Obstetrics & Gynaecology

Anemia - Iron-Deficiency
Anemia is a condition wherein the blood has low levels of red blood cells (RBC), hemoglobin (oxygen-carrying pigment in whole blood) and/or hematocrit (intact RBC in blood).
Iron-deficiency anemia is the anemia that resulted from inadequate iron supplementation or excessive blood loss.
It is the most common nutritional disorder worldwide and accounts for more than half of anemia cases.
It is prevalent among preschool children and women.

Breast Cancer
Breast cancer is the presence of malignant breast nodule, mass or abscess.
Most common symptom of breast cancer is a new lump or mass in the breast. The lump or mass is usually painless, hard & irregular but it can also be tender, soft, rounded or painful.
Other signs & symptoms include breast pain or nipple pain, nipple discharge, nipple retraction and presence of breast skin changes (eg peau d' orange, nipple excoriation, scaling, inflammation, skin tethering, ulceration, abscess).
Cervical Cancer - Prevention & Screening
Mortality due to cervical cancer can be reduced by prevention, early detection & treatment.
Vaccination may be started as early as 9 years old.
Vaccination may reduce the incidence of HPV-related disease.
Screening for cervical cancer after vaccination is still recommended because only 70% of the virus types associated w/ invasive cervical cancer consist of HPV 16 & 18 types & women may not be entirely protected if they have been infected w/ other HPV types prior to vaccination.
Cervical Cancer - Treatment
Patients w/ abnormal Pap smear are referred for colonoscopy to screen for presence of cervical cancer.
Colposcopic exam should include inspection of the transformation zone, definition of the extent of the lesion & biopsy of the most abnormal area for tissue diagnosis.
The earliest stages of cervical carcinoma are generally asymptomatic.
Watery vaginal discharge & postcoital bleeding or intermittent spotting may be present & are usually unrecognized by the patient.

Chlamydia - Uncomplicated Anogenital Infection

Chlamydia is a gram negative obligate intracellular bacteria that causes sexually-transmitted infection.

Chlamydia trachomatis is the primary cause of pelvic inflammatory disease (PID) in women which may lead to ectopic pregnancy, infertility, or chronic pelvic pain.
Most infected females are asymptomatic.
But some females may experience vaginal discharge, dysuria, lower abdominal pain, abnormal vaginal bleeding (postcoital or intermenstrual) or breakthrough bleeding, dyspareunia, conjunctivitis, proctitis and reactive arthritis.

Chronic Pelvic Pain in Women
Chronic pelvic pain (CPP) is a persistent, distressing, & severe pain of >6 month duration.
It occurs intermittently, cyclically, or situationally.
Localized to the pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks.
It is severe enough to cause functional disability or need medical care.
In women, CPP is not restricted to intercourse or menstruation & is not associated w/ pregnancy.
It is a symptom w/ a number of contributory factors & not a diagnosis; pathophysiology is complex & not well understood.
It is assumed that in the development of chronic pain, the nervous system is affected among others by inflammatory & chemical mediators & hormones.
A complex problem that is both multifactorial & multidimensional.
Dysmenorrhea - Primary
Primary dysmenorrhea is a painful menstruation without demonstrable pelvic disease.
Symptoms include intermittent painful spasms, crampy labor-like pain localized over the lower abdomen & the suprapubic area which may radiate to the lower back or inner thighs.
The pain may also be described as a dull ache or as a stabbing pain.
Accompanying symptoms include nausea and vomiting, diarrhea, headaches, lightheadedness, fatigue, fever, nervousness & fainting.
Ectopic Pregnancy
Ectopic pregnancy happens when the fertilized ovum implants outside the endometrial lining of the uterus.
Accurate early diagnosis is life-saving, reduces invasive diagnostic procedures & allows conservative treatment that can preserve fertility.
Ectopic pregnancy must be excluded in women of reproductive age w/ a positive pregnancy test, abdominal pain & vaginal bleeding.
Ruptured ectopic pregnancy remains to be the leading cause of maternal mortality in the first trimester.
Endometriosis

Endometriosis is having extrauterine endometrial tissue that causes chronic inflammatory response.

The patient experiences chronic pelvic pain, pain during intercourse and/or menstruation and infertility.

Diagnosis is attained by pathologic examination of the tissue obtained from laparoscopy or laparotomy.

Goals of treatment are decreasing pain, enhancing fertility, and preventing progression or recurrence. 

