *or urodyna0 cs :rst
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Gynaecolo) cal
cancers
Endo0etr al cancer
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• @ost co00on )ynae cancer• &denocarc no0a 0ost co00on 8 -8<?• @ean a)e A yrs• R s$s- 7ull arous obes ty E" only HRT
late 0eno ause(Oestro)en %
Sy0 to0s and 5 a)nos s
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y )• P@B• Heavy rre)ular bleed n)• 7one
• T +SS (&ssess endo0etr al th c$ness%• !"00 re0eno ause 400
ost0eno ause• P elle b o sy• Hysterosco y3 5KC
Sta) n)
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) )
Stage I Confined to uterusStage Ia No myometrial invasion
Stage Ib Myometrial invasion <50%
Stage Ic Myometrial invasion >50%
Stage II Involvement of cervix
Stage III Pelvic s readStage I! "ladder#rectum#distant $lung
Treat0ent
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• Hysterecto0y• Pelv c clearance
o0entecto0y1a end cecto0y• Che0othera y1 Hor0one thera y
(advanced%• < yr surv val Stage I &5%
Stage II 5'%
Stage III (0%
Stage I! )0%
Ovar an cancer
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• @ost deadly• Pea$ a)e A8-8<yrs old• = ? s orad c3 ! ? )enet c• E thel al tu0ours 8<?• Increased r s$ 7ull arous3 h )her soc al
class3 ovulat on nduct on•
5ecreased r s$- COC use
Sy0 to0s and 5 a)nos s
8/18/2019 Obs and Gynae Revision Lecture
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y )
• &bdo d stens on10ass• &bdo a n• /e )ht loss1loss o* a et te
• Ca!"< ;6< ost 0eno ausal• &sc t c ta• I0a) n)- T +SS3 CT3 @RI3 CJR• .a aroto0y
Ovar an tu0our
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Sta) n)
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) )
Stage I *+5% Confined to ovariesStage Ia ,ne ovary
Stage Ib "ot- ovaries
Stage Ic .ve ascitic cytology
Stage II *)0% Confined to elvis
Stage III */5% Confined to eritoneal cavityStage I! *+0% istant s read
Treat0ent
8/18/2019 Obs and Gynae Revision Lecture
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•
Pelv c clearance 'che0othera y
• Rad othera y• < yr surv val
Stage I 1&%
Stage II 5)%
Stage III +0%
Stage I! 5%
Cerv cal cancer
8/18/2019 Obs and Gynae Revision Lecture
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• Pea$ a)e 4<-<< (can occur as youn) as " %• R s$s 9 5e*ault n) s0ears @ult le artners HP !A'!8 (8 -= ?% COC use S0o$ n)
Cerv cal screen n)
8/18/2019 Obs and Gynae Revision Lecture
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• C s0ear- 7ICE )u del nes• Every 6 yrs *ro0 a)e " -A<yrs• . Fu d based cytolo)y• Re) stered # th SCCRS• &bnor0al results re*erred to Col osco y
*or cold coa)ulo athy1..ETV•
U ade Goody e ect Increase "!? u ta$e
Cerv cal s0ear
8/18/2019 Obs and Gynae Revision Lecture
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Pre-cancerous chan)es
8/18/2019 Obs and Gynae Revision Lecture
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•
Trans*or0at onNone
• 5ys$aryos s• Cerv cal
ntrae thel alneo las a (CI7%
• @ay ers st *or
years• Can revert to
nor0al• 6 ? CI7 6 # ll
CIN ) 2bnormal cells inlo3er )#(e it-elium only4
CIN + 2bnormal cells inlo3er only4
CIN ( Carcinoma in*situ46ull t-ic7ness ofe it-elium
Cerv cal cancer
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Sy0 to0s and 5 a)nos s
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• Post co tal bleed n)• &bnor0al d schar)e1 bleed n)• /e )ht loss• Pa n
• E+&3 cystosco y3 roctosco y• Cone b o sy• ..ETV
Sta) n)
8/18/2019 Obs and Gynae Revision Lecture
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Stage Ia Micro <(mm in de t-
Stage Ib Confined to Cx
Stage II 8xtends to u er vagina
Stage III 8xtends to elvic side 3all or lo3er
vaginaStage I! istant s read* bladder#rectum#beyond4
Treat0ent
8/18/2019 Obs and Gynae Revision Lecture
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•
Hysterecto0y-Rad cal
• Rad othera y• Che0othera y• <yr surv val
Stage I '0%
Stage II 1)%
Stage III (+%
Stage I! )5%
acc nat on
8/18/2019 Obs and Gynae Revision Lecture
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• Gardas l• Protects a)a nst HP !A K !83 A K !!• ==? e ect ve• G rls a)e !"-!6 yrs old• / ll st ll need s0ears as rare C
cancers and current o ulat on notrotected2
ulval cancer
8/18/2019 Obs and Gynae Revision Lecture