 

Genital Herpes
Genital herpes is a recurrent lifelong disease with no cure, caused by herpes simplex virus (HSV).
HSV-2 is usually the cause but HSV-1 may occur in up to 1/3 of new cases.
HSV-1 tends to cause fewer recurrences & milder disease than HSV-2.
The incubation period is 2 days-2 weeks after exposure.
Gestational Diabetes Mellitus
Gestational diabetes mellitus (DM) is any degree of glucose intolerance with onset or first recognition during pregnancy.
However, overt DM is the diagnosis in women presenting with risk factors for type 2 DM during the first prenatal visit.
Identification and diagnosis of hyperglycemic disorders in pregnancy is recommended to all women not known to have DM prior to pregnancy.
All women that will be identified to have overt DM during pregnancy or have gestational DM should have postpartum glucose testing.
Gonorrhea - Uncomplicated Anogenital Infection
Gonorrhea is a sexually or vertically transmitted infection secondary to gram-negative diplococcus Neisseria gonorrhoeae.
It is one of the most common bacterial sexually transmitted infections that may cause pelvic inflammatory disease leading to infertility or ectopic pregnancy.
Most of the infected females are asymptomatic but may present with increased or altered vaginal discharge, dysuria, urethral discharge, abnormal vaginal bleeding, vulval itching or burning, dyspareunia, conjunctivitis and proctitis.
Heavy Menstrual Bleeding
Heavy menstrual bleeding is prolonged (>7 days) or excessive (>10 mL) uterine bleeding occurring at regular intervals over several menstrual cycles.
It is menstrual blood loss that is excessive and interferes with patient's physical, emotional, social and quality of life.
It is also referred to as menorrhagia or hypermenorrhea.
It is a common problem in women of reproductive age that usually causes anemia.
Uterine fibroids and polyps are the most common pathology identified.
Hormonal Contraception
Contraceptive methods are used to prevent pregnancy and sexually transmitted infections (STIs).
Contraception allows women/couples to explore plan on childbearing and family planning.
Hormonal contraception is a method with high rate of effectiveness & ease of administration. It is the widely used method of reversible contraception.
It does not protect against STIs/HIV.
Hypertension in Pregnancy
Hypertension in pregnancy is defined as an average diastolic blood pressure of ≥90 mmHg, based on at least 2 measurements, ≥4 hr apart or systolic blood pressure of ≥140 mmHg taken at least 6 hr apart.
Diagnosis of severe hypertension is made when blood pressure is ≥160/110 mmHg.
Measurement should be repeated after 15 min for confirmation.
Infertility

Infertility is when a couple of reproductive age is unable to conceive after a year or more of regular unprotected intercourse.

It can be primary if no pregnancy has ever occurred or secondary if pregnancy has occurred irrespective of the outcome.

Ovulation induction is part of patient's management which aims to achieve development of a single follicle & subsequent ovulation in woman w/ anovulation.

Labor Induction
Labor induction is when an external agent is employed to stimulate contractions before the onset of spontaneous labor.
Labor augmentation uses the same techniques as labor induction but uterine contractions (frequency, duration and strength) are enhanced once labor has started.
Labor induction is generally indicated when the benefits of delivery outweigh the risks of continuing the pregnancy.
Women at 42 weeks of gestation who chose not to undergo labor induction should be monitored more often with at least twice-weekly assessment of fetal well-being (cardiotocography & estimation of maximum amniotic pool depth by ultrasound).
Labor Pain
Labor pain experience is highly individualized and will depend on a woman's emotional, motivational, cognitive, cultural and social circumstances.
There is no other circumstance where it is considered acceptable for a patient to experience severe pain that is amenable to safe intervention while under a physician's care.
The pain felt during the 1st stage of labor originates from the rhythmic contractions of the lower uterine segment and progressive cervical dilation mediated via T10-L1 spinal nerves.
The pain in the 2nd stage of labor is more intense due to stretching of the vagina, vulva and perineum as the fetus descends in the birth canal superimposed by the pain of uterine contractions, and is transmitted through the S2-S4 spinal segments.
Leiomyomas

Leiomyomas or uterine fibroids are benign tumors of the uterus that consist of smooth muscle & extracellular matrix collagen and elastin.

Most common solid pelvic tumors and one of the most frequent clinical conditions encountered in gynecologic practice.