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• .east co00on• Pea$ a)e A<- yrs old• SFua0ous carc no0a ="?• R s$s- HS HP (!A1!8% S0o$ n)
I00unosu res on• I7
Sy0 to0s and 5 a)nos s
8/18/2019 Obs and Gynae Revision Lecture
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• Pru tus vulva• ulval a n1 d schar)e• .u0 or ulcer
• 5 a)nosed by vulval b o sy
ulval cancer
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Sta) n)
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Stage I <+cm lesion confined to vulva
Stage II >+cm lesion confined to vulva
Stage III 9ocal s read or node involvement
Stage I! 2dvanced local s read or bilateralnode involement4 $inguinal: femoral:
elvic4
Treat0ent
8/18/2019 Obs and Gynae Revision Lecture
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•
Sta)es I-III 9Rad calvulvecto0y• Rad othera y1
Che0othera y• Sta)e I - Pall at ve
only• < yr surv val
Stage I ;&%
Stage II '5%
Stage III &/%
Strage I! (0%
Poly cyst c ovar an
8/18/2019 Obs and Gynae Revision Lecture
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Poly cyst c ovar ansyndro0ePCOS
PCOS
8/18/2019 Obs and Gynae Revision Lecture
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• ary n) de)rees• +n$no#n aet olo)y•
Cl n cal s )ns- Ol )o0enorrhoea - Obes ty - H rsut s0
Endocr ne 0easure0ents
8/18/2019 Obs and Gynae Revision Lecture
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• Increased .H1 .o# ,SH---; ncreased.H ,SH rat o
• Increased testosterone• 5ecreased SHBG• Insul n res stance and 0 a red )lucose
tolerance2 (!!?%•
@oderate hy er rolact nae0 a-occas onally
+SS assess0ent
8/18/2019 Obs and Gynae Revision Lecture
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• Increased ovar an volu0e• ! -!< 0 crocysts ! 00 n d a0eter• UStr n) o* earls
PCOS
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PCOS
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5 a)nos s can be 0ade * has " o* 6• Cl n cal *eatures• Endocr ne :nd n)s• +SS :nd n)s
Treat0ent
8/18/2019 Obs and Gynae Revision Lecture
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• /e )ht loss• @et*or0 n• .aser R *or h rsu t s0• COC3 @ rena3 5e o rovera• ,ert l ty R # th clo0 d
8/18/2019 Obs and Gynae Revision Lecture
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Ecto c
re)nancy
Ecto c re)nancy
8/18/2019 Obs and Gynae Revision Lecture
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I0 lantat on outs de uterus!2"? o* re)nanc esInc dence r s n)• Tubal -= ?• Cerv• Ovary• Per toneu0• &bdo0 nal
R s$ *actors
8/18/2019 Obs and Gynae Revision Lecture
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• STI1PI5• I+51@ rena• Prev ous Ecto c• Ster l sat on1 Tubal Sur)ery• &ss sted re roduct on
Presentat on
8/18/2019 Obs and Gynae Revision Lecture
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• &0enorrhoea3 've re)nancy test• Ty cally at A-8 #$s )estat on• 7o sy0 to0s• Pa n (.I,1RI,1Shoulder t % -= ?• P s ott n)- ?• ,a nt3 colla se3 hae0odyna0 c
co0 ro0 se -!<?
5 a)nos s
8/18/2019 Obs and Gynae Revision Lecture
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• Cl n cal ( er ton s03 adne al 0ass3unstable%
• Seru0 HCG trac$ n)• T +SS (no I+ re)nancy3 adne al 0ass3
*ree Du d%• .a arosco y
T +SS
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@ana)e0ent
8/18/2019 Obs and Gynae Revision Lecture
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• I &ccess3 ,BC3 GKS1 J-0atch• Resusc tat on * reFu red• &nt 5 * Rh-ve• Sur) cal vs @ed cal vs Conservat ve
Sur) cal
8/18/2019 Obs and Gynae Revision Lecture
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• .a arosco cSal n)ecto0y
• &ny s )ns o*ru ture
• .a aroto0y• Chec$ other tube
s not da0a)ed
@ed cal• @ethotre ate < 0)10"
8/18/2019 Obs and Gynae Revision Lecture
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@ethotre ate- < 0)10"• @ust :t cr ter a and be
co0 l ant to *ollo# u• Chec$ +KE s and .,T s• HCG trac$ n)- 0ay n t ally r se• <-! ? reFu re sur)ery•
7o re)nancy *or 6 0onths• &vo d alcohol1 sunl )ht
8/18/2019 Obs and Gynae Revision Lecture
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,ollo# u 1 ,uturere)nanc esA # $ * ll #
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)• A #ee$ *ollo# u a t• 5e br e* • Good contrace t on• S n)le ecto c- A - ? # ll have I+
re)nancy• SubseFuent re)nanc es ! -!<? # ll be
ecto c•