They tend to grow during the reproductive years and usually regress during menopause.

 

Mastitis
Mastitis is the inflammation of the breast that may or may not be associated with bacterial infection.
Staphylococcus aureus is the most common organism associated with mastitis.
It may occur spontaneously or during lactation. It most frequently occurs during the first 6-8 weeks postpartum, although it may occur any time during breastfeeding.
Nonpuerperal mastitis is most commonly associated with breast cyst.
Breast abscess (collection of pus in the breast) is a complication of mastitis.
Menopause & Hormone Therapy
Spontaneous/Natural menopause is the final menstrual period confirmed after 12 consecutive months of amenorrhea with no pathological cause.
Induced menopause is the permanent cessation of menstruation after bilateral oophorectomy (ie surgical menopause) or iatrogenic ablation of ovarian function (eg pelvic radiation therapy, chemotherapy).
Perimenopause/Menopause transition/Climacteric is the duration when menstrual cycle & endocrine changes occur a few years before and 12 months after the final menstrual period resulting from natural menopause.
Premature menopause is menopause before 40 years of age whether natural or induced while early menopause is spontaneous or induced menopause that occurs before the average age of natural menopause at 51 years or under 45 years of age.
Miscarriage - Spontaneous

Spontaneous miscarriage is the loss of fetus before 20 weeks of gestation or delivery of a fetus weighing <500 g, in the absence of elective medical or surgical measures to terminate pregnancy.
Early loss is considered if it occurred before menstrual week 12 while late loss refers to those that occurred from menstrual week 12-20.
It is also known as spontaneous abortion, spontaneous pregnancy loss or early pregnancy failure.

Nausea & Vomiting in Pregnancy
Nausea & vomiting in pregnancy (NVP), commonly known as "morning sickness", affects 50-90% of pregnant women.
In most women, the condition manifests between the 4th-7th week after last menstrual period and resolves by the 16th week of gestation.
It manifests in a spectrum of severity from mild nausea to very rare life-threatening symptoms.
The etiology is multifactorial.
The pregnant woman's sense of well-being and her daily activities are greatly affected by nausea and vomiting; the physical and emotional impact often leads to anxiety and worry about the effect of the symptoms on the fetus and reduced job efficiency.
Osteoporosis in Women
Osteoporosis is the progressive, systemic skeletal disease characterized by decreased bone mass and micro-architectural deterioration of bone tissue leading to bone fragility and increased susceptibility to fractures.
The more risk factors (eg history, of fracture, advanced age, comorbidities, impaired vision) that are present, the greater the risk of fracture.
Ovarian Cancer
Ovarian cancer is a type of cancer that begins in the ovaries.
It is the 7th most common cancer in women (excluding skin cancer) and the leading cause of death from gynecologic cancer in developed countries.
The 3 histologic types of ovarian cancer are epithelial (primarily seen in women >50 years of age), germ cell (most commonly seen in women <20 years of age) and sex cord stromal (rare and produces steroid hormones).
The median age at the time of diagnosis is 63 years old and >70% present with advanced disease.

    Ovarian Mass
    Ovarian cysts are typically noted after clinical screening, or as a result of exam for a suspected pelvic mass, or an incidental finding in investigations done for other reasons.
    Most ovarian masses manifest with few or mild nonspecific symptoms.
    Ovarian masses in women of reproductive age are mostly benign but the risk of malignancy increases with age.
    Ovarian cysts in the prepubertal patients especially after the first week of life are abnormal and likely to be neoplastic. In adolescent patients, majority of ovarian masses are functional cysts.
    Pelvic Inflammatory Disease
    Pelvic inflammatory disease (PID) is the ascent of bacteria from the vagina or cervix resulting in infection of the reproductive organs eg uterus, fallopian tubes, ovaries. It may also be a complication of sexually transmitted infections.
    The most common symptoms of PID are lower abdominal pain (crampy or dull) that usually starts a few days after the onset of the last menstrual period, dyspareunia, abnormal vaginal or cervical discharge, postcoital or irregular vaginal bleeding, dysuria, fever, nausea and vomiting, although some have minimal symptoms or silent pelvic inflammatory disease.
    Polycystic Ovarian Syndrome
    Polycystic ovarian syndrome (PCOS) is the accumulation of underdeveloped follicles in the ovaries due to anovulation. It is is characterized by menstrual abnormalities and clinical or biochemical features of hyperandrogenism.
    It results mainly from abnormal steroidogenesis that may be caused by insulin resistance leading to hyperinsulinemia.
    There is increased sensitivity to androgens and the majority of women have elevated androgen levels.
    Postpartum Hemorrhage
    Postpartum hemorrhage is defined as blood loss of ≥500 mL for vaginal delivery or 1000 mL for abdominal (Caesarean) delivery after completion of the 3rd stage of labor.
    Another proposed definition is a 10% fall in hematocrit value.
    Since the clinical estimation of the amount of blood loss is typically inaccurate, the diagnosis of postpartum hemorrhage remains a subjective clinical assessment of the amount of blood loss that jeopardizes a woman's hemodynamic stability.
    Postpartum hemorrhage may produce hemodynamic instability during the 1st 24 hours after delivery.
    Premenstrual Dysphoric Disorder
    Premenstrual dysphoric disorder is a cyclical disorder presenting with distressing mood and behavioral symptoms that occur during the late luteal phase of the ovulatory cycle; it is a severe form of premenstrual syndrome.
    It results in considerable impairment of the patient's personal functioning that occurs in approximately 5% of women of reproductive age.
    Syphilis - Primary
    Syphilis is a sexually or vertically transmitted infection caused by Treponema pallidum subspecies pallidum.
    A person with primary syphilis has a 60% risk of infecting her sex partner and 70-100% risk of passing the infection to the fetus.
    In the primary stage of acquired syphilis, there is an appearance of a painless ulcer (chancre). Then in the secondary stage, there are skin rashes and sores on mucous membranes.
    In the latent stage, it is asymptomatic and not communicable. It is in the tertiary or late stage that it is symptomatic but not communicable; it usually appears 10-20 years after 1st infection.
    Urinary Incontinence in Women
    Urinary incontinence is the complaint of involuntary urine leakage.
    Stress urinary incontinence is the involuntary urine leakage on effort or exertion or when coughing or sneezing.
    Urge urinary incontinence is the one associated with or immediately preceded by urgency.
    Mixed urinary incontinence is the involuntary urine leakage associated with both urgency and with exertion, effort, coughing or sneezing.
    Urinary Tract Infection - Uncomplicated
    Acute uncomplicated urinary tract infection (UTI) is one of the most common bacterial infections in adults that may involve the lower or upper urinary tract or both.
    Acute cystitis is an infection limited to the lower urinary tract while acute pyelonephritis is an infection that involves the upper urinary tract (renal parenchyma & pelvicaliceal system) that usually has significant bacteriuria.
    Recurrent UTI is characterized by 2 episodes of uncomplicated UTI in the last 6 months or ≥3 episodes with positive cultures in the last 12 months in patients with no structural or functional abnormalities.
    Urinary Tract Infection in Women - Complicated
    Urinary tract infection (UTI) is complicated if the UTI is associated with factors that increases colonization and decreases therapy efficacy. Factors may include one or all of the following: Structural or functional abnormalities of the genitourinary tract; presence of an underlying disease that interferes with host defense mechanisms or the patient being immunocompromised; and being infected by a multi-drug resistant bacteria.
    Principles of therapy includes effective antimicrobial antimicrobial therapy, optimal management of the underlying abnormalities or other diseases & adequate life-supporting measures.
    Vaginitis: Trichomoniasis, Candidiasis, Bacterial Vaginosis

    Trichomoniasis is caused by a flagellated protozoan, Trichomonas vaginalis. It is always sexually transmitted.

    Bacterial vaginosis is the most common cause of vaginitis, vaginal discharge or malodor. It results from overgrowth of anaerobic bacteria.

    Vulvovaginal candidiasis is caused by overgrowth of yeasts where 70-90% of cases are secondary to Candida albicans. It most commonly occurs when the vagina is exposed to estrogen (ie, reproductive years, pregnancy) and may be precipitated by antibiotic use.

    Warts - Anogenital
    Anogenital warts (condylomas) are caused by human papillomavirus (HPV) with >90% of the lesions caused by genotypes 6 & 11.
    Patients who present with visible warts may also be infected with high-risk HPVs (eg types 16 & 18) which can cause subclinical lesions that are associated with intraepithelial neoplasia, cervical cancer and anogenital cancer.
    Many HPV infections are subclinical, transient, and clear spontaneously within 12 months but may also remain latent and reactivate after several years